ERSPC 23-year data reinforce need for risk-based PSA screening

The European Randomized Study of Screening for Prostate Cancer (ERSPC) remains the largest randomized trial evaluating prostate-specific (PSA)-based prostate cancer screening, enrolling over 163,000 men randomized to screening or control arms. After 23 years of follow-up, results showed a 13% relative reduction in prostate cancer mortality among screened men.¹ However, in this video interview, Monique Roobol, PhD, MSc, emphasized that this mortality benefit must be balanced against the risks of overdiagnosis and overtreatment. Roobol is an epidemiologist, a professor of Decision Making in Urology, and the head of the scientific research office within the department of urology at Erasmus Medical Center in Rotterdam, Netherlands.

Roobol noted that approximately half of the 30% higher incidence of prostate cancer in the screened arm represents overdiagnosis, primarily of low-risk cancers. To mitigate this, she advocated for risk-based screening, targeting men with higher risk of life-threatening disease while reducing or discontinuing screening in older or frail men who gain little benefit. Avoiding unnecessary diagnoses is key—active surveillance and MRI-based approaches can help reduce harms, but ideally, low-risk cancers should not be detected at all.

Regarding PSA thresholds, Roobol advised retaining the current cutoff but improving interpretation using PSA density and risk-adjusted strategies before proceeding to MRI or biopsy. PSA remains a valuable first step in population-based screening, effectively ruling out cancer in roughly half of men with very low PSA levels. She highlights that screening frequency should be reduced for men with low PSA (<1 ng/mL), recommending re-testing intervals of up to 5 years to avoid anxiety and overtreatment.

Roobol stressed that modern management—active surveillance, focal therapy, and risk-adapted screening—can maintain mortality benefits while minimizing harm. For clinicians, her central message is clear: Adopt a personalized, de-escalated screening approach, focusing efforts on men most likely to benefit.

REFERENCE

1. Roobol MJ, I de Vos I, Månsson, M, et al. European Study of Prostate Cancer Screening - 23-year follow-up. N Engl J Med. 2025;393(17):1669-1680. doi:10.1056/NEJMoa2503223