Level 1 evidence shows PSA testing saves lives, with numbers needed to screen and treat per life saved better than for breast or colon cancer. Carefully done, it probably halves death rates. The issues with PSA testing relate to downsides of potential over-diagnosis and overtreatment of insignificant cancer. Recent advances in MRI diagnostics, improvements in radical therapies, and surveillance of low-risk cases are gradually mitigating these issues. It is important to discuss the pros and cons of reduced death rates vs. potential over-diagnosis and overtreatment with patients before embarking on PSA testing. Men 40-70 years of age are those most likely to benefit from early detection. WHEN TO START FIRST PSA at 40-45yo to risk-stratify (i.e. before BPH develops to confound the result) ½ of all men dying of prostate cancer had a baseline PSA >1.5 in early 40’s.  PSA <0.6 at this age confers a very low risk. HOW OFTEN?  Recommendations vary. The following is my personal interpretation of “smart screening”. 40’s   PSA <1.0 - once every 5 years PSA >1.0 or high risk  once/ year  (watch especially carefully if >1.5)   50+      PSA <1.0  - once every 5 years PSA   1.0 to 2.0  - every 2-3 years PSA >2.0 or high risk  - once/ year                 HIGH RISK  - Family History Ca Prostate (especially if <60yo), BRACA, or Lynch Syndrome nb Lower urinary tract symptoms are not associated with early Ca Prostate (but can be with advanced disease)   WHEN TO REFER? - Recommendations vary. a) 40’s - PSA >2     >50  - PSA >3 (more aggressive approach) OR      b) use lab reference ranges (less aggressive approach) PSA’s can bounce quite a bit – if there is an odd jump in a PSA (and there is no hard prostatic nodule), a repeat reading 6-8 weeks later is reasonable. Even if the repeat reading is lower, still consider referral if the level remains abnormal.   Do a PR to check for a nodule if thinking of just “seeing what the PSA does” Palpable hard nodule, irrespective of PSA   WHEN TO STOP? Elderly or infirm with <10 year anticipated survival 75 yo with PSA <3.0 (mortality from prostate cancer approaches zero) A routine annual PR in the elderly/infirm to screen for locally advanced disease is reasonable.   Other PSA tips - There is no need to order a routine U/S urinary tract if the only issue is an elevated screening PSA - Don’t order a PSA in acute cystitis, acute retention, or acute symptoms of uncertain etiology as the result will usually be high, uninterpretable, and cause a lot of anxiety.   What about MRI Prostate? This is a game-changer in prostate cancer diagnostics, with better detection of significant cancers. When combined with alterations in biopsy techniques, it may also reduce identification of insignificant cancers, and hence reduce over-diagnosis and overtreatment.  mpMRI prostate is very difficult to perform and interpret correctly. It requires specialised MRI techniques, specific radiologist training, and urologist clinical input. Even in the best of hands, some significant cancers are still MRI invisible. Given the potential for misinterpretation and misunderstanding of this emerging diagnostic aid, the general radiological and urological view is to refer any patient of concern to a Urologist before performing prostate MRI.