Prostate cancer

What the prostate is

The prostate is a walnut-sized gland that sits below the bladder and surrounds the start of the urethra. It produces part of the fluid that makes up semen. Prostate cancer arises from the glandular tissue of the prostate, most commonly in the peripheral zone.

How it is diagnosed

• PSA - a blood test. Elevated or rising PSA is a trigger for further investigation, not a diagnosis in itself.
• Digital rectal examination - can detect larger or nodular cancers.
• Multiparametric MRI - used before biopsy in most modern pathways; reported with a PI-RADS score.
• Transperineal prostate biopsy - the current standard biopsy technique, with systematic and targeted cores.
• Histology - reported as ISUP grade group 1 through 5, where higher is more aggressive.

Staging

Staging determines whether the cancer is still confined to the prostate (localised), has extended into surrounding structures (locally advanced), or has spread (metastatic). Tools include mpMRI for local extent and, for intermediate- and high-risk disease, PSMA-PET/CT for staging of nodes and distant sites.

Treatment options

• Active surveillance - structured monitoring with repeat PSA, MRI and biopsy, reserved for lower-risk disease that does not need immediate treatment.
• Radical prostatectomy - removal of the prostate, usually robotically, for men with localised or locally advanced disease who prefer a surgical approach.
• External beam radiotherapy with or without hormone therapy.
• Brachytherapy in selected cases.
• Focal therapy (HIFU, NanoKnife, cryotherapy) in carefully selected low- to intermediate-risk cases - see focaltherapy.au.
• Systemic therapy for advanced disease.

Role of robotic surgery

For men who choose surgery, robotic prostatectomy offers equivalent cancer control to open surgery in contemporary series, with lower blood loss, shorter hospital stay and often earlier return of urinary continence.^4,5 The choice of surgery vs radiotherapy vs surveillance is separate from the choice of surgical platform; the right first conversation is about which treatment category suits the cancer and the person.