Prostate cancer screening: Who should we screen? Defining high-risk populations

Abstract

Introduction:

Interest in targeted prostate cancer screening has increased following the UK National Screening Committee’s November 2025 draft recommendation and public consultation, which supported a risk-stratified approach rather than population-wide prostate-specific antigen (PSA) screening. This literature review summarises current evidence for screening in high-risk groups, including men of Black ethnicity, those with a family history of prostate cancer, and carriers of pathogenic BRCA1/2 variants.

Methods:

A narrative review of landmark randomised screening trials, guideline documents, modelling studies, and prospective cohort data was performed, focusing on the effectiveness and limitations of targeted screening strategies in high-risk populations.

Results:

PSA-based screening reduces prostate cancer mortality in some settings but remains associated with substantial overdiagnosis. Contemporary pathways incorporating pre-biopsy magnetic resonance imaging (MRI) and active surveillance have improved the balance between benefit and harm. Recent UK modelling suggests that population screening is unlikely to be cost-effective, whereas targeted screening may offer greater value in selected high-risk groups, particularly BRCA2 carriers and potentially men of Black ethnicity.

Discussion:

Current evidence supports a move away from universal PSA screening towards structured, risk-stratified early detection. The strongest rationale exists for targeted screening in men with pathogenic BRCA2 variants, while evidence for other high-risk groups continues to evolve. Ongoing studies, including TRANSFORM, will be important in defining future UK screening policy.

Level of evidence:

Not applicable.