Prostate Cancer Symptoms: PSA Screening Pros and Cons

Key takeaways

• Most men live WITH prostate cancer, rather than dying OF the tumour: 64% of all men develop hidden prostate cancer by age 60, but only 2.5% die from it.
• PSA screening saves NO lives over 16 years: Large-scale trials demonstrate that PSA screening does not lower prostate cancer mortality – the net benefit is zero.
• 1 in 1,000 men benefits: For every 1,000 men screened over a 16-year period, a maximum of 1 death from prostate cancer is prevented.
• 25 times higher risk of overdiagnosis: You are 25 times more likely to be overdiagnosed with a cancer that would never have caused symptoms or harm than to have your life saved by screening.
• 150 in 1,000 men receive false-positive results: One in seven men undergoing PSA screening tests positive, yet two-thirds of subsequent biopsies show normal results.
• Prostate biopsy carries complications: Pain, blood in the semen, and in 1% of cases, severe infections requiring hospital admission.
• One surgical death for every life saved: 3 in 1,000 men die during or shortly after radical prostatectomy – offsetting the mortality benefit of screening.
• Substantial surgical side effects: 20% of operated men suffer from long-term urinary incontinence, and 66% experience erectile dysfunction.
• 89% of men overestimate the benefits: Most believe PSA screening prevents 50% of deaths – in reality, it is 1 in 1,000.
• An informed decision rather than routine testing: 85% of medical professional associations worldwide advise against routine PSA screening. Men should make an informed choice.

Prostate cancer: The uncomfortable truth

How dangerous is prostate cancer really?

Prostate cancer has a surprisingly low fatality risk compared to how common it is. The figures from clinical studies show:

64% of all men develop hidden prostate cancer (known as latent carcinomas) by the age of 60, as identified in post-mortem examinations. In contrast, only 11% are diagnosed with prostate cancer during their lifetime. The risk of actually dying from prostate cancer is just 2.5% – occurring at an average age of 80.

The core message: most men have prostate cancer, but they die with their tumour and not because of it. The majority of men live their entire lives with prostate cancer without ever knowing they have it.

This highlights one of the fundamental challenges in cancer screening: many detected cases of prostate cancer would never cause harm even if left undiscovered. Nevertheless, not all men are so fortunate – around 30,000 men die annually from prostate cancer in the US (and around 12,000 in the UK).

How long can you live with prostate cancer?

The prognosis for prostate cancer depends heavily on the stage of the disease:

Localised prostate cancer (Stage I–II): When the cancer is confined to the prostate, the 5-year survival rate is almost 100%. Most men do not die of this disease, but with it. Many stage 1 prostate cancer symptoms never develop at all because the tumour grows so slowly that it remains asymptomatic.

Locally advanced prostate cancer (Stage III): The tumour has broken through the prostatic capsule but has not yet spread to distant sites. The 5-year survival rate is approximately 90–95%.

Metastatic prostate cancer (Stage IV): If the cancer has spread to the lymph nodes or bones, the 5-year survival rate drops to around 30–40%. Median survival is between 2 and 5 years, though modern treatments continue to extend this.

The crucial fact is that the vast majority of prostate carcinomas grow extremely slowly. In older men (over 75) with low-grade tumours, active surveillance or watchful waiting is often the best approach, as they are significantly more likely to die of other causes than of prostate cancer.

What is the difference between prostate cancer and benign prostatic hyperplasia (BPH)?

Prostate cancer (prostatic carcinoma) and benign prostate enlargement (benign prostatic hyperplasia, BPH) are two completely distinct conditions, though they can present with similar symptoms:

Benign prostatic hyperplasia (BPH):

• Non-cancerous (benign) enlargement of the prostate gland
• Affects nearly one in two men over the age of 50
• Causes symptoms due to pressure on the urethra: increased urinary frequency, a weak urinary stream, and nocturia (waking at night to urinate)
• Does NOT raise the risk of developing prostate cancer
• Managed with lifestyle adjustments, medications, or minimally invasive procedures

Prostate cancer (prostatic carcinoma):

• A malignant condition that has the potential to metastasise
• Usually symptom-free during the early stages
• Symptoms only emerge when the tumour is sufficiently large or has spread
• Managed through active surveillance, surgery, radiotherapy, or hormone therapy
• Can elevate prostate specific antigen (PSA) levels (though BPH does as well)

Important: Difficulties with urination are not specific prostate cancer symptoms. These urinary issues occur far more commonly with benign prostatic hyperplasia. An elevated PSA level can be present in both conditions and is not definitive proof of cancer.

Prostate cancer symptoms and signs

What are the signs of prostate cancer?

The uncomfortable truth regarding prostate cancer symptoms is simple: in the early stages, there are none.

In many instances, prostate cancer develops very slowly and initially causes no discomfort. The disease frequently goes undetected for years because the tumour remains too small to provoke any physical signs. This absence of symptoms is the primary reason why prostate cancer screening is so widely debated.

Symptoms typically arise only when the tumour reaches a certain size or has spread to other organs. The following signs are warning indicators of advanced prostate cancer:

Urinary difficulties (the most common symptoms):

• A weak or interrupted urinary stream
• Increased urinary frequency, particularly at night (nocturia)
• Hesitancy (straining or taking longer to start urinating)
• A feeling that the bladder has not emptied completely
• Pain or a burning sensation during urination

Bleeding:

• Blood in the urine (haematuria)
• Blood in the semen (haemospermia)

Sexual dysfunction:

• Erectile dysfunction
• Pain during ejaculation

Pain (suggesting possible metastasis):

• Back pain (most commonly localized in the lower spine)
• Pelvic pain or discomfort
• Bone pain in the hips, thighs, or ribs
• Pain when opening the bowels

Good to know: All of these complaints can also be caused by benign prostatic hyperplasia, urinary tract infections, or other benign conditions. They are NOT definitive signs of prostate cancer. However, if these symptoms persist for longer than two weeks, you should consult your GP.

How do you know if you have prostate cancer?

The honest answer is that in most cases, you do not notice it. Early-stage prostate cancer produces no tangible symptoms. A diagnosis is typically established through one of three routes:

1. PSA blood test and digital rectal examination: Around 75% of prostate cancer diagnoses today are made through screening assessments before any symptoms develop. An elevated PSA level leads to further clinical investigations.

2. Incidental finding: During surgery performed for benign prostatic hyperplasia, cancerous tissue is sometimes found incidentally in the resected prostate tissue.

3. Symptomatic diagnosis: Symptoms generally manifest only once the cancer has progressed (as outlined above). This form of diagnosis has become less frequent because many men now undertake PSA blood tests.

The core dilemma: early diagnosis through routine screening can lead to substantial overdiagnosis – detecting indolent cancers that would never have caused symptoms, illness, or death during a man’s lifetime, potentially leading to overtreatment.

Early signs of prostate cancer: How is it detected in the early stages?

Early-stage prostate cancer cannot be detected through symptoms alone, as it produces none. The primary diagnostic tools available include:

PSA blood test: Measures the level of prostate specific antigen in the blood. Elevated levels can indicate prostate cancer, but also benign enlargement, prostatitis, or recent physical irritation (such as cycling or ejaculation). It is not specific to cancer.

Digital rectal examination (DRE): The doctor assesses the prostate gland by palpating through the rectum. Hardened areas or nodules can suggest the presence of a tumour. However, only tumours situated on the posterior surface of the prostate can be felt, meaning small or anterior lesions will be missed.

Prostate biopsy: If the PSA blood test or digital rectal examination reveals abnormalities, 10 to 12 tissue samples are taken from the prostate under ultrasound guidance. Only a biopsy can definitively confirm or rule out cancer.

The controversy: as the following sections explore, early detection through screening remains both an advantage and a significant clinical risk.

When do the first prostate cancer symptoms appear?

Initial prostate cancer symptoms typically appear only when the tumour has grown large enough to press against the urethra or adjacent tissues, or once metastasis has occurred. This progression often takes years or even decades.

In slow-growing tumours (with a Gleason score of 6 or lower), men may remain entirely symptom-free for the rest of their lives. In contrast, aggressive tumours (with a Gleason score of 8–10) can cause symptoms to manifest within a few years.

On average, roughly 10 to 15 years elapse between the initial cellular changes and the onset of the first clinical symptoms. This explains why so many older men with prostate cancer never experience symptoms – they pass away from other causes long before the cancer poses a health threat.

Understanding the PSA Blood Test and Prostate Cancer Screening

What Happens During a PSA Blood Test?

PSA stands for prostate specific antigen, an enzyme produced by the prostate gland that liquefies semen and cervical mucus to facilitate fertilisation. A PSA blood test is a straightforward blood check measuring the concentration of PSA in the bloodstream, frequently carried out when investigating early signs of prostate cancer or when screening asymptomatic men before any prostate cancer symptoms develop.

The procedure:

1. Blood sample: A routine blood sample is drawn from a vein in the arm. The test can be carried out during a routine consultation with your GP.
2. Laboratory analysis: The PSA level is measured in nanograms per millilitre (ng/ml). “Normal” reference ranges vary with age:
   • Under 50 years: below 2.5 ng/ml
   • 50–60 years: below 3.5 ng/ml
   • 60–70 years: below 4.5 ng/ml
   • Over 70 years: below 6.5 ng/ml
3. Interpretation: Elevated levels may point towards prostate cancer, but can also be caused by:
   • Benign prostatic hyperplasia (BPH) / benign prostate enlargement
   • Inflammation of the prostate (prostatitis)
   • Urinary tract infection (UTI)
   • Physical stimulation or manipulation (cycling, recent sexual intercourse, digital rectal examination)
4. In the event of an elevated level: The blood test is repeated after several weeks. If the level remains elevated, a digital rectal examination follows, alongside a referral for a prostate biopsy if clinically indicated.

Important: A raised PSA level is NOT definitive proof of cancer. In roughly two-thirds of men with a raised PSA level, no cancer is detected on biopsy.

At What Age Should You Consider Prostate Cancer Screening?

This topic remains highly controversial and recommendations differ internationally:

UK guidance and NHS policy:

In the UK, the NHS does not offer a universal screening programme for men without prostate cancer symptoms because PSA testing is not sufficiently specific. However, under the NHS Prostate Cancer Risk Management Programme (PCRMP), men aged 50 and over can request a free PSA blood test from their GP after a balanced discussion regarding the potential benefits and harms. In private clinics or healthcare systems abroad, such tests are often offered as self-pay checks (costing around £25–£40 / €25–€40).

Urological organisations and clinical guidelines advocate an individualised approach:

• From age 50: A structured consultation regarding the benefits and risks of the PSA blood test
• From age 45: For men with a positive family history (father or brother diagnosed with prostate cancer) or men of Black African or Caribbean descent
• Shared decision-making: Following comprehensive counselling, the individual decides whether to proceed

International recommendations (USPSTF 2018):

The US Preventive Services Task Force (USPSTF) updated its guidance in 2018: prostate cancer screening must remain an individual decision. Men aged between 55 and 69 should be informed about the potential benefits and harms before making a choice. Men who are undecided or do not clearly favour screening should NOT be screened.

Bottom line: There is NO routine recommendation for population-wide PSA screening. Any decision should be made individually after detailed, objective discussion.

The Minimal Benefits of Prostate Cancer Screening

Why Is Prostate Cancer Screening Controversial?

Prostate cancer screening is one of the most fiercely debated preventive health measures in modern medicine, largely because the demonstrated benefits are modest whilst the potential risks are substantial. Scientific evidence from extensive randomised controlled trials demonstrates:

The proven benefit:

For every 1,000 men who undergo regular PSA screening over a 16-year period, at most 1 death from prostate cancer is prevented. This means that 999 men do NOT benefit from screening, yet all 1,000 are exposed to the associated diagnostic risks.

No reduction in overall mortality:

Crucially, PSA screening does NOT reduce all-cause mortality. The reason: for every life saved through early detection, another life is lost as a result of severe treatment complications. Approximately 3 in every 1,000 men die during or shortly after radical prostate removal (radical prostatectomy).

Why do men overestimate the benefits?

Scientific research indicates that 89% of men significantly overestimate the benefits of screening or have no accurate grasp of the real numbers. Most assumed that 50% of fatal prostate cancers could be avoided among 1,000 regularly screened men. In reality, it is just 1 single case.

Similarly, 92% of women surveyed overestimated the mortality reduction from mammography screening by a factor of ten or more.

The controversial reality:

The US Preventive Services Task Force originally recommended against routine PSA screening. Major clinical organisations, including the American Academy of Family Physicians and around 85% of medical professional associations in developed countries worldwide, have taken a similarly cautious position.

The Substantial Risks: From Biopsy to Overtreatment

What Are the Risks of a Prostate Biopsy?

A prostate biopsy is the conventional next step following a suspicious PSA reading. The risks of this procedure are frequently understated:

False-positive results are extremely common:

Around 1 in 7 men undergoing PSA screening receives a positive result. Yet in two-thirds of these cases, the subsequent biopsy reveals completely benign tissue — it was a false alarm. Out of 1,000 screened men, roughly 150 will have an elevated PSA level and undergo an invasive biopsy despite having no cancer whatsoever.

Complications of a biopsy:

An ultrasound-guided transrectal biopsy carries genuine clinical risks:

• Common (10–50%): Discomfort, pain, blood in the urine (haematuria), blood in the stools, and blood in semen (haematospermia) lasting several days to weeks
• Rare but severe (1%): Bloodstream infections (sepsis) requiring immediate hospitalisation and intravenous antibiotics
• Very rare: Acute urinary retention, severe haemorrhage, and septic shock

In practice, out of 1,000 screened men, approximately 150 undergo an unnecessary biopsy, with 1 to 2 developing severe, life-threatening complications.

What Should You Do If You Have an Elevated PSA Level?

A single raised PSA result is NO cause for panic. Clinical guidelines recommend the following stepped approach:

1. Repeat the PSA test: Re-test after 4–6 weeks. In 25–30% of men, the level returns to normal.

2. Eliminate confounding factors: For 48 hours prior to the blood draw:

• Avoid sexual intercourse and ejaculation
• Avoid cycling or vigorous exercise
• Avoid digital rectal examination or prostate manipulation
• Ensure any suspected urinary tract infection is treated and cleared

3. Monitor PSA kinetics: PSA velocity (the rate of increase over several months) and PSA doubling time provide much greater prognostic value than an isolated reading.

4. Consider advanced diagnostics:

• Digital rectal examination
• Multiparametric MRI of the prostate (mpMRI) — widely used on the NHS to avoid unnecessary biopsies
• Specialised biomarker assays: PHI (Prostate Health Index), 4Kscore, or PCA3 test

5. Biopsy only where there is justifiable clinical suspicion: A biopsy should never be automatic following an initial high reading, but guided by careful risk stratification.

Important: For men over 75 years of age or those with significant co-morbidities (a life expectancy under 10 years), routine PSA screening is generally NOT advised, as treatment causes far more harm than benefit.

What Are the Side Effects of Prostate Cancer Surgery?

Radical removal of the prostate (radical prostatectomy) is the standard surgical intervention for localised disease. Its adverse effects are substantial and often life-changing:

Mortality:

Around 3 in 1,000 men die during a radical prostatectomy or shortly afterwards. Statistically, this completely offsets the survival benefit of screening: for every life saved by early detection, another is lost to surgical complications.

Severe complications (5%):

50 in every 1,000 men suffer severe surgical complications, such as major haemorrhage, wound infections, deep vein thrombosis, pulmonary embolism, bowel perforation, or damage to the ureters.

Urinary incontinence (20%):

Even after successful surgery, roughly 1 in 5 men suffers from long-term urinary incontinence, requiring daily incontinence pads. In severe cases, an indwelling catheter or an artificial urinary sphincter implant becomes necessary.

Erectile dysfunction (66%):

Two out of three men suffer from persistent erectile dysfunction following surgery, even when nerve-sparing techniques are employed. Even in specialist centres with experienced urological surgeons, rates remain between 40% and 60%, and normal sexual function frequently does not return.

Side effects of radiotherapy:

Most men who undergo radiotherapy also experience chronic sexual dysfunction (60–70%). Additionally, 1 in 6 men suffers long-term bowel issues, including chronic diarrhoea, faecal incontinence, or rectal bleeding. Bladder irritation (urinary urgency, pain on urination, weak urinary stream) affects 20–30% of patients.

The Overdiagnosis Paradox and Prostate Cancer Symptoms

How Common Is Overdiagnosis in Prostate Cancer?

Overdiagnosis is the single greatest drawback of PSA screening programmes. It occurs when a tumour is diagnosed that would never have produced prostate cancer symptoms, caused clinical harm, or led to death during the patient’s lifetime. The individual is labelled a “cancer patient”, despite the fact that without screening they would have lived a completely normal life until dying of unrelated, natural causes.

The figures are striking:

Large randomised clinical trials reveal that between 20% and 50% of men diagnosed with prostate cancer through screening are overdiagnosed. They would have experienced no adverse health consequences had they never been tested. Instead, they must now navigate difficult choices: undergoing invasive treatments with permanent side effects, or enduring the chronic anxiety of active surveillance.

The paradox:

Over a 16-year observation window, an individual is 25 times more likely to be overdiagnosed with an indolent tumour via PSA screening than to have his life saved by it.

This creates a profound psychological paradox: the men who suffer the greatest harm — undergoing unnecessary, debilitating surgery or radiation — often feel the most grateful. Following treatment, they are convinced that the screening test saved their life, even though they would never have experienced stage 1 prostate cancer symptoms or illness without it.

When Is Prostate Cancer Treatment Necessary?

Deciding on active intervention is complex and must be tailored to the individual tumour profile. Not every newly diagnosed prostate cancer requires immediate medical or surgical treatment:

Active surveillance:

For low-grade, organ-confined disease (Gleason score 6, PSA below 10 ng/ml, minimal biopsy core involvement), active surveillance represents a safe, guideline-supported approach:

• Regular PSA blood tests every 3–6 months
• Annual digital rectal examination
• Periodic repeat biopsies or mpMRI surveillance every 1–3 years
• Curative treatment initiated only if disease progression is detected

Long-term studies confirm that in well-selected patients, the 10-year survival rate is identical to immediate radical surgery or radiotherapy — without subjecting patients to immediate overtreatment and side effects.

Immediate treatment is recommended for:

• High-grade tumours (Gleason score 8–10)
• Locally advanced tumour stages (T3–T4)
• Symptomatic cancer (severe bone pain, acute urinary retention, changes to the urinary stream, nocturia, or high urinary frequency)
• Rapidly rising PSA levels (doubling time under 3 years)
• Younger men (under 65) presenting with aggressive histology

Active treatment is generally not advisable for:

• Men over 75 years with low-grade localised cancer
• Patients with a life expectancy under 10 years due to other serious health conditions
• Slow-growing, low-risk tumours (Gleason score 6)

UK and International Recommendations

What Should You Consider Before Deciding on Prostate Cancer Screening?

Before deciding whether to undertake a PSA test in the absence of prostate cancer symptoms, every man should be aware of the following baseline figures:

Statistical outcomes per 1,000 men over 16 years:

• Benefit: 1 prostate cancer death prevented
• Risk: 3 deaths related to surgical or treatment complications
• Overdiagnosis: 20–50 men diagnosed with a harmless tumour that would never have caused symptoms
• False positives: 150 men receive an elevated PSA reading without having cancer and undergo an unnecessary biopsy
• Incontinence: 20 men suffer long-term urinary incontinence
• Impotence: 66 men develop permanent erectile dysfunction

International guidelines (USPSTF 2018):

Men aged 55 to 69 should be fully informed about the balance of risks and benefits and make an individual choice. Men who are undecided or unenthusiastic about testing should NOT be screened.

UK NHS guidelines:

In the UK, the NHS does not operate a national screening programme for asymptomatic men. However, men aged 50 and over can access a free PSA blood test via their GP under the Prostate Cancer Risk Management Programme, provided they have had a comprehensive consultation detailing the risks of false positives, biopsy complications, and overtreatment.

Personal risk factors to weigh up:

• Family history and ethnicity: Having a father or brother with prostate cancer increases risk 2- to 3-fold; men of Black heritage also face a higher statistical risk
• Age: Screening offers negligible benefit under 50 and is generally discouraged over 70
• Overall health: If life expectancy is under 10 years, potential screening harms clearly outweigh benefits
• Personal values: Whether you prefer knowing about potential disease early despite the risks of overdiagnosis, or would rather avoid invasive procedures unless clear signs of prostate cancer arise

Frequently Asked Questions

Where does prostate cancer spread first?

Prostate cancer metastasises first to locoregional lymph nodes (50–60%), particularly pelvic lymph nodes. In advanced disease, bone metastases follow (80–90%), predominantly in the spine, pelvis, and ribs. These cause pain and pathological fractures. Less common sites of metastasis include the lungs, liver, and brain (under 10%). Years to decades can pass between initial diagnosis and metastasis, depending on tumour aggressiveness (Gleason score).

Where does prostate cancer most commonly metastasise?

By far the most common site of metastasis is the skeletal system. In 80–90% of all men with metastatic prostate cancer, bone metastases are present (spine, pelvis, ribs), whereas visceral organ metastases (lungs, liver) are significantly less common (under 10%). The reason: prostate cancer cells produce factors that stimulate bone growth (osteoblastic metastases).

What pain does prostate cancer cause?

Prostate cancer causes NO pain in its localised stage. Pain is a late sign of advanced disease: bone pain (deep, aching, or boring pain in the spine, pelvis, and ribs – often worse at night), pain during urination (burning sensation, discomfort), pelvic pain (dull pressure), and pain during bowel movements. When these prostate cancer symptoms appear, the cancer has usually already metastasised.

What should you do if diagnosed with prostate cancer?

Treatment depends on the stage. Localised cancer: active surveillance (for low-grade tumours), radical prostatectomy (surgery), or radiotherapy. Locally advanced: radiotherapy alongside hormone therapy, or surgery with lymph node dissection. Metastatic: hormone therapy (androgen deprivation), chemotherapy, novel agents (abiraterone, enzalutamide, radium-223), and palliative pain management. The choice is made individually based on age, general health, and personal preferences.

Scientific References

• Nelson WG, De Marzo AM, Isaacs WB. (2003). Prostate cancer. New England Journal of Medicine. 349(4):366-381.
• US Preventive Services Task Force, Grossman DC, Curry SJ, et al. (2018). Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA. 319(18):1901-1913.
• Draisma G, Etzioni R, Tsodikov A, et al. (2009). Lead time and overdiagnosis in prostate-specific antigen screening. Journal of the National Cancer Institute. 101(6):374-383.
• Tikkinen KAO, Dahm P, Lytvyn L, et al. (2018). Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline. BMJ. 362:k3581.
• Gigerenzer G, Mata J, Frank R. (2009). Public knowledge of benefits of breast and prostate cancer screening in Europe. Journal of the National Cancer Institute. 101(17):1216-1220.