Prostate Cancer

Diagnosis

Prostate cancer diagnosis usually begins with an exam and a blood test. These tests may be done as part of prostate cancer screening or if you have symptoms. If initial tests show something concerning, imaging tests can help evaluate the prostate, and a biopsy may be needed to confirm cancer.

Screening tests include a prostate-specific antigen (PSA) blood test and a digital rectal exam. Experts recommend discussing prostate cancer screening around age 50, or earlier for Black individuals, those with a family history, or other risk factors.

A digital rectal exam allows a healthcare professional to feel the prostate through the rectum to check for abnormalities in size, shape, or texture.

A PSA test measures the level of prostate-specific antigen in the blood. Elevated PSA can indicate prostate cancer, but other conditions like infection or enlargement can also raise PSA. High PSA levels are often rechecked before considering imaging or biopsy.

Imaging tests for diagnosis may include a transrectal ultrasound, which uses sound waves to create images of the prostate, or a prostate MRI, which provides detailed pictures and helps plan biopsies. MRI types include contrast-enhanced MRI, MRI with endorectal coil, and multiparametric MRI.

Prostate biopsy involves removing tissue samples to test for cancer. Methods include transrectal biopsy and perineal biopsy, guided by imaging. Biopsy results help determine cancer grade using the Gleason score and grade group, indicating how quickly cancer may grow.

Biomarker tests can provide additional information on cancer risk, guiding decisions for biopsy and treatment. Imaging tests such as bone scans, CT scans, MRI, PET scans, and PSMA PET scans help detect cancer spread.

Cancer stage is determined based on tumor size, spread to lymph nodes or other organs, PSA level, and grade group. Stages range from 1 to 4, with higher stages indicating more advanced disease.

Prostate cancer prognosis depends on age, overall health, cancer stage, PSA levels, biopsy results, and grade group. Survival rates are high when cancer is confined to the prostate and lower if it has spread.

Treatment

Prostate cancer treatment includes surgery, radiation therapy, medicines, and sometimes ablation therapy. Treatment plans depend on cancer size, spread, growth rate, overall health, and patient preferences.

Active surveillance may be recommended for slow-growing cancers, involving regular tests and biopsies to monitor progression.

Surgery, or prostatectomy, removes the prostate and can be done laparoscopically, robotically, or through open surgery. Risks include bleeding, infection, urinary incontinence, and erectile dysfunction.

External beam radiation therapy uses high-energy beams to target cancer. It can be used alone or after surgery, and also for advanced cancer to control symptoms. Side effects include bowel and urinary issues and potential erectile dysfunction.

Brachytherapy places radioactive seeds in the prostate for permanent low-dose radiation or temporary high-dose radiation. Side effects include urinary and bowel problems and sexual dysfunction.

Ablation therapy, including cryoablation and high-intensity focused ultrasound (HIFU), directly destroys cancer cells with extreme cold or heat. It is used for small tumors or recurrent cancer and may cause pain, swelling, or urinary issues.

Hormone therapy reduces testosterone, which prostate cancer cells need to grow. This can include medications or orchiectomy. Side effects include hot flashes, decreased libido, erectile dysfunction, and increased risk of diabetes or heart disease.

Chemotherapy uses strong medicines to kill cancer cells, often combined with hormone therapy for advanced prostate cancer. Common side effects include fatigue, infection risk, and nerve damage.

Targeted therapy attacks specific chemicals in cancer cells and is used for cancer that spreads or recurs. Medicines include niraparib, olaparib, rucaparib, and talazoparib. Side effects include fatigue, nausea, diarrhea, and infections.

Immunotherapy helps the immune system recognize and kill cancer cells. Treatments include cell therapy and immune checkpoint inhibitors like pembrolizumab, mainly for metastatic prostate cancer. Side effects can be flu-like symptoms or immune-related organ effects.

Radiopharmaceutical treatments deliver targeted radiation through the bloodstream, such as PSMA-targeted therapy or bone-targeted therapy like radium Ra-223, for advanced or metastatic prostate cancer. Side effects include fatigue, nausea, diarrhea, and bone-related symptoms.