The title is not a trick question. At first glance, the answer to the riddle seems obvious. The goal is to find prostate cancer as early as possible. Right?
Well, it’s not quite as simple as that. The complication lies in the standard PSA test. For nearly half a century it’s been the least expensive and most common detection tool for prostate cancer. The real answer comes from a September, 2026 article from the esteemed medical journal The Lancet.
The article’s four expert authors from University College London describe the problem:
Despite decades of research and widespread use of opportunistic prostate-specific antigen (PSA) testing, most countries have not implemented population-based prostate cancer screening programmes. Long-term follow-up of large-scale screening studies shows that interval PSA testing reduces mortality, but at the cost of overdiagnosis and overtreatment of disease that would never have caused harm. The question is, thus, not whether screening works—it does—but how to deliver the benefits of early detection without creating unacceptable harm.[i]
Traditional screening is a two-sided coin
Use of the PSA test is a two-sided coin. On one side, PSA screening detected countless prostate cancers early, when a local treatment with intent to cure has high chances of success. If those cancers had been missed, eventually symptoms like difficulty urinating, blood in urine, erectile dysfunction, or pain in the back or pelvis would occur. For such advanced cases, a local treatment is ruled out. Instead, systemic treatments like hormones and chemotherapy are used to extend life, but at the price of unpleasant side effects. Therefore, early detection spared men from ultimate death due to prostate cancer.
However, here’s the flip side. Broad PSA screening has inflicted two significant harms.
- Overdetection. For decades, PSA tests with suspiciously high results led to immediate needle biopsy as the only way to rule prostate cancer in or out. Prostate biopsy is not without risks (e.g., bleeding, discomfort/pain, infection, even sexual dysfunction). Yet in the U.S. alone, based on PSA results, roughly a million biopsies have been performed annually—of which only a third actually diagnosed prostate cancer. And of the positive diagnoses, at least a third were inaccurate by either overestimating or underestimating the tumor’s aggression.
- Overtreatment. For the men whose biopsy turned out positive for prostate cancer, in most cases the recommendation was immediate whole gland treatment: either remove or radiate the prostate gland. This approach was based on the belief that all prostate cancer is multifocal (scattered throughout the gland) and equally dangerous. However, we now know that some prostate cancers do not behave aggressively. Now there are Active Surveillance protocols and focal therapy for prostate cancer that does not need immediate whole gland treatment.
Redefining the goal of screening
A Sep. 24, 2026 article in Renal & Urology News poses a challenge: “The goal should not be to find more prostate cancer but rather to find more prostate cancers that matter.”
To that end, the authors of The Lancet article point to how MRI rebalances the PSA-biopsy pathway. “Already embedded in the diagnostic pathway, MRI enables many men with elevated PSA to safely avoid biopsy and reduces detection of clinically insignificant disease.”[ii] It allows preserving the early warning system of PSA, yet avoids the overdetection and overtreatment harms by following up a suspicious PSA with MRI instead of an immediate biopsy.
To address the naysayers concerned about the time and economic costs of multiparametric MRI (mpMRI), the authors propose following a suspicious PSA with a 10-15 minute biparametric MRI (bpMRI, which eliminates the sequence using IV contrast). In most instances, bpMRI is sufficient to identify a lesion suspicious for significant prostate cancer, which can then undergo a less invasive MRI-guided targeted biopsy. And, if no suspicious area is visible on bpMRI, the patient can safely be monitored via the ongoing PSA-MRI pathway at prescribed intervals.
The cancer that truly matters
Finally, the authors define what truly matters as “cancers likely to cause significant morbidity or mortality if left untreated. … With the introduction of pre-biopsy MRI, the spectrum of detected disease has shifted, with fewer Gleason 3+3 cancers and increasing detection of small-volume Gleason 3+4 lesions.”[iii]
And, the news article mentioned above names other technological improvements that refine prostate cancer diagnosis, such as molecular imaging (PSMA/PET MRI) and genomic biomarkers.
The Sperling Prostate Center provides a full array of MRI-based detection, diagnosis, and image-guided focal therapy methods for qualified patients. We offer excellence in monitoring for those patients who choose to go on Active Surveillance. If you or a loved one is concerned about prostate cancer, contact us for more information.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
References
[i] Thorley N, Atkinson D, Emberton M, Punwani S. Rethinking prostate cancer screening: finding what matters. The Lancet. 2026;1(2); 100020. https://www.thelancet.com/journals/lanmit/article/PIIS3117-4523(26)00020-1/fulltext
[ii] Ibid.
[iii] Ibid.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
