After 23 years of follow-up in a large prostate cancer screening trial, around 456 men had to be invited and 12 cancers diagnosed to prevent 1 death from that cancer. The benefit is real, but it has to be weighed against the risk of diagnosing and treating cancers that would never have threatened life.
If a PSA result is abnormal, if you have urinary symptoms or if you simply want to understand your own risk, Noria Health Hub can arrange a full check-up or a second medical opinion in Brussels, with a report within 24 h, coordinate your care where needed across more than 40 medical pathways in 48 h, then, if your medical condition allows, arrange surgery within 7 days.
Prostate cancer screening, what 23 years of follow-up show
The European randomised study of screening for prostate cancer is the only one with follow-up long enough to yield stable figures. Here is what it gives at 23 years.
| What is measured | The result at 23 years |
|---|---|
| Reduction in prostate cancer mortality | Real and significant |
| Men to invite to screening to avoid 1 death | 456 |
| Men to diagnose to avoid 1 death | 12 |
| What the second figure means | 11 men out of 12 diagnosed draw no survival benefit from that diagnosis |
It is one of the few screening programmes for which we have the number needed to diagnose and not only the number needed to invite. That figure of 12 is the real subject of the debate.
The equivalent American trial found no benefit, with a rate ratio of 1.09. That result is regularly quoted to conclude that screening is useless. It should be known that in that trial a very large share of the control group had been screened outside the protocol, which makes the comparison between the 2 arms hard to interpret.
A third, British trial, testing a single PSA measurement, finds no difference in all-cause mortality at 15 years, 23.2% against 23.3%. The correct reading is that a single measurement is not enough, not that repeated screening has no effect.
Overdiagnosis, a risk that varies sharply with age
Overdiagnosis is not a single value. It rises steeply with age, because the probability of dying of something else rises.
| Age at diagnosis | Estimated share of overdiagnosis |
|---|---|
| Around 55 | About 16% |
| Around 75 | About 58% |
| What this implies | The same test does not have the same value depending on the age of the person taking it |
| What cannot be measured individually | No test says which of the diagnosed cancers is the one that would have killed |
This is why guidelines speak of shared decision-making rather than systematic screening. The benefit-risk balance genuinely tips with age.
MRI before biopsy, the major shift in diagnostic strategy
On this point the result is clear-cut and it comes from 2 independent trials.
| What is compared | The result |
|---|---|
| Sensitivity of multiparametric MRI for clinically significant cancers | 93% |
| Sensitivity of standard systematic transrectal biopsy | 48% |
| Significant cancers detected, MRI with targeted biopsy against systematic biopsy | 38% against 26% |
| Insignificant cancers detected, that is, overdiagnosed | 9% against 22% |
The last line is the one that matters most. MRI does not only find more useful cancers, it finds markedly fewer useless ones. That is rare, and it is why the strategy changed.
A practical consequence follows. In the PRECISION trial, 71 of the 252 men assessed by MRI first had a non-suspicious MRI, that is 28%, and went on to have no biopsy. One man in four therefore avoids a procedure that carries an infectious and a bleeding risk. That is not a matter of comfort, it is a measured reduction in morbidity.
Treatment, benefits, adverse effects and no benefit at all for some men
A British trial randomised men with PSA-detected localised cancer between active monitoring, surgery and radiotherapy. At 15 years, prostate cancer mortality was 2.7% across all randomised men, with no significant difference between the 3 arms.
The difference lay in metastases, 9.4% under monitoring against 4.7% after surgery and 5.0% after radiotherapy. In other words, treating early reduces metastases without that translating, at 15 years, into a survival difference. Both results must be quoted together, because one is used to justify treatment and the other to defer it.
In real practice, the share of low-risk cancers placed under active surveillance in the United States rose from 26.5% to 59.6%. It is the most important practice change of the period, and it points towards less overtreatment.
PSA screening, why guidelines differ from one country to another
| The authority | The position | What explains the gap |
|---|---|---|
| United States, Preventive Services Task Force | Grade C, individual shared decision from 55 to 69 | Weights overdiagnosis equally with benefit |
| France, Haute Autorité de santé | Systematic screening not recommended | Judges the benefit insufficient against the adverse effects |
| Europe, European Association of Urology | A risk-adapted individual strategy | Incorporates MRI and active surveillance, which change the calculation |
These 3 positions rest on the same trials. They differ in the weight given to overdiagnosis, not in the data. We will not decide in their place.
Two other urological subjects that are often overlooked
Kidney stones are one of the few conditions whose recurrence is precisely quantified, 31% at 10 years. That datum is actionable, because a metabolic work-up after a first episode identifies a correctable cause in a share of patients.
Benign prostatic enlargement affects 50 to 60% of men between 60 and 69. It is not cancer, it is not serious, and it is nonetheless the leading reason for urological consultation. Confusion between the 2 subjects is a source of considerable and entirely avoidable anxiety.
How long people wait
In England, 66.3% of patients referred to urology start treatment within 18 weeks. In other words, about 1 patient in 3 exceeds that period. That figure covers the whole specialty, cancers and benign conditions together, and says nothing about the wait specific to suspected cancer.
What the studies do not allow anyone to claim
We will not write that PSA screening saves lives without adding that 12 men must be diagnosed for 1 to be saved. We will not claim that it is useless, because the 23-year trial shows a real reduction in disease-specific mortality. Nor will you read here that a normal PSA rules out cancer, or that a raised PSA means there is one.
What we will say is that the step that changed things most is not the blood test itself, it is MRI placed before biopsy, and that any man considering screening should know that this sequence exists before he is biopsied.
In practice, if this concerns you
You set out your problem, your symptoms or your question. Reports, test results and images already available can be studied before you arrive, so that the pathway is prepared. The aim is not to run every examination as a matter of course, but to select those that can genuinely help confirm a hypothesis, rule out a risk or guide a decision. The findings are then summarised and the next steps organised. Follow-up is coordinated from there.
Need medical advice quickly? For a worry that does not call for emergency services, you can ask to speak to a doctor at any time through Noria Health Hub. This on-demand medical consultation is billed separately from the assessment pathway.
Further reading
The companion articles.
Cancer” rel=”noopener” target=”_blank”>https://noriahealth.com/blog/cancer-screening-what-the-trials-demonstrate/”>Cancer screening, what the trials demonstrate
Who” rel=”noopener” target=”_blank”>https://noriahealth.com/blog/who-performs-your-examination-changes-what-it-finds/”>Who performs your examination changes what it finds
Sources
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Andriole GL et al., PLCO, Prostate cancer screening in the randomized Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, mortality results after 13 years, Journal of the National Cancer Institute, 2012. https://doi.org/10.1093/jnci/djr500
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Hamdy FC et al., ProtecT, Fifteen-year outcomes after monitoring, surgery or radiotherapy for prostate cancer, New England Journal of Medicine, 2023. https://doi.org/10.1056/NEJMoa2214122
Cooperberg MR et al., Trends in management for patients with localized prostate cancer, JAMA, 2015 and subsequent registry updates. https://doi.org/10.1001/jama.2015.6036
US Preventive Services Task Force, Screening for Prostate Cancer, Recommendation Statement, JAMA, 2018. https://doi.org/10.1001/jama.2018.3710
Haute Autorité de santé, Dépistage du cancer de la prostate par dosage du PSA, position. https://www.has-sante.fr/
European Association of Urology, Guidelines on Prostate Cancer, early detection chapter. https://uroweb.org/guidelines/prostate-cancer
Rule AD et al., The ROKS nomogram for predicting a second symptomatic stone episode, Journal of the American Society of Nephrology, 2014. https://doi.org/10.1681/ASN.2013091011
Berry SJ et al., The development of human benign prostatic hyperplasia with age, Journal of Urology, 1984. https://doi.org/10.1016/S0022-5347(17)50354-7
NHS England, Referral to Treatment Waiting Times, urology. https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/