Prostate Cancer

Prostate cancer is malignant growth in the prostate gland, usually adenocarcinoma. It is the most common cancer in men. Most cases are slow-growing and detected before causing symptoms. The challenge is distinguishing clinically significant cancers needing treatment from indolent ones managed conservatively.

PSA (Prostate-Specific Antigen) is a protein produced by prostate cells. Elevated PSA (>4 ng/mL) or rapidly rising PSA prompts further evaluation. PSA density (PSA/prostate volume), PSA velocity, and free-to-total PSA ratio improve specificity. PSA screening in men 50-70 (or 45 with family history) is recommended after shared decision-making.

The Gleason score grades how abnormal prostate cancer cells look under a microscope (1-5 scale). The two most common patterns are added to give a score out of 10. Gleason 6 (3+3): low grade, slow-growing. Gleason 7 (3+4 or 4+3): intermediate. Gleason 8-10: high grade, aggressive. The Grade Group system (1-5) is now preferred.

MRI prostate (mpMRI) identifies suspicious lesions and guides targeted biopsy. Transrectal or transperineal biopsy (12-16 cores, TRUS-guided or cognitive/fusion) confirms diagnosis. Staging uses CT and bone scan or PSMA-PET for high-risk cases. Clinical staging: T1-T2 (localized), T3-T4 (locally advanced), M1 (metastatic).

Active surveillance monitors low-risk prostate cancer with regular PSA, MRI, and repeat biopsies (at 1 year, then every 2-3 years) without immediate treatment. It avoids overtreatment and preserves quality of life. About 50% of low-risk patients remain on surveillance long-term; the rest are converted to treatment when the cancer shows signs of progression.

Radical prostatectomy removes the entire prostate and seminal vesicles. Robotic-assisted (RARP) and open approaches are available. Nerve-sparing techniques preserve erectile function in 50-80%. Urinary incontinence affects 5-20% long-term. 5-year biochemical recurrence-free survival for localized disease exceeds 85%.

External beam radiotherapy (EBRT/IMRT) delivers precise radiation over 4-8 weeks. Stereotactic body radiotherapy (SBRT) treats in 5 sessions. Brachytherapy implants radioactive seeds permanently or temporarily. Radiation is equivalent to surgery for localized cancer but side effects differ. ADT is added for high-risk disease.

Androgen deprivation therapy (ADT) lowers testosterone to starve cancer cells. Medical castration uses LHRH agonists (leuprolide) or antagonists (degarelix). Anti-androgens (bicalutamide, enzalutamide) block testosterone receptors. ADT is used for metastatic, high-risk localized, and biochemically recurrent disease. Side effects: hot flashes, bone loss, metabolic syndrome.

BPH (benign prostatic hyperplasia) and prostate cancer can coexist. BPH causes obstructive symptoms (weak stream, frequency) but is not cancer. Key differences: BPH does not spread; prostate cancer can be asymptomatic early. PSA is elevated in both. An enlarged prostate on DRE does not distinguish them — biopsy is needed for definitive diagnosis.

Localized prostate cancer: 5-year survival nearly 100%. Regional disease: 5-year survival >95%. Distant metastasis: 5-year survival 30%. With modern treatments including novel hormonal agents (enzalutamide, abiraterone), PSMA-targeted radioligand therapy, and immunotherapy, even metastatic disease has improving outcomes. Early detection remains the key.