Guidance

Advising men without symptoms of prostate disease who ask about the PSA test

Updated 12 December 2024

This prostate cancer risk management programme (PCRMP) information helps GPs give clear and balanced information to asymptomatic men who ask about prostate specific antigen (PSA) testing. The PSA test is available free to men who request it.

GPs should use their clinical judgement to manage asymptomatic men and those who they consider to be at increased risk of prostate cancer.

GPs should follow National Institute for Health and Care Excellence (NICE) guideline NG12 for the management of men who have symptoms of prostate disease.

1. Prostate cancer

Each year in the UK about 50,000 men are diagnosed with prostate cancer and about 12,000 die from the disease. See Cancer Research UK prostate cancer statistics.

Factors that increase the risk of prostate cancer include:

• age – prostate cancer is rare under the age of 50 and risk increases with age
• family history – if you have a close relative, for example brother or father, who has had prostate cancer
• ethnicity – the lifetime risk is 1 in 4 for men of black ethnic origin compared to 1 in 8 for white men

Prostate cancer is common and may not cause symptoms or shorten life. Some tested men may therefore face unnecessary diagnosis (overdiagnosis) of prostate cancer as well as associated anxiety, medical tests and treatments with side effects.

2. PSA test

The prostate specific antigen (PSA) test is a blood test that can help diagnose prostate problems. PSA levels can be raised in a number of conditions, such as a urinary infection, an enlarged prostate, prostatitis or prostate cancer.

Most men have a PSA level less than 3ng/ml.

Around 75% (3 in 4) of men with raised PSA level (greater than or equal to 3ng/ml) will not have cancer.

A small proportion of men who have a low PSA level will later be found to have prostate cancer.

Before a PSA test, men should not have:

• an active urinary infection or within previous 6 weeks
• ejaculated in previous 48 hours
• exercised vigorously, for example cycling in the previous 48 hours
• had a urological intervention such as prostate biopsy in previous 6 weeks

When taking blood for PSA testing:

• ensure the specimen will reach laboratory in time for the serum to be separated within 16 hours
• send samples to an ISO accredited laboratory
• repeat the test if not taken in ideal circumstances

A PSA test will not distinguish between aggressive tumours (which are at an early stage but will develop quickly) and those which are not. Further tests may provide valuable information.

In the presence of symptoms of prostate disease, GPs should refer to NICE guideline NG12.

In the absence of symptoms, GPs should discuss the pros and cons of PSA tests with the patient. If a subsequent PSA test result shows raised PSA levels, the GP should use their clinical judgement to consider whether a referral is appropriate.

2.1 PSA testing and prostate cancer patient pathway

3. Digital rectal examination (DRE)

DRE allows assessment of the prostate for signs of prostate cancer (a hard gland, sometimes with palpable nodules) or benign enlargement (smooth, firm, enlarged gland). A gland that feels normal does not exclude a tumour.

NICE guideline NG131 suggests that the following investigations and treatments will be part of the onward diagnosis and management of your patient.

4. Multiparametric MRI (mpMRI)

Pre-biopsy mpMRI of the prostate gland aims to accurately locate clinically significant prostate cancer and facilitate targeted biopsy. Studies suggest that by using mpMRI prostate biopsy can be avoided by more than 25% of men and may reduce detection of clinically insignificant cancers.

5. Biopsy

A biopsy may confirm the diagnosis of prostate cancer and provide useful prognostic information. Techniques include transrectal ultrasound (TRUS) and transperineal (TP) biopsies.

Most men experience blood in urine and semen after biopsy. About 2 out of 5 men describe a biopsy as painful. The most common complications are bleeding and infections including a small risk of sepsis. In this context, it is important for men considering the PSA test to understand the effects that biopsy can have on their quality of life.

Neither mpMRI nor prostate biopsy will detect all prostate cancers.

6. Management and treatment

Evidence about how best to treat localised prostate cancer is not clear in all cases.

NICE guideline NG131 includes recommendations about the treatment and management options for localised prostate cancer. The options include one or more of:

• monitoring (surveillance)
• radical prostatectomy (open, laparoscopic or robotically assisted laparoscopic)
• targeted and external beam radiotherapy (EBRT)
• brachytherapy (low and high dose rate)
• hormone therapy

The options chosen will depend on a number of factors including the man’s general health and the stage of disease. Surgery and radiotherapy may offer the possibility of a cure but can have significant adverse effects on a man’s quality of life and wellbeing.

In this context it is important for men considering the PSA test to understand the effects that treatments may have on their quality of life, balanced against the risk of dying from prostate cancer.

6.1 Information for well men

You can refer to the infographic above and direct patients to the information sheet for well men for a summary of the potential benefits and risks of PSA testing.

The information sheet for well men includes the above infographic, which explains the PSA test. It also includes a list of the potential advantages and disadvantages of the PSA test for men to consider when making a decision.

The Office for Health Improvement and Disparities created this information on behalf of the NHS.