Prostate cancer: Full guide

What is prostate cancer?

The prostate is a small gland below the bladder. It sits in front of the rectum. It helps make the fluid in semen.

Prostate cancer starts when cells in the prostate grow out of control. Other than skin cancer, it is the most common cancer in men in the US. It is more common with older age, in Black men, and in families with prostate, breast, ovarian, or pancreatic cancer.

Many prostate cancers grow very slowly and may never cause harm. Others grow faster and need treatment. Your care team will look at several test results to learn which kind you have.

Prostate cancer often needs the male hormone testosterone to grow. That is why many treatments lower testosterone or block how it works.

Types and disease stages

Adenocarcinoma

This is the type almost everyone has. It starts in the gland cells of the prostate.

Localized prostate cancer

The cancer is only in the prostate, or just around it. It may be watched closely or treated with surgery or radiation.

Biochemical recurrence

The PSA blood test rises after surgery or radiation, but scans do not show cancer elsewhere yet. This is a sign cancer cells may still be present.

Hormone-sensitive (castration-sensitive) metastatic cancer

The cancer has spread beyond the prostate, but it still responds to lowering testosterone. Treatment usually combines hormone therapy with other medicines.

Castration-resistant prostate cancer

The cancer keeps growing even though testosterone is very low. It can be with or without spread. There are still many treatment options at this stage.

Neuroendocrine or small cell prostate cancer

A rare, fast-growing type. It often does not make much PSA. It is treated more like small cell lung cancer, with chemotherapy.

Tests you may have

PSA blood test

PSA (prostate-specific antigen) is a protein made by the prostate. A high or rising level can be a sign of cancer, but also of other prostate problems. It is used to find and follow the cancer.

Digital rectal exam (DRE)

The doctor gently feels the prostate with a gloved finger through the rectum. It checks for lumps or hard areas.

Prostate MRI

An MRI uses magnets to take detailed pictures of the prostate. It can show areas that look suspicious and guide the biopsy. Sometimes it helps people avoid a biopsy they do not need.

Prostate biopsy

A doctor takes small samples of prostate tissue with a thin needle, usually about 12 samples. A pathologist looks at them under a microscope to confirm cancer and give it a grade.

PSMA PET scan

A scan that uses a small amount of a tracer that sticks to prostate cancer cells. It can find small spots of cancer that other scans miss. It is often used for higher-risk cancer and when PSA rises after treatment.

Bone scan and CT scan

These look for cancer that may have spread to the bones, lymph nodes, or other organs. They are used when the cancer may be higher risk.

Genomic test of the tumor (such as Decipher)

A lab test on the biopsy or surgery tissue that looks at tumor genes. It can help estimate how likely the cancer is to grow or spread.

Testosterone level

A blood test to check your testosterone. It shows whether hormone therapy is working and helps define the stage of disease.

Bone density scan (DEXA)

A quick, painless X-ray that checks bone strength. It is often done if you will be on hormone therapy, which can thin the bones.

What the stage and grade mean

Your care team uses three main things to decide how serious the cancer is: the stage, the grade, and the PSA level. Together these put localized cancer into a risk group.

The grade is often given as a Gleason score (usually 6 to 10) or a Grade Group (1 to 5). A higher number means the cancer cells look more abnormal and may grow faster. For example, Gleason 3+4 (Grade Group 2) is usually slower growing than 4+3 (Grade Group 3).

The stage tells how far the cancer has spread. The risk group helps guide whether watching or treating is the better fit for you.

Very low and low risk

Small, low-grade cancer (Grade Group 1) with a low PSA. Active surveillance is usually the preferred choice.

Favorable intermediate risk

A bit more cancer or a slightly higher grade (often Grade Group 2). Some people can choose active surveillance. Others choose surgery or radiation.

Unfavorable intermediate risk

More cancer in the biopsy or Grade Group 3. Treatment with surgery, or radiation with a short course of hormone therapy, is often advised.

High and very high risk

Higher grade (Grade Group 4 or 5), a PSA above 20, or cancer growing outside the prostate. Treatment is usually radiation with longer hormone therapy, or surgery. Some people also get extra hormone medicines.

Lymph node positive

Cancer has reached nearby lymph nodes in the pelvis. Treatment often combines radiation with hormone therapy and other medicines.

Metastatic (stage 4)

Cancer has spread to distant lymph nodes, bones, or other organs. It is usually not curable, but it is very treatable, and many people live for years.

Gene tests and tumor markers

Some prostate cancers are linked to gene changes you were born with (inherited). Others have gene changes only in the tumor. Knowing about them can open up more treatment choices.

Inherited gene testing is recommended for everyone with metastatic or high-risk prostate cancer, and for people with a strong family history. A result can also matter for your children, brothers, and sisters.

PSA

The main tumor marker for prostate cancer. It is checked over time to see how the cancer is behaving and how treatment is working.

BRCA1 and BRCA2

Genes that help repair damaged DNA. Changes in these genes raise the risk of prostate, breast, ovarian, and pancreatic cancer. They can make the cancer respond to a type of pill called a PARP inhibitor.

Other DNA repair genes (HRR)

Genes such as ATM, CHEK2, and PALB2. Changes in these may also make PARP inhibitors an option in advanced cancer.

Mismatch repair (MMR) genes and MSI-high

Changes linked to Lynch syndrome. When present in advanced cancer, immunotherapy may be an option.

HOXB13

An inherited gene change that raises the risk of prostate cancer. It can matter for screening in family members.

PSMA

A protein on the surface of most prostate cancer cells. A PSMA PET scan shows where it is. If the cancer shows PSMA, a radioactive medicine that targets it may be an option.

PTEN

A tumor gene that can be tested in advanced cancer. Loss of PTEN may make a targeted pill an option in some people. Ask your care team if this test applies to you.

Main treatments

Active surveillance

Close watching of low-risk cancer with regular PSA tests, exams, MRI, and sometimes repeat biopsies. Treatment starts only if the cancer shows signs of growing. This avoids or delays side effects of treatment.

Watchful waiting

A gentler approach with fewer tests. It is for people who have other serious health problems or a shorter life expectancy. Treatment is aimed at symptoms if they happen.

Surgery (radical prostatectomy)

Removal of the whole prostate, often with nearby lymph nodes. It is used for cancer that has not spread. Radiation may be added later if PSA rises.

Radiation therapy

High-energy beams from outside the body, or small radioactive seeds placed in the prostate (brachytherapy). It is often combined with hormone therapy for intermediate or high-risk cancer.

Hormone therapy (ADT)

ADT (androgen deprivation therapy) lowers testosterone. It is given as shots, implants, or a daily pill. It is the backbone of treatment for advanced prostate cancer.

Newer hormone pills (ARPIs)

Pills such as abiraterone, enzalutamide, apalutamide, and darolutamide. They block testosterone more completely. They are added to ADT for metastatic cancer and some higher-risk cancers.

Chemotherapy

Medicines such as docetaxel and cabazitaxel that kill fast-growing cells. Docetaxel may be added to ADT and a hormone pill for cancer that has spread widely.

PARP inhibitors

Pills such as olaparib, niraparib, talazoparib, and rucaparib. They work best in cancers with BRCA or other DNA repair gene changes. They are used for advanced cancer.

PSMA-targeted radioligand therapy (lutetium-177 PSMA-617)

A radioactive medicine given by IV that seeks out PSMA on cancer cells and treats them from the inside. It is used for advanced cancer that shows PSMA on a PET scan.

Other options for advanced cancer

These include radium-223 for cancer in the bones, sipuleucel-T (a vaccine made from your own immune cells), and immunotherapy for rare tumors with MSI-high changes. Bone-strengthening medicines help protect the bones.

Common side effects and what helps

Leaking urine (incontinence)

Common after surgery and usually improves over months. Pelvic floor exercises (Kegels) and physical therapy help. Tell your team if it is not getting better.

Erection problems

Surgery, radiation, and hormone therapy can all affect erections. Medicines, devices, and other treatments can help. It is okay to bring this up with your team.

Bladder and bowel irritation

Radiation can cause frequent or urgent urination, burning, loose stools, or rectal irritation. These often improve after treatment ends. Your team can suggest diet changes and medicines.

Hot flashes

Common with hormone therapy. Dressing in layers, cooling fans, and avoiding triggers like alcohol and spicy food help. Some medicines can also reduce them.

Fatigue

Feeling very tired is common with hormone therapy and radiation. Regular walking or strength exercise is one of the best ways to fight it. Plan rest and ask for help with tasks.

Bone thinning

Hormone therapy can weaken bones and raise fracture risk. Calcium, vitamin D, weight-bearing exercise, and sometimes bone medicines help. You may need a bone density scan.

Loss of muscle, weight gain, and heart and sugar changes

Hormone therapy can change body shape and raise blood sugar, cholesterol, and heart risk. Strength training, healthy eating, and regular checkups help.

Mood, memory, and sex drive changes

Low testosterone can lower sex drive and affect mood or focus. Talk openly with your partner and team. Counseling and support groups can help.

Side effects of hormone pills

Some can raise blood pressure, lower potassium, cause swelling, rash, falls, or rarely seizures. Your team will check blood tests and blood pressure. Tell them about all your other medicines.

Low blood counts

Chemotherapy and PSMA-targeted therapy can lower blood counts. This raises the risk of infection, bleeding, and tiredness. Your team will check your blood regularly.

Living with and after prostate cancer

Many people live a long time after a prostate cancer diagnosis. For some, prostate cancer becomes a long-term condition that is managed like other chronic illnesses.

You will have regular PSA tests after treatment. Try not to worry over each small change. Your care team looks at the trend over time, not one single number.

Staying active, eating well, not smoking, and keeping up with heart health checks are especially helpful if you are on hormone therapy.

Sexual health, bladder control, and emotions are a normal part of care. Ask for referrals to urology, pelvic floor therapy, sexual health clinics, or counseling. Partners and caregivers may want support too.

If you have an inherited gene change, your family members may benefit from genetic counseling and earlier screening.