# Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening, 1986 to 2005

Source: https://onco.cc/key-papers/paper-welch-albertsen-psa-era-diagnosis-treatment-jnci-2009/  
OnCo record `paper-welch-albertsen-psa-era-diagnosis-treatment-jnci-2009` (Key paper). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Counting what the blood test did to a country. In the twenty years after PSA testing began in the United States, an extra 1.3 million men were diagnosed with prostate cancer and about a million were definitively treated, for a benefit that on the most generous assumption reached one man in twenty of them.

## Summary

H. Gilbert Welch and Peter Albertsen took age-specific incidence and initial treatment from the Surveillance, Epidemiology, and End Results programme and United States Census population estimates, and computed the excess number of men diagnosed and treated in each year after 1986, the year before prostate-specific antigen screening was introduced.

The age pattern is the part usually left out of the summary. Relative incidence in 2005 against 1986 was 0.56 in men aged 80 and over, and 7.23 in men under 50: the test moved diagnosis down the age distribution, into men with decades of life ahead of them and the most to lose from incontinence and erectile dysfunction. The authors then made the most favourable possible assumption, that the entire fall in prostate cancer mortality over the period was caused by screening, and still found that more than 20 men had to be diagnosed for each one who benefited.

## Fields

- Kind: Key paper
- Last checked: 2026-09-25
- Also known as: Welch and Albertsen 2009; 1.3 million extra prostate cancer diagnoses
- Tags: prostate-evidence
- Journal: JNCI: Journal of the National Cancer Institute
- Year: 2009
- DOI: 10.1093/jnci/djp278
- Authors: Welch HG, Albertsen PC.
- Findings: An estimated additional 1,305,600 men were diagnosed with prostate cancer in the United States after 1986, of whom 1,004,800 were definitively treated.; Relative incidence in 2005 against 1986 was 0.56 in men aged 80 and over, 1.09 at 70 to 79, 1.91 at 60 to 69, 3.64 at 50 to 59, and 7.23 in men under 50.; Under the most optimistic assumption, that the entire decline in prostate cancer mortality over the period is attributable to the additional diagnosis, more than 20 men had to be diagnosed for each man who experienced the presumed benefit.; Overall incidence rose rapidly after 1986, peaked in 1992 and then declined to levels still considerably above 1986.; The authors concluded that most of the excess incidence must represent overdiagnosis, given the time elapsed since screening began.
- What it means: The number that anchors the overdiagnosis argument in prostate cancer: over a million American men treated for a cancer that, for most of them, was never going to surface. It is the reason active surveillance exists as a formal pathway and the reason magnetic resonance imaging was brought in front of the biopsy.
- Caveats: An ecological analysis of registry data, not a randomised comparison; the excess is inferred from trends rather than observed per man.; The estimate of benefit assumes the entire mortality decline came from screening, which is generous and is stated as such by the authors; some of the decline is treatment.; United States figures in a period of unusually intense opportunistic testing; the size of the excess in systems with less testing is smaller.

## Sources

- J Natl Cancer Inst 2009: https://doi.org/10.1093/jnci/djp278
- PubMed: https://pubmed.ncbi.nlm.nih.gov/19720969/

## Connected records

- key papers: [Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context](https://onco.cc/key-papers/paper-draisma-lead-time-overdiagnosis-psa-jnci-2009/), [Long-term follow-up of a large active surveillance cohort of patients with prostate cancer (Sunnybrook)](https://onco.cc/key-papers/paper-klotz-active-surveillance-jco-2015/), [Overdiagnosis and overtreatment of prostate cancer](https://onco.cc/key-papers/paper-loeb-overdiagnosis-overtreatment-prostate-eur-urol-2014/), [Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate](https://onco.cc/key-papers/paper-stamey-psa-serum-marker-nejm-1987/)
- ideas: [An international body to rename indolent lesions so 'cancer' means something](https://onco.cc/ideas/idea-prev-indolent-lesion-nomenclature-body/)
- roadmaps: [Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch](https://onco.cc/roadmaps/prostate-roadmap/)
- cancers: [Localised prostate cancer, very low and low risk](https://onco.cc/cancers/prostate-low-risk/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- fronts: [Early Detection & Screening](https://onco.cc/fronts/early-detection/), [Prevention & Risk](https://onco.cc/fronts/prevention/)
- terms: [Lead time, and lead-time bias](https://onco.cc/terms/lead-time-bias/), [Overdiagnosis](https://onco.cc/terms/overdiagnosis/), [Overtreatment](https://onco.cc/terms/overtreatment/), [PSA (prostate-specific antigen)](https://onco.cc/terms/psa/), [Screening](https://onco.cc/terms/screening/)
- bottlenecks: [Overdiagnosis and false alarms](https://onco.cc/bottlenecks/b-overdiagnosis/), [The hardest cancers are found late](https://onco.cc/bottlenecks/b-early-detection/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)
- journals: [JNCI: Journal of the National Cancer Institute](https://onco.cc/journals/jnci/)

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