Jeremy Clarkson’s recent diagnosis has put prostate cancer back in the media, especially screening.
An aggressive tumour had been caught early the previous year, and a follow-up PSA test had come back clear. He used the moment to press a message on other men.
Get tested, he said, and if a GP turns you away because you have no symptoms, invent some. “Just lie,” he advised, tell them you are up half the night needing to urinate.
Around 12,000 men in the UK die of prostate cancer each year, he pointed out, and no man should let himself become one of them.
Jeremy Clarkson’s advice was heartfelt, he wanted to save lives. But the advice could lead to thousands of healthy men becoming impotent or incontinent without helping them live any longer. That is why prostate cancer screening (en masse regardless of symptoms) has never been rolled out in the UK.
If every man were screened, the arithmetic would be this:
- about 1 in 100 men would die of prostate cancer whether screened or not – for them screening changes nothing;
- about 1 in 500 men would be spared a death from prostate cancer because of screening;
- yet the same number of men still die, and at the same age.
His conviction is understandable given his circumstance. However, there are many assumptions that led to his conclusion and they are not all correct, let’s look at the data and use some common sense.
I will warn you now, if you are looking for a simple yes/no answer, you will not get it. That is not how clinical life works.
Prostate cancer is now the most commonly diagnosed cancer in men in the UK, and understandably, many men are now asking whether they should have a prostate specific antigen (PSA) blood test. It seems like a simple question, but the answer is anything but simple.
Imagine a disease so common that autopsy studies show up to two thirds of elderly men have microscopic evidence of it at death, yet most never knew it was there and died from something entirely unrelated.
That is the reality of prostate cancer.
While some prostate cancers are aggressive and life threatening, many grow so slowly that they would never have caused symptoms during a man’s lifetime, beyond a nighttime wee.
The challenge is identifying the dangerous cancers while avoiding unnecessary diagnosis and treatment of those that would never have become clinically important.
PSA is a protein produced by normal prostate tissue as well as cancerous tissue. A raised PSA does not necessarily mean cancer. It may simply reflect benign enlargement of the prostate, inflammation (prostatitis), a urinary tract infection, recent ejaculation or even vigorous cycling.
Richard Ablin, the scientist who first identified prostate specific antigen in 1970, became one of the test’s strongest critics.
In a 2010 article for The New York Times, he described widespread PSA screening as a “profit driven public health disaster.”
His concern was not that PSA had no value, but that it was being used as a population screening test despite its inability to distinguish harmless cancers from aggressive ones.
PSA is therefore prostate specific, not cancer specific.
It tells us that something may be happening within the prostate, but it cannot reliably distinguish cancers that are life threatening from those that would never have caused harm.
The latest 2026 Cochrane Review analysed six randomised trials involving almost 800,000 men followed for up to 23 years.
The review concluded that PSA screening “probably reduces deaths from prostate cancer”, preventing approximately two prostate cancer deaths for every 1,000 men invited for screening over long term follow up.
However, the review did not demonstrate that PSA screening reduces overall mortality.
(I think it is worth highlighting the word “probably”, which is not very reassuring, and that 2 deaths per 1000 screening is a number needed to treat of 500).
Hence, why the site www.THENNT.com do not recommend it per se.
https://thennt.com/nnt/psa-test-to-screen-for-prostate-cancer-2/
They conclude “Time and further evidence may identify a group of asymptomatic men who benefit from PSA screening, however at this time such a cohort has not been elucidated. Medical providers who continue to use the PSA test despite these data should ensure that their patients understand the harm-benefit balance of the test through shared decision-making, a position that the AUA has moved toward as well.”
At first glance this appears contradictory, but it reflects the fact that although a small number of men avoid dying from prostate cancer, they may still die later from heart disease, stroke, dementia, another cancer or another unrelated illness.
Prostate cancer represents only one of many competing causes of death as men age.
This distinction between reducing deaths from prostate cancer and reducing deaths overall lies at the heart of the PSA screening debate.
For some, preventing even a small number of prostate cancer deaths justifies screening.
Others argue that a screening programme should demonstrate that people live longer overall, not simply die from a different cause after diagnosis and treatment.
And mortality is only one outcome that matters.
Screening also creates false positive results, unnecessary investigations and overdiagnosis.
Many men diagnosed through PSA screening have cancers that would never have caused symptoms during their lifetime.
An elevated PSA usually leads to further investigations, often including MRI scanning and sometimes a prostate biopsy.
Traditionally, biopsies have been performed through the rectal wall (transrectal biopsy), carrying a recognised risk of infection because bacteria from the bowel can be introduced into the prostate.
Fortunately, increasing numbers of centres now perform biopsies through the skin between the scrotum and anus (the transperineal approach), which substantially reduces the risk of infection.
One of the greatest challenges of PSA screening is that finding more cancers does not necessarily mean saving more lives.
Many of the cancers detected through screening would never have become clinically significant during a man’s lifetime.
For these men, the greatest risk may come not from the cancer itself, but from its treatment.
The landmark ProtecT trial, which followed men with localised prostate cancer for up to 12 years, compared active monitoring, surgery and radiotherapy.
Although prostate cancer specific mortality remained low across all three treatment groups, quality of life outcomes differed substantially.
Seven to twelve years after radical prostatectomy:
- Around four out of five men continued to have erections insufficient for intercourse.
- Around one in five required urinary pads because of persistent urinary leakage.
Radiotherapy generally caused less urinary incontinence than surgery but was associated with bowel problems, including faecal leakage in around one in eight men, together with erectile dysfunction that increased over time.
Some decline in bladder control and sexual function naturally occurs with ageing, even in men who are not treated.
However, both surgery and radiotherapy substantially increased these problems compared with active monitoring, with many men continuing to experience reduced quality of life a decade later.
These physical complications often extend far beyond bladder or sexual function. They can affect confidence, intimate relationships, self esteem, mental wellbeing and overall quality of life. Anxiety, depression and relationship difficulties are recognised consequences for some men following treatment.
Evidence supporting a more conservative approach comes from several important studies.
The PIVOT trial in the United States and the Scandinavian Prostate Cancer Group Study demonstrated little or no overall survival advantage from immediate radical prostatectomy compared with observation or watchful waiting for many men, particularly those with low risk disease.
These findings helped change clinical practice.
Today, the vast majority of men with low risk prostate cancer are offered active surveillance rather than immediate treatment. Regular PSA testing, MRI scans and selective repeat biopsies allow many men to avoid surgery or radiotherapy altogether, while still identifying those whose cancer later becomes more aggressive and requires treatment.
For any screening programme, the ultimate goal is not simply to reduce deaths from one specific disease, but to improve both the length and quality of life.
While some men may avoid dying from prostate cancer, the current evidence has not shown that screened men experience lower overall mortality than those who are not screened.
At the same time, PSA screening inevitably identifies many cancers that would never have become clinically significant.
Given that autopsy studies suggest that up to two thirds of elderly men die with microscopic prostate cancer rather than from it, overdiagnosis remains a central concern. Some of these men may undergo biopsies, surgery or radiotherapy for cancers that would never have affected either their lifespan or their health.
The decision to undergo PSA screening is therefore not a simple choice between testing and not testing. It is a careful balance between a probable but modest reduction in prostate cancer mortality and the possibility of unnecessary investigations, overdiagnosis and treatments that can permanently affect quality of life.
This is why most expert organisations recommend informed, shared decision making, ensuring every man understands both the potential benefits and the potential harms before deciding whether PSA testing is right for him.
PSA is neither the miracle screening test that some hoped for, nor the complete failure that others have claimed.
It is an imperfect tool with both measurable benefits and measurable harms if treatment is not needed.
Understanding both sides of the evidence allows men to make informed decisions that reflect their own values, priorities and tolerance of risk.
Once again, we need to use testing for clinical symptoms and apply some common sense.
Optimal testing does offer a finger prick PSA test as needed, especially for those with symptoms, and those that want to monitor PSA after a diagnosis or treatment.
https://optimaltesting.co.uk/product/prostate-specific-antigen-psa
