Our findings reflect the reality of contemporary clinical practice and confirm that men with abnormal screening tests, but without prostate cancer on biopsy, show increased cancer-related worry compared to men with PSA values in the reference range, as reported by other investigators.6
In particular, men with abnormal PSA results are often caught in a prolonged cycle of testing and re-testing, in which, “no one has found cancer, but no one can reassure [men] that they do not have it.”19
Similar results have been observed in women with false positive mammograms, who show substantial psychological distress and a heightened sense of susceptibility to breast cancer.15,20
Men often have inadequate knowledge about screening with PSA and are not aware of the test’s limitations with regard to false-positive and false-negative test results.21
Not surprisingly, we found that the majority of men with abnormal screening tests had distorted perceptions of their risk of developing prostate cancer (either too high or too low). Similar findings have been reported for men in primary care who are presented with elevated PSA results.22
Indeed, it is concerning that a large proportion of cases (40%) mistakenly believed that their five-year risk of getting prostate cancer was one percent or less. The reassurance from a negative biopsy may not be entirely justified as up to 19% of these patients have been determined to have cancer on repeat biopsy.23
In this study, we also found that biopsy recipients reported worse sexual function and more bother with sexual function over the short-term. These findings may be related to residual pain or other troublesome side effects following the biopsy procedure, such as hematospermia; for most patients, these symptoms resolve within seven days of the biopsy.8,24
Alternatively, increased bother with sexual function may stem from persistent worries about prostate cancer. The relationship between false-positive screening tests and sexual functioning should be explored further in prospective studies.
Although biopsy recipients showed more cancer-related worry and worsened sexual function than PSA controls, we found no significant differences in state anxiety or SF-36 scores between these groups over the short-term. Physiological stress, as measured by serum cortisol, tends to be greatest shortly after patients are informed of an abnormal PSA test result, and then drops to baseline levels once patients are informed of their biopsy results.25
Differences in state anxiety related to screening status in the present study may have been attenuated by the time that patients were surveyed (approximately two months after the index test). Another possible explanation for the lack of difference between groups is lack of power; this is unlikely, however, given that the study sample had 85% power to detect a 3-point difference in SAI6 scores between cases and controls.
The limitations of this study deserve comment. First, this was a cross-sectional analysis and we did not collect data on the outcomes of interest prior to screening. We cannot rule out the possibility that increased cancer-related worry predisposes
men to develop abnormal PSA results (e.g., by seeking more frequent screening).26
Indeed, our analysis reflects the cumulative effect of serial testing and eventual biopsy for group 1 patients, several of whom were receiving surveillance of an initially abnormal PSA and who tend to receive more frequent PSA testing than group 2 patients.6
Second, our findings could possibly be explained by the method of assembly of the case and control groups. Specifically, cases had fewer years of education and higher AUA scores; more prostate-related symptoms and abnormal DRE findings could have led cases to worry more about prostate cancer than controls (irrespective of their test results). We note, however, that results were unchanged after extensive adjustment for demographic variables, medical and psychological comorbidity, family history, and AUA score in multivariable regression models. Third, we did not collect qualitative data to explain why biopsy recipients reported greater worry or what patients were told by their physicians following their biopsy or PSA results. Finally, the study sample had few men from minority groups. Thus, it is unknown whether our findings can be generalized to men in different racial or ethnic groups.
Our results reinforce the importance of discussing the potential benefits and harms of prostate cancer screening, including psychological effects, with patients up front.27,28
Many men obtain reassurance after a negative PSA test.29
To reduce patient anxiety, however, efforts should be made to expedite the work-up of men with abnormal screening tests, and counseling should be offered to those men with persistent worry despite having a negative biopsy for prostate cancer. Moreover, our results highlight the need to improve the specificity of current prostate cancer screening strategies and to provide education and feedback to primary care physicians in order to minimize the inappropriate use of prostate cancer screening.30