High-risk prostate cancer screening – More Bang for our buck?

Abstract

Background/Aim:

Prostate cancer screening remains limited by the biological heterogeneity of the disease and the inability of current approaches to reliably distinguish indolent from high-risk cancer. Population-based screening has demonstrated only modest reductions in prostate cancer-specific mortality, accompanied by substantial overdiagnosis and overtreatment, highlighting the need for more selective strategies. Risk-stratified screening has therefore emerged as a potential solution, aiming to enrich the detection of aggressive disease while minimising harm. This mini-review evaluates the evidence supporting targeted screening approaches, focusing on high-risk groups including men with a family history, inherited genetic susceptibility, Black ethnicity, and older age.

Methods:

A narrative review of the literature covering targeted screening approaches, focusing on men with a family history of prostate cancer, inherited genetic susceptibility to cancer, Black ethnicity, and older age.

Results:

While family history, inherited genetic susceptibility, Black ethnicity, and older age are consistently associated with increased prostate cancer incidence, their utility in identifying men at risk of high risk of disease is variable. Germline BRCA2 mutation carriers represent the most clearly defined high-risk group, with evidence of earlier onset, higher incidence, and a greater proportion of aggressive disease, although their low population prevalence limits impact at scale. In contrast, family history and ethnicity are heterogeneous and context-dependent, while older age reflects a high burden of disease but uncertain screening benefit due to competing mortality and delayed treatment effects. Advances in imaging, biomarkers, and multivariable risk models have created the potential for layered screening pathways that combine low-cost triage tests with progressively more specific risk-enrichment tools.

Conclusions:

Current evidence suggests that effective screening will require an integrated, risk-adapted approach delivered within organised programmes. Ongoing trials are expected to define optimal implementation strategies, including eligibility criteria, screening intervals, and diagnostic pathways.

Level of evidence:

Not applicable