Prostate cancer screening: what you need to know
There’s still no UK screening programme for prostate cancer, but men do have the right to ask for a test if they’re worried. We answer all your questions.
There’s still no UK screening programme for prostate cancer, but men do have the right to ask for a test if they’re worried. We answer all your questions.
“The prostate is a gland that helps to make semen – the fluid sperm swim in,” explains Chiara De Biase, Prostate Cancer UK‘s director of health services.
“It is about the size and shape of a walnut and surrounds the urethra (the tube that carries urine out of the body) just underneath the bladder.
“Prostate cancer occurs when abnormal cells divide and grow in an uncontrolled way,” says De Biase.
It is the most common cancer among men in the UK. One in eight will be diagnosed in their lifetime – that’s more than 63,000 every year. More than 510,000 men are currently living with or after the disease. It is the second most common cause of cancer deaths in men after lung cancer.
“Prostate cancer mainly affects men over 50, and your risk increases as you get older,” explains De Biase.
“The three main factors that increase a man’s risk of the disease are age, being black, and having a family history of the disease.
“For black men, the risk is double that of the general population – one in four will get prostate cancer. They are also twice as likely to die from the disease.
“Additionally, if your father or brother has had prostate cancer, you are two-and-a-half times more likely to get it compared to a man who has no relatives with the disease.
“Every man should know his risk – it’s the first step to understanding your chance of developing the disease and what to do if it happens. Men can use Prostate Cancer UK’s 30-second online risk checker or call the Risk Information Service on 0800 448 0821.”
Find out if you are at risk of prostate cancer, how to help prevent it and the Gleason score explained.
That’s the trouble: there are often no symptoms, especially in the early days.
“Sometimes, men think: ‘Well, I’ve no symptoms, so obviously I don’t have prostate cancer.’ But this can be of no comfort at all really, because when prostate cancer is in the early stages, it causes no symptoms,” says Stephen Langley, professor of urology at the Royal Surrey Cancer Centre & NHS Hospital, and a Prostate Project Charity trustee.
“In fact, prostate cancer is symptomless until it has spread beyond the prostate.”
Later symptoms can mimic those of a non-cancerous condition called benign prostatic hyperplasia (BPH) – an enlarged prostate. These can include difficulty urinating, a weak urine flow, needing to urinate more often (especially at night), blood in your urine or semen, erectile dysfunction, lower back pain and losing weight without trying to.
The only way to know if you might have early prostate cancer is to be screened for the disease using a PSA blood test, explains Professor Langley.
“It measures the amount of a certain protein – the prostate-specific antigen – in a man’s blood,” he says.
“If this is raised, you’ll be moved on to an MRI-first directed pathway.” That means you'll have an MRI scan, which can detect 90% of clinically significant prostate cancer.
Prostate cancer is the last major cancer without a screening programme. This is partly because the PSA test divides opinion. The Office for Health Improvement and Disparities currently warns: “The PSA test is not a perfect test. It will miss some prostate cancers, will detect some that would never go on to cause harm, and can show a raised PSA level when there is no prostate cancer present”. In fact, around 75% of men with a raised PSA level (3 nanograms/mL or higher) do not have prostate cancer.
In November, the UK National Screening Committee (NSC) decided against recommending routine prostate cancer checks for the majority of men aged 45 to 70 at high risk of prostate cancer. Instead, they recommended that only those with a genetic risk (meaning they are confirmed as carriers of the BRCA gene variant) should be screened.
A 12-week consultation period opened on 28 November to allow doctors, researchers, charities and members of the public to provide feedback. Health Secretary Wes Streeting will then examine the arguments for and against mass screening for prostate cancer, and announce his final decision in March.
Some doctors – including those at Cancer Research UK and at the Royal College of GPs – agree with the committee that the PSA test isn’t reliable enough to be the basis for a population-wide prostate cancer screening programme.
But some charities and experts, including Professor Langley, argue that this opinion is based on the old system – where men with a raised PSA would go straight to having a biopsy (expensive and invasive).
The current recommended pathway is that men have a PSA blood test, and if the results of that lead their GP to suspect they may have prostate cancer, then they should be sent for an MRI scan and potentially a guided biopsy. You might not be referred if raised PSA is thought to be due to a current urinary tract infection (UTI), for example.
“Today’s approach to prostate cancer testing is far safer and more accurate than the system on which these opinions of PSA screening were based,” says Professor Langley.
“The reason we don’t have a screening programme to date is that it was thought that PSA was too inaccurate, and in the past too many people were having biopsies based on a raised PSA result, some of which were finding insignificant, non-life-threatening cancer, for which patients may have then undergone radical treatment with unpleasant side effects.”
Today, a PSA test is just the starting point, not a trigger for an automatic biopsy.
“Crucially, MRI only really sees significant prostate cancer,” says Professor Langley. “Over 90% of clinically significant prostate cancers are detected, and we are diagnosing far less low-grade, clinically insignificant cancer.
“When we do find low-risk cancers, we undertake active surveillance, carefully monitoring the patient, but not looking to treat them. That means many men with a slightly high PSA can simply be reassured and discharged without any invasive procedures.”
Professor Langley does not approve of the idea that only men who have the faulty BRCA 1 or BRCA 2 gene will be screened – that’s only one in 300 or 400 men. And many men will be unaware that they even have the gene.
“The NSC is recommending we test a vanishingly small genetic subgroup of men – ones who have the BRCA gene – while overlooking thousands of black men whose fathers have had prostate cancer who are at a similar risk,” says Professor Langley.
“So it seems the NSC recognises the importance of targeted screening, but in a group so tiny they virtually don’t exist. I find it unbelievable that one would choose one group at high risk and not another.”
De Biase, who also backs a wider screening programme, adds, “We’ve reached a tipping point in the UK, with too many men dying from a curable disease, and worse outcomes for men at higher risk, like black men and men from working-class communities. It’s time for change.”
It comes down to awareness of the disease – and knowing you can request a PSA test once you turn 50.
“The Prostate Cancer Risk Management Programme, the government’s public health guidance to GPs, says that a man aged over 50, when suitably counselled, has the right to a PSA test on the NHS,” explains Professor Langley.
“But it also says that if a man doesn’t bring up the PSA test with his GP, it should not be proactively discussed.
“This means that men who are better informed – which often means men who are of a higher socio-economic status – are more likely to ask for PSA and get checked, while men in deprived areas or with less health awareness are diagnosed later and die more often because it just isn’t on their radar at all.
“It’s why people like former Prime Minister David Cameron get checked and treated early, while those who are not so well versed about their health will assume that their GP will tell them if they need a test – but their GP won’t because they've been told not to by Public Health England.
“You simply couldn’t come up with a more divisive system that’s going to be inequitable for different socio-economic groups.”
“All men over 50 have the right to a PSA blood test, and we strongly encourage black men and men with a family history to ask their GP about the test from 45,” says De Biase.
“If you then decide that you want a test, your GP should offer you one.”
You could certainly make an appointment with your GP to talk about the advantages and disadvantages of having the PSA blood test.
There is increasing evidence that screening is successful. “Just last month, a big screening study of over 160,000 men across Europe, published in the New England Journal of Medicine, clearly showed that men who were offered PSA screening were 13% less likely to die from prostate cancer than those who weren’t screened, with the benefits still growing up to 23 years later,” says Professor Langley.
“With prostate cancer, if one can detect it early then the disease is eminently curable in over 80% of men. But if you catch it late, when it has spread and has symptoms, then it’s no longer as easily curable. Men often need lifelong treatment and it has a significant morbidity.
“Ultimately, for over 12,000 men in the UK every year, it becomes a lethal cancer, which is why a targeted screening programme is essential.”
De Biase adds, "We know that a mass screening programme could save thousands of men’s lives. While screening men with BRCA gene variations will save only a fraction of that number, the committee’s decision is the first time they’ve recommended screening of any kind for prostate cancer, which shows that research and evidence can shift the dial and save men’s lives.”
Yes, there is. A major prostate cancer screening trial, Transform, is now recruiting volunteers across the UK. It aims to find the most effective method of detecting the disease, and improve the accuracy of cancer diagnosis.
Funded by Prostate Cancer UK and the National Institute for Health and Care Research, it will cost £42m.
“It’s the largest and most ambitious trial of its kind in 20 years,” says Dr Matthew Hobbs, director of research at Prostate Cancer UK. “It will involve hundreds of thousands of men, run over a decade, and begin delivering results in as little as two years.”
The chief investigator of the trial, Professor Hashim Ahmed, who is chair of urology at Imperial College Healthcare NHS Trust and professor of urology at Imperial College London, explains: “Using the latest screening techniques like fast MRI scans, PSA blood tests and genetic tests, we’re aiming to find the best way to screen men for prostate cancer, minimising late diagnosis, saving more lives and doing so with fewer harms. Importantly, we’ve designed the study so that we can evaluate promising new tests as soon as they’re developed.
“It’s truly game-changing – the biggest and most ambitious trial I’ve ever been part of, and a pivotal step towards getting the results men urgently need to make prostate cancer diagnosis safe and more effective.”
GPs have begun to recruit for the study, sending letters of invitation out, offering men aged 50-74 (with a lower age limit of 45 for black men) the opportunity to volunteer.
“While it's not possible to volunteer yourself, anyone who receives a letter is strongly encouraged to take part,” says Dr Hobbs.
“There are a number of exciting methods for diagnosis being tested by world-leading experts, which have gathered media interest recently, including the ‘at-home spit test’ being trialled at The Institute of Cancer Research,” says Dr Hobbs.
In April this year, a new study, BARCODE 1, published in the New England Journal of Medicine, reported that the at-home spit test, which calculates the risk of developing prostate cancer from DNA in saliva (called a polygenic risk score), was proven to be more accurate at identifying future risk of prostate cancer for men at higher risk than the PSA blood test.
“It’s a real story of success, but we still need to make sure that it works at scale, and for men of all ethnicities, so we've committed the funding and expertise needed to try to get this into the NHS, where it can benefit all men,” says Dr Hobbs. It’s hoped that the results will become available from late 2027.
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