Diagnosis and Management of Prostate Cancer

Management of prostate cancer follows the stage of the disease. Low-grade early cancer can be monitored or treated with surgery or radiation, and more aggressive localised disease goes to radiotherapy or radical prostatectomy. In the practice of Dr. Shafiq Ahmad, locally advanced and selected oligometastatic disease now also go to robotic surgery, while widespread metastatic disease is controlled with androgen deprivation.

Dr. Ahmad chose prostate cancer for this masterclass for a specific reason. The disease is more common in men of African descent than in any other population, and when it occurs in them it tends to be more aggressive. For doctors treating men across Africa, it is one of the cancers most worth understanding well.

Dr. Ahmad is Senior Director of Urology, Andrology and Renal Transplant at BLK-Max Super Speciality Hospital, New Delhi. He has practised in the Delhi NCR region for about 18 years, and his urology department covers every subspecialty, from kidney transplantation and uro-oncology to paediatric, reconstructive and endoscopic urology and andrology. He has operated with the robot since it began to spread through Indian hospitals from 2012 onwards.

His teaching rests on one clinical judgement that shapes everything else: in prostate cancer, the gland can endanger a man as much as the tumour does. This guide sets out who develops the disease, why survival depends so heavily on where a man lives, how treatment changes with each stage, and how metastatic disease is controlled with hormone therapy. Two companion articles go deeper into the PSA test and prostate cancer diagnosis, from PSA to PSMA PET CT and into robotic radical prostatectomy, step by step.

How common is prostate cancer, and how often is it fatal?

Prostate cancer is common but rarely fatal. On the United States data Dr. Ahmad presented, a 50-year-old man has a 42 per cent lifetime risk of an indolent prostate cancer but a risk of only about 3 per cent of dying from it.

Prostate cancer affects only men, and it is a disease of old age: it is rare in young men, and about six in ten cases are diagnosed in men aged 65 or older.

The United States figures frame the disease precisely. A 50-year-old man with 25 years of life ahead of him carries:

• a 42 per cent lifetime risk of an indolent prostate cancer, one that may never cause symptoms or trouble;
• a risk of about 9.5 per cent, nearly 10 per cent, of a clinically evident, significant cancer;
• a risk of about 3 per cent of dying from prostate cancer.

Autopsy studies point the same way: the proportion of men with cancer cells in the prostate rises steadily with age, and by the eighties a majority of men carry some prostate cancer, most of it never diagnosed in life.

Set against lung, kidney or bladder cancer, prostate cancer is far less threatening. Its survival sits closer to that of testicular and thyroid cancer, where outcomes are very good. Dr. Ahmad's message to patients is that prostate cancer is not a disease to be afraid of. It is a disease to be aware of, along with every way in which it can present.

Why is prostate cancer more common in Black men?

Black men have the highest incidence of prostate cancer, and when they develop it, the disease is more aggressive. The literature attributes the gap to a combination of genetic, environmental and socioeconomic factors.

In the United States, incidence follows race and ethnicity closely. Black men have the highest incidence, followed by white men, then Hispanic and Latino men, with the lowest rates among Asian and Pacific Islander men. A separate Jivo Masterclass guide covers prostate cancer symptoms and risk factors in more depth.

The disparity runs across the whole course of the disease, not only its frequency. When a Black man develops prostate cancer, the disease is more aggressive than in Asian, Hispanic or Pacific Islander men.

Dr. Ahmad also noted that men in African countries may harbour prostate cancer at lower levels of prostate-specific antigen (PSA), the blood marker used in screening, a point covered in the companion article on diagnosis and staging.

Why does prostate cancer survival vary by country?

Prostate cancer survival depends largely on whether a country screens for the disease. Countries that screen find it early, while it is still confined to the gland; countries that do not find it late.

Prostate cancer is detected most often in the United States, ahead of the United Kingdom, China and India. The difference largely reflects screening.

Countries with robust programmes find the disease early, and their survival figures show it: in the United States, five-year relative survival for prostate cancer now exceeds 95 per cent. Survival is markedly lower across India and South-East Asia, a gap Dr. Ahmad called an eye-opener for every clinician, since it concerns the same disease.

The reason, in his account, is that organised prostate cancer screening is largely absent in his part of the world. The cases his team sees are already clinically significant. Men arrive with urinary problems, or the cancer is found incidentally during investigations for something unrelated. These patients present late, and their overall survival is lower than in countries where screening is routine.

Screening itself rests on three steps:

1. a digital rectal examination;
2. a PSA blood test;
3. a transrectal ultrasound-guided biopsy when either of the first two is suspicious.

How each step works, where PSA misleads, and how the disease is then staged with MRI and PSMA PET CT (a scan that tracks prostate-specific membrane antigen, a protein on prostate cancer cells) are covered in the companion article on diagnosis and staging.

Management of prostate cancer by stage

Once the disease is staged, treatment follows the stage, the grade on biopsy and the man's fitness. The grade is expressed as a Gleason score, which describes how abnormal the cancer cells look under the microscope; the higher the score, the more aggressive the cancer. As Dr. Ahmad presented it, the options move as follows.

Stage I: low-grade disease

A well-differentiated, low-grade cancer with a Gleason score of 3 + 3, involving one half of one lobe or less and with a PSA below 10 ng/mL, is stage I; fewer than three positive biopsy cores mark it as very low risk. After proper counselling, these men can choose monitoring, robotic radical prostatectomy, brachytherapy (radiation delivered from sources placed inside the prostate) or radiotherapy. Monitoring of low-risk disease is now usually structured as active surveillance, with scheduled PSA tests, MRI and repeat biopsy, and treatment offered if the disease shows signs of progressing. These are the patients screening is designed to find.

Stage II: more extensive, more aggressive disease

In stage II, as he described it, the tumour involves both lobes of the prostate, more cores are positive, and the histology is somewhat more aggressive, with a Gleason score of 3 + 4 or 4 + 3. These men should go directly to radiotherapy or radical prostatectomy. Brachytherapy and high-intensity focused ultrasound (HIFU) move down the list.

Stage III: locally advanced disease

Stage III covers cancer that has spread beyond the capsule into neighbouring tissue, and also organ-confined cancer with a PSA of 20 ng/mL or more or the highest grade; stage IV denotes spread to the pelvic lymph nodes (IVA) or to distant sites (IVB). Since the arrival of the robot, Dr. Ahmad's team commonly takes men with locally advanced disease to radical prostatectomy rather than to other treatments. The reasoning is set out in the next section.

Oligometastatic disease

The newest group his team operates on, in carefully selected men, is oligometastatic disease: a prostate cancer with only a few bone deposits showing uptake on a PSMA PET scan (definitions commonly allow up to three, sometimes five). In younger men, he advocates multimodality treatment combining surgery, focused radiation and hormone therapy, or radiation together with hormones. Radiotherapy to the prostate alongside hormone therapy is the guideline-supported local treatment for low-volume metastatic disease; surgery in this setting remains under investigation in clinical trials.

Why operate on locally advanced prostate cancer?

Surgery is chosen for locally advanced prostate cancer because the man faces two separate threats, and removing the prostate deals with both. The first is the cancer itself, with a high chance of progressing to metastasis. The second is mechanical. Prostate cancer grows slowly, but benign prostatic hyperplasia (BPH), the non-cancerous enlargement of the gland, grows alongside it as men age, and the two together obstruct the urethra and, as the mass extends, the ureteric orifices.

Dr. Ahmad has seen men with locally advanced, and even metastatic, disease die of the obstructive effects of the prostate mass rather than of the cancer itself. His example is a tumour invading the bladder neck and trigone: in his view that man is at greater risk from ureteric obstruction and renal failure than from the spread of the cancer. Removing the prostate deals with both threats at once.

The same reasoning shapes his view of HIFU. The technique is practised in the West by urologists, and possibly by medical oncologists and interventional radiologists, but in India and other developing countries the facility is not widespread and the urology community has not accepted it. In his reasoning, the cancer must be treated whichever method is used, whether HIFU, radiotherapy, brachytherapy or surgery, but only surgery removes the gland that will otherwise keep growing and obstructing.

Over the last decade, most of his patients diagnosed with prostate cancer have chosen robotic radical prostatectomy, whether they come from rural areas or from metropolitan cities. How the operation is done, and what recovery looks like, is covered in the companion article on robotic radical prostatectomy.

How is metastatic prostate cancer treated?

Metastatic prostate cancer is treated mainly with androgen deprivation, which removes the testosterone that drives the cancer, and with chemotherapy once the disease becomes resistant. When prostate cancer is diagnosed after it has spread widely, the outlook is poor. Metastatic prostate cancer is an aggressive disease, and androgen deprivation is the mainstay of treatment. Current guidelines add a newer hormonal agent (abiraterone, enzalutamide, apalutamide or darolutamide) from the outset, with or without docetaxel chemotherapy, because the combination prolongs survival compared with androgen deprivation alone. In Dr. Ahmad's description, the response to hormone treatment usually wanes after about two years, as the disease becomes resistant. Progression or relapse at that point is treated with chemotherapy or a newer hormonal agent not yet used, and further approved options include PARP inhibitors for tumours with DNA repair mutations and lutetium-177 PSMA therapy.

Orchidectomy or hormone injections?

Androgen deprivation can be achieved medically or surgically, and surgical and medical castration achieve comparable control of the cancer. Two classes of drugs are used for androgen blockade, agonists and antagonists. They are given as injections, and tablet forms have now become available. Surgical castration is bilateral orchidectomy, the removal of both testes.

In Dr. Ahmad's setting, orchidectomy is now rarely performed, because medical androgen deprivation is readily available. He reserves it for stage IV disease. Where injectable agonists or antagonists are unavailable, or where a man cannot attend regular follow-up for repeat injections, surgical castration is the most commonly practised option, and he considers it the right choice.

A general surgeon at a district hospital described exactly this situation in the session's live discussion. His patient presented with weakness of both legs (power 2/5), a hard prostate on rectal examination and a PSA above 100, consistent with advanced prostate cancer with spinal metastasis. With no hormone therapy available, the team performed a bilateral orchidectomy, and the man was walking within five days. Dr. Ahmad confirmed that the surgeon had done the right thing.

Dr. Ahmad described orchidectomy as cost-effective: a one-time procedure that achieves androgen deprivation with certainty, with no harm in it as such. The difference between the two routes is personal. For a man, losing the testes carries a real psychological impact, so where a patient can afford medical therapy, or where it is available, Dr. Ahmad prefers androgen deprivation by injection or tablet. He noted that health insurance is also spreading in developing countries, which helps patients afford these medicines. Orchidectomy remains a well-accepted procedure for stage IV disease.

Orchidectomy versus prostatectomy

Orchidectomy and radical prostatectomy are not alternatives, because the two serve different purposes. Asked to compare them, Dr. Ahmad was clear that there is no comparison. Orchidectomy is a form of androgen deprivation for men with widespread metastasis to the lymph nodes or bones. Radical prostatectomy is for fit men with an expected lifespan of more than 10 years whose disease is organ-confined, locally advanced or oligometastatic.

Managing the side effects of androgen deprivation therapy

The side effects of androgen deprivation resemble the menopause, and Dr. Ahmad manages them through education, symptom control, and bone and metabolic protection. Removing testosterone produces an androgen depletion syndrome. The district surgeon's patient developed excessive heat, central abdominal obesity and breast enlargement after his orchidectomy. Men also describe hot flushes, palpitations, sweating and an intense sense of discomfort.

Dr. Ahmad's management is multifold:

• Education first. The patient is told not to panic: most men settle within a few months, although the hot flushes can be very distressing while they last.
• Symptom control. Gabapentin is started for hot flushes, and sometimes an anti-anxiety medicine.
• Bone protection. Every man on androgen deprivation is started on calcium and vitamin D supplements and advised to get regular sunlight, because his bones become fragile.
• Metabolic protection. A high-protein, low-fat diet and regular exercise, because these men are prone to obesity, coronary artery disease and hypertension.

In metastatic, stage IV disease, he described care as a multimodality approach.