Prostate cancer

Prostate cancer occurs when cells in the prostate gland divide and grow out of control, forming an abnormal mass of cells called a tumor. Only people AMAB have a prostate, a walnut-sized gland that sits behind the base of the penis, below the bladder, and in front of the rectum.

Enlarged prostate vs. prostate cancer

The prostate gland surrounds the urethra, the tube that carries urine and semen through the penis. The prostate helps make seminal fluid, which is the liquid in semen that helps protect and transport sperm.

As a person AMAB gets older, their prostate typically grows larger, which may cause a condition called benign prostatic hyperplasia (BPH). Also referred to as an enlarged prostate, BPH compresses the urethra, which impedes the flow of urine through the urinary tract. As a result, symptoms such as a weaker urine stream and urinary urgency and frequency may occur in people with BPH. In rare cases, though, these symptoms are not due to an enlarged prostate but to prostate cancer.

BPH causes an overgrowth of benign (noncancerous) tissue in the prostate, which thickens the bladder wall. In contrast, prostate cancer causes an overgrowth of malignant (cancerous) cells. These malignant cells can invade nearby tissue and metastasize (spread) to distant parts of the body.

Back to top

Prostate cancer often grows and progresses slowly and it may take years for symptoms to develop. In many cases, though, cancer cells may spread quickly and aggressively.

Prostate cancer symptoms may not occur early in the course of the disease, as the tumor is likely still small and cancer cells haven’t spread to nearby or distant organs and tissue. Symptoms may start to develop as the disease advances, although some people don’t experience symptoms until distant spread of cancer occurs.

Signs and symptoms of prostate cancer may include:

• Blood in the urine or semen
• Difficulty starting urine flow
• New onset of erectile dysfunction (difficulty getting or keeping an erection)
• Pain or a burning sensation felt while urinating
• Pain or discomfort felt while seated due to an enlarged prostate
• Urinary retention (inability to completely empty the bladder of urine) or straining to empty the bladder
• Loss of bladder control
• Urinary urgency and frequency, especially at night
• Weak urine stream, or a stream that starts and stops

These prostate cancer symptoms can overlap with those experienced with BPH or other conditions such as a urinary tract infection (UTI). Once cancer cells spread beyond the prostate gland, other symptoms may also develop such as:

• A change in bowel habits, like constipation or diarrhea
• Edema (swelling due to fluid buildup) in the legs and/or feet
• Unexplained weight loss

Prostate cancer cells most often spread to the bones (such as those in the hips, thighs, ribs, or spine), which can cause bone pain and weakness. As such, people may be more prone to fractures, such as hip fractures.

Cancer cells that spread to the spine can cause symptoms that affect the spinal cord such as pain, numbness, tingling, and paralysis. Fecal (bowel) incontinence and urinary incontinence may also occur. Incontinence refers to the inability to control bowel or bladder function.

Anemia (low number of red blood cells) may also develop. This can cause symptoms such as dizziness, fatigue, rapid heartbeat, and shortness of breath.

Back to top

Prostate cancer causes aren’t clear-cut, but scientists are working to determine how certain risk factors contribute to the development of the disease.

These include risk factors such as:

Age when prostate cancer occurs

The risk of prostate cancer increases with age. Around 60 percent of prostate cancer cases are diagnosed in people age 65 and older. It rarely occurs before age 40, but the risk goes up quickly after age 50.

Family history of prostate cancer

People with relatives who have a history of prostate cancer may be at higher risk for developing the disease themselves. This is referred to as familial prostate cancer, which accounts for roughly 20 percent of all prostate cancer cases. That said, most people who develop prostate cancer have no known family history of the disease.

Familial prostate cancer may be due to genes family members share, as well as environmental and lifestyle factors they have in common. The risk more than doubles for people who have a biological parent or sibling with the disease, with the risk being higher for people with a biological sibling versus a biological parent with a history of prostate cancer. The risk goes up further for those with multiple relatives who have had the disease, especially if these relatives were diagnosed with early onset prostate cancer (before 55 years old).

Gene mutations linked to prostate cancer

Around 5 to 10 percent of prostate cancer cases are associated with inherited changes in genes known as mutations. These changes in genes that are passed directly from a parent to a child with each generation are called germline mutations.

Examples of gene mutations tied to hereditary (inherited) prostate cancer include:

Breast cancer (BRCA) genes: BRCA1 and BRCA2

BRCA1 and BRCA2 are typically tumor suppressor genes. That means they help fix mistakes that occur within a cell’s DNA or cause cell death if the mistake can’t be repaired. But mutations to BRCA genes can cause ovarian cancer and breast cancer in people assigned female at birth (AFAB) along with a small number of prostate cancers in people AMAB.

Other DNA-repair genes

Mutations in other DNA-repair genes have also been tied to prostate cancer, including those that occur in the:

• Ataxia-telangiectasia mutated (ATM) gene
• Checkpoint kinase 2 (CHEK2) gene
• Partner and localizer of BRCA2 (PALB2) gene
• CDK12 (cyclin-dependent kinase 12) gene

DNA mismatch repair genes

These genes usually fix defects (called mismatches) that occur while DNA is copying itself as it prepares to divide into two new cells (a process called DNA replication). Mutations involving the following genes disrupt this mismatch repair process:

• Epithelial cell adhesion molecule (EPCAM) gene
• MutL homolog 1 (MLH1) gene
• MutS homolog 2 (MSH2) gene
• MutS homolog 6 (MSH6) gene
• PMS1 homolog 2 (PMS2) gene

People AMAB who inherit these gene mutations have Lynch syndrome, a condition that raises the risk for certain cancers. In addition to prostate cancer, these include:

• Endometrial (uterine) cancer
• Brain cancer
• Kidney cancer
• Liver cancer
• Skin cancer (certain types)
• Stomach cancer
• Colorectal cancer

Other gene mutations

Prostate cancer has also been tied to gene mutations involving the ribonuclease L (RNASEL) gene, which was formerly called the hereditary prostate cancer 1 (HPC1) gene. The RNSAL gene helps facilitate cell death when errors that occur inside them can’t be fixed. Mutations in this gene may prolong the lives of these defective cells, which may raise prostate cancer risk.

Homeobox B13 (HOXB13) usually aids in the development of the prostate gland. Rare mutations in HOXB13 have been linked with early onset prostate cancer.

Examples of other mutations associated with prostate cancer include those that occur in the:

• Fanconi anemia complementation group A (FANCA) gene
• HPC2 gene
• HPC, X-linked (HPCX) gene
• Protein 53 (P53, also called tumor protein P53) gene
• Transmembrane-serine protease gene-erythroblast transformation-specific (TMPRSS2-ETS) gene family, including TMPRSS2-ERG and TMPRSS2-ETV1/4

Locations with higher rates of prostate cancer

Prostate cancer rates are highest in Australia, the Caribbean islands, northwestern Europe, and North America. It occurs less often in Africa and Asia, as well as Central and South America. Scientists aren’t sure why this is the case, although some experts think these differences may be due in part to more widespread prostate cancer screening practices that occur in certain parts of the world.

Other factors such as lifestyle differences in these regions may also contribute to these rates. For instance, the risk of prostate cancer is often lower among Asian American people compared to white Americans. But Asian Americans are at higher risk for the disease compared to people AMAB living in Asia with similar ethnic backgrounds.

Race/ethnicity of people with prostate cancer

African American people AMAB and Caribbean people AMAB of African descent experience the highest rates of prostate cancer. They also tend to be younger when the disease develops.

Non-Hispanic white people AMAB experience higher rates of prostate cancer compared to people AMAB of Asian, Hispanic, and Latino descent. The reasons for these differences aren’t known.

Other factors with less clear ties to prostate cancer

Scientists continue to study a range of other potential contributors to prostate cancer risk. These include:

Chemical exposure and prostate cancer

Exposure to Agent Orange has been tied to a higher risk of prostate cancer. The herbicide (plant-killing chemical) was widely used by the U.S. military during the Vietnam War to eliminate tree cover, clear vegetation, and destroy crops. Around 3 million U.S. military personnel were deployed to Vietnam and nearby areas during this conflict, with many exposed to Agent Orange. Millions of people living in Vietnam were also likely exposed.

Some evidence suggests that firefighters may be at higher risk for several types of cancer. For instance, a 2023 analysis of studies published in Safety and Health at Work found that firefighters experience higher rates of prostate cancer along with higher rates of:

• Bladder cancer
• Colon cancer
• Non-Hodgkin’s lymphoma, a form of blood cancer that starts in white blood cells called lymphocytes
• Melanoma skin cancer
• Mesothelioma, which is cancer of the thin tissue (mesothelium) that lines the abdomen, lungs, and chest wall
• Testicular cancer
• Thyroid cancer

A 2023 analysis of studies published in Frontiers in Oncology also found significantly higher rates of prostate cancer and skin cancers such as melanoma among firefighters. Scientists are still trying to determine why these cancers are more likely to occur among firefighters, but exposure to certain chemicals and occupational hazards may play a role.

Firefighters may inhale, ingest, or have skin contact with substances that can cause cancer (called carcinogens). These might include:

• Asbestos
• Combustion products such as benzene and polycyclic aromatic hydrocarbons (PAHs)
• Chemicals in firefighting foams such as perfluorinated and polyfluorinated substances (PFAS)
• Diesel fuel exhaust
• Flame retardants
• Ultraviolet radiation

Firefighters also often work 24-hour shifts. Night-shift work may suppress production of melatonin. This hormone helps regulate the body’s immune system and circadian rhythm—the brain’s 24-hour internal clock, which controls the body’s sleep-wake cycle.

Circadian rhythm disruptions may suppress the immune system and increase oxidative stress, which is an imbalance between particles called free radicals that can harm the body and antioxidants that help protect it. These disruptions along with reduced melatonin levels have been tied to an increased risk for several cancers, including prostate cancer.

Diet

The connection between diet and prostate cancer isn’t clear. Some studies suggest that consuming dairy products (such as milk) may raise the risk for prostate cancer, although researchers are still trying to determine the possible mechanisms behind this.

No clear-cut recommendations can be made about dairy consumption, as researchers aren’t sure which parts of dairy products (such as dietary fats) may contribute to the development or progression of prostate cancer. It’s possible the risk of prostate cancer in this instance is actually due to the cumulative effects of the Western diet, according to the authors of a 2021 review of studies published in The World Journal of Men’s Health. This style of eating, common to the U.S., includes substantial amounts of meat, dairy products, and processed food.

Obesity

Being overweight or obese has been linked to multiple cancers in addition to prostate cancer. These include:

• Breast cancer
• Colon cancer
• Esophageal cancer
• Gallbladder cancer
• Head and neck cancer
• Liver cancer
• Pancreatic cancer
• Thyroid cancer

People with prostate cancer who are obese may be more likely to experience more aggressive tumor growth and worse outcomes. Having a high body mass index (BMI) may also raise the risk of death from prostate cancer, according to a 2022 review and analysis of studies published in Medicine—a finding supported by other studies. (BMI is one measure used to assess weight status and health.)

Prostatitis (Prostate inflammation)

Some studies have found a higher risk of prostate cancer in people with prostatitis, a condition that causes inflammation of the prostate and, in some cases, the area around it. Not all study results support these findings, however.

Inflammation is often observed in prostate tissue samples that contain cancer cells. Therefore, scientists continue to investigate the connection between prostate cancer and prostatitis.

Sexual activity and sexually transmitted infections

The risk of prostate cancer has also been associated with starting sexual activity early in life and/or having multiple sexual partners.

Some studies also suggest that certain sexually transmitted infections (STIs) may increase prostate cancer risk, while other studies have found no such link. Examples of STIs that may play a role in the development of the disease include:

• Chlamydia
• Gonorrhea
• Syphilis

Human papillomavirus (HPV) is also suspected to play a possible role in prostate cancer, but the evidence is inconclusive at this time.

Vasectomy

The question of whether having a vasectomy (a sterilization procedure for people AMAB) raises the risk of prostate cancer has been debated for decades. Many studies have failed to confirm this connection, but the results of a 2021 analysis of studies published in Prostate Cancer and Prostatic Diseases suggest there may be a link.

The analysis, which included 58 studies and close to 17 million participants, found that having a vasectomy was significantly associated with higher rates of prostate cancer. Another large review and analysis of studies published in European Urology Open Science in 2022 found a higher risk of localized prostate cancer (cancer that hasn’t spread) in people AMAB who have had a vasectomy.

Back to top

The various types of prostate cancer are named based on where they begin. These include:

Adenocarcinoma of the prostate

Most prostate cancers start in the gland cells that make prostate fluid, which makes up about 25 to 30 percent of semen. Prostate fluid helps nourish and protect sperm by keeping semen chemically alkaline (as opposed to acidic).

Adenocarcinoma of the prostate (also called prostatic adenocarcinoma or glandular prostate cancer) is further subdivided into two types:

Acinar adenocarcinoma

Most prostate cancers are this type, which is also referred to as a conventional adenocarcinoma. The cancer starts in the gland cells that line the prostate, usually toward the back of the prostate near the rectum.

Prostatic ductal adenocarcinoma (PDA)

Although it occurs much less often than acinar adenocarcinoma, PDA is a more aggressive form of prostate cancer. With PDA, cancer starts in the ducts (tubes) of the prostate gland. It also tends to develop alongside acinar adenocarcinoma.

Small cell carcinoma of the prostate (SCCP)

This form of cancer is classified as a neuroendocrine tumor (NET), a type of tumor once referred to as carcinoids. SCCP cancer cells can release hormones that affect body function.

This rare but aggressive form of prostate cancer tends to grow and spread quickly, although PSA levels tend to be low. (More on PSA below.) In many cases, cancer cells have spread to other parts of the body (such as the bones) by the time SCCP is diagnosed.

Squamous cell carcinoma of the prostate

This is a rare cancer that tends to grow quickly. The cells involved in this form of cancer are unlike like the gland cells of adenocarcinoma and they do not produce PSA.

Transitional cell carcinoma of the prostate (TCCP)

Also called urothelial carcinoma of the prostate, TCCP usually starts in the transitional (also called urothelial) cells that line the urethra. The cancer then spreads to the prostate. Cancer cells may initially form in the prostate in some instances, but this is rarely the case.

Prostate sarcoma

This rare cancer starts in the soft tissue that surround the prostate, such as muscles and nerves.

Back to top

To reach a diagnosis, a healthcare provider (HCP) will likely begin by asking you about your symptoms, personal and family health history, and lifestyle and occupational risk factors. They’ll then conduct a physical exam to examine your body and to feel for possible signs of prostate cancer, such as abnormal lumps.

They may also perform a digital rectal exam (DRE). During a DRE, the HCP will insert a gloved, lubricated finger into the rectum to feel the prostate and nearby areas for lumps and/or other abnormalities.

The results of a DRE may not always be precise, depending on the expertise of the HCP performing the technique. In many cases, DREs fail to detect early prostate cancer.

Based on your symptoms, risk factors, and the results of your physical exam and DRE (if performed), your HCP may recommend one or more of the following tests to screen for prostate cancer and/or confirm or rule it out.

Lab tests for prostate cancer

These might include a:

Prostate-specific antigen (PSA) test

This test measures the total amount of PSA protein in the blood, including PSA that is and is not bound to other proteins. PSA is made and released by the prostate and a small amount of it typically makes its way into the bloodstream.

Higher levels of PSA in the blood may be due to prostate cancer or other factors such as an enlarged, inflamed, infected, or injured prostate.

PSA levels are measured in nanograms per milliliter of blood (ng/mL). Although there is no specific point that determines for sure the presence of prostate cancer, HCPs use a general range of scores to help decide whether a patient could use further evaluation. Generally speaking:

• Most people without prostate cancer have PSA levels under 4 ng/mL of blood. (That said, roughly 15 percent of people with PSA levels below 4 will be positive for prostate cancer if a biopsy is done.)
• People with PSA levels between 4 and 10 have about a 25 percent chance of having prostate cancer.
• If a PSA level is more than 10, the chance of having prostate cancer is greater than 50 percent.

Certain medications can also affect PSA levels. Examples include:

• 5-alpha reductase inhibitors used to treat BPH and hair loss
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
• Statins used to treat high cholesterol
• Thiazide diuretics used to treat high blood pressure
• Testosterone or medicines that raise testosterone levels
• Certain herbal supplements

Some medications can raise PSA levels, while others can reduce levels. It’s important to talk to your HCP about any drugs or supplements you take because drugs that influence PSA levels may interfere with an accurate diagnosis of prostate cancer.

Free PSA test

This version of the PSA blood test measures free PSA, which is PSA that isn’t bound to proteins; that is, they float freely in the bloodstream. The test results provide a ratio of free PSA to total PSA.

In general, the higher the ratio of free PSA to total PSA, the lower the risk of prostate cancer. The lower the ratio, the higher the risk of prostate cancer tends to be. Although the test results of standard and free PSA tests may suggest prostate cancer, additional tests will be needed to confirm the diagnosis.

Biomarker tests for prostate cancer

A biomarker is a biological characteristic or substance that can be measured and analyzed. In this case, the biomarker (also called a tumor marker) can be detected in the blood, urine, or body tissue of a person with prostate cancer. The detectable substance is made by the body or the tumor itself in response to prostate cancer.

Examples of these biomarker tests include the:

• Prostate Health Index (PHI): The PHI blood test helps predict the chances of a person having prostate cancer.
• 4Kscore: This blood test identifies a person’s risk for having a prostate cancer that might need to be treated.
• ExoDx Prostate IntelliScore (EPI): The EPI urine test helps determine a person’s risk for high-grade (or more serious) prostate cancer.
• Prostate cancer antigen 3 (PCA3) gene test: This urine test measures PCA3 levels. High levels of the gene are usually found in prostate cancer cells. It’s often conducted after a DRE, as the rectal exam helps push prostate cancer cells into the urine. The higher the PCA3 level, the greater the likelihood of prostate cancer.

Prostate cancer biopsy

Although the results of certain tests may suggest prostate cancer, a biopsy is the only way to confirm the diagnosis. This involves removing tissue samples from several areas of the prostate for closer examination under a microscope.

Transrectal ultrasound (TRUS) guided biopsy

Also called a prostate sonogram or endorectal ultrasound (US), a TRUS scan uses high-frequency sound waves (called echoes) to create images of the prostate and the tissues around it. Your HCP may recommend this imaging test if your PSA levels are high, if they feel an abnormal area during a DRE, or if you have possible prostate cancer symptoms such as trouble urinating.

In these cases, a TRUS may be done to look at the size and shape of the prostate, as well as for atypical growths and any other abnormalities. The test may also be used during a biopsy, in which case the procedure is referred to as a TRUS-guided biopsy. During this type of biopsy, an HCP will typically take about 12 samples from different parts of the prostate.

MRI/ultrasound fusion prostate biopsy

With this approach, a magnetic resonance imaging (MRI) scan is conducted a few days or weeks before the biopsy to look for abnormalities within the prostate or surrounding tissue. An ultrasound scan of the prostate is then performed.

A special software program combines these MRI and ultrasound images. These fused, 3-dimensional images help provide a precise area to target during the biopsy.

Lymph node biopsy

A lymph node biopsy (or dissection) involves removal of one or more lymph nodes to check for cancer cells. Also called a lymphadenectomy, this procedure may be performed to see if prostate cancer cells have spread to nearby lymph nodes. (Lymph nodes are small structures located throughout the body that contain immune cells and that help filter out foreign substances and fight infection.)

A lymph node biopsy isn’t usually performed as a stand-alone procedure. It’s sometimes conducted at the same time as a procedure to remove the prostate called a radical prostatectomy (see below).

Imaging tests

Imaging tests commonly used to look for prostate cancer (as well as whether and where cancer cells have spread) include:

Magnetic resonance imaging (MRI)

MRI uses radio waves and strong magnets to produce detailed images of the prostate and to measure tumor size. It may also be used to see if cancer cells have spread outside of the prostate into the seminal vesicles (a pair of nearby glands that produce fluid that makes up semen), as well as other nearby or distant areas of the body.

A contrast dye called gadolinium may be injected into a vein to make the images even clearer. In some cases, imaging may be improved by having the patient wear a device that effectively wraps the MRI antenna around the body and is worn like a pair of shorts. In other cases, a probe called an endorectal coil may also be inserted inside the rectum to improve MRI accuracy. Since this may cause discomfort, a sedative may be given prior to insertion of the coil.

The results of the MRI can help your HCP determine whether a biopsy is needed. During a prostate biopsy, an MRI (or an ultrasound) can also be used to help guide the needle used during the procedure.

Multiparametric MRI

This involves the use of more than one type of MRI. A standard MRI is performed first to view the anatomy of the prostate. This is followed by at least one other type of MRI, such as diffusion weighted imaging, dynamic contrast MRI, or MR spectroscopy.

A comparison of these scans helps your HCP detect possible areas of cancer in the prostate more accurately. The additional scans can also provide a better sense of how quickly cancer cells are growing and spreading.

The Prostate Imaging Reporting and Data System (PI-RADS) is used to report these MRI results when prostate cancer is suspected. Abnormal areas in the prostate are rated on a scale ranging from PI-RADS 1 (very unlikely to be a clinically significant cancer) to PI-RADS 5 (very likely to be a clinically significant cancer).

Computed tomography (CT) scan

A CT scan (with or without contrast dye) uses X-rays taken from different angles to create detailed, cross-sectional images of the body. Although it may not be as useful at viewing the prostate gland as an MRI, a CT may be able to show whether prostate cancer has spread into nearby lymph nodes. CT scans may also show whether cancer has spread to other organs or structures in the body such as the pelvis, particularly in cases in which prostate cancer has returned after treatment.

Whole body bone scan

A bone scan may help show whether cancer has spread to the bones, a common area for metastasis. Prior to the test, a small amount of a radioactive substance called a tracer is injected into the person’s vein. The amount of radiation used in the tracer (known as Technetium-99m) is too low to cause harm.

The tracer collects in areas throughout the body where bone has been damaged. A special camera detects the radioactive tracer to produce images of affected areas of the skeleton.

Structural damage to bones might be due to cancer, but it may also be due to other issues that can cause bone injury or damage. These include arthritis, and particularly fractures associated with osteoarthritis. Another imaging test or possibly a bone biopsy may therefore be needed to determine whether prostate cancer has spread to the bones.

Positron emission tomography (PET)

A PET scan also involves the use of a low-level radioactive tracer injected into the vein. Unlike a bone scan, these tracers tend to settle in cancer cells.

Although a type of sugar called fluorodeoxyglucose (FDG) is commonly used for standard PET scans, FDG is not as useful at detecting prostate cancer cells in the body. Newer tracers (like choline C11, fluciclovine F18, and sodium fluoride F18) are better at finding prostate cancer cells.

Other newer tracers bind to a protein called prostate-specific membrane antigen (PSMA). Large amounts of PSMA are found on prostate cancer cells. As such, they may show where cancer cells have spread.

When a PSMA tracer is used, the imaging test is called a PSMA PET scan. Examples of these tracers include:

• Gallium (Ga) 68 PSMA-11 (also called Ga 68 gozetotide, Illuccix, and Locametz)
• 18F-DCFPyl (also called piflufolastat F 18 or Pylarify)
• 18F-rhPSMA-7.3 (also called flotufolastat F 18 or Posluma)

These newer types of PET scans may be helpful in cases where it isn’t clear if or where the cancer has spread. Although the images produced by a PET scan aren’t as detailed as those created by an MRI or CT scan, they may show where metastasis has occurred.

The results of a PSMA PET scan can also help determine whether a radiopharmaceutical (a drug that contains radioactive substances) that targets PSMA can be used to treat prostate cancer. (See below.)

Back to top

The Tumor, Node, Metastasis (TNM) staging system developed by the American Joint Committee on Cancer is most often used to stage prostate cancer. It describes these aspects:

• T: Tumor size and location
• N: Presence of involved lymph nodes
• M: Whether cancer cells have metastasized (spread) to other parts of the body

Staging also factors in the PSA level and the Gleason grade group.

What is the Gleason Grade Group?

The Gleason Grade Group system is the most common method of grading prostate cancer. The updated system replaces the Gleason Scoring system.

After examining tissue obtained from a biopsy, a number or grade is assigned based on how distorted the cells look. The current Gleason Grade Group system assigns a group number between 1 and 5, whereas the older Gleason Scoring system assigns a score between 6 and 10. The higher the grade assigned, the more aggressive the cancer tends to be and the greater the likelihood of metastasis.

The Gleason score may contain two grades in the form of numbers, followed by a total score. The first number is the primary Gleason grade pattern, whereas the second number is the secondary (or minor) pattern.

Gleason Grade Group:

• 1: Gleason score of 3+3=6
• 2: Gleason score of 3+4=7
• 3: Gleason score of 4+3=7
• 4: Gleason score of 8
• 5: Gleason score of 9 and 10

Low-grade tumors carry a Gleason score of 3+3=6 or less. Intermediate-grade cancers carry a Gleason score of 3+4=7, which means that most of the tumor is grade 3, but a smaller section is the more aggressive grade 4. High-grade cancers include those that score a grade of 4+3=7 or higher.

Stage I prostate cancer

During this early stage, cancer cells tend to grow slowly and are confined to the prostate. The Gleason Grade Group is 1 and the PSA level is less than 10. The cancer:

• Is found during a biopsy but can’t be felt during a digital rectal exam (DRE), or it
• Can be felt during a DRE and is found in one-half or less of one side of the prostate

Stage II prostate cancer

Prostate cancer is more advanced at this stage, but cells haven’t spread beyond the prostate. During stage IIA, the Gleason Grade Group stays at 1 but the cancer is either found in:

• One-half or less of one side of the prostate and the PSA level is at least 10 but less than 20, or is it found in
• More than one-half of one side of the prostate or in both sides of the prostate and the PSA level is lower than 20

During stage IIB, cancer is found in one or both sides of the prostate. The Gleason Grade Group is 2 and PSA level is less than 20. During stage IIC, cancer is detected in one or both sides of the prostate, the Gleason Grade Group is 3 or 4, and the PSA level is less than 20.

Stage III prostate cancer

Stage III is also divided into stages IIIA, IIIB, and IIIC. With both stage IIIA and IIIB, the Gleason Grade Group is 1, 2, 3, or 4.

During stage IIIA, cancer is found in one or both sides of the prostate and the PSA level is at least 20. During stage IIIB, the PSA may be any level. The cancer may have spread from the prostate to the seminal vesicles, or it has spread to other nearby tissues, such as the bladder, pelvic wall, or rectum.

During stage IIIC, the PSA may be any level, but the Gleason Grade Group is 5. The cancer may or may not have spread from the prostate to nearby tissues.

Stage IV prostate cancer

Stage IV includes stages IVA and IVB. During stage IV, the PSA may be any level and the Gleason Grade Group may be 1, 2, 3, 4, or 5.

During stage IVA, the cancer may or may not have spread to the seminal vesicles or tissues close to the prostate such as the bladder, pelvic wall, or rectum, but it has spread to nearby lymph nodes.

In stage IVB, the cancer may or may not have spread to the seminal vesicles or tissues close to the prostate and it may or may not have spread to nearby lymph nodes. But the cancer has spread to other parts of the body such as the bones, distant lymph nodes, or other organs.

Back to top

Prostate cancer treatment may include one or more of the following:

Watchful waiting and active surveillance

Watchful waiting may be the best option for people assigned male at birth (AMAB) with slow-growing, low-risk prostate cancer or limited life expectancy due to factors such as age or having another life-threatening illness. Rather than tracking routine test results, people monitor their own symptoms and let their HCP know if prostate cancer symptoms develop or change.

Treating prostate cancer in these situations may inflict more damage than the disease itself. These harms might include treatment side effects such as erectile dysfunction or incontinence. Treatment may therefore be delayed until symptoms develop and the person’s condition worsens.

During active surveillance, an HCP keeps a close eye on the progression of the disease. The approach usually includes the use of tests such as PSA tests, DRE, transrectal ultrasound, or needle biopsy to monitor the growth and spread of cancer cells.

Treatment is initiated if test results indicate the person’s condition is getting worse or the cancer is growing and/or spreading. At this point, the HCP may recommend starting treatment to halt the progression of prostate cancer at a curable stage.

As with watchful waiting, people may opt to delay prostate cancer treatment because of their risks and side effects. Expectant management, observation, and watch and wait are other terms used to describe delaying prostate cancer treatment for these reasons.

Prostate cancer surgery

Surgery removes the prostate and/or some of the lymph nodes that surround the gland. Your HCP will consider factors such as the stage of the disease and your overall health when determining if and which procedure is most appropriate.

Radical prostatectomy

This procedure entails removal of the entire prostate along with the seminal vesicles and possibly the lymph nodes in the pelvis. When possible, the surgeon tries to avoid damaging the nerves that allow erections and orgasm to occur. This is called nerve-sparing surgery.

Common types of radical prostatectomy include a/an:

Open radical prostatectomy: Surgery is performed by making an incision in the lower abdomen (called the retropubic area) or the area between the anus and scrotum (called the perineum). Nerve-sparing surgery may be harder to conduct with the perineum approach.

Radical laparoscopic prostatectomy: The surgeon makes a few small incisions in the abdominal wall, after which a laparoscope is inserted through one of these incisions to help guide the surgery. (A laparoscope is a thin, tube-like instrument equipped with a lens and light for viewing.) Surgical instruments are inserted through the other incisions to perform the surgery itself.

Robot-assisted laparoscopic radical prostatectomy: This procedure is similar to a radical laparoscopic prostatectomy. In this case, the surgeon inserts an instrument equipped with a camera through one of the small incisions. This camera provides a 3-dimensional (3D) view of the prostate and the structures that surround it.

With the help of robotic arms, surgical instruments are placed through the other small incisions. While sitting at a computer monitor close to the operating table, the surgeon uses the robotic arms to perform the surgery itself.

Pelvic lymphadenectomy

This involves surgical removal of lymph nodes in the pelvis that contain cancer.

Transurethral resection of the prostate (TURP)

During a TURP, the surgeon uses a narrow, lighted tube equipped with a cutting device (called a resectoscope or cystoscope) to remove prostate tissue. The procedure can help treat benign prostatic hyperplasia (BPH). In some cases, it may also be used to relieve symptoms caused by a tumor prior to starting other cancer treatments, as well as to remove a tumor in the prostate when a radical prostatectomy isn’t an option.

Radiation therapy for prostate cancer

Radiation therapy uses high-energy X-rays or other types of radiation to destroy cancer cells or keep them from growing. The method of delivering radiation depends on each person’s prostate cancer type and stage.

Having radiation may raise the risk of bladder cancer and gastrointestinal cancer. Side effects such as erectile dysfunction and urinary issues may occur due to treatment.

Examples of radiation therapy used to treat prostate cancer include:

External-beam radiation therapy for prostate cancer

This is the most common type of radiation treatment. With this approach, a radiation device located outside of the body focuses the X-ray beams on the area with cancer.

Examples of external radiation therapy used to treat prostate cancer include:

Hypofractionated radiation therapy: This treatment delivers a higher daily dose of radiation therapy over a shorter period compared to standard radiation therapy. With extreme hypofraction radiation therapy, the entire treatment is given in five or fewer treatments.

In contrast, moderate hypofraction radiation therapy is given over the course of 20 to 28 sessions. This approach is also referred to as stereotactic body radiation therapy or stereotactic ablative radiation therapy.

Some may opt to go with hypofractionated radiation therapy because it affords a more convenient schedule, but the approach may raise the risk for short-term side effects.

Intensity-modulated radiation therapy (IMRT): Prior to treatment, a computer creates a 3D image of the tumor, after which the radiation beam is fitted to the size, shape, and location of the tumor. This targeted approach is less likely to damage nearby healthy tissue and organs.

Proton therapy: Proton therapy, also called proton beam therapy, is a type of external-beam radiation therapy that uses high-energy protons rather than X-rays to treat prostate cancer.

Internal radiation therapy (brachytherapy)

With this approach, radioactive substances are inserted directly into or near the prostate with the help of images produced from a CT scan or transrectal ultrasound. For example, radioactive seeds may be placed through the perineum into the body using needles or other applicators.

Lower doses may be left for longer periods (such as up to a year). In contrast, high-dose brachytherapy may be left for less than 30 minutes, although the treatment may need to be repeated.

Radiopharmaceutical therapy for prostate cancer

Radiopharmaceuticals are a class of drugs that deliver radiation therapy directly to cancer cells. For instance, a radioactive substance known as radium-223 is injected into a vein to treat prostate cancer that has spread to bone. The substance travels through the bloodstream, pooling in areas of bone with cancerous cells, effectively destroying them.

Another form of radiopharmaceutical therapy is 177Lu-PSMA-617, which targets prostate-specific membrane antigen (PSMA), a protein found on prostate cancer cells.

Systemic therapy for prostate cancer

Systemic therapies may be given in cases where cancer has spread beyond the prostate gland. These medications travel through the bloodstream to reach cancer cells throughout the body.

Systemic treatments for prostate cancer may include:

Chemotherapy (chemo)

Chemotherapy uses drugs to kill cancer cells or stop them from growing, dividing, and making more cancer cells. Chemo may be taken by mouth or injected into a vein or muscle.

Hormone therapy

Androgens (hormones that promote male sex characteristics) such as testosterone can trigger cancer growth. Hormone therapy for prostate cancer helps reduce androgen levels, thereby keeping them from reaching cancer cells. As such, the treatment is also known as androgen-deprivation therapy (ADT).

Lowering testosterone levels may involve medical or surgical castration. Medical castration involves taking certain medication to turn off the function of the testicles. Surgical castration involves surgical removal of the testicles. Castration-sensitive prostate cancer refers to prostate cancer that responds to these treatments.

Examples of ADTs used to treat prostate cancer include:

Antiandrogens: Also called androgen receptor (AR) inhibitors, these medications block the action of androgens, including testosterone. Examples of AR inhibitors used to treat prostate cancer include apalutamide, bicalutamide, darolutamide, enzalutamide, flutamide, and nilutamide.

Androgen synthesis (AS) inhibitors: These medications stop cancer cells from producing testosterone by targeting an enzyme called CYP17. They also prevent other organs in the body, such as the adrenal glands, from producing androgens to help stop the growth of tumors.

For instance, abiraterone acetate may be an option for people with advanced prostate cancer who haven’t improved with other ADTs. It may also be an option for people with high-risk prostate cancer that has gotten better with other ADTs. These drugs are usually taken with a corticosteroid such as prednisone or prednisolone to help ease potential side effects.

Ketoconazole is another AS inhibitor that may be considered, although it’s no longer commonly used because of multiple drug interactions.

Orchiectomy: Because the testicles are the main source of androgens such as testosterone, surgical removal of the testicles is considered a form of hormone therapy. Removal of both testicles (bilateral orchiectomy) is no longer commonly used, as the results are permanent and irreversible. In some cases, removal of only one testicle may be considered.

Luteinizing hormone-releasing hormone (LHRH) agonists: These medications are injected or implanted under the skin. They keep the testicles from receiving messages sent by the body to produce testosterone.

By blocking these signals, LHRH agonists are just as effective at lowering testosterone levels as a bilateral orchiectomy. The effects of LHRH agonists may be reversed, although this may take anywhere from 6 to 24 months. For a small number of patients, however, testosterone production never resumes.

Early in the course of treatment, LHRH agonists may cause testosterone levels to spike or flare briefly before they decrease to very low levels. This flare may boost prostate cancer cell activity, causing symptoms and side effects such as bone pain in cases where bone metastasis has occurred.

Gonadotropin-releasing hormone (GnRH) antagonist: Like LHRH agonists, these medications stop testosterone production by the testicles. But they do so more quickly without causing the testosterone flare associated with LHRH agonists. Degarelix and relugolix are GnRH antagonists approved by the FDA to treat advanced prostate cancer.

Combined androgen blockade: This is a combination approach that uses AR inhibitors in conjunction with bilateral orchiectomy or LHRH agonist therapy. Doing so may prevent flares associated with the use of LHRH agonists while maximizing androgen blockade.

Side effects of hormone therapy may include hot flashes, impaired sexual function, reduced libido, and weakened bones. Your HCP may recommend certain medications to take alongside hormone therapy to reduce these and other side effects.

Immunotherapy for prostate cancer

Immunotherapy uses the person’s own immune system to treat prostate cancer. These treatments may include substances naturally made by the body or produced in a laboratory to boost, direct, or restore the body’s natural immune defenses.

Sipuleucel-T is a type of cancer immunotherapy that may be used in some people with metastatic prostate cancer, particularly those with castration-resistant metastatic prostate cancer who have little to no cancer symptoms and have not had chemo.

Targeted therapy for prostate cancer

These treatments target specific features present within cancer cells. These may be specific genes, proteins, or other factors that contribute to cancer growth. By identifying and targeting these individual abnormalities, targeted drug therapies can cause cancer cells to die while causing less damage to healthy cells.

Targeted therapy for prostate cancer blocks the poly adenosine diphosphate-ribose polymerase (PARP) enzyme, which is involved in various cells functions such as repairing DNA damage. As a result, cancer cells may be unable to repair damage to their DNA, causing cell death.

One such PARP inhibitor is olaparib, which is used to treat metastatic prostate cancer in people with certain gene mutations such as BRCA1 or BRCA2. Other examples of PARP inhibitors used to treat prostate cancer include rucaparib and talazoparib, as well as niraparib in combination with the androgen synthesis inhibitor abiraterone.

Focal therapy

Focal therapies use heat, cold, and other methods to treat prostate cancer. They destroy small tumors in the prostate without affecting other parts of the gland. These treatments are therefore considered less invasive and may be less likely to damage unaffected parts of the prostate.

Clinical trials involving focal therapies are ongoing. Most therapies haven’t yet been approved as standard treatments for prostate cancer.

Cryosurgery

Also known as cryotherapy or cryoablation, this form of focal therapy involves freezing cancer cells with a metal probe that’s inserted through a small incision made between the rectum and the scrotum (the skin sac that houses the testicles).

High-intensity focused ultrasound (HIFU)

During HIFU treatment, an ultrasound probe is placed inside the rectum. The probe directs sound waves at parts of the prostate with cancer cells while limiting damage to other parts of the gland. Although HIFU is an FDA-approved treatment for prostate tissue, knowing who may benefit from this focal therapy remains unknown.

Bisphosphonate therapy for prostate cancer

Bisphosphonates (such as clodronate and zoledronate) are medications that can help reduce bone damage when prostate cancer has spread to the bone. Certain prostate cancer treatments, such as antiandrogen therapy or orchiectomy, also raise the risk of bone loss and osteoporosis. Bisphosphonate therapy may help lower the risk of bone fractures in these situations. Patients on long-term hormonal therapy are also often advised to take calcium and vitamin D supplements to help maintain bone strength.

Back to top

Complications may stem from prostate cancer treatments or the disease itself. These can include:

• Erectile dysfunction (ED): Prostate cancer and treatments (such as surgery, radiation, and hormone therapy) can cause ED.
• Urinary incontinence: Loss of bladder control and leakage may result from prostate cancer and various treatments.
• Infertility: Prostate cancer treatments may affect a person’s ability to produce or ejaculate sperm.
• Metastasis: Cancer cells can metastasize to nearby organs such as the bladder or to bones and distant organs. Pain and/or fractures may result from bone metastasis. Although treatments can help control metastatic prostate cancer, it’s unlikely to be cured once this occurs.

Back to top

It’s important to see your HCP if you suspect you might have prostate cancer or you experience signs or symptoms that persist, are severe, or that cause you to worry. These might include symptoms such as:

• Bloody urine or semen
• Trouble urinating
• Increased urinary frequency
• Pain while urinating or during sex
• Urinary incontinence

What questions should you ask your healthcare provider?

Don’t hesitate to ask any questions you might have about prostate cancer. These might include the following:

• What type of prostate cancer do I have?
• What stage am I in and what’s my prognosis?
• Has the cancer spread beyond my prostate gland?
• What treatment options would you recommend for the stage and type of prostate cancer I have? What are the benefits, risks, and side effects associated with these treatments?
• How will I know if my condition is getting better or worse?
• Are certain members of my family at risk for developing prostate cancer, too? If so, would you recommend we get certain genetic tests?
• What type of follow-up care do I need after I complete treatment?

Back to top

Although you may not be able to fully prevent prostate cancer, you can take steps to lower your risk for the disease.

Follow a healthful eating plan. Although there isn’t a specific diet for prostate cancer prevention, focusing on healthy eating habits can support your overall health. This includes eating a wide array of fruits, vegetables, and whole grains while limiting processed foods, added sugars, saturated fats, and red meats.

Focus on whole foods instead of dietary supplements, as research is mixed on the benefits of supplements for prostate cancer risk reduction.

Make exercise part of your routine. Try to get at least 30 minutes of moderate-intensity physical activity most days of the week. This might include taking a brisk walk, swimming, or taking a spin on the dance floor.

If you have haven’t worked out in a while, start slowly and gradually increase the pace, intensity, and duration of your workout. Be sure to check with your HCP if you have any health issues that may affect your ability to exercise safely.

Stick to a healthy weight range. Talk with your HCP if you don’t know your ideal weight or if you need help attaining and maintaining your weight loss goals in a healthy way.

Talk with your HCP about your risk factors for prostate cancer. Certain medications and other treatments may be considered for people at very high risk for prostate cancer. In addition to controlling enlargement of the prostate gland and hair loss, some studies suggest that taking 5-alpha reductase inhibitors (such as finasteride and dutasteride) may help reduce the risk of developing the disease.

Other research that looked at prostate cancer patients who took 5-alpha reductase inhibitors before diagnosis found that use of the medications was linked to more advanced disease at the time of diagnosis. This may be a result of the medications’ effect of lowering measured PSA levels and thus delaying diagnosis.

Get screened for prostate cancer. How often you need to get screened for prostate cancer depends on your risk factors. Ask your HCP how often you need to get screened.

Back to top

In the U.S., prostate cancer that’s detected early and hasn’t spread beyond the prostate carries a 5-year survival rate of close to 100 percent. That is, almost all people at this stage live at least five years after being diagnosed with the disease.

In contrast, the 5-year survival rate drops to 32 percent for people with metastatic prostate cancer (cancer that has spread beyond the prostate). In general, the following features are associated with a poorer prognosis:

• Higher-grade disease
• More advanced stage
• Higher PSA levels
• Younger age
• Shorter PSA doubling time

Back to top

Prostate cancer can take a toll on your physical and mental health as well as your relationships. Don’t try to go it alone. Reach out for help when you can.

Let your friends, loved ones, and family members know how they can provide support, even if it’s simply being your sounding board in times of frustration or helping with daily tasks such as cooking and cleaning. It might also be helpful to reach out to a spiritual advisor or to seek help from a licensed mental health provider for individual, group, family, or relationship counseling.

Joining an in-person or online support group for people with prostate cancer or who have survived the disease can help you connect with others who understand and can empathize with your experiences. You may find that reaching out to others helps lift some of the fears, anxieties, and burdens you may be feeling.

Lastly, if you’re unable to work and experiencing financial hardship because of your condition, talk with your HCP or social worker about disability benefits or community organizations that may help.

Back to top

• Is It Prostate Cancer or Something Else?
• What is the Treatment for Metastatic Prostate Cancer?
• When is Prostate Cancer Considered Advanced?