Summary
Definition
History and exam
Key diagnostic factors
- elevated prostate-specific antigen (PSA)
Other diagnostic factors
- abnormal digital rectal exam (DRE)
- nocturia
- urinary frequency
- urinary hesitancy
- dysuria
- hematuria
- weight loss/anorexia
- lethargy
- bone pain
- palpable lymph nodes
Risk factors
- age >50 years
- black ethnicity
- Northern European, Caribbean, Australian, New Zealand, North American, and Southern African populations
- positive family history/genetic factors
- high levels of dietary fat
Diagnostic investigations
1st investigations to order
- serum prostate-specific antigen (PSA)
- prebiopsy multiparametric MRI
- prostate biopsy
Investigations to consider
- prebiopsy biomarker tests and risk calculators
- testosterone
- LFTs
- CBC
- renal function
- bone scan (technetium-99)
- CT scan
- MRI
- prostate-specific membrane antigen (PSMA)-PET/CT
- PSMA-PET/MRI
- tumor molecular and genetic testing
- genetic evaluation and germline testing
Treatment algorithm
very low-risk disease
low-risk disease
favorable intermediate-risk disease
unfavorable intermediate-risk disease
high-risk or very high-risk disease
nonmetastatic disease: postradical prostatectomy
nonmetastatic disease: postradiation therapy
nonmetastatic disease: castration-resistant
metastatic disease: castration-sensitive
metastatic disease: castration-resistant
Contributors
Authors
Timothy J. Wallace, MD, PhD
Radiation Oncologist
Department of Radiation Oncology
Virginia Commonwealth University
Richmond
VA
Disclosures
TJW declares that he has no competing interests.
Mitchell S. Anscher, MD, FACR, FACRO, FASTRO
Professor Emeritus
Department of Radiation Oncology
Virginia Commonwealth University
Richmond
VA
Disclosures
MSA declares that he has no competing interests.
Peer reviewers
Emma Alexander, MBBS
Clinical Oncology Registrar
St Luke's Cancer Centre
Royal Surrey Hospital
Guildford
Surrey
UK
Disclosures
EA has received consultation fees from the following organizations: Blue Cross/Blue Shield Association, Sanofi-Aventis, Ferring Pharmaceuticals, Pfizer Corporation, American Urological Association, National Institutes of Health, Accreditation Council for Graduate Medical Education, Royal Hallamshire Hospital, Hartford County Medical Association. EA owns shares in Pfizer Pharmaceuticals, Johnson and Johnson, and General Electric Corporation.
Peter Albertsen, MD
Medical Director
UConn Medical Group
University of Connecticut Health Center
Farmington
CT
Disclosures
PA declares that he has no competing interests.
Patrick C. Walsh, MD
University Distinguished Service Professor of Urology
Professor Emeritus of Urology
Brady Urological Institute
Johns Hopkins University
Baltimore
MD
Disclosures
PCW declares that he has no competing interests.
James Kearns, MD
Assistant Professor of Urology
NorthShore University HealthSystem
Chicago
IL
Disclosures
JK declares that he has no competing interests. JK is an author of an article cited in the topic.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: prostate cancer [internet publication].Full text
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: prostate cancer early detection [internet publication].Full text
Parker C, Castro E, Fizazi K, et al. Prostate cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2020 Sep;31(9):1119-34.Full text Abstract
Morgan SC, Hoffman K, Loblaw DA, et al. Hypofractionated radiation therapy for localized prostate cancer: an ASTRO, ASCO, and AUA evidence-based guideline. J Clin Oncol. 2018 Oct 11;36(34):JCO1801097.Full text Abstract
Morgan TM, Boorjian SA, Buyyounouski MK, et al. Salvage therapy for prostate cancer: AUA/ASTRO/SUO guideline part I: introduction and treatment decision-making at the time of suspected biochemical recurrence after radical prostatectomy. J Urol. 2024 Apr;211(4):509-17.Full text Abstract
Morgan TM, Boorjian SA, Buyyounouski MK, et al. Salvage therapy for prostate cancer: AUA/ASTRO/SUO guideline part II: treatment delivery for non-metastatic biochemical recurrence after primary radical prostatectomy. J Urol. 2024 Apr;211(4):518-25.Full text Abstract
Morgan TM, Boorjian SA, Buyyounouski MK, et al. Salvage therapy for prostate cancer: AUA/ASTRO/SUO guideline part III: salvage therapy after radiotherapy or focal therapy, pelvic nodal recurrence and oligometastasis, and future directions. J Urol. 2024 Apr;211(4):526-32.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Benign prostatic hyperplasia
- Chronic prostatitis
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- NCCN clinical practice guidelines in oncology: genetic/familial high-risk assessment breast, ovarian, pancreatic, and prostate
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