Prostate cancer screening

Dr Mia Hugo educates us on the age at which men should start prostate cancer screening.

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Prostate cancer represents a significant spectrum of disease, ranging from non-aggressive, slow-growing tumours to highly-aggressive disease with a high risk of metastases. 

After skin cancer, it’s the most diagnosed cancer in males globally. Since there are often no symptoms in its early stages, screening is the primary tool for early detection. However, deciding exactly when and who to screen requires balancing the benefits of catching aggressive cancers early against the risks of overdiagnosing and overtreating slow-growing tumours.

The paradigm of shared decision-making

Historically, widespread prostate-specific antigen (PSA) screening led to a dramatic downward trend in prostate cancer stage at diagnosis, reducing mortality but inadvertently causing high rates of overtreatment.¹ 

Today, local and international guidelines emphasise that screening must be rooted in informed, patient-based shared decision-making.

The foundational principle is that screening should be offered to healthy individuals only after a thorough discussion of the potential harms and benefits. Furthermore, South 

African and international guidelines all agree that screening is generally inappropriate for individuals with a life expectancy of less than 10 years.^1,2,3

The local approach: South African guidelines

South Africa faces a distinct demographic reality: prostate cancer disproportionately affects Black African men, who tend to develop the disease at younger ages. Consequently, local guidelines utilise a risk-stratified approach to determine the appropriate age to initiate screening.

According to South African guidelines, informed patient-based screening is recommended in males with a life expectancy of more than 10 years in the following situations:³

• High risk (Age 40): Screening is initiated at age 40 for Black African patients and for individuals with a positive family history of prostate and/or breast cancer in a first-degree relative.
• Average risk (Age 45): Baseline PSA testing is recommended starting at age 45 for all other males.

In addition, patients with a history of lower urinary tract symptoms (LUTS) and/or a clinical suspicion of prostate cancer should have their PSA tested regardless of their age group.

International perspective 

The European Association of Urology (EAU) strongly advocates for a risk-adapted strategy based on individualised life expectancy and baseline PSA values to dictate screening intervals.² Their age-based recommendations are:

• • Average risk (Age 50): Baseline PSA testing should commence at age 50.
• • High risk (Age 45): Screening should begin at age 45 for men of African descent and those with a positive family history of prostate cancer.
• • Genetic risk (Age 40): Screening should begin at age 40 for men carrying known BRCA2 mutations.

The National Comprehensive Cancer Network (NCCN) gives a USA perspective and the 2026 guidelines notes a concerning recent increase in the incidence of metastatic disease in individuals under 55 years of age, particularly in Black/African American men. Their key age-based recommendations lean slightly earlier than the EAU, aligning closer to South Africa:

• Average risk (Age 45): Initiate informed testing at age 45.
• High risk (Age 40): Initiate shared decision-making at age 40 for those of African ancestry, those with germline variants linked to prostate cancer (BRCA1/2), and those with a concerning family history.
• Discontinuation (Age 75+): Continuing screening beyond age 75 should be  done only on an individualised basis considering the risks and benefits of testing, treatment, co-morbidities, and life expectancy. 

Digital rectal examination (DRE)

A DRE is when a doctor inserts a gloved, lubricated finger into the rectum to feel the prostate. Including a DRE as part of prostate cancer screening is controversial as a DRE only examines the posterior aspect of the prostate (although this is where most cancers occur) and may miss anterior or small tumours in the early stages of the disease that the PSA will pick up. 

It’s not a very sensitive test which is why some guidelines no longer recommend DRE as a primary screening test for prostate cancer. It’s also dependent on the experience of the doctor doing the examination. In combination with a PSA blood test and done by an experienced professional, it may increase prostate cancer detection, but it’s best to consider this on an individual basis depending on patient symptoms and risk factors.⁴

Screening intervals

Screening intervals are dictated by the patient’s underlying risk – whether high risk or average risk and the initial screening PSA. Depending on initial risk, PSA can be  repeated every one to two years and in some low-risk cases even up to 2-4 yearly.¹ 

In South Africa the general recommendation would be 1-2 yearly. 

Investigations following screening

A focused urological history and clinical examination form the basis of all assessments in the South African context. Both the EAU and NCCN strongly recommend the use of multi-parametric MRI (mpMRI) prior to a prostate biopsy to avoid unnecessary procedures.^1,2 

If a mpMRI reveals suspicious lesions, an image-guided targeted biopsy (often combined with a systematic regional biopsy) is the preferred standard of care. This imaging-first approach preserves the diagnostic lead time while significantly minimising the detection of indolent disease.

Conclusion

The decision of when to start prostate cancer screening is dependent on individual risk factors. Average-risk men should initiate screening conversations between ages 45 and 50, while high-risk men, particularly those of African descent or with a strong family history, should begin as early as age 40. 

By integrating robust clinical evaluations with advanced diagnostic pathways like pre-biopsy mpMRI, practitioners can maximise the detection of treatable disease while minimising the burden of overdiagnosis.

References

1. National Comprehensive Cancer Network. (2026). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Prostate cancer early detection (Version 2.2026).
2. European Association of Urology. (2024). EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on prostate cancer—2024 update. Part I: Screening, diagnosis, and local treatment with curative intent.
3. South African Urological Association. (2017). SOUTH AFRICAN PROSTATE CANCER GUIDELINES

Dr Mia Hugo is a radiation oncologist in private practice. She participates in weekly multi-disciplinary oncology team meetings for breast, urology, gastrointestinal, gynaecological, and head and neck cancers. She provides radiation to patients at Wits Donald Gordon, Netcare Milpark, Pinehaven and Olivedale hospitals, as well as at Busamed and 200 Rivonia Medical Centre.

Header image by Magnific