Prostate Cancer — PSA Screening, Staging, Surgery & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

Prostate cancer is the most common malignancy in men worldwide, with approximately 1.4 million new cases and 375,000 deaths annually. It arises predominantly from the prostatic epithelium as adenocarcinoma (95% of cases). The disease is highly heterogeneous — ranging from indolent, slow-growing cancer that may never cause clinical harm (Gleason Grade Group 1) to aggressive, rapidly metastatic disease. This biological spectrum drives the distinction between conservative management (active surveillance) and immediate curative treatment. PSA-based early detection has significantly increased the proportion of cancers detected in localised, potentially curable stages. The peripheral zone of the prostate is the commonest site of origin (70%), with transition zone cancers increasingly detected through TURP specimens and MRI. Localised prostate cancer detected at PSA screening has a near 100% 5-year survival with treatment, while metastatic disease carries a 5-year survival of approximately 30% — underscoring the value of early detection through PSA testing combined with informed shared decision-making.

Age is the most important risk factor — incidence rises sharply after age 50, with over 60% of cases diagnosed in men over 65. Race/ethnicity: African-American men have the highest incidence globally (approximately 60% higher than White men) and poorer outcomes. Family history: first-degree relative with prostate cancer doubles lifetime risk; BRCA2 mutations (inherited) increase risk 5–8-fold and are associated with aggressive disease; BRCA1, HOXB13, and Lynch syndrome also increase risk. Dietary factors: high-fat, high-red-meat diets are associated; lycopene (from tomatoes), selenium, and vitamin E have been studied but not proven protective. Obesity increases aggressive prostate cancer risk. Exposure to cadmium, Agent Orange, and oestrogen-rich environments may contribute. The hormone testosterone drives prostate cancer proliferation — androgen deprivation is a key treatment principle.

Early localised prostate cancer is typically asymptomatic — the majority of cases are detected through elevated PSA on routine testing. Locally advanced prostate cancer may cause lower urinary tract symptoms (LUTS) similar to benign prostatic hyperplasia: weak urine flow, urinary frequency and urgency, nocturia, hesitancy, incomplete bladder emptying, and haematuria or haematospermia. However, LUTS are more commonly caused by BPH than cancer, and their absence does not exclude cancer. Advanced or metastatic prostate cancer presents with: bone pain (particularly axial skeleton — spine, pelvis, ribs — from osteoblastic metastases), weight loss, fatigue, pathological fractures, lower limb weakness or sensory loss (spinal cord compression — oncological emergency requiring immediate assessment), anaemia, and ureteric obstruction causing hydronephrosis.

PSA (prostate-specific antigen) blood test: not cancer-specific (elevated in BPH, prostatitis), but rising PSA, PSA density above 0.15 ng/mL/cm3, and PSA velocity above 0.75 ng/mL/year increase cancer suspicion. Age-specific PSA reference ranges apply. Digital rectal examination (DRE): detects posterior or lateral hard nodules suspicious for cancer. Multiparametric MRI (mpMRI): the recommended pre-biopsy investigation (PROMIS trial, PRECISE guidelines) — PI-RADS 4–5 lesions have >50% probability of clinically significant cancer; PI-RADS 1–2 may allow biopsy deferral. Transperineal template biopsy (preferred over transrectal — lower infection risk) guided by mpMRI: Gleason grading and Grade Group 1–5 (Grade Group 1: Gleason 3+3=6, low risk; Grade Group 5: Gleason 9–10, very high risk). Staging: CT chest/abdomen/pelvis; bone scan; PSMA PET-CT (superior staging for biochemical recurrence and metastatic disease — increasingly replacing conventional imaging).

Low-risk localised prostate cancer (Grade Group 1, PSA below 10): active surveillance (AS) with PSA 3–6 monthly, MRI annually, repeat biopsy at 12 months and 3–5 years — curative treatment deferred unless progression. Intermediate and high-risk localised disease: radical prostatectomy (robot-assisted laparoscopic prostatectomy — RALP) removes the whole gland and seminal vesicles; external beam radiotherapy (IMRT, VMAT, SBRT/SABR — hypofractionated schedules of 20 fractions now equivalent to 37–39 fractions); brachytherapy (low-dose rate seeds or high-dose rate — for low-risk disease); high-risk localised disease: radiotherapy plus 2–3 years of androgen deprivation therapy (ADT). Locally advanced disease: combination ADT + radiotherapy or docetaxel chemotherapy upfront with ADT (STAMPEDE trial). Metastatic hormone-sensitive prostate cancer: ADT (LHRH agonists: leuprorelin, goserelin + anti-androgen) + abiraterone (Zytiga)/enzalutamide (Xtandi)/darolutamide + docetaxel (PEACE-1, ARASENS trials — triplet therapy). Castrate-resistant prostate cancer (CRPC): enzalutamide, abiraterone, cabazitaxel, lutetium-PSMA-617 (Pluvicto — targeted radiotherapy).

Metastatic prostate cancer spreads predominantly to bone (80-90% of cases) causing severe pain, pathological fractures, and spinal cord compression — an oncological emergency requiring immediate dexamethasone and urgent radiotherapy to prevent permanent paralysis. Castrate-resistant prostate cancer (CRPC) develops after a median of 18-24 months of androgen deprivation therapy (ADT), limiting subsequent treatment options. ADT side effects include hot flushes, osteoporosis (requiring bisphosphonate or denosumab prophylaxis), metabolic syndrome, cardiovascular disease, cognitive changes, and sexual dysfunction. Ureteric obstruction from pelvic nodal disease causes hydronephrosis and acute kidney failure. Locally advanced disease causes urinary outflow obstruction, haematuria, and haematospermia.

No proven strategy definitively prevents prostate cancer. A Mediterranean-pattern diet (plant-based, oily fish, olive oil, tomatoes, low red and processed meat) is associated with reduced prostate cancer risk in observational studies. Maintain healthy body weight — obesity is associated with more aggressive disease. Regular exercise improves outcomes in established cancer. PSA screening: NICE (UK) recommends informed choice for men over 50 — discuss benefits (earlier detection of curable cancers) and harms (overdiagnosis of indolent cancers, biopsy complications, treatment side effects) before testing. High-risk men (Black ethnicity, family history of prostate or BRCA-related cancers) should start discussions about PSA testing at 40–45 years. 5-alpha-reductase inhibitors (finasteride, dutasteride) reduce prostate cancer incidence by 25% in trials but are not routinely recommended for prevention due to modest effect on high-grade cancer.

Consult your GP if you experience haematuria (blood in urine), haematospermia (blood in semen), difficulty passing urine, new lower back or bone pain (especially if persistent), or unexplained weight loss. Men over 50 (or 45 for Black men and those with a family history of prostate cancer or BRCA mutations) should discuss PSA testing with their doctor as part of a prostate health assessment. Seek urgent emergency assessment for sudden-onset lower limb weakness, numbness, or loss of bladder or bowel control — these may indicate spinal cord compression from prostate cancer metastasis and require same-day MRI and oncological review. Men on active surveillance who notice rising PSA, new urinary symptoms, or bone pain should contact their uro-oncology team promptly.