Prostate-Specific Antigen (PSA) Testing

🔍 When to Suspect

A man requesting a PSA test, or presenting with LUTS, suspected prostate cancer, or concerns about risk (e.g., family history)

From the full topic in The Ocean Library: Prostate-Specific Antigen (PSA) Testing

🧭 When to offer or consider PSA testing

Testing an asymptomatic man for prostate cancer is a shared decision-making and counselling process, not a diagnostic test or a screen. The prostate-specific antigen (PSA) blood test is offered through the Prostate Cancer Risk Management Programme (PCRMP): any asymptomatic man aged 50 and over who asks can have a free NHS PSA test after a balanced discussion of the benefits and harms. Officially, GPs are advised not to proactively raise PSA testing with average-risk asymptomatic men.

Two things have shifted the picture. The 2024 Prostate Cancer UK clinical consensus recommends a proactive discussion from age 45 in men at higher-than-average risk. And in 2026 the UK National Screening Committee (UK NSC) recommended – and the Government accepted – the UK's first prostate cancer screening programme: a targeted programme for men with a high-risk genetic profile. Population screening is still not recommended, because across the whole population the PSA test causes more harm than good.

The key primary-care skill is to identify who to test, counsel honestly on benefits and harms, and never miss a malignant prostate.

Who	When / what to do
Average-risk man aged ≥ 50	He can request a free NHS PSA test after a balanced discussion; current PCRMP advice is that GPs do not proactively raise it.
Black men (African / African-Caribbean family origin) aged ≥ 45	Proactively discuss – lifetime risk ~1 in 4 (vs ~1 in 8 in White men), with higher mortality and more metastatic disease at diagnosis.
Family history of prostate cancer (first-degree relative) aged ≥ 45	Proactively discuss; consider an earlier conversation if a relative was diagnosed young or died of the disease.
Pathogenic BRCA2 variant + family history of breast / ovarian / pancreatic / prostate cancer, aged 45–61	Now eligible for the new NHS targeted screening programme – 2-yearly PSA testing (UK NSC, 2026).
Symptomatic man of any age (LUTS, visible haematuria, erectile dysfunction, bone pain, weight loss)	Assess and refer as a symptomatic patient under NICE NG12 – this is not screening.
Man aged > 79 or with limited life expectancy	PSA testing is not routine; consider only if symptomatic and fit enough for radical treatment.

The discussion stands or falls on an honest account of what the test can and cannot do.

Benefits to discuss	Harms to discuss
• May detect an aggressive cancer early, when treatment can be curative or life-extending.	• A raised PSA is often benign (benign prostatic hyperplasia, prostatitis, urinary tract infection) – causing anxiety and further tests.
• A reassuringly low PSA (for example < 1 ng/mL at 60) indicates a very low long-term risk.	• False reassurance – up to ~15% of cancers occur with a PSA in the normal range (false negatives).
• The modern pathway (MRI before biopsy) has reduced – though not removed – the harms of investigation.	• Leads to MRI ± prostate biopsy, which carries a risk of bleeding, infection and sepsis.
	• Overdiagnosis of a slow-growing cancer that would never have caused harm, and overtreatment side effects – urinary, bowel and erectile problems.

Source: NICE NG12 · PCRMP · UK NSC · Prostate Cancer UK

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