Prostate Cancer Screening: The Population Benefit Outweighs the Harm (Pro)

Long-term evidence from randomized trials demonstrates that prostate-specific antigen (PSA)-based screening reduces prostate cancer (PCa)-specific mortality, and modern risk-adapted strategies reduce unnecessary investigations and overdiagnosis. The relevant policy choice is no longer between screening and no screening. PSA testing is already widespread and largely opportunistic. This "Wild West" approach has three fundamental shortcomings: it is less effective in reducing PCa mortality, consumes substantial health care resources, and perpetuates socioeconomic disparities. Organized screening offers an opportunity to screen better by focusing screening and diagnostic evaluation workup on men most likely to benefit while reducing unnecessary interventions among those at low risk. Replacing opportunistic testing with organized, risk-adapted screening can therefore maximize population benefit while minimizing harms, inefficient resource use, and inequity. The debate should move beyond whether PCa screening should occur to how screening can be organized to achieve the greatest population benefit.