Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.
Prostate Cancer
Overview & Incidence
- Prostate cancer is the most common cancer in men in the UK
- Most early and localised prostate cancers are asymptomatic
- Many prostate cancers are slow-growing and may never become clinically significant, but some behave aggressively, present at a later stage, or progress rapidly.
- Management options include active surveillance, watchful waiting, radical treatment, androgen deprivation therapy, systemic therapy and palliation. Decisions are made through the cancer MDT and individualised according to disease risk, stage, symptoms, life expectancy, comorbidities and patient preference.
As an SHO, you may encounter patients with suspected prostate cancer, complications from treatment, or metastatic disease.
History
Risk factors
✓Age >50
✓African or Caribbean ancestry
✓Family history of prostate cancer or hereditary cancer syndromes (e.g., BRACA2/Lynch)
Symptoms
- Early / localised – often asymptomatic
- LUTS – hesitancy, poor stream, frequency, nocturia, urgency
- Erectile dysfunction (if locally advanced)
Red flags
- Suggestive of advanced/ metastatic disease — haematuria, bone pain, constitutional symptoms (weight loss, lethargy, etc), anaemia, raised ALP, lymphoedema (if bulky nodal disease)
- Consider MSCC — new leg weakness / painless urinary retention/ saddle anaesthesia (read more HERE)
Background
- Previous PSA tests, MDT outcomes, previous treatments for prostate cancer,
- Past medical history
- Performance status
Examination
General examination
- Assess for cachexia, palpable bladder, bone tenderness, lymphoedema
- Assess fitness for investigations / treatment
Digital Rectal Examination (DRE)
- Hard, irregular, or nodular prostate suggests malignancy
- Smooth, symmetrically enlarged = more likely BPH
- Fixed prostate suggests locally advanced disease
- Weak tone may suggest spinal cord compression
Neurological exam if red flag symptoms (cord compression)
NICE Suspected Cancer Referral for Prostate Cancer
- Refer men, and trans women and non-binary people with male reproductive organs if abnormal / malignant DRE
- Consider a PSA test and DRE to assess for prostate cancer in men, and trans women and non-binary people with male reproductive organs who have:
- LUTS
- Erectile dysfunction
- Visible haematuria
- Symptoms of prostate cancer (as listed above) if their PSA levels are above the threshold for their age in table below. Take into account their preferences and any comorbidities when making the decision.
Age-specific PSA thresholds for people with possible symptoms of prostate cancer
| Age (years) |
Prostate-specific antigen threshold (micrograms/litre) |
| Below 40 |
Use clinical judgement |
| 40 to 49 |
More than 2.5 |
| 50 to 59 |
More than 3.5 |
| 60 to 69 |
More than 4.5 |
| 70 to 79 |
More than 6.5 |
| Above 79 |
Use clinical judgement. AoMRC/EBI advises referral if PSA >20 ng/mL, or PSA >7.5 ng/mL with symptoms suggestive of metastatic disease. |
Investigations
1Bloods
✓Prostate-Specific Antigen (PSA)
- PSA can be raised due to various reasons; PSA alone may not be diagnostic of cancer unless very high – interpret this alongside symptoms, DRE, PSA trend, MRI results
- Leaflet on “Advice to patients requesting PSA measurement” - HERE
- It may be raised due to:
- BPH
- UTI and prostatitis
- Urinary retention
- Recent instrumentation / catheterisation
- DRE and ejaculation can also raise PSA, but this is usually minor and not clinically significant
- Consider and treat reversible benign causes of PSA elevation, but remember these can occur alongside prostate cancer
- Do not delay referral/escalation if there are red flags, abnormal DRE, suspected metastatic disease, concerning imaging, or a very high PSA, e.g. >50 ng/mL.
- If PSA is modestly raised and there are no red flags or evidence of prostate cancer on imaging, it is often reasonable to repeat PSA after 4–6 weeks once UTI/prostatitis, retention or recent instrumentation has resolved.
✓Other useful PSA measures:
- PSA velocity or doubling time - adds additional concern about clinically significant cancer
- PSA density (PSA ÷ prostate volume) – can aid in cancer diagnosis, risk stratification and in cases of equivocal MRI. A PSA density of ≥0.15 ng/mL/mL is commonly used as a threshold that increases concern for clinically significant prostate cancer.
✓U&Es - consider malignant ureteric obstruction/ high pressure chronic retention
✓FBC - consider anaemia
✓ALP - raised in bone metastasis
2Imaging
✓Prostate MRI (biparametric or multiparametric)
- First-line imaging for those who may be fit for radical treatment.
- Aim: diagnostics, staging, detect areas for targeted biopsy, assess prostate volume and anatomy, determine potential other causes for raised PSA (e.g. prostatitis)
- MRI grades risk of prostate cancer with PI-RADS or Likert score:
- 1-2 = very low/low probability of prostate cancer
- 3 = equivocal
- 4 = high probability
- 5 = very high probability
✓CT TAP
- If suspected metastatic disease
- Not sufficient for diagnostic prostate assessment
✓Bone scan – if suspected bone mets. More sensitive than CT.
✓PSMA-PET
- has greater sensitivity and specificity for prostate cancer metastases than conventional CT and bone scan
- May also detect complications like malignant ureteric obstruction and/or incidental findings on the CT element of the imaging
- Not available in all centres currently
- Financial cost is more than conventional staging, usually discussed in MDT first and requires consultant
Considerations
Does everyone need MRI? – No. This is reserved for patient who are fit for radical treatment as this will add little to their management.
Does everyone need staging scan? – No. Staging scans are usually reserved for patients with symptoms/signs suspicious for metastatic disease or higher-risk cancer. Otherwise, need for scans is guided by risk stratification and cancer MDT discussion.
3Prostate Biopsy
- Read about the procedure HERE
- Allows for histological confirmation of prostate cancer, such as:
- Histological type, grade (Gleason score – see below), volume and distribution, adverse pathological features, pre-malignant changes
- This is then used for risk stratification
Gleason’s Score
What is it?
A histological grading system for prostate cancer. It describes how abnormal the cancer glands look under the microscope.
Patterns are graded from 3 to 5 in modern reporting:
- Pattern 3 = less abnormal / lower grade
- Pattern 4–5 = more abnormal / higher grade
The score is usually written as the predominant pattern + highest-grade pattern, e.g. 3+4=7 or 4+3=7.
What is it used for?
- Helps estimate how aggressive the cancer is
- Helps to stratify prostate cancer in risk groups
- Guides treatment decisions
- Helps compare disease over time, especially in patients on active surveillance.
Higher Gleason scores are associated with a higher risk of progression and metastasis.
TNM Classification (UICC/AJCC 8th Ed.)
UICC/AJCC 8th edition staging summary for prostate cancer.
| Stage |
Description |
| TPrimary Tumour |
| T1 |
Clinically inapparent tumour |
| T1a |
Incidental finding ≤5% of resected tissue |
| T1b |
Incidental finding >5% of resected tissue |
| T1c |
Identified by needle biopsy (e.g. elevated PSA) |
| T2 |
Confined to prostate |
| T2a |
≤half of one lobe |
| T2b |
>half of one lobe but not both lobes |
| T2c |
Both lobes |
| T3 |
Extends through prostatic capsule |
| T3a |
Extracapsular extension |
| T3b |
Seminal vesicle invasion |
| T4 |
Fixed or invades adjacent structures (bladder neck, external sphincter, rectum, levator muscles, pelvic wall) |
NRegional Nodes
N0 – No regional lymph node metastasis
N1 – Regional lymph node metastasis
MMetastasis
M0 – No distant metastasis
M1 – Distant metastasis
M1a – Non-regional lymph node(s)
M1b – Bone
M1c – Other site(s) with or without bone disease
Risk Stratification
- Once prostate cancer is confirmed, patients are usually risk-stratified to estimate their risk of disease progression to metastatic disease
- The risk group will then aid in determining management options
- There are several risk stratification systems, but the Cambridge Prognostic Group (CPG) system is commonly used in UK practice and NICE guidance
Cambridge Prognostic Group Scoring system:
| Group |
Criteria |
Practical meaning |
| CPG 1 |
Gleason 3+3=6 / Grade Group 1 AND PSA <10 AND T1–T2 |
Low-risk disease |
| CPG 2 |
Gleason 3+4=7 / Grade Group 2 OR PSA 10–20 AND T1–T2 |
Favourable intermediate-risk disease |
| CPG 3 |
Gleason 3+4=7 / Grade Group 2 AND PSA 10–20 AND T1–T2 OR Gleason 4+3=7 / Grade Group 3 AND T1–T2 |
Unfavourable intermediate-risk disease |
| CPG 4 |
One high-risk feature: Gleason 8 / Grade Group 4 OR PSA >20 OR T3 |
High-risk disease |
| CPG 5 |
Two or more high-risk features: Gleason 8, PSA >20, or T3 OR Gleason 9–10 / Grade Group 5 OR T4 |
Very high-risk disease |
Management
- Management options will depend on – risk group, disease stage, symptoms, patient fitness and comorbidities, patient preferences, life expectancy.
- The cancer MDT recommends which treatment options are clinically appropriate; the patient then makes an informed choice between these options.
Localised prostate cancer
- Active surveillance – low-risk and selected favourable intermediate-risk disease. Involves regular PSA monitoring, repeat MRI and/or biopsies
- Watchful Wait – usually patients with limited life expectancy. Treatment is deferred until symptomatic or evidence of clinically significant progression/metastatic disease. Aims to avoid unnecessary treatment and treatment-related side effects.
- Radical prostatectomy – surgical removal of prostate (open, laparoscopic, robotic)
- Radical Radiotherapy – external beam (EBRT) ± brachytherapy. Can be combined with ADT depending on risk group.
- Androgen deprivation therapy (ADT) – mainly with EBRT
- Commonly referred to as hormone therapy or just as “hormones”
- May be added to radiotherapy in intermediate/high-risk disease
- Not routinely given before radical prostatectomy
- ADT can affect prostate biopsy histology significantly
- It is usually best to wait until the patient has had prostate biopsies and a discussion in MDT before starting ADT in patients who could have radical treatment
Locally advanced, non-metastatic
- Locally advanced cancer = extends beyond the prostate (T3/4) and/or involves regional pelvic LNs with no distant mets M0
- Treatment options are further dependent on nodal involvement (cN0 or cN1)
- Options – usually combination of below:
- Radical radiotherapy +/- with brachytherapy boost
- ADT – long term or rarely alone
- Androgen receptor pathway-targeted agents (e.g., Abiraterone)
- Radical prostatectomy – in selected patients as part of multimodal treatment
Metastatic Disease (M1)
- Treatment choice depends on whether disease is:
- hormone-sensitive or castration-resistant
- metastatic burden
- symptoms
- previous treatment
- MDT/oncology recommendation
- Options:
- ADT – see section below for details
- Androgen receptor pathway-targeted agents (e.g., Abiraterone, Enzalutamide)
- Chemotherapy (e.g., docetaxel) – in selected fit patients
- Radium-223 – selected patients with symptomatic bone mets and no visceral mets
- Bone-targeted therapy – bisphosphonates/denosumab for bone metastases and patients at high risk of osteoporosis with ADT
- Radiotherapy
- Palliative - painful bone metastases or metastatic spinal cord compression
- SABR/SBRT – for selected oligometastatic lesion or limited progression
Androgen Deprivation Therapy (ADT) - in depth explanation
Prostate cancer progression is dependent on androgens (testosterone and its derivatives). ADT reduces testosterone to castrate levels (<50 ng/dL or 1.7 nmol/L), starving tumours of their growth signals.
Side effects of ADT:
- Hot flushes, loss of libido, erectile dysfunction, fatigue, weight gain, gynaecomastia, osteoporosis, metabolic syndrome, increased risk of cardiovascular events, cognitive changes, depression
Forms of ADT
It is important for SHOs to understand the different types of ADT as you will encounter these medications regularly. You may also be asked to prescribe them.
LHRH Agonists (Goserelin (Zoladex), Leuprorelin (Prostap))
- Administered as a depot injection — monthly or 3-monthly
- Mechanism: continuously stimulate the pituitary LHRH receptors → initial surge in FSH and LH levels → downregulation due to the lack of pulsatile stimulation → LH and FSH become reduced, leading to reduced testosterone
- The initial surge in FSH and LH (and subsequent testosterone) can lead to a tumour flare during the first 1 – 2 weeks after treatment
- This can worsen symptoms and potentially result in oncological emergencies
- Bone pain, urinary obstruction, cord compression
- Therefore, it is key to prescribe an anti-androgen receptor medication (e.g., bicalutamide) before starting an LHRH agonist
- This is usually prescribed for at least 2 weeks before and 2 weeks after their first injection to block flare
LHRH Antagonists (Degarelix, Relugolix)
- Mechanism: direct competitive inhibitors of pituitary LHRH receptors.
- They result in the immediate suppression of LH/FSH production and lead to rapid testosterone reduction.
- These do not lead to the tumour flare and achieve castrate levels within days without a testosterone surge.
- Therefore can be used in emergency situations for patients diagnosed with widespread metastases who have or at high risk of life or organ threatening emergencies due to prostate cancer progression, e.g. metastatic cord compression/cauda equina syndrome, malignant ureteric obstruction.
- You must discuss it with your registrar or consultant before prescribing!
- Disadvantages – Injection site reactions and high financial costs.
Androgen Receptor Antagonists (Anti-Androgens)
- First-generation (non-steroidal) — e.g. bicalutamide, flutamide, nilutamide
- Block the androgen receptor
- Used to protect against the tumour flare, as monotherapy (less effective than LHRH agonists) or to achieve maximum androgen blockade with LHRH agonists
- Second-generation (novel agents) — Enzalutamide, apalutamide, darolutamide
- More potent AR blockade
- Used in castration-resistant prostate cancer (CRPC) or metastatic hormone-sensitive disease
- Generally prescribed by or with the advice of Oncologists
ADT: Practical Points for SHOs
- Starting LHRH agonist? - Always prescribe anti-androgen cover (bicalutamide 50mg OD) from 2 week before to 2 weeks after first injection
- Impending cord compression or obstruction? Use LHRH antagonist (degarelix) or surgical castration to avoid flare
- Check baseline: Bone density (DEXA), cardiovascular risk, diabetes screening – ADT increases these risks
- Monitor: PSA regularly to assess response; testosterone levels to confirm castrate range
- Intermittent ADT: May be used in selected patients to reduce side effects – this is a specialist decision
Oncological emergencies seen in prostate cancer
1Metastatic cord compression/cauda equina
- Read acute management — HERE
- Prostate cancer specifics:
- Check PSA
- LHRH antagonist if new diagnosis
2Malignant ureteric obstruction (MUO)
- Caused by locally advanced prostate cancer, nodal disease
- This can result in hydronephrosis and a subsequent AKI
- Signs - gradually declining renal function, flank pain, hydronephrosis on imaging
- Management – treatment of disease + de-obstruction (stent or nephrostomy)
- The management depends on the severity and acuity of the renal decline, the patient’s likely life expectancy and preferences over treatment options
- Some patients may not require urgent treatment if their renal function is stable and the declining renal function is unlikely to significantly worsen or if the patient is to be managed palliatively
3Hypercalcaemia
- Bone mets are typically osteoblastic so hyperCa is uncommon, but can occur in advanced disease
- Manage with IV fluids, refer to oncology and consider prescribing bisphosphonates
4Severe bone pain
- Manage with analgesia and consider referring to oncology for palliative radiotherapy
References
- Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2023;388(17):1547-1558. doi:10.1056/NEJMoa2214122.
- Bosaily AES, Parker C, Brown LC, Gabe R, Hindley RG, Kaplan R, et al. PROMIS—Prostate MR imaging study: A paired validating cohort study evaluating the role of multiparametric MRI in men with clinical suspicion of prostate cancer. Contemp Clin Trials. 2015;42:26-40. doi:10.1016/j.cct.2015.02.008.
- Cancer Research UK. Cambridge Prognostic Group (CPG) for prostate cancer [Internet]. London: Cancer Research UK; [cited 2026 Jun 13]. Available from: Cancer Research UK – Cambridge Prognostic Group
- STAMPEDE Trial Management Group. Publications repository [Internet]. STAMPEDE Trial; [cited 2026 Jun 13]. Available from: STAMPEDE Publications Repository
- European Association of Urology (EAU) Guidelines on Prostate Cancer 2026
- National Institute for Health and Care Excellence (NICE). Prostate cancer: diagnosis and management (NG131)