Exeter Collaboration for Academic Primary Care (APEx) Blog
Exeter Collaboration for Academic Primary Care (APEx) Blog
Posted by ma403
24 October 2025By Dr Sam Merriel
NHS GP and Clinical Senior Lecturer, University of Manchester
LinkedIn – https://www.linkedin.com/in/dr-sam-merriel-69078661/
A global wave of prostate cancer is coming. According to the recent Lancet Commission on prostate cancer[SM1] , new cases of the disease are expected to double between 2020 and 2040. Even though the coming wave is largely driven by demographic changes in East Asia and Sub-Saharan Africa, the incidence of new prostate cancer cases in the UK is anticipated to rise from 50,000 in 2020 to 80,000 by 2040. Crucially, there are no known effective methods for preventing prostate cancer, meaning that the focus for the NHS and healthcare systems around the world needs to be on early detection, more accurate diagnostics, and wider access to effective treatments.
Primary care is the main route to diagnosis for prostate cancer in the UK, with over 80% of new cases being diagnosed following presentation to primary care and referral for diagnostic testing or specialist input[SM2] . NHS GPs have one test at their disposal to detect prostate cancer: the Prostate Specific Antigen (or PSA) blood test. PSA is a substance naturally made by the prostate and detectable in the bloodstream. The presence of prostate cancer is one of a number of explanations for an elevated PSA level. Whilst PSA testing can be used for earlier detection of prostate cancer, the test suffers from a high false positive rate and the performance of the test for detecting clinically significant prostate cancer in primary care settings remains unknown.[SM3]
PSA testing for prostate cancer in NHS primary care usually occurs in one of two scenarios. Either a GP recommends a PSA test as part of clinical assessment for a patient presenting with prostate-related symptoms, such as lower urinary tract symptoms, or a patient attends requesting a PSA test for prostate cancer screening. National guidance for GPs differs depending on whether PSA testing is undertaken for symptomatic assessment or prostate cancer screening, which is challenging for both clinicians and patients[SM4] . Given the UK National Screening Committee currently does not recommend a nationally commissioned PSA-based prostate cancer screening programme, PSA testing is only accessible through NHS primary care opportunistically. This scenario creates inequity and frustration for patients and additional workload pressure on NHS primary care for which there is no dedicated funding or resources.[SM5]
Recent advances in prostate cancer diagnostics presents an opportunity to improve the status quo in primary care. Pre-biopsy prostate magnetic resonance imaging (MRI) has become the new standard of care in secondary care following trials in the UK and Europe demonstrating MRI is highly sensitive for clinically significant prostate cancer. [SM6] Prostate cancer is the most heritable and genetically driven type of cancer, with genomic risk scores (GRS) showing promise for risk stratification for clinically significant prostate cancer across different ethnic groups[SM7] . Neither prostate MRI nor GRS are utilised in primary care yet. However, the ‘Modernising General Practice TESTing for the detection of clinically significant PROstate cancer (GP-TEST-PRO study)’[SM8] , recently funded by the NIHR will compare the performance of prostate MRI and a multi-ancestry prostate cancer GRS to PSA a prospective primary care cohort, with the aim of identifying the optimal diagnostic strategy for detecting clinically significant prostate cancer in NHS primary care.
[SM1]REF: James ND, Tannock I, N’Dow J, Feng F, Gillessen S, Ali SA, et al. The Lancet Commission on prostate cancer: planning for the surge in cases. The Lancet. 2024.
[SM2]REF: NDRS. Routes to Diagnosis 2024 [Available from: https://www.cancerdata.nhs.uk/routestodiagnosis.
[SM3]REF: Merriel SWD, Pocock L, Gilbert E, Creavin S, Walter FM, Spencer A, et al. Systematic review and meta-analysis of the diagnostic accuracy of prostate-specific antigen (PSA) for the detection of prostate cancer in symptomatic patients. BMC Medicine. 2022;20(1).
[SM4]REF: Merriel SWD, Seggie A, Ahmed H. Diagnosis of prostate cancer in primary care: navigating updated clinical guidance. Br J Gen Pract. 2023;73(727):54-5.
[SM5]REF: Vickers A, O’Brien F, Montorsi F, Galvin D, Bratt O, Carlsson S, et al. Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit. BMJ. 2023;381:e071082.
[SM6]REF: Ng A, Asif A, Agarwal R, Panebianco V, Girometti R, Ghai S, et al. Biparametric vs Multiparametric MRI for Prostate Cancer Diagnosis: The PRIME Diagnostic Clinical Trial. JAMA. 2025.
[SM7]REF: Huynh-Le MP, Karunamuni R, Fan CC, Asona L, Thompson WK, Martinez ME, et al. Prostate cancer risk stratification improvement across multiple ancestries with new polygenic hazard score. Prostate Cancer Prostatic Dis. 2022;25(4):755-61.