Prostate Cancer: Symptoms, Risk Factors, Diagnosis, Staging and Treatment. By Dr. M. G. Giriyappagoudar Senior Radiation Oncologist | HCG Cancer Centre, North Karnataka
Prostate cancer is one of the most common cancers affecting men, particularly as they get older. The good news is that when prostate cancer is detected early, many patients can be treated successfully and may be completely cured.
However, prostate cancer can be difficult to detect in its early stages because it often causes no symptoms initially. This is why understanding the risk factors and discussing appropriate PSA testing with a doctor is important.
What is the prostate? The prostate is a small gland found only in men.
It is located below the urinary bladder and surrounds part of the urinary passage, called the urethra.
The prostate produces some of the fluid that forms semen.
As men grow older, the prostate commonly becomes enlarged. This is called benign prostatic enlargement (BPH) and is not cancer.
However, cancer can also develop in the prostate.
Who is at risk of prostate cancer? The risk of prostate cancer increases with age.
Important risk factors include:
- Increasing age Prostate cancer is uncommon in very young men and becomes much more common with increasing age.
Many prostate cancers are diagnosed after the age of 50–60 years.
- Family history Men whose father, brother or son has had prostate cancer have a higher risk.
The risk may be particularly important if:
A close relative developed prostate cancer at a young age
More than one close relative has prostate cancer
There is a family history of breast, ovarian, pancreatic or prostate cancer
- Genetic factors Certain inherited gene changes can increase prostate cancer risk.
These include genes such as:
BRCA1
BRCA2
Other hereditary cancer-related genes
Men with a strong family history may benefit from genetic counselling and, when appropriate, genetic testing.
- Lifestyle factors Age and genetics are important factors. Maintaining a healthy weight, exercising regularly, eating a balanced diet and avoiding smoking are sensible measures for overall health.
What are the symptoms of prostate cancer? Early prostate cancer may have NO symptoms. This is one of the most important things men should understand.
A man can have prostate cancer and still have:
Normal urination
No pain
No blood in urine
No obvious urinary difficulty
Therefore, absence of symptoms does not completely rule out prostate cancer.
When symptoms occur, they may include:
Urinary symptoms Difficulty starting urination
Weak urine stream
Frequent urination
Increased urination at night
Urgency to pass urine
Feeling that the bladder has not emptied completely
Difficulty stopping or controlling urine
Other symptoms Some men may experience:
Blood in urine
Blood in semen
Erectile or sexual problems
Pain in the pelvis or lower back
However, these symptoms are not specific to prostate cancer. Benign prostate enlargement and prostate infection can cause similar symptoms.
Advanced prostate cancer If prostate cancer spreads outside the prostate, particularly to the bones, it can cause:
Persistent back pain
Hip pain
Pelvic pain
Bone pain
Weakness or numbness in the legs in severe cases
Severe back pain with weakness, numbness or difficulty controlling urine or stools requires urgent medical assessment.
At what age should men think about prostate cancer screening? There is no single PSA testing schedule that is appropriate for every man.
For men at average risk, screening decisions are generally discussed around the 50–55 year age group, depending on individual circumstances.
Men with increased risk may need to discuss PSA testing earlier.
For example:
Strong family history of prostate cancer
Father or brother diagnosed at a young age
Known hereditary cancer gene mutation
Multiple family members with prostate or related cancers
Some international recommendations consider discussion of PSA testing from around 40–45 years in selected high-risk men, while average-risk screening is generally considered later.
Important PSA testing should ideally be a shared decision between the patient and doctor because PSA can be elevated for reasons other than cancer.
What is PSA? PSA means Prostate-Specific Antigen.
It is a substance produced by prostate cells and can be measured with a simple blood test.
A raised PSA may occur because of:
Prostate cancer
Benign prostate enlargement
Prostate inflammation or infection
Other prostate-related conditions
Therefore:
A high PSA does NOT automatically mean cancer.
Similarly:
A normal PSA does not completely rule out prostate cancer.
The PSA value must be interpreted together with age, prostate examination, previous PSA results, prostate size, MRI findings and other risk factors.
How is prostate cancer detected? The evaluation generally follows several steps.
Step 1: Medical history and examination The doctor will ask about:
Urinary symptoms
Previous prostate problems
Family history of prostate cancer
Other cancers in the family
Previous PSA reports
General health and life expectancy
A Digital Rectal Examination (DRE) may also be performed.
During DRE, the doctor feels the prostate through the rectum to assess whether it is enlarged, hard or irregular.
Step 2: PSA blood test A blood test measures PSA.
Depending on the situation, the doctor may also consider:
Repeat PSA
PSA trend over time
PSA density
Free PSA and related measurements
The important point is that one PSA number should not be interpreted in isolation.
Step 3: Multiparametric MRI of the prostate When prostate cancer is suspected, a multiparametric MRI (mpMRI) can provide detailed information about the prostate.
MRI can help:
Identify suspicious areas
Estimate the likelihood of clinically significant cancer
Determine the location of a suspicious lesion
Assess whether the cancer may have extended outside the prostate
Help guide biopsy
MRI findings are commonly reported using the PI-RADS scoring system, generally from 1 to 5.
A higher PI-RADS score indicates a greater likelihood of clinically significant prostate cancer.
Step 4: Prostate biopsy Biopsy is what confirms prostate cancer. During a biopsy, small tissue samples are taken from the prostate and examined by a pathologist under a microscope.
Modern practice increasingly uses MRI information to target suspicious areas, often combined with systematic sampling.
Biopsy may be performed through:
Transperineal approach
Transrectal approach
The biopsy report provides extremely important information.
What is Gleason Score and Grade Group? After the biopsy, the pathologist examines the cancer cells.
The cancer is assigned a Gleason score, which helps describe how aggressive the cancer appears.
The results are also expressed as a Grade Group, generally from:
Grade Group 1 – least aggressive
Grade Group 2
Grade Group 3
Grade Group 4
Grade Group 5 – most aggressive
In simple terms:
The higher the Grade Group, the greater the concern that the cancer may behave aggressively.
The biopsy also helps determine whether further treatment or additional staging investigations are necessary.
How is prostate cancer staged? Finding prostate cancer is only the beginning.
The next question is:
Has the cancer remained inside the prostate or has it spread elsewhere?
This is called staging.
Prostate cancer is broadly classified into:
Stage I Cancer is small and confined to the prostate and generally has favourable features.
Stage II Cancer is still confined to the prostate but may have higher-risk features or a larger extent.
Stage III Cancer has grown outside the prostate or involves nearby structures/seminal vesicles, depending on the exact stage.
Stage IV Cancer has spread to lymph nodes or distant organs, commonly including the bones.
The exact stage is more detailed than these four broad categories and depends on TNM stage, PSA and Grade Group.
What tests may be required for staging? The tests depend on the PSA level, Grade Group, clinical examination and estimated risk of spread.
They may include:
-
PSA blood test PSA is an important component of risk assessment and staging.
-
MRI prostate It provides information about the local extent of the tumour.
-
CT scan A CT scan may be used in selected patients to evaluate lymph nodes and other areas.
-
Bone scan A bone scan may be considered when there is significant risk of cancer spreading to the bones.
-
PSMA PET-CT PSMA PET-CT is an important modern imaging test in prostate cancer.
It can identify prostate cancer cells in the prostate, lymph nodes and distant sites in appropriate patients.
It is particularly useful in selected patients with higher-risk disease or suspected recurrent/metastatic disease.
Not every patient with newly diagnosed prostate cancer needs every staging test. The investigations should be selected according to the patient's risk category.
How is prostate cancer treated? There is no single treatment that is suitable for every prostate cancer patient.
Treatment depends on:
Age
General health
Life expectancy
PSA
Grade Group/Gleason score
Stage
MRI findings
PSMA PET-CT findings when indicated
Patient preference
Urinary and sexual function
Whether cancer has spread
Treatment options include:
- Active surveillance Not every prostate cancer requires immediate treatment.
Some low-risk and selected favourable intermediate-risk cancers can be safely monitored.
This may involve:
Regular PSA tests
Clinical assessment
Repeat MRI
Repeat biopsy in selected situations
Treatment can be started if there is evidence that the cancer is becoming more aggressive.
This approach avoids or delays treatment-related side effects in appropriately selected men.
- Surgery A radical prostatectomy removes the prostate gland and surrounding tissues as appropriate.
Surgery may be an option for men with localized prostate cancer who are fit for an operation.
Possible side effects include:
Urinary leakage/incontinence
Erectile dysfunction
Other surgical complications
The risk varies between individuals.
- Radiation therapy Radiation therapy is an important curative treatment for localized and locally advanced prostate cancer. Radiation can be delivered externally using modern techniques such as:
IMRT – Intensity-Modulated Radiation Therapy
IGRT – Image-Guided Radiation Therapy
VMAT
Stereotactic techniques in selected situations
Modern radiation techniques allow radiation to be shaped accurately around the prostate while reducing unnecessary radiation to surrounding normal organs such as the bladder and rectum.
Radiation therapy may be used:
As the primary curative treatment
Along with hormone therapy in higher-risk disease
After surgery when indicated
For recurrent disease
To relieve symptoms from advanced disease, such as painful bone metastases
For many patients, radiation therapy can provide an effective alternative to surgery.
- Hormone therapy Prostate cancer often depends on male hormones, particularly testosterone, for growth.
Androgen deprivation therapy (ADT) reduces the effect of these hormones.
Hormone treatment may be used:
Along with radiation in intermediate/high-risk disease
In locally advanced cancer
In metastatic prostate cancer
In recurrent disease
Depending on the disease, additional hormone-directed medicines may also be used.
- Treatment for metastatic prostate cancer If prostate cancer has spread to distant parts of the body, treatment is usually systemic rather than surgery or radiation alone.
Treatment may include combinations of:
Hormone therapy
Newer androgen-receptor pathway medicines
Chemotherapy in selected patients
Radiation therapy for painful or threatening metastases
Bone-directed treatment in appropriate patients
Other targeted treatments for selected genetic or molecular abnormalities
The treatment plan should ideally be individualized by a multidisciplinary team.
Can prostate cancer be cured? Yes — many prostate cancers can be cured when diagnosed early. The prognosis depends mainly on:
Stage
Grade Group
PSA
Tumour extent
Presence or absence of lymph node involvement
Presence or absence of distant metastases
Localized prostate cancer can often be treated with curative intent using surgery, radiation therapy or, in selected low-risk patients, active surveillance.
Even when prostate cancer is advanced, modern treatments can often control the disease for prolonged periods and improve quality of life.
Is every enlarged prostate cancer? No. This is a very common misconception.
An enlarged prostate is often due to benign prostatic hyperplasia (BPH).
BPH is not prostate cancer.
Similarly, urinary symptoms do not automatically mean cancer.
However, persistent urinary symptoms—especially in an older man—should be evaluated rather than ignored.
When should a man consult a doctor? Men should consider medical evaluation if they develop:
New urinary difficulties
Weak urine stream
Frequent nighttime urination
Blood in urine or semen
Persistent pelvic or back pain
Unexplained bone pain
Erectile problems
An abnormal PSA result
A strong family history of prostate cancer
And importantly:
Do not wait for symptoms if you are at increased risk. Early prostate cancer may not produce any warning signs.
A simple prostate cancer check-up pathway Think of it as:
Risk assessment → PSA → Clinical examination → MRI when indicated → Biopsy → Grade Group/Gleason score → Staging → Personalized treatment
This approach helps doctors avoid both missing significant cancer and over-treating cancers that may never cause problems.
Five things every man should know about prostate cancer
- Prostate cancer can have no symptoms in the beginning.
- Increasing age is an important risk factor.
- Family history matters.
- A high PSA does not automatically mean cancer.
- Early detection can provide an opportunity for curative treatment. Don't be afraid of the word "Cancer" A diagnosis of prostate cancer can be frightening.
But prostate cancer is not one single disease. Some prostate cancers grow very slowly, while others are more aggressive.
Modern diagnosis using PSA, MRI, biopsy, Grade Group and appropriate staging scans such as PSMA PET-CT allows doctors to understand the biology and extent of the disease much better than before.
The right treatment should therefore be chosen based on the individual patient—not simply the word "cancer."
Message to men in North Karnataka If you are above 50, have urinary symptoms, have a family history of prostate cancer, or have an abnormal PSA report, do not ignore it.
A simple consultation and appropriate evaluation can help determine whether you need observation, further testing or treatment.
Early evaluation can make a difference.
Dr. M. G. Giriyappagoudar Senior Radiation Oncologist HCG Cancer Centre, North Karnataka
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