Prostate Cancer: Detection, Staging and Treatment

Prostate cancer is the most common cancer in men in developed countries and the second leading cause of male cancer death, after lung cancer. Approximately 1.4 million men are diagnosed worldwide each year. In China, incidence has risen dramatically as the population ages and PSA testing becomes more widespread — from a historically low-incidence country to one with a rapidly growing prostate cancer burden.

Most prostate cancers are slow-growing and confined to the prostate — many men with prostate cancer die with the disease rather than from it. However, a significant subset are aggressive and potentially fatal if not treated early. The central challenge in prostate cancer management is distinguishing cancers that require aggressive treatment from those that can be safely monitored.

The Prostate and Cancer Development

The prostate is a walnut-sized gland sitting at the base of the bladder, surrounding the urethra. It produces fluid components of semen. Prostate cancer — almost always adenocarcinoma — arises from the glandular epithelial cells, most commonly in the peripheral zone of the gland.

Prostate cancer growth is driven by male sex hormones (androgens) — primarily testosterone and its more potent derivative dihydrotestosterone (DHT), which bind to androgen receptors and stimulate tumour cell proliferation. This is why androgen deprivation therapy (ADT) is central to treatment of advanced disease.

Risk Factors

• Age — the dominant risk factor; rare under 50; incidence rises steeply after 60; 70% of cases diagnosed in men over 65
• Family history — first-degree relative with prostate cancer: 2–3× increased risk; BRCA1/BRCA2 mutations (particularly BRCA2) confer high risk of aggressive disease
• Black African / Caribbean ethnicity — 2–3× higher incidence; more likely to present at younger age and with aggressive disease
• Diet — high-fat, low-fibre Western diet; possibly processed red meat; lycopene (tomatoes) and selenium possibly protective
• Obesity — associated with higher-grade and more advanced disease at diagnosis
• Smoking — associated with higher risk of aggressive and fatal prostate cancer

Screening and Detection

PSA (Prostate-Specific Antigen)

PSA is a glycoprotein produced almost exclusively by the prostate gland; measured by a simple blood test. Elevated PSA (>4 ng/mL in most guidelines, though no single threshold is universally accepted) indicates possible prostate pathology — cancer, benign prostatic hyperplasia, prostatitis, or recent prostate manipulation.

PSA limitations:

• Not cancer-specific: PSA is prostate-specific, not cancer-specific; BPH and prostatitis both raise PSA
• False negatives: approximately 15% of prostate cancers occur with PSA <4 ng/mL; clinically significant cancers can occur with normal PSA
• Overdiagnosis: population PSA screening detects many indolent low-grade cancers that would never have caused symptoms; this risks overtreatment with significant side effects

PSA-derived measures improve specificity:

• PSA velocity/kinetics — rapidly rising PSA (>0.75 ng/mL/year) suggests cancer even with normal absolute PSA
• PSA density — PSA adjusted for prostate volume (measured by MRI); high density in a small prostate is more concerning than in a large BPH prostate
• Free-to-total PSA ratio — benign PSA tends to be in free form; cancer tends to produce more complexed PSA; ratio <10–15% is more suggestive of cancer
• PSA isoforms (PHI — prostate health index; 4Kscore) — more accurate risk stratification

Screening recommendations: no universal consensus; most major organisations (EAU, ACS) recommend informed individual decision-making; PSA testing from age 50 (or 40–45 for high-risk groups); annual testing if baseline PSA >1 ng/mL at age 40.

Multiparametric MRI (mpMRI)

mpMRI (T2-weighted + diffusion-weighted + dynamic contrast-enhanced imaging) of the prostate is now recommended before biopsy in most guidelines. It:

• Identifies and characterises suspicious lesions (PI-RADS scoring system 1–5: PI-RADS 1 = very low probability; PI-RADS 5 = very high probability)
• Guides targeted biopsy of suspicious areas
• Reduces detection of clinically insignificant cancers
• Reduces unnecessary biopsies (PI-RADS 1–2 lesions: biopsy can often be deferred)

Prostate Biopsy

Tissue diagnosis is required to confirm cancer. Modern approaches:

• MRI-targeted biopsy: combining cognitive or software fusion of MRI images with real-time transrectal ultrasound (TRUS) to biopsy the mpMRI-identified lesion; superior detection of clinically significant cancer
• Transperineal (TP) biopsy: via the perineum (skin between scrotum and anus) rather than through the rectum; lower infection risk; becoming the preferred route at leading centres
• Systematic biopsy: 10–12 random cores from standardised prostate zones, taken alongside targeted biopsy

Gleason grading of biopsy cores:

• Pathologist assigns two grades (1–5) for the two predominant architectural patterns; summed to Gleason score
• International Grade Groups (GG): GG1 (Gleason 6) — low grade; GG2 (Gleason 3+4=7) — intermediate-favourable; GG3 (Gleason 4+3=7) — intermediate-unfavourable; GG4 (Gleason 8); GG5 (Gleason 9–10) — high grade

Staging

Clinical Staging (TNM)

• T1: not palpable; found incidentally
• T2: palpable tumour confined to prostate
• T3: extends through prostate capsule; involves seminal vesicles (T3b)
• T4: invades adjacent structures (bladder, rectum, pelvic wall)
• N1: regional lymph node metastasis
• M1: distant metastasis (bones, lymph nodes, viscera)

Imaging for Staging

• CT abdomen/pelvis: pelvic lymph node assessment
• Bone scan (technetium-99m): detects bone metastases in intermediate/high-risk disease
• PSMA-PET CT (prostate-specific membrane antigen PET): the most sensitive staging and restaging tool — detects metastatic disease (lymph nodes, bone, viscera) at PSA levels as low as 0.2 ng/mL; rapidly replacing conventional bone scans

Risk Stratification

Risk Group	PSA	Grade Group	Clinical Stage	Management
Very low / Low	<10 ng/mL	GG1	T1–T2a	Active surveillance
Intermediate	10–20 ng/mL	GG2–3	T2b–T2c	Surgery or radiotherapy
High	>20 ng/mL or GG4–5	T3–T4	Multimodal treatment
Metastatic	Any	Any	N1/M1	Systemic therapy

Treatment

Active Surveillance (AS)

For low-risk and selected intermediate-risk prostate cancer — monitoring without immediate treatment. AS involves regular PSA testing (every 3–6 months), repeat MRI, and systematic biopsy at defined intervals. Curative treatment is initiated if there is evidence of disease progression (PSA kinetics, biopsy upgrade, MRI progression).

AS avoids or defers overtreatment of indolent cancers. Approximately 50% of men on AS for GG1 disease remain on surveillance at 10 years without requiring treatment. For GG1 (Gleason 6) disease, 15-year prostate cancer-specific mortality is <1% — making AS the standard of care.

Radical Prostatectomy

Surgical removal of the entire prostate with the seminal vesicles and pelvic lymph nodes. The standard approach is now:

Robot-assisted radical prostatectomy (RARP): performed laparoscopically using the da Vinci robotic system; the surgeon operates with magnified 3D vision and wristed instrument control with superior precision. Benefits: 10× magnified view of the neurovascular bundles; nerve-sparing where oncologically safe; smaller incisions; faster recovery; lower blood loss.

• Nerve-sparing surgery — preservation of the neurovascular bundles running alongside the prostate; crucial for post-operative erectile function
• Post-operative continence: 90–95% dry at 12 months in high-volume centres
• Post-operative potency with bilateral nerve-sparing: 60–80% with aids at 12 months

Radical prostatectomy is particularly preferred in younger, fit patients with longer life expectancy, those with high-risk localised disease, and those concerned about radiotherapy's late effects.

Radiation Therapy

External beam radiotherapy (EBRT): modern stereotactic body radiotherapy (SBRT) delivers high-dose, precisely focused radiation over 5 fractions (PACE-B trial: equivalent to 39 fractions); intensity-modulated and image-guided techniques maximise dose to prostate while minimising bladder and rectal dose.

Brachytherapy: radioactive seeds (permanent low-dose-rate brachytherapy) or catheters (high-dose-rate temporary brachytherapy) implanted directly into the prostate under ultrasound guidance; highly conformal dose delivery; excellent outcomes for localised disease.

Combined EBRT + brachytherapy boost is recommended for high-risk localised disease.

Radiotherapy is combined with 6–36 months of androgen deprivation therapy (ADT) for intermediate and high-risk disease — ADT sensitises prostate cancer cells to radiation and eliminates micrometastatic disease.

Androgen Deprivation Therapy (ADT)

The backbone of treatment for metastatic prostate cancer — reduces testosterone to castrate levels (<50 ng/dL):

• LHRH agonists (leuprolide, goserelin): monthly to 6-monthly SC/IM injections; cause initial testosterone flare then sustained suppression
• LHRH antagonists (degarelix, relugolix): immediate testosterone suppression without flare; oral relugolix preferred for cardiovascular safety
• Bilateral orchiectomy: surgical castration; immediate, permanent, cheap; rarely chosen

Side effects of ADT: hot flushes, fatigue, weight gain, loss of libido, erectile dysfunction, osteoporosis, cognitive changes, metabolic syndrome.

Novel Hormonal Agents (NHA) for Advanced Disease

Abiraterone acetate (Zytiga) + prednisone: blocks androgen synthesis in the adrenal glands and tumour; approved for metastatic castration-resistant prostate cancer (mCRPC) and — with ADT — for high-risk metastatic castration-sensitive prostate cancer (mCSPC).

Enzalutamide, apalutamide, darolutamide: second-generation androgen receptor inhibitors; block testosterone binding at the receptor level; highly effective in mCRPC and mCSPC.

Combination treatment for metastatic disease (standard of care): ADT + NHA (e.g., ADT + abiraterone/enzalutamide) + docetaxel chemotherapy for high-volume metastatic disease (PEACE-1, ARASENS trials): triplet therapy improves overall survival vs ADT alone.

PSMA-Targeted Therapy

Lutetium-177 PSMA-617 (Pluvicto): radioligand therapy that targets PSMA-expressing prostate cancer cells; approved for PSMA-positive mCRPC after ARAT and docetaxel; VISION trial: 38% improvement in overall survival.

Prostate Cancer Care in China

China's urology and oncology centres offer:

• PSA testing and risk stratification: PSA, free/total PSA, PHI score, and mpMRI; PSMA-PET CT for staging at leading centres
• Robot-assisted prostatectomy: da Vinci Xi robotic surgical systems at major centres; experienced robotic urological surgeons with high case volumes; nerve-sparing techniques
• PSMA-PET CT: available at major nuclear medicine centres; earlier and more sensitive staging than conventional bone scan
• Novel hormonal agents: abiraterone, enzalutamide, apalutamide, and darolutamide available, including domestic Chinese versions
• Radiation therapy: SBRT (5-fraction) and image-guided EBRT at major radiation oncology centres
• Cost: care in China is generally less expensive than UK private treatment, but the hospital prices each case individually — ask us for the written quote before you commit.
• Full English care navigation from PSA testing through biopsy, treatment decision, and surgery or systemic therapy

Contact a ChinaMedicalTour care navigator to arrange a prostate cancer assessment, biopsy, or treatment consultation.

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Medical content based on MSD Manuals and international prostate cancer guidelines (EAU, NCCN). Evidence reviewed 2025.

Frequently Asked Questions

Can overseas urological patients receive a preliminary review of imaging and lab results?

Yes. Multiparametric prostate MRI, urinary CT scans, ultrasound reports, and PSA or urinalysis findings can be reviewed through pre-consultation coordination with senior Chinese urologists.

What minimally invasive urological procedures are evaluated in Chinese tertiary centers?

Urology departments evaluate laser prostate enucleation (HoLEP/ThuLEP), flexible ureteroscopic stone lithotripsy, transurethral resections, and robotic laparoscopic urological surgery.

How are appointments and hospital fee quotations confirmed for international patients?

Hospital consultations and surgical schedules are confirmed directly with the department, with all medical fees paid directly to the treating public hospital according to published counter schedules.