Current Opinion in Urology · Oct 27, 2026

The future of prostate cancer screening: from prostate-specific antigen to smart, risk-adapted pathways

By Zhang DZ, Carson DS, Tosoian JJ

Purpose of review: Contemporary guidelines endorse multiparametric MRI (mpMRI) and noninvasive, blood- or urine-based biomarker testing to reduce unnecessary biopsies and overdiagnosis of low-grade disease in men with elevated PSA. Evidence guiding the optimal combined use of these tools remains limited. This review summarizes the comparative strengths of mpMRI and biomarkers and proposes a pragmatic, sequential pathway for their use in contemporary practice. Recent findings: mpMRI offers strong rule-in performance, improving detection of clinically significant prostate cancer (csPCa) through targeted biopsy, but its rule-out performance is limited outside expert centers, with negative predictive values approximating 75% in real-world settings. Biomarker testing offers objective, reproducible rule-out performance (90–95% sensitivity) and greater accessibility compared to MRI, though has limited specificity. As evidenced in the randomized ProScreen trial, we herein propose the optimal use of these tools in a biomarker-first, MRI-second pathway that leverages the complementary strengths of each. Summary: A biomarker-MRI pathway offers a practical, evidence-supported strategy to meaningfully reduce the harms of prostate cancer screening while preserving detection of clinically significant disease. Broader validation across diverse populations and maturing randomized data will further refine its optimal clinical application.

doi.org/10.1097/mou.0000000000001452PubMed 43017916Biomarkers