How to cite: Rose B. Screening Strategies: Debating Optimal Approaches – Risk-Stratified Screening. Grand Rounds in Urology. November 13, 2025. Accessed Feb 2026. https://grandroundsinurology.com/screening-strategies-debating-optimal-approaches-risk-stratified-screening/
Summary
Brent Rose, MD, Associate Professor of Radiation Medicine and Applied Sciences and Urology, University of California, San Diego, California, presents a counterpoint perspective on prostate cancer screening, emphasizing that while prostate-specific antigen (PSA)-based screening does save lives, its overall impact is modest and accompanied by meaningful limitations. He explains that long-term data from large European screening studies demonstrate a reduction in prostate cancer mortality of approximately 13 percent, but many men still die from prostate cancer despite undergoing PSA testing. In addition, screening results in substantial overdiagnosis, with many indolent cancers detected that may never cause harm.
Dr. Rose notes that PSA alone is an imperfect screening biomarker due to its low signal-to-noise ratio. Elevated PSA levels often lead to biopsies that identify low-grade disease, while some clinically significant cancers are missed altogether. As a result, universal PSA screening yields mediocre outcomes and does not optimally balance benefits and harms. He argues that doing nothing is not the answer, but screening everyone the same way is also not appropriate.
The presentation focuses on risk-adapted screening strategies designed to improve the detection of aggressive prostate cancer while minimizing unnecessary biopsies and overdiagnosis. Dr. Rose reviews magnetic resonance imaging (MRI)-integrated screening pathways, which are now considered the standard of care. In these pathways, MRI serves as a triage tool after PSA testing, guiding biopsy decisions.
Dr. Rose also discusses emerging approaches, including polygenic risk score-based screening and midlife baseline PSA testing. He highlights data showing that men with very low PSA levels in midlife have an extremely low risk of prostate cancer diagnosis or death many years later, allowing screening intensity to be safely reduced. He concludes that risk-stratified screening, rather than universal PSA testing alone, offers the most promising path forward to improve outcomes while reducing harm.
About the 32nd Annual Perspectives in Urology: Point Counterpoint conference: Presented by Program Chair and Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, this conference brought together leading experts in urology, medical oncology, and radiation oncology to discuss and debate the latest topics in genitourinary cancers, primarily prostate cancer and bladder cancer. This interactive conference offered topical lectures, pro/con debates, interesting-case presentations, interactive panel discussions, and interactive audience and faculty networking.
ABOUT THE AUTHOR
Brent Rose, MD, is an Associate Professor and the Director of the Division of Radiation Oncology at the University of California, San Diego, and serves as Co-Lead of the Moores Cancer Center Genitourinary Disease Team. Dr. Rose specializes in treating prostate cancer, head and neck cancer, skin cancer, brain metastases and primary brain tumors. His expertise includes conformal radiation therapy, intensity-modulated radiation therapy, image-guided radiation therapy, and high-dose rate and low-dose rate brachytherapy.
