Should I have a PSA blood test? - Benefits, Risks and Prostate Screening explaned
PSA explained by The Prostate Health Clinic
A PSA blood test can sometimes help find prostate cancer earlier, but it can also lead to worry, extra tests, and diagnosis of cancers that may never have caused harm. The right choice depends on your personal risk, your health, and how your feel about the possible benefits and downsides
What a PSA can and cannot do
PSA is a blood marker linked to the prostate. A raised PSA does not automatically mean prostate cancer. 50-75% of raised PSA signals are not prostate cancer related
PSA can also rise because of an enlarged prostate, inflammation, infection, recent ejaculation, cycling or other prostate irritation.
A normal PSA does not completely rule out prostate cancer either.
PSA is helpful
Its can be an important first step in identifying men who may need further assessment
PSA is imperfect
A high result does not always mean cancer, and a normal result does not always exclude it.
PSA needs context
The best decisions are made when PSA is combined with history, examination, MRI imaging and risk assessment.
What is PSA?
Prostate Specific Antigen (PSA) is a protein enzyme produced in the prostate
Its job is to help liquify and activate sperm on ejaculation
A small amount is released into the blood stream in normal conditions which can be detected on the blood test
Problems affecting the prostate can lead to an increase level in the blood (including prostate cancer)
Pros and Cons of having a PSA test
May find important cancer earlier
For some men, PSA testing can help identify clinically significant prostate cancer before symptoms appear.
Can guide next steps
A PSA result may help decide whether an MRI scan, follow-up, or further assessment is sensible.
Useful in higher-risk men
PSA testing men be especially relevant in men with a family history, black ethnicity, known BRCA gene mutations.
Supports a tailored pathway
When used alongside other investigation modalities, PSA becomes part of a more personalised risk assessment rather than a stand-alone test.
Benefits of PSA testing
False alarms happen
A raised PSA often reflects non-cancer causes. This can create unnecessary worry and further testing.
Furthermore a low PSA may miss cancer.
May lead to MRI scan and biopsy
An abnormal PSA may lead to more investigations, including biopsy, which can involve discomfort, bleeding, infection risk and anxiety.
Can detect harmless cancers
Some prostate cancers grow so slowly that they would never have caused problems during a man’s lifetime.
Can lead to overtreatment
Once cancer is found, some men go on to treatment they may never truly have needed, with possible urinary, sexual, and bowel side effects.
Risks and Limitations of PSA
Why don't we offer simple PSA-only screening for every man?
PSA on its own is not accurate enough to be used as a blanket screening tool for all men
PSA is not cancer-specific
Many raised PSA results are caused by non-cancer conditions such as benign enlargement or inflammation.
PSA-only screening can lead to overdiagnosis
It may identify slow-growing cancers that would never have caused symptoms or shorten life.
Overdiagnosis can lead to overtreatment
Some men may undergo treatment with subsequent side effects for cancers that may never have harmed them.
Not every man benefits equally
Potential benefits depend on personal risk, life expectancy, overall health, and how each man values the trade-offs
Modern care is more precise than PSA alone
Today we combine PSA with clinical assessment, MRI prostate scan, risk calculators, and selective biopsy to improve accuracy and reduce unnecessary harm.
What is the "normal" PSA level?
Unfortunately there is no PSA which can be defined as normal. This is because roughly 1 in 10 prostate cancers do not present with an elevated PSA. 50-75% of raised PSA results are not due to prostate cancer.
Levels above these age specific reference ranges are the “sweet-spot” for helping clinicians detect prostate cancer in populations
The upper reference PSA limit changes with age to reflect the natural enlargement of the prostate with age, helping to lower the chance of identifying “insignificant prostate cancer” as men age.
Insignificant Vs Significant Prostate Cancer
Not all prostate cancer acts aggressively
Many cancers in the prostate are found to be slow growing and non-aggressive
- These may not influence life expectancy
- Many people will refer to; “dying WITH the disease rather than FROM the disease”
- These are known as clinically INSIGNIFICANT prostate cancer
A smaller proportion of prostate cancers are faster growing and aggressive
- May shortern estimated life expectancy
- These patients may die FROM their prostate cancer if untreated
- These are known as clinically SIGNIFICANT prostate cancer
The PSA blood test alone is unable to differentiate between insignificant and significant prostate cancer.
Screening for Prostate Cancer - Evidence Vs Recommendation
"Screening using the PSA blood test alone is NOT currently recommended in the UK"
- The rationale behind the above statement is based upon;
- The Test
- The PSA is simply not accurate enough to find prostate caner that needs treatment.
- The Intervention
- No single best treatment for early stage prostate cancer exists. Treatment effectiveness to be weighed up against their side effects
- The Screening Programme
- It is unclear how PSA screening impacts deaths due to prostate cancer.
Prostate Cancer assessment is recommended through opportunistic testing with PSA
Prostate Screening Evidence
Screening = 13% reduction in Prostate Cancer mortality
Unpicking the facts
- 13% reduction in cancer mortality in those having PSA testing every 4 years, compared to those who did not
- We need a long lead time
- Need to screen huge numbers for small population gains
Who should consider a PSA test?
Men with a family history
A father, brother, or multiple relatives with prostate cancer may increase your personal risk.
Men with genetic risk
Certain inherited mutations, such as BRCA2 , can increase prostate cancer risk
Black men
Some men may carry a higher risk of clinically significant prostate cancer. The lifetime risk for men is 1 in 8. This rises to 1 in 4 for black men.
Men who want clarity
Some men place a high value on early detection, even knowning the limitations of the test.
Your PSA journey in
Talk first
The doctor discusses your age, symptoms, family history, ethnicity, general health and what matters to you.
PSA and examination
PSA is used as one part of the picture, sometimes alongside physical examination.
Refine the risk
If needed, a prostate MRI, risk calculators, or additional biomarkers can help clarify the likelihood of significant cancer.
Chose proportionate care
If cancer is found, not every man needs immediate treatment. Some are better served by careful monitoring.
The PSA blood test alone is not good enough to conclude your risk of prostate cancer. It does serve as a helpful tool for men to have the conversations about prostate cancer and begin a risk stratified assessment.
Questions to ask yourself
How concerned am I about missing an important prostate cancer
How concerned am I about false alarms, biopsy, or finding a cancer that may never have caused harm?
What is my personal risk based on age, family history, ethnicity, and overall health
The best decision is an informed one
There is no single right answer for every man. Some men value the chance of earlier detection. Others want to avoid unnecessary tests and treatment. A PSA test is best considered as part of a shared decision-making conversation.
Should YOU have a PSA test?
How we assess prostate cancer risk at The Prostate Health Clinic
We believe that knowledge is power
The PSA is not robust enough to accurately assess for prostate cancer. We have therefore designed an assessment which combines all investigations as standard to give you a full understanding of your prostate cancer risk.
PSA
MRI prostate
Digital rectal examination
Rotterdam risk calculator
Novel biomarkers (supplementary testing)