The PSA test after 50: what the European guidelines actually say
A raised PSA is not a diagnosis. Here is how European urology now uses a single blood test to decide who needs an MRI, who needs a repeat in two years, and who can wait five.
What PSA is
Prostate-specific antigen is a protein made by the prostate. It rises with age, with a benign enlarged prostate, with infection and after ejaculation or cycling. It also rises with prostate cancer. A single number therefore tells you about risk, not about diagnosis.
Who should be tested
European guidance recommends offering a first test at 50 to men who want to be informed, earlier at 45 for men with a family history of prostate cancer or of African descent, and from 40 for carriers of a BRCA2 mutation. The decision is shared: the test is offered with an explanation of what a result could lead to, not applied automatically.
How the result is used
The European Association of Urology moved to a risk-adapted schedule rather than testing everyone every year:
- Under 1.5 ng/ml: low risk. Repeat in about five years.
- 1.5 to 3 ng/ml: intermediate. Repeat in about two years.
- Over 3 ng/ml: further assessment, which today means a multiparametric MRI before any biopsy is considered.
Research presented at EAU 2024 supported a five-year interval as safe for the low-risk group. The point of the structure is to find significant cancers while sparing most men repeated testing and unnecessary biopsies.
Why MRI comes first
A biopsy used to follow a raised PSA almost automatically. Now an MRI scan is used to look for a suspicious area. If the scan is clear, many men avoid a biopsy altogether. If it shows a target, the biopsy is aimed at it (an MRI-fusion biopsy), which finds important cancers more reliably and misses fewer.
What a raised result does not mean
Most raised PSA results are not cancer. Before concluding anything we repeat the test after a few weeks, check for infection, ask about recent activity and examine the prostate. Only then is imaging arranged.
In practice at the clinic
A men's health consultation includes a PSA where appropriate, a discussion of family history, and a clear plan for the next test date. Results are explained in writing. If imaging is needed we arrange it and review the report with you.
Sources: EAU 2024 five-year interval research, International prostate screening recommendations.
