Across the United Kingdom, a silent debate is intensifying in the world of men’s health. At the heart of it lies a question with enormous consequences: when should men diagnosed with prostate cancer actually receive treatment, and when is it safer—and wiser—to simply watch and wait?
Prostate cancer is the most common cancer among men in the UK, with around 55,000 new cases diagnosed each year, according to Prostate Cancer UK and reporting from BBC. Yet, not every diagnosis means urgent surgery or radiotherapy. In fact, about one in four of these cases involve slow-growing cancers that are unlikely to ever cause harm. For these men, the best course of action may be what’s called “Active Surveillance”—a careful, non-invasive monitoring regime involving blood tests and scans, rather than immediate, potentially life-altering treatment.
However, a growing chorus of researchers, clinicians, and patient advocates are warning that thousands of men are being treated too soon, exposed unnecessarily to the risks of surgery or radiotherapy. The root of the problem, they say, is a set of “outdated” guidelines from the National Institute for Health and Care Excellence (NICE), the body responsible for setting national standards for NHS care. These guidelines, last updated in 2021, recommend Active Surveillance only for men in the lowest-risk category of prostate cancer. The NHS, however, updated its own guidance in 2024 to extend Active Surveillance to men in the second-lowest risk group, creating a confusing contradiction.
This contradiction has real-world consequences. According to new data from Prostate Cancer UK and analysis by The Independent, 35 hospitals across the country have responded by creating their own guidelines, leading to what some experts describe as a “postcode lottery” in prostate cancer care. Hayley Luxton, Head of Research and Impact at Prostate Cancer UK, told Greatest Hits Radio, “It’s creating a little bit of a postcode lottery and it really depends on where you live and what the hospitals that you visit decide to do. We don’t think that’s good enough for men. We think men all over the country should have the best form of treatment.”
For men with low-risk cancers, the stakes are high. Treatments like surgery and radiotherapy, while effective at removing or destroying cancer, come with the possibility of life-changing side effects. “Some men might decide to have surgery, which is a really good way of cutting out the prostate cancer,” explained Ms Luxton. “But behind the prostate are a bundle of nerves, and these nerves are almost invisible to the surgeon’s eyes, so it’s really hard to protect these nerves. If you cut these nerve bundles, men could have erectile dysfunction, and they can also develop incontinence.” Radiotherapy, she added, can result in bowel problems, including loss of control of bowel function. “So, if these side effects can be avoided, then they should be.”
The numbers are sobering: up to 5,000 men each year in the UK may be receiving unnecessary treatment for prostate cancer, according to estimates from Prostate Cancer UK cited by BBC and The Independent. Overtreatment rates vary widely, from as low as 2% to as high as 24% depending on the hospital. This inconsistency is not just a matter of statistics—it’s about men’s lives and well-being. Michael Lewis, a 63-year-old nurse from Dudley, shared his experience with The Independent: “My doctors told me my cancer was ‘low-risk’ and not likely to spread quickly, so I was put on active surveillance until 2024, when my PSA level started to rise again, so I had surgery to remove my prostate. Being on active surveillance meant I didn’t have to have treatment until I needed to. I was able to continue my everyday life with no side effects. I’m glad I was able to get treatment when I needed it, but having the time without it was so valuable.”
Why the confusion? NICE’s current guidelines recommend Active Surveillance only for those with the lowest-risk prostate cancer, where nine in ten men will have no signs of cancer progression within five years. But research now shows that even among those in the second-lowest risk group, eight in ten will remain stable over the same period. In other words, many men are being treated for cancers that would likely never have caused them harm.
Professor Vincent Gnanapragasam, a professor of urology at the University of Cambridge, described the situation to The Independent as a “wild west.” He said, “Active surveillance is the best treatment option for men whose cancer is unlikely to progress or cause them problems in their lifetime. But NICE’s outdated guidelines have created a deeply concerning wild west on how surveillance is implemented by different health care teams. This inconsistency is resulting in a lack of confidence from patients in surveillance, who may instead opt to have treatment they may not have ever needed, risking harmful side effects.”
The result is a system where patient choice often fills the void left by clear national guidance. Men are generally given the option of treatment even if they are low-risk, but without consistent advice, many err on the side of caution—sometimes to their detriment. Amy Rylance, assistant director of health improvement at Prostate Cancer UK, told NationalWorld, “Thanks to advances in research, we can now tell which prostate cancers require immediate treatment, and which men would be better off being monitored with blood tests and scans—enabling them to delay treatment or even avoid treatment altogether.” She added, “To reduce the harm caused by prostate cancer and build the foundations for a screening programme, we need to both save lives and prevent unnecessary treatment but official guidelines still haven’t caught up with the clinical evidence.”
Calls for change are growing louder. Prostate Cancer UK has twice asked NICE to update its guidance on Active Surveillance, but both requests were rejected. Now, with mounting evidence that thousands of men could avoid unnecessary treatment each year, the charity is renewing its plea. The issue is also complicating efforts to introduce a national screening programme for prostate cancer—something currently under review by the UK’s National Screening Committee. Concerns about overtreatment are a major reason the UK does not already offer routine screening, despite prostate cancer’s prevalence.
Routine PSA testing, the main blood test for prostate cancer, is not currently offered across the NHS. Men over 50 can request the test from their GP, even if they have no symptoms, but there are ongoing debates about the risks of overdiagnosis and overtreatment. As Evening Standard reports, some argue that widespread PSA testing could identify cancers that never would have caused problems, leading to unnecessary interventions.
For its part, NICE says it is listening. A spokesperson told The Independent, “We are committed to ensuring our guidelines continue to reflect the best available evidence and give patients the best possible outcomes. They are developed by an independent committee, including NHS clinical experts, and are kept under review to ensure they remain current. We are updating our prostate cancer guideline, including a review of the recommendations around active surveillance, and will be assessing whether our suspected cancer guideline recommendations around age-related thresholds for PSA tests for prostate cancer for onwards referral from primary care require updating.”
As the debate continues, the stakes remain high. For thousands of men, the question is not just when to treat—but whether to treat at all. With evidence mounting and calls for reform growing louder, the hope is that future guidelines will bring clarity, consistency, and better outcomes for men across the UK.
