For years, experts have debated whether prostate cancer screening with the PSA test saves lives and if its benefits outweigh the potential harms posed by additional testing and treatments it can necessitate.
Updated findings from an ongoing major European study provide some clarity, suggesting that screening with the PSA blood test can reduce deaths from prostate cancer. Moreover, a Cleveland Clinic expert says screening may be even more beneficial than the study suggests.
“I’m glad they continue to update these findings, because it gives us urologists who treat prostate cancer a better sense that we’re doing the right thing,” says Cleveland Clinic urologic oncologist Zeyad Schwen, MD. “It also gives primary care doctors and patients more confidence about the benefits of prostate cancer screening.”
Nevertheless, screening isn’t for everyone, so discuss with your physician whether it’s appropriate for you, and ask about additional testing that can improve PSA screening and help you avoid unnecessary downstream effects.
PSA Test Benefits Grow
The screening test is a measurement of PSA, or prostate-specific antigen, in the blood that can alert you to prostate cancer in its earliest, most treatable stages.
But the PSA test has limitations. It can raise suspicions of noncancerous prostate conditions as well as cancer, and it cannot distinguish between aggressive and indolent tumors. Consequently, it can identify many slow-growing cancers that may never become life-threatening, and thus prompt unnecessary invasive biopsies and treatments that can cause significant urinary and sexual side effects.
The European Randomized Study of Screening for Prostate Cancer (ERSPC) included 162,236 men, ages 55 to 69 when the study began in 1993, who were assigned to repeated PSA testing or a nonscreened control group.
At nine, 11, 13, and 16 years, screening was associated with a 20% reduction in the risk of death from prostate cancer, compared with nonscreening, the study found. In the latest results, at an average 23-year follow-up period, the ERSPC researchers (from Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands, and other European medical centers) reported that screening with the PSA test continued to show a 13% reduction in prostate cancer-related deaths.
Importantly, at 23 years, one death from prostate cancer was prevented for every 456 men who were invited for screening and for every 12 men in whom prostate cancer was diagnosed. That compares with one death for every 628 men screened and 18 men diagnosed at 16 years of follow-up (numbers needed to screen and diagnose are used to assess the benefits and harms of a particular intervention). These findings suggest that the risk-benefit profile of PSA screening continues to become more favorable as time goes on, the study authors noted (New England Journal of Medicine, Oct. 30, 2025).
“We see that PSA screening, even more than 20 years ago, was helpful,” Dr. Schwen says. “Primary care doctors should take notice and discuss it with their patients to make a shared decision about whether prostate cancer screening is in their best interest.”
Screening with the PSA Test Today
Dr. Schwen says the benefit-to-harm ratio for screening seen in the ERSPC is even more favorable today. If results of a PSA test raise alarms, doctors can now order more advanced blood tests like IsoPSA, the Prostate Health Index, and the 4Kscore, as well as sophisticated urine tests for genetic markers—e.g., ExoDx Prostate Intelliscore, MyProstateScore, and SelectMDx—to gauge a man’s risk of having cancer (and high-grade disease) on biopsy.
Another major step forward has been the emergence of prostate magnetic resonance imaging (MRI), which allows clinicians to visualize the prostate and identify suspicious lesions, if any are present, before considering a biopsy. Dr. Schwen says, “We’re better at filtering out men who have an elevated PSA but don’t need a prostate biopsy, which used to lead to overdiagnosis of low-risk prostate cancers.”
Other advanced testing is enabling clinicians to steer men diagnosed with low-risk and some intermediate-risk prostate cancers toward active surveillance, an observation strategy that defers curative treatment unless testing suggests progression of the disease. Thus, many of these men can avoid, or at least delay, the side effects of surgical or radiation treatment.
In short, with newer testing and management patterns, the harms of screening with the PSA test have been greatly reduced, Dr. Schwen says.
However, not every man should be screened for prostate cancer, but rather those expected to live at least 10 years (see “Screening Recommendations”). Since most prostate cancers grow slowly, men with shorter life expectancies are more likely to die from another cause before they could benefit from screening and, if a cancer were found, curative treatment.
“If we know screening in older men is not going to improve their life expectancy, the best thing to do is not screen them at all rather than expose them to the risks of biopsy, the anxiety of potentially having a diagnosis of prostate cancer, and then the difficult decision about whether to treat prostate cancer if we find it,” Dr. Schwen says.
Routinely follow up with your primary care doctor and review your risk of prostate cancer based on your family history of the disease and other factors. Then examine the pros and cons of the PSA test and prostate cancer screening and, with your doctor’s input, make the best decision for you.
Screening Recommendations
Medical organizations recommend that men engage in shared decision-making with their doctors, carefully evaluating the risks and benefits of screening to make an informed decision. Here’s a look at prostate cancer screening guidelines from three expert medical groups:
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American Urological Association |
American Cancer Society |
National Comprehensive Cancer Network |
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Screening age recommendations |
Begin discussion at ages 45–50 (ages 40–45 for high-risk men*); offer screening to men ages 50–69 |
Begin discussion at age 50 (age 45 for high-risk men and 40 for men at even higher risk#) |
Begin discussion at age 45 (age 40 for high-risk men); offer screening until age 75 |
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Screening interval |
Every 2–4 years** |
Annually if initial PSA is ≥2.5 ng/ml; every other year if PSA is ≤2.5 ng/ml |
Every 2–4 years if PSA is <1 ng/ml; every 1–2 years if PSA is 1–3 ng/ml or in high-risk men if PSA is ≤3 ng/ml |
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Recommended screening test(s) |
PSA; digital rectal exam (DRE) may complement PSA |
PSA; DRE may complement PSA |
PSA and DRE |
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Other considerations |
Repeat PSA before using other tests or biopsy; PSA should not be sole determinant for proceeding to secondary biomarker testing, imaging or biopsy. |
Men with a life expectancy of less than 10 years should not be offered screening. Consider health status, not age alone, in screening decisions |
Screening may be done with caution in select very healthy men over age 75; men ages ≥60 with PSA <1 ng/ml and age >75 with PSA <3 ng/ml have very low risk of metastasis |
* Men at high risk of prostate cancer include those with Black ancestry, a strong family history of prostate cancer, or certain germline genetic mutations.
** Physicians may individualize the screening interval or discontinue screening based on a patient’s personal preference, PSA level, age, prostate cancer risk, and life expectancy/overall health.
# High-risk men are Black men or men with a first-degree relative (father or brother) diagnosed with prostate cancer before age 65; even higher-risk men have more than one first-degree relative who had prostate cancer before age 65.
What You Can Do
- Carefully review the pros and cons of prostate cancer early detection with your physician. PSA screening can reduce deaths from prostate cancer, but it can also lead to invasive testing and treatments that can cause urinary and sexual side effects.
- Understand your risk of prostate cancer, based on your age, race, family history of prostate cancer, and previous PSA test results, and take these factors into account when considering screening. Use the risk assessment calculator on the Cleveland Clinic website: http://cle.clinic/1iXyMSI.
- Ask your doctor if a prostate exam (digital rectal exam) should be done in conjunction with PSA screening.
- Inquire about MRI and advanced biomarker testing that can augment PSA screening and help determine your need for a prostate biopsy.
