This week’s decision by the UK’s national screening committee not to recommend prostate cancer screening for the general population has sparked a new debate in the international medical community. The rationale behind the decision is familiar: While PSA (prostate-specific antigen) testing can save some lives, it also carries the risk of unnecessary diagnosis and unnecessary treatment. Furthermore, recent evidence suggests that this balance remains delicate (https://www.ft.com/content/9065a8d8-8bfb-40e7-a64d-a326275a00e8).
The 23-year results of the European ERSPC randomized trial, one of the most comprehensive screening data, are as follows: The relative likelihood of dying from prostate cancer is approximately 13 percent lower in the group receiving regular PSA screening. However, this “relative” difference translates to a very small real-world gain: over a 23-year follow-up, only 2 or 3 out of every 1,000 men screened appear to have prevented prostate cancer deaths. In contrast, the rate of prostate cancer diagnosis increases by 30 percent in the screened group, meaning many men are labeled “diseased” for an indolent tumor that will never cause problems. This can mean unnecessary biopsies, unnecessary surgeries, and complications that diminish quality of life (https://pubmed.ncbi.nlm.nih.gov/41160819/).
One of the most important questions in prostate cancer screening remains the accuracy of the PSA test, a fundamental tool. The false-positive rate of PSA is quite high; for example, approximately 70 percent of men with elevated PSA levels do not have cancer detected upon biopsy. Prostate enlargement, infections, and even recent sexual intercourse can all elevate PSA levels. This translates to a significant burden of anxiety, unnecessary biopsies, and sometimes unnecessary treatments. On the other hand, the false-negative nature of PSA cannot be ignored; approximately 15% of prostate cancers can be missed even when the PSA is normal. This rate maintains the concern about aggressive tumors (https://bmjoncology.bmj.com/content/2/1/e000039).
Another prominent issue in current discussions is which method should be preferred if screening is to be performed. In the past, digital rectal examination (DRE) was routinely recommended for prostate cancer screening. However, recent studies have shown that DRE has very low sensitivity when used for screening. Most current guidelines emphasize that DRE should be considered as a complementary physical examination tool in men with specific complaints or high PSA levels, rather than as a screening test. If a screening decision is to be made, the PSA test is the preferred method due to its higher sensitivity. However, it should be remembered that PSA alone does not provide definitive results and carries the risk of both false-positive and false-negative results. Many countries are now adopting a more selective approach, rather than recommending screening for the entire population.
The USPSTF recommendations recommend screening men aged 55–69 only after a comprehensive consultation between physician and patient, with a clear discussion of the potential benefits and harms (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening). It emphasizes that the harms of screening in men with limited life expectancy or over 70 outweigh the benefits. The UK’s recent decision, however, rejects universal screening but supports biennial screening only for men with BRCA1/2 mutations, as prostate cancer can progress earlier and more aggressively in this group. Germany is also ending the systematic “rectal examination + automated biopsy” era; the German guideline recommends a more personalized strategy (based on risk, age, PSA value, demand, etc.) based on PSA. However, this strategy is still not “mandatory for everyone” or a “mass screening program” (https://register.awmf.org/assets/guidelines/043-022OLl_S3_Prostatakarzinom_2025-08.pdf).
Recent medical advances indicate that multiparametric prostate MRI, in addition to PSA, is becoming an increasingly powerful tool. MRI has the potential to reduce unnecessary biopsies and detect clinically significant cancers more accurately. However, the applicability, cost-effectiveness, and ideal age ranges for MRI-based screening in the general population are not yet fully understood (https://bmjopen.bmj.com/content/12/11/e059482).
All these data clearly demonstrate that prostate cancer screening is not a simple “have it or not have it” decision. Each man’s risk profile, life expectancy, family history, and personal preferences are different. Good communication between physician and patient requires honest discussion of the potential benefits of screening, as well as the physical and psychological harms that can result from overdiagnosis, overtreatment, and testing errors.
Ultimately, current evidence does not support mandatory or automatic screening in the general population. However, Screening should be carefully considered for healthy men aged 50–70, especially those with a family history or in high-risk groups. The sole purpose of screening is not early detection; it also empowers men to take an active role in their own health decisions. In medical practice, the goal is not more testing, but more information and less harm. Current debates surrounding prostate cancer screening call us to this very point.
