Prostate screening

Prostate cancer behaves very differently from patient to patient: some tumours grow so slowly that they never cause a man any problems in his lifetime, while others are aggressive and should be detected early. Modern prostate screening therefore pursues two goals – detecting dangerous carcinomas early while avoiding unnecessary biopsies and treatments. That PSA-based early detection can save lives was shown in particular by the large European ERSPC study: after 16 years of follow-up, repeated PSA screening produced a meaningful reduction in prostate-cancer-specific mortality – while also making clear that screening needs to become more precise to reduce overdiagnosis.

When to start? Personal risk decides

There is no longer a single age limit that applies to all men. European guidelines recommend that men without particular risk factors discuss PSA-based screening from around age 50; the American guideline already considers a first baseline PSA value a reasonable strategy between ages 45 and 50. An earlier start – from around age 45, or as early as 40 with a known BRCA2 mutation – is recommended for men with prostate cancer in the family or of African descent. Early counselling is especially important with several affected men in the family, prostate cancer at an unusually young age within the family, or a known hereditary tumour syndrome such as BRCA2.

PSA, digital rectal exam and PSA density

The PSA value is determined with a simple blood draw and is the most important starting point for early detection. An elevated value does not automatically mean cancer, however – we never assess it in isolation, but always together with age, prior values, prostate size, family history and other risk factors; with a newly elevated PSA, the value is first rechecked before any further steps. The large German PROBASE study also showed that a very low baseline PSA in midlife allows for long follow-up intervals. The classic digital rectal examination has proven considerably less reliable as a stand-alone screening test than long assumed, and is therefore no longer part of our routine screening – but it remains a useful complementary examination in case of symptoms, a suspicious PSA or elevated risk. Since a larger prostate naturally produces more PSA, we relate the value to the prostate volume determined by ultrasound or MRI where needed (PSA density), and for selected patients also draw on the Stockholm3 blood test for a more precise risk assessment.

Imaging before biopsy: mpMRI and fusion biopsy

Rather than proceeding straight to biopsy with an elevated PSA, we first clarify with a high-resolution multiparametric MRI (mpMRI) whether an area suspicious for a clinically significant tumour is even visible. International studies such as PROMIS, PRECISION and MRI-FIRST show that this MRI-based pathway avoids unnecessary biopsies while improving detection of clinically significant tumours; the Swedish GÖTEBORG-2 study was able to roughly halve overdiagnosis of insignificant tumours this way. Whether a biopsy is actually needed is never decided on the PI-RADS score alone, but always together with PSA, PSA density and family history. Where a tissue sample is required, we perform an MRI/ultrasound fusion biopsy using the Artemis® system, which digitally overlays the MRI images onto the live ultrasound – enabling millimetre-precise sampling from suspicious areas.

If prostate cancer is found

Even a cancer diagnosis today does not automatically mean surgery or radiation: for a low-aggressiveness tumour, active surveillance is often appropriate, with structured monitoring through PSA, clinical checks and MRI. Where treatment is needed, our regional network offers Da Vinci robot-assisted radical prostatectomy or radiotherapy at the specialised robotic urology unit of Lucerne Cantonal Hospital (LUKS). We decide on the right path together with you, based on the tumour's aggressiveness and extent, PSA value, MRI and biopsy findings, and your personal wishes. For more on treatment options, see Prostate cancer.