Rethinking prostate specific antigen (PSA) testing policy: why age matters

24 July 2026

In the UK, there is no formal organised prostate cancer population screening programme, but PSA (prostate specific antigen) testing is available from GPs on request for any man older than 50. This means that it is largely left up to men themselves to decide when they should request a PSA test.

While testing can prevent deaths from prostate cancer, the balance between the benefits and harms of having a PSA test changes significantly with age. However current NHS guidance does not fully account for these age-related differences, and many men are unaware of this.

In this blog, Dr Adam Brentnall discusses why age is the main driver for the benefits and harms from PSA testing; and why this means that current NHS policies need to change.

 

In a nutshell

• Millions of men without new or worsening symptoms of possible prostate cancer have had PSA tests in the UK - many when older than 70.
• The balance between the benefits and harms of PSA testing changes substantially with age. While the risk of overdiagnosis is relatively low in men in their 50s and early 60s, it rises sharply in men aged over 70.
• Current NHS guidance does not fully reflect these age-related differences.
• Updated guidance is needed to support informed decision-making and minimise avoidable harm.

 

We’re sometimes told to take charge of our own health - see your GP, ask questions, don’t ignore potential warning signs. But what if doing the ‘right thing’ isn’t always straightforward?

At first glance, it might appear that any screening test that finds cancer early will be worthwhile for you as an individual. Detecting disease early for prompt treatment should help you live a longer, healthy life. 

But for men considering a PSA test for prostate cancer, the decision can be more complicated than it first appears. While the test can help detect cancer early, it can also lead to harms related to overdiagnosis - finding cancers that would never have been diagnosed in the man’s life otherwise.

For men with overdiagnosed prostate cancer the test doesn’t help increase life expectancy, and it can reduce quality of life. Additional medical tests, worry, treatments, and potential consequences for mental and physical health – all for no purpose.

Population health considers the impact and trade-offs of healthcare interventions on large groups of people. At an individual level, it is always possible that a screening test can help by diagnosing the disease early; but equally it might just cause harm. The problem is that we can’t say for certain at an individual level.

This means that policymakers need to consider policies that work, on average, across the population. Epidemiologists and trialists use statistical methods to determine the impact of interventions on the health of populations. These methods show that age is a key factor for the effect of PSA testing on population health.

 

Why age matters for population health

It might seem counterintuitive that screening becomes less beneficial with age. After all, cancer risk generally increases as we get older. But the balance between the benefits and harms of PSA testing changes substantially with age.

The main reason is that PSA testing can detect prostate cancer at an early stage preventing metastatic prostate cancer and prostate cancer death, but it can also cause overdiagnosis.

Overdiagnosis becomes increasingly likely following a PSA test in men older than 70 without new or worsening symptoms of possible prostate cancer because many of the cancers detected would never have become clinically significant.

Overdiagnosis can lead to treatment of cancers that would never have caused harm including:

• Long-term side effects (e.g. urinary incontinence, sexual dysfunction)
• Psychological distress
• Increased healthcare costs without improved outcomes

 

What does the evidence show?

1. Overdiagnosis increases with age of screening

Long-term data from a large UK randomised trial clearly shows that:

• Overdiagnosis is relatively low in younger men and
• It increases significantly with age

This evidence is consistent with other empirical studies that have looked at the excess number of cancers after screening stops, suggesting that overdiagnosis is strongly influenced by age, with lower levels seen in studies when men have longer periods of follow-up.

2. Benefits decrease significantly with age at screening

Randomised-trial evidence shows that the benefits of screening are greatest when testing begins at younger ages.

In contrast, screening men older than 70 years is unlikely to reduce cancer deaths at population level for the following reasons.

Firstly, you need to find the cancer early. We know that for many men this can be a decade or more early for prostate cancer, because many prostate cancers grow slowly. This is often called the 'lead time’.

Secondly, men without screening don’t die immediately their cancer is detected. Many prostate cancers have fairly good prognosis, so that the time from clinical diagnosis (without screening) to death from prostate cancer, should this be the cause of death, can also take many years. This is often called the ‘survival time’.

Adding up the lead time and survival time means that, for some men, it might be decades before any benefits from screening can be realised.

The issue is that many men with cancer detected at screening in their 70s will have died from other causes before the lead + survival time period has ended. For others who would die from prostate cancer without screening, life can only be extended beyond the time at which death from prostate cancer would occur without screening. Therefore, it makes sense that the older a man is when tested, the shorter the absolute gain, if any, in life expectancy.

In sum, empirical evidence and causal reasoning support the hypothesis that population health benefits from screening decrease with age, and remaining life expectancy.

3. Older men are most likely to be tested

Audit data and national statistics indicate that PSA testing rates are highest in men older than 70 years, despite evidence that the balance of benefits and harms becomes increasingly unfavourable with age.

 

Why current policy needs to change

The challenge is not simply whether PSA testing works, but whether it is being used in the men most likely to benefit. In the UK an organised programme is not recommended, and instead national healthcare policy makes PSA testing available opportunistically on demand. This approach risks exposing older men to the harms of overdiagnosis with minimal or no benefit.

The overall impact of PSA testing as currently implemented on is likely to be far inferior to an organised programme that would target PSA tests to those who stand to benefit most. This is because screening needs to be organised properly to be effective. Due to the complexity of screening (as discussed in the first blog in this series), opportunistic screening policies are invariably a bad way to allocate screening tests.

For instance, this was seen decades ago with cervical screening. Initially Pap smears were only available opportunistically. Consequently, the impact of screening was poor because those at lowest risk of dying from cervical cancer received them. Once an organised `call and recall’ cervical cancer screening programme was introduced, one estimate is that cervical screening  ‘prevented an epidemic that would have killed about one in 65 of all British women born since 1950.’

 

What should change

Policymakers in the UK have indicated that further research is needed to reduce uncertainties in their health economic modelling, before the decision to recommend against population screening will be revisited. One source of this data will be the TRANSFORM trial, as described in our previous blog. Other studies in the UK including IMProVE and internationally, ProScreen, and other trials will also provide further evidence as data mature.

Waiting for new evidence to update the UK NSC health economic model (including to address substantive criticisms), and waiting for new evidence and an updated screening recommendation, before making any change to NHS guidance is not a neutral decision without consequence for population health.

Evidence supports that the benefits and harms of current policy on population health can be substantially improved. Therefore, at a minimum,  new guidance to GPs and the public is needed.

Principally, NHS guidance needs to be updated to reflect the strong impact of age and competing mortality on harms and benefits of PSA testing for men without new or worsening symptoms of possible prostate cancer, who are concerned about their risk.

A further step would be to make guidance for opportunistic testing in line with organised risk-based prostate screening as far as possible, such as by promoting re-testing guidance in line with the consensus algorithm used in the European Union.

In parallel, communication on the pros and cons of PSA testing to the public needs improving.

Men should be appropriately informed on the evidence that PSA testing when older than 70 will unlikely reduce their chance of dying from prostate cancer by a clinically significant amount. In fact, direct evidence from a randomised controlled trial suggests no benefit at all from screening men aged 70-74.  On the other hand, other randomised trial evidence strongly supports a high risk of being diagnosed with a cancer that otherwise would never have been detected in their lifetime.

Men should also be better informed about the very different trade-off between benefits and harms from testing in their 50s and early 60s, where men with screen-detected cancer will have a greater expected gain in life years, and a much lower chance of overdiagnosis. 

One of the most difficult aspects of overdiagnosis is how to communicate it, and improvements could be made. Decision aids, risk calculators, and clearer public information could all play a role. Involvement of patients and the public in developing and evaluating new communication strategies will be essential.

 

Conclusion

Healthcare policies should be designed to deliver meaningful population health benefits while minimising harm.

The evidence shows that age is a major factor driving both the benefits and harms from PSA testing, but current policy has led to high rates of PSA testing in older men.

Future NHS guidance should better reflect this, helping men and healthcare professionals make informed decisions about both when to start PSA testing, and when to stop.

 

Acknowledgement

I thank Matejka Rebolj and Jane Rigney for comments, suggestions and editorial changes that improved this piece.

 

Want to read more?

Authors Adam Brentnall, Peter Sasieni and Rhian Gabe wrote about their study on age and overdiagnosis for The Conversation UK


Read the research paper in International Journal of Cancer (IJC)

 

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