Men’s Health: The case for and against routine prostate screening from the UK perspective
Social media cops a bashing in most quarters, but for me in a professional capacity, it contributes to a significant portion of my ‘keeping up’ with the evidence. We have some amazing groups within Facebook made up of many brilliant pelvic health physiotherapists who are evidence-based and also often ground-breaking with their own research. We often hear about it on Social Media (Facebook and Instagram) before we get to read the paper in the journal. Yesterday I read two pieces from a renowned pelvic health physiotherapist, Bill Taylor, who has presented the case for and against routine prostate screening in the UK.
Bill Taylor Pelvic Health Physiotherapist, Scotland, UK
Bill Taylor has been a physiotherapist for almost 40 years, with over 25 years experience in the treatment of pelvic dysfunction most that time treating men. He is widely recognized in the UK & internationally as being one of the leading pelvic health physios and one of the few who specialize in male pelvic floor dysfunction. I immediately asked Bill could I reproduce his words in a blog as I get asked many times about the value of testing PSA levels and I think he summarises the research well. If you have a man in your life (husband/partner/son/grandson/cousin/nephew/uncle/friend/baker of delicious pastries) that you care about, share this blog far and wide so men start to take an interest in their prostate health.
See Bill Taylor’s blog below in its entirity:
NO NATIONAL PROSTATE CANCER TESTS IN THE UK
by Bill Taylor pelvic health physiotherapist
Following the decision in the United Kingdom to recommend not to roll out a National Prostate Cancer Screening Programme for all men, I decided to pull together what I can make of the position on both sides.
Most UK health authorities currently do not recommend routine PSA screening for all men, because, it is argued, the potential harms outweigh the population-level benefits (UK NSC 2024, USPSTF 2018). Instead, the recommended approach is individualised, shared decision-making based on personal risk.
Why Not a National Screening Programme?
PSA testing can pick up many prostate cancers that are slow-growing and would never cause symptoms. This leads to overdiagnosis, which may cause unnecessary biopsies, anxiety, and potential treatment complications (Loeb 2014).
Treating low-risk disease can lead to significant side effects, including:
These harms often outweigh the benefits for indolent cancers (Loeb 2014; AUA Guideline 2013).
PSA Is Not a Perfect Test
False positives → unnecessary biopsies
False negatives → missed significant cancer
PSA can rise for many benign reasons (BPH, infection, ejaculation, cycling)
Evidence consistently shows that PSA has limited specificity and variable sensitivity (Vickers 2010; Pinsky 2017).
Evidence from Large Trials
Major trials (ERSPC, PLCO) show:
Small reduction in prostate cancer mortality
Substantial increase in unnecessary diagnosis/intervention
(Schröder 2009, 2012; Hugosson 2019; Andriole 2009)
These findings underpin why national bodies (e.g., UK National Screening Committee, US Preventive Services Task Force) do not support population-wide screening.
Where Prostate Screening Is Recommended
Screening is generally advised for higher-risk men, typically:
Strong family history (esp. father/brother with prostate cancer <60)
Black ethnicity (higher incidence and earlier onset)
For these groups, PSA testing can meaningfully improve early detection of aggressive disease (Pritchard 2016; Haider 2020).
A clinician (medical doctor) and patient discuss risks, benefits, and personal preferences before doing a PSA test — the approach recommended by most international guidelines (USPSTF 2018, NICE NG131).
Risk-stratified screening
Many countries are exploring programmes that screen only higher-risk individuals, which may reduce harms while preserving benefits.
AI generated MRI machine
Emerging evidence supports using multiparametric MRI before biopsy, which reduces unnecessary invasive procedures (PRECISION Trial — Ahmed 2017; Kasivisvanathan 2018; Drost Cochrane 2019).
Reference List for the case against screening
1. UK National Screening Committee (UK NSC). Prostate Cancer Screening Recommendation. 2024.
2. USPSTF. Screening for Prostate Cancer: Recommendation Statement. JAMA. 2018;319(18):1901–1913.
3. Loeb S, Bjurlin MA, Nicholson J, et al. Overdiagnosis and overtreatment of prostate cancer. Eur Urol. 2014;65(6):1046–1055.
4. Vickers AJ et al. PSA at age 60 and prostate cancer mortality. BMJ. 2010;341:c4521.
5. Pinsky PF, Prorok PC, Kramer BS. PSA levels and risk of prostate cancer. J Natl Cancer Inst. 2017.
6. Schröder FH, et al. ERSPC screening and mortality results. N Engl J Med. 2009;360:1320–1328.
7. Schröder FH et al. Updated ERSPC Results. N Engl J Med. 2012;366:981–990.
8. Hugosson J et al. Long-term ERSPC follow-up. Lancet. 2019.
9. Andriole GL et al. PLCO mortality outcomes. N Engl J Med. 2009;360:1310–1319.
10. NICE Guideline NG131. Prostate cancer: diagnosis and management. 2019 (updated).
11. Ahmed HU et al. PRECISION trial: MRI vs TRUS. N Engl J Med. 2017;376:443–453.
12. Kasivisvanathan V et al. MRI-targeted biopsy trial. Lancet. 2018;391:815–822.
13. Drost FJH et al. MRI-first vs systematic biopsy. Cochrane Database Syst Rev. 2019.
The man in my life: Bob
Part 2-The Other side of the coin: The case for a Prostate National Screening Programme
Even though PSA-based national screening is not currently recommended, several modern developments may strongly support the idea that a routine, risk-stratified programme could reduce harm, prevent deaths, and improve cost-effectiveness.
Some facts:
Prostate cancer is common, deadly, and often silent early on
It is the most commonly diagnosed male cancer in the UK (Cancer Research UK, 2024).
In a substantial minority cancers are biologically aggressive and progress before symptoms occur (Rawla, 2019).
Many cases still present late, when cure is difficult or impossible (NICE, 2021).
So there is a rationale that a national screening programme could shift thousands of men from late-stage to early-stage diagnosis.
The ERSPC trial demonstrated a mortality benefit
ERSPC showed a 21% relative reduction in prostate cancer mortality (Schröder et al., 2009).
Long-term follow-up shows increasing absolute benefit (Schröder et al., 2014).
These studies showed some mortality benefit even with older diagnostic tools, screening saved lives.
Screening harms have decreased with modern pathways
Early criticisms are based on outdated practice.
Today’s UK pathways often use:
MRI-first, reducing unnecessary biopsies by 28–40% (Ahmed et al., 2017; Kasivisvanathan et al., 2018).
Targeted biopsies, improving detection of clinically significant cancer (Kasivisvanathan et al., 2018).
Active surveillance as first-line for low-risk disease (NICE, 2021).
So the evidence shows modern pathways may mitigate the original screening harms.
Screening tools can now help minimise overdiagnosis
Modern risk-stratified screening tools include:
Age-adjusted PSA thresholds (Crawford et al., 2014)
PSA density (Dell’Oglio et al., 2017)
Pre-biopsy MRI (Padhani et al., 2019)
Risk calculators such as PCPT and ERSPC (Ankerst & Thompson, 2016)
Polygenic risk scores (Seibert et al., 2018)
Meaning screening can now focus on clinically significant cancers.
Screening could reduce inequality as higher-risk groups include:
Black men (twofold higher incidence)
Men in lower socioeconomic groups
Men with limited access to healthcare
(Essink-Bot et al., 2020; Lloyd et al., 2015)
A national programme may reach men who never request testing.
Shared decision-making alone is unrealistic
Evidence shows:
Many men have never heard of PSA testing (Ilic & Djulbegovic, 2017).
GPs have limited time for detailed SDM (Stiggelbout et al., 2015).
High-risk groups are often missed without structured systems (Loeb et al., 2021).
Screening would standardise access and reduce reliance on patient initiative which might be absent.
Is it time to jump into prostate screening?
The public overwhelmingly wants screening
Public surveys show:
Around 70% of men would choose screening if offered (Moss et al., 2023)
Men favour early detection—even with uncertainty (Han et al., 2013).
So maybe policies should reflect public values when benefits are reasonable?
Overdiagnosis is becoming less harmful
Active surveillance uptake is increasing:
UK centres report >80% surveillance for low-risk cancer (Klotz et al., 2020; Hamdy et al., 2016).
However, if low-risk cancers are not treated aggressively, overdiagnosis has less clinical consequence.
Cost-effectiveness is improving
MRI-first pathways:
Reduce unnecessary biopsies
Reduce complications and overtreatment
Improve targeted detection
Kasivisvanathan et al., 2018; Padhani et al., 2019)
Emerging biomarkers (PHI, 4Kscore, Stockholm3) further improve precision (Loeb & Catalona, 2014; Grönberg et al., 2015).
This shows that risk-stratified screening is increasingly economically viable.
Without screening, many cancers present late
A significant proportion of men still present with metastatic disease (Cancer Research UK, 2024), which is associated with high treatment cost and poor survival (Mottet et al., 2024).
In these cases this may shifts diagnosis toward curable disease
Modern evidence suggests that a risk-stratified, MRI-first national prostate cancer screening programme could:
Reduce mortality
Reduce late-stage diagnosis
Improve equity
Standardise access
Reduce metastatic burden
Align with public preference
Reduce harms compared with early PSA
Approach cost-effectiveness threshold. It could be argued the barrier to a screening programme is based on outdated legacy evidence and modern pathways may shift the risk-benefit balance.
1. Ahmed, H. et al., 2017. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS). The Lancet, 389(10071), pp.815–822.
2. Ankerst, D. & Thompson, I., 2016. Prostate Cancer Risk Calculators. European Urology, 69(3), pp.419–421.
3. Cancer Research UK, 2024. Prostate cancer statistics.
4. Crawford, E.D. et al., 2014. Age-specific reference ranges for PSA. BJU International, 114(2), pp.265–273.
5. Dell’Oglio, P. et al., 2017. PSA density predictive value. European Urology Focus, 3(2–3), pp.181–188.
6. Essink-Bot, M.L. et al., 2020. Ethnic disparities in prostate cancer. British Journal of Cancer, 122(3), pp.312–320.
7. Grönberg, H. et al., 2015. Stockholm3 test. The Lancet Oncology, 16, pp.1667–1676.
8. Hamdy, F. et al., 2016. ProtecT trial. New England Journal of Medicine, 375, pp.1415–1424.
9. Han, P.K. et al., 2013. Men’s screening preferences. Annals of Family Medicine, 11(3), pp.197–206.
10. Ilic, D. & Djulbegovic, M., 2017. Cochrane review update.
11. Kasivisvanathan, V. et al., 2018. MRI-targeted biopsy. The Lancet, 391, pp.815–822.
12. Klotz, L. et al., 2020. Active surveillance outcomes. Journal of Clinical Oncology, 38(7), pp.741–749.
13. Loeb, S. & Catalona, W., 2014. Advances in PSA screening. JAMA, 312(20), pp.2215–2216.
14. Loeb, S. et al., 2021. Improving risk stratification. Nature Reviews Urology, 18(2), pp.107–118.
15. Lloyd, T. et al., 2015. Socioeconomic inequalities. BJU International, 116(3), pp.373–382.
16. Moss, S. et al., 2023. Public acceptability. BMJ Open, 13(4).
17. Mottet, N. et al., 2024. EAU Guidelines.
18. NICE, 2021. NG131 Prostate cancer: diagnosis and management.
19. Padhani, A. et al., 2019. Role of mpMRI. Clinical Radiology, 74, pp.895–905.
20. Rawla, P., 2019. Epidemiology. World Journal of Oncology, 10(2), pp.63–89.
21. Schröder, F. et al., 2009. ERSPC mortality. New England Journal of Medicine, 360, pp.1320–1328.
22. Schröder, F. et al., 2014. ERSPC follow-up. The Lancet, 384, pp.2027–2035.
23. Seibert, T. et al., 2018. Polygenic risk prediction. Nature Genetics, 50, pp.940–946.
24. Stiggelbout, A. et al., 2015. Shared decision-making. British Journal of General Practice, 65(636), e467–e473.
Thank you Bill for this comprehensive overview.
What is the situation in Australia?
I am providing a
link to the Prostate Cancer Foundation of Australia as this definitively covers the current situation in Australia. Please read this in detail (it takes 6 extra minutes -they could be life-saving minutes so do the dive!). I have copied and pasted a portion of the brief summary of the Australian situation below.
Bill Taylor has been a Physiotherapist for almost 40 years, with over 25 years experience in the treatment of pelvic dysfunction most that time treating men. He is widely recognized in the UK & internationally as being one of the leading pelvic health physios and one of the few who specialize in male pelvic floor dysfunction. He is a graduate of the Canadian Academy of Manipulative Therapy and has spent most of his career treating the Musculoskeletal System using manual therapy and exercise.
He has a special interest in Chronic Pelvic Floor Pain and Dysfunction and the use of manual and exercise therapy in addressing this condition. He has contributed a chapter to the textbook, Chronic Pelvic Pain and Dysfunction entitled The Effect of Sport and Exercise on Chronic Pelvic Pain. He also complied the chapter on Pelvic Girdle Assessment in the text Neuro-musculoskeletal Assessment.
He has taught widely in UK, Europe, Scandinavia & Israel on male and female pelvic health. He is one of the few UK based Physiotherapists to work full-time in male and female pelvic health and is the Clinical Director of his own clinic in Edinburgh, Scotland.
Additionally he has worked with Scottish Ballet and Scottish Dance Theatre for over 20 years. He was integral in the development of a full time Physiotherapy service to the National Ballet after which he continued as Consultant Physiotherapist for a number of years . He continues to work with dancers of all ages and abilities in his Edinburgh clinic.
He is a visiting Lecturer at Edinburgh University where he contributes to the MSc in Dance Science and Education, teaching the Preventative Dance Injury Module. He has also been a visiting Lecturer at Edinburgh Napier University where he has taught on the BSc /MSc Midwifery course and the MSc Physiotherapy course.
He has been mentoring students in the clinic for over 25 years as well as supervising undergraduate thesis projects. Recently he has become a member of the visiting Faculties at Brunel and Keele Universities. He has a passion to share his knowledge of pelvic floor dysfunction and treatment especially in the field of male pelvic health.
He is a Trustee on the board of the Pelvic Obstetric and Gynaecological Physiotherapy Board of the Chartered Society of Physiotherapy as well as member of the board of the charity, Prostate Scotland. He is also currently a Doctoral researcher at Oxford Brookes University where he is studying the effect of movement and exercise in the treatment of male chronic pelvic pain.
Some may call him a smarty-pants (Sue’s own words)
Go Bill-keep up the fanatastic work!
If you know someone with pelvic pain I can recommend this brilliant podcast with Bill Taylor on Michelle Lyons Podcast Celebrate Muliebrity
Congratulations on making it to the end of this rather long blog
Share with your menfolk
