Prostate cancer screening is the screening process used to detect undiagnosed prostate cancer in men without signs or symptoms. When abnormal prostate tissue or cancer is found early, it may be easier to treat and cure, but it is unclear if early detection reduces mortality rates.
Screening precedes a diagnosis and subsequent treatment. The digital rectal examination (DRE) is one screening tool, during which the prostate is manually assessed through the wall of the rectum. The second screening tool is the measurement of prostate-specific antigen (PSA) in the blood. The evidence remains insufficient to determine whether screening with PSA or DRE reduces mortality from prostate cancer.
Most recent guidelines have recommended that the decision whether or not to screen should be based on shared decision-making, so that men are informed of the risks and benefits of screening. In 2012, the American Society of Clinical Oncology recommended screening be discouraged for those who are expected to live less than ten years, while for those with a longer life expectancy, a decision should be made by the person in question. In general, they concluded that based on recent research, "it is uncertain whether the benefits associated with PSA testing for prostate cancer screening are worth the harms associated with screening and subsequent unnecessary treatment."
History and published evidence
Screening of PSA began in the 1990s. In the European Randomized Study of Screening for Prostate Cancer (ERSPC) initiated in the early 1990s, the researchers concluded that PSA-based screening did reduce the rate of death from prostate cancer but created a high risk of overdiagnosis, i.e., 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent just one death from prostate cancer within 9 years.
A study published in the European Journal of Cancer (October 2009) documented that prostate cancer screening reduced prostate cancer mortality by 37 percent. By utilizing a control group of men from Northern Ireland, where PSA screening is infrequent, the research showed this substantial reduction in prostate cancer deaths when compared to men who were PSA tested as part of the ERSPC study.
A study published in the New England Journal of Medicine in 2009 found that over a 7 to 10-year period, "screening did not reduce the death rate in men 55 and over." Former screening proponents, including some from Stanford University, have come out against routine testing. In February 2010, the American Cancer Society urged "more caution in using the test." And the American College of Preventive Medicine concluded that "there was insufficient evidence to recommend routine screening."
A further study, the NHS Comparison Arm for ProtecT (CAP), as part of the Prostate testing for cancer and Treatment (ProtecT) study, randomized GP practices with 460,000 men aged 50–69 at centers in 9 cities in Britain from 2001–2005 to usual care or prostate cancer screening with PSA (biopsy if PSA ≥ 3). The "Comparison Arm" has yet to report as of early 2018.
A 2026 Cochrane review found that prostate cancer screening with PSA likely reduces deaths from prostate cancer and may reduce deaths overall.
Initial screening tests Prostate-specific antigen
Prostate-specific antigen (PSA) is secreted by the epithelial cells of the prostate gland and can be detected in a sample of blood. PSA is present in small quantities in the serum of men with healthy prostates, but is often elevated in the presence of prostate cancer or other prostate disorders. PSA is not a unique indicator of prostate cancer, but may also detect prostatitis or benign prostatic hyperplasia.
A 2018 United States Preventive Services Task Force (USPSTF) recommendation adjusted the prior opposition to PSA screening, suggesting shared decision-making regarding screening in healthy males 55 to 69 years of age. The recommendation for that age group states screening should only be done in those who wish it. In those 70 and over, screening remains not recommended.
Screening with PSA has been associated with a number of harms including over-diagnosis, increased prostate biopsy with associated harms, increased anxiety, and unneeded treatment. In an updated systematic review (2026) involving over 789,000 men demonstrated that screening likely reduces prostate cancer-specific mortality and maybe overall mortality.
On the other hand, up to 25% of men diagnosed in their 70s or even 80s die of prostate cancer, if they have high-grade (i.e., aggressive) prostate cancer. Conversely, some argue against PSA testing for men who are too young, because too many men would have to be screened to find one cancer, and too many men would have treatment for cancer that would not progress. Low-risk prostate cancer does not always require immediate treatment but may be amenable to active surveillance. A PSA test cannot 'prove' the existence of prostate cancer by itself; varying levels of the antigen can be due to other causes.
Digital rectal examination During a digital rectal examination (DRE), a healthcare provider slides a gloved finger into the rectum and presses on the prostate, to check its size and to detect any lumps on the accessible side. If the examination suggests anomalies, a PSA test is performed. If an elevated PSA level is found, a follow-up test is then performed.
A 2018 review recommended against primary care screening for prostate cancer with DRE due to the lack of evidence of the effectiveness of the practice.
The USPSTF recommends against digital rectal examination as a screening tool due to a lack of evidence of benefits. Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age.
The American Urological Association in 2018 stated that for men aged 55 to 69, they could find no evidence to support the continued use of DRE as a first-line screening test; however, in men referred for an elevated PSA, DRE may be a useful secondary test.
A study by Krilaviciute et al. (2023) examined the effectiveness of the DRE as a standalone screening test for prostate cancer in >46,000 young men in Germany (age 45). It was found that DRE has a much lower detection rate for prostate cancer compared to PSA screening. Therefore, the authors recommend not to use DRE as a screening test for prostate cancer in young men, as it does not provide an improvement in detection compared to PSA screening.
Follow-up tests
Prostate biopsy Prostate biopsies are used to diagnose prostate cancer but are not done on asymptomatic men and therefore are not used for screening. Infection after prostate biopsy occurs in about 1%, while death occurs as a result of biopsy in 0.2%. Prostate biopsy guided by magnetic resonance imaging has improved the diagnostic accuracy of the procedure. Prostate biopsies are considered the gold standard in detecting prostate cancer. Infection after the biopsy procedure is a possible risk. MRI-guided techniques have improved the diagnostic accuracy of the procedure. Biopsies can be done through the rectum or perineum. The biopsy technique includes factors such as needle angle and prostate mapping method. People who have localized cancer and perineural invasion may benefit more from immediate treatment rather than adopting a watchful waiting approach.
Ultrasound Transrectal ultrasonography (TRUS) has the advantage of being fast and minimally invasive, and better than MRI for the evaluation of superficial tumors. It also gives details about the layers of the rectal wall, accurate and useful for staging primary rectal cancer. While MRI is better in visualization of locally advanced and stenosing cancers, for staging perirectal lymph nodes, both TRUS and MRI are capable. TRUS has a small field of view, but 3D TRUS can improve the diagnosis of anorectal diseases.
Magnetic Resonance Imaging MRI is used when screening suggests a malignancy. This model potentially minimizes unnecessary prostate biopsies while maximizing biopsy yield. Despite concerns about the cost of MRI scans, compared to the long-term cost burden of the PSA/TRUS biopsy-based standard of care, the imaging model has been found to be cost-effective. MRI imaging can be used for patients who have had a previous negative biopsy but whose PSA continues to increase. Online open-access datasets of Prostate Cancer MRI examinations are available for review and training. Consensus has not been determined as to which of the MRI-targeted biopsy techniques is more useful. In a study involving 400 men aged 50 – 69, MRI screening identified more men with prostate cancer than PSA tests or ultrasound and did not increase the number of men who needed a biopsy. A large-scale trial of MRI screening, TRANSFORM, began in the UK in spring 2024.
Multiparametric MRI Multiparametric magnetic resonance imaging (mpMRI) has emerged as a transformative tool in prostate cancer screening, helping to reduce unnecessary biopsies while improving detection of clinically significant cancers.Launer BM, Ellis TA, Scarpato KR. A contemporary review: mpMRI in prostate cancer screening and diagnosis. Urol Oncol. 2025 Jan;43(1):15-22. PMID: 39129080. Current American guidelines recommend mpMRI before initial biopsy in biopsy-naïve patients, as studies demonstrate mpMRI can identify 28% more clinically significant cancers while reducing unnecessary biopsies by up to 30%. The PI-RADS (Prostate Imaging Reporting and Data System) scoring system standardizes mpMRI interpretation, with PI-RADS 3–5 lesions warranting targeted biopsy. Studies in 2024 showed that 96% of patients with normal MRI results do not develop aggressive prostate cancer within three years, supporting an "MRI-first" screening approach.
Other imaging
68Ga-PSMA PET/CT imaging has become, in a relatively short period of time, the gold standard for restaging recurrent prostate cancer in clinical centers in which this imaging modality is available. It is likely to become the standard imaging modality in the staging of intermediate-to-high risk primary prostate cancer. The potential to guide therapy, and to facilitate more accurate prostatic biopsy is being explored. In the theranostic paradigm, 68Ga-PSMA PET/CT imaging is critical for detecting prostate-specific membrane antigen-avid disease which may then respond to targeted 177Lu-PSMA or 225Ac-PSMA therapies. For local recurrence, 68Ga-PSMA PET/MR or PET/CT in combination with mpMR is most appropriate. PSMA PET/CT may be potentially helpful for locating the cancer when combined with multiparametric MRI (mpMRI) for primary prostate care. Prostate multiparametric MR imaging (mpMRI) is helpful in evaluating recurrence of primary prostate cancer following treatment.
Other Several biomarkers (blood, urine, and tissue-based tests) for screening, diagnosing, and determining the prognosis of prostate cancer are supported by evidence and used widely. EpiSwitch® PSE is a blood test used for screening and diagnosing prostate cancer utilizing epigenetic markers to identify specific changes in regulatory looping structures (chromosome conformation signatures) associated with prostate cancer. Used in conjunction with a PSA test, the PSE test boosts accuracy from 55% to 94% offering a more effective and precise method for detecting and diagnosing prostate cancer. The 4Kscore combines total, free, and intact PSA with human kallikrein 2. It is used to try to determine the risk of a Gleason score greater than 6. The Prostate Health Index (PHI) is a PSA-based blood test for early prostate cancer screening. It may be used to determine when a biopsy is needed.