PassFinals
Renal & Urology

Prostate Cancer

Prostate cancer is often silent while confined to the peripheral zone; PSA and DRE trigger assessment, mpMRI precedes biopsy, and PSA, grade group and stage determine whether surveillance, radical treatment or systemic therapy is appropriate.

In a nutshell

Prostate cancer often grows silently in the peripheral zone. PSA and DRE identify risk but do not diagnose cancer; mpMRI comes before biopsy, and PSA, ISUP grade group and stage form the Cambridge Prognostic Group. CPG 1 disease is usually offered active surveillance, CPG 2 has a choice of surveillance or radical treatment, CPG 3 to 5 generally need radical treatment when suitable, and advanced disease requires androgen deprivation with selected systemic additions.

Classic presentation

An older person with an abnormal PSA or hard/irregular prostate, or later with axial bone pain or spinal-cord-compression symptoms.

Key points

  • PSA is non-specific and a normal PSA does not exclude cancer.
  • Offer mpMRI first-line before biopsy for suspected clinically localised disease.
  • Likert 3 or above generally leads to MRI-influenced biopsy; Likert 1 or 2 allows shared decision-making about omitting biopsy.
  • Risk is based on PSA, ISUP grade group/Gleason pattern and stage, summarised as CPG 1 to 5.
  • Active surveillance is the default offer for CPG 1, and an option for selected CPG 2; do not offer it for CPG 4 or 5.
  • For radical radiotherapy in CPG 2 to 5, combine radiotherapy with ADT; duration and added systemic treatment depend on risk and current protocol.
  • Bone pain with neurological symptoms is a spinal emergency, not routine progression.

First-line investigation

PSA and DRE followed by specialist mpMRI before biopsy, with stage/risk-directed imaging after diagnosis.

Management

Identify urgent risk

  • Assess PSA, DRE, urinary symptoms, family/genetic risk and red flags; urgently escalate suspected spinal cord compression, obstruction or pathological fracture.4,1

MRI before biopsy

  • Offer mpMRI first-line; use Likert score and shared decision-making to determine whether an MRI-influenced biopsy is needed.3,5

Risk-stratify and discuss options

  • Use PSA, ISUP grade group and stage to assign CPG; discuss life expectancy, comorbidity, continence, sexual function, bowel function and personal priorities.3,6

Choose surveillance, radical or systemic treatment

  • Offer active surveillance for CPG 1, offer appropriate choice for CPG 2, offer radical options for CPG 3 to 5 when suitable, and use ADT plus current oncology options for advanced disease.3,9,7

Monitor PSA and treatment effects

  • Use structured PSA/MRI/DRE surveillance, monitor ADT bone, metabolic, cardiovascular and sexual effects, and integrate palliative care and emergency safety-netting for metastatic disease.3,6,7

Exam traps

  • A raised PSA is not synonymous with cancer: BPH, infection, retention and instrumentation can raise it.
  • Urinary symptoms are more characteristic of BPH or locally advanced disease than early peripheral-zone cancer.
  • Do not biopsy every person with Likert 1 or 2 MRI; shared decision-making and PSA-risk context matter.
  • Do not offer active surveillance to CPG 4 or 5 localised/locally advanced disease.
  • Hormone therapy alone does not cure localised disease and is not a substitute for radical radiotherapy when curative treatment is indicated.
  • New back pain, weakness, sensory loss or sphincter symptoms requires urgent assessment for spinal cord compression.

Illustrations

Prostate zonal anatomy and site of cancer originDiagram of the prostate showing the peripheral zone, where many cancers arise, contrasted with the transitional zone of BPH.PassFinals · original
Plain pelvic radiograph showing patchy sclerotic (osteoblastic) bone metastases, typical of prostate cancerCT image showing sclerotic (osteoblastic) metastatic deposits in the pelvis and proximal femora, typical of prostate cancer.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NHS: Symptoms of prostate cancer (NHS information on the often asymptomatic early presentation, urinary symptoms, bone symptoms, PSA counselling and referral; page last reviewed 31 July 2025.)Updated 31 Jul 2025
  2. NHS: What is prostate cancer? (NHS information on prostate-cancer risk, natural history and early asymptomatic presentation; page last reviewed 31 July 2025.)Updated 31 Jul 2025
  3. NICE NG131: Prostate cancer: diagnosis and management (Current NICE recommendations on MRI-first diagnosis, biopsy, Cambridge Prognostic Groups, active surveillance, radical treatment, hormone therapy, metastatic disease and treatment toxicity; last reviewed 13 August 2025, with an update in progress.)Updated 13 Aug 2025
  4. NICE NG12: Suspected cancer: recognition and referral (Current NICE suspected-cancer pathway and PSA/DRE referral guidance.)Updated 1 Jul 2026
  5. NHS: Tests and next steps for prostate cancer (NHS information on MRI, biopsy and staging tests; page last reviewed 31 July 2025.)Updated 31 Jul 2025
  6. NHS: Treatment for prostate cancer (NHS information on surveillance, surgery, radiotherapy, hormone therapy, chemotherapy and palliative care; page last reviewed 31 July 2025.)Updated 31 Jul 2025
  7. BNF online (Current UK prescribing information for androgen-deprivation medicines, anti-androgen agents, corticosteroids, chemotherapy, bone-protection medicines and treatment-toxicity management.)
  8. NHS England: Stereotactic ablative radiotherapy for localised prostate cancer (NHS England clinical commissioning policy published 15 June 2026, recommending routine availability for eligible low- and intermediate-risk localised disease not requiring ADT as an alternative to moderately hypofractionated external-beam radiotherapy.)Updated 15 Jun 2026
  9. NICE TA1110: Abiraterone for newly diagnosed high-risk hormone-sensitive metastatic prostate cancer (Current NICE technology appraisal for abiraterone plus androgen deprivation therapy with prednisone or prednisolone in newly diagnosed high-risk hormone-sensitive metastatic prostate cancer.)Updated 1 Nov 2025

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.