Opportunistic PSA testing is not the safe alternative

Summary Austria has never implemented an organized prostate cancer screening program, yet opportunistic PSA testing has been widespread for more than three decades. This has produced the harms of screening without the safeguards of a program: testing outside appropriate age and life-expectancy windows, repeated testing of low-risk men, unnecessary biopsy, overdiagnosis and overtreatment, while generating little systematic information on quality or outcomes. Randomized evidence shows that organized, repeated screening can reduce prostate cancer mortality substantially, whereas opportunistic testing delivers less benefit with more overdiagnosis. Contemporary risk-adapted pathways further improve the balance of benefit and harm: defined start and stop ages, PSA-based risk stratification, MRI before biopsy, targeted biopsy, and active surveillance can reduce unnecessary biopsies and detection or treatment of indolent disease without compromising detection of clinically significant cancer. Europe has therefore moved toward organized, PSA-based screening with MRI as a follow-up test. Austria is now participating in PRAISE-U Plus and has initiated a national multidisciplinary consensus process involving 65 experts from 22 organizations. The policy question is no longer whether Austrian men are being screened—they are—but whether screening remains unstructured or becomes organized, quality-assured and equitable. The evidence supports the latter: invite the right men, stratify risk, biopsy selectively, treat only clinically relevant disease, and measure outcomes systematically.