How Common Is Prostate Cancer?
Prostate cancer is the most frequently diagnosed cancer in men (excluding skin cancers), accounting for roughly 1 in 8 male cancer diagnoses in the United States. The lifetime risk of diagnosis is approximately 12.5%. However, death from prostate cancer is far less common — about 1 in 44 men — because the vast majority of prostate cancers are slow-growing and either never become clinically significant or are caught early.
Risk Factors
- Age — rare before 50; incidence rises sharply after 65
- Family history — first-degree relative with prostate cancer doubles risk; BRCA2 mutation carriers have 5–8× higher risk
- Race/ethnicity — Black men have the highest incidence and mortality rates globally; reasons are multifactorial (biological, access to care, diet)
- Diet — high intake of red and processed meat; evidence for protective effect of tomatoes (lycopene) and fish is suggestive but not definitive
- Obesity — associated with more aggressive disease and worse outcomes
Symptoms
Early prostate cancer typically causes no symptoms. Symptoms usually only appear with locally advanced or metastatic disease:
- Difficulty starting urination or weak urine stream
- Frequent urination, especially at night (nocturia)
- Blood in urine (haematuria) or semen (haematospermia)
- Painful ejaculation
- Erectile dysfunction (if nerves are involved)
- Bone pain in hips, spine, or pelvis (sign of metastasis)
These urinary symptoms overlap significantly with benign prostatic hyperplasia (BPH), a non-cancerous prostate enlargement that is extremely common in older men. A PSA test and biopsy are needed to differentiate.
PSA Screening: What It Tells You (and What It Doesn't)
Prostate-specific antigen (PSA) is a protein produced by prostate cells. Elevated levels (>4 ng/mL) can indicate cancer, BPH, prostatitis, or even vigorous exercise or sexual activity. PSA is not a yes/no cancer test — it is a risk stratifier.
Current screening recommendations vary:
- USPSTF (US): Shared decision-making discussion for men aged 55–69; not recommended for 70+
- AUA: Baseline PSA at age 40–45 for high-risk men (Black men, BRCA2 carriers, strong family history); discuss at 45–50 for average-risk men
- EAU: Risk-adapted early detection strategy; annual PSA for men with PSA >1 ng/mL at 40, or >2 ng/mL at 60
The benefit of screening is reducing metastatic cancer deaths; the harm is overdiagnosis and overtreatment of clinically insignificant cancers.
Diagnosis: Biopsy and Gleason Score
An elevated PSA prompts further investigation. MRI-guided prostate biopsy (MRI fusion biopsy) is now the preferred diagnostic method — it identifies clinically significant cancers while reducing unnecessary biopsies of low-risk areas.
The Gleason score grades the biopsy tissue from 6 (low grade) to 10 (most aggressive), based on the two most prevalent tumour patterns. Scores are now grouped into Grade Groups 1–5:
- Grade Group 1 (Gleason 6) — very low risk; grows very slowly
- Grade Group 2 (Gleason 3+4=7) — favourable intermediate risk
- Grade Group 3 (Gleason 4+3=7) — unfavourable intermediate risk
- Grade Group 4 (Gleason 8) — high risk
- Grade Group 5 (Gleason 9–10) — very high risk
Treatment Options
Active Surveillance
For Grade Group 1 (and carefully selected Grade Group 2) cancer: regular PSA testing, repeat MRI, and periodic rebiopsy. Treatment is deferred unless the cancer progresses. This avoids overtreatment and preserves quality of life — about 50–60% of eligible men remain on surveillance at 10 years without treatment.
Surgery (Radical Prostatectomy)
Removal of the entire prostate gland and seminal vesicles. Robotic-assisted laparoscopic prostatectomy is the most common approach. Potential side effects: urinary incontinence (usually temporary) and erectile dysfunction (varies by nerve-sparing technique and baseline function).
Radiation Therapy
External beam radiation therapy (EBRT) with intensity-modulated radiotherapy (IMRT) or stereotactic body radiotherapy (SBRT), or brachytherapy (radioactive seed implants). Equivalent cure rates to surgery for localised disease; different side effect profile (bowel symptoms more common than with surgery).
Hormone Therapy (ADT)
Androgen deprivation therapy — either LHRH agonists/antagonists or surgical castration. Used for high-risk localised disease (with radiation) and metastatic disease. Side effects: hot flushes, loss of libido, bone loss, metabolic syndrome.
Advanced and Metastatic Disease
Newer agents have transformed metastatic prostate cancer management: enzalutamide, abiraterone, apalutamide, and darolutamide extend survival. PARP inhibitors (olaparib, rucaparib) for BRCA-mutated disease. Lutetium-177 PSMA therapy (a targeted radionuclide therapy) is approved for metastatic castration-resistant disease.