Prostatic cancer

Epidemiology and risk factors. The commonest non-cutaneous cancer in men; incidence rises steeply with age, with median age at diagnosis around 66–70 years and latent histological cancer present in over 70% of men above 80 at autopsy. Risk factors: age, African ancestry, family history, BRCA2 and Lynch syndrome, obesity and a high-fat diet. Over 95% are adenocarcinomas arising in the peripheral zone.

Clinical features. Early disease is asymptomatic and detected by PSA testing or a hard, nodular, irregular prostate with loss of the median sulcus on digital rectal examination. Later: lower urinary tract symptoms, haematuria, haematospermia, retention. Advanced disease characteristically presents with osteoblastic (sclerotic) bone metastases causing back pain, pathological fracture or spinal cord compression, and with anaemia, weight loss or renal failure from ureteric obstruction — in older men, bone pain is often the first presentation.

Diagnosis. PSA (raised also in BPH, prostatitis, catheterisation, retention and after DRE; use age-specific ranges, free:total ratio, PSA density and velocity to improve specificity). Multiparametric MRI before biopsy (PI-RADS scoring) is now standard, followed by MRI-targeted transperineal or transrectal biopsy. Histology is graded by the Gleason score, reported as ISUP Grade Groups 1–5 (Gleason 6 = GG1 up to Gleason 9–10 = GG5). Staging by TNM with bone scan and CT, or PSMA PET-CT.

Risk stratification. Low risk — PSA <10, Gleason ≤6 (GG1), ≤T2a. Intermediate risk — PSA 10–20, Gleason 7 (GG2–3), T2b–c. High risk — PSA >20, Gleason 8–10 (GG4–5), ≥T3. This determines whether surveillance, radical treatment or systemic therapy is appropriate.

Management of localised disease. Active surveillance for low-risk disease (PSA, DRE, MRI and repeat biopsy) — the preferred option in most older men. Watchful waiting with deferred palliative hormonal treatment is appropriate when life expectancy is under 10 years. Radical prostatectomy or radical radiotherapy (external beam or brachytherapy) with neoadjuvant/adjuvant androgen deprivation for high-risk disease is offered when life expectancy exceeds 10 years. Radical treatment is justified by life expectancy and health status, not by chronological age; complications are incontinence and erectile dysfunction (surgery) and radiation proctitis and cystitis.

Management of advanced disease. Androgen deprivation therapy is the backbone — LHRH agonists (goserelin, leuprolide, with anti-androgen cover for 2 weeks to prevent tumour flare), the LHRH antagonist degarelix, or bilateral orchidectomy. Adverse effects of ADT are heavily examinable in geriatrics: hot flushes, loss of libido and erectile dysfunction, sarcopenia and fatigue, weight gain, osteoporosis and fracture (give calcium, vitamin D and a bisphosphonate or denosumab with DEXA monitoring), metabolic syndrome, diabetes, cardiovascular events, anaemia, gynaecomastia, and cognitive change. For metastatic hormone-sensitive disease, ADT is intensified with an androgen receptor pathway inhibitor (abiraterone, enzalutamide, apalutamide, darolutamide) ± docetaxel. In castration-resistant disease: abiraterone, enzalutamide, docetaxel, cabazitaxel, radium-223 for bone-predominant disease, olaparib for BRCA mutations, and Lu-177 PSMA radioligand therapy. Palliative radiotherapy for bone pain and cord compression, plus a bone-protecting agent.

PSMA PET-CT and geriatric assessment are now embedded in guidelines. The EAU 2025 and AUA/ASTRO 2026 guidelines recommend PSMA PET-CT for staging high-risk disease and for biochemical recurrence when PSA >0.2 ng/mL, since the proPSMA trial showed sensitivity for nodal disease of 91% versus 59% for conventional imaging, and it frequently changes management. Equally important for the geriatric answer, the EAU gives a strong recommendation to use the Geriatric 8 (G8), mini-Cog and Clinical Frailty Scale to assess health status, and states explicitly that life expectancy and comorbidity, not age, should drive treatment decisions — with more than 10 years of life expectancy considered mandatory before any radical local treatment. Cross-reference: Positron emission tomography, including PSMA PET, is covered in Question 41.