Why every over-50 man MUST be screened for prostate cancer: Now experts reveal who'd be tested, at what age... and how to minimise the shattering side-effects

It’s 37 years since breast cancer screening was introduced in the UK to save women’s lives. Yet men still don’t have access to a national screening programme for prostate cancer – despite the fact that the disease, which affects the doughnut-shaped gland that sits around the urethra, has now become the most common cancer in England.

The first step in checking the prostate is currently a prostate-specific antigen (PSA) test, a blood test for a protein produced by the prostate gland – levels usually rise in prostate cancer.

Diagnosis is then confirmed after an MRI scan, followed by a biopsy. But this is only if a man has symptoms (such as an increased need to pee and poor flow).

If you’re over 50 and don’t have symptoms, the only way you can get a PSA test is by asking for it. And even then, your GP can turn you down – a study last year by the charity Prostate Cancer Research found that more than half of those surveyed had problems getting a PSA test, with 39 per cent of them saying their GP was reluctant to offer it.

The main problem is the long-standing argument that PSA is an unreliable screening tool, as PSA levels rise with age and can be affected by numerous factors, including infection and even a bike ride (intense cycling can increase PSA levels for up to 24 hours).

All may lead to false positives, resulting in unnecessary, invasive investigations and even treatments. Indeed, research has suggested the risks outweighed the benefits – including the largest study to date looking at PSA testing, the Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP) – published in the journal JAMA last April.

This found there was only a tiny improvement – less than 1 per cent – in the risk of dying from prostate cancer over the 15-year study timeframe in men who were screened with a PSA test compared with no screening at all. It’s this kind of evidence that has stood in the way of a screening programme.

Yet weighed against this are the results of other studies, such as the European Randomised Study of Screening for Prostate Cancer, published in 2019, which found that men screened with PSA testing had a 20 per cent lower risk of dying from prostate cancer than men who weren’t screened.

‘This study was a very well-designed study which followed scientific principles and got accurate results, unlike the CAP trial,’ says Nick James, a professor of prostate and bladder cancer research at the Institute of Cancer Research in London.

The UK’s National Screening Committee (NSC) is due to publish its next review on prostate cancer screening at the end of this year. It comes as many experts – backed by a new Daily Mail campaign – argue that it’s time for a rethink.

‘The evidence in favour of introducing routine screening for prostate cancer has been pretty strong for a number of years and the weight of public opinion is also shifting behind it,’ says Chris Eden, a professor of urology at the University of Surrey. ‘I’ve seen too many cases where men have discovered their disease too late and treatment options are very limited.’

‘I would support nationwide screening for men if it could be targeted and properly planned,’ adds Mike Kirby, a physician and the President of the British Society for Sexual Medicine.

‘As well as it being cost-saving to detect the disease as early as possible, earlier diagnosis means better outcomes in terms of quality of life, in particular reducing side-effects such as incontinence and erectile dysfunction.’

Professor Kirby argues for ‘risk-adapted’ screening – essentially treating each man as an individual based on his risk of getting prostate cancer according to his PSA ‘baseline’ – then inviting him back to have regular tests at longer or shorter intervals. He says this is more efficient than applying the same gap between screening to all men.

Supporters of screening add that technological developments mean it’s now possible to avoid many of the risks previously associated with prostate screening.

For example, many men who are referred to NHS clinics for tests after having high PSA tests are now routinely offered MRI scans, (which can identify a tumour and indicate the likely grade – how aggressive it is) so avoiding unnecessary invasive biopsies.

Professor James says: ‘In my clinic at the Royal Marsden, for example, we do an MRI and if it’s normal we often decide not to take a biopsy at all. In the past, most men had to have a biopsy.’

New screening options are being assessed in the TRANSFORM trial, led by Imperial College London, involving hundreds of thousands of men aged 50 to 75, as well as black men aged from 45.

These include short MRI scans (which do not need to be conducted in a hospital setting; more on this later).

Although some experts are keen to see a national screening programme launched as soon as possible, Professor Hashim Ahmed, chair of urology at Imperial, who is leading the TRANSFORM trial, hopes the NSC will wait for the results before reaching a decision.

He says: ‘We need to be sure we’re not going to create a huge amount of harm by screening for prostate cancer and while there is a need to reduce the mortality rates, we don’t yet know if screening will make a huge difference.’

The data may take years, however. Professor Kirby is among those who believe that a national screening programme that targets high-risk men – those from black ethnic backgrounds, for example (one in four will get the disease, double the risk of white men) and those with a family history of the disease – should get the go-ahead as soon as possible.

‘The TRANSFORM trial has only just started and may take a while to deliver results which I think is too long for men to wait.’ But what would a screening programme look like? Here, leading experts explain all.

The experts largely agree that a national screening programme would ideally involve a short MRI and a PSA test at the age of 45 – as a ‘baseline’ PSA.

Thereafter, the man would have follow-ups, every five years for men at low risk of the disease (ie their PSA was below 0.5ng/ml at age 45), or every three years or annually for men at medium (PSA 1-3ng/ml at age 45) to high risk (above 3ng/ml), suggests Professor Kirby.

PSA rises naturally with age, so for older men the baseline rises. According to guidance from the National Institute for Health and Care Excellence, up to age 49, the cut-off for further investigation is a reading of 2.5ng/ml; 50-59, it’s 3.5; 60-69, 4.5; 70-79, 6.50.

Short MRI scans, also known as prostagrams or biparametric MRIs, take a third of the time as standard MRI scans – 15 to 20 minutes compared with 30 to 40 minutes (they take two sequences of images, rather than three).

Studies show they are reliable – most recently, in February the journal European Urology reported that short MRI scans allowed radiologists to correctly identify tumours in 88.6 per cent of cases compared with 89.4 per cent for standard MRIs.

‘We know that PSA tests can be unreliable, but the short MRI combined with PSA tests does appear to boost accuracy and reduce false positives, and could be used in a national screening programme,’ says Professor Kirby.

A study in the journal BMJ Oncology in 2024 found that the MRI can pick up significant cancerous changes before PSA levels start to rise, offering an opportunity for early detection.

Initially, the thinking is that a national screening programme would be focused on men who are at higher risk, because of their ethnicity or strong family history of prostate cancer, for example, from the age of 45 (black men are more likely to get prostate cancer at a younger age; for other men the risk increases from the age of 50, says Prostate Cancer UK).

This is what the Mail campaign is calling for.

‘This would certainly be much less costly and would target the main effort on those men most at risk,’ says Professor Kirby.

‘Screening would probably stop at around the age of 70 because cancers detected after that are usually very slow growing’, he adds. NHS breast cancer screening ends when a woman is 71, although a woman can request mammograms after that.)

In some pilot schemes in Europe (see panel, right) men are being sent DIY PSA tests to do at home.

‘There’s no doubt that a PSA test should ideally be done by a health professional such as a practice nurse or GP,’ says Professor Kirby.

Short MRIs could be done in a hospital or pop-up clinic, as with mammograms.

‘The downside of screening is always said to be over diagnosis and over treatment due to unreliable tests,’ says Professor Eden.

In other words, men undergoing invasive treatments they don’t need either because their cancer was never life-threatening – or they didn’t have cancer at all.

‘However, that argument is getting weaker – and ignores the risk of under diagnosis and under treatment, which is death,’ says Professor Eden.

Professor James agrees, adding: ‘Screening can also lead to false negatives, leading to the possibility of the problem not being detected in its early stages.’

When it comes to PSA, Professor Eden says: ‘Research has shown it’s actually accurate when it comes to predicting a man’s future risk of prostate cancer when it’s done as a baseline test at 45.’

There are concerns about whether the NHS, and GPs, will be able to cope with the increased workload.

Professor James says: ‘At the moment PSA testing falls to GPs. As with some other screening programmes, a prostate cancer screening programme could take work off GPs.’

However, without proper measures in place, a screening programme could soon clog up a health system already at maximum capacity – ‘any service expansion would need to be properly planned to avoid this, it could not be switched on overnight’, says Professor James.

And there is a shortage of MRIs and trained staff – increased demand for prostate MRI meant that in 2019, only 62 per cent of men in England and Wales who needed one received a prostate MRI.

Artificial intelligence (AI) to interpret scans could help, says Professor James:

‘We already use AI to assess mammograms. This would also help deal with the NHS shortage of radiologists who can assess scans – key if we are to expand early diagnosis programmes.’

As for the financial cost, a recent report by Prostate Cancer Research calculated that, while a national screening programme would have an economic cost to implement, early diagnosis of prostate cancer could potentially save more than £200million, driven by improved patient outcomes.

Many men are put off the idea of prostate checks because they fear they have to have a digital rectal examination (DRE).

A survey of more than 2,000 men by Prostate Cancer UK in 2023 found that 60 per cent were concerned about having it, with 37 per cent of them reporting they would not speak to a GP about prostate worries because of the check.

‘The fact that many men don’t like the idea is a major drawback with the DRE,’ says Professor Kirby.

‘And it only allows for the clinician to feel the back wall of the prostate, so any abnormalities located in the middle or front part of the gland can’t be felt.’

In 2022 the British Journal of General Practice reported that DRE wasn’t reliable and probably does more harm than good – and that these days many doctors forgo them.

‘It is likely that the DRE will be discontinued as an unnecessary and invasive test,’ says Professor Kirby.

Professor Eden adds that DREs are culturally unacceptable in some communities, and could impact take up of any screening programme.

There are a number of new tests, including the EpiSwitch PSE, which is done following a PSA test and measures five markers and combines these with the patient’s PSA score. It claims to boost accuracy from 55 per cent to 94 per cent.

But Professor Kirby says: ‘It can take months to get results back for genetic tests from NHS laboratories and tests identifying multiple biomarkers can be very expensive. So they’re unlikely to form part of a national screening programme.’