Early detection of prostate cancer with PSA testing and a digital rectal exam

This fact box will help you to weigh the benefits and harms of prostate cancer early detection with PSA testing and digital rectal exam. The information and numbers are based on the best scientific evidence currently available.

This fact box was developed by the Harding Center for Risk Literacy.

What is prostate cancer?

Prostate cancer is the development of malignant cells in the prostate gland, an internal organ in the male reproductive system. The prostate is found between the bladder and pelvic floor muscles and surrounds the urethra. It produces one of the fluids that compose semen [2].

Uncontrolled growth of cancerous cells can lead to enlargement of the prostate gland and affect the urethra. This can cause urinary problems such as an increased urge to urinate or a decreased flow of urine [2]. However, prostate cancer does not always cause symptoms or pain. Benign changes can also affect the lower urinary tract and increase PSA levels in the blood [3].

PSA stands for prostate-specific antigen, a protein that is produced in the prostate. High PSA levels can indicate cell growth in the prostate, but can also be due to other causes [2].

Prostate cancer is the most common cancer and the third most common cancer-related cause of death in men in Germany [4]. It is more common in black men and in men with a history of prostate cancer in the family [5].

What is early detection of prostate cancer with  PSA testing and a digital rectal exam?

Early detection (screening) targets people who do not show symptoms of a particular disease (here, prostate cancer). The aim is to detect and treat prostate cancer at an early stage.

A PSA test is intended to determine the PSA level in the blood. To this end, a blood sample is analyzed [2]. The PSA test is not part of the cancer screening covered by statutory health insurance in Germany but is an individual health service that must be paid for out of pocket [6]. Ultimately, taking a tissue sample (biopsy) will show whether tissue is cancerous or not.

In a digital rectal exam, the doctor inserts a finger into the patient’s rectum to feel the prostate gland and check for irregularities in its size, hardness, and texture [2]. This exam is covered by statutory health insurance in Germany as part of its cancer prevention services.

Who might consider prostate cancer screening?

Men aged 45 and above may consider prostate cancer screening [2].

Fact box_PSA screening_EN

What does the fact box show?

The fact box shows the benefits and harms of prostate cancer screening compared to no screening.

The table may be read as follows:

With or without screening, 7 out of every 1,000 men died from prostate cancer over a time period 11 years.

The numbers in the fact box are rounded. The data were reported in five studies with approximately 340,000 participants [1].

Do the results provide a proof (evidence) for the benefits and harms of the screening?

Overall, the evidence is of low to moderate quality: Further research is likely to have an important impact on some findings (where the quality of evidence is moderate) and very likely to affect other findings (where the quality of evidence is low).

Icon Array visualizing the data

Icon Array_PSA_EN

The Great Prostate Mistake

In a New York Times article, published in March 2010, Richard Ablin, the scientist who discovered PSA in 1970, argues against routine screening as "a profit-driven public health disaster", which in fact is hardly more effective than a coin toss. You can find the whole article here.

In the United States, a recommendation against prostate screening caused an outcry, even though the benefit of these screenings was called into question through objective data.

A study by Hal Arkes and Wolfgang Gaissmaier investigates why people are often more convinced by personal anecdotes than by statistical facts.


Information within the fact box was obtained from the following sources:

[1] Ilic D, Neuberger MM, Djulbegovic M, et al. Screening for prostate cancer. Cochrane Database Syst Rev 2013(1) doi: 10.1002/14651858.CD004720.pub3

[2] IQWiG. Prostatakrebs 2013 [Available from: www.gesundheitsinformation.de/prostatakrebs.2066.de.html accessed 10.11.2017

[3] Jones C, Hill J, Chapple C. Management of lower urinary tract symptoms in men: summary of NICE guidance. BMJ 2010;340:c2354 doi: 10.1136/bmj.c2354.

[4] Robert Koch-Institut. Krebs in Deutschland 2011/2012 2015 [Available from: https://edoc.rki.de/handle/176904/3249accessed 02.11.2017.

[5] Gronberg H. Prostate cancer epidemiology. Lancet 2003;361(9360):859-64 doi: 10.1016/s0140-6736(03)12713-4.

[6] IGeL-Monitor. PSA-Test zur Früherkennung von Prostatakrebs 2017 [Available from: www.igel-monitor.de/igel-a-z/igel/show/psa-test-zur-frueherkennung-von-p... accessed 13.11.2017.

Fact boxes

The idea of fact boxes was developed by Lisa Schwartz and Steven Woloshin. In several studies they demonstrated that fact boxes were effective tools for informing the general public about benefits and harms of medical interventions. Read more in the overview.

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