Common Male Genitourinary Issues: Prostate Cancer Screening and Treatment

Prostate cancer is the second most common cancer in US men. Guidelines for screening vary, underscoring the need to engage patients in shared decision-making and counsel them about potential benefits and harms. When screening is undertaken, it is based on the prostate-specific antigen test, with digital rectal examination used selectively as an adjunct. Men with an abnormal prostate-specific antigen level should have a repeat test within a few months, before proceeding to biomarker testing, referral to urology, biopsy, and potentially imaging. Patients with newly diagnosed prostate cancer should be risk-stratified using clinical tumor (T) stage as determined by digital rectal examination, International Society of Urological Pathology grade group (Gleason score), prostate-specific antigen level, and tumor volume on biopsy. Treatment options vary by risk. Active surveillance is recommended for patients with low-risk disease, typically those with grade group 1/Gleason score of 6 (3 + 3). For patients with favorable intermediate-risk prostate cancer, treatment options are active surveillance, radiation therapy, or radical prostatectomy. For patients with unfavorable intermediate- or high-risk prostate cancer and estimated life expectancy greater than 10 years, options are radical prostatectomy or radiation therapy plus androgen deprivation therapy. For patients with prostate-specific antigen levels greater than 40 ng/dL, a Gleason score of 9 or higher, or locally advanced prostate cancer, treatment with radiation therapy and androgen deprivation therapy can additionally include concurrent abiraterone plus prednisone for 2 years. Focal ablation is also an option for some patients. Prognosis varies by disease features; men with low-risk prostate cancer are much more likely to die from other causes, whereas those with distant metastases have a 5-year relative survival rate of 38.3%.