Prostate Cancer: Complete Guide

Written by: James Wilson, MD

Reviewed by: Dr. Mark Stevens, Urologic Oncologist

Last reviewed: January 24, 2026

Quick Facts

Most common cancer in men (excluding skin cancer)
1 in 8 men will be diagnosed with prostate cancer
Most prostate cancers grow slowly
5-year survival rate is nearly 100% for localized disease
Average age at diagnosis is 66 years
Often has no symptoms in early stages
Many men die WITH prostate cancer, not FROM it

What is Prostate Cancer?

Prostate cancer is cancer that occurs in the prostate — a small walnut-shaped gland in men that produces seminal fluid. The prostate surrounds the urethra, the tube that carries urine from the bladder out through the penis.

Key Points

Most prostate cancers are adenocarcinomas (99%)
Many prostate cancers grow slowly and remain confined to the prostate
Some types can be aggressive and spread quickly
Early detection when cancer is confined to prostate has best prognosis
Treatment decisions must balance cancer risk with quality of life

Prostate Anatomy and Function

The prostate gland:

Located below the bladder and in front of the rectum
About the size of a walnut in younger men
Produces prostate-specific antigen (PSA) and prostatic fluid
Divided into zones: peripheral (70%), central (25%), transition (5%)
Most cancers (70%) arise in the peripheral zone

Types of Prostate Cancer

Adenocarcinoma (>95%)

Acinar adenocarcinoma: Most common type
Ductal adenocarcinoma: More aggressive, originates in duct cells
Mucinous carcinoma: Rare, produces mucin
Signet ring cell carcinoma: Very rare and aggressive

Other Rare Types (<5%)

Small cell carcinoma: Neuroendocrine, very aggressive
Transitional cell carcinoma: Starts in urethra
Squamous cell carcinoma: Very rare
Sarcomas: Start in muscle cells

Pre-Cancerous Conditions

Prostatic Intraepithelial Neoplasia (PIN):
- Low-grade PIN: Not linked to cancer risk
- High-grade PIN: May progress to cancer
Atypical Small Acinar Proliferation (ASAP): Suspicious cells, requires follow-up
Proliferative Inflammatory Atrophy (PIA): May be precursor lesion

Signs and Symptoms

Early Stage (Usually No Symptoms)

Most early prostate cancers cause no symptoms and are detected through screening.

Locally Advanced Symptoms

Urinary symptoms:
- Difficulty starting urination
- Weak or interrupted urine flow
- Frequent urination, especially at night
- Difficulty emptying bladder completely
- Pain or burning during urination
Blood in urine (hematuria)
Blood in semen (hematospermia)
Erectile dysfunction
Pain or discomfort when sitting (enlarged prostate)

Advanced/Metastatic Symptoms

Bone pain (especially back, hips, ribs)
Loss of appetite and weight loss
Fatigue and weakness
Swelling in legs or feet
Paralysis or weakness in legs (spinal cord compression)
Loss of bowel or bladder control

⚠️ Important Note

These symptoms are more commonly caused by benign prostatic hyperplasia (BPH) or prostatitis than cancer. However, any persistent urinary symptoms should be evaluated by a healthcare provider.

⚠️ Seek Immediate Medical Attention For:

Sudden inability to urinate (acute urinary retention)
Severe bone pain with weakness or numbness in legs
Loss of bowel or bladder control
Signs of spinal cord compression

Risk Factors

Non-Modifiable Risk Factors

Age:
- Rare before age 40
- Risk increases significantly after 50
- About 60% of cases in men over 65
Race/Ethnicity:
- African American men: 70% higher incidence, 2x mortality
- Caribbean men of African ancestry: Increased risk
- Asian American and Hispanic men: Lower risk
Family History:
- Father or brother with prostate cancer: 2x risk
- Multiple affected relatives: Higher risk
- Early-onset in family: Increased risk
Genetic Factors:
- BRCA1/BRCA2 mutations (especially BRCA2)
- Lynch syndrome
- HOXB13 mutations
- ATM, CHEK2, PALB2 mutations

Possible Risk Factors (Under Study)

Diet high in red meat and high-fat dairy
Obesity (may increase risk of aggressive cancer)
Smoking (linked to aggressive cancer)
Chemical exposures (Agent Orange, firefighting chemicals)
Prostatitis (chronic inflammation)
Sexually transmitted infections
Vasectomy (controversial, likely no association)

Protective Factors (Possible)

Regular physical activity
Healthy diet (vegetables, especially tomatoes/lycopene)
Vitamin D (adequate levels)
Ejaculation frequency (controversial)

Screening Guidelines

🔍 Shared Decision-Making

Current guidelines emphasize informed, shared decision-making between patients and providers about PSA screening, weighing benefits and harms.

Major Organization Recommendations

American Urological Association (AUA) 2023

Age 40-54:
- Average risk: Shared decision-making
- High risk: Consider screening
Age 55-69: Shared decision-making (strongest evidence for benefit)
Age 70+: Not recommended for men with <10 year life expectancy

U.S. Preventive Services Task Force (USPSTF) 2018

Age 55-69: Individualized decision (Grade C)
Age 70+: Not recommended (Grade D)

High-Risk Groups (Earlier/More Frequent Screening)

African American men: Consider starting at age 40-45
Family history of prostate cancer: Start at age 40-45
BRCA2 mutation carriers: Start at age 40
Lynch syndrome: Consider enhanced screening

Screening Tests

PSA (Prostate-Specific Antigen) Test:
- Normal: Generally <4 ng/mL (age-adjusted)
- Age 40-49: <2.5 ng/mL
- Age 50-59: <3.5 ng/mL
- Age 60-69: <4.5 ng/mL
- Age 70+: <6.5 ng/mL
Digital Rectal Exam (DRE): Less sensitive than PSA
Additional PSA-based tests:
- PSA velocity (rate of change)
- PSA density (PSA/prostate volume)
- Free PSA percentage
- PHI (Prostate Health Index)
- 4Kscore Test

Benefits vs. Harms of Screening

Benefits

20-30% reduction in prostate cancer mortality
Earlier detection when more treatable
Peace of mind from negative results

Potential Harms

False-positive results (anxiety, unnecessary biopsies)
Overdiagnosis of indolent cancers
Complications from biopsy (bleeding, infection)
Overtreatment and associated side effects

Diagnosis

Diagnostic Pathway

Abnormal PSA or DRE
Risk assessment tools (PCPT, ERSPC calculators)
Additional biomarkers (optional)
Imaging (MRI preferred before biopsy)
Prostate biopsy for tissue diagnosis

Imaging Studies

Multiparametric MRI (mpMRI):
- PI-RADS scoring system (1-5)
- Helps target biopsies
- Can avoid unnecessary biopsies
Transrectal Ultrasound (TRUS): Guides biopsy
CT scan: For staging (lymph nodes, distant spread)
Bone scan: If PSA >20, Gleason ≥8, or symptoms
PSMA PET/CT: Most sensitive for metastases

Prostate Biopsy

Standard TRUS biopsy: 12 core systematic sampling
MRI-targeted biopsy: Targets suspicious areas
MRI-TRUS fusion biopsy: Combines approaches
Transperineal biopsy: Lower infection risk
Saturation biopsy: 20+ cores for repeat biopsy

Pathology and Gleason Score

The Gleason grading system assesses tumor architecture:

Grade Group	Gleason Score	Risk Category
Group 1	Gleason 6 (3+3)	Low risk
Group 2	Gleason 7 (3+4)	Favorable intermediate
Group 3	Gleason 7 (4+3)	Unfavorable intermediate
Group 4	Gleason 8	High risk
Group 5	Gleason 9-10	Very high risk

Molecular Testing

Genomic classifiers:
- Oncotype DX
- Prolaris
- Decipher
Germline testing: For hereditary cancer syndromes
Somatic testing: For advanced disease (BRCA, ATM, MSI)

Staging and Risk Groups

TNM Staging

Stage	Description
T1	Clinically inapparent, not palpable
T2a	Involves ≤50% of one lobe
T2b	Involves >50% of one lobe
T2c	Involves both lobes
T3a	Extracapsular extension
T3b	Seminal vesicle invasion
T4	Invades adjacent structures
N0	No lymph node metastasis
N1	Regional lymph node metastasis
M0	No distant metastasis
M1a	Non-regional lymph nodes
M1b	Bone metastases
M1c	Other sites

Risk Stratification (NCCN)

Very Low Risk

T1c
Grade Group 1
PSA <10 ng/mL
<3 positive cores, ≤50% cancer in each
PSA density <0.15

Low Risk

T1-T2a
Grade Group 1
PSA <10 ng/mL

Intermediate Risk

T2b-T2c OR
Grade Group 2-3 OR
PSA 10-20 ng/mL

High Risk

T3a OR
Grade Group 4-5 OR
PSA >20 ng/mL

Very High Risk

T3b-T4 OR
Primary Gleason pattern 5 OR
>4 cores Grade Group 4-5 OR
2+ high-risk features

Treatment Options

Active Surveillance

For low-risk and selected intermediate-risk cancers:

Regular PSA tests (every 3-6 months)
DRE (every 6-12 months)
Repeat biopsies (year 1, then every 2-4 years)
MRI monitoring
Intervention if progression detected

Surgery - Radical Prostatectomy

Open retropubic: Traditional approach
Laparoscopic: Minimally invasive
Robotic-assisted (RALP): Most common in US
- Less blood loss
- Shorter hospital stay
- Similar cancer outcomes
Nerve-sparing: Preserves erectile function when possible
Pelvic lymph node dissection: For intermediate/high risk

Radiation Therapy

External Beam Radiation (EBRT)

3D-CRT: Three-dimensional conformal
IMRT: Intensity-modulated (standard)
SBRT/SABR: Stereotactic (5 treatments)
Proton beam: Reduced dose to normal tissue
Typical dose: 76-81 Gy conventional, 36.25-40 Gy SBRT

Brachytherapy

Low-dose rate (LDR): Permanent seed implants
High-dose rate (HDR): Temporary implants
Can be combined with EBRT for high-risk disease

Hormone Therapy (Androgen Deprivation Therapy - ADT)

LHRH Agonists

Leuprolide (Lupron)
Goserelin (Zoladex)
Triptorelin (Trelstar)
Histrelin (Vantas)

LHRH Antagonists

Degarelix (Firmagon)
Relugolix (Orgovyx) - oral

Anti-Androgens

Bicalutamide (Casodex)
Flutamide
Nilutamide (Nilandron)

Newer Hormone Agents

Enzalutamide (Xtandi)
Apalutamide (Erleada)
Darolutamide (Nubeqa)
Abiraterone (Zytiga) + prednisone

Treatment by Risk Group

Very Low/Low Risk

Active surveillance (preferred)
Radical prostatectomy
Radiation therapy (EBRT or brachytherapy)

Intermediate Risk

Radical prostatectomy ± pelvic lymph node dissection
Radiation + 4-6 months ADT
Brachytherapy ± EBRT ± ADT

High/Very High Risk

Radical prostatectomy + pelvic lymph node dissection
EBRT + long-term ADT (18-36 months)
EBRT + brachytherapy + ADT

Advanced/Metastatic Disease

Hormone-Sensitive Metastatic

ADT + docetaxel chemotherapy
ADT + abiraterone
ADT + enzalutamide
ADT + apalutamide
Triplet therapy (ADT + docetaxel + abiraterone/darolutamide)

Castration-Resistant (CRPC)

Enzalutamide, apalutamide, or darolutamide
Abiraterone + prednisone
Docetaxel chemotherapy
Cabazitaxel chemotherapy
Radium-223 (for bone metastases)
Lutetium-177-PSMA (PLUVICTO)
Sipuleucel-T (Provenge) immunotherapy

Targeted Therapy

Olaparib or rucaparib (BRCA mutations)
Pembrolizumab (MSI-H/dMMR tumors)

Focal Therapy (Investigational)

High-intensity focused ultrasound (HIFU)
Cryotherapy
Focal laser ablation
Irreversible electroporation
Photodynamic therapy

Prognosis and Survival

Overall Survival Rates

5-year relative survival: 97%
10-year relative survival: 98%
15-year relative survival: 96%

By Stage

Localized/Regional: Nearly 100% 5-year survival
Distant metastases: 32% 5-year survival

Prognostic Factors

Favorable

Low Gleason score (≤6)
Low PSA at diagnosis
Early stage
Younger age
Good performance status

Unfavorable

High Gleason score (8-10)
High PSA (>20 ng/mL)
Advanced stage
PSA doubling time <3 months
Presence of metastases
Neuroendocrine features

Biochemical Recurrence

PSA rise after definitive treatment:

After surgery: PSA ≥0.2 ng/mL
After radiation: PSA nadir + 2 ng/mL
Occurs in 20-40% within 10 years
Not all biochemical recurrences progress clinically

Treatment Side Effects

Surgery Side Effects

Erectile dysfunction: 30-80% (depends on nerve-sparing)
Urinary incontinence: 5-20% at 1 year
Urethral stricture: 1-8%
Infertility: Loss of ejaculation
Penis shortening: 1-2 cm average
Inguinal hernia: 15-20%

Radiation Side Effects

Acute (during treatment)

Urinary frequency/urgency
Dysuria (painful urination)
Diarrhea
Rectal irritation
Fatigue

Long-term

Erectile dysfunction: 40-60% at 5 years
Urinary incontinence: 5-10%
Bowel problems: 10-20%
Secondary cancers: Small increased risk
Urethral stricture

Hormone Therapy Side Effects

Hot flashes (70-80%)
Loss of libido
Erectile dysfunction
Fatigue
Weight gain
Loss of muscle mass
Osteoporosis
Metabolic syndrome
Cardiovascular risk
Cognitive changes
Depression
Gynecomastia (breast enlargement)

Living with Prostate Cancer

Managing Side Effects

Erectile Dysfunction

PDE5 inhibitors (sildenafil, tadalafil)
Vacuum erection devices
Penile injections
Penile implants
Penile rehabilitation programs

Urinary Incontinence

Pelvic floor exercises (Kegel)
Biofeedback
Medications
Male slings
Artificial urinary sphincter

Hot Flashes

Lifestyle modifications
Medications (venlafaxine, gabapentin)
Acupuncture

Follow-up Care

After surgery/radiation:
- PSA every 3 months for 2 years
- Then every 6 months for 3 years
- Then annually
On ADT:
- PSA and testosterone levels
- Bone density monitoring
- Metabolic panel

Lifestyle Recommendations

Regular exercise (resistance and aerobic)
Heart-healthy diet
Weight management
Calcium and vitamin D supplementation
Smoking cessation
Limit alcohol
Stress management

Psychosocial Support

Support groups
Individual counseling
Couples therapy
Sexual health counseling
Online communities

Frequently Asked Questions

Should I get PSA screening?

This is an individual decision. Discuss with your doctor about your risk factors, the benefits of early detection, and potential harms of overdiagnosis. Most guidelines recommend shared decision-making for men 55-69.

Does an elevated PSA mean I have cancer?

No. PSA can be elevated due to BPH, prostatitis, recent ejaculation, vigorous exercise, or DRE. Only 25% of men with PSA 4-10 ng/mL have cancer on biopsy.

Can prostate cancer be cured?

Yes, when caught early. Localized prostate cancer has nearly 100% 5-year survival. Many men with low-risk cancer may never need treatment and can be safely monitored.

Will treatment make me impotent?

Not necessarily. Nerve-sparing surgery and modern radiation techniques reduce this risk. Recovery varies, and many treatments are available for erectile dysfunction. Discuss options with your doctor.

What's the difference between Gleason 6 and higher grades?

Gleason 6 (Grade Group 1) is the lowest grade cancer that rarely metastasizes. Gleason 7 and higher have more aggressive potential and may require immediate treatment.

Is active surveillance safe?

Yes, for appropriately selected men with low-risk cancer. Studies show no difference in long-term survival compared to immediate treatment, while avoiding treatment side effects.

Can diet and lifestyle affect prostate cancer?

Yes. A healthy diet, regular exercise, and maintaining a healthy weight may slow cancer progression and improve treatment outcomes. Some studies suggest tomatoes (lycopene) and cruciferous vegetables may be protective.

Should my family members be tested?

Men with a father or brother with prostate cancer should discuss earlier screening (age 40-45). Genetic counseling may be appropriate for families with multiple cases or early-onset disease.

What is castration-resistant prostate cancer?

CRPC occurs when cancer progresses despite very low testosterone levels from ADT. It doesn't mean hormone therapy has failed completely—newer hormone agents can still be effective.

Can prostate cancer come back after treatment?

Yes, about 20-40% of men experience biochemical recurrence (PSA rise) within 10 years. Not all recurrences require immediate treatment, and many can be successfully managed.

Sources

National Cancer Institute. Prostate Cancer Treatment (PDQ) - Health Professional Version. Updated January 2026.
American Cancer Society. Prostate Cancer Statistics 2026.
NCCN Clinical Practice Guidelines. Prostate Cancer. Version 1.2026.
American Urological Association. Prostate Cancer Guidelines. 2023 Update.
EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer. 2025.
USPSTF. Prostate Cancer Screening Recommendation Statement. JAMA. 2018.
Parker C, et al. Prostate Cancer: ESMO Clinical Practice Guidelines. Ann Oncol. 2025.