Prostate cancer is the most common cancer in American men apart from skin cancer. Many prostate cancers grow so slowly that they never cause harm, while others are aggressive and life-threatening. That is why decisions about testing and treatment are more personal than for most cancers. This guide explains the PSA test, the warning signs and the treatment options.
What the prostate does
The prostate is a walnut-sized gland below the bladder that makes part of the fluid in semen. It often enlarges with age, a non-cancerous condition called benign prostatic hyperplasia (BPH), which causes urinary symptoms in many older men.
Who is at higher risk
- Age: risk rises sharply after 50, and most cases are diagnosed after 65
- Black men are more likely to develop prostate cancer and more likely to die from it
- Family history: a father or brother with prostate cancer raises risk, especially if diagnosed young
- Inherited gene changes, including BRCA1, BRCA2 and Lynch syndrome
Symptoms
Early prostate cancer usually causes no symptoms. When symptoms occur, they can include:
- Needing to urinate often, especially at night
- A weak or interrupted urine stream
- Difficulty starting to urinate
- Blood in the urine or semen
- Erectile dysfunction
- Pain in the back, hips or pelvis that does not go away, which can be a sign of spread to the bones
Most urinary symptoms in older men are caused by BPH rather than cancer, but they should still be checked.
The PSA test
PSA (prostate-specific antigen) is a protein made by the prostate. A simple blood test measures it. Higher levels can be a sign of prostate cancer, but PSA also rises with BPH, prostate infection or inflammation, recent ejaculation, vigorous cycling and age.
There is no single cut-off that proves cancer. Doctors look at your PSA level, how quickly it is rising, your age, prostate size and other risk factors.
Benefits and downsides of screening
Benefits: PSA screening can find cancers early, before symptoms, and has been shown to reduce deaths from prostate cancer modestly over the long term.
Downsides: it can produce false alarms, lead to biopsies that carry small risks such as infection, and find slow-growing cancers that would never have caused problems. Treating those cancers can cause side effects such as urinary leakage and erectile dysfunction without improving survival.
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Current recommendations
The U.S. Preventive Services Task Force recommends that men aged 55 to 69 make an individual decision about PSA screening after discussing the benefits and harms with their doctor. It recommends against routine screening for men 70 and older. Many specialists suggest starting the conversation at 40 to 45 for Black men and men with a strong family history or known genetic risk.
If your PSA is high
A raised PSA does not mean you have cancer. Your doctor may repeat the test, check for infection, and often arrange an MRI of the prostate before any biopsy. MRI helps identify suspicious areas and allows some men to avoid an unnecessary biopsy. If a biopsy is needed, it can be targeted at the suspicious areas.
Cancer found on biopsy is graded using the Gleason score and Grade Group (1 to 5), which describe how aggressive it looks under the microscope. Grade Group 1 is the least aggressive.
Treatment options
Treatment depends on the grade, stage, your age, overall health and preferences.
Active surveillance. For low-risk cancers, many men choose careful monitoring with regular PSA tests, MRI scans and repeat biopsies instead of immediate treatment. Treatment starts only if the cancer shows signs of progressing. This approach avoids or delays side effects, and studies show it is safe for appropriately selected men.
Surgery (radical prostatectomy). Removal of the prostate, usually robot-assisted. Possible side effects include urinary leakage, which usually improves over months, and erectile dysfunction.
Radiation therapy. External beam radiation or brachytherapy (radioactive seeds placed in the prostate), sometimes combined with hormone therapy. Side effects can include bowel, urinary and sexual problems.
Hormone therapy (androgen deprivation therapy) lowers testosterone, which fuels most prostate cancers. It is used for advanced cancer and alongside radiation for higher-risk disease.
Treatments for advanced cancer include newer hormone medicines, chemotherapy, targeted drugs for tumors with certain gene changes, and radiopharmaceuticals that deliver radiation directly to cancer cells.
For localized prostate cancer, long-term survival is very high with any of the main approaches, so men often choose based on side effects and personal priorities. Getting opinions from both a urologist and a radiation oncologist is a good idea.
Living well and lowering risk
There is no proven way to prevent prostate cancer, but staying active, keeping a healthy weight, not smoking and eating plenty of vegetables support overall health and may help.
The bottom line
Prostate cancer is common and often slow-growing, but some cases are aggressive. Men aged 55 to 69, and higher-risk men from their 40s, should talk with their doctor about whether PSA testing makes sense for them. If cancer is found, options range from active surveillance to surgery or radiation, and there is time to make an informed choice.
This article is for general information and does not replace medical advice.