Men's Health
·
4 min
Dr Shad Asinger
Professor Prasanna Sooriakumaran
PSA testing has long been debated — some call it life-saving, others question its value. But the test has quietly evolved, and for men over 40, this shift could be life-changing.
The Truth Nobody's Talking About
Let's start with the facts. Right now, as you read this, over 50,000 men in the UK will be diagnosed with prostate cancer this year. More than 11,000 won't survive it. In fact, one man dies of prostate cancer every 45 minutes. And prostate cancer is now the most common cancer in England, with more men diagnosed of it than women being diagnosed of breast cancer. These aren't just statistics—they're fathers at school pickup, colleagues who never miss a meeting, friends who seem invincibly healthy.
The challenging part? Prostate cancer is a silent operator. By the time you notice something's wrong—urinary symptoms like difficulty urinating, unexplained back pain—it's often already advanced prostate cancer that's spread beyond the prostate gland. It's like discovering your house has termites only when the floorboards start collapsing.
But here's where everything changes. When researchers followed 180,000 European men for 16 years, they discovered something remarkable: PSA screening reduces prostate cancer mortality by 20%. Even better, it cuts your risk of developing advanced (technically termed metastatic) cancer—the kind that spreads to other parts of your body—by nearly a third.
Think about that. A simple PSA blood test, taking less time than your morning coffee run, could literally save your life.
Your Prostate Specific Antigen (PSA): It's Not What You Think
Here's something most men don't realise: PSA isn't actually a test to diagnose cancer directly. Surprised?
PSA is a protein produced by your prostate gland. When your prostate is happy, PSA levels in your blood stay low. When it's irritated or inflamed (often called prostatitis), or enlarged (often called benign prostatic hyperplasia), or when prostate cancer is developing, PSA levels can rise. It's like a smoke detector which sounds the alarm but doesn't distinguish between burnt toast and a house fire.
For years, this was PSA's Achilles’ heel. But here's the revolution: we've learned to read the smoke patterns.
Age is Crucial
Your normal PSA level depends entirely on your age:
In your 40s and 50s? The median PSA is remarkably low—just 0.6 to 0.7 ng/ml. Anything above 1 deserves frequent monitoring and anything above 2.5 requires further assessment.
Hit your 60s? The threshold rises to 4.0 ng/ml, with normal ranges between 1.0 and 1.5.
Over 70? It gets more individual, but levels naturally climb higher.
But here's the game-changer that nobody talks about: your PSA level at age 45 is like a crystal ball for your prostate's future.
Men with PSA test results below 1.0 at age 45-50? You're in an excellent position. Your risk of aggressive cancer over the next decade is extremely low. You can relax, screen every 3 years, and sleep soundly.
PSA above 1 at that age? You need to pay attention. Not panic—just pay attention. Annual checks become more important, like the MOT for your car. And if the PSA continues to rise by more than ¾ of a point per year, regardless of the actual numbers, you should speak to a doctor.
Elevated PSA Levels: The MRI Revolution Changes Everything
Historically an elevated PSA level required a biopsy to confirm the findings. It typically involved an invasive needle procedure through the rectum. Those days are over.
Enter the quiet hero of our story: multiparametric magnetic resonance imaging (MRI).
Picture this: your PSA blood test comes back with a raised or rising PSA level. Your heart sinks. But instead of rushing to biopsy, your doctor suggests imaging tests—specifically an MRI first. This isn't just any scan—it's like switching from a grainy black-and-white TV to 4K ultra-HD.
The results are staggering. MRI can rule out significant cancer with 90% accuracy. In groundbreaking trials, adding MRI before biopsy cut unnecessary prostate cancer diagnosis in half. That means fewer men diagnosed with harmless, slow growing cancers that would never have caused problems. Fewer men facing cancer treatment they don't need. Fewer lives disrupted by overdiagnosis.
When Biopsy Gets Smart
Let's say your MRI shows something that might be suspected cancer. In the old days, this meant systematic biopsy—essentially trying to find areas of concern with multiple tries. Today? It's completely different.
MRI-ultrasound fusion technology combines your detailed MRI images with real-time ultrasound. Think of it like your phone's GPS overlaying directions on a live camera view. The doctor knows exactly where to sample inside your prostate to diagnose prostate cancer accurately. It means more accurate diagnosis with fewer side-effects from a “targeted” biopsy.
The latest 2024 evidence shows this approach catches the dangerous cancers while finding 50% fewer harmless ones. It's precision medicine at its finest.
Even better, the new biopsy approach goes through the skin between your scrotum and rectum (what doctors call the perineum), not through the rectum itself. Yes, it sounds uncomfortable, but here's what matters: it's virtually eliminated the 1-2% risk of infection associated with older techniques. It's an outpatient procedure, you're home the same day, and most men describe it as "not nearly as bad as I expected." It can also be done while you’re asleep under an anaesthetic to make it totally painless (though it can hurt a bit when you pee afterwards).
The Life-Changing Truth About Finding Prostate Cancer
Here's something that might blow your mind: finding localised prostate cancer doesn't mean you need immediate prostate cancer treatment.
I know, it sounds crazy. But stay with me.
The ProtecT study done in the UK and led by Oxford University followed men with prostate cancer for over a decade. The results? For low-risk cancers, there was no difference in survival between men who had immediate surgery, radiation therapy, or just careful monitoring.
This isn't wishful thinking—it's hard science backed by the National Cancer Institute (USA) and National Institute for Health and Care Excellence (NICE/ UK) guidelines. Today, if you're diagnosed with low-grade prostate cancer, you'll likely be offered "active surveillance” where the cancer is just monitored.
Think of it like having a suspicious mole. You don't immediately cut it out—you photograph it, measure it, watch for changes. With prostate cancer, this means regular PSA tests, periodic MRIs, and only treating if things change.
You avoid surgery. You avoid radiotherapy. You avoid the potential side effects like urinary incontinence or erectile dysfunction. Yet you maintain the safety net of treatment if needed.
Who Actually Needs Prostate Cancer Screening? Let's Get Personal
Forget the “one-size-fits-all” advice. Your screening strategy should be as individual as your Netflix recommendations.
If You're Higher Risk (Start Thinking at 40-45)
You're in this category if you're:
Black: Your risk of prostate cancer is double that of white men. It's not fair, but it's real.
BRCA2 positive: That gene mutation gives you 8 times the normal risk.
Got family history: Father or brother with prostate cancer? Your risk doubles.
For you, annual PSA testing isn't paranoid—it's smart. Like checking your tyre pressure more often when you do a lot of motorway driving.
If You're Average Risk (The Sweet Spot at 50)
This is most of us. The key is getting that baseline specific antigen PSA test at age 45-50. This single blood sample can shape your entire screening future. It's like your credit score for prostate health—one number that predicts so much.
The "Am I Too Old?" Question
Here's what nobody tells you: it's not about your age, it's about your future. A small, untreated prostate cancer in its early stage will typically become life-threatening after 10+ years.
So you're a healthy 75-year-old who cycles, plays golf, and plans to see your grandkids graduate? Keep screening.
But if you're 65 with serious heart disease or other major health issues? The maths changes. Have an honest conversation with your doctor about what makes sense for you.
The Smart Screening Revolution: Your Personal Roadmap
Here's your practical guide to navigating this new world:
Step 1: Get Your Baseline (Ages 45-50)
Think of this as your prostate gland's starting point. One simple test is a blood test that predicts your future risk better than any family history or genetic test.
Step 2: Follow Your Personal Schedule
PSA under 1.0? Relax. Check again in 3 years.
PSA 1.0-2.5? Stay aware. Test every year until stable and then check every 3 years.
PSA above 2.5? Go and see a prostate expert (urologist) to discuss if you need further tests like an MRI scan.
Step 3: If Your PSA Rises
Don't panic. Seriously. An abnormal PSA level can jump from:
Recent sexual activity (avoid for 48 hours before testing)
Cycling or vigorous exercise
Urinary infections
Even constipation
Always repeat the PSA test measures after a few weeks. If elevated PSA levels persist, consider newer biomarkers like free PSA or the 4Kscore that can spare 40% of men from unnecessary other tests.
Step 4: MRI Before Biopsy
If your PSA in your blood stays elevated, insist on an MRI first. Not all hospitals offer this yet, but it's worth pushing for it. It could save you from an unnecessary biopsy.
Step 5: If Biopsy Is Needed
Ask about:
MRI-fusion guidance (the GPS-guided approach)
Transperineal technique (the safer route)
How many samples from prostate tissue they'll take (fewer is often better with a targeted approach as less biopsies means less side-effects)
Remember: even if they find cancer, it doesn't mean immediate treatment.
Addressing the Elephant in the Room
Let's tackle the controversies head-on:
"But I heard PSA screening doesn't work!"
You're probably thinking of the American Preventive Services Task Force concerns based on the PLCO trial that showed no benefit. Here's the problem: that study was flawed. Nearly half the "unscreened" men had PSA tests anyway. It's like testing whether umbrellas work by comparing people with umbrellas to people with... smaller umbrellas.
Meanwhile, the trials done in Europe tell a different story—they consistently show lives saved.
"Won't I end up getting treatment I don't need?"
Valid fear. In 2010, absolutely justified. Today? We've solved this. MRI screening means we find fewer harmless cancers. Active surveillance means we don't treat cancers that don't need treatment. The game has completely changed. Just find a specialist that understands how to treat, when to treat, and crucially when not to treat prostate cancer.
"My doctor seems reluctant"
Some institutions are still working from old playbooks. The evidence has moved faster than some guidelines. If your doctor dismisses PSA testing entirely or won't discuss digital rectal examination alternatives, it might be time for a second opinion. This is your life we're talking about.
The Biomarker Revolution: PSA Gets Upgraded
PSA is a protein that's getting some impressive teammates. The Swedish STHLM3 test combines PSA with genetic markers and other factors, achieving 74% accuracy compared to PSA's 56%. The 4Kscore can tell you if that elevated PSA is worth worrying about, reducing false positive test results.
These aren't future technologies—they're available now. They're turning the screening test from a blunt instrument into a precision tool. At present, they are typically offered at specialist centres by expert urologists.
The Global Wake-Up Call
While we debate screening nuances in prostate cancer in the UK and beyond, The Lancet Commission has announced that prostate cancer cases will double by 2040.
This isn't someone else's problem. It's ours. The tools we're perfecting today—PSA plus MRI plus smart biopsies—need to become standard everywhere, not just in well-funded hospitals.
Interestingly, countries with organised screening programmes (rather than the ad-hoc approach in the US and UK) see better outcomes with less risk of missing significant prostate cancer. There's a lesson there about doing things properly rather than leaving it to chance.
What This Actually Means for You
The quiet revolution in PSA testing isn't really about the test itself. It's about intelligence over fear, precision over guesswork, and control over chance.
Twenty years ago, PSA testing was like using a sledgehammer to crack a nut. Today, it's more like keyhole surgery—precise, targeted, effective.
The men benefiting from this revolution aren't medical experts. They're ordinary guys who've taken the time to understand their options. They're having informed conversations with their doctors about prostate symptoms and test results. They're making decisions based on their individual risk, not population statistics.
Your Next Move
If you're over 45, here's your action plan:
This week: Book a GP appointment to discuss PSA testing if you have not already. Don't wait for prostate disease symptoms—remember, early prostate cancer has none.
At the appointment: Discuss your risk factors. Ask about your baseline PSA. Understand what happens if it's elevated. Some doctors will recommend a digital rectal exam alongside PSA—discuss all options.
Moving forward: Follow your personalised screening schedule. Remember that finding cancer early doesn't automatically mean treatment.
The quiet revolution in PSA testing represents medicine at its best - learning from mistakes, embracing technology, and putting patients in control.
We've transformed a controversial test into a sophisticated screening system. We've turned overdiagnosis from a bug into a feature we can control. We've given men the tools to take charge of their health destiny.
But tools are only useful if you use them. The revolution is here, but it requires your participation.
Your prostate health isn't about following rigid rules or living in fear. It's about being smart, staying informed, and taking appropriate action. It's about having the confidence that comes from knowledge and the peace of mind that comes from being proactive.
Because in this quiet revolution, the biggest change isn't in the technology or the protocols. It's in the shift from reactive medicine—waiting for problems—to proactive health—preventing them.
The question isn't whether to get tested. It's whether you're ready to take control.
Ready to join the quiet revolution? Book your PSA test today. Have the conversation with your doctor. Because when it comes to your health, knowledge isn't just power - it's life.
References
Hugosson J, Roobol MJ, Månsson M, et al. A 16-yr follow-up of the European Randomized Study of Screening for Prostate Cancer. European Urology. 2019;76(1):43-51.
Hugosson J, Månsson M, Wallström J, et al. Prostate Cancer Screening with PSA and MRI Followed by Targeted Biopsy Only. New England Journal of Medicine. 2022;387(23):2126-2137.
The Lancet Commission. The Lancet Commission on prostate cancer: planning for the surge in cases. The Lancet. 2024;403(10437):1683-1722.
Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer (ProtecT Trial). New England Journal of Medicine. 2016;375:1415-1424.
Nordström T, Discacciati A, Bergman M, et al. Prostate cancer screening using a combination of risk-prediction, MRI, and targeted prostate biopsies (STHLM3-MRI): a prospective, population-based, randomised, open-label, non-inferiority trial. The Lancet Oncology. 2021;22(9):1240-1249.
Auvinen A, Tammela TLJ, Mirtti T, et al. Prostate Cancer Screening With PSA, Kallikrein Panel, and MRI: The ProScreen Randomized Trial. JAMA. 2024;331(17):1452-1459.
Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet. 2017;389(10071):815-822.
Early Detection of Prostate Cancer: AUA/SUO Guideline. American Urological Association. 2023. Available at: https://www.auanet.org/guidelines-and-quality/guidelines/early-detection-of-prostate-cancer-guidelines
Mottet N, van den Bergh RCN, Briers E, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer. European Urology. 2024;79(2):243-262.
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