The PSA Test Paradox: Why Millions of Men May Be Overtreated for Prostate Cancer

The prostate-specific antigen (PSA) test creates a medical paradox: it's excellent at tracking known prostate cancer but terrible as a standalone cancer detector, leading to massive overtreatment of harmless tumors. Over half of men treated for prostate cancer have low-risk "autopsy" cancers that would never cause problems and only would have been discovered during an autopsy.

Medical journalist Howard Wolinsky learned this firsthand when a routine PSA test at age 55 launched him into a 15-year odyssey through the prostate cancer screening maze. His PSA level of 3.9 in 2002 triggered a biopsy that found low-risk cancer, yet within a year, his cancer "disappeared" and hasn't been seen in four subsequent biopsies or two magnetic resonance imaging (MRI) scans.

Why Does PSA Testing Lead to So Much Overtreatment?

The PSA test's fundamental problem lies in its lack of specificity. While sensitive at detecting elevated protein levels, roughly 70% to 75% of "PSA-positive" screens turn out to be false alarms. Around 20% of men with prostate cancer have normal PSA levels, while only 25% to 30% of those biopsied for elevated PSA actually have cancer.

When PSA screening became widespread in the early 1990s, prostate cancer diagnoses doubled within two years, creating a testing-induced "epidemic." The human cost proved steep for men with lower-risk cancers who underwent prostatectomies:

• Urinary Problems: 15% to 20% developed urinary incontinence after surgery
• Sexual Function: 50% to 60% faced significant erectile dysfunction following treatment
• Unnecessary Surgery: About 80% of 80-year-olds harbor silent prostate tumors but die from heart disease, strokes, or accidents—almost anything but prostate cancer

How Do Different Countries Handle PSA Thresholds?

International practice reveals stark differences in PSA interpretation. United States guidelines generally remain stuck at 4.0 nanograms per milliliter as the threshold for starting cancer surveillance, though many academic centers now use 3.0 ng/mL for younger men. The United Kingdom's National Institute for Health and Care Excellence takes an age-graded approach: 3.0 for ages 50-59, 4.0 for ages 60-69, and 5.0 for men 70 and older.

"Your prostate is small," Wolinsky's doctor remarked after his digital rectal exam, yet his 3.9 PSA reading would have been unremarkable in London or Stockholm but triggered biopsies and anxious conversations in Chicago.

These philosophical differences produce dramatically different treatment rates. The United States treats about 40% of low-risk prostate cancers, while the United Kingdom treats under 10%—same disease, different medical cultures.

What Role Do Financial Incentives Play?

Economic factors cannot be ignored in the overtreatment equation. A Mayo Clinic study found that six years after diagnosis, mean costs per patient were $12,143 for active surveillance, $17,781 for radical prostatectomy, and $29,238 for external beam radiotherapy.

PSA screening helped transform urology from "the specialty of syphilis and kidney stones" into a major cancer-fighting field, with urologists now earning about $500,000 annually, placing them among the top 10 most lucrative specialists. At major United States centers, surveillance rates now exceed 80% to 90%, but in community practice—where most men receive treatment—rates remain stubbornly below 50%.

The psychological burden proves real for men living with untreated cancer. PSA anxiety becomes its own disease, with MRI scans, biopsies, and urology visits adding emotional distress that experts call "SCANxiety" and "anxious surveillance." About 10% of United States men with low-risk prostate cancer request aggressive treatment despite being candidates for surveillance.

As new prostate cancers are projected to double by 2040 and deaths predicted to increase globally by 85%, the debate over PSA screening continues. The challenge remains finding the balance between catching dangerous cancers early while avoiding unnecessary treatment of harmless ones.