Prostate Cancer Screening: Deciding With Your Doctor

Prostate cancer screening is different from many other screenings. There is no age when it simply happens to everyone. Instead, it is a personal decision you make together with your doctor.

The main tool is a blood test called the PSA test, sometimes paired with a physical exam of the prostate. The reason screening is a decision, and not automatic, is that it has real benefits and real downsides that have to be weighed against each other.

Prostate cancer screening is a shared decision, not a routine test for all.

Screening here means the PSA test.

• The PSA test measures the level of prostate-specific antigen, a protein made by the prostate, in a blood sample. Higher levels can be a sign of cancer, but many other things can raise PSA too. This is the test the recommendations are about.
• The digital rectal exam (DRE), where a doctor feels the prostate through the wall of the rectum, is a different matter. The US Preventive Services Task Force does not recommend it as a screening test, because there is a lack of evidence that it brings any benefit. Some clinicians still examine the prostate when investigating symptoms or an abnormal PSA. That is not the same thing as screening.

Neither test diagnoses cancer by itself. A raised PSA is a reason to look further. The doctor may repeat the PSA after an interval, look for other explanations, order imaging, or recommend a prostate biopsy to check the tissue directly.

These tests raise or lower suspicion; they do not diagnose cancer on their own.

It is easy to assume a high PSA means cancer, but that is not the case. There is no single number that means someone has prostate cancer.

Many things besides cancer can raise PSA, including an enlarged prostate (a common change with age), a prostate infection or inflammation, a recent exam or biopsy, and even vigorous cycling or recent ejaculation. Some medicines can lower PSA.

Because of this, a raised PSA is a reason to look further rather than a diagnosis. What comes next varies: repeating the test after an interval your clinician chooses, checking for infection or another explanation, imaging, or referral. Ask what the plan is and when.

A high PSA is a reason to look closer, not proof of cancer.

The U.S. Preventive Services Task Force, a group of independent experts, offers clear guidance on who should consider screening.

• For men aged 55 to 69, the decision to have periodic PSA screening should be an individual one. Before deciding, a man should discuss the benefits and harms with his doctor and consider his own values and preferences.
• For men 70 and older, routine PSA screening is generally not recommended.

Some organizations also suggest that men at higher risk, such as Black men, men with a family history of prostate cancer, or men with certain inherited gene changes, begin these conversations earlier, around age 40 or 45.

Ages 55 to 69 is where the decision is most clearly an individual one.

The reason this is a decision, rather than a routine test, comes down to a balance.

The benefit is that screening may find prostate cancer earlier, when it may be easier to treat, and can slightly lower the chance of dying from prostate cancer over time.

The harms are important too:

• False positives. A raised PSA when there is no cancer is common. It can cause anxiety and lead to a biopsy, which carries small risks like infection, pain, or bleeding.
• Overdiagnosis. Some prostate cancers grow so slowly they would never cause harm. Screening can find these, and treating them, called overtreatment, can bring side effects such as urinary, bowel, or sexual problems.
• No guarantee. Finding cancer early does not always lead to a cure, since some cancers may have already spread.

For men who prefer to avoid these downsides, choosing not to screen is a valid choice. For men who most want the chance to catch a cancer early, screening may be worth it. Both can be reasonable.

The right choice depends on your values, your risk, and a real conversation with your doctor.

This article focuses on the decision to screen. If you want a closer look at how the PSA test works, what the numbers mean, and how it is used after a diagnosis, see our companion article on the PSA test. Together, the two give you a fuller picture as you talk with your care team.

The screening tests themselves are a blood draw and a brief exam. The prostate biopsy that may follow is where the real risks sit: infection that can turn into sepsis, trouble passing urine, and bleeding. Soreness, and small amounts of blood in urine, stool or semen for days to weeks, are expected and not a warning sign on their own.

• Call 911 or go to an emergency department if you cannot pass urine at all in the hours after a biopsy, or you feel suddenly and badly unwell with shaking chills, which can be the start of sepsis.
• Call your care team the same day if you run a temperature of 100.4°F (38°C) or higher after a biopsy, or you are passing blood clots or bleeding steadily from the rectum.
• Call your care team within a day or two if blood in your urine or semen is getting heavier instead of fading, or it stings more and more when you pass urine.

Sources for these signs: MedlinePlus — Prostate biopsy and the NCI PSA fact sheet.