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INTRODUCTION — Prostate cancer is a cancer of the prostate gland. The prostate is an organ that forms a ring around the urethra near its connection to the bladder (figure 1). The urethra is the tube that carries urine from the bladder to the outside of the body.
Most males are diagnosed with prostate cancer at an early stage when the cancer is highly curable. Often, the diagnosis is made based on an elevated prostate-specific antigen (PSA) result. The PSA level is measured with a blood test that is done to screen for prostate cancer in some situations. A separate article discusses screening tests for prostate cancer. (See "Patient education: Prostate cancer screening (Beyond the Basics)".)
This article discusses the symptoms, diagnosis, and treatment of stage I to III prostate cancer. The treatment of advanced (stage IV, metastatic) prostate cancer is discussed separately. (See "Patient education: Treatment for advanced prostate cancer (Beyond the Basics)".)
More detailed information about early stage prostate cancer, written for health care providers, is available by subscription. (See 'Professional level information' below.)
CANCER CARE DURING THE COVID-19 PANDEMIC — COVID-19 stands for "coronavirus disease 2019." It is an infection caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and has since spread throughout the world. Getting vaccinated lowers the risk of severe illness; experts recommend COVID-19 vaccination for anyone with cancer or a history of cancer.
In some cases, if you live in an area with a lot of cases of COVID-19, your doctor might suggest rescheduling or delaying medical appointments. But this decision must be balanced against the importance of getting care to screen for, monitor, and treat cancer. Your doctor can talk to you about whether to make any changes to your appointment schedule. They can also advise you on what to do if you test positive or were exposed to the virus.
PROSTATE CANCER SYMPTOMS — Prostate cancer is usually found in asymptomatic males based on an elevated PSA, and many males never experience any symptoms related to the cancer. Urinary symptoms such as urgency, frequency, and a feeling of incomplete bladder emptying are usually caused by a large prostate gland (called benign prostatic hyperplasia) but may also occur with prostate cancer. Other much less common symptoms include blood in the urine or semen, and erectile dysfunction. Rarely, patients present with fatigue, weight loss, or pain due to metastatic prostate cancer. (See "Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)".)
In many cases, your doctor or nurse may suspect that you have prostate cancer if you have an abnormal blood test (prostate-specific antigen [PSA]) or an abnormal rectal examination. To be certain about the diagnosis, you will need to have a prostate biopsy.
PROSTATE BIOPSY — A prostate biopsy is used to establish the diagnosis of prostate cancer and is usually done in a doctor's office. It involves using a needle to take a sample from the prostate for testing. You may be given a course of antibiotics to take before and after the biopsy to reduce the risk of infection from the procedure.
There are two ways to do a prostate biopsy: through the rectum using an ultrasound probe (transrectal ultrasound [TRUS]-guided biopsy), or using magnetic resonance imaging (MRI) to guide the needle.
Where available, state of the art biopsy is performed using imaging guidance obtained from a pre-biopsy prostate MRI. An ultrasound probe is placed in the rectum and the ultrasound image is fused with the MRI image where the areas worrisome for cancer have been marked. A needle is then passed into the suspicious areas and sometimes in randomly selected normal appearing areas to obtain tissue for pathologic diagnosis. The needle may be passed either through the rectum (called transrectal biopsy) or through the perineum (called transperineal biopsy). While both are commonly performed, the transperineal approach has a lower risk of infection and may be more accurate. Both procedures can be done under local anesthesia, sedation, or general anesthesia depending upon the experience of the biopsy team and local practice routines.
High frequency micro-ultrasound is an emerging alternative imaging technique that may obviate the need for prostate MRI. If MRI is not available, a standard transrectal ultrasound-guided biopsy may be done.
After the procedure, you will probably feel soreness in your rectum or the area around your rectum (called the perineum). You may have some bleeding from your rectum, in your urine (for several days), or in your semen (for up to several months). In addition, there is a small risk of infection in the prostate or in the bloodstream, which may require antibiotics.
Regardless of the way the biopsy is performed, the tissue sample will be examined by a pathologist using a microscope. The results are usually available within one week. In addition to the tissue examination, molecular tests may be done on the sample; this can provide additional information that may be useful in choosing a treatment approach.
Gleason grade group — If cancer is found in the prostate biopsy, the amount of cancer and the aggressiveness of the tumor will be determined. The Gleason grade depends on how the tumor looks under the microscope. The higher the Gleason grade, the more likely the tumor is to behave aggressively (grow faster). The Gleason grades from different areas of the prostate gland are combined to form the Gleason grade group (grade group 1 to 5). In addition to the Gleason grade group, there are other biopsy features that also may influence prognosis and treatment.
Prostate cancer stage and risk group — Once prostate cancer is diagnosed, the next step is to determine its stage and assign it to a risk category. The categories include the following:
●Very low risk
●Low risk
●Intermediate risk (this group is further divided into "favorable" and "unfavorable" depending on how much cancer was found in the biopsy result)
●High risk
●Very high risk
Staging is a system used to describe the size, aggressiveness, and spread of a cancer. A cancer's stage helps to guide treatment and can help predict the chance of curing the cancer.
A prostate cancer's stage is based on the following:
●How far the tumor extends in the prostate and surrounding tissue
●Evidence of cancer spread to nearby lymph nodes
●Signs of cancer in other organs (liver, bone)
These three categories, along with the prostate-specific antigen (PSA) level and the grade group (see 'Gleason grade group' above), are used to assign a prognostic stage group. The stage groups range from I to IV. In general, lower stage cancers are less aggressive and are generally curable. Stage I and II prostate cancers are referred to as "localized" prostate cancers, stage III prostate cancer is referred to as "locally advanced" prostate cancer, and stage IV prostate cancer is referred to as "advanced" or "metastatic" prostate cancer.
Together, the stage, PSA level, grade group, and biopsy results are used to assess how aggressive the tumor is and what treatment options are available; this process is called "risk stratification." In general, when the cancer is localized to the prostate, very low-risk tumors correspond to stage I prostate cancer, while very high-risk tumors correspond to stage III cancers, but there is not perfect overlap. Furthermore, other features of the tumor (such as molecular or genetic factors) that are not included in these classifications might also influence the tumor's level of aggressiveness. Nevertheless, these risk categories have become important in helping males make decisions about treatment options, particularly active surveillance. (See 'Active surveillance' below.)
Further testing — Other imaging tests, such as MRI, ultrasound, or bone scan, may be done before treatment begins to determine whether the cancer has spread beyond the prostate. Newer tests, such as a scan based on the prostate-specific membrane antigen (PSMA), are becoming available; in the future, these may have a role in determining whether the cancer has spread.
STAGE I TO II (LOCALIZED) PROSTATE CANCER TREATMENT — Localized prostate cancer is cancer that has not spread to the lymph nodes or distant organs. There are three standard ways to treat localized prostate cancer:
●Surgery to remove the prostate gland (called radical prostatectomy) (see 'Radical prostatectomy' below)
●Radiation therapy (RT; external beam or brachytherapy), sometimes combined with androgen deprivation therapy (ADT) (see 'Radiation therapy' below)
●Active surveillance (see 'Active surveillance' below)
Focal therapy with high-intensity focused ultrasound, cryotherapy, or laser ablation are being studied as alternatives to active surveillance in select patients. These approaches can target the specific area in the prostate gland that contains the tumor Long-term data with these techniques are not available, and they have not been adequately compared with standard treatment approaches, but they may be suitable for some males after a consideration of all of the potential risks and benefits.
The best treatment depends on your age and health, your preferences, and the stage of your cancer. (See 'Which treatment is right for me?' below.)
Radical prostatectomy — Radical prostatectomy (also called prostatectomy) is a surgery done to remove the prostate gland and then reconnect the urethra and bladder (figure 1).
The most common complications of prostatectomy are as follows:
●Urinary incontinence (leakage of urine)
●Erectile dysfunction (difficulty having an erection)
There are two ways to perform prostatectomy: open and robotic.
●Open prostatectomy requires an up-and-down incision (cut) that is three to four inches (7.5 to 10 cm) long, beginning from the top of the pubic bone.
●Robotic prostatectomy is done through several small incisions, usually a total of 5 to 6 cm in combined length. Small instruments and a camera are placed through the incisions. The surgeon operates while looking at a monitor that displays what is seen through the camera. This is now the most common way prostatectomy is performed.
The likelihood of curing your cancer and minimizing postsurgery complications depends on the skill and experience of the surgeon, not whether the surgery is done open or with a robot. In experienced hands, issues like needing a blood transfusion, pain, time in the hospital, and return to full activity (approximately three weeks) are similar with both approaches. Asking about your surgeon's experience is important in getting a good result.
Talk to your surgeon about the potential risks and benefits of the different types of prostatectomy to determine which is right for you.
Radiation therapy — Two forms of RT are used to treat prostate cancer: external beam RT and brachytherapy. These are sometimes used together, especially for males with intermediate- and high-risk tumors.
External beam radiation therapy — External beam RT (which is also often referred to as intensity-modulated RT) uses a machine that moves around you, directing X-rays at the pelvis. External beam RT is typically done in multiple daily treatments given over several weeks, depending on the specific technique used. Each treatment takes just a few minutes, and you can usually continue your normal activities during treatment. External beam RT is usually used in combination with short-term hormone therapy (ADT), particularly for males with intermediate- and high-risk disease. (See 'Androgen deprivation therapy' below.)
Possible side effects of external beam RT include needing to use the bathroom frequently to urinate, bladder pain, erectile dysfunction, and swelling and pain in the rectum (called proctitis). These symptoms are usually temporary, although long-term complications (such as rectal bleeding and blood in the urine) may occur many years after external beam RT.
Brachytherapy — In brachytherapy, radioactive sources are placed directly into the prostate gland. There are two types of brachytherapy, both of which are done under anesthesia:
●One type of brachytherapy, called low dose rate brachytherapy, involves placing rice-sized seeds that emit radiation into the prostate. The seeds gradually lose their radioactivity over time and are not removed. This is done as an outpatient procedure and does not require a hospital stay.
●High dose rate brachytherapy, which is used less frequently, involves temporarily implanting a radioactive source into the prostate gland, then removing it after one or two days. This is often combined with external beam radiation therapy.
Males who undergo brachytherapy usually develop inflammation and swelling of the prostate gland, which can lead to urinary urgency (needing to urinate frequently), burning with urination, and occasionally, retention of urine (being unable to empty the bladder completely, which requires temporary use of a catheter). Compared with other treatments, brachytherapy does the best job of preserving erectile function in the short term, but it has similar rates of erectile dysfunction in the long term. Less commonly, some males have bowel urgency and frequency, rectal bleeding, and rectal ulcers. These problems usually resolve within a few weeks to months.
Androgen deprivation therapy — Male hormones (androgens, the most common of which is testosterone) fuel the growth of prostate cancer. Treatments that decrease the body's levels of androgens (called androgen deprivation therapy or ADT) decrease the size and slow the growth of prostate cancer. For males with localized prostate cancer, ADT is usually done by taking medications that interfere with androgens rather than by having surgery to remove the testicles (called orchiectomy).
Medication therapy typically involves periodic injections that provide sustained delivery of medication.
A short course of ADT (ranging from four to six months for intermediate-risk disease to 18 to 24 months for high-risk disease) might be recommended in addition to external beam RT for males with intermediate- and high-risk prostate cancer.
Side effects of androgen deprivation therapy — The side effects of ADT are related to the lowered levels of male hormones and include the following:
●Decreased libido (sex drive) and difficulties with erection (erectile dysfunction)
●Hot flashes
●Enlargement of the breasts (called gynecomastia) (see "Patient education: Gynecomastia (breast enlargement in men) (Beyond the Basics)")
●Loss of muscle and an increase in body fat
●Thinning and weakening of the bones (called osteoporosis), which can increase the risk of bone fractures (see "Patient education: Osteoporosis prevention and treatment (Beyond the Basics)")
●An increased risk of developing type 2 diabetes
●Loss of muscle mass
Many of these side effects are serious but most are reversible after discontinuing the short-course ADT that is typically used in conjunction with radiation. However, not all males have all of these side effects. It is important to balance the risk of side effects with the risk of not using ADT, which could allow your cancer to grow or spread. In addition, there are ways to prevent or treat many of these side effects.
Active surveillance — With this approach, immediate treatment is avoided or postponed, with serial monitoring (which may include additional examinations, prostate biopsies, blood tests, and imaging tests) to determine if the cancer has grown or progressed and reached a point that requires treatment. Active surveillance differs from "watchful waiting," in which a decision is made at the outset to forego definitive treatment and to provide treatment only to improve symptoms if the cancer grows or metastasizes. Watchful waiting may be an option in males who have a limited life expectancy or chronic serious medical conditions.
In general, active surveillance is considered the preferred option for males with very low- and low-risk cancers for males who are comfortable with this approach. While it may also be considered for a male with a "favorable" intermediate-risk tumor, active surveillance comes with a higher risk of progressing to metastatic (stage IV) disease than definitive treatment with surgery or RT in this situation. Surgery and RT are appropriate options for males in all risk categories, including very low risk, if they are more comfortable with immediate treatment rather than surveillance.
STAGE III (LOCALLY ADVANCED) PROSTATE CANCER TREATMENT — Locally advanced prostate cancer has spread outside the prostate gland to areas such as the seminal vesicles (figure 1). There is no one "best" treatment for locally advanced prostate cancer. Treatment often includes a combination of two approaches:
●Radiation therapy (RT) with androgen deprivation therapy (ADT)
●Radical prostatectomy
Radiation therapy — RT involves the use of X-rays to destroy cancer cells. There are two forms of RT used to treat prostate cancer: external beam RT (see 'External beam radiation therapy' above) and brachytherapy (see 'Brachytherapy' above).
Most males who have RT for locally advanced prostate cancer are also given ADT (see 'Androgen deprivation therapy' below). Having both treatments helps to control the cancer and improves the chance of survival. Most experts recommend treatment with ADT for 18 to 24 months.
Surgery — Radical prostatectomy is a surgery that completely removes the prostate gland (see 'Radical prostatectomy' above), and it has become more popular for treatment of stage III prostate cancer. For males with high-risk disease who have radical prostatectomy, RT is often recommended following surgery, based on data showing improved long-term outcomes. While this may be done immediately afterwards (called "adjuvant" RT), most males can delay RT until there are signs that the cancer has returned (called "early salvage" RT). This is based on monitoring tests that can detect a rise in prostate-specific antigen (PSA) (see 'Monitoring for a recurrence of the tumor' below). Delaying radiation until the PSA is rising prevents unnecessary treatment as well as the side effects that are associated with RT. Studies are underway to determine if genomic markers can identify a subset of males most likely to benefit from earlier use of RT (ie, when the PSA is undetectable).
Androgen deprivation therapy — As discussed above, treatments that decrease the body's levels of androgens (called androgen deprivation therapy or ADT) decrease the size and slow the growth of prostate cancer. In males with locally advanced prostate cancer, ADT is usually given in combination with RT. (See 'Androgen deprivation therapy' above.)
MONITORING FOR A RECURRENCE OF THE TUMOR — After treatment for localized prostate cancer, experts advise follow-up testing to monitor for signs that the cancer has returned. This follow-up testing usually includes a blood test called prostate-specific antigen (PSA). The PSA test is very sensitive, meaning that the PSA may begin to rise well before you can see or feel that the cancer has returned. Many males with a rising PSA will not have any sign that the cancer has come back for many years (even 15 or more). Thus, not all males with a rising PSA need immediate treatment.
However, in some males with a rising PSA, treatment is recommended to reduce the chance that the cancer will continue to grow or spread. Talk to your doctor or nurse to discuss your options.
The best treatment for a rising PSA depends on what treatment you had before and whether the recurrence is localized to the region of the prostate or has spread to other sites, especially the bone:
●Males who had radiation therapy (RT) initially are usually advised to have a prostate biopsy and imaging studies. If those tests show residual cancer and if the cancer has not grown beyond the prostate, "salvage" therapy, such as surgery (called salvage prostatectomy) or brachytherapy, may be an option with the potential for cure.
●Males who initially had prostate surgery and whose tumor recurrence is localized to the region of the prostate are usually treated with RT plus a short course of androgen deprivation therapy (ADT).
●Males who cannot have RT or surgery, or those whose tumors have spread (metastasized) to other sites, such as the bone, are treated with ADT.
WHICH TREATMENT IS RIGHT FOR ME? — For males with early stage (localized) prostate cancer, the decision between active surveillance, radiation therapy (RT), and surgery is largely a matter of preference. The available information suggests that cancer outcomes are similar regardless of the choice of therapy. The choice also depends on the risk that the cancer will grow quickly or come back after treatment. Active surveillance is the preferred option for males with very low- and low-risk tumors, but some males with favorable intermediate-risk tumors may choose this approach. Focal therapy may be an alternative to active surveillance in males who desire treatment with a smaller risk of erectile dysfunction and incontinence.
The potential risks and complications of surgery, RT, and active surveillance are unique. The following table lists the advantages and disadvantages of each type of treatment (table 1).
Localized (stage I to II) prostate cancer — Males who have very low- and low-risk tumors that are unlikely to grow quickly have the option to have treatment (with surgery or RT) or monitoring (active surveillance) with treatment delayed to when there is evidence that the cancer may be becoming aggressive. Males who are older or who have other serious illnesses might prefer watchful waiting or active surveillance over surgery or RT. Focal therapy may be an alternative for some males, although equivalent efficacy to standard therapy is not available.
Males who have intermediate- or high-risk tumors that could behave aggressively, making them hard to cure later, are usually encouraged to have immediate treatment (surgery or RT). Males who have RT will often be recommended for short-term androgen deprivation therapy (ADT).
Locally advanced (stage III) prostate cancer — There is no single best treatment for males with locally advanced prostate cancer. Most experts recommend a combination of either ADT plus RT or surgery plus adjuvant RT with or without ADT.
Advanced (stage IV) prostate cancer — Treatment for advanced prostate cancer is discussed separately. (See "Patient education: Treatment for advanced prostate cancer (Beyond the Basics)".)
CLINICAL TRIALS — Progress in treating prostate cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials or read about clinical trials at:
●www.cancer.gov/clinicaltrials/
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Prostate cancer (The Basics)
Patient education: Prostate cancer screening (PSA tests) (The Basics)
Patient education: Hydronephrosis in adults (The Basics)
Patient education: Choosing treatment for low-risk localized prostate cancer (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Prostate cancer screening (Beyond the Basics)
Patient education: Treatment for advanced prostate cancer (Beyond the Basics)
Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)
Patient education: Sexual problems in men (Beyond the Basics)
Patient education: Gynecomastia (breast enlargement in men) (Beyond the Basics)
Patient education: Osteoporosis prevention and treatment (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Active surveillance for males with clinically localized prostate cancer
Brachytherapy for low-risk or favorable intermediate-risk, clinically localized prostate cancer
Chemoprevention strategies in prostate cancer
Clinical presentation and diagnosis of prostate cancer
Cryotherapy and other ablative techniques for the initial treatment of prostate cancer
Localized prostate cancer: Risk stratification and choice of initial treatment
External beam radiation therapy for localized prostate cancer
Follow-up surveillance after definitive local treatment for prostate cancer
Interpretation of prostate biopsy
Side effects of androgen deprivation therapy
Measurement of prostate-specific antigen
Initial approach to low- and very low-risk clinically localized prostate cancer
Radical prostatectomy for localized prostate cancer
Rising serum PSA after radiation therapy for localized prostate cancer: Salvage local therapy
Role of systemic therapy in patients with a biochemical recurrence after treatment for localized prostate cancer
Rising serum PSA following local therapy for prostate cancer: Definition, natural history, and risk stratification
Rising serum PSA following local therapy for prostate cancer: Diagnostic evaluation
Rising or persistently elevated serum PSA following radical prostatectomy for prostate cancer: Management
Initial management of regionally localized intermediate-, high-, and very high-risk prostate cancer and those with clinical lymph node involvement
The following organizations also provide reliable health information.
●National Cancer Institute
1-800-4-CANCER
(www.cancer.gov/types/prostate)
●American Society of Clinical Oncology
●National Library of Medicine
