Overview
Prostate cancer is the most common cancer in men in the UK, with over 52,000 new cases annually. Most prostate cancers grow slowly and may never cause symptoms or shorten life. A minority are aggressive and spread rapidly. The challenge in management is distinguishing low-risk disease that can be monitored from high-risk disease requiring active treatment.
How common is it?
Prostate cancer accounts for 1 in 4 male cancer diagnoses. Lifetime risk for a UK man is 1 in 8. It is predominantly a disease of older men — 85% of cases are diagnosed in men over 60. Incidence is higher in men of African and Caribbean descent.
Causes and risk factors
Prostate cancer arises from malignant transformation of prostate epithelial cells. Age and androgen stimulation are fundamental requirements.
Common risk factors
- Age (rare under 50; incidence rises steeply from 60)
- Family history: first-degree relative with prostate cancer doubles risk; BRCA2 mutation increases risk 5-fold
- Black African and Caribbean ethnicity (2 to 3 times higher risk)
- Obesity (associated with more aggressive disease)
- Diet high in red and processed meat
- High testosterone levels (endogenous androgen exposure)
Symptoms
- Early: often no symptoms (detected on PSA testing)
- Lower urinary tract symptoms (similar to BPH): poor flow, frequency, nocturia, urgency, hesitancy — these are non-specific
- Haematuria or haematospermia
- Erectile dysfunction
- Metastatic disease: bone pain (especially spine, pelvis, ribs), unexplained weight loss, anaemia, spinal cord compression (emergency)
When to see a doctor
Men with urinary symptoms should see their GP. PSA testing can be requested after discussion of benefits and harms. Men with a family history of prostate cancer or BRCA2 mutation and black men should discuss prostate cancer screening from age 45. Bone pain in older men without obvious cause needs investigation.
Diagnosis
PSA test (prostate specific antigen): elevated levels warrant further investigation. MRI prostate (mpMRI) before biopsy to identify suspicious areas. Transperineal template biopsy for histological diagnosis. Gleason score and Grade Group determine aggressiveness. Staging: bone scan and CT for metastases.
Treatments
Active surveillance
Regular PSA testing, MRI, and repeat biopsy for low-risk and favourable intermediate-risk disease (Grade Group 1 and some 2). Avoids side effects of treatment while catching any progression early. About 50% of men on active surveillance never need treatment.
Radical prostatectomy
Surgical removal of the prostate. Robotic-assisted laparoscopic prostatectomy is now the most common approach. Curative in localised disease. Side effects: urinary incontinence (usually temporary) and erectile dysfunction.
Radiotherapy (external beam and brachytherapy)
External beam radiotherapy or brachytherapy (radioactive seed implants) have equivalent cure rates to surgery for localised disease. Combined with androgen deprivation therapy for high-risk disease.
Androgen deprivation therapy (ADT)
GnRH agonists (leuprorelin, goserelin) suppress testosterone, slowing cancer growth. Used for metastatic disease, combined with radiotherapy for high-risk localised disease. Not curative but produces remission for years. Side effects: fatigue, hot flushes, loss of libido, osteoporosis.
Enzalutamide, abiraterone, and docetaxel
Newer androgen pathway inhibitors and chemotherapy significantly prolong survival in castration-resistant prostate cancer and high-risk metastatic hormone-naive disease.
Self-care and lifestyle
- Maintain a healthy weight and limit red and processed meat
- Regular physical exercise reduces cancer mortality and ADT side effects (fatigue, loss of muscle)
- Bone protective treatment during long-term ADT (bisphosphonate or denosumab)
- Pelvic floor exercises before and after prostatectomy reduce urinary incontinence duration
Prevention
No proven prevention. Population screening with PSA is not currently offered on the NHS (benefits and harms are closely balanced). Men can request a PSA test after informed discussion with their GP.