Prostate cancer (PCa) screening has long relied on PSA testing, a strategy that has shaped diagnostic pathways for decades but remains limited by substantial overdiagnosis and downstream overtreatment. As screening practices evolve, the relevance of historical evidence must be reconsidered in the context of contemporary diagnostic workflows that now incorporate imaging, refined biopsy techniques, and risk-adapted management. This narrative review examines the transition from PSA-only screening toward modern, risk-adapted early detection strategies. We synthesize evidence supporting the integration of mpMRI, refined biopsy techniques, and active surveillance (AS) as key components of contemporary screening pathways aimed at improving the detection of clinically significant disease while minimizing unnecessary interventions. Particular emphasis is placed on second-line MRI-based approaches, which consistently reduce the number of avoidable biopsies and enhance the diagnostic precision. In addition, we review the role of blood-based and genomic biomarkers in pre-biopsy risk stratification, discussing established tools within a unified framework of individualized screening. The review also contextualizes very recent regulatory developments, including the FDA approval of a novel structure-based PSA assay, as part of the ongoing evolution of biomarker-supported screening rather than a paradigm shift. Overall, this article provides a timely synthesis of mature randomized evidence and emerging diagnostic innovations, offering a clinically grounded perspective on how PCa screening is being reshaped toward more personalized and harm-aware strategies.

Background and purpose: We aimed to describe temporal changes in diagnostic work-up, treatment, and prostate cancer (PCa) mortality in locally advanced PCa in 2016–2024 in Sweden. Patient/material and methods: Men registered in the National Prostate Cancer Register of Sweden in 2016–2024 with locally advanced PCa; clinical T stage 3–4, no distant metastases, and prostate-specific antigen < 100 ng/ml were included. We computed the proportion of use of prostate magnetic resonance imaging (MRI) before biopsy, radical prostatectomy, radical radiotherapy, androgen deprivation therapy, and abiraterone, and described the trend in PCa mortality across three calendar periods.Results: During the 9-year study period 7,484 men with locally advanced PCa were identified. Use of MRI before biopsy increased from 3% in 2016 to 73% in 2024. Concomitantly, radical treatment increased from 35% to 48%, entirely due to increased use of radiotherapy. Abiraterone was not used before 2022 but 31% received this treatment in 2024. The 3-year PCa mortality decreased from 8% (95% confidence interval [CI]: 7–9) in 2016–2018 to 6% (95% CI: 4–8) in 2022–2024. Interpretation: In this nationwide, population-based study of men with locally advanced PCa, the use of MRI before biopsy, radical radiotherapy, and treatment with abiraterone increased over time. These changes coincided with a modest decrease in 3-year PCa mortality.