PSA Testing in 2025: New Evidence, New Risks, New Rules (and Old Guidelines)
- The Review Course in Family Medicine
- 4 hours ago
- 2 min read
A "gland" new approach to screening.
In 2025, we now have 23 years of follow-up data that changes the conversation about the harms and benefits of screening for prostate cancer… but the CTFPHC Canadian “Don’t Screen” guidelines were last updated in 2014. Your patients might hear about this in the news, and ask why you’re saying no to PSA. The data with longer-term PSA screening shows:
Mortality risk dropped by 13%
Absolute risk reduction is rising
One death prevented per 456 screened (was 628)
It's a classic hallway consult: a 58-year-old patient wants a prostate-specific antigen test because their friend just had a "targeted MRI" for screening. Since 2014, the Canadian Task Force on Preventive Health Care has recommended against routine screening (disagreeing with the Canadian Urological Association guidelines suggesting to discuss at age 50 if life expectancy is over 10 years). This created a mess of "opportunistic screening." Patients with high health literacy get tested, while underserved populations often present with metastatic disease.
The 2025 data from the European Study of Prostate Cancer Screening (ERSPC) is a game-changer. With 23 years of follow-up, the absolute risk reduction for death is increasing while the harm-to-benefit ratio is improving. We are moving away from the "PSA-to-biopsy" pipeline. Instead, we use a risk-stratified approach.
Management:
Active Surveillance: Monitoring low-risk tumours with serial PSAs and imaging to avoid the "Big Three" harms (impotence, incontinence, and anxiety).
Risk Stratification: Using pre-biopsy magnetic resonance imaging or microultrasonography to decide who actually needs a needle in the prostate.
Organized Programs: Proposing provincial trials where patients are invited based on age and risk, rather than waiting for them to ask.
What about the "Big Three"? We still need to discuss impotence, incontinence, and the psychological burden of a cancer diagnosis. However, 2025 evidence shows that modern diagnostic pathways—like using upfront magnetic resonance imaging—can reduce harm from the diagnostic process by nearly 80%.
EXAM TIP: On a prostate SAMP, don't forget that Active Surveillance is a management step, not a "do nothing" approach. If the question asks for management of a low-risk, asymptomatic patient, look for Active Surveillance (serial PSAs/imaging) rather than "Watchful Waiting," which is typically reserved for those with limited life expectancy where we only treat symptoms.
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