PSA and MRI-first prostate cancer screening
Whether men should be screened for prostate cancer is still debated; the modern approach uses a PSA blood test followed by an MRI scan, which finds the cancers that matter while leaving harmless ones alone.
Overview
The European ERSPC trial showed that PSA screening reduces prostate cancer mortality (rate ratio 0.80 at 16 years, with 570 men invited and 18 diagnosed per death averted), while the UK CAP trial of a single PSA test found only a small absolute difference at 15 years (0.69% versus 0.78% prostate cancer deaths). Overdiagnosis of low-grade disease was the price. The Göteborg-2 trial (NEJM 2022) showed that using MRI after an elevated PSA and biopsying only MRI-visible lesions halved the detection of clinically insignificant cancer while missing few significant cancers, and PROBASE in Germany is testing risk-adapted screening from age 45. In the UK, TRANSFORM (Prostate Cancer UK and government funded, opened 2025-26) compares PSA, fast MRI and genetic risk approaches in tens of thousands of men, with at least one in ten Black men, ahead of a decision on a national programme; the UK National Screening Committee has not recommended population screening. The USPSTF gives a grade C (individual decision) for men 55 to 69, and the EU Council in 2022 asked member states to evaluate stepwise PSA-plus-MRI programmes.
How it works
A PSA threshold selects men for multiparametric or biparametric MRI; only PI-RADS 3-5 lesions are biopsied, with active surveillance for low-grade disease.
- MRI-first roughly halves overdiagnosis of insignificant cancer
- Mortality benefit of PSA screening is established in ERSPC
- MRI capacity and reader variability
- Benefit-harm balance still contested by screening committees
- Uncertain value in Black men and men with a family history, who are under-represented in trials
Latest papers
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