The silent epidemic: the pros and cons of screening for prostate cancer

The Guardian

10 hours ago

'You will feel a little pressure.'
My doctor had instructed me to lower my boxers, bend forward and place my elbows on the table. As with most men over 50, it was time for my annual digital rectal exam, or DRE: those riveting moments when the doctor takes a 'look' at the prostate gland, which is just below the bladder and in front of the rectum.
Its position makes the examination difficult. The physician inserts a well-lubricated finger into the patient's rectum to feel for abnormalities such as lumps, nodules or areas of hardness. As uncomfortable as the procedure can be, in my experience, it rarely lasts for more than 10 seconds.
As always, she said everything looked fine. In my rush to pull my boxers up and change the subject, I didn't bother to ask any more questions. At the time, I was clueless that as men age, the prostate becomes increasingly susceptible to cancer.
In the rare event the disease tops the news cycle, it's because of high-profile diagnoses, such as for former US president Joe Biden in May, Nelson Mandela, Robert De Niro and the Chicago Cubs hall of famer Ryne Sandberg, who died in late July. Even so, important details of the illness often go unreported. I – like many others – typically dismissed the topic with a yawn, being of the uninformed but persistent impression that it's 'the best cancer to have'. All I knew was that prostate cancer tends to move slowly and can be successfully treated when detected early.
Now I am a prostate cancer survivor, whose prostatectomy in 2020 almost came too late. I didn't know that in the US, prostate cancer is the second leading cause of cancer death in men. One in eight will be diagnosed with it. One in 44 will die from it.
Being uninformed about those details and testing options could have killed me.
'Prostate cancer has been called the Silent Epidemic,' said Dr Samuel L Washington, a urologic surgeon who specializes in oncology at the University of California in San Francisco. Even with an active lifestyle, healthy nutritional regimen and digital screenings, cancer can sneak in undetected.
'Many men with prostate cancer won't experience any outward signs or symptoms until the disease is advanced, which is why testing is so critical,' said Dr Clifford Gluck, a urologist and Founder of Dr Gluck's Wellness Center in Massachusetts. 'If not caught early, it can break free of the prostate and run unchecked through the body, with a particular penchant for bone.' Once prostate cancer has spread to other parts of the body, the five-year relative survival rate is only 37%.
'In 2023, only about 38% of men between 50 and 64 were screened for the disease,' said Washington. 'Sadly, a lack of screening remains one of many factors leading to increased rates of men presenting with more advanced disease over the last decade. The more advanced the cancer, the harder it is to treat.'
Before my 62nd year, I routinely postponed my annual physical, assuming I was bulletproof. I was athletic and ate a plant-based diet. My life was free of processed foods, recreational drugs, tobacco, asbestos and weapons-grade plutonium. I experienced no symptoms indicative of prostate cancer, such as erectile dysfunction or urinary issues that reportedly led to the former president's diagnosis.
Then, after a couple of cross-country moves with my family, I no longer had a primary physician. Dismissing my claims of invincibility, my wife handed me a list of internists. I booked a physical, and my new doctor ordered my first-ever PSA (prostate-specific antigen) test. PSA is a protein produced by the prostate. Normal and cancerous prostate cells produce it, but cancerous ones tend to produce more. That said, an elevated PSA level is not always indicative of cancer.
Generally, a normal, or non-elevated score for men over 60 is under four; for men under 59, under two-and-a-half; and for younger men, under one. But 'PSA levels differ for each person,' said Dr Ash Tewari, professor and chairperson of the department of urology at the Icahn School of Medicine at Mount Sinai. 'While scores below four are preferred, it is most important to understand whether a PSA level is changing from year to year.' Variables such as family history, overall health, nutrition and race can have an effect. 'At the very least, I urge patients to have the conversation with their doctor,' he said.
Mine was a harrowing 17. My doctor called, speaking with a breathless urgency that made me feel I might not live to the end of the conversation. 'It's almost certain,' he said, 'that you have prostate cancer.'
The PSA test is a common, though imperfect, screening test for prostate cancer recommended by many urologists and primary care physicians for men starting at age 50. It is also one of the only ways to catch prostate cancer early. I asked my two previous primary care physicians why they had never ordered one, and they argued that the test sets off too many false alarms and causes undue stress; elevated PSA levels can be symptomatic of issues other than cancer, such as an infection. Also, I had never asked for one. (They must have confused my BA in English with a medical degree.)
After hearing I had been diagnosed with prostate cancer, one conceded: 'In hindsight, a PSA test would have been a good idea.'
Their reluctance is not unusual. Many doctors in the US shy away from prescribing the test because of the uncertainty of what an elevated score means, how patients react to that uncertainty and risks associated with subsequent exploratory procedures like biopsies.
A PSA test can correctly indicate that prostate cancer is present, as it did for me. But it can also result in a false positive, suggesting cancer is present when it isn't (6 to 7% per screening round); a false negative, or not picking up that cancer is present (according to the UK's National Institute for Health and Care Excellence, 15% of people with a normal PSA test result may have prostate cancer); or catch slow-growing cancers that might never have caused issues.
The latter is called overdiagnosis, and treatment can expose 'a person unnecessarily to potential complications', according to the National Cancer Institute: these include urine leakage, increased urination, loose stools or rectal bleeding, and loss of erections or decreased erections. Current estimates suggest that 20%–40% of screen-detected prostate cancers may never have caused harm, with risk varying by age, PSA levels, and Gleason Score.
'There are risks to the test,' said Dr Nancy L Keating, MD, MPH, professor of healthcare policy & medicine at Harvard Medical School. The PSA test has a C rating from the US Preventive Services Task Force (USPSTF). For context, an A rating means the USPSTF strongly recommends the test. A C means doctors may offer it, 'but that patients should make an individual decision about screening after discussing potential benefits and harms with their doctor', said Keating.
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'There appears to be a modest benefit to screening for some men,' said Keating. 'But most prostate cancers are not likely to be deadly, and many men will experience the harms of screening, such as anxiety and unnecessary biopsies, and treatments like radiation or removal of the prostate that can lead to incontinence and erectile dysfunction, without experiencing benefits,' said Keating, who thinks it is important for patients to understand the test's limitations.
In one 2024 study that followed more than 400,000 men aged 50-69, one invitation to do a PSA test produced a small mortality benefit. 'The small reduction in prostate cancer deaths by using the test to screen healthy men does not outweigh the potential harms,' Professor Richard Martin, lead author of the study and cancer research scientist at the University of Bristol in the UK, said at the time. 'This results in some men going on to have invasive treatment that they don't need, many years earlier than without screening, and the test is also failing to spot some cancers that do need to be treated.'
Regret following a prostate biopsy isn't rare – even when no cancer is found. A 2024 multicenter cohort study reported that about 5% of men regretted undergoing the procedure, often due to pain, bleeding, or unexpected psychological distress. In qualitative studies, men who believed they had been overdiagnosed and unnecessarily treated reported lasting regret, uncertainty, and emotional distress – even years after treatment.
Men more susceptible to prostate cancer, and therefore more likely to benefit from a PSA test, include African American men, men with a family history of prostate cancer, and those with genetic mutations such as BRCA1 or BRCA2, according to the American Cancer Society.
Gluck noted that the PSA test has a low USPSTF grade 'primarily due to concerns about side-effects from surgery or radiation treatments'. But advances in technology, treatment and surgical techniques – such as high-intensity focused ultrasound (HIFU), a non-invasive treatment that uses targeted sound waves to destroy prostate cancer while preserving urinary and sexual function – make screening a 'far more favorable proposition' now, he said.
My PSA score definitely spiked my anxiety, despite knowing I might only have an infection. The only way to determine what it meant was an MRI and a prostate biopsy. I dreaded the biopsy, which was to a digital exam what a root canal is to flossing. My urologist explained that there were some risks, such as infection and false negatives, but for me, confirming whether I had cancer far outweighed them.
Nothing about these processes counted as pleasant. For the MRI, I was ensconced in the machine for about 40 minutes. A week after that, the doctor inserted an ultrasonic probe into my rectum to guide him as he extracted 12 small samples of my prostate. The biopsy redefined my concept of vulnerability, but although it seemed like hours, it took less than 20 minutes – and anticipating the pain was worse than the actual pain. After a few days of mild tenderness, I was back to normal.
For all of the worry and discomfort, if the biopsy revealed no trace of cancer, I would have uncorked the champagne. Unfortunately, my results showed a high Gleason score – which measures how different cancer cells look under a microscope compared with normal cells – consistent with aggressive prostate cancer. But I was relieved to hear that the disease hadn't spread beyond the prostate membrane. Had I waited another two or three months, according to my post-operation pathology report, it probably would have.
Six weeks after the biopsy, I underwent a radical robotic nerve-sparing prostatectomy, a roughly five-hour operation to remove the prostate using minimally invasive tools. Finding data on success rates was frustrating given the myriad factors that can affect the outcome, which include Gleason scores, age, health, obesity, comorbidities and whether or not the cancer has metastasized beyond the prostate. I banked on my fitness and the skill of my surgeon as deciding factors to undergo the operation. My greatest fears were long-term incontinence or erectile dysfunction, but I was fortunate not to suffer either.
As lucky as I was, earlier testing and detection would have afforded me more treatment options. 'The benefits of early detection can't be overstated, which is why I advise men between 50 and 70 years of age to have a PSA discussion annually,' said Tewari. 'PSA screening combined with imaging is an important approach to effectively screen for prostate cancer.'
It took moving across the country, my wife's diligence and a doctor who routinely prescribed PSA tests for my cancer to be diagnosed. It was a complicated road, and experts' divergence on the effectiveness of screening show just how difficult it can be for a layperson to make these kinds of medical decisions. It's not ideal to rely on a testing option that at best results in an estimated 10 out of 1,000 people avoiding death from prostate cancer, with treatment options that can result in incontinence and sexual dysfunction.
But taking the test when I did had a dramatic impact. It saved my life. At the very least, I wish I'd had an earlier opportunity for a detailed discussion with my doctor. Given what I know now, I would have preferred screening and early detection, because for me, there is no such thing as the best type of cancer.
Ed Manning is a 67-year-old technology executive, jazz pianist and freelance writer who is writing a memoir about surviving prostate cancer