Prostate Cancer

What the prostate does

The prostate surrounds the urethra, the tube that carries urine and semen out of the body. It produces fluid that forms part of semen. It enlarges with age (benign prostatic hyperplasia, BPH), which is a separate, non-cancerous condition. Prostate cancer usually starts in the outer (peripheral) zone, so small cancers often do not affect urination.

Risk factors

• Age: rare before 40; about 6 in 10 cases are diagnosed in men 65 and older
• Race: Black men have a higher risk and are more likely to develop aggressive disease and die from it
• Family history: a father or brother with prostate cancer roughly doubles the risk
• Inherited genes: BRCA2, BRCA1, Lynch syndrome and HOXB13 mutations
• Possibly: obesity (linked to more aggressive cancer) and smoking

Symptoms

Early prostate cancer usually causes no symptoms. When symptoms occur, they may include:

• weak or interrupted urine flow, difficulty starting
• frequent urination, especially at night
• blood in the urine or semen
• erectile dysfunction
• with advanced disease: bone pain (back, hips, ribs), weight loss, fatigue, leg swelling, and spinal cord compression

Most urinary symptoms in older men are caused by benign prostatic hyperplasia or prostatitis, not cancer.

Screening and the PSA test

PSA (prostate-specific antigen) is a protein made by prostate cells. Levels rise with cancer but also with BPH, infection, recent ejaculation, cycling and age. A PSA test cannot diagnose cancer by itself.

Who should consider screening

• USPSTF: men aged 55 to 69 should make an individual decision with their clinician about PSA screening; routine screening is not recommended at 70 and older.
• AUA: offers shared decision-making for men 50 to 69 at average risk, starting at 40 to 45 for Black men, men with a strong family history or known germline mutations.

Benefits and harms

• Benefit: screening reduces the chance of dying from prostate cancer modestly.
• Harms: false positives, biopsies with risk of infection and bleeding, and overdiagnosis of slow-growing cancers that would never have caused harm, leading to unnecessary treatment.

Active surveillance for low-risk cancers has reduced the harms of overdiagnosis.

Diagnosis

1. PSA test and digital rectal exam
2. Repeat PSA and sometimes additional blood or urine biomarkers
3. Multiparametric MRI of the prostate to identify suspicious areas, often before biopsy
4. Biopsy: needle samples through the rectum or the perineum (transperineal biopsy has lower infection risk), targeting MRI lesions
5. Staging tests for intermediate and high risk: PSMA PET scan, CT and bone scan

Gleason score and Grade Group

Pathologists grade cancer cells by how abnormal they look:

Stages and risk groups

• Localized: confined to the prostate (stages I to II)
• Locally advanced: spread just outside the prostate or to seminal vesicles (stage III)
• Metastatic: spread to lymph nodes, bones or other organs (stage IV)

Risk groups (very low to very high) combine PSA, Grade Group and stage to guide treatment.

Treatment

Active surveillance

For low-risk (and some favorable intermediate-risk) cancers: regular PSA tests, MRI and repeat biopsies, with treatment only if the cancer shows signs of progressing. It avoids or delays side effects of treatment without reducing survival for appropriate patients. Watchful waiting is a less intensive approach for older men or those with other serious illnesses.

Surgery

Radical prostatectomy, usually robot-assisted, removes the prostate and seminal vesicles, sometimes with lymph nodes. Main side effects are urinary incontinence (usually improving over months) and erectile dysfunction.

Radiation therapy

• External beam radiation, including intensity-modulated and stereotactic body radiation therapy (SBRT, in 5 sessions)
• Brachytherapy: radioactive seeds placed in the prostate
• Often combined with short or long courses of hormone therapy for intermediate and high-risk disease
• Side effects include urinary and bowel irritation and erectile dysfunction

Hormone therapy (androgen deprivation therapy)

Prostate cancer depends on testosterone. ADT lowers testosterone with injections (such as leuprolide) or tablets (relugolix), or rarely surgery. Side effects include hot flashes, fatigue, loss of sex drive, weight gain, bone loss and cardiovascular risk.

Advanced and metastatic disease

• Androgen receptor pathway inhibitors: abiraterone, enzalutamide, apalutamide, darolutamide, combined with ADT
• Chemotherapy: docetaxel, cabazitaxel
• PARP inhibitors (olaparib, rucaparib) for cancers with BRCA or related mutations
• Radioligand therapy: lutetium-177 PSMA-617 for PSMA-positive disease
• Radium-223 for bone metastases
• Bone protection: denosumab or zoledronic acid; radiation for painful bone metastases

Focal therapy

Treatments such as HIFU or cryotherapy that target only the cancer area are options in selected cases and are still being evaluated.

Outlook

Five-year relative survival for localized and regional prostate cancer is close to 100%. For metastatic disease it is around 35 to 40%, and improving with newer treatments. Many men with prostate cancer die of other causes.

Prevention

There is no proven way to prevent prostate cancer. A healthy weight, regular exercise, not smoking and a diet rich in vegetables are good for overall health and may lower the risk of aggressive disease. Men with strong family history or BRCA mutations should discuss earlier screening.

Frequently asked questions

What are the early signs of prostate cancer?

Early prostate cancer usually causes no symptoms. Urinary changes such as a weak stream or frequent urination are much more often caused by benign prostate enlargement. That is why screening decisions with a doctor matter, especially for men at higher risk.

What PSA level is concerning?

There is no single cutoff. A PSA above about 3 to 4 ng/mL often leads to further evaluation, but age, prostate size, PSA trend over time and risk factors all matter. A doctor may repeat the test, order an MRI or use additional markers before recommending a biopsy.

Is prostate cancer curable?

Yes, when found before it spreads, it is usually curable with surgery or radiation, and many low-risk cancers never need treatment. Metastatic prostate cancer is not usually curable but can be controlled for years with modern treatments.

What is active surveillance?

Active surveillance means closely monitoring a low-risk prostate cancer with regular PSA tests, MRI scans and repeat biopsies, rather than treating it right away. Treatment starts only if the cancer shows signs of growing, avoiding side effects for many men.

What are the side effects of prostate cancer treatment?

The main side effects of surgery and radiation are urinary leakage, erectile dysfunction and, with radiation, bowel irritation. Hormone therapy causes hot flashes, fatigue, low libido and bone loss. Side effects vary, and many improve with time and treatment.