In early 2020, I accepted an invitation to participate in a live debate with a nationally prominent academic urologist at the annual scientific meeting of the American Society for Men's Health. The topic: "The Great Debate of the 21st Century: To PSA screen or not to screen." Unfortunately, the COVID-19 pandemic caused the meeting to the canceled. By the time I was re-invited in 2021, my academic interests had drifted away from prostate cancer screening, so I declined. But over the past 5 years, I have watched with increasing dismay as family physicians and urologists (mis)interpreted the U.S. Preventive Services Task Force's more permissive stance on PSA screening as a license to start screening indiscriminately again without warning men about the adverse consequences of doing so. "We Should Be Doing Fewer PSA Tests, But We Are Doing More," I pleaded in a 2022 Medscape commentary for primary care physicians. I moved to Lancaster and was appalled when my program's residents received a lecture from a urologist chastising us for not ordering enough PSA tests because we apparently cared more about a few patients avoiding erectile dysfunction and urinary incontinence than the "millions" of lives that could be extended by screening. So I dove back into the evidence, read pretty much every paper on PSA screening published since the pandemic began, and concluded that our current approach to shared decision making is fatally flawed, and that we would be better off not using the PSA test for screening at all.
Then I wrote a paper about it. Here is my unfiltered conclusion:
Even though [the PSA] test's flaws, including poor accuracy and the cascade of interventions that follow a positive result, are well established, guideline developers have assumed that shared decision-making would limit the population of men being screened to those prepared to endure the lifelong monitoring and interventions that follow a positive PSA result. The preponderance of the evidence has not reflected this assumption. The net population benefit of prostate cancer screening is too small—particularly in men older than 70 years—to justify continuing this failed approach. Rather than treating PSA as an elective test and trying unsuccessfully to present “both sides” of the screening decision, primary care physicians should go back to discouraging its use.
