Prostate Cancer: Detection, Staging and Treatment

Prostate Cancer: Detection, Staging and Treatment

Prostate cancer is the most common cancer in men in developed countries and the second leading cause of male cancer death, after lung cancer. Approximately 1.4 million men are diagnosed worldwide each year. In China, incidence has risen dramatically as the population ages and PSA testing becomes more widespread — from a historically low-incidence country to one with a rapidly growing prostate cancer burden.

Most prostate cancers are slow-growing and confined to the prostate — many men with prostate cancer die with the disease rather than from it. However, a significant subset are aggressive and potentially fatal if not treated early. The central challenge in prostate cancer management is distinguishing cancers that require aggressive treatment from those that can be safely monitored.

The Prostate and Cancer Development

The prostate is a walnut-sized gland sitting at the base of the bladder, surrounding the urethra. It produces fluid components of semen. Prostate cancer — almost always adenocarcinoma — arises from the glandular epithelial cells, most commonly in the peripheral zone of the gland.

Prostate cancer growth is driven by male sex hormones (androgens) — primarily testosterone and its more potent derivative dihydrotestosterone (DHT), which bind to androgen receptors and stimulate tumour cell proliferation. This is why androgen deprivation therapy (ADT) is central to treatment of advanced disease.

Risk Factors

• Age — the dominant risk factor; rare under 50; incidence rises steeply after 60; 70% of cases diagnosed in men over 65
• Family history — first-degree relative with prostate cancer: 2–3× increased risk; BRCA1/BRCA2 mutations (particularly BRCA2) confer high risk of aggressive disease
• Black African / Caribbean ethnicity — 2–3× higher incidence; more likely to present at younger age and with aggressive disease
• Diet — high-fat, low-fibre Western diet; possibly processed red meat; selenium supplements have not been shown to prevent prostate cancer and should not be taken for that purpose; evidence for lycopene prevention remains uncertain
• Obesity — associated with higher-grade and more advanced disease at diagnosis
• Smoking — associated with higher risk of aggressive and fatal prostate cancer

Screening and Detection

PSA (Prostate-Specific Antigen)

PSA is a glycoprotein produced almost exclusively by the prostate gland; measured by a simple blood test. Elevated PSA (>4 ng/mL in most guidelines, though no single threshold is universally accepted) indicates possible prostate pathology — cancer, benign prostatic hyperplasia, prostatitis, or recent prostate manipulation.

PSA limitations:

• Not cancer-specific: PSA is prostate-specific, not cancer-specific; BPH and prostatitis both raise PSA
• False negatives: a PSA result below 4 ng/mL does not exclude prostate cancer; interpretation and any further assessment depend on the overall clinical risk
• Overdiagnosis: population PSA screening detects many indolent low-grade cancers that would never have caused symptoms; this risks overtreatment with significant side effects

PSA-derived measures improve specificity:

• PSA velocity/kinetics — changes in PSA need interpretation alongside other clinical risk information; PSA velocity alone should not determine whether imaging or biopsy is needed
• PSA density — PSA adjusted for prostate volume (measured by MRI); high density in a small prostate is more concerning than in a large BPH prostate
• Free-to-total PSA ratio — benign PSA tends to be in free form; cancer tends to produce more complexed PSA; ratio <10–15% is more suggestive of cancer
• PSA isoforms (PHI — prostate health index; 4Kscore) — more accurate risk stratification

Screening recommendations: no universal consensus; most major organisations (EAU, ACS) recommend informed individual decision-making; PSA testing from age 50 (or 40–45 for high-risk groups); follow-up intervals should be agreed with the clinician according to baseline PSA, age, individual risk, health and the applicable guideline.

Multiparametric MRI (mpMRI)

mpMRI (T2-weighted + diffusion-weighted + dynamic contrast-enhanced imaging) of the prostate is now recommended before biopsy in most guidelines. It:

• Identifies and characterises suspicious lesions (PI-RADS scoring system 1–5: PI-RADS 1 = very low probability; PI-RADS 5 = very high probability)
• Guides targeted biopsy of suspicious areas
• Reduces detection of clinically insignificant cancers
• A negative MRI can support deferring biopsy only when the overall clinical suspicion is low, after considering PSA density, family history and other risk factors, with an agreed monitoring plan; a negative MRI alone does not rule out clinically significant cancer.

Prostate Biopsy

Tissue diagnosis is required to confirm cancer. Modern approaches:

• MRI-targeted biopsy: combining cognitive or software fusion of MRI images with real-time transrectal ultrasound (TRUS) to biopsy the mpMRI-identified lesion; superior detection of clinically significant cancer
• Transperineal (TP) biopsy: via the perineum (skin between scrotum and anus) rather than through the rectum; lower infection risk; becoming the preferred route at leading centres
• Systematic biopsy: 10–12 random cores from standardised prostate zones, taken alongside targeted biopsy

Gleason grading of biopsy cores:

• The pathologist assesses the tumour’s architectural patterns to assign a Gleason score and Grade Group. In core biopsies, a higher-grade component can affect the score even when it is not one of the two most common patterns.
• International Grade Groups (GG): GG1 (Gleason 6) — low grade; GG2 (Gleason 3+4=7) — intermediate-favourable; GG3 (Gleason 4+3=7) — intermediate-unfavourable; GG4 (Gleason 8); GG5 (Gleason 9–10) — high grade

Staging

Clinical Staging (TNM)

• T1: clinically inapparent and not palpable; includes tumours detected by needle biopsy (T1c), not only incidental findings
• T2: palpable tumour confined to prostate
• T3: extends through prostate capsule; involves seminal vesicles (T3b)
• T4: invades adjacent structures (bladder, rectum, pelvic wall)
• N1: regional lymph node metastasis
• M1: distant metastasis (bones, lymph nodes, viscera)

Imaging for Staging

• CT abdomen/pelvis: pelvic lymph node assessment
• Bone scan (technetium-99m): detects bone metastases in intermediate/high-risk disease
• PSMA-PET CT (prostate-specific membrane antigen PET): the most sensitive staging and restaging tool — detects metastatic disease (lymph nodes, bone, viscera) at PSA levels as low as 0.2 ng/mL; rapidly replacing conventional bone scans

Risk Stratification

Risk assessment combines PSA, Grade Group and clinical stage; a specialist interprets these together with health status and patient preferences when discussing surveillance or treatment. Regional lymph-node involvement (N1, M0) is distinct from distant metastatic disease (M1), and the treatment plan must reflect that distinction.

Treatment

Active Surveillance (AS)

For suitable low-risk and selected favourable intermediate-risk prostate cancer, active surveillance is monitoring without immediate treatment. Selection considers disease features, health and life expectancy, and whether treatment would be appropriate if progression is confirmed. AS involves regular PSA testing (every 3–6 months), repeat MRI, and systematic biopsy at defined intervals. Changes in PSA or MRI prompt reassessment and, when appropriate, repeat biopsy. Decisions to move from surveillance to treatment depend on confirmed disease reclassification and the overall clinical situation, discussed with the specialist; a PSA or MRI change alone does not automatically require curative treatment.

Active surveillance can avoid or defer treatment-related harms in suitable patients with low-risk disease. Its suitability and follow-up are individual decisions, not a guaranteed long-term outcome. For patients whose health or limited life expectancy makes curative treatment inappropriate, watchful waiting may be a different option to discuss.

Radical Prostatectomy

Radical prostatectomy removes the entire prostate and seminal vesicles. Pelvic lymph node dissection is selected separately according to the estimated risk of nodal involvement and the balance of staging benefits and complications; it is not required in every operation. Surgical approaches include:

Robot-assisted radical prostatectomy (RARP) is a minimally invasive surgical approach using a robotic platform controlled by the surgeon. Open and laparoscopic approaches are also used. The choice depends on the clinical situation, surgical expertise and an informed discussion of cancer control, urinary and sexual function, and other risks; a robotic approach does not guarantee better functional recovery for every patient.

• Nerve-sparing surgery may preserve nerves involved in erectile function when oncologically appropriate; it is not suitable in every case.
• Urinary continence and erectile function after surgery vary with baseline function, age, disease, the operation and other individual factors. Discuss likely outcomes, possible persistent problems and rehabilitation with the surgical team rather than relying on a universal recovery percentage.

Radical prostatectomy is an option for selected patients with localised disease, including some with high-risk disease as part of a broader treatment plan. Choice among surgery, radiotherapy and monitoring depends on risk, health, life expectancy, expected adverse effects and patient preferences; age or concern about one treatment’s late effects does not by itself establish a preferred treatment.

Radiation Therapy

External beam radiotherapy (EBRT) uses planned radiation techniques, including intensity-modulated and image-guided approaches, to treat the prostate while limiting dose to nearby organs. Five-fraction stereotactic body radiotherapy (SBRT) is an option for appropriately selected patients. PACE-B found non-inferior biochemical or clinical control compared with longer schedules in its defined low-to-intermediate-risk population; that result does not apply to every risk group, and later urinary toxicity was higher with SBRT in that trial. The radiation oncology team selects the schedule according to disease and urinary function and discusses benefits and harms.

Brachytherapy: radioactive seeds (permanent low-dose-rate brachytherapy) or catheters (high-dose-rate temporary brachytherapy) implanted directly into the prostate under ultrasound guidance; highly conformal dose delivery; excellent outcomes for localised disease.

Combined EBRT with a brachytherapy boost may be offered to selected patients with high-risk localised disease who have good urinary function, generally with appropriate ADT. The team should discuss the potential for additional genitourinary toxicity and the individual balance of benefits and harms; it is not the automatic treatment for every high-risk patient.

Adding androgen deprivation therapy (ADT) to radiotherapy and deciding its duration depend on the risk group and individual clinical assessment. ADT is generally considered with radiotherapy for unfavourable intermediate- or high-risk disease, but is not routinely used for favourable intermediate-risk disease — ADT can improve outcomes when appropriately combined with radiotherapy; this is not a guarantee that all cancer cells have been eliminated.

Androgen Deprivation Therapy (ADT)

The backbone of treatment for metastatic prostate cancer — reduces testosterone to castrate levels (<50 ng/dL):

• LHRH agonists (leuprolide, goserelin): monthly to 6-monthly SC/IM injections; cause initial testosterone flare then sustained suppression
• LHRH antagonists (degarelix, relugolix): immediate testosterone suppression without flare; selection of an antagonist, including oral relugolix, requires individual assessment of cardiovascular risk, other medical conditions and drug interactions
• Bilateral orchiectomy: surgical castration; immediate, permanent, cheap; rarely chosen

Side effects of ADT: hot flushes, fatigue, weight gain, loss of libido, erectile dysfunction, osteoporosis, cognitive changes, metabolic syndrome.

Novel Hormonal Agents (NHA) for Advanced Disease

Abiraterone acetate (Zytiga) + prednisone: blocks androgen synthesis in the adrenal glands and tumour; approved for metastatic castration-resistant prostate cancer (mCRPC) and — with ADT — for high-risk metastatic castration-sensitive prostate cancer (mCSPC).

Enzalutamide, apalutamide, darolutamide: androgen receptor inhibitors used in selected prostate-cancer settings. Their indications and supporting evidence differ by medicine and disease state; they are not interchangeable treatments for every castration-sensitive or castration-resistant cancer. The oncology team selects a regimen according to the applicable approval, disease stage and prior treatment.

Combination treatment for metastatic hormone-sensitive disease: For selected patients fit for docetaxel, triplet treatment may combine ADT and docetaxel with abiraterone plus prednisone (PEACE-1) or with darolutamide (ARASENS). In the PEACE-1 population receiving ADT plus docetaxel, adding abiraterone improved overall survival; ARASENS found an overall-survival benefit from adding darolutamide to ADT plus docetaxel. These cited triplet comparisons used ADT plus docetaxel as the treatment backbone, rather than ADT alone. The oncology team selects treatment according to disease features, fitness and individual circumstances.

PSMA-Targeted Therapy

Lutetium-177 PSMA-617 (Pluvicto) is radioligand therapy for selected patients with PSMA-positive metastatic prostate cancer. Eligibility depends on disease state, previous treatment, PSMA imaging and the applicable current local product approval; prior docetaxel is not required in every approved setting. In VISION, adding this treatment to permitted standard care reduced the hazard of death relative to standard care alone; this is not a percentage increase in an individual patient’s survival time.

Prostate Cancer Care in China

China's urology and oncology centres offer:

• Assessment and staging: ask the specific hospital which PSA-related tests, prostate MRI and PSMA imaging are appropriate and available for the clinical question.
• Surgery and radiotherapy: confirm the treating team, suitable technique, individual risks and the actual programme offered rather than assuming that a city or hospital tier establishes a particular technology or outcome.
• Medicines and radioligand treatment: the oncology team should confirm the exact product, current local indication, prior-treatment requirements and supply; do not assume that every medicine or a domestic version is available.
• Costs and communication: obtain a written hospital quote and confirm interpretation, consent, reports and follow-up language arrangements separately. PriumCare coordination does not itself establish hospital treatment availability, outcomes, prices or an entirely English clinical pathway.

Contact a PriumCare care navigator to arrange a prostate cancer assessment, biopsy, or treatment consultation.

---

Medical content based on MSD Manuals and international prostate cancer guidelines (EAU, NCCN). Evidence reviewed 2025.

---

Targeted editorial source check — 26 October 2026: Only the risk-table interpretation, medicine-specific treatment scope, VISION outcome wording, selenium prevention, PSA velocity and core-biopsy grading descriptions were checked against NCI treatment guidance, prescribing information, NCI supplement evidence, AUA/SUO guidance and RCPath reporting guidance. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

---

Targeted editorial source check — 26 October 2026: Only pelvic lymph-node dissection selection, the non-guaranteed benefit wording for ADT with radiotherapy, and the medicine-specific PEACE-1/ARASENS triplet regimens and comparators were checked against EAU staging guidance, NCI hormone-therapy information, the original PEACE-1 trial abstract and ARASENS trial abstract. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

---

Targeted editorial source check — 26 October 2026: Only the PSA follow-up interval and the blanket cardiovascular-safety preference for relugolix were checked against EAU early-detection guidance, EAU treatment guidance and U.S. relugolix prescribing information. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

---

Targeted editorial source check — 26 October 2026: Only the trigger for reassessment and a change from active surveillance to treatment was checked against EAU active-surveillance guidance. PSA or MRI changes are distinguished from confirmed progression and an individual treatment decision. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

---

Targeted editorial source check — 26 October 2026: Only the T1 staging description and the risk-specific selection of ADT with radiotherapy were checked against NCI staging information and the AUA/ASTRO localized-prostate-cancer guideline. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

---

Targeted editorial source check — 26 October 2026: Following a once-through check of the article’s recommendation wording, the MRI/biopsy conditions, surveillance and surgery selection, unqualified functional-recovery figures, trial-specific SBRT comparison, brachytherapy-boost selection, current radioligand eligibility and institution-specific service assertions were clarified using EAU diagnostic guidance, EAU treatment guidance, NCI treatment information, the original PACE-B trial and current U.S. Pluvicto labeling. Local approvals and actual services must be checked with the treating institution. This is not a whole-article medical review, does not certify other retained statistics or any hospital’s performance, and retains the original publication date.

---

Targeted editorial source check — 26 October 2026: Only the PSA false-negative and denominator wording was checked against NCI PSA information and its screening-trial explanation. A low PSA result alone does not exclude cancer; this correction does not prescribe a biopsy threshold or a screening interval. This is not a whole-article medical review, does not verify other retained statistics or treatment statements and retains the original publication date.