From Test to Talk: Reframing Prostate Cancer Screening in Your Clinic

By Dr. Avinash Deo, Medical Oncologist

September 13, 2025

A Story That Changed My Perspective

Many years ago, I met a worried friend in the ICU of a prominent Mumbai hospital where I was seeing a patient. On asking why she was there, she told me her father was admitted with septic shock following a transrectal prostate biopsy. The biopsy was performed because a high PSA was found on a routine health check-up. This was a time when the dangers of screening for prostate cancer were not yet fully understood, but that episode was a stark preview of the complex balancing act we would all face in the future.

That man’s story is the perfect illustration of the central challenge of prostate cancer screening: the path from a simple blood test to a potential life-saving diagnosis is also a path fraught with potential harms, including overdiagnosis, overtreatment, and serious complications.

Unlike other screening tests, our primary recommendation for prostate cancer is not the test itself, but a conversation. Our role is to be expert counsellors, guiding each man through a process of shared decision-making. Here is a framework to structure that conversation.

The Core of the Conversation: True Shared Decision-Making

Before we discuss risk categories, we must be clear on what a shared decision-making discussion entails. It means explaining the pros and cons in plain language:

• The Potential Benefit: A PSA test may find an aggressive cancer early, when it is more curable, potentially saving a life.
• The Potential Harms:

• False Positives: A high PSA can be caused by benign conditions (BPH, prostatitis), leading to anxiety and unnecessary biopsies.
• Overdiagnosis: The test may find slow-growing, indolent cancers that would never have caused harm in a man’s lifetime.
• Overtreatment: Treating these indolent cancers can lead to significant side effects like incontinence and erectile dysfunction, without providing any survival benefit.
• Biopsy Complications: As my friend’s father experienced, a biopsy carries risks of bleeding, pain, and life-threatening infection (sepsis).

Category 1: The Average-Risk Man

Who He Is:

• Age 50 or older.
• No strong family history.

Your Management Plan:

• Begin the Conversation at Age 50.
• Screening Tool: Discuss a Prostate-Specific Antigen (PSA) blood test, with or without a digital rectal exam (DRE).
• Frequency: If he opts for screening, the interval can be every 1-2 years, often guided by the baseline PSA level.

Category 2: The Man with Increased / Moderate Risk

Who He Is:

• Has a first-degree relative (father, brother, son) diagnosed with prostate cancer before age 65.

Your Management Plan:

• Begin the Conversation Earlier, at Age 45.
• Screening Tool: PSA test +/- DRE.
• Frequency: Every 1-2 years.

Category 3: The High-Risk Man (Hereditary Risk)

Who He Is:

• Has a known BRCA1 or BRCA2 mutation.
• Has a known mutation associated with Lynch Syndrome.
• Has more than one first-degree relative diagnosed with prostate cancer before age 65.

Your Management Plan:

• Begin the Conversation Earliest, at Age 40.
• Screening Tool: PSA test +/- DRE.
• Frequency: Annually.

Global Guideline Differences: The US vs. Europe

It’s important to know that even the experts disagree, which underscores the uncertainty.

• The American View (USPSTF): The U.S. Preventive Services Task Force is more cautious. It gives a “Grade C” recommendation for men aged 55-69. This means the USPSTF concludes with at least moderate certainty that there is only a small net benefit to screening, so the decision to offer the service should be an individual one based on professional judgment and patient preferences. They actively recommend against routine screening for men 70 and older.
• The European View (EAU): The European Association of Urology is generally more proactive, recommending an offer of PSA testing to well-informed men starting at age 50 (or 45/40 for higher-risk groups) as part of a risk-adapted strategy.

This contrast highlights that there is no single “right” answer, further cementing the role of the individual patient’s values and preferences.

The Indian Context: Why Western Guidelines Don’t Fit

As of 2025, there is no national prostate cancer screening program in India, and the Urological Society of India (USI) does not recommend mass population screening. Applying Western guidelines directly is problematic for several reasons:

1. Lower Incidence: While rising, the baseline incidence of prostate cancer in India is significantly lower than in the West. This means you need to screen many more men to find one cancer, which tips the balance towards more harm than good for a population-based program.
2. Resource Constraints: The infrastructure for follow-up (urologists, biopsy facilities, advanced treatment centres) is limited and concentrated in urban areas, making widespread screening impractical and inequitable.
3. High Risk of Sepsis: The rates of antibiotic resistance are higher in India, making the risk of post-biopsy sepsis—like the case I witnessed—a more pronounced concern compared to Western settings.
4. Cost: The cascade of testing, biopsy, and potential treatment represents a catastrophic out-of-pocket expense for the vast majority of Indian men.

A Pragmatic Approach in India:

Focus on opportunistic, informed screening. The conversation is still paramount. For the man who asks, especially if he is in a higher-risk category, the discussion is warranted. But the idea of adding a PSA to a “master health check-up” for every man over 50 without this detailed counselling should be strongly discouraged.

The Bottom Line

The era of reflexive PSA testing is over. Our primary tool is not the test, but the conversation. By understanding the nuances of overdiagnosis, the real risks of a workup, and the specific context of our practice in India, we can guide our patients to a decision that truly aligns with their values. Sometimes, the wisest course of action is to watch and wait, a decision that requires as much clinical courage and patient trust as ordering the test itself.