American Cancer Society Urges Regular Prostate Cancer Screening, Ending 'Shared Decision' Language for Most Men

On Thursday, the American Cancer Society changed how it talks to men about prostate cancer. In a guideline update published in CA: A Cancer Journal for Clinicians, the group stopped asking men to merely discuss screening with a doctor and told them directly to get a PSA blood test: every two years starting at 50 for men at average risk, and every year starting at 45 for Black men and for men with a strong family history.

The previous guideline dates to 2010 and leaned on "informed decision-making." Dr. William Dahut, the society's chief scientific officer, said that at the time it was not clear the benefits of prostate screening outweighed the harms. Two things have changed since, he said. Doctors have taken steps to reduce the harms of screening, and long-term studies, mostly from Europe, now show lower prostate cancer mortality among men screened every two years. A European study published last year in the New England Journal of Medicine found men invited to repeated PSA testing were 13% less likely to die of the disease than men who were not. At 70, Dahut said, men return to individual decision-making.

The urgency is partly about trends. Prostate cancer is the second-leading cause of cancer death among US men, behind lung cancer. Diagnoses rose about 3% a year from 2014 through 2022, with more late-stage cases. About 1 in 8 men will be diagnosed in their lifetime, and the society expects more than 330,000 diagnoses this year. Caught before it spreads, the disease is survivable for at least five years in more than 99% of patients.

Dr. Yaw Nyame of the Fred Hutchinson Cancer Center, who served on the expert panel that reviewed the update, tied the rise in advanced cases to the retreat from screening. In 2012 the US Preventive Services Task Force advised against PSA screening, citing overdiagnosis and overtreatment, with men getting biopsies and treatment for low-risk cancers that would never have threatened them. Screening fell afterward, and metastatic cases climbed. Nyame said he sees men arriving with PSAs that are too high, and curable windows lost to delay.

The PSA test is imperfect, and the experts say so. It measures a protein made by the prostate, and high levels can reflect cancer but more often reflect an enlarged prostate or, less commonly, infection. The new guideline defines an abnormal result as 3 ng/mL or higher for men 69 and younger, and 6.5 ng/mL or higher for men 70 to 74. Nyame also stressed the value of a first test in the 40s or 50s: a baseline under 1 ng/mL signals a much lower lifetime risk and can shape later screening. Dr. Neeraj Agarwal of Dana-Farber added that MRI, biomarkers and genomic tests now let doctors limit biopsies to the highest-risk men and watch many low-risk cancers instead of operating, which lowers the cost of treatment while preserving the benefit of testing.

Some critics may be uneasy about dropping "shared decision-making." Dr. Justin Gregg of MD Anderson, who was not part of the update, noted the document still says clinicians should review the benefits, limitations and harms before a patient starts screening. Agarwal argued that leaving the matter to patient and doctor meant many men were never offered the test at all.

The society's stance differs from the federal one. The USPSTF's 2018 recommendation, which still calls PSA screening an individual decision for men 55 to 69, carries a C grade. The Affordable Care Act requires insurers to cover, at no cost, preventive services graded A or B. The task force's website says an update is under way. Medicare already covers prostate screening, many states require private insurers to cover it, and Dahut noted private plans often follow Medicare without being required to.

Agarwal said the larger gap is what follows an abnormal PSA. MRI, biomarker tests and biopsy are often billed as diagnostic care, exposing patients to deductibles and coinsurance. In a 2024 study in the journal Cancer of privately insured men, more than three-quarters had out-of-pocket costs for follow-up testing. He expects the biggest change in coverage only if the USPSTF grade or legislation moves.

The age for Black men is also contested. Agarwal thinks screening should begin nearer 40 rather than 45, as do the Prostate Cancer Foundation and the American Urological Association. He said modeling suggests Black men reach clinically significant disease three to nine years earlier, that about 1 in 6 will be diagnosed, and that their risk of dying is two to four times higher. With the task force revision pending, how that update is graded will likely decide whether the society's clearer message reaches men's insurance coverage.