Prostate cancer

Last reviewed: 28 Aug 2022
Last updated: 08 Mar 2022



History and exam

Key diagnostic factors

  • presence of risk factors
  • elevated prostate-specific antigen (PSA)
More key diagnostic factors

Other diagnostic factors

  • abnormal digital rectal examination (DRE)
  • nocturia
  • urinary frequency
  • urinary hesitancy
  • dysuria
  • haematuria
  • weight loss/anorexia
  • lethargy
  • bone pain
  • palpable lymph nodes
Other diagnostic factors

Risk factors

  • age >50 years
  • black ethnicity
  • Northwest European, Caribbean, Australian, New Zealand, North American, and Southern African populations
  • positive family history/genetic factors
  • high levels of dietary fat
More risk factors

Diagnostic investigations

1st investigations to order

  • serum prostate-specific antigen (PSA)
  • testosterone
  • LFTs
  • FBC
  • renal function
  • prostate biopsy
More 1st investigations to order

Investigations to consider

  • bone scan
  • plain radiographs
  • pelvic CT scan
  • pelvic MRI/endorectal MRI
More investigations to consider

Emerging tests

  • genetic biomarkers
  • 18F-sodium fluoride PET/CT and 11C-choline PET/CT
  • prostate cancer antigen 3 (PCA3) assay
  • TMPRSS2-ERG gene fusions
  • prostate health index (PHI)
  • 4Kscore test

Treatment algorithm


very low-risk disease

low-risk disease

favourable intermediate-risk disease

unfavourable intermediate-risk disease

high-risk or very high-risk disease


non-metastatic disease: post-radical prostatectomy

non-metastatic disease: post-external beam radiotherapy

non-metastatic disease: castration-resistant

metastatic disease: castration-sensitive

metastatic disease: castration-resistant



Timothy J. Wallace, MD, PhD

Radiation Oncologist

Department of Radiation Oncology

Virginia Commonwealth University




TJW declares that he is the principal investigator of an R-21 NIH research grant investigating the tumour-mediated immune responses in African-American men with prostate cancer.

Mitchell S. Anscher, MD, FACR, FACRO, FASTRO

Professor Emeritus

Department of Radiation Oncology

Virginia Commonwealth University




MSA declares that he has no competing interests.

Peer reviewers

Emma Alexander, MBBS

Clinical Oncology Registrar

St Luke's Cancer Centre

Royal Surrey Hospital





EA has received consultation fees from the following organisations: 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




PA declares that he has no competing interests.

  • Differentials

    • Benign prostatic hyperplasia
    • Chronic prostatitis
    More Differentials
  • Guidelines

    • Initial management of non-castrate advanced, recurrent or metastatic prostate cancer
    • Advanced prostate cancer: AUA/ASTRO/SUO guideline
    More Guidelines
  • Patient leaflets

    Prostate cancer

    Prostate cancer: questions to ask your doctor

    More Patient leaflets
  • Calculators

    Prostatism Symptom Score

    More Calculators
  • Videos

    Male urethral catheterisation animated demonstration

    More videos
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer