Prostate cancer: early detection and advances in management

Prostate cancer remains one of the most common malignancies affecting men, particularly those over 50 years of age. While it typically progresses slowly, allowing for prolonged disease management, early detection and timely intervention are key to improving clinical outcomes.  

The asymptomatic nature of early-stage prostate cancer highlights the importance of routine screening and awareness of potential symptoms, such as lower urinary tract symptoms, haematuria, erectile dysfunction, or pelvic and lower back pain. These symptoms often overlap with benign conditions like benign prostate hyperplasia or prostatitis, necessitating careful differential diagnosis through appropriate clinical investigations. 

Screening and diagnosis 

The prostate specific antigen (PSA) test remains a cornerstone for initial prostate cancer screening, despite its limitations in specificity. Elevated PSA levels warrant further investigation, which may include multiparametric prostate MRI scan and/or a prostate biopsy, to confirm malignancy.  

Advanced imaging modalities, such as PSMA PET scans, are invaluable for staging, providing crucial information about extracapsular extension or potential metastatic spread. 

Early diagnosis of prostate cancer significantly improves the chances of successful treatment. Early-stage localised prostate cancer, typically confined to the gland, offers an opportunity for curative interventions, such as radical prostatectomy or radiation therapy (RT).  

In contrast, advanced-stage disease, requires a multidisciplinary and multimodality treatment approach that incorporates androgen deprivation therapy (ADT), systemic therapies, palliative RT, and palliative care. Understanding the disease’s variable progression – ranging from slow-growing to more aggressive forms – is critical for developing personalised management strategies 

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Treatment modalities and innovations 

For localised prostate cancer, treatment options such as surgery and radiation therapy offer comparable cancer control outcomes, necessitating patient-centred discussions about potential side effects, recovery, quality of life, and potential salvage treatment options for local recurrent disease.  

Advances in radiation therapy, including technologies such as volumetric modulated arc therapy (VMAT) and stereotactic ablative body radiotherapy (SABR), allow for highly precise tumour targeting and while minimising damage to adjacent healthy tissues. Recent evidence demonstrates that SABR (e.g. 5-fraction regimens), offer excellent cancer control rates exceeding 95% at five years for early-stage disease. This approach also reduces treatment durations, improving patient convenience without compromising outcomes. 

Supportive technologies such as absorbable rectal spacers further reduce radiation exposure to critical structures. These innovations make radiation therapy a viable, non-invasive alternative to surgery, often offering reduced recovery times and preserving functional outcomes. 

Research and clinical trials 

Clinical trials play a vital role in advancing prostate cancer management, offering patients access to emerging and novel therapies and technologies. The ASTuTE clinical trial, currently recruiting intermediate-risk patients in Western Australia, is an excellent example of innovation in action.  

This trial is evaluating the use of an artificial intelligence biomarker test to determine the need for ADT alongside radiation therapy. By stratifying patients based on tumour biology, the test aims to optimise treatment decisions, enhance prognostic accuracy, and potentially reduce ADT-related side effects for suitable patients. 

– References available on request 

Author competing interests – the author is involved in the ASTuTE trial 

Key messages 

• Early Detection is Crucial: Routine PSA screening and advanced imaging improve early prostate cancer diagnosis and outcomes. 
• Advanced Treatments Offer Options: Techniques such as stereotactic provide effective, less invasive alternatives to surgery. 
• Research Drives Progress: Clinical trials, such as ASTuTE, offer opportunities for patients to access new technologies. 

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