Prostate Cancer - Diagnosis & Treatment

PSA (Prostate-Specific Antigen) is not a simple threshold - it must be interpreted in context. General age-adjusted upper limits: Age 40–49: PSA >2.5 ng/mL warrants further assessment. Age 50–59: >3.5 ng/mL. Age 60–69: >4.5 ng/mL. Age 70–79: >6.5 ng/mL. However, PSA can be elevated by BPH, prostatitis, urinary tract infection, and even recent ejaculation or vigorous exercise. Conversely, significant prostate cancer can exist with a PSA below the threshold. PSA velocity (rate of rise) and free-to-total PSA ratio also matter. A raised PSA should be discussed with a urologist - the next step is usually an MRI, not a biopsy.

Multi-parametric MRI (mpMRI) of the prostate is an advanced imaging technique that provides detailed information about areas within the prostate that look suspicious for cancer. It is reported using the PIRADS scoring system (PIRADS 1–5). PIRADS 4 and 5 lesions carry a high probability of clinically significant cancer. The mpMRI is performed before biopsy because: (1) it allows targeted biopsy of suspicious areas rather than random sampling, increasing detection of significant cancer; (2) it avoids biopsy if the MRI is reassuring (PIRADS 1–2); (3) it provides staging information before treatment. MRI-targeted biopsy combined with systematic biopsy detects significantly more clinically significant cancers than systematic biopsy alone.

The Gleason score grades prostate cancer aggressiveness on a scale of 1–5 based on how abnormal the cancer cells appear under the microscope. Two areas are graded and added together to give a combined Gleason score. Modern reporting uses Grade Groups: Grade Group 1 (Gleason 3+3=6) - low-grade; may be suitable for active surveillance. Grade Group 2 (Gleason 3+4=7) - intermediate risk; treatment usually recommended. Grade Group 3 (Gleason 4+3=7) - intermediate-high risk; treatment recommended. Grade Group 4 (Gleason 4+4=8) - high risk; aggressive treatment recommended. Grade Group 5 (Gleason 9–10) - very high risk; systemic treatment often added to local treatment.

Active surveillance (AS) is the monitoring of low-risk prostate cancer rather than immediate treatment. It is suitable for: PSA <10 ng/mL, Gleason score 3+3=6 (Grade Group 1), clinical stage T1c or T2a, fewer than 3 positive biopsy cores, and cancer involvement <50% of any core. The rationale: low-grade prostate cancer grows very slowly and many men will not need treatment for years or decades. AS avoids the side effects of surgery and radiotherapy (incontinence, erectile dysfunction) in men who may never need treatment. Monitoring involves: PSA every 3–6 months, MRI annually, repeat biopsy at 1–2 years and then every 3–5 years. Intervention is triggered by PSA doubling time <3 years, grade progression, or patient choice.

Robot-Assisted Radical Prostatectomy (RARP) is the surgical removal of the prostate using the Da Vinci Surgical System - performed through 5–6 small incisions (1–2 cm each). The robotic platform provides 10x magnified 3D vision and instruments with 7 degrees of freedom, allowing precise dissection of the neurovascular bundles that control erections and the sphincter that controls urinary continence. Compared to open surgery: less blood loss (transfusion rarely needed), shorter hospital stay (2 nights vs 4–5), earlier catheter removal, and equivalent oncological outcomes (cancer control). Nerve-sparing RARP preserves erections in approximately 70–80% of previously potent men with localised disease. Dr. Nitin performs RARP at Apollo Hospital Gurugram.

The main side effects of all treatments for prostate cancer are urinary incontinence and erectile dysfunction. After RARP: urinary continence is usually regained within 3–12 months; most men use no pads at 12 months after nerve-sparing surgery. Erectile function recovers gradually over 12–24 months after nerve-sparing surgery; oral medication (sildenafil) or penile rehabilitation helps. After radiotherapy: urinary urgency and frequency are common during and after treatment; bowel side effects (proctitis) can occur; erectile dysfunction develops over months to years in 40–60%. Hormone therapy (LHRH agonist/antagonist) causes hot flushes, fatigue, reduced libido, and muscle loss. The right treatment depends on age, cancer stage, starting erectile function, bladder symptoms, and patient preference.

Yes - family history is a significant risk factor. Men with a first-degree relative (father or brother) with prostate cancer have 2–3 times the average risk. Hereditary prostate cancer accounts for 5–10% of cases. Mutations in BRCA2 (and to a lesser extent BRCA1) significantly increase prostate cancer risk and are associated with more aggressive disease. Lynch syndrome (HNPCC) also increases risk. Men with BRCA2 mutations should start PSA screening at age 40–45. Genetic testing should be considered if: prostate cancer before age 55, high-grade disease (Gleason ≥8), multiple family members affected across generations, or family history of breast/ovarian/pancreatic cancer (BRCA-associated cancers).