My Clinical Approach to Prostate Cancer
At my urology practice in Rhodes, prostate cancer management follows EAU Guidelines 2024 with a focus on individualised care. The goal is not simply to detect cancer — but to detect the clinically significant cancer that actually requires treatment, avoiding unnecessary interventions for indolent disease.
I apply a PSA + mpMRI protocol before any biopsy, eliminating the need for blind transrectal biopsies. Transperineal biopsy is used exclusively — essentially eliminating the risk of sepsis associated with the transrectal approach.
- PSA + mpMRI as the first step in the diagnostic algorithm.
- Transperineal biopsy — near-zero risk of infection.
- Active Surveillance as standard of care for low-risk cancers.
- Robotic radical prostatectomy for localised disease requiring curative treatment.
What is Prostate Cancer
Prostate cancer arises when malignant cells develop within the prostate gland — a walnut-sized gland located below the bladder, surrounding the urethra. In 90% of cases it is an adenocarcinoma (arising from glandular cells).
According to GLOBOCAN 2022, over 7,000 new cases are diagnosed annually in Greece, making prostate cancer the most common cancer in men in the country.
Biological Behaviour
Biological behaviour varies dramatically: some tumours grow very slowly and pose no threat to life (ISUP Grade Group 1), while others are aggressive (Grade Group 4-5) and require immediate treatment. This distinction is critical to therapeutic decision-making.
Risk Factors & Epidemiology
Main risk factors for prostate cancer:
Age
Risk increases significantly after age 50. Prostate cancer is rare below 40.
Family History
Men with a father or brother diagnosed with prostate cancer have 2–3× the average risk.
Genetic Mutations
BRCA2 (and to a lesser extent BRCA1) carriers have a higher risk of aggressive cancer — screening from age 40 is recommended.
Ethnicity
Men of African descent have significantly higher risk and more commonly present with aggressive disease.
When to start screening
- Age 50 for average-risk men.
- Age 45 if a first-degree relative (father or brother) was diagnosed.
- Age 40 for BRCA2 mutation carriers or men of African descent.
Symptoms & Clinical Presentation
In early, curable stages, prostate cancer is usually completely asymptomatic. When the tumour grows or spreads:
Urinary Symptoms
Weak urine stream, hesitancy, frequency, nocturia, sensation of incomplete bladder emptying — all also common with benign prostatic hyperplasia.
Haematuria / Haematospermia
Blood in urine or semen. Requires immediate urological assessment — often benign, but malignancy must be excluded.
Metastatic Symptoms
Back, pelvic, or bone pain — present only in advanced, metastatic disease. Fatigue and weight loss may also occur.
Prostate Cancer Is Often Asymptomatic in Early Stages — Screening Saves Lives
Urinary symptoms may be caused by benign prostatic hyperplasia or other benign conditions. However, regular PSA testing is essential regardless of symptoms:
- PSA in men >50 (or earlier if risk factors are present).
- Digital rectal examination (DRE) at annual urological check-up.
- Do not ignore a rising PSA — even without symptoms.
PSA — The Screening Marker
The PSA (Prostate-Specific Antigen) blood test is a valuable clinical tool, but is not specific to cancer alone. PSA is also elevated by:
- Benign Prostatic Hyperplasia (BPH) — the most common cause of elevated PSA.
- Prostatitis (prostate inflammation) — acute or chronic — causes significant PSA elevation.
- Recent ejaculation or vigorous cycling.
Therefore a raised PSA does not automatically mean cancer. If the level is suspicious (e.g. 3–10 ng/mL), risk stratification and — if warranted — mpMRI are the next steps.
Diagnosis — mpMRI & Biopsy
The modern diagnostic algorithm according to EAU Guidelines 2024:
Clinical Assessment & PSA
Patient history, PSA measurement, PSA density, Digital Rectal Examination (DRE). Risk score calculation (ERSPC, PCPT).
Multiparametric MRI (mpMRI)
Performed before any biopsy. Evaluates suspicious lesions with PIRADS Score (1-5). PIRADS 1-2: low probability of significant cancer. PIRADS 4-5: high probability — biopsy indicated.
Transperineal Prostate Biopsy
Preferred over transrectal — eliminates the risk of post-biopsy sepsis. Targeted (fusion) biopsy of suspicious mpMRI lesions. Performed under local anaesthesia as an outpatient procedure.
Staging (if cancer confirmed)
CT abdomen/pelvis, bone scintigraphy (or PSMA-PET/CT) to exclude metastases in Grade Group ≥3 or PSA >20 ng/mL.
Gleason Score & ISUP Grade Group
Cancer aggressiveness is classified by the ISUP Grade Group system (1–5):
Grade Group 1
Gleason 6Low RiskIndolent cancer. Active Surveillance — no immediate treatment. Serial PSA and mpMRI monitoring.
Grade Group 2
Gleason 3+4=7Intermediate (Favourable)Relatively slow growth. Active Surveillance or definitive treatment depending on clinical features.
Grade Group 3
Gleason 4+3=7Intermediate (Unfavourable)Treatment indicated. Radical prostatectomy or radiotherapy.
Grade Group 4
Gleason 8High RiskAggressive disease. Definitive treatment ± adjuvant hormone therapy. Staging mandatory.
Grade Group 5
Gleason 9–10Very High RiskVery aggressive disease. Definitive treatment + hormone therapy. Metastatic staging required.
Treatment Options
Treatment is decided individually based on ISUP Grade Group, disease stage, age, and patient preferences:
Active Surveillance
Standard of care for Grade Group 1 (and selected Grade Group 2). Regular PSA (6 months), repeat mpMRI, confirmatory biopsy. Avoids treatment side effects without compromising oncological safety.
Radical Prostatectomy (Robotic)
Surgical removal of the prostate for localised Grade Group 2-5 disease. Robotic technique (RALP) ensures faster recovery and better preservation of continence and erectile function.
Radiotherapy (EBRT ± Brachytherapy)
Equivalent oncological outcomes to surgery for localised disease. Frequently combined with hormone therapy for Grade Group ≥3 or high-risk disease.
Hormone Therapy (ADT) ± Chemotherapy
For locally advanced or metastatic disease. Novel agents (abiraterone, enzalutamide, darolutamide) combined with ADT have significantly improved outcomes.
Follow-up & Prognosis
Structured follow-up after prostate cancer treatment:
- PSA every 3 months in year 1, every 6 months years 2–5, then annually.
- Biochemical recurrence (BCR): PSA ≥0.2 ng/mL after prostatectomy — evaluate for salvage radiotherapy or ADT.
- On Active Surveillance: mpMRI every 18 months and confirmatory biopsy every 3-5 years.
- Long-term quality-of-life monitoring: urinary continence, erectile function, bone density (ADT).
Prognosis
Localised cancer (Grade Group 1-3, Stage I-II): 15-year cancer-specific survival >85–95% with appropriate treatment. Locally advanced disease (Stage III): often curable with combined radiotherapy + hormone therapy. Metastatic disease: novel agents have significantly improved overall survival.
Frequently Asked Questions (FAQ)
Does a high PSA always mean prostate cancer?
No. Benign prostatic hyperplasia (BPH) and prostatitis frequently elevate PSA. A raised PSA requires further evaluation — not immediate panic or biopsy. Multiparametric MRI (mpMRI) is the next step to assess cancer probability.
Is a biopsy always needed when PSA is elevated?
No. Current EAU Guidelines recommend mpMRI before biopsy. If the MRI shows PIRADS 1-2 (low suspicion), biopsy can often be safely deferred. If PIRADS 4-5, a targeted transperineal biopsy is performed.
Does every patient with prostate cancer need surgery?
No. For very-low and low-risk cancers (ISUP Grade Group 1), Active Surveillance is the standard of care — no immediate treatment, with regular PSA checks and MRI monitoring. Treatment decisions are individualised based on grade, age, and patient preference.
Can benign prostatic hyperplasia (BPH) turn into cancer?
No. BPH and prostate cancer are completely different conditions. They can coexist and cause similar urinary symptoms, but benign tissue does not transform into malignant tissue.
When should I start PSA screening?
Age 50 for average-risk men. Age 45 if you have a first-degree relative (father or brother) diagnosed with prostate cancer. Age 40 for BRCA2 mutation carriers or men of African descent, who are at higher risk of aggressive disease.
What does the Gleason score and ISUP Grade Group mean?
The Gleason score (6–10) grades the aggressiveness of cancer on biopsy. The newer ISUP Grade Group (1–5) is more clinically intuitive: Grade Group 1 = low risk (indolent), Grade Group 5 = very high risk (aggressive). It determines which treatment is appropriate.
What are the side effects of prostate cancer treatment?
Side effects depend on the treatment. Radical prostatectomy may cause urinary incontinence (usually temporary) and erectile dysfunction. Radiotherapy is associated with bowel and urinary irritation. Hormone therapy (ADT) causes hot flushes, loss of libido, fatigue, and bone density loss with long-term use.
Can prostate cancer be completely cured?
Yes — localised cancer (Stage I-II, Grade Group 1-3) has an excellent prognosis, with >85-95% 15-year cancer-specific survival with appropriate treatment. Even locally advanced disease (Stage III) is often curable with combined radiotherapy and hormone therapy. Early detection through PSA screening is key.
Related Topics
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Elevated PSA, urinary symptoms, or prostate cancer screening? Specialised urological assessment with a modern protocol (mpMRI + transperineal biopsy) at our practice in Rhodes.
References – Sources
- EAU Guidelines on Prostate Cancer 2024 — uroweb.org
- GLOBOCAN 2022: Cancer Statistics for Greece — gco.iarc.who.int
- Mottet N, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer. Eur Urol 2021;79(2):243–262.
- National Cancer Institute: Understanding PSA Testing — cancer.gov
- Ahmed HU, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer. BMJ 2017;359:j5023.
Medical Review
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas runs a private urology practice in Rhodes with expertise in prostate cancer diagnosis and treatment using the latest mpMRI and transperineal biopsy protocols. He follows the EAU Guidelines 2024.
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