Should Men Screen for Prostate Cancer? Biden Diagnosis Reignites Debate
Guidelines have gone back and forth over years on whether men should be screened at all
By Brianna Abbott
Blood sample tube on a PSA blood test requisition form. / At the heart of the issue is a simple test that looks for prostate-specific antigen, or PSA, in a man’s blood. Photo: Image Source/Getty ImagesKey Points
- Biden’s cancer diagnosis has sparked a debate over prostate-cancer screening guidelines.
- Increased diagnoses of later-stage cancers are suspected to be linked to changing screening guidance.
- Some prostate-cancer specialists said that there has also been a shift in how they manage lower-risk prostate cancer.
Former President Joe Biden’s diagnosis of an aggressive, stage-4 prostate cancer has reignited a long-simmering medical debate: When should men get screened for prostate cancer?
For decades, doctors have wrestled with how often to screen men for the disease and when to start and stop.
Some medical groups disagree in their recommendations, and guidelines have gone back and forth on whether men should be screened at all.
As doctors have debated, the diagnoses of later-stage prostate cancers have been increasing, according to the American Cancer Society.
Some studies suggest that the changing screening guidance could be responsible.
“The flip-flop in the screening recommendations led to a reduction in screening, which led to men being diagnosed at a later stage,” said Dr. Shawn Dason, a urologic oncologist at the Ohio State University Comprehensive Cancer Center.
“I strongly suspect what happened is that we lost that lead time.”
At the heart of the debate is a simple test that looks for prostate-specific antigen, or PSA, in a man’s blood.
An elevated PSA level suggests that a man could have prostate cancer but it could also indicate infection, inflammation or even recent vigorous exercise.
There are also some rare, more aggressive prostate cancers that don’t secrete enough PSA to be picked up by the test.
“The PSA is not a perfect test,” said Dr. Toni Choueiri, director of the center for genitourinary oncology at Dana-Farber Cancer Institute.
A man’s PSA levels tend to rise with age, since the prostate continues to grow and can increase the amount of antigen it releases.
For men around age 60, a normal PSA level is below 4 nanograms of antigen per milliliter of blood.
If a man has an elevated PSA, it can raise an early flag for potential prostate cancer.
Doctors deployed the test widely after it was introduced in the late 1980s, causing incidence of the disease in the U.S. to spike in the 1990s, as they caught cancers earlier and treated them.
But the test also raised false alarms that required follow-ups and biopsies and found slower-growing, low-risk cancers that likely weren’t life-threatening, particularly among older men.
Men were left with urinary incontinence or sexual dysfunction after surgery and radiation for a cancer that likely wouldn’t have harmed them.
“If I go and screen men and do tests on men above 70 and 80, we’d find prostate cancer in over 50% of those men.
But the majority have cancers that would never impact their life,” said Dr. Behfar Ehdaie, a urologic surgeon at Memorial Sloan Kettering Cancer Center.
“In most cases, the treatment is more aggressive than the cancer itself.”
Two large trials looking at whether PSA testing provided a mortality benefit on a population level in men primarily in their 50s and 60s showed mixed results.
And the data didn’t include older men above age 75.
The U.S. Preventive Services Task Force, a government-backed volunteer panel of experts who make health guidelines, recommended against screening for men aged 75 and older in 2008 and for all men in 2012, saying that the potential benefit didn’t outweigh the harms.
President Biden in the White House Rose Garden in November. / Joe Biden’s last known prostate-cancer blood screening test was performed in 2014, according to his spokesman. Photo: Ben Curtis/Associated PressTheir guidelines carry particular weight among health insurers and primary care providers, who are often the ones providing the test.
Many providers and medical groups followed suit, and prostate-cancer diagnoses began to fall.
Other doctors pushed back against the guidance and later pointed to flaws in one of the trials used to inform the recommendation.
In 2018, the Task Force changed its recommendation again, saying men ages 55 to 69 should make an informed decision with their doctor but advised against it for men ages 70 and older.
Others including the American Cancer Society recommend that the decision to continue screening be an individual one that factors in a man’s health status and preferences.
“The challenge is figuring out what to do with men above 70,” said Dason at Ohio State University.
“The standard of evidence is really not there.
You have to use extrapolation.”
Some guidelines advise stopping screening if a man is estimated to have less than a 10-year life expectancy, with the understanding that they are more likely to die of something else first.
In 2020, more than 50% of surveyed men ages 70 to 79 and nearly 40% age 80 and older still reported recent PSA screening, according to a paper in JAMA Network Open.
“I lean toward wanting to know and dealing with the results when they come up,” said Dr. Phillip Koo, chief medical officer at the Prostate Cancer Foundation.
“In general, I’d recommend screening for those over 70 just because today we are living longer.”
More men are also getting diagnosed at a later stage, with a roughly 5% increase each year in more-advanced diagnoses since around 2011, with many doctors suspecting the pullback era of screening playing a role.
The death rate from prostate cancer declined by about half from 1993 to 2022, according to the American Cancer Society, thanks to both screening and newer treatments, but that decline has stalled in recent years.
Some medical groups have also reviewed their guidelines in recent years, with many doctors wanting to encourage more high-risk groups including Black men or those with genetic risk to get screened earlier.
Prostate-cancer specialists said that there has also been a shift in how they manage lower-risk prostate cancer, after data suggested that it is safe for patients with slow-growing cancers to be carefully monitored instead of rushing into treatment, reducing the risk of harm.
Other tests including a prostate MRI and biomarkers can now help cut down on false positives.
“Only because we have so many additional tests we can do to decide if we need a biopsy, I think the math has really changed,” said Dr. David Penson, secretary of the American Urological Association and prostate-cancer expert.
“I think a lot of men in 2025 are going to opt to have their PSA tested.”
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