There was a recent article in the New England Journal of Medicine by Monique J. Roobol et al, published on October 29, 2025 titled “European Study of Prostate Cancer Screening — 23-Year Follow-up. “ The article is attached in PDF format for your information, and below is a summary for your convenience.
BACKGROUND
The European Randomized Study of Screening for Prostate Cancer (ERSPC) was initiated in 1993 to assess the effect of prostate-specific antigen (PSA) testing on prostate cancer mortality. Because deaths from prostate cancer are expected to rise worldwide owing to increased life expectancy and population growth, a final analysis of the long-term outcomes of prostate cancer screening is essential to understanding the benefits and harms of PSA testing.
METHODS
We updated the findings from ERSPC, a multicenter, randomized study conducted across eight European countries with a focus on a predefined core age group of 162,236 men who were 55 to 69 years of age at the time of randomization. Participants were randomly assigned to the screening group and offered repeated PSA testing or to the control group and not invited for screening. The primary outcome was prostate cancer mortality.
RESULTS
After a median follow-up of 23 years, prostate cancer mortality was 13% lower in the screening group (rate ratio, 0.87; 95% confidence interval [CI], 0.80 to 0.95), and the absolute risk reduction was 0.22% (95% CI, 0.10 to 0.34). The cumulative incidence of prostate cancer was higher in the screening group than in the control group (rate ratio, 1.30; 95% CI, 1.26 to 1.33). At a median of 23 years of follow-up, one death from prostate cancer was prevented for every 456 men (95% CI, 306 to 943) who were invited for screening, and one death from prostate cancer was averted for every 12 men (95% CI, 8 to 26) in whom prostate cancer was diagnosed, as compared with one death from prostate cancer prevented for every 628 men (95% CI, 419 to 1481) and one death averted for every 18 men (95% CI, 12 to 45) at 16 years of follow-up.
CONCLUSIONS
Long-term follow-up confirms a sustained reduction in deaths from prostate cancer with PSA testing, alongside an improved harm–benefit ratio. Future screening strategies should adopt risk-based approaches to minimize overdiagnosis while maintaining clinical benefits.
INTERPRETATION
Prostate specific antigen screening reduces the risk of death from prostate cancer by 13%, one of the largest randomized studies of its kind concludes. This overall reduction in mortality was similar to that seen with breast or bowel cancer screening. The results of the study, with a median follow-up of 23 years, come amid ongoing debate about the value of a PSA based screening program, owing to the substantial risk of overdiagnosis and overtreatment.
The European Randomized Study of Screening for Prostate Cancer, conducted across eight European countries from 1993 to 2003, included 162 236 men aged 55 to 69 years.
DISCUSSION
Prostate cancer mortality is projected to double worldwide by 2040 owing to increased life expectancy and population growth. Therefore, the role of early detection and treatment to counter this burden remains a public health priority. Given the typically slow progression of prostate cancer and the competing risk of death from other causes, current guidelines recommend against routine PSA screening in men over 70 years of age or those with a life expectancy of less than 15 years. Nonetheless, up to 40% of men 75 years of age or older continue to undergo PSA screening.
The harms associated with PSA-based screening, including unnecessary testing, biopsies, overdiagnosis, and subsequent overtreatment, remain a critical concern. With only 16% of PSA tests yielding elevated results and merely 24% of the subsequent biopsies confirming prostate cancer, a considerable number of these tests and procedures may have been unnecessary. More important, considerable harm arises from the overdiagnosis and subsequent overtreatment of tumors that are unlikely to cause prostate cancer illness or death, as indicated by the excess incidence of prostate cancer of 27 cases per 1000 men and, in particular, the doubling in detection of low-risk cancers in the screening group. These findings highlight the need for a more targeted strategy for prostate cancer screening that focuses on identifying population subgroups that are most likely to benefit from early detection while reducing unnecessary interventions for those with the highest risk of overdiagnosis.
A stepwise, risk-based approach, guided by risk stratification tools such as risk calculators and magnetic resonance imaging, limits biopsies to men with a confirmed elevated risk, a strategy that breaks the traditional link between elevated PSA and immediate biopsy. Several ongoing, population-based, randomized screening trials that incorporate a risk-based screening approach have shown a reduction in unnecessary biopsies and detection of low-grade prostate cancer while maintaining detection of high-grade cancers. This improved ratio of the detection of high-grade to indolent cancers, as compared with traditional PSA-based screening, suggests a substantial reduction in overdiagnosis.
In addition, the frequency of PSA screening plays a key role in balancing benefits and harms — more frequent PSA screening, such as annual testing, is associated with greater potential benefit but also with increased risk of harm. Although the optimal screening interval remains debatable, unnecessary repeated screening may be reduced by limiting screening in men with very low PSA levels at baseline or a PSA value of 1 or less at age 60, both of which indicate a very low risk of death from prostate cancer. Given the strong association between age and the prevalence of prostate cancer, particularly high-risk disease, as well as the global rise in life expectancy, determining the appropriate age range for screening is a key question.
This large study, including more than two decades of follow-up, shows a reduction in prostate cancer mortality of 13% in favor of PSA screening.