Prostate Cancer: Diagnosis and Latest Treatment Guidelines

Prostate cancer is diagnosed by combining a prostate-specific antigen (PSA) blood test, a digital rectal examination and an ultrasound-guided biopsy, then staged with MRI and a PSMA PET scan and sorted into low, intermediate or high risk. Current prostate cancer treatment guidelines match therapy to that risk group, the patient's fitness and his life expectancy, from watchful waiting to robotic surgery, radiotherapy and hormone therapy.

Dr. Anurag Puri, Additional Director Urology, Fortis Hospital, Shalimar Bagh, New Delhi, India, is a urologist and kidney transplant surgeon. He addressed his Jivo Masterclass to international doctors with a practical question at its centre: when a man with a suspected prostate cancer walks into the clinic, what should the doctor do? The discussion that followed turned to which patients gain most from treatment that is not available locally. This guide follows that logic. It covers the scale of the disease, who is at risk, how it presents, the diagnostic and treatment pathway in outline, screening for men of African descent, the role of diet, how to tell benign enlargement from cancer, and when referral abroad makes sense. Two companion articles go deeper: one on diagnosis and risk stratification and one on treatment by stage, age and fitness, both linked below.

Why prostate cancer demands attention in Africa

Prostate cancer is the second most commonly diagnosed cancer in men worldwide, with about 1.4 million new diagnoses each year and roughly 375,000 deaths. In Europe it is the most frequently diagnosed cancer in men and the third most common cause of cancer death in men.

The burden falls disproportionately on men of African descent. Dr. Puri cited incidence and mortality rates in Africa as high as 29 and 16 per 100,000 respectively, and noted that both the incidence of the disease and its mortality are higher in the African population than in Asian populations. The disease is also more common among African American men. For a referring doctor, the implication is direct: a raised PSA or a hard prostate in an African man should never be put down to age alone.

Who is at risk of prostate cancer

Dr. Puri identified four groups of risk factors.

• Age. Incidence climbs steadily with age. In autopsy studies, more than half of men over 80 carry some focus of prostate cancer. Most of these men die of other causes, which is why the presence of cancer at an advanced age does not automatically call for treatment.
• Family history. A strong family history is a recognised risk factor, and first-degree male relatives of a patient need closer screening.
• African ancestry. The disease is considerably more common in men of African descent, in Africa and in the African diaspora.
• Diet. Some dietary and nutritional factors are thought to contribute, although the evidence is weaker than for the first three.

What prostate cancer is

About 95% of prostate cancers are adenocarcinomas, arising from the glandular acini of the prostatic ducts. The remainder include small cell, squamous cell and urothelial cancers, which behave differently and are rare.

Location matters for diagnosis. Dr. Puri noted that about 70% of prostate cancers arise in the peripheral zone of the gland and about 20% in the transition zone. The peripheral zone lies against the rectal wall, which is why a finger examination through the rectum can detect many of these tumours, and why a normal examination does not rule out a cancer sitting deeper in the gland.

How prostate cancer presents, stage by stage

The most important clinical point is that early prostate cancer is silent. Most men with organ-confined disease have no symptoms at all and are found only because a PSA blood test is raised. Symptoms, when they appear, generally signal that the cancer has grown beyond its earliest stage.

• Locally advanced disease can cause obstructive voiding symptoms: hesitancy, an intermittent stream, a weaker stream, straining to pass urine, blood in the urine or blood in the semen.
• Spread to the lymph nodes can cause swelling of the legs (lower-limb oedema) from compression of lymphatic drainage, along with perineal discomfort and pain.
• Spread to the bones, the most common site of distant spread, causes bone pain, fractures and, when the spine is involved, paralysis of the lower limbs.

Because early disease produces no warning, a doctor who waits for symptoms will mostly see men whose cancer is already advanced. That is the case for structured testing in high-risk men, set out below.

The diagnostic pathway in outline

Dr. Puri's sequence for a suspected case is straightforward. Take a full history, including family history and urinary symptoms, and perform a digital rectal examination. Then order three tests: a serum PSA, a complete urine analysis and an ultrasound scan. A PSA above 4 ng/mL is suspicious, although a urinary infection can also raise it. A raised PSA without infection, or a nodule felt on rectal examination, is an indication for a transrectal ultrasound-guided biopsy, typically of 12 cores. Once cancer is confirmed, a multiparametric MRI of the prostate, which combines several imaging sequences, stages the local disease. A PSMA PET scan, which uses a tracer that binds to a protein present in large amounts on prostate cancer cells, looks for distant spread.

The detail of each step, including how to read a borderline PSA with the free PSA percentage, how the Gleason score is built and how the European Association of Urology (EAU) risk groups are defined, is covered in prostate cancer risk stratification: PSA, Gleason and EAU groups.

The latest prostate cancer treatment guidelines in outline

Treatment follows the risk group and the extent of disease, not the diagnosis alone. Dr. Puri summarised the options in five categories:

1. Early disease confined to the prostate: treatment is curative, by robotic radical prostatectomy or radiotherapy.
2. Locally advanced disease that has spread somewhat outside the gland but not through the body: radiotherapy combined with androgen deprivation therapy (ADT), which lowers the testosterone on which most prostate cancers depend, or radical prostatectomy as part of multimodal treatment.
3. Advanced local disease not amenable to surgical removal: a less aggressive approach, with radiotherapy and hormone deprivation.
4. Metastatic disease: the intent is suppressive rather than curative, through removal of both testes or regular hormone-depleting injections.
5. Hormone-resistant disease: chemotherapy or newer oral agents are added.

For metastatic disease, current EAU guidelines add an androgen receptor pathway inhibitor, such as abiraterone or enzalutamide, or docetaxel chemotherapy to hormone therapy in men fit enough to receive them.

For older or frail men without symptoms, watchful waiting (no treatment until symptoms appear) or hormone therapy alone may be the right choice, and men with low risk disease can be offered active surveillance (close monitoring, with treatment if the cancer progresses). These options, how age and fitness shift the decision, and how recovery after robotic surgery compares with older open operations are covered in prostate cancer treatment by stage, age and fitness.

Screening men of African descent from age 45

Asked whether prostate cancer can be prevented, Dr. Puri was direct: it is very hard to prevent. What can be prevented is death from it. His recommendation for the African population is more aggressive screening, especially in men with relatives who have had the disease: an annual PSA test and an annual digital rectal examination by a doctor from the age of 45. Screening of this kind may not reduce how many men develop prostate cancer, but it finds the disease early, when it is curable, and so reduces mortality.

He rejected prophylactic removal of the prostate. Unlike some hereditary breast cancers, where preventive mastectomy is an established option, prophylactic prostatectomy has no proven role. The answer for first-degree male relatives is closer screening and treatment of any cancer found.

Diet, supplements and prostate cancer

A clinical dietician on the session asked whether nutrition is part of prostate cancer care. Dr. Puri acknowledged that diet receives little emphasis in routine conversations with patients and agreed that dietary advice can be promoted. He was careful about the evidence. Dietary factors have been proposed but not proven to play a major role. Reduced fat intake has been associated with a lower chance of prostate cancer. Lycopene, found in tomatoes, and vitamin E and selenium have each been promoted as protective, but no randomised controlled studies have proved a protective effect.

The randomised evidence that does exist points the other way for supplements. A large trial of selenium and vitamin E supplements (SELECT) found that neither prevented prostate cancer, and vitamin E alone was associated with a small increase in risk. A balanced diet is sensible; high-dose supplements are not a prevention strategy.

On glutathione, which has been studied for its antioxidant properties in prostate and other cancers, Dr. Puri was clear that it is not a standard of treatment.

Benign enlargement is not cancer: managing BPH

Many men referred with urinary symptoms have benign prostatic hyperplasia (BPH), the non-cancerous enlargement of the prostate that comes with age and can also have a genetic component. Dr. Puri made one point emphatically: prostate size does not decide treatment, symptoms do. A 100-gram prostate growing outwards that causes no symptoms needs no treatment. A 22-gram prostate growing inwards and blocking the flow of urine does.

Drug treatment of BPH relieves symptoms; it does not eradicate the enlargement.

• Alpha-blockers such as tamsulosin relax the prostate to improve urinary flow. Alfuzosin is commonly used, and newer agents such as silodosin are more uroselective. Dr. Puri prescribes either: alfuzosin more often for younger, sexually active men, and silodosin for older men, because of its sexual side effects.
• 5-alpha-reductase inhibitors such as finasteride and dutasteride shrink the prostate over time.

PSA screening is not mandatory for every man with BPH, but Dr. Puri checks a baseline PSA before starting a 5-alpha-reductase inhibitor such as dutasteride. These drugs lower the PSA, roughly halving it after about six months, so a baseline value is needed to interpret later readings and avoid missing a cancer.

Asked why sexual performance declines with age, he attributed it mainly to atherosclerosis, which reduces blood supply to the penis. A fuller treatment of BPH surgery and its complications is available in Dr. Nitin Shrivastava's guide to BPH treatment.

When to refer a prostate cancer patient abroad, and when not to

Every stage of prostate cancer requires some form of treatment, Dr. Puri stressed, and the earlier a man presents, ideally without symptoms and detected incidentally, the better his cure rate, prognosis and life expectancy. A man who already has symptoms or complications still needs treatment.

On referral, he turned the question around: rather than asking who should be referred, ask who should not.

• Treat locally when the referring doctor can offer the full treatment the patient's stage requires.
• Refer when the modalities needed for assessment or treatment are lacking, such as PET scans, radiotherapy or robotic surgery, and the patient cannot otherwise receive complete treatment. Indicative costs for treatment abroad are listed under robotic radical prostatectomy cost and radiotherapy cost.
• Avoid sending a patient who is very frail and unfit to travel or to undergo a major procedure.

Sharing the reports with a specialist before any travel decision clarifies whether the patient will meaningfully benefit from treatment abroad. The questions doctors raised on referral, staging and individual cases are collected on the Live Discussion page for this masterclass, and Dr. Puri's profile is at Dr. Anurag Puri.

Related prostate cancer series

Other Jivo Healthcare masterclasses approach the disease from different angles: prostate cancer early detection with Dr. Nitin Shrivastava, robotic radical prostatectomy with Dr. Yajvender Pratap Singh Rana, prostate cancer symptoms and risk factors with Dr. Amit Goel, and the diagnosis and management of prostate cancer with Dr. Shafiq Ahmed. The broader specialty is covered on the urology hub.