A Well-Intentioned Recommendation With Unintended Consequences
In 2012, when the U.S. Preventive Services Task Force (USPSTF) recommended against PSA testing for all men, it may have registered as little more than a page-two headline for the public. Inside medicine, it was seismic. I was early in my training at the time, and I vividly remember the uproar—on both sides of the argument.
The concerns that motivated the recommendation were real. PSA screening had, at times, led to overdiagnosis—finding slow-growing cancers that might never cause harm—and overtreatment, exposing men to risks like incontinence or erectile dysfunction for cancers that may never have threatened their lives. No physician is comfortable with that trade-off.
But there was always another side to the equation.
Prostate cancer is the most common cancer in men, the third leading cause of cancer death, and it is nearly always silent in its early, curable stages. You don’t feel it coming. And when symptoms finally appear, the window for cure may already be closed. Some form of screening was always going to be necessary.
So when screening declined, we didn’t eliminate prostate cancer—we delayed its diagnosis. And delayed prostate cancer is often deadly.
What Happened When Screening Stopped
After the 2012 recommendation, PSA screening rates fell sharply—by nearly 46% between 2008 and 2020 [1].
As fewer men were screened, early-stage prostate cancer diagnoses dropped. At the same time, advanced and aggressive disease increased.
A large observational study from a California health system showed that after the USPSTF recommendation, PSA screening declined by about 23%, prostate cancer diagnoses fell by more than 50%, and metastatic (stage IV) prostate cancers rose by roughly 37% [2]. The authors summarized the impact starkly: for every 25 fewer early cancers detected, one additional man was diagnosed with incurable metastatic disease.
National data told the same story. Population-based analyses demonstrated a clear rise in distant metastatic prostate cancer diagnoses across the U.S. following reductions in PSA screening, including data from the Veterans Health Administration [3] and state-level analyses showing similar patterns [4].
Mortality trends followed. After decades of steady decline, prostate cancer death rates flattened after 2012. Age-adjusted prostate cancer mortality, which had been falling from 1999 to 2012, essentially stalled from 2014 to 2019 [5]. Among men aged 60–69, mortality rates began to rise. Even more concerning, men under 75 treated for localized prostate cancer in the post-2012 era experienced higher prostate cancer–specific mortality than those treated earlier—strong evidence that cancers were being found later and behaving more aggressively [6].
The Course Correction
Medicine adapted.
In 2018, the USPSTF walked back its blanket opposition and shifted to a shared decision-making model for men aged 55–69 [7].
Professional societies never abandoned screening. The American Urological Association, the American Cancer Society, and the National Comprehensive Cancer Network have consistently supported PSA screening using a risk-adapted approach that accounts for age, life expectancy, and individual risk [8,9].
The pendulum has settled where it belongs—not at “screen everyone” or “screen no one,” but at screening intelligently.
Why Screening Is Different Now
One reality often missing from public discussions is how much prostate cancer management has changed.
Twenty years ago, a diagnosis almost guaranteed treatment. Today, many low-risk cancers are managed with active surveillance—careful monitoring with PSA tests, imaging, and periodic biopsies, intervening only if the cancer shows signs of progression. Use of active surveillance has more than doubled over the past decade, increasing from about 25% in 2014 to now almost 60% in 2021 [10].
We also have better tools. Secondary blood and urine tests such as the 4Kscore and isoPSA help reduce unnecessary biopsies, and prostate MRI improves detection of clinically significant disease [11, 12, 13].
Simply put, we are far better at finding the cancers that matter and leaving the rest alone. We can catch the tiger without shooting every housecat.
Why I Still Advocate for Screening
I have sat across from men who skipped screening and arrived with bone pain—only to learn their cancer had already spread. I have also seen the opposite: cancers found early, treated successfully, and never spoken of again except as a footnote in a long life.
Since PSA testing became widespread in the early 1990s, prostate cancer mortality in the U.S. has fallen dramatically. Multiple analyses document reductions approaching 50% during the PSA screening era [14]. Countries that did not adopt PSA screening never saw those gains.
The European Randomized Study of Screening for Prostate Cancer, with 23 years of follow-up, demonstrated that PSA screening prevents one prostate cancer death for every 456 men screened and one death for every 12 men diagnosed with prostate cancer [15].
These are not abstract projections. They are men whose cancers would otherwise be found too late.
A Simple Test, Used Well
Like breast and colon cancer, prostate cancer demands a screening tool. A PSA blood test is simpler and less invasive than mammography or colonoscopy.
When used correctly, PSA reassures most men (~75%) that their risk is very low. For the remainder, an elevated or rising PSA does not mandate biopsy—it signals the need for smarter evaluation with tools we already have, such as MRI, isoPSA, and the 4Kscore [11, 12, 13].
Used this way, PSA is not a blunt instrument. It is a triage test that focuses attention where it belongs.
The worst outcome is discovering prostate cancer only after symptoms appear. At that point, the opportunity for cure may already be gone.
A Personal Appeal
Screening is a personal decision. It should reflect your health, your risk factors, and your values. But choosing not to decide—doing nothing—is still a choice, and it carries risk.
We have seen what happens when screening disappears.
Early detection saves lives.
Author: AJ Pomajzl, MD
Board – Certified Urologist
Nebraska Urology
Lincoln, NE
References
Merrill RM, Gibbons IS. Prostate-Specific Antigen Testing in the United States During 2008–2022 in Relation to the US Preventive Services Task Force Recommendations. Scientific Reports. 2024;14:31345. PubMed: https://pubmed.ncbi.nlm.nih.gov/31820217/
Roobol MJ, de Vos II, Månsson M, et al. European Study of Prostate Cancer Screening — 23-Year Follow-up. N Engl J Med. 2025;393:1669–1680. PubMed: https://pubmed.ncbi.nlm.nih.gov/41160819/