PSA screening: about two fewer prostate cancer deaths per 1,000 men

Design

Cochrane systematic review of randomised trials (abridged update)

Population

6 RCTs, 789,086 men without prior prostate cancer

Primary outcome

Prostate cancer-specific and all-cause mortality

Effect

Cancer-specific RR 0.87 (0.80-0.95); all-cause RR 0.99 (0.97-1.00)

An abridged update of the Cochrane review (BJU International, 1 October 2026) included six randomised trials with 789,086 men followed for 3 to 23 years; five tested PSA alone, and one (ProScreen) PSA with a kallikrein panel and MRI.

Based mainly on the ERSPC trial in a risk-of-bias sensitivity analysis, screening likely reduces prostate cancer-specific mortality (RR 0.87, 95% CI 0.80-0.95; moderate certainty) - about two fewer deaths per 1,000 men screened. Across four trials, screening may slightly reduce all-cause mortality (RR 0.99, 0.97-1.00; low certainty), an interval that includes no effect. There was little or no difference in screening-related adverse events. ProScreen increased detection, and its mortality results are not yet mature.

The review moves the evidence from 'no clear benefit' in 2013 to a likely, modest benefit. That supports offering informed, shared decisions about screening rather than either routine testing or discouragement, and the balance with overdiagnosis still needs explaining.

• Offer men a shared decision about PSA screening, explaining a likely benefit of about 2 fewer deaths per 1,000
• Explain overdiagnosis and the possibility of treating a cancer that would never have caused harm
• Use MRI before biopsy where available to reduce unnecessary biopsies
• Follow your national guidance on screening ages and intervals

Why it matters

The best summary of screening trials now finds a likely mortality benefit, which shifts how screening conversations should be framed.

Don't overread it

A modest, moderate-certainty benefit on cancer deaths - not proof screening extends overall life.

The statistics, in plain English

An RR of 0.87 means about 13% fewer prostate cancer deaths, which against a baseline of 16 per 1,000 is about 2 per 1,000. The all-cause mortality interval reaches 1.00, so a real effect on overall survival is uncertain. Certainty ratings reflect bias and inconsistency across the trials.

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