Should I Have a PSA Test If I Have No Symptoms?

Some people will have noticed a headline in the news this week:

“Men lose right to prostate cancer test.”

This was an unnecessarily sensational headline. It may cause unnecessary anger and worry.

But is it, in fact, true?

It’s less than two months since I wrote a blog here called ‘Prostates, PSA tests and the conversation men should not avoid’. Link below.

I concluded there:

If you are over 50, consider discussing PSA testing with your GP.

If you are Black, or if prostate cancer runs in your family, consider having that conversation from 45.

If you have a known BRCA2 gene change, or a strong family history of related cancers, make sure your GP knows.

I’m writing about this again so soon because the guidance has changed subtly.

And if you are a man without symptoms, you may still reasonably wonder whether you should have a PSA blood test for prostate cancer, and indeed now whether you can have one if you want.

Unfortunately, there isn’t a simple yes or no answer.

So, what has changed?

Previously, the NHS Prostate Cancer Risk Management Programme (PCRMP) explicitly said:

“The PSA test is available free to any man aged 50 or over who requests it.”

That guidance has now been withdrawn.

Be clear: this change concerns PSA testing in men without symptoms.

If you have symptoms, you need a clinical assessment rather than simply deciding for yourself whether to have a screening PSA.

If you have no symptoms, you can still ask your GP for a PSA. However, the new position places greater emphasis on your GP’s clinical judgement, taking account of your individual prostate cancer risk and the potential benefits and harms of testing.

In very brief:

Old guidance:

Man over 50 + informed choice → entitled to NHS PSA on request.

New position:

Man asks for PSA → GP assesses individual risk → GP decides whether testing is appropriate.

That’s why the Telegraph can reasonably describe this as men “losing the right” to a PSA test, although the Government objects to that characterisation.

The Government says that every man still has the right to ask his GP for a PSA test and argues that the ultimate decision was always intended to be a clinical one.

The distinction, therefore, is between the right to ask and the previous explicit entitlement to receive the test after making an informed choice.

Why all the uncertainty?

Because PSA isn’t a perfect test.

But it is currently the best simple blood test that we use to identify men who may have prostate cancer.

The important thing is to understand what the test can — and cannot — tell you, and then be able to make an informed choice.

What is a PSA test?

PSA stands for prostate-specific antigen. It is a protein produced by the prostate, and a small amount normally circulates in your blood.

A raised PSA does not mean that you have prostate cancer. PSA can also rise because of benign enlargement of the prostate, inflammation, infection and other factors.

Equally, a normal PSA does not completely rule out prostate cancer.

Why might I want a PSA test?

The main potential benefit is simple:

A PSA test may help find an important prostate cancer before it causes symptoms, when it may still be curable.

That matters because early prostate cancer often causes no symptoms at all.

Your personal risk is also important.

Prostate cancer becomes more common as you get older, and the risk is higher in Black men and in men with a family history of prostate cancer.

What are the disadvantages?

PSA testing creates uncertainty as well as providing useful information.

A raised result may turn out not to be cancer.

PSA can occasionally be normal despite cancer being present.

And PSA testing can lead to the discovery of a very slow-growing prostate cancer that would never have caused you problems during your lifetime.

That last point is important because finding a cancer can lead to further potentialy painful investigation, anxiety and sometimes treatment that might ultimately have been unnecessary.

What happens if my PSA is raised?

It does not mean that you automatically need a prostate biopsy.

Nowadays, the next stage will usually involve assessing your individual risk and, where appropriate, an MRI scan of the prostate.

The MRI and other information can then help decide whether a biopsy is actually necessary.

This is an important improvement in the way we investigate raised PSA results.

So, should I have one?

That depends partly upon how you feel about the uncertainties.

One man may think:

“I’d rather avoid investigations that might ultimately prove unnecessary.”

Another may say:

“I understand that risk, but I’d rather have the opportunity to find an important cancer early.”

Both are perfectly reasonable decisions.

What should I say to my GP?

If you have no symptoms but would like a PSA test, ask to discuss it with your GP.

And if, having understood the advantages and disadvantages, you decide that you want the test, you can simply say:

“I understand the limitations and possible consequences of PSA testing. I’ve considered them, and I would still like to have the test.”

In reality, that conversation is probably very similar to what was already happening in most GP surgeries.

This is about informed choice

This is not an argument that every man should be routinely screened for prostate cancer.

Nor am I saying that PSA is a perfect test. It clearly isn’t.

I’m arguing for something much simpler.

If you’ve had a proper discussion about the pros and cons, understand the uncertainties and still want a PSA test, I believe that decision should ultimately be yours. Your GP is there to help you make that decision, not simply to order a blood test.

Under the new guidance, however, the final decision rests more clearly with your GP.

In practice, I suspect it will be unusual for a GP to decline a reasonable, informed request.

There are circumstances where I might advise against testing — for example, an asymptomatic man with several previous normal PSA results asking to have them repeated unnecessarily frequently.

There may also be little benefit from PSA testing in someone whose age or general health means that finding an early prostate cancer would be very unlikely to improve either their quality or length of life.

That is what clinical judgement is for.

But for a well man who understands the uncertainties and, having considered them, still wants to know his PSA, my own view remains simple:

the final choice should be his.

And if you do have symptoms?

This article is about men without symptoms.

If you have new urinary symptoms, blood in your urine or semen, unexplained persistent pain, or anything else that makes you concerned about prostate cancer, don’t use this article to decide whether you need a PSA.

See your GP and get properly assessed.

This blog is written for general information and encouragement. It is not a substitute for personal medical advice. Every man’s health, circumstances and risks are different. If you have concerns about your own health, urinary symptoms, prostate cancer risk, or whether PSA testing is right for you, please speak to your own GP or healthcare professional. I cannot discuss individual cases.

I welcome your feedback and any suggestions for future men’s health articles.

Dr Mick Watts MBBS MRCGP is a GP at Windsor Wellness Clinic with a particular interest in men’s health, healthy ageing and lifestyle medicine.

For a link to Windsor Wellness Clinic click here.