We review the role of prostate-specific antigen (PSA) and the importance of patient education in the management of prostate cancer, based on discussions held at a European symposium on managing prostate cancer. Although PSA is the most widely used serum marker for detecting prostate cancer and for monitoring treatment responses, its use as a diagnostic marker is controversial due to concerns of over-diagnosis and low specificity. PSA isoforms, as well as PSA doubling time, might improve the specificity for earlier prostate cancer detection and can be used as surrogate markers for treatment efficacy. Patients can differ considerably in the importance they place on health-related quality of life aspects and fear of cancer progression. Consequently, there needs to be active, educated discussion of risk and outcomes between physicians and patients. Risk assessment tools, e.g. validated nomograms, enable clinicians to improve their decision analysis and form the basis for subsequent discussion of treatment options between the physician and patient, thereby enabling informed consent and appropriate decision-making.