Clinical blood tests, traditionally used for the early detection of prostate cancer, are increasingly demonstrating the phenomenon of overdiagnosis in modern urological practice, provoking false alarms among both medical specialists and patients. A new large-scale review study by international experts in the field calls into question the absolute effectiveness and feasibility of mass screening, since clinically unjustified prostate surgeries are often accompanied by the development of severe and irreversible side effects that reduce the quality of life for men.
Regular preventive screening for prostate cancer by determining the concentration of specific markers in blood plasma potentially has the capacity to save patient lives at critical stages of oncogenesis. However, its absolute clinical benefit on a general population scale has turned out to be relatively small—this is the balanced conclusion reached by the authors of the most representative scientific study on this medical topic to date. Due to statistical error and the specifics of the test itself, many men may face aggressive and unnecessary treatment, followed by severe therapeutic and surgical complications.
As part of this fundamental review work, scientists thoroughly analyzed consolidated data from six independent long-term clinical trials involving a total of nearly 800,000 men from various age groups. Statistical analysis showed that population screening using prostate-specific antigen (PSA) reduced the mortality rate from prostate cancer by only two cases per 1,000 screened patients. In practical terms, this means that to prevent a single death, clinicians need to screen at least 500 people, which points to the high resource intensity and debatable effectiveness of the method when applied indiscriminately.
The positive therapeutic effect of early diagnosis became statistically apparent only after the control groups of patients were kept under medical observation over a long historical period. In particular, this pattern emerged clearly during the European Randomised Study of Screening for Prostate Cancer (ERSPC), where specialists observed the health status of men for 23 years after the initial laboratory test.
“Prostate cancer screening does show the ability to reduce mortality from this disease, but with a strict scientific caveat: it takes a lot of time and long-term dynamic observation before this potential benefit becomes clinically noticeable for a specific patient,” the authoritative British publication The Guardian quotes the head of the research project, leading urologist from the University of Minnesota Philipp Dahm. “This analytical conclusion is an important milestone in outpatient urology, and I reasonably believe that it will have a significant impact on the strategic decisions of many healthcare leaders at the national level.”
In Germany, the current state program for the early detection of prostate cancer for insured citizens over the age of 45 traditionally includes an annual digital rectal examination of the gland as part of the initial check-up. However, updated national medical guidelines no longer prescribe this traditional method as mandatory due to its low sensitivity in the early stages. Instead, specialists recommend regular blood tests for PSA, the full cost of which state health insurance funds still refuse to reimburse under basic coverage. The main reason for this position of the regulators lies precisely in the diagnostic unreliability and specificity of this laboratory test.
A laboratory blood test does indeed effectively detect life-threatening aggressive tumors that require immediate medical intervention. But at the same time, it detects with high frequency a multitude of latent, benign, or extremely slowly progressing forms of cancer that, in their natural course, might never cause clinical problems or affect the overall life expectancy of an elderly person. As a result, panicking over poor indicators, men agree to undergo radiation, invasive hormone therapy, or radical surgical intervention, unjustifiably risking severe iatrogenic complications such as chronic urinary incontinence and persistent impotence.
Inclusion of Prostate Screening into the Medical Insurance System
The clinical trials included in the aforementioned review work did not initially systematically study the long-term impact of mass screening on the daily quality of life of men. However, the parallel ProtecT research project clearly demonstrated that between 8% and 47% of participants openly reported serious urinary problems or the manifestation of persistent sexual dysfunction after undergoing a course of radiation therapy or radical surgery.
Dr. Juan Franco from the Heinrich Heine University Düsseldorf, who is the lead author of the published review, emphasized particularly that the obtained results should by no means serve as a reason for the ubiquitous and uncontrolled implementation of universal mandatory screening. Instead, he drew the medical community’s attention to the very real and mathematically provable risks of overdiagnosis and excessive therapeutic procedures. “Ultimately, in modern oncourology, it is critically important to maintain an open and honest dialogue with patients, practicing what we in international medicine call the concept of shared decision-making based on informed consent,” the specialist noted.
Prostate carcinoma is consistently among the most common oncological diseases among the male population of European countries. In Germany, more than 79,600 new cases of this pathology are registered and verified annually. One in eight men in the country faces this diagnosis during his lifetime, and among men of African American descent, this epidemiological indicator rises to one in four due to genetic characteristics. According to official demographic statistics, 15,000 people died from this disease in 2023, which maintains its status as a serious social problem.
Last October, Germany’s Federal Joint Committee (G-BA) began official expert discussions on the extent to which risk-adapted prostate cancer screening using the PSA test should be covered by statutory health insurance funds. To completely avoid unnecessary surgical operations in cases of erroneous or borderline laboratory diagnoses, it is proposed to additionally introduce magnetic resonance imaging (MRI) of the prostate into the protocol if reasonable suspicion arises. If the imaging also confirms a high probability of an invasive tumor, only then are doctors recommended to proceed with a targeted biopsy for histological analysis.
According to the well-founded opinion of Professor Philipp Dahm, undergoing regular screening makes practical sense primarily in clinical cases where the life expectancy of a man, taking into account his age, is still at least 10–15 years. “If an elderly person already suffers from a multitude of other co-existing severe somatic ailments that limit his life prognosis much more severely, then in most cases one does not need to worry specifically about slow-growing prostate cancer, because such tumors in old age most often grow extremely slowly and do not have time to metastasize,” the urologist explained in detail.
Advanced Screening with the Help of MRI
In the presented review work, researchers also studied in detail fundamentally new, combined approaches to patient examination directly aimed at increasing diagnostic accuracy and reducing the number of traumatic and unnecessary biopsies. Among them are the simultaneous detection of additional specific biomarker proteins in blood serum and the mandatory application of high-resolution MRI images of the prostate. These methods look technologically promising; however, the researchers stated that at this stage of medical development, it is still too early to judge whether they statistically help save more lives or significantly reduce the level of overall harm to public health.
An official representative of the British organization Prostate Cancer UK, David James, noted in a thematic conversation with The Guardian journalists that the published review convincingly confirms the fundamental ability of screening to reduce mortality rates when patients are correctly selected. “It is also important to objectively recognize how much diagnostic technologies and prostate cancer treatment protocols have advanced since many of these long-term studies began,” the expert added. “Modern high-precision diagnostics supported by MRI, more targeted fusion biopsy, active medical surveillance tactics, and new molecular biomarker tests are gradually changing the ratio of benefits and risks when undergoing screening.”
In turn, Dr. Ian Walker, representing Cancer Research UK, explained in detail why there is still no mass population screening program at the state level in the UK. “This deep analysis clearly shows that the test can indeed prevent one to two deaths from carcinoma for every 1,000 men screened. But it also mathematically demonstrates that about 30 more healthy men out of that thousand will be falsely diagnosed with this disease, even though this cancer would never have seriously threatened many of them. As a result, they will have to go through severe and unnecessary treatment with long-term negative consequences in the form of urinary sphincter weakness and irreversible erectile dysfunction.”
Dr. Matthew Hobbs from the specialized organization Prostate Cancer UK commented on the current situation for the Science Media Center expert analytical platform, fully agreeing that PSA screening saves lives, but this isolated test alone is clearly insufficient for 21st-century medicine. He added: “Further coordinated clinical trials are required to close the critical gaps in our knowledge and find the safest and most effective screening pathway, where the real health benefit to the patient is guaranteed to outweigh the associated risks of overdiagnosis.”
Meanwhile, while science looks for optimal solutions, it is necessary at the public level to systematically ensure that all men who are at an increased genetic or age risk of developing prostate cancer are comprehensively and objectively informed. This is essential for them to make a conscious and independent decision on the feasibility of taking a routine PSA blood test. “This large-scale scientific work proves once again: this is far from a simple choice, and we, as a medical community, are obliged to speak honestly with men about both the undeniable advantages of early detection and the quite tangible long-term risks of overtreatment,” Hobbs summarized.
In conclusion, it should be noted that the current discussion around the effectiveness of PSA screening reflects a paradigm shift in oncology toward personalized medicine. Moving away from indiscriminate testing in favor of multi-stage diagnostic systems using MRI and biomarker panels allows for a reduction in the level of unjustified surgical intervention, preserving the health and quality of life of patients. For a thinking person, the key factor remains not blind adherence to outdated protocols, but obtaining expert information and participating in decision-making together with the treating physician.
