Prostate cancer is the most common non-skin cancer in men. Much of the APP's work is screening conversations, structured PSA follow-up, biopsy coordination and performance, risk stratification, and survivorship.
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Prostate cancer
is the most common non-skin cancer in men. Much of the APP's work is
screening conversations, structured PSA follow-up, biopsy
coordination and performance, risk stratification, and survivorship.
The through-line is shared decision-making and matching treatment
intensity to risk — most prostate cancer will never kill the
patient, and some absolutely will. Advanced and metastatic disease
has its own chapter (Chapter 20); imaging is in Chapter 21.
8.1 PSA screening — shared decision-making
Discuss
benefits and harms and individualize. The AUA framework centers
shared decision-making, with the strongest emphasis on men roughly
55–69, where the mortality benefit is best established.
Start
earlier (age ~40–45) for higher-risk men: African ancestry, a
strong family history (a first-degree relative with prostate cancer,
especially young or lethal disease), or a known germline mutation
(BRCA2 in particular).
Screening
interval is individualized — often every 2–4 years for
average-risk men with a low baseline PSA. A baseline PSA in a man's
40s is highly predictive of lifetime risk.
De-emphasize
or stop screening when life expectancy is under ~10 years — an
elderly man with comorbidity gains nothing from finding an indolent
cancer, and much can be lost.
What raises PSA besides cancer
BPH (the most common
reason), prostatitis/UTI, recent ejaculation (abstain 48 hours),
catheterization or instrumentation, vigorous cycling, and a
recent prostate biopsy (wait 6 weeks).
5-alpha-reductase inhibitors
(finasteride/dutasteride) roughly halve the PSA — double the
measured value to interpret, and evaluate any rise on therapy.
Repeat an isolated elevation (after ruling out infection)
before acting on it. Do NOT biopsy on a single value drawn during
a UTI.
Screening position — lead with PSA, not DRE
DRE is a poor stand-alone screening test for prostate cancer: it
has a low positive predictive value, is operator-dependent, and
cannot assess the entire gland. Requiring it may also turn some
patients away from screening.
Lead with PSA-based screening. Repeat a newly elevated PSA after
excluding reversible causes. When PSA or overall risk is
concerning, refine risk with PSA density and validated biomarkers,
then use multiparametric prostate MRI to guide the biopsy decision
and target suspicious lesions. That is the pathway in 8.2.
DRE is not the primary screening test. It can still be used selectively
as a supplementary risk-assessment exam after an elevated PSA or
when symptoms make the examination clinically relevant. Use
ultrasound, not DRE, to measure prostate size in BPH.
8.2 Working up an elevated PSA
Repeat
the PSA and exclude reversible causes (infection, recent
instrumentation or ejaculation). Treat a UTI/prostatitis and recheck
in 6+ weeks.
Refine risk
before biopsy rather than reflexively biopsying: use PSA density
(PSA ÷ prostate volume; > 0.15 is concerning), free/total PSA (a
LOW free fraction, < 10%, favors cancer), PSA velocity, and
validated reflex biomarkers (4Kscore, PHI, ExoDx, SelectMDx,
MyProstateScore).
Multiparametric
prostate MRI increasingly precedes biopsy — it improves detection
of CLINICALLY SIGNIFICANT cancer, allows targeted sampling, and can
spare some men a biopsy altogether. Lesions are scored PI-RADS 1–5;
PI-RADS 4–5 warrants targeted biopsy.
Prostate
biopsy — MRI-targeted plus systematic cores (typically 12). At our practice
our APPs perform biopsies (Chapter 26). Counsel on hematuria,
hematospermia (which can last weeks to months and is alarming but
harmless), and the small but real risk of sepsis. The transperineal
approach has a markedly lower infection risk than transrectal and is
increasingly preferred.
Post-biopsy red flag
Fever or rigors after a prostate biopsy is sepsis until proven
otherwise — this patient goes to the ER, not to a same-day
clinic slot. It can progress to septic shock within hours. Counsel
every biopsy patient explicitly before they leave.
8.3 Grading, staging, and risk stratification
Pathology is
reported as a Gleason score (the sum of the most common and the
highest-grade patterns) and the corresponding ISUP Grade Group (1–5),
which is the cleaner modern language. Risk stratification then
combines Grade Group, PSA, and clinical stage to guide management.
Grade Group
Gleason
Implication
1
≤ 6 (3+3)
Low-grade; essentially never metastasizes; most are candidates
for active surveillance
Active surveillance is PREFERRED for the large majority
Favorable intermediate
Grade Group 2 with limited volume, PSA < 10–20
Surveillance is reasonable for selected men; otherwise definitive
therapy
Unfavorable intermediate
Grade Group 3, or multiple intermediate factors
Definitive therapy (surgery, or radiation ± short-course ADT)
High / Very high
PSA > 20, Grade Group 4–5, or ≥ cT3
Definitive therapy (radiation + 18–36 months ADT, or surgery ±
adjuvant therapy) plus staging work-up (PSMA PET — Chapter 21)
and germline testing
8.4 Management options
Active
surveillance: monitor low-risk (and selected
favorable-intermediate) disease with scheduled PSA (~every 6
months), exams, MRI, and confirmatory/repeat biopsy — treating
only if the disease reclassifies to a higher grade. This is not
“doing nothing”; it is a structured protocol that avoids
overtreatment while preserving the window to cure. Roughly a third
will eventually be reclassified and treated. Surveillance also
preserves future treatment optionality: as the disease and technology
evolve, an appropriate patient may later choose established focal
therapy or an emerging option such as Vanquish water-vapor ablation
when evidence, indication, and local availability support its use.
Radical
prostatectomy: surgical removal of the prostate and seminal
vesicles, commonly robotic, with pelvic lymph node dissection for
higher risk. Key side effects to counsel: erectile dysfunction
(depends on nerve-sparing and baseline function) and stress
incontinence (usually improves substantially over 6–12 months).
Advantages: definitive pathology, an undetectable PSA to track, and
salvage radiation remains available.
Radiation
therapy: external beam (often hypofractionated or SBRT) or
brachytherapy, ± androgen deprivation for intermediate/high risk.
Side effects: irritative urinary and bowel symptoms acutely, and
later ED. our practice uses a rectal spacer (Barrigel) and fiducial markers to
displace the rectum and target the dose precisely — this
measurably reduces rectal toxicity. PSA does not fall to zero after
radiation; recurrence is defined as a rise of 2 ng/mL above the
nadir.
Focal
therapy — our practice offers a full menu: for selected localized, often
intermediate-risk disease with a well-defined MRI-visible lesion,
treating just the cancer-bearing zone to spare continence and
potency. Options include HIFU (high-intensity focused ultrasound),
PEF/pulsed-field ablation (irreversible electroporation,
NanoKnife-type), and Vanquish water-vapor therapy. Careful MRI- and
biopsy-based patient selection is essential, and ongoing
surveillance afterward is mandatory — focal therapy treats the
lesion, not the whole gland.
Androgen
deprivation therapy (ADT): not a treatment for localized disease
by itself; used as an adjunct to radiation for intermediate/high
risk, and as the backbone of advanced disease. Counsel on hot
flashes, bone loss, metabolic and cardiovascular effects, libido/ED
(Chapters 20 and 23).
Advanced/metastatic
disease: a large and rapidly evolving topic — ADT
intensification with androgen-receptor pathway inhibitors,
chemotherapy, PARP inhibitors, PSMA radioligand therapy, and more.
See Chapter 20.
Practical survivorship notes
After prostatectomy, the PSA
should become UNDETECTABLE (< 0.1). A measurable or rising PSA
signals biochemical recurrence — flag it and restage (PSMA PET;
Chapter 21).
Every man on ADT needs a baseline DEXA and denosumab — 60 mg
every 6 months unless bone metastases require 120 mg every 12 weeks
instead. Before denosumab, obtain dental clearance and check calcium
and vitamin D levels; use OTC calcium citrate + vitamin D3 gummies
providing 1,200 mg calcium daily. Also address cardiometabolic risk
(Chapter 23).
Encourage germline genetic
counseling for high-risk, metastatic, strong-family-history, or
Ashkenazi patients — it changes treatment and it changes their
family's screening.
Sexual rehabilitation after treatment is a real part of
the plan, not an afterthought: early PDE5 inhibitors, VED,
injection therapy, and honest expectation-setting (Chapter 13).
Clinical Pathway
Click any node to expand
The through-line of localized prostate cancer is shared decision-making and matching treatment intensity to risk — most prostate cancer will never kill the patient, and some absolutely will. Advanced and metastatic disease is Chapter 20; imaging is Chapter 21.
Shared decision-making, individualized intervals, and a PSA-first approach that does not rely on DRE for screening.
Select a box to open its teaching details.
The framework
The AUA framework centers shared decision-making, with the strongest emphasis on men roughly 55–69, where the mortality benefit is best established.
Ch 8.1
When does this man start screening?
Start early for
African ancestry
A strong family history — a first-degree relative with prostate cancer, especially young or lethal disease
A known germline mutation — BRCA2 in particular
Ch 8.1
Interval
Individualized — often every 2–4 years for average-risk men with a low baseline PSA
A baseline PSA in a man's 40s is highly predictive of lifetime risk
Ch 8.1
Why
An elderly man with comorbidity gains nothing from finding an indolent cancer, and much can be lost.
Ch 8.1
What raises PSA besides cancer
BPH — the most common reason
Prostatitis / UTI
Recent ejaculation — abstain 48 hours
Catheterization or instrumentation
Vigorous cycling
Recent prostate biopsy — wait 6 weeks
Ch 8.1 — what raises PSA besides cancer
How to interpret
Double the measured value to interpret it
Evaluate any rise on therapy
Ch 8.1 — what raises PSA besides cancer
Pitfall
Do NOT biopsy on a single value drawn during a UTI
Ch 8.1 — what raises PSA besides cancer
Local policy
Why DRE is not the primary screening test
Low positive predictive value as a stand-alone screening test
Operator-dependent and cannot assess the entire gland
Evidence is insufficient to support routinely adding it to PSA-based screening
Requiring it may turn some patients away from screening
Use PSA first, then MRI when risk is concerning
Lead with PSA-based screening. Repeat a newly elevated PSA after excluding reversible causes. If PSA or overall risk remains concerning, refine risk with PSA density and validated biomarkers, then use multiparametric prostate MRI to guide the biopsy decision and target suspicious lesions.
Use DRE selectively — not as the screening gate
It may supplement risk assessment after an elevated PSA or when symptoms make the examination clinically relevant
Use ultrasound, not DRE, to measure prostate size in BPH
Ch 8.1 — PSA-first screening position
Refine risk before biopsy rather than reflexively biopsying.
Select a box to open its teaching details.
Action
Treat a UTI/prostatitis and recheck in 6+ weeks
Ch 8.2
The numbers
PSA density = PSA ÷ prostate volume; > 0.15 is concerning
Free/total PSA — a LOW free fraction, < 10%, favors cancer
PSA velocity
Validated reflex biomarkers
4Kscore
PHI
ExoDx
SelectMDx
MyProstateScore
Ch 8.2
How to read it
Lesions are scored PI-RADS 1–5
PI-RADS 4–5 warrants targeted biopsy
Why
mpMRI increasingly precedes biopsy — it improves detection of CLINICALLY SIGNIFICANT cancer and allows targeted sampling.
Ch 8.2
Local policy
Our practice
MRI-targeted plus systematic cores — typically 12
At our practice our APPs perform biopsies (Chapter 26)
The transperineal approach has a markedly lower infection risk than transrectal and is increasingly preferred
Counsel on
Hematuria
Hematospermia — can last weeks to months; alarming but harmless
The small but real risk of sepsis
Ch 8.2
Time-critical
Why it cannot wait
It can progress to septic shock within hours.
Do this every time
Counsel every biopsy patient explicitly before they leave
Ch 8.2 — post-biopsy red flag
The mapping
GG 1 — Gleason ≤ 6 (3+3): low-grade; essentially never metastasizes; most are candidates for active surveillance
GG 5 — Gleason 9–10: highest-grade / most aggressive
What Gleason means
The Gleason score is the sum of the most common and the highest-grade patterns.
Ch 8.3 — grading
Risk stratification combines Grade Group, PSA, and clinical stage to guide management — matching treatment intensity to risk.
Select a box to open its teaching details.
Localized risk groups
Very low / Low — PSA < 10, Grade Group 1, cT1–T2a, low volume
Favorable intermediate — Grade Group 2 with limited volume, PSA < 10–20
Unfavorable intermediate — Grade Group 3, or multiple intermediate factors
High / Very high — PSA > 20, Grade Group 4–5, or ≥ cT3
Ch 8.3 — risk stratification
Direction by risk group
Direction
Active surveillance is preferred for the large majority of these men.
Ch 8.3 — risk stratification
Direction
Surveillance is reasonable for selected men; otherwise definitive therapy.
Ch 8.3 — risk stratification
Options
Surgery
Radiation ± short-course ADT
Ch 8.3 — risk stratification
Treatment
Radiation + 18–36 months ADT, or surgery ± adjuvant therapy
Also order
Staging work-up — PSMA PET (Chapter 21)
Germline testing
Ch 8.3 — risk stratification
The schedule
Scheduled PSA — ~every 6 months
Exams
MRI
Confirmatory / repeat biopsy
The trigger to treat
Treat only if the disease reclassifies to a higher grade. Roughly a third will eventually be reclassified and treated.
Preserve future options
Active surveillance preserves treatment optionality. As the disease and technology evolve, an appropriate patient may later choose established focal therapy or an emerging option such as Vanquish water-vapor ablation when evidence, indication, and local availability support its use.
Ch 8.4 — active surveillance
Side effects to counsel
Erectile dysfunction — depends on nerve-sparing and baseline function
Stress incontinence — usually improves substantially over 6–12 months
Advantages
Definitive pathology
An undetectable PSA to track
Salvage radiation remains available
Also
Pelvic lymph node dissection for higher risk
Ch 8.4 — radical prostatectomy
Our practice
our practice uses a rectal spacer (Barrigel) and fiducial markers to displace the rectum and target the dose precisely — this measurably reduces rectal toxicity
Side effects
Irritative urinary and bowel symptoms acutely
Later ED
Reading the PSA afterward
PSA does NOT fall to zero after radiation
Recurrence is defined as a rise of 2 ng/mL above the nadir