Newly Diagnosed With Prostate Cancer: First Steps

NCI's PDQ names the PSA level, the Gleason score and the clinical stage as inputs used to estimate risk.

Write all three at the top of your notes. Many conversations ahead will refer back to them.

For scale, the American Cancer Society projects about 333,830 new US cases and 36,320 deaths for 2026; those are projections, carried on SEER's stat facts page rather than counted by SEER. SEER's own measured figures give a median age at diagnosis of 68. Five-year relative survival for 2016 through 2022 was 100.0% for cancer confined to the prostate, 100.0% when it has reached nearby lymph nodes, and 40.1% once it has spread to distant sites.

The Gleason system scores how abnormal the cells look, on a scale from 2 to 10. Pathologists report it as two numbers added together, such as 3+4=7. The first number describes the most common pattern. The second describes the next most common.

PDQ maps them onto ISUP grade groups:

• Grade Group 1: Gleason 6 or lower.
• Grade Group 2: Gleason 3+4=7.
• Grade Group 3: Gleason 4+3=7.
• Grade Group 4: Gleason 8.
• Grade Group 5: Gleason 9 or 10.

A Gleason 7 can be Grade Group 2 or Grade Group 3, depending on which pattern came first. Ask for both numbers.

Ask for the grade group number on your pathology report.

PDQ states that many men with localized prostate cancer may die of other illnesses without ever suffering disability from the cancer. It estimates that 30% to 70% of prostate cancers found in men over 60 are clinically indolent, meaning they would never cause harm.

Active surveillance is the formal response. PDQ says it often involves regular visits, digital rectal exams, PSA tests and, in some series, ultrasound and repeat needle biopsies.

PDQ is honest about the limits. It says patient selection, testing intervals and criteria for intervention are not established in controlled trials. So ask exactly what your surveillance schedule would be, and what specific change would trigger treatment.

If immediate treatment is recommended for Grade Group 1 disease, you can ask why, and ask whether active surveillance fits your case.

PDQ sets a threshold for staging studies: a PSA above 20 ng/mL together with a Gleason score above 7, or clinical suspicion that the cancer has spread.

For that group, PSMA PET has changed the picture. PSMA stands for prostate-specific membrane antigen, a protein on prostate cancer cells that a radioactive tracer can attach to.

PDQ reports that PET-CT with the tracer 68Ga-gozetotide found metastatic disease with 85% sensitivity, compared with 38% for conventional imaging. Specificity was 98%, compared with 91%.

That is a large gap in the study PDQ cites. FDA has approved 68Ga-gozetotide and 18F-piflufolastat for initial staging and for evaluating recurrence.

Ask whether PSMA PET is indicated in your case. If it is not, ask what threshold would make it so.

USPSTF gives numbers from screening evidence. It quantifies outcomes for 1,000 men aged 55 to 69 screened over 13 years.

Benefits:

• 1.3 men avoid death from prostate cancer.
• 3 men avoid metastatic prostate cancer.

Harms along the way:

• 240 men have at least one positive PSA test.
• 220 men undergo a prostate biopsy.
• 2 men are hospitalized for biopsy complications.
• 100 men are diagnosed with prostate cancer.
• 50 men experience sexual dysfunction caused by treatment.
• 15 men develop urinary incontinence caused by treatment.

The last two lines are worth raising in a treatment discussion. They describe effects USPSTF attributes to treatment.

These numbers come from screened men, so ask your team how they apply to you.

USPSTF grades screening for men aged 55 to 69 as C, meaning the decision should be an individual one. For men 70 and older, it grades PSA screening D, meaning it recommends against it.

The main options PDQ names for localized disease are active surveillance, radical prostatectomy, external-beam radiation and brachytherapy. Hormonal therapy appears for stage III and IV disease. PDQ lists chemotherapy and immunotherapy among options for recurrent disease.

Useful ways to narrow the choice:

• Get your grade group, PSA, and clinical stage in one written sentence.
• Ask what risk group those three place you in, and what that risk group implies.
• Ask whether you can talk with both a surgeon and a radiation oncologist, since they offer different treatments.
• Ask the surgeon or center about their own outcomes for continence and erectile function.
• Ask whether a team of specialists can review your case together.

• What is my grade group, and what were the two Gleason components?
• How many biopsy cores were positive, and what percentage of each core was involved?
• What is my clinical stage, and was it based on exam, MRI, or both?
• Which risk group am I in, and would active surveillance be reasonable?
• Do I meet the criteria for PSMA PET?
• If I choose surveillance, what is the exact schedule, and what result would change the plan?
• What are this center's own rates of incontinence and erectile dysfunction after the treatment being proposed?

• https://www.cancer.gov/types/prostate/hp/prostate-treatment-pdq
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
• https://seer.cancer.gov/statfacts/html/prost.html