Ctrl

K

Table of contents

Expand All Topics

Prostate cancer

What's new

The Canadian Urological Association (CUA) has published an updated guideline for the management of metastatic castration-naïve and castration-sensitive prostate cancer. Recommended systemic therapy includes continuous androgen deprivation therapy (ADT) for all patients, with the addition of abiraterone plus prednisone in patients with low-volume disease. Androgen receptor pathway inhibitors (enzalutamide, apalutamide, darolutamide) are suggested regardless of disease volume. In patients eligible for docetaxel chemotherapy, a triplet regimen is recommended. External beam radiotherapy (EBRT) is suggested for low-volume metastatic disease, while radical prostatectomy should be considered only within a clinical trial setting. .

Background

Overview

Definition
Prostate cancer is a neoplastic disease arising from malignant transformation of cells within the prostate gland, of which adenocarcinoma is the most common subtype.
1
Pathophysiology
Risk factors include advanced age, race (African black men, Caucasians), family history, exposure to radiation, UTIs, smoking, obesity, physical inactivity, diet factors (red meat, dairy protein, dietary fat), and elevated endogenous hormones (insulin-like growth factors).
2
Epidemiology
The incidence of prostate cancer in the US is estimated at 123-183 cases per 100,000 person-years.
3
Disease course
The progression of prostate cancer is impingent on activation of the androgen receptor nuclear receptor, and as such, treatment options for invasive disease rely on targeting this pathway. Progression to castrate-resistant prostate cancer is mediated by aberrant reactivation of the androgen receptor, as well as alterations in cell cycle pathways that result in uncontrolled proliferation.
4
Prognosis and risk of recurrence
In men with localized prostate cancer, the 10-year disease-specific mortality ranges from 3% to 18%, depending on the risk category. In men with metastatic prostate cancer, the 5-year survival rate is estimated at 29.3%. In the US, the median survival following a diagnosis of metastatic castration-resistant prostate cancer is reported to be 25.6 months.
1
5
6

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of prostate cancer are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2025,2023,2022,2020), the Canadian Urological Oncology Group (CUOG/CUA 2025,2022), the European Association of Urology (EAU 2025), the International Society of Urological Pathology (ISUP/EANM/SIOG/ESUR/EAU/ESTRO 2025), the American Urological Association (AUA/SUO/ASTRO 2024,2021), the American ...
Show more

Screening and diagnosis

Indications for screening, general considerations: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, do not subject males to PSA testing without counseling them on the potential risks and benefits.
D
Show 3 more
Create free account

More topics in this section

  • Indications for screening (general population, age < 54 years)

  • Indications for screening (general population, age 55-69 years)

  • Indications for screening (general population, age > 70 years)

  • Indications for screening (high-risk population)

  • Indications for screening (repeat screening)

Classification and risk stratification

Risk assessment, undiagnosed: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, use one of the following tools to decide on biopsy indication in asymptomatic males with a PSA level of 3-20 ng/mL and a normal DRE:
risk-calculator, provided it is correctly calibrated to the population prevalence
A
prostate MRI
A
additional serum or urine biomarker test.
B
Create free account

More topics in this section

  • Risk assessment (newly diagnosed, localized disease)

  • Risk assessment (newly diagnosed, advanced disease)

  • Staging

Diagnostic investigations

Prostate MRI: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, do not obtain multiparametric MRI as an initial screening tool in all patients.
D
Show 2 more
Create free account

More topics in this section

  • Adjunctive biomarkers

  • Imaging for staging (clinically localized)

  • Imaging for staging (metastatic)

  • Germline testing (general indications)

  • Germline testing (positive family history)

  • Germline testing (metastatic disease)

Diagnostic procedures

Prostate biopsy, indications: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, perform targeted biopsy with perilesional sampling in patients with positive MRI (PI-RADS ≥ 4).
B
Show 3 more
Create free account

More topics in this section

  • Prostate biopsy (pre-biopsy evaluation)

  • Prostate biopsy (approach)

  • Prostate biopsy (antibiotics prophylaxis)

  • Prostate biopsy (technical considerations)

  • Prostate biopsy (reporting)

  • Prostate biopsy (counseling)

  • Prostate biopsy (repeat biopsy)

  • Molecular testing

Medical management

Management of local/locoregional disease, initial treatment, low-risk localized disease: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, offer watchful waiting in patients with a life expectancy < 10 years.
A
Show 7 more
Create free account

More topics in this section

  • Management of local/locoregional disease (initial treatment, intermediate-risk localized disease)

  • Management of local/locoregional disease (initial treatment, high-risk localized disease)

  • Management of local/locoregional disease (initial treatment, locally advanced disease)

  • Management of local/locoregional disease (initial treatment, non-curative/palliative intent)

  • Management of local/locoregional disease (technical considerations for radical prostatectomy)

  • Management of local/locoregional disease (technical considerations for radiotherapy)

  • Management of local/locoregional disease (adjuvant therapy after radical prostatectomy)

  • Management of local/locoregional disease (salvage therapy)

  • Management of advanced/metastatic disease (evaluation)

  • Management of advanced/metastatic disease (general principles of management)

  • Management of advanced/metastatic disease (systemic therapy)

  • Management of advanced/metastatic disease (radiotherapy)

  • Management of advanced/metastatic disease (radical prostatectomy)

  • Management of advanced/metastatic disease (management of metastases)

  • Management of castration-resistant prostate cancer (non-metastatic, pretreatment evaluation)

  • Management of castration-resistant prostate cancer (non-metastatic, surveillance)

  • Management of castration-resistant prostate cancer (non-metastatic, observation and androgen deprivation therapy)

  • Management of castration-resistant prostate cancer (non-metastatic, nonsteroidal antiandrogens)

  • Management of castration-resistant prostate cancer (non-metastatic, chemotherapy and immunotherapy)

  • Management of castration-resistant prostate cancer (metastatic, pretreatment evaluation)

  • Management of castration-resistant prostate cancer (metastatic, general principles of management)

  • Management of castration-resistant prostate cancer (metastatic, hormonal therapy)

  • Management of castration-resistant prostate cancer (metastatic, chemotherapy)

  • Management of castration-resistant prostate cancer (metastatic, PARP inhibitors)

  • Management of castration-resistant prostate cancer (metastatic, immunotherapy)

  • Management of castration-resistant prostate cancer (metastatic, radioligand therapy)

  • Management of castration-resistant prostate cancer (metastatic, small cell neuroendocrine carcinoma)

  • Management of castration-resistant prostate cancer (metastatic, prevention of skeletal-related events)

  • Management of castration-resistant prostate cancer (metastatic, assessment of response)

  • Management of biochemical recurrence (evaluation)

  • Management of biochemical recurrence (androgen deprivation therapy)

  • Management of biochemical recurrence (salvage radiotherapy)

  • Management of biochemical recurrence (other modalities)

  • Management of biochemical recurrence (monitoring)

  • Management of local recurrence

  • Management of regional or distant recurrence

Specific circumstances

Elderly patients: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, take into account individual life expectancy, health status, and comorbidities in the management of prostate cancer.
A
Show 5 more
Create free account

More topics in this section

  • Patients with premalignant lesions

Patient education

General counseling: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, counsel patients with prostate cancer regarding the following:
the global QoL with active surveillance in eligible patients is equivalent to radical prostatectomy or EBRT - for up to 5 years
that all active local treatments have side effects (Strong)
about the negative impact of surgery on urinary and sexual function, as well as the negative impact of radiotherapy on bowel function (Strong)
about the negative impact of brachytherapy on irritative urinary symptomatology at 1 year but not after 5 years (Weak)
no active treatment modality has shown superiority over any other active management options or deferred active treatment in terms of overall and prostate cancer-specific survival for clinically localized disease. (Strong).
A
Create free account

Preventative measures

5-ARIs: as per ASCO/AUA 2009 guidelines, consider discussing the benefits of 5-ARIs for 7 years for the prevention of prostate cancer and the potential risks (including the possibility of high-grade prostate cancer) to be able to make a better-informed decision in asymptomatic males with a PSA level ≤ 3.0 undergoing regular screening with PSA or anticipating to undergo annual PSA screening for early detection of prostate cancer, as well as in patients taking 5-ARIs for benign conditions such as LUTS.
⁄
Create free account

Follow-up and surveillance

Monitoring for progression, on active surveillance: as per EANM/EAU/ESTRO/…/SIOG 2025 guidelines, repeat biopsies at least once every 3 years for 10 years.
B
Show 5 more
Create free account

More topics in this section

  • Monitoring for progression (after local treatment)

  • Monitoring for progression (on systemic treatment)

  • Monitoring for recurrence

  • Surveillance for osteoporosis

  • Multidisciplinary rehabilitation