I treat prostate cancer every day – now I'm launching a study that could transform screening and save lives

28 March 2025, 07:52

The debate on screening for prostate cancer has been raging for over two decades.

It will continue to rage for another two decades if we do not bring new information and evidence to the table.

On one side, are over 12,000 men every year in the UK who have their lives cut short by prostate cancer. Families are devastated by these losses. Finding these cases of prostate cancer early can save thousands of lives every year. It is not just about living longer, of course. Finding and treating aggressive cancers can also reduce the impact of the cancer on quality of life as there are fewer problems with pain or bleeding or urination; we tend to use less aggressive treatments if the cancers are smaller and confined to the prostate.

On the other side, are the legitimate concerns about the harms of screening. When we talk about screening, we mean inviting almost all men between the ages of 50 and 75 years age, to have a test for prostate cancer. Currently, this test is called prostate specific antigen or PSA. It is a blood test and generally if it is above three then further tests are required such as an MRI scan and biopsy.

If these tests lead to a diagnosis of prostate cancer, men can be managed with a confusing array of different approaches that range from monitoring the cancer (active surveillance) through to radical prostatectomy (surgical removal of the whole prostate) or radical radiotherapy (radiation targeted to the whole prostate). Some men need hormones that make them castrate. The type of treatment depends on the risk characteristics of the cancer.

So far so good. But there are lots of problems with the current pathway that make lots of doctors and policy makers hesitate about recommending screening.

First, the PSA blood test can be high due to prostatitis (inflammation of the prostate), an enlarged prostate or an infection. Heavy exercise or sexual activity in the day or so beforehand can make the PSA temporarily go above. These false positives can then trigger unnecessary anxiety and sometimes invasive biopsy tests.

Second, although we are doing better with MRI scans before biopsy to reduce the number of men we need to biopsy, the biopsy tests are invasive and can cause bleeding, pain, urination problems and infections.

Third, one of the biggest issues with screening is finding what we call indolent cancers. If we took 1,000 men aged 50-75 years off the street regardless of their PSA level, and looked at their prostates in detail, about 300 of them would have tiny little areas of prostate cancer. These low risk cancers on the whole sit in the prostate and do not grow or spread or cause harm during the lifetime of those men.

So unlike cancers are they, that we are even debating not calling them ‘cancer’. If we biopsy the prostate, there is a chance of finding these cancers that do not need to be treated. If we can be sure about the cancer being low risk then we are pretty good at managing these with active surveillance but we need to do better in not finding them in the first place. This is because the so-called over-diagnosis of cancers can then lead to the fourth issue.

Fourth, when the cancer is contained in the prostate (and this will be the case for the majority of men diagnosed if we had screening), most men are treated with radical prostatectomy or radical radiotherapy that treat the whole prostate. The prostate is surrounded by nerves, muscles, the water passage runs through its middle and the back passage and bladder are millimetres away. This can mean quite significant and life changing side effects of the treatment. Leakage of urine, urination issues, erectile dysfunction and back passage problems. When studies have shown that treating early prostate cancer only has a small effect on survival compared to monitoring the cancer, many patients and experts argue that the treatment benefit is not worth the impact it is has on quality of life.

Into this fiery arena comes TRANSFORM. This new study was funded by Prostate Cancer UK and the UK government’s National Institute of Health Research to over £42 million to address the evidential gap that has existed for many years. International experts and the UK’s National Screening Committee have reviewed the study and agree that it is necessary in order to shift the pendulum.

TRANSFORM will look at new ways of screening to reduce false positives, reduce biopsy rates and reduce diagnosing low risk cancers whilst finding more high risk cancers that need to be treated. TRANSFORM will then choose the best way to screen and run a large national study to show whether or not screening should be delivered compared to what we are currently doing. We will ask that men have access to minimally invasive focal therapy which targets individual cancers rather than the whole prostate so that most men will have 5-10 fold lower side effects of treatment compared to radical therapies.

Radical therapies will still have a role for the very aggressive cancers. TRANSFORM Discovery will be our parallel research stream where we will ask men to donate extra blood, urine, and tissue as well as their images for future research so that the best commercial biomarkers and the best academics around the UK and beyond can continue to innovate and find new ways to diagnose and treat prostate cancer.

TRANSFORM is not being taken lightly. The team is determined to get the answers that men and their families deserve.

TRANSFORM will take many years. We need to be patient as the current evidence is just too uncertain.

TRANSFORM is the culmination of two decades of truly UK-led innovation in how we diagnose and treat prostate cancer. We trust everyone will support us going forward.

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Professor Hashim Ahmed is an internationally renowned expert in diagnosing and treating prostate cancer, and benign prostate enlargement.

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