Key performance indicators for organized risk stratified prostate cancer screening in Europe: first results from the PRAISE-U and EUCanScreen pilots and the Swedish organised prostate cancer testing programme

Prostate cancer is the most commonly diagnosed cancer in men across the European Union, yet finding it at the right moment presents a difficult balancing act. Doctors have long relied on a blood test that measures a substance called prostate-specific antigen, or PSA, to look for signs of the disease. However, this test is not perfect; it often flags men who do not have cancer, leading to unnecessary anxiety and invasive procedures. Furthermore, it sometimes detects slow-growing cancers that would never have caused harm in a man's lifetime, leading to treatments that carry their own risks. To solve this, European health authorities have begun testing a more sophisticated approach. Instead of treating every man the same, this new strategy sorts men into different risk groups based on their initial test results. Those with higher risk then undergo a specialized magnetic resonance imaging scan, known as an MRI, which acts as a filter to identify only the most dangerous tumors before a biopsy is performed. The goal is to catch the cancers that truly need treatment while sparing men from the harms of over-testing.

A major collaborative effort across Europe has now taken the first real-world measurements of how well this complex system works in practice. Researchers from the PRAISE-U project, along with partners in the EUCanScreen initiative and the established Swedish screening program, gathered data from five pilot sites in Spain, Lithuania, Poland, and Ireland, as well as from other ongoing programs. They did not just look at whether the tests were done; they tracked the entire journey of a man from the moment he received an invitation to the final decision on treatment. This journey involves several steps: an initial invitation, a blood test, a risk assessment, an MRI scan if needed, and potentially a tissue sample. The team defined twenty-one specific measures, or performance indicators, to see how smoothly each step flowed and how many men were actually found to have cancer.

The results show that the medical pathway itself is feasible and can be managed effectively. When men were invited to participate, between 7.1 percent and 43.0 percent of them showed up for the initial screening, depending on the location. Once a man had a blood test that suggested a higher risk, the system worked well to guide him forward. In the pilot sites, between 76.4 percent and 96.0 percent of men who needed a risk assessment completed it. Even more impressive, between 89.9 percent and 98.3 percent of those who were referred for an MRI actually went for the scan, and between 78.9 percent and 99.0 percent of those who needed a biopsy received one. This high level of follow-through suggests that the complex chain of decisions required by this risk-stratified approach can be successfully implemented in a clinical setting.

The data also revealed how many cancers were found and what kind they were. Across the five pilot sites, the number of cancers detected ranged from 8 to 26 for every 1,000 men screened. The types of cancer found varied significantly from place to place. In some locations, the majority of detected cancers were low-grade and slow-growing, while in others, a larger share were more aggressive. For instance, in one Lithuanian site, over 80 percent of the cancers found were the slow-growing kind, whereas in a Spanish site, that figure was closer to 20 percent. This variation highlights that the specific mix of cancers found depends heavily on local conditions and the precise details of how the screening is run. Crucially, the system successfully identified clinically significant cancers that needed attention, while also identifying many low-risk cases that could be safely monitored without immediate surgery.

Time is a critical factor in screening, and the study measured how long it took for men to move from one step to the next. In the most efficient locations, it took as little as 19 days for a man to get an MRI after his blood test results were known. In other places, this wait stretched to 114 days, largely because of logistical hurdles like mailing home test kits and scheduling clinic visits. Similarly, the time between getting a biopsy result and starting treatment varied, with some sites taking over five months. These delays matter because long waits can reduce a man's trust in the system and potentially affect his health outcomes. The Swedish program, which has been running for years with a national registry, reported the shortest times, suggesting that established infrastructure makes a significant difference in speed.

Perhaps the most revealing finding concerns the long-term success of the program. While the pilots proved that the medical steps could be completed, only the Swedish program was able to report on the broader, long-term impact of the screening. This is because Sweden has a national system that tracks every citizen over many years, allowing them to see who returns for a second or third round of screening and to measure whether the program is actually saving lives. The pilot sites, which are newer and smaller, could not yet measure these long-term effects or track how many men stayed in the program over time. This distinction is vital: it shows that while doctors can successfully perform the tests, running a true, organized screening program that benefits the entire population requires a level of data infrastructure that goes beyond the clinic.

Ultimately, this study confirms that the new, risk-based approach to prostate cancer screening is workable. It successfully guides men through a series of tests, filters out those who do not need invasive procedures, and finds the cancers that matter. However, the paper also makes it clear that turning this into a standard, nationwide system requires more than just good medical protocols. It demands a robust national infrastructure capable of tracking millions of people over decades, ensuring that men are invited at the right times and that their long-term health outcomes are monitored. The path forward is clear, but it requires building the digital and administrative foundations to support the medical advances that are already in place.