Screening for cancer is a critical part of primary care in the western world. ‘Screening’ is defined as conducting a test on a patient prior to any symptoms or signs of disease. Prostate cancer is the most common non-skin cancer in American men and the second leading cause of male cancer death. In 2011, there were more than 200,000 diagnosed cases and 28,000 men died from it. It is rare before the age of 50 and very few men die from it before the age of 60 years. Older age and family history of prostate cancer are considered risk factors. African Americans have a higher incidence and death rates. However, if it occurs in younger men it tends to be more aggressive with much higher mortality. 

Symptoms of prostate cancer include problems with urine flow, frequent nightly urination, blood in urine, painful ejaculation or urination and persistent pain in the back, hips and pelvis. Recent studies have shown that multivitamins, specifically vitamin E and selenium, do not decrease the risk for prostate cancer. Prostate cancer may frequently remain localized, symptomless, and never need any treatment. It is commonly said that “men usually die with prostate cancer rather than from it”. It is often curable but over-diagnosis and over-treatment are a growing concern – cancers that would not have caused illness or death are being discovered and treated with negative consequences. There is no evidence that screening causes a reduction in deaths from prostate cancer. More cancers get diagnosed but more lives are not saved, thus making the PSA test ineffective. Treatment may be surgical, radiation, or hormonal – all associated with serious adverse effects. 

Screening for prostate cancer with the PSA test (prostate specific antigen) has been a controversial issue. Once detected to be high a biopsy may be recommended. Though this test may diagnose prostate cancer, the surgical treatment is associated with serious side effects like incontinence of urine and impotence. Many of these cancers may remain indolent and require no treatment at all. Elevated PSA may also be caused by other disorders of the prostate than cancer, like benign enlargement, infection, inflammation, or medications. In such cases, an abnormal PSA test result can cause increased anxiety, unnecessary procedures, complications from prostate biopsy like bleeding and infection, and more frequent PSA testing.

In 2012, the US Preventive Services Task Force released their recommendation statement that concluded that screening for prostate cancer with PSA causes more harms than benefits and must not be done routinely in men without any symptoms. The recommendations were based on the results from three randomized controlled trials published recently, one in the US and two in Europe. Regardless, many physicians and patients continue to perform the test, some as frequently as every year. Understanding this, the Centers for Disease Control and Prevention (CDC) advocates shared decision making between physicians and patients. Until we find better ways to screen for prostate cancer, open conversations between physicians and patients must be promoted so that decisions can be made based on the preferences and values of the patient.