Prostate cancer: Tests for men at the highest risk

Approximate read time: 15 minutes

On 3 September 2025, the House of Lords is due to consider the following question for short debate:

Lord Mott (Conservative) to ask His Majesty’s Government what steps they are taking to ensure that GPs proactively discuss prostate cancer with men at the highest risk; and inform them of their right to a free prostate specific antigen test.

1. Risk factors for prostate cancer and data on diagnoses

The prostate is a small gland located below the bladder that makes semen and controls the flow of urine from the bladder to the penis.^[1] According to the National Institute for Health and Care Excellence (NICE), risk factors for prostate cancer include:^[2]

• Increasing age: NICE described this as one of the strongest risk factors for prostate cancer, with a higher risk for people aged 50 or older. The estimated incidence is 0.1% in men younger than 50, but autopsy studies show that by the age of 80, 70% of men will have evidence of prostate cancer.
• Black ethnicity: There is a higher incidence of prostate cancer in men of Black ethnicity than in White men. The reason for this is unknown. The lifetime risk of being diagnosed with prostate cancer is one in four for Black men, compared with one in eight for White men. The incidence rate is lower in Asian men.
• Family history of prostate cancer and genetics: People are at higher risk if they have a close relative, for example a brother or father, who has had prostate cancer. NICE said the genetic basis for the hereditary cause is still unclear, but prostate-cancer specific mutations have been implicated. Gene mutations associated with other cancers (such as BRCA1 and BRCA2) have also been associated with an increased risk of prostate cancer.

Prostate cancer was the most commonly diagnosed cancer in England in 2022, and the most common form of cancer diagnosed in males aged 45 years and over.^[3] There were 54,732 new cases diagnosed, an increase of 26% compared to the previous year. NHS England attributed some of this increase to an awareness campaign: in February 2022, the NHS and Prostate Cancer UK ran a six-week campaign urging men to use the charity’s online risk checker.^[4] This resulted in what NHS England described as an all-time high number of urgent referrals for suspected cancer in March 2022.^[5]

Preliminary data indicates there were 54,107 new prostate cancer diagnoses in England in 2023 and 58,132 in 2024.^[6]

In 2022, 53% of prostate cancer cases were diagnosed relatively early at stage 1 or 2, and 47% were diagnosed at stage 3 or 4.^[7] NHS England states that earlier diagnosis is associated with better prognosis on average. NHS England data on cancer survival indicates that around 92% of men diagnosed with stage 1 or 2 prostate cancer were alive five years after diagnosis, but this fell to 60% for men who had stage 4 prostate cancer at the time they were diagnosed.^[8]

2. Testing and screening for prostate cancer

2.1 Prostate specific antigen tests

A prostate specific antigen (PSA) test is a blood test that checks the level of PSA in the blood.^[9] PSA is a protein produced by normal cells in the prostate and also by prostate cancer cells.^[10] A PSA test alone cannot usually tell if someone has prostate cancer. A small amount of PSA in the blood is normal, and the amount rises slightly as men age. A raised PSA level may suggest a problem with the prostate but does not necessarily indicate prostate cancer. For instance, prostatitis or an enlarged prostate could cause a high PSA level.

Routine PSA testing is not offered on the NHS, but patients may be offered a test if their GP thinks they have symptoms that could be prostate cancer.^[11] Additionally, anyone aged over 50 who has a prostate can ask for a PSA test even if they have no symptoms.^[12]

Guidance to GPs from the Office for Health Improvement and Disparities (OHID) sets out a PSA testing and prostate cancer patient pathway.^[13] This says that if someone requests a PSA test, the GP’s course of action depends on whether the patient has symptoms that could indicate prostate disease:

• Symptoms are present: The GP should follow guidelines from the National Institute for Health and Care Excellence (NICE) on suspected prostate cancer. These guidelines state the GP should consider carrying out a PSA test and a digital rectal examination (physical examination of the prostate using a finger).^[14] If the prostate feels malignant on digital rectal examination, the GP should refer the patient on a suspected cancer pathway referral. If the patient’s PSA levels are above a threshold for their age as set out in the NICE guideline, the GP should consider referring them, taking into account the patient’s preferences and any comorbidities.
• Symptoms are not present: The GP should discuss the pros and cons of PSA testing with the patient.^[15] If the patient chooses to have a PSA test and this shows raised PSA levels, the GP should use their clinical judgment to decide whether to refer them for further testing.

Further tests to diagnose prostate cancer for patients who are referred include an MRI scan and biopsy.^[16]

The OHID states that GPs should not proactively raise the issue of PSA testing with people who do not have symptoms.^[17] It says “prostate cancer is common and may not cause symptoms or shorten life”.

An OHID information leaflet for patients summarises the potential advantages and disadvantages of PSA testing for those with no symptoms as follows:^[18]

Possible advantages

• A PSA test can help pick up prostate cancer before you have any symptoms.
• A PSA test can help pick up a fast-growing cancer at an early stage, when treatment could stop it spreading and causing problems and shortening your life.

Possible disadvantages

• You might have a raised PSA level, without cancer. Many individuals with a raised PSA level do not have cancer.
• The PSA test can miss prostate cancer. A small proportion of men who have a low PSA level will later be found to have prostate cancer.
• If your PSA level is raised you may need a biopsy. This can cause side effects, such as pain, infection and bleeding. Not all men will need to have a biopsy.
• You might be diagnosed with a slow-growing cancer that would never have caused any problems or shortened your life. Being diagnosed with cancer could make you worry, and you might decide to have treatment you do not need.
• Treatments can cause side effects which can affect you daily for the rest of your life, such as urinary, bowel and erection problems.

The charity Prostate Cancer UK suggests that for men with a high risk, another possible advantage is that a regular PSA test could detect any unusual increase in PSA level that could be a sign of prostate cancer.^[19]

2.2 Screening programme for prostate cancer?

The UK does not have a screening programme for prostate cancer. In 2020, the UK National Screening Committee (UK NSC)—the body that advises ministers about screening programmes—recommended against a prostate cancer screening programme.^[20] The UK NSC said this was based on the following factors:^[21]

• It is unclear how PSA screening impacts prostate cancer outcomes, specifically death due to prostate cancer.
• There are many harms of PSA screening, such as incorrect diagnosis and complications from further testing and treating.
• There is not enough evidence at present to show that there are better tests than PSA.
• There is no single treatment that is definitely better for patients with early-stage prostate cancer. So, finding these patients by screening would not be worthwhile.

The UK NSC’s next review of whether there should be a prostate cancer screening programme was due to be completed by 2024, but is still ongoing.^[22] As part of the process, the UK NSC is currently undertaking a comprehensive evidence review to assess six potential approaches for targeted screening for those at higher risk of developing prostate cancer.^[23] The UK NSC is due to receive cost effectiveness modelling to explore these various screening strategies by early autumn 2025.^[24] It will then review this and consider next steps before opening a public consultation.

The UK NSC’s final recommendation could be for a screening programme for all men, targeted screening of men at highest risk, or no screening.^[25]

Organisations such as Prostate Cancer UK, Prostate Cancer Research and the British Association of Urological Surgeons (BAUS), as well as many GPs, back the introduction of some form of screening programme.^[26] The Telegraph newspaper has also recently been running a campaign for men at the highest risk of the disease to proactively be offered a test.^[27]

2.3 Calls for change to current guidelines

In the meantime, while the UK NSC is continuing its review, there have been calls for change to the current guidelines on PSA testing. Prostate Cancer UK argues that “not all men have the same risk of prostate cancer—but the current guidelines treat all men the same”. It says the guidance that tells GPs not to raise the subject of prostate cancer with men unless they have symptoms is “outdated” and “putting lives at risk”. It argues that proactively informing men who are at the highest risk of prostate cancer about PSA testing is likely to reduce prostate cancer deaths, and that ending the reliance on men themselves asking for a test would enable earlier diagnoses.^[28] Prostate Cancer UK is calling on the government to update relevant guidelines so GPs can proactively talk to Black men about prostate cancer from the age of 45.^[29]

The British Association of Urological Surgeons (BAUS) and Prostate Cancer UK are also calling for an end to the routine use of digital rectal examinations.^[30] They argue the information a GP can gather from performing this examination is “of extremely limited value”, and fear and stigma around it may deter many men from speaking to their GP about their prostate cancer risk. ‘Getting it right first time’ (GIRFT) guidance on prostate cancer diagnosis produced by BAUS, the British Association of Urological Nurses and NHS England in 2024 advises that in a primary care setting, no digital rectal examination is needed if a man’s PSA level is raised.^[31]

In addition, there are calls for more action to ensure men are aware of their own risk of prostate cancer. For example, ahead of any decision on screening, Prostate Cancer UK is asking the government to fund a nationwide public awareness campaign and to swap what it describes as “confusing health information” for its own ‘risk checker’.^[32] The All Party Parliamentary Group on Prostate Cancer has recommended the Department of Health and Social Care should initiate a nationally funded awareness campaign targeted at those at high risk of prostate cancer as part of its forthcoming national cancer plan for England.^[33]

3. Government position

Health Secretary Wes Streeting said in April 2025 that he would like to see a national prostate cancer screening programme for men at high risk, but it would need to be “evidence-based and evidence-led”.^[34] The government later said it will be guided on its screening policy by the UK NSC.^[35]

The government has continued to restate OHID’s current prostate cancer risk management guidance that GPs should not proactively offer a PSA test to men with no symptoms because of the level of inaccuracy with the PSA test.^[36] However, it is also investing £16mn in a new trial, in support of efforts to find a better test.^[37] Prostate Cancer UK is also providing £26mn for the TRANSFORM trial.^[38] The trial aims to compare multiple screening options to each other and the current system to find the safest, most accurate and most cost-effective way to screen for prostate cancer.^[39]

The first stage, running between 2025 and 2027 and involving around 13,500 participants, will compare four potential screening options (including fast MRI scans, genetic testing and PSA testing) against a control group following the current process where men can request a PSA test but are not offered one.^[40] The second stage, involving up to 300,000 participants and running between 2028 and 2033, will test the most promising option(s) to see how well cancer is detected as well as any harms caused. In the third stage, from 2034 to 2043, men will be followed up for at least a decade to determine the long-term impact of screening on rates of disease progression and survival. At least 10% of the men invited to join the trial will be Black. Prostate Cancer UK says this is “vital as previous trials have not included enough Black men to adequately show the harms and benefits of screening these men”.^[41] The UK NSC will be assessing evidence that emerges from the trial as it is published.^[42]

Highlighting other actions to improve the diagnosis of prostate cancer, the government said NHS England has introduced a “best-practice timed pathway” so patients suspected of prostate cancer receive an MRI scan first, which ensures that only those men most at risk of having cancer undergo an invasive biopsy.^[43] Additionally, three projects specifically related to prostate cancer are being funded through the ‘AI in health and care award’, a programme that aims to accelerate the testing and development of artificial intelligence technologies that align with the NHS long-term plan.^[44]

The government has no current plans for a specific national prostate cancer awareness campaign.^[45] However, it has said NHS England runs campaigns to increase knowledge of the symptoms of a wide range of cancers and encourage people to see their GP.

The government says its forthcoming national cancer plan will include further details on how outcomes and experiences of cancer patients in England can be improved, including earlier diagnosis.^[46]

---

Cover image by People Creations on Freepik.