To the Editor:
In Dr. Lin’s editorial, his argument that physicians should not screen for prostate cancer overrules the patient’s right to receive early diagnosis and make their own treatment decisions.1 Prostate cancer will kill between 30,000 and 40,000 men this year, comparable to the number of women who will die of breast cancer. Discouraging prostate-specific antigen (PSA) screening makes little sense when early screening improves outcomes and lowers the risk of metastatic disease, even with the high probability of treatments resulting in impotence and incontinence; both have been reduced with nerve-sparing surgery and high-dose brachytherapy.2,3
As Dr. Lin notes, the pretesting shared decision-making recommended by the US Preventive Services Task Force (USPSTF) often does not occur. Instead of observation and serial testing, many physicians screen all men between ages 50 and 70 years and then discuss active treatment options. The PSA test is a simple blood test that can be added to annual or periodic testing. When PSA levels rise, options can be discussed with the attention this cancer deserves. Patients can ask questions, research, and seek additional opinions if they desire.
Free-PSA testing and prostate magnetic resonance imaging can improve sensitivity.4 Prostate biopsy, although an uncomfortable procedure for the patient, has limited risks and can accurately guide treatment. A study on MyProstateScore 2.0 urine testing after a digital examination, now covered by Medicare, found 97% specificity for high-risk cancers.5 Therefore, Dr. Lin’s specificity argument may soon be moot.
PSA testing is not perfect, yet the argument that we should quit screening because of possible complications, anxiety, and discomfort could apply to almost any treatment for any condition. With this common and dangerous cancer, we should screen and provide treatment options. Sacrificing early diagnosis and keeping patients in the dark disrespects patient maturity, resilience, and autonomy.
A study published after Dr. Lin’s editorial indicated a marked increase in metastatic prostate cancer since screening guidelines were relaxed by the USPSTF.6 We need more aggressive screening, not less.
In Reply:
Dr. Kelleher proposes that physicians perform PSA testing universally in men between ages 50 and 70 years and then discuss the benefits and harms of active treatment based on the results, rather than have decision-making conversations about PSA screening with eligible male patients.
I disagree with this approach for three reasons. First, indiscriminate PSA testing would lead to many more false-positive results, which studies show can produce lasting psychological harm.1 Dr. Kelleher asserts that all eligible men should have the opportunity for prostate cancer screening; I contend they should also have the right to avoid screening.
Second, more screening results in more overdiagnosis and overtreatment. Harms are associated with long-term active surveillance, which can involve multiple prostate biopsies in addition to PSA tests and digital rectal examinations. A high percentage of men who choose surveillance switch to definitive treatment within the first few years, even when no objective evidence shows treatment is necessary.2
Finally, physicians are no better at having shared decision-making discussions about treatment than about screening. A 2025 US Department of Veterans Affairs study showed that among men with intermediate-risk prostate cancer and a life expectancy of less than 10 years who were unlikely to benefit from treatment (and who I believe should not have been screened in the first place), those who underwent radiotherapy or prostatectomy increased from 38% in 2000 to 60% in 2019.3
Regarding the increasing incidence of metastatic prostate cancer in California between 2011 and 2021,4 the timing of this trend relative to the 2012 and 2018 USPSTF recommendations is inconsistent with a cause-and-effect relationship. Given continuing increases in metastatic prostate cancer after the USPSTF stopped discouraging PSA screening in men younger than 70 years, it is difficult to believe clinicians changed screening practices 1 year before the 2012 recommendation but ignored the 2018 recommendation. Since PSA testing mostly identifies indolent and low-grade cancers, studies show it takes several years for routine screening to cause a reduction in metastatic prostate cancer.5
