Prostate Cancer:
PSA Test, Active Surveillance & Treatment

1. What is prostate cancer?

Prostate cancer (prostate carcinoma) is a malignant tumour of the prostate — the chestnut-sized gland below the bladder that produces part of the seminal fluid. It is the most common cancer in men in Germany and occurs above all in later life.^¹,²

What sets prostate cancer apart: many of these tumours grow very slowly. A considerable proportion of the men affected do not die of their prostate cancer but with it — without ever having had any symptoms. But there are aggressive courses too, which should be treated early. Understanding that range is the key to almost every decision in this disease: from the PSA test to the choice of treatment.

The risk factors regarded as established are above all age and a family history: if your father or brother has had the disease, your own risk is higher — and screening that starts earlier and is done more closely can then make sense.^¹

2. The PSA test: an honest appraisal

The PSA test measures prostate-specific antigen in the blood — a protein made only by the prostate. Cancer cells often release more PSA than healthy tissue does. That sounds simple, but it is not: a benign enlargement, inflammation, cycling or a digital rectal examination shortly before the blood sample can all raise the level too. A raised PSA level is a pointer, not a diagnosis.

What the test can do — and what it cannot

The PSA test can pick up prostate cancer years before it causes any noticeable symptoms, and in trials it lowered deaths from prostate cancer in the screened group. Set against that are serious drawbacks: false alarms leading to distressing biopsies — and above all overdiagnosis, that is, finding tumours that would never have caused symptoms but are then often treated, with all the consequences that has for continence and potency.^²,³

That is why, in Germany, the PSA test as a screening test is not covered by statutory health insurance but is an individual health service (IGeL) that you pay for yourself. The IGeL-Monitor, run by the Medical Service, is critical of the test as a screening measure, because the possible harm can outweigh the benefit.^³ The German S3 guideline recommends that anyone considering the test should first be given open, balanced information about its benefits and harms — the decision is yours.^¹ Where there is a concrete suspicion to be investigated (after an abnormal rectal examination, for instance), the PSA test is covered by statutory health insurance and is unquestionably useful.

• Good reasons for the test: You want to know, you have been informed about the consequences, and with an abnormal result you would be able to decide calmly — for active surveillance, say, rather than immediate treatment.
• Good reasons against: You do not want to carry the risk of false alarms and overdiagnosis — that too is an informed and legitimate decision.
• Not a good idea: Having the test “in passing”, without proper information and without a plan for what should happen if the level comes back raised.

3. Symptoms and warning signs

In its early stages prostate cancer as a rule causes no symptoms at all — the tumour usually arises in the outer parts of the gland, well away from the urethra. That is precisely why symptoms are no use for early detection. Problems often appear only once the tumour has grown larger or has spread:

• Problems passing urine — a weak stream, needing to go more often, getting up at night. These problems are, however, far more often the result of benign prostate enlargement.
• Blood in the urine or in the semen — always needs looking into, even though the cause is often harmless.
• Pain when passing urine or on ejaculation, and newly appearing erection problems.
• Bone pain, above all in the back or the pelvis — possible in advanced disease, but far more often down to something harmless.

4. The Gleason score and risk groups explained

If cancer is found in the tissue samples, the pathologist assesses how far the tumour cells deviate from healthy glandular tissue. That gives the Gleason score: the two predominant growth patterns are each given a number and the two are added together — values from 6 to 10 are the usual ones. Put simply: the higher the value, the more aggressively the tumour behaves. Today the score is often also translated into the more intuitive grade groups 1 to 5.^¹,⁴

The Gleason score, the PSA level and how far the tumour extends together give the risk group — the most important basis for the treatment decision:

5. Diagnosis: MRI, biopsy and what it all means

• Rectal examination and the PSA trend: A first appraisal; a single raised value is as a rule checked again before any further steps follow.
• MRI scan of the prostate: Recommended today before a biopsy — it shows suspicious areas and helps to avoid unnecessary biopsies and to take samples more precisely.^¹
• Biopsy (taking tissue samples): Only this confirms the diagnosis. Several samples are taken, usually guided by ultrasound and fused with the MRI images.
• Staging investigations: With a higher risk, further imaging to rule out involvement of the lymph nodes or the bones.
• Your medication history: Worth knowing: medicines for benign prostate enlargement from the class of 5-alpha-reductase inhibitors can roughly halve the PSA level — that has to be taken into account when the result is interpreted. Have your medication list to hand at your urology appointment.

There is room for time between the findings and the decision: in the great majority of cases prostate cancer is not an emergency. Use that time for a second opinion if you are unsure — in hardly any other cancer do the possible routes differ as much as they do here.

6. Treatment: the options at a glance

Hardly any other cancer offers routes as different, and as equally valid, as localised prostate cancer does. For low risk the guideline places active surveillance on an equal footing with surgery and radiotherapy — there is no “best” option in general, only one that fits your findings, your age, your other conditions and your priorities.^¹ The decision is always made together with the urology team.

7. Active surveillance: treating when it becomes necessary

Active surveillance is the logical answer to the problem of overdiagnosis: if many small tumours would never cause symptoms, they do not have to be operated on or irradiated straight away — they only have to be kept reliably in view. For men with a low-risk profile it is a full, guideline-backed first option, not “doing nothing” and not going without treatment.^¹,²

In practice that means regular PSA checks and rectal examinations, plus MRI scans and repeat biopsies at set intervals. If the tumour shows signs of growth or of greater aggressiveness, the switch is made to treatment aimed at cure — and on the experience of large follow-up studies, as a rule without the chance of a cure having been lost. Some men go on to be treated; others stay permanently without an intervention — and so spare themselves its side effects entirely.

One thing has to be said honestly as well: living with an untreated tumour is not psychologically bearable for everyone. Some men opt for treatment despite a low risk, because the uncertainty weighs on them more than possible side effects would. That too is a legitimate, informed decision — it just should not be made in a moment of panic.

8. Surgery or radiotherapy: the honest comparison

Both approaches can cure localised prostate cancer with comparable prospects — they differ above all in what they involve and in their side effects. A rose-tinted picture helps nobody, so here are the consequences that are too rarely talked about openly:^¹,²

One thing matters: both consequences are treatable. Pelvic floor training is the most effective first step against incontinence — how to stick with it is covered in the article Urinary incontinence. For erection problems there are several levels, from tablets to aids; the article Erectile dysfunction sets out the possibilities. Raise both of them yourself at your follow-up appointments — they are medical matters, not embarrassments.

9. Hormone therapy: how it works and managing side effects

Prostate cancer cells grow under the influence of testosterone. Androgen deprivation therapy interrupts that signal — usually with GnRH analogues or GnRH antagonists given as a depot injection, which turn down testosterone production in the testicles, supplemented depending on the situation by tablets that block the signal at the cancer cell. It is used above all in advanced or metastatic disease, and sometimes for a limited period to support radiotherapy.^¹,⁴ What makes sense and when is decided by the treating practice.

The treatment works — but withdrawing testosterone affects the whole body. Knowing the side effects lets you counter them instead of stopping:

• Hot flushes and sweats — very common; you will find practical strategies in the article Hot flushes.
• Tiredness and low drive — regular exercise is the best-evidenced countermeasure; the article Fatigue helps put it in context.
• Muscle loss and weight gain — strength training twice a week works against both.
• Loss of bone density — a bone density scan, exercise, calcium and vitamin D; the background is in the article Osteoporosis.
• Loss of libido and low mood — talk about it openly; persistent low mood can develop into depression and is treatable. The article Low libido also helps put it in context.

Because other medicines often run alongside hormone therapy — for blood pressure, bones or mood — it is worth a regular look at Drug interactions. And keep a structured record of side effects: the guide Medication side effects shows how vague complaints become information your practice can actually use.

10. Everyday life with prostate cancer

• Treat check-ups like dental appointments — firmly in the calendar, with a reminder. Whether it is active surveillance or follow-up care: continuity is half the treatment.
• Write your PSA values down yourself — date, value, laboratory. A record of your own makes conversations more precise and takes the fright out of individual outliers.
• Take pelvic floor training seriously — before and after an operation. It is unspectacular, but it is the most effective thing you can do yourself against incontinence.
• Build exercise and strength training in — against tiredness, muscle loss and bone loss on hormone therapy there is hardly anything better.
• Organise how you take things properly — especially when tablets and injection appointments come together. Practical routines are in the guide How to take medications.
• Talk about sex — with your partner and with your treatment team. For almost every problem there are more options today than most men expect.

PSA trend and treatment under control — with brite

Values, appointments, medicines and side effects in one place. Free.

Start free now