Roobol MJ, de Vos II, Månsson M, Godtman RA, Talala KM, den Hond E, et al. European Study of Prostate Cancer Screening – 23-Year Follow-up. N Engl J Med. 2025 Oct 30;393(17):1669–80.
Long-Term Outcomes of PSA Screening
This paper caught my eye while reading a summary in one of the broadsheets. Also, being a man of a certain age, it has a more personal relevance. It was the reporting of the final 23-year results of the European Randomized Study of Screening for Prostate Cancer (ERSPC), providing a comprehensive assessment to date of PSA-based screening. After more than two decades of follow-up, prostate-cancer-specific mortality was 13 % lower in men invited for screening compared with controls.
This represented an absolute risk reduction (ARR) of 0.22 %, meaning one prostate cancer death was prevented for every 456 men invited or every 12 men diagnosed. Although the absolute benefit remains small, it has strengthened over time — from an ARR of 0.14 % at 16 years to 0.22 % at 23 years — indicating a gradually improving mortality benefit with extended follow-up. Screening continued to increase prostate cancer incidence by around 30 %, largely through the detection of low-risk tumours unlikely to cause symptoms or death. Only one in four positive biopsies confirmed malignancy, highlighting the burden of unnecessary investigations and potential over-treatment. The data reinforced the enduring challenge of balancing early detection with the harms of over-diagnosis.
A Changing Clinical Context
The landscape of prostate cancer diagnosis and management has evolved substantially since the ERSPC began in 1993. Multi-parametric MRI, targeted biopsy techniques, and risk-stratified screening algorithms have reshaped practice, allowing clinicians to focus investigation on those most likely to benefit. Meanwhile, active surveillance (I have a handful of patients undergoing this) and nerve-sparing surgery have reduced the long-term morbidity once associated with over-treatment. Collectively, these innovations have improved the harm–benefit profile of PSA-based screening.
Towards Risk-Based Screening
I get asked by a lot of men about prostate screening and if they can add a PSA to a well man profile. Admittedly these are men in their mid 40s to early 50s (the ERSPC inclusion age was 55-69). My interpretation is the ERSPC is a valuable contribution to quantifying the trade-off between benefit and harm over time. The evidence supports a move away from population-wide screening towards individualised, risk-based assessment, taking into account age, comorbidity, life expectancy, and patient preference. As diagnostic precision improves, the rationale for targeted screening—rather than universal testing—becomes more relevant. The long-term data remind us that progress in screening is incremental: the aim is not simply to detect more cancers, but to detect the right cancers, in the right patients, at the right time.
Welcome to antonywillman.org 