Men who consistently avoid prostate cancer screening appointments face a disproportionately higher risk of dying from the disease, finds research identifying a new high-risk group.

An analysis of data from across seven countries from the world’s largest prostate cancer screening study, the European Randomized study of Screening for Prostate Cancer (ERSPC), is presented at the European Association of Urology (EAU) Congress in Madrid.

Prostate cancer is the most common form of cancer in men in 112 countries, with prevalence expected to double by 2040. If introduced on a national scale, prostate cancer screening programs that measure levels of prostate-specific antigen (PSA) in the blood have the potential to give men earlier access to treatment and a better chance of being cured. They can also prevent costly treatment associated with advanced prostate cancer.

Long-term follow-up data from the ERSPC consistently report that PSA screening programs can lead to a 20% reduced risk of dying from prostate cancer.

Now, a sub-analysis of 20-year follow-up data from the ERSPC is the first to look at the link between consistently declining screening invitations and the risk of dying from prostate cancer. It reveals a stark contrast that emphasizes the potential consequences of avoiding screening.

The analysis was led by researchers from the Department of Urology, Erasmus MC Cancer Institute at the University Medical Center Rotterdam, The Netherlands.

Of 72,460 men invited to the screening, around one in six men (over 12,400) were non-attenders and skipped every appointment. This group had a 45% higher risk of dying from prostate cancer compared with those who attended screening appointments.

When comparing outcomes with the control group—men who were never invited to screening—men who attended screening appointments had a 23% lower risk of dying from prostate cancer, while non-attenders faced a 39% higher risk of death from the disease.

Deciding not to participate in screening is a choice that may be driven by a complex mix of factors, according to the study’s lead author, Renée Leenen MD, a Ph.D. researcher in the group of Professor Monique Roobol at the Erasmus MC Cancer Institute.

“It may be that men who opted not to attend a screening appointment are care avoiders, meaning they’re less likely to engage in healthy behaviors and preventative care in general. This is the opposite behavior of people who are perhaps more health-conscious and are more likely to attend a screening appointment.

“Our study identifies that men who were invited for screening, but do not attend screening appointments are at significantly higher risk of dying from prostate cancer compared to men who were not offered screening or accepted an invitation for screening.

“We need to better understand who these men are, why they choose not to attend appointments, and how to motivate them. This will help us to design population-based prostate cancer screening programs that encourage higher rates of informed participation. Tackling attendance rates in this way could be a big factor in the long-term success of a national prostate screening program.”

Through the EAU-led PRAISE-U project, several EU countries are working to align approaches to patient-tailored, risk-based population screening programs for prostate cancer. This latest research highlights the critical issue of attendance if national prostate cancer screening programs are to be successful, and the need to improve awareness and address inequalities in access to screening for this higher-risk group of men.

The new analysis also suggests that the overall benefit of screening for prostate cancer is higher than previously thought, says Dr. Tobias Nordström, Clinical Urologist at the Karolinska Institute in Sweden, and Member of the EAU Scientific Congress Office.

“For countries around Europe that are planning to introduce a national prostate screening program, this analysis focusing on attendance shows that men who participate in screening have a much-improved long-term benefit than what we’ve seen from previous studies,” he said.

“But it highlights a group of men who need our attention, as they’re more at risk of developing advanced prostate cancer and dying from it. We need to better understand why these men might actively choose not to participate in screening, despite being invited to attend, and how this behavior is linked to worse outcomes when they get a diagnosis.”

The sub-analysis included 20-year follow-up data from 161,000 men aged 55–69 years in the ERSPC across Finland, the Netherlands, Italy, Sweden, Switzerland, Belgium and Spain.

The ERSPC was launched in 1990 across eight European countries, and the full results of this sub-analysis are expected to be published later in 2025.