What factors should be considered when discussing the risks and benefits of PSA testing with patients?

When discussing the risks and benefits of prostate-specific antigen (PSA) testing with patients, several key factors should be considered to support informed decision-making. First, it is essential to explain that PSA testing can help detect prostate cancer early, potentially improving long-term survival if clinically significant cancer is found and treated promptly. However, PSA testing is not specific to prostate cancer and can lead to overdiagnosis of clinically insignificant cancers that may never cause harm but could result in unnecessary monitoring or treatment ¹.

Patients should be informed about the limitations of PSA testing, including false positives and false negatives, and that a raised PSA does not confirm cancer, nor does a normal PSA exclude it ¹. The decision to proceed with further investigations, such as multiparametric MRI or biopsy, should be based on PSA levels in conjunction with other clinical factors like digital rectal examination findings, age, ethnicity (notably higher risk in black African–Caribbean men), comorbidities, and previous biopsy history ¹.

It is important to discuss the potential harms of subsequent procedures following PSA testing, particularly prostate biopsy, which carries risks such as infection (including sepsis), bleeding, pain, and urinary retention ¹. Patients should understand that biopsies may detect cancers that are unlikely to affect their health, leading to psychological distress and possible overtreatment ¹.

Shared decision-making is crucial, ensuring patients understand the balance between the benefits of early detection and the risks of overdiagnosis and overtreatment. Patients’ preferences and values regarding involvement in decision-making should be assessed, and they should be provided with clear, reliable, and tailored information, possibly supported by decision aids and nomograms to help predict biopsy outcomes and treatment risks ¹.

Finally, patients should be made aware that current evidence does not show a clear mortality benefit from PSA screening in all populations, and guidelines recommend individualized discussion rather than routine screening for all men (US Preventive Services Task Force et al., 2018). This nuanced approach helps patients weigh the potential benefits against the harms in the context of their personal risk factors and health status (US Preventive Services Task Force et al., 2018).