Early prostate cancer does not usually have any symptoms. So, when discussing with men the pros and cons of having a prostate-specific antigen (PSA) test, it is important to consider the risk factors.  

There are three main risk factors for developing prostate cancer:  

• Getting older — prostate cancer mainly affects men aged 50 or over, with the most common age for men to be diagnosed being between 75 and 79 years  
• Having a family history of prostate cancer — men are 2.5 times more likely to develop prostate cancer if their father or brother has had it  
• One in four black men will get prostate cancer. Black men are more likely to get prostate cancer than other men, who have a one in eight chance (Lloyd et al, 2015). 

Prostate Cancer UK recently ran a public awareness campaign in partnership with NHS England to find the 14,000 men who have not started treatment due to the pandemic (https://bit.ly/3wOX7Zl). The campaign prompted more than half a million men to complete our online risk checker, which allowed more men to understand their risk of developing prostate cancer and make an informed choice about whether the PSA test is right for them. The specialist nurses at Prostate Cancer UK were contacted by over 228 people enquiring about prostate cancer who had heard about the campaign.  

WHY A SCREENING TOOL NEEDS TO BE THE RIGHT TEST  

An accurate and reliable test to detect prostate cancer is needed. This would form the basis of a screening programme, but the tests need to save lives and not lead to over-treatment. This is difficult to achieve in prostate cancer, as not all cases are harmful or aggressive, so there is a real risk of over-diagnosis and over-treatment.

PSA TEST  

The PSA test at times has been a topic for rather controversial conversations among healthcare professionals. In itself, it is not a complicated blood test, ‘it does what it says on the tin’, measures the amount of prostatic-specific antigen in the blood.  

A raised PSA may indicate a problem with the prostate, which can include benign prostatic hyperplasia, prostatitis or prostate cancer. Depending on the extent of the rise, this may prompt a GP to refer their patient to a urologist for further review and testing.  

There can be many other reasons why a man’s PSA level is high, including:  

• Urinary tract infections (UTIs)  
• Vigorous exercise  
• Ejaculation 
• Anal sex and/or prostate stimulation  
• Prostate biopsy  
• Medications, such as finasteride  
• Tests, procedures or surgery including cystoscopies, digital rectal examinations (DRE) and other procedures for the urinary tract or the prostate  
• Urinary catheters (Prostate Cancer UK, 2020; 2021).  

The National Institute for Health and Care Excellence (NICE, 2022) has published information for assessing a person who is symptomatic, considering their age and PSA threshold.  

About one in seven men may have a PSA considered ‘normal’ and still have prostate cancer (Eldred-Evans et al, 2021), in these men a PSA test would miss their cancer. Many men with a raised PSA level also do not have clinically significant cancer (Eldred-Evans et al, 2021). This could lead a man to have a cancer treated which would have no impact on his life.  

Prostate Cancer UK recommends that men should make an informed decision about if the PSA test is right for them after discussing the pros and cons with their GP. All men over the age of 50 are entitled to a free PSA test once they have made an informed choice.  

PSA AS A SCREENING TOOL  

If the PSA test was used in a national screening programme, some lives would be saved as some cases of prostate cancer would be caught early. However, the problem is that there would be many cases of over-diagnosis and over-treatment of cancers which may never cause harm. Not all prostate cancers are harmful and often the side-effects of treatment can be life changing.  

Prostate Cancer UK has analysed the latest results from a massive European screening trial (Zappa et al, 2019) and summarised them in Figure 1.

If PSA tests were to be used in a national screening programme, a great deal of cancer would be caught earlier, and some lives would be saved, but far more men will have multiple tests, and potential side-effects from a biopsy, only to be told that they do not have cancer or that the cancer they have will never cause them harm. Some of these men may also go through unnecessary treatments for a cancer that would never have impacted on their life. This is why, even though PSA-based screening has been tested and shown to save lives, it has not been approved by the UK’s National Screening Committee.  
 

NEXT STEPS  

Prostate Cancer UK is funding research to find a better, more reliable test which could focus on screening men at highest risk.  

In the meantime, the charity continues to support men and their loved ones by providing balanced support and information through its specialist nurses — https://prostatecanceruk.org/for-health-professionals/patient-support.  

Free education and resources are also delivered to health professionals, including advice and guidance on the complexities of PSA testing and how to have conversations about the pros and cons of the test with men considering a PSA test.