Research Analysis · Health & function
PSA screening lowered prostate-cancer mortality—and increased diagnoses
After 21 years in Rotterdam’s ERSPC section, repeated PSA-based screening reduced prostate-cancer mortality and metastatic disease in the primary age group, while producing substantially more prostate-cancer diagnoses.
By Lois Rune
Published August 24, 2026 · Updated August 24, 2026 · AI-assistance disclosure
Evidence scope
Human prostate-cancer mortality and diagnosis · long randomized screening follow-up
Cancer-specific benefit and overdiagnosis risk must be read together
In the primary age group, prostate-cancer mortality was lower with screening (RR 0.73), as was metastatic disease (RR 0.67). Screening also produced 57 excess prostate-cancer diagnoses per 1,000 men randomized.
Who and what was tested
42,376 men age 55–74 in Rotterdam; the primary analysis focused on 34,831 men age 55–69 offered repeated PSA-based screening about every four years or usual care.
What led
Lower prostate-cancer mortality in the primary age group, alongside excess diagnoses and false positives.
What remains unknown
Which individual cancers would become harmful, whether the balance is favorable for a particular person, and any effect on all-cause survival.
The bottom line
The long Rotterdam follow-up shows why screening cannot be summarized as simply effective or ineffective. Fewer prostate-cancer deaths and metastatic diagnoses came with more cancer diagnoses, some representing disease that would never have caused symptoms or death.
What the randomized evidence found
In men age 55–69, prostate-cancer mortality relative risk was 0.73 (95% CI 0.61–0.88), and metastatic prostate cancer relative risk was 0.67 (95% CI 0.58–0.78).
The study reported 57 excess prostate-cancer diagnoses per 1,000 men randomized to screening. Across five ERSPC centers, 17.8% of screened men experienced at least one false-positive result.
Benefit and harm travel together
Benefit measured
Lower prostate-cancer mortality and metastatic disease in the primary age group.
Extra diagnoses
57 additional prostate-cancer diagnoses per 1,000 men randomized to screening.
Older entry age
For men randomized at age 70 or older, mortality RR was 1.18 (95% CI 0.87–1.62); no difference was demonstrated.
Why screening results are easy to misread
Lead-time bias can make survival after diagnosis look longer because diagnosis happens earlier even if death does not. Length bias makes periodic screening more likely to find slower-growing disease. Overdiagnosis means finding disease that would never have caused symptoms or death.
Lead-time bias can make survival after diagnosis look longer because the clock starts earlier even when the date of death does not change. Length bias makes periodic screening more likely to find slower-growing disease. Overdiagnosis means finding a cancer that would not have caused symptoms or death.
The paper treated all-cause death as competing-risk context; it did not demonstrate that PSA screening extends overall survival. Cancer-specific mortality is not a substitute for lifespan.
What this means for a screening decision
Current final U.S. guidance calls for individual decision-making for men age 55–69 and recommends against PSA-based screening at age 70 or older. An update is in progress. Preferences about possible mortality benefit, biopsy, treatment effects and overdiagnosis are central.
Screening can create both benefits and harms. Eligibility, prior testing, family and medical history, competing health risks, and personal preferences belong in a conversation with a qualified clinician.
Sources, funding and editorial method
Funding and conflicts. The Rotterdam follow-up was funded by the Dutch Cancer Society, the Netherlands Organisation for Health Research and Development, the Dutch Cancer Research Foundation and an unconditional grant from Beckman-Coulter-Hybritech. The focal paper reports no author conflicts relevant to the manuscript; “unconditional” is the paper’s description and does not hide the commercial support.
- Rotterdam ERSPC 21-year follow-up
- Corrected Rotterdam proof record
- ERSPC false-positive analysis
- USPSTF prostate-cancer screening recommendation
- Evidence review and prose drafting were separate. The article uses a frozen claim map with claim-by-claim source support.
- Primary population, outcomes, absolute context, limitations, adverse events, funding and conflicts were checked before publication.
- Lois Rune is responsible for the byline and final editorial framing. AI assisted with research organization and drafting under the published editorial disclosure.
- This is educational reporting, not personal medical advice.
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Article history
- : First published after three evidence-review passes and source/correction verification.
- Sources will be rechecked when guidance or the primary records change.