Diagnosis and Management of Prostate Cancer

Prostate cancer diagnosis and management follows a defined clinical sequence: a PSA blood test and digital rectal examination raise suspicion, a targeted biopsy confirms the diagnosis and grades it with a Gleason score, MRI and PSMA PET CT scans stage the disease, and treatment is then chosen by risk category, from active surveillance through robotic surgery to hormone therapy for advanced disease. This guide is based on a Jivo Masterclass by Dr. Amit Goel, Director and Head of Unit for Renal Transplant, Uro-oncology, Urology and Robotic Surgery at Max Hospital, Gurugram, who has performed over 3,500 urological cancer surgeries and more than 500 kidney transplants across a 23-year career, and introduces a complete series on the diagnosis and management of prostate cancer.

Who Gets Prostate Cancer, and Why Detection Timing Matters

Prostate cancer incidence rises sharply after age 65 and varies enormously by region, with northern Europe recording the highest rates and south-central Asia among the lowest. Men of African descent carry the highest risk of any ethnic group. Age, family history and diet all influence risk, while soy protein, vitamin E and selenium have some protective effect. Most patients are asymptomatic at diagnosis, which is why PSA screening from age 55 onward is how the disease is usually caught before it causes symptoms at all.

How Prostate Cancer Is Diagnosed and Graded

Diagnosis begins with a PSA blood test and a digital rectal examination, which reveals a hard nodule in cases that turn out to be cancer roughly half the time. A confirmed suspicion leads to a biopsy, either a transrectal ultrasound-guided biopsy or an MRI fusion biopsy that overlays a multiparametric MRI onto real-time ultrasound to target suspicious areas precisely. A standard biopsy takes 12 cores across the base, mid-gland and apex of the prostate. The result is scored using the Gleason system, which grades how differentiated the cancer cells are and is central to deciding treatment: Gleason 6 or below is low-grade, while Gleason 8 to 10 marks a highly aggressive cancer.

Staging With MRI and PSMA PET CT

Multiparametric MRI gives a fairly reliable indication of whether cancer is present even before biopsy confirmation, while a PSMA PET scan, using a tracer specific to the prostate-specific membrane antigen, or a bone scan confirms whether the disease has spread beyond the prostate. Staging follows the TNM system: T-stage describes how far the tumour has grown within and beyond the prostate capsule, N-stage whether nearby lymph nodes are involved, and M-stage whether the cancer has reached distant lymph nodes, bone or other organs.

Treatment Options, From Active Surveillance to Robotic Surgery

Treatment choice depends on the stage, the patient's age and life expectancy, and the Gleason score together, which is why Dr. Goel called prostate cancer one of the more complex cancers to plan treatment for. Localised, low-risk disease can be managed with active surveillance or watchful waiting. Intermediate and high-risk localised disease is generally treated with radical prostatectomy, done as an open, laparoscopic or robotic procedure, or with radiotherapy, including brachytherapy and external beam radiotherapy. Metastatic disease is managed with androgen deprivation therapy; once the cancer becomes castration-resistant, treatment escalates to anti-androgens such as abiraterone or enzalutamide, chemotherapy, or, for widespread painful bone metastases, lutetium-177 PSMA radioligand therapy.

Why Robotic Surgery Has Become the Preferred Surgical Approach

Radical prostatectomy is technically demanding because of bleeding risk from the dorsal venous complex, but robotic and laparoscopic techniques control this with pneumoperitoneum pressure and precise, magnified dissection. Comparative studies show robotic surgery matches open surgery on urinary and sexual function while producing fewer biochemical recurrences, a difference attributed to the more precise, magnified vision the robotic platform provides. A newer Retzius-sparing approach, operating entirely from behind the bladder without entering the retropubic space, further improves how quickly patients regain continence and erectile function.

In This Series

Prostate Cancer Risk Factors and Why Men of African Descent Face the Highest Risk | Recognizing Prostate Cancer: From Early Symptoms to Advanced and Metastatic Disease | How Prostate Cancer Is Diagnosed: PSA Testing and Digital Rectal Examination | Prostate Biopsy: TRUS-Guided and MRI Fusion Techniques | The Gleason Score: Grading Prostate Cancer and What It Means for Treatment | Staging Prostate Cancer: TNM Classification and PSMA PET Scans | Choosing a Treatment: Risk-Based Options From Active Surveillance to Surgery | Robotic, Laparoscopic and Open Radical Prostatectomy: Comparing the Evidence | The Retzius-Sparing Technique: Protecting Continence and Erectile Function After Surgery | Managing Metastatic and Castration-Resistant Prostate Cancer

This article is based on a Jivo Masterclass session conducted by Dr. Amit Goel, Director and Head of Unit, Renal Transplant, Uro-oncology, Urology and Robotic Surgery, Max Hospital, Gurugram, India. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording