After a robust, expert-led review of current evidence, the UK National Screening Committee (UK NSC) has announced a draft recommendation for a targeted prostate cancer screening programme and launched a public consultation period.

If implemented, the proposed programme will invite men aged 45 to 61 with a mutation in genes called BRCA1 or BRCA2 for prostate cancer screening every two years.

We support this recommendation for men with BRCA mutations, who are more likely to develop aggressive prostate cancer than men without BRCA mutations, but there’s more to do before screening can be rolled out. First, the recommendation will need to be approved, and then health systems across the UK will need to find the best way to implement the programme.

In this article, we’re setting out what the UK NSC’s draft recommendation is, why the proposal is to specifically target men with BRCA mutations, and what’s going to happen next.

What is the UK NSC proposing and how have they reached their decision?

Before recommending a screening programme, the UK NSC needs robust evidence that it would do more good than harm.

We’ve written about that decision process in depth here. On the one hand, programmes need to help save the lives of the people who could benefit from earlier diagnosis. On the other, they need to minimise the risk of mistaken diagnoses and overdiagnosis (finding a slow-growing cancer that wouldn’t have actually caused someone harm), which can lead to unnecessary treatment. Because the resources we have for diagnosing and treating cancers are limited, it’s also important to understand whether a programme would be cost-effective.

For prostate cancer screening, striking the right balance means considering the strengths and limitations of the potential screening test, the Prostate Specific Antigen (PSA) test, and identifying the group of men who are most likely to benefit from being offered it.

So, in recent months, the UK NSC brought together all the current evidence and asked an expert team to model several different scenarios to understand which men are at the highest risk of prostate cancer and who would benefit most from any screening programme. The UK NSC then reviewed this modelling to inform their decision.

Overall, the analysis found strong enough evidence to show that limiting screening to men aged 45 to 61 with confirmed BRCA1/2 mutations would likely result in the best balance of harms and benefits compared to screening all men, men with a family history, or just screening Black men.

Importantly, the evidence suggests this approach is more likely to identify people who have a fast-growing cancer before it has progressed to a late stage. These cancers need prompt treatment and finding them at an earlier stage increases the chances that treatment will be successful, which could help save more lives. Focusing on this group also means the risk of over-diagnosing slow-growing prostate cancers that would never have gone on to cause people harm is lower.

Why only offer the PSA test to 45 to 61-year-old men with BRCA mutations? 

The overall evidence, as well as the expert modelling, shows that when all men within a defined age range are screened with the PSA test, there are too many harms compared to the benefits.  

This is linked to the limitations of the PSA test, which measures the level of a protein called prostate specific antigen in the blood. PSA is only produced by the prostate, so measuring it helps doctors understand prostate conditions in men, trans women and non-binary people assigned male at birth.  

In some cases, high PSA levels can be a sign of prostate cancer, but this isn’t always the case. In fact, they can also be a sign of things like recent exercise, recent ejaculation, an infection, or older age. As a result, many men who have high PSA levels picked up through PSA testing go on to have further prostate cancer tests when they don’t actually need them. These tests, especially biopsies, are not risk free and can cause harm.

The PSA test can also miss some prostate cancers (false negatives) and increase the chance of overdiagnosing slow-growing ones, which can lead to overtreatment with surgery and radiotherapy. This creates a risk that some men will experience serious side effects like impotence (difficulty getting an erection) and incontinence (losing bladder control) without having their life extended.

The UK NSC also specifically considered whether Black men should be included in a targeted screening programme. They found that the evidence wasn’t conclusive enough to be sure of the potential benefits and harms for these men.

There are lots of unanswered questions when it comes to how Black men specifically are impacted by prostate cancer and how we can improve outcomes for them. One of the big unknowns is if Black men with different ethnic backgrounds are at different risk of prostate cancer.

You can read more about this in our technical briefing but, in short, more evidence is needed to understand whether screening Black men would benefit them or inadvertently lead to more harms like overdiagnosis and overtreatment without saving any lives.