Four flawed arguments against prostate-specific antigen screening (and 1 good one)

Critics of prostate cancer screening have advanced several arguments as to why prostate-specific antigen (PSA) testing should be dramatically curtailed. In this personal reflection, I review 5 of these arguments, 4 of which are invalid. It is not true that the major randomized trial supporting prostate cancer screening, the European Randomized Study of Screening for Prostate Cancer, is flawed. Similarly, it is untrue that effects on prostate cancer mortality are only small, or that there are no effects at all on overall mortality. The fourth invalid argument is that PSA is a poor test and that it is impossible to tell whether screen-detected cancers are aggressive or indolent. But a fifth argument is indeed valid. PSA screening as it is currently practiced may not do more good than harm because of a high prevalence of screening of older men, gross overtreatment of low-risk disease, inadequate treatment of high-risk disease, and excessive rates of treatment at low-volume centers. The question for the urology community is whether it can be more restrictive about screening, biopsy, and treatment and more readily refer patients to higher volume institutions. Ultimately, the way to win the debate about PSA screening is not only to bring good data to bear but also to change practice so as to ensure that PSA screening does more good than harm.