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Navigating the prostate specific antigen (PSA) screening quagmire is challenging without falling into prostate cancer’s “heterogeneity black hole.” I read the 23 year follow-up of the European Randomized Study of Screening for Prostate Cancer (ERSPC), presented as confirming a “sustained reduction in deaths,” as exacerbating this dilemma by amplifying modest gains (13% relative risk reduction; rate ratio 0.87, 95% confidence interval 0.80 to 0.95) while downplaying substantial harms.1 With an absolute risk reduction of 0.22% (0.10 to 0.34; number needed to invite 456, 306 to 943), the update reinforces why no country mandates routine PSA screening: the overdiagnosis burden rarely justifies the benefit.2