Comparing the effectiveness of prostate cancer screening protocols: European Association of Urology– and European Randomized Study of Screening for Prostate Cancer–based strategies

Prostate cancer (PC) screening reduces PC mortality but also causes burden such as overdiagnosis and unnecessary biopsies. The European Association of Urology (EAU) recently proposed a risk-adapted screening protocol incorporating prostate-specific antigen (PSA)-based intervals, a risk calculator (RC), and magnetic resonance imaging (MRI), though its long-term outcomes remain unquantified. We constructed the MIcrosimulation SCreening Analysis-PSA model by adapting the existing MIcrosimulation SCreening Analysis-PROstate microsimulation framework to simulate individual PSA trajectories. The model parameters were calibrated to outcomes of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Using this model, we simulated five screening protocols for men aged 55-69: fixed 4-year intervals between PSA tests and a biopsy when PSA ≥3.0 ng/mL (ERSPC protocol); PSA-based intervals; MRI prior to biopsy; the RC and MRI prior to biopsy; and the full EAU protocol (PSA-based intervals, RC, and MRI). Outcomes included PC mortality, overdiagnoses, the number of PSA tests, biopsies, and MRIs. Compared to the ERSPC protocol, PSA-based intervals reduced PSA tests by 21%. The MRI-only protocol decreased overdiagnosis by 6% but also required many MRIs. Incorporating the RC further reduced overdiagnosis to 10% and required 36% fewer MRIs than the MRI-only protocol. The EAU combines the best of all these approaches while maintaining equal PC mortality (200 deaths per 10,000 men). The EAU protocol optimizes long-term screening efficiency, significantly reducing biopsies and overdiagnosis with minimal mortality trade-offs. MRI and RC integration enhance resource allocation.