Prostate cancer: what all men need to know (2025)

Prostate cancer has overtaken breast cancer as the most common form of the disease in the UK. A record 55,000 men were diagnosed with it in 2023, up from 44,000 in 2019. These are frightening numbers. Should all midlife men demand that they have a screening test?

Professor Hashim Ahmed, chair of urology at Imperial College London, and an internationally renowned expert in prostate cancer diagnosis, working in the NHS and privately, says the “huge rise” is essentially a backlog.

So few men were diagnosed during Covid and post-pandemic that NHS England and Prostate Cancer UK launched a successful campaign “to find those missing men”. By fundraising and campaigning on behalf of related charities several celebrities have also raised awareness of a disease, which has affected them personally, including Chris Hoy, Linford Christie and Rod Stewart.

Yet prostate cancer kills 12,000 men each year — despite being treatable and curable, especially if caught early. More accurate, non-invasive early testing is urgently needed to save lives — and the £42 million Transform study, co-led by Ahmed, into how effective, prompt diagnosis of prostate cancer can best be achieved is under way.

What symptoms should I be looking for?

Prostate cancer doesn’t cause any symptoms in its early stages, Ahmed says. By the time it’s causing pain, blood in the urine, or problems passing urine, it’s advanced. But issues with passing urine aren’t necessarily a cause for worry. Ahmed says. “Generally, problems passing urine, getting up at night, or the flow being slow, or having to go frequently, are not symptoms of cancer. Those are symptoms of men ageing, and the prostate growing in a non-cancerous way and putting pressure on the water passage.

“In fact, there is no real correlation with symptoms,” he adds. It’s why campaigns have focused on, “Men, do you know that there’s a blood test that you can have to check for prostate cancer?” rather than symptoms.

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What is the blood test?

The PSA (prostate-specific antigen). The prostate-specific antigen is a chemical secreted from the prostate, and if it’s above three nanograms per millilitre of blood — that’s the threshold used in men between the ages of 50 and 75 — then the GP will refer you to hospital, Ahmed says, unless there are other causes for the PSA being raised, eg inflammation caused by a urinary infection, sexual activity, or heavy exercise in the 48 hours before the PSA test, such as cycling.

However, the PSA has relatively poor accuracy — 15 per cent of men with high-risk cancers have low PSA scores. And 75 per cent of men with a raised PSA score will not have cancer.

Why is there no screening programme?

GPs are advised against proactively offering the PSA test to any man without symptoms. “There is no screening programme, no letter through the post saying, ‘Come and have a test to check for prostate cancer’,” Ahmed says. Many find this baffling and outrageous, but he says, “Of three big studies to look at whether screening improves survival of men compared to not screening, only one showed an increase in survival. It means the evidence is still uncertain.”

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Plus, he says, when you screen for prostate cancer, you find cancers in the prostate that don’t need to be treated. “A third of men above 50 have tiny bits of cancer in their prostate that they will never know about, that will never grow or spread, that will never cause them any problems in quality or quantity of life.” But if they’re found in screening, “A lot of men end up wanting to be treated for these low-risk cancers because they get so anxious.”

However, Ahmed emphasises that GPs aren’t “banned” from offering the PSA, and if a man is certain he’d benefit he believes that “most GPs will say you can have it”.

Meanwhile, researchers are investigating the value of a targeted screening programme. Ahmed says: “There are a number of small studies, looking at men aged 45 to 50 who have a higher risk of prostate cancer, either from a family history or because they are of black ethnicity.”

Why not for men in their early forties? For men aged 40 to 44, the risk of prostate cancer is “very, very low’’. Plus, “MRI scans in that group are known to be much less accurate, so we have to be very careful about calls to start screening men from the age of 40.”

If I’m a man approaching 50, should I get a PSA test anyway?

Surely Ahmed has had a PSA test? “I’m 48,” he says. “I don’t have a family history of it, I’m not black — which are the two additional risk factors — so, no.” Though if you have family members who’ve suffered from prostate cancer, breast and ovarian cancers, or are of black ethnic origin, a group whose risk of prostate cancer is twice that of other ethnicities, “We certainly think you should start to test your PSA at the age of 50. Some people think 45.” Why not earlier? At present, it’s not thought to be safe. “We could end up doing too many invasive biopsies.”

If my PSA is raised, should I pay for a ‘second opinion’ screening?

The EpiSwitch prostate screening test (PSE), for example, is designed to work in conjunction with a PSA test. If your PSA is raised, this blood test costing £905 is advertised as helping to provide a more accurate risk assessment — potentially avoiding the need for a biopsy.

Ahmed says it’s one of several tests that look at raised biomarkers to help to determine risk. But, he says, “There’s so much ‘noise’ in the blood it’s quite difficult to be accurate.” A promising approach, but more research is needed, he says. In the private sector for prostate cancer screening “almost none of us are using additional biomarkers”.

MRI on the NHS

You should receive PSA test results within a fortnight. If you’re then referred for an MRI, you should get an appointment within two weeks. The standard NHS scan is a 40-minute multiparametric MRI (mpMRI) for prostate cancer.

“It has three elements,” Ahmed says. The first scans the anatomy, but doesn’t show cancers very clearly. “The second is looking at how densely packed cells are in the prostate. And cancers tend to be more densely packed. Those scans are very good at showing up cancers.” The third element involves contrast dye. “Cancers generally have more blood supply, and if you inject dye into the vein, those tumours light up like lightbulbs.”

Ahmed led the UK study in 2017 that showed that this approach (PSA, then MRI, then biopsy if necessary) is much more accurate and safe than going straight from PSA to biopsy. However, he says an MRI might not be suitable for men with pacemakers, kidney problems or hip replacements. This group might simply be monitored, or go straight to a biopsy, or have an ultrasound scan.

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A biopsy is less invasive than it was

If the MRI indicates that a biopsy is advisable, most men will have one under local anaesthetic, although, “It’s not a nice experience,” Ahmed says. “You have to leave your dignity at the door — we place men in the gynaecological position that women are used to. It’s tolerable in the vast majority. In the right hands, it’s very straightforward.”

Previously, “We’d go straight to a biopsy,” he adds. “It was a horrendous test. The needles went through the rectum. They were dirty, caused lots of infections, and they were random. You couldn’t see where the tumours were.” Thankfully, since 2017, biopsies are transperineal — “they go through the skin rather than through the back passage. That has led to a huge drop in infection risk. It’s much more accurate as well.”

What should one do if cancer is low-risk?

If you have a confirmed diagnosis of cancer that is low risk, you should really not have any treatment, Ahmed says. “‘Active surveillance’ is what we would advise. We’ll keep a careful eye on it. In the small percentage of men where it changes, we can step in, treat it.”

This means, Ahmed says, “You’ve gone through a PSA, it’s a little bit high, you’ve had an MRI scan that’s shown something mildly or moderately suspicious, you’ve had a biopsy, and on that biopsy, when the pathologist looks under the microscope at the cancer cells, he gives the cancer cells a score — what we call a Gleason Score.” This starts at 3+3=6 — that’s the lowest score; low-risk disease. (It goes up to 5+5=10.)

If you have 3+3=6, the chance that cancer will become more significant over five to ten years is 5 per cent. “That means 95 per cent of men see no change in their cancer. It just sits there doing nothing. That’s why we shouldn’t be treating these men, providing they’re psychologically comfortable with it,” Ahmed says.

These men should be monitored with PSA blood tests every three to six months. If the level starts to consistently rise, they get another MRI scan, and potentially another biopsy, he says. “It’s really safe, even if they’re in that 1 in 20 where the cancer changes and needs to be treated, they don’t lose that window of curability.”

And what’s wrong with getting treatment?

Studies have shown that if you treat these low-risk cancers, treatment versus doing nothing offers no survival advantage, Ahmed says. For the vast majority diagnosed, “Your treatment options are surgery or radiotherapy. And surgery or radiotherapy can cause leakage of urine in up to a third of men. They have to wear pads for the rest of their life.

“At least 50 per cent will lose sexual function completely — even with Viagra. And 5-10 per cent, if they have radiotherapy, will have back passage problems — bleeding, diarrhoea, discomfort.” There are reports of depression and divorce. “It has a massive effect on men’s quality of life,” he says.

What If I’m diagnosed as medium risk?

The vast majority of men diagnosed are medium risk. In most NHS centres, they have a choice between a prostatectomy, surgery that removes the prostate, or radiotherapy, which irradiates the prostate, Ahmed says. These treatments are effective “but at a significant cost. The nerves that give rise to sexual function are wrapped around the prostate. So if you treat the whole prostate, those nerves get damaged.”

Almost all prostate surgeries are robotically assisted, Ahmed says. “What that simply means is there are robotic arms placed inside the tummy of the man through 1cm incisions, and those arms mimic what the surgeon is doing at another station.

“It’s fantastic technology in that it’s led to less pain, less bleeding, quicker recovery. But, compared to open surgery, where you make a big cut, studies show it hasn’t reduced the risk of erectile dysfunction or urine leakage.”

The muscle that stops you from leaking urine is partly inside the prostate and partly just outside it. “Again, if you treat the whole prostate, the water passage and that muscle get damaged.” The back passage and bladder are millimetres from the prostate.

“If you have radiation, unfortunately, it’s not that accurate even with modern technology, and can cause back passage symptoms — bleeding, diarrhoea, discomfort — or bladder symptoms — needing to rush to the toilet, not making it in time.”

Ahmed notes that a minority of men with medium-risk disease — with a Gleason score of 7 — can also go under active surveillance “very safely”. “They have a 1 in 5 chance that the cancer will change and grow,” he says.

Ask for focal therapy (privately or in 5 NHS centres)

About half of men with medium-risk prostate cancer have just one tumour, occupying just 5 to 10 per cent of the prostate, Ahmed says. For this group, focal therapy — cryotherapy and HIFU (high-intensity focused ultrasound) — is a superior option to surgery or radiotherapy.

“Cryotherapy and HIFU are ways of destroying the cancer by freezing or heating. By treating just the tumour, the damage caused to the nerves, muscles, back passage and bladder are massively reduced.” With surgery or radiotherapy 50 per cent of men will lose erectile function. With HIFU and cryotherapy it’s 5 to 10 per cent.

With a prostatectomy, a third of men will leak urine. “With HIFU and cryotherapy that goes down to 1 per cent. And back passage symptoms are very rare.” Recurrence risks are similar, he adds (for 20 per cent, even with surgery or radiotherapy, cancer will recur). “The difference is, you can have HIFU and cryotherapy again.” HIFU and cryotherapy have a survival rate of 99.9 per cent at 10 years. “So you don’t compromise your survival or recurrence. And you have a vastly reduced side-effect profile.”

Focal therapy costs £15,000 to £16,000 privately — but five NHS centres, in London and the southeast, offer it. “Most men eligible for this — 10,000 to 12,000 every year — are not even told about it,” Ahmed says.

What if your prostate cancer is deemed high-risk?

High-risk prostate cancer is when the cancer’s quite big or spread beyond the prostate, Ahmed says. Then, “Men have to be treated quite aggressively with surgery, sometimes a combination of surgery and radiotherapy and chemotherapy drugs. They have most to lose in terms of survival if we don’t treat aggressively.”

What if the disease is advanced?

“Almost every two to three years a new drug comes along that shows an improvement in survival over the standard drugs,” Ahmed says. And according to a recent study from UCL, “If you treat the prostate in men whose cancer has spread with radiotherapy, there seems to be an improvement in survival.

“If you then hit the areas of the cancer that has spread with some targeted very precise radiotherapy, that also seems to improve survival, according to a number of studies.” It’s not a cure, he adds, but getting rid of as many cancer cells as possible seems to prevent these cancers from becoming resistant to drugs.

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Can I protect my prostate by making lifestyle changes?

Ahmed’s five dietary recommendations include cooked tomatoes, pomegranate (fruit or juice), green tea (one cup a day), mixed nuts as they contain antioxidants that help to calm tissue down and lead to fewer mutations, and brassica vegetables, such as cauliflower and kale. It’s not known whether “power foods” prevent cancer, he says, “but there’s reasonable evidence that they are good for your prostate and protect it from becoming inflamed”.

If you’re on active surveillance, he adds, “There’s really good evidence to show if you make those dietary changes it reduces the chance of the cancer getting worse or recurring.”

Ahmed also recommends “aerobic exercise — swimming, jogging, cycling, brisk walking — for at least 20 to 30 minutes three times a week, so you get a bit breathless from it. That will help protect your prostate.”

If I require surgery, how should I prepare?

As well as the dietary and exercise advice above, Ahmed recommends pelvic floor strengthening exercises to “help recover your urine control”. (Try an app such as Squeezy for guidance.) Ahmed suggests two to three sets every day. This may also help with recovering erectile function, Ahmed says. He adds that regular sexual activity, alone or partnered, “is really important before and after to maximise the chances of erectile function recovery”.