# Prostate Cancer Detection and Treatment: A New Approach for Patients

Prostate cancer is the most common cancer in men, with approximately 75,000 new diagnoses each year in Germany alone. This article explains a major shift in how doctors now approach prostate cancer — from who gets screened and how, to which patients truly need treatment. New guidelines recommend a personalized, risk-adapted approach: measuring a baseline PSA level at age 45, using MRI to avoid unnecessary biopsies, and expanding active surveillance to more low-risk patients. For patients, this means fewer unnecessary procedures and side effects, while still catching dangerous cancers early.

# Prostate Cancer Detection and Treatment: A New Approach for Patients

## Table of Contents

- Key Points
- Why This Research Matters
- How This Review Was Conducted
- Risk-Adapted Early Detection: The New PSA Strategy
- Digital Rectal Examination: What Has Changed
- The New PSA-MRI Diagnostic Algorithm
- Prostate Biopsy Techniques
- PSMA-PET/CT Imaging
- Genetic Counseling and Testing
- Treatment of Localized Prostate Cancer
- Active Surveillance: Monitoring Instead of Surgery
- Surgery and Radiation Therapy
- What This Means for Patients
- Study Limitations
- Recommendations for Patients
- Frequently Asked Questions
- Source Information

## Key Points

- A baseline PSA at age 45 personalizes screening; most men need no repeat test for 5 years.
- Prostate MRI before biopsy avoids up to 70% of invasive biopsies and doubles cancer detection accuracy.
- Low-risk prostate cancer (ISUP grade group 1) should be managed with active surveillance, not immediate surgery or radiation.
- In the ProtecT trial, 15-year cancer-specific survival exceeded 97% for surgery, radiation, or active monitoring.
- PSMA-PET/CT is significantly more accurate than CT with bone scan for staging lymph node metastases (92% vs 65%).

## Why This Research Matters

Prostate cancer is the most commonly diagnosed type of cancer in men in Germany, and the second most common cause of cancer-related deaths — behind only lung cancer and ahead of colorectal cancer. In 2022, approximately **75,000 new cases** were diagnosed. About **10-15% of all men** will receive a prostate cancer diagnosis at some point during their lifetime.

The good news: the 5-year survival rate is approximately **90%**. Three-quarters of all tumors are detected at an early stage (T1 or T2), meaning they are still confined to the prostate. Prostate cancer is more common in older men, with an average age at diagnosis of **71 years** (as of 2021).

However, there's a critical problem hiding in those statistics. **Half of all diagnosed prostate cancers** are what doctors call "latent" — they are undetected, clinically indolent tumors that would never cause symptoms or shorten a man's life. The dilemma facing medicine is that as prostate cancer becomes more common, it becomes increasingly important to distinguish these harmless tumors from aggressive ones that can spread (metastasize) — and to make that distinction as early as possible.

The challenge of "overdiagnosis" is significant. Currently, for every man who is saved from dying of prostate cancer by early detection, **14 men** receive a cancer diagnosis that is unnecessary in every respect, and some of them are treated for cancer as well. Looking ahead, the number of new prostate cancer cases worldwide is expected to **double** over the next 20 years due to the aging population, while deaths are projected to rise by **85%**.

The concept of overdiagnosis can't be completely eliminated because no diagnostic test is precise enough to detect only cancers that will become life-threatening. But this article, and the new German S3 clinical practice guideline it's based on, shows how individualized, highly precise early detection can at least limit overdiagnosis and the overtreatment that follows it.

## How This Review Was Conducted

This is a narrative review article, meaning the authors synthesized findings from the medical literature to provide a comprehensive overview. It is based on the systematic literature searches that were carried out to update the S3 clinical practice guideline on prostate cancer (AWMF registration number 043–022OL) for 2025.

The research team conducted **11 systematic literature searches** covering the years 2020–2024, using the Medline and Cochrane databases. Data were extracted and evidence was evaluated according to the sign-grading system, a standardized method for rating the quality of scientific evidence.

The authors represent multiple German academic institutions, including the Heinrich-Heine University Medical Faculty in Düsseldorf, the German Cancer Research Center (DKFZ) in Heidelberg, University Hospital Jena, the University Medical Center Schleswig-Holstein in Lübeck, the University Hospital Bonn, and the University Hospital Ulm.

## Risk-Adapted Early Detection: The New PSA Strategy

The biggest change in the new guidelines is a move away from "one-size-fits-all" annual screening toward a personalized, risk-adapted approach. Here's how it works:

If a man chooses to pursue early detection — and the advantages and disadvantages should be openly discussed with a doctor first — the process should begin at **age 45** with a baseline measurement of **prostate-specific antigen (PSA)**. PSA is a protein (specifically, a serine protease) produced by prostate cells that helps liquefy ejaculate. PSA levels rise when prostate cells are damaged, whether from prostatitis (inflammation), trauma (such as cycling or digital rectal examinations), or prostate cancer.

Age 45 was also recommended in the past as a starting point, but the reasoning has changed. The key insight: with a baseline PSA value at this young age, most men can be spared the previously recommended annual early detection tests for at least five years. This matters because less frequent testing lowers both the number of **false-positive findings** (abnormal PSA levels without any cancer on follow-up tests) and the number of **overdiagnoses** (detecting a cancer that would never have caused harm).

At age 45–50, the detection rate of clinically relevant prostate cancer — defined by a grading group (GG) of 2–5 in the International Society of Urological Pathology (ISUP) classification — is just **0.2–0.4%**. These relatively low prevalence figures come from the PROBASE study and the first round of the Swedish OPT implementation study.

Here is how the baseline PSA value determines the recommended follow-up:

-
**Below 1.5 ng/mL** — Low risk: no further PSA testing needed for at least 5 years. This applies to **89% of men aged 45** and **82% of men aged 50**.
-
**Between 1.5 and 3.0 ng/mL** — Intermediate risk: biennial (every 2 years) follow-up testing is recommended.
-
**3.0 ng/mL or above (confirmed)** — High risk: further evaluation is needed. Prostate cancer is found in **25–30%** of these patients.

For high-risk men, the next steps are confirmation of the PSA level within three months and a full risk assessment. If the PSA is still above 3 ng/mL and cannot be explained by an enlarged prostate gland, acute inflammation, or other known causes, an **MRI of the prostate** is recommended. These initial diagnostic steps eliminate the need for invasive biopsy in half of men with an initially abnormal PSA level.

A baseline PSA measurement at age 45–50 has another powerful type of predictive value: it can predict the **lifelong risk of developing metastatic prostate cancer**. This predictive potential is highest at age 45–50 because men at this age have not yet developed age-related benign prostatic enlargement, making the PSA value a cleaner "baseline" measurement.

One of the major reasons for overdiagnosis and overtreatment in Germany is self-initiated testing at the wrong age. According to data from AOK (a German statutory health-insurance carrier) for 2022, most men undergo cancer screening for the first time only when they are already over **75 years old** — probably in combination with a PSA test. Only **13%** undergo their first test at the ideal diagnostic age of 45–50.

Men with a suggestive family history — defined as one first-degree relative (brother or father) diagnosed with prostate cancer before age 60, or more than one first-degree relative with prostate cancer at any age — are offered the same early-detection strategy. Men with a genetic predisposition (such as pathogenic variants of the BRCA2 gene or the Lynch-syndrome-associated genes MSH2 and MSH6) should begin PSA-based screening from **age 40**. Smoking is not considered a risk factor for prostate cancer.

Here are the benefits and drawbacks of PSA-based screening, according to the guideline's evidence review:

**Advantages:**

- Lowers the probability of dying from prostate cancer: approximately **3 out of 1,000 men screened** do not die of prostate cancer.
- Lowers the probability of developing metastatic prostate cancer: approximately **4 out of 1,000 men screened** do not develop metastases.
- Reduces the need for frequent testing: **9 out of 10 men aged 45** have a PSA below 1.5 ng/mL and need no further testing for 5 years.

**Disadvantages:**

- Psychological stress from diagnostic testing for men with early-detected but non-life-threatening tumors.
- Overdiagnosis: detection of cancer in 14 men to prevent one death, with a risk of overtreatment (surgery or radiotherapy for tumors that would never become life-threatening if left untreated).
- Unnecessary diagnostic testing if the baseline PSA level is elevated with no other evidence of tumor.
- False-positive findings: **3 out of 10 MRIs** show normal findings; **3 out of 4 biopsies** after elevated PSA levels show no tumor; **1 out of 4 biopsies** after abnormal MRI show no tumor.
- Low probability of a falsely negative (normal) PSA baseline value despite a real, clinically relevant tumor: false negative rate of **0.7 per 1,000**.
- Frequent repetition of PSA tests needed in **1 out of 10 men** with a baseline PSA of 1.5–3 ng/mL (every two years).

## Digital Rectal Examination: What Has Changed

For over 50 years, the digital rectal examination (DRE) has been part of the annual cancer screening recommended by German statutory health insurance carriers. That is no longer the case.

The reason is straightforward: DRE's sensitivity in early detection of prostate cancer has been shown to be **insufficient at just 5%**. This means that DRE alone misses the vast majority of prostate cancers. The updated guidelines no longer recommend DRE for the early detection of prostate cancer.

Instead, the focus is on PSA testing combined with MRI when indicated — a far more accurate approach.

## The New PSA-MRI Diagnostic Algorithm

There is now an international consensus that any man of any age with a life expectancy of **10 years or more** and a PSA level of **3 ng/mL or higher** should undergo diagnostic testing for prostate cancer. Life expectancy can be derived from the physician's estimate or from the gait speed table of Studenski et al. (based on mean walking speed over a distance of 6 meters).

However, the process looks very different now. Before any invasive testing, patients should first undergo confirmation of PSA and a risk assessment that considers all factors that might elevate PSA — earlier diagnostic examinations, prostate size, inflammation, trauma, family history, and ethnicity. **Online risk calculators** (such as ERSPC or Cancer Research UK) are available for objective risk assessment.

If the calculators suggest an increased risk of prostate cancer (for example, a risk greater than 10% with the ERSPC No. 2 risk calculator), the next step is an **MRI of the prostate** — not an immediate biopsy, as was previously recommended. This is the heart of the new **"PSA-MRI algorithm."**

Why the change? Multiple randomized trials, primarily in prostate screening settings, have shown that this algorithm **eliminates the need for up to 70% of prostate biopsies**. That's a massive reduction in invasive procedures.

The quality of the MRI and the expertise of the radiologist interpreting it are crucial. The new S3 guideline recommends that prostate MRI be performed according to current quality standards, with interpretation by a radiologist who is specially trained and **certified in prostate MRI** (a Q2 special certificate from the German Society of Radiology).

The MRI findings guide whether a biopsy is performed. The guideline specifies precisely:

- A so-called **MRI-ultrasound fusion biopsy** is indicated when suspicion of prostate cancer on MRI is rated **PI-RADS (Prostate Imaging – Reporting and Data System) 4 or 5**.
- Biopsy may also be considered at **PI-RADS 3** if the patient is at high individual risk — for instance, when the **PSA density** (the PSA level in ng/mL divided by the prostate volume in mL) is greater than **0.15**.
- PI-RADS 1–2 lesions should **not** be biopsied.

This targeted approach increases the tumor detection rate for clinically relevant prostate cancer in screening studies to **nearly 50%**. The rationale is to avoid unnecessary biopsies of clinically indolent carcinomas (ISUP GG 1) while catching the dangerous cancers. This strategy is backed by high-level evidence from multiple randomized trials.

To put the improved accuracy in perspective: with modern MRI-guided biopsy techniques, the **positive predictive value** of an elevated PSA level rises to **42%** — meaning that when a biopsy is performed after an abnormal MRI, cancer is found nearly half the time. This includes approximately 16% clinically indolent carcinomas in ISUP grade group 1 — those harmless tumors that wouldn't have caused problems. In men aged 55 to 69 with an elevated PSA level, traditional biopsy (without MRI guidance) finds cancer in only about **25%** of cases.

## Prostate Biopsy Techniques

When a biopsy is needed, the guideline offers some flexibility. Based on multiple randomized trials, both **perineal** and **transrectal** fusion biopsies can be recommended. There is an important caveat: transrectal biopsies should only be performed with **antibiotic protection** to prevent infection. Both types of biopsy can be performed under either local or general anesthesia.

The choice of approach can be individualized based on patient anatomy, risk factors, and physician expertise.

## PSMA-PET/CT Imaging

A newer imaging tool called **PSMA-PET/CT** (positron emission tomography with prostate-specific membrane antigen as the target molecule) is gaining an important role. In this scan, a radioactive tracer targets PSMA, a protein found on prostate cancer cells, making even small areas of cancer visible on the scan.

Initial evidence suggests PSMA-PET/CT can provide valuable information during primary diagnostic testing, including information about how aggressive the cancer is (its ISUP grade group). The new guideline recommends PSMA-PET/CT primarily to rule out **lymph node and distant metastases** in locally advanced prostate cancer — defined by ISUP grade group 3 or higher, stage cT3/cT4, or PSA above 20 ng/mL.

The evidence for this is strong. In randomized trials, PSMA-PET/CT was found to be **significantly superior to conventional imaging** (computed tomography [CT] and bone scintigraphy). The accuracy of staging for lymph node metastases was:

-
**92%** with PSMA-PET/CT (confidence interval 88–95%)
-
**65%** with conventional staging using CT and bone scintigraphy (confidence interval 60–69%)

This difference was highly statistically significant (p < 0.0001), meaning there is virtually no chance it was due to random variation.

Why does this matter? Detecting lymph node or distant metastases has major therapeutic consequences. When cancer has already spread, local therapy alone (surgery or radiation to the prostate) is no longer sufficient — systemic treatment is needed instead.

## Genetic Counseling and Testing

A new recommendation in the S3 guideline: genetic counseling and the offer of **germline testing** (testing the DNA you inherited from your parents) should be offered to **all patients with metastatic prostate cancer**.

The background for this recommendation is the high prevalence — **greater than 10%** — of pathogenic variants in DNA repair genes among these patients. Knowing about these genetic changes can matter for treatment decisions, especially for newer targeted therapies.

## Treatment of Localized Prostate Cancer

Approximately **68% of prostate cancer cases** are localized and non-metastatic (UICC stages I and II, meaning T1-T2c N0 M0) at the time of initial diagnosis. This is the group where treatment decisions are most nuanced.

Prostate cancer is classified into different ISUP grade groups after biopsy, based on the Gleason score (a measure of how abnormal the cancer cells look under the microscope). These groups define clinical risk categories, each with its own risk of mortality. The most commonly used and best-validated classification is the **NCCN (National Comprehensive Cancer Network)** system, though the older D'Amico risk classification is still used in some places. The new subdivision of the intermediate-risk group has important implications for treatment.

The single most important study underpinning the new treatment recommendations is the British **ProtecT trial**, whose 15-year results were published in 2023. This landmark randomized trial compared the classic forms of treatment:

- Radical prostatectomy (surgical removal of the prostate)
- Radiotherapy (radiation therapy)
- Active monitoring (close observation with treatment only if needed)

The headline finding after 15 years of follow-up: there was **no difference in cancer-specific survival** among the three approaches — survival was **greater than 97% in each case**. In other words, the vast majority of men with localized prostate cancer did not die from their cancer regardless of which approach they chose.

This means patients with localized prostate cancer must be informed **neutrally** by urologists and radiation oncologists about all three treatment options, with due consideration of their individual health status (comorbidity) and life expectancy. The analysis implies that low-risk tumors should be managed with active surveillance, as recommended in the new S3 guideline.

## Active Surveillance: Monitoring Instead of Surgery

Active surveillance is a strategy of close monitoring rather than immediate treatment. Patients in the NCCN **low-risk** and **very-low-risk** groups make up approximately **half of all patients with localized prostate cancer**, and they can be managed with active surveillance instead of surgery or radiation.

A significant novelty in the German guideline: a defined group of patients at **"favorable intermediate risk"** is also considered appropriate for active surveillance. This decision is based on large-scale histopathological studies of prostatectomy specimens (prostates removed during surgery), which showed a clear correlation between the frequency of **Gleason pattern 4** (out of 5) and the PSA recurrence rate after radical prostatectomy. Patients with ISUP grade group 2 prostate cancer who have only a small amount of Gleason pattern 4 can also be managed primarily with active surveillance. In practice, this means less than 25% Gleason pattern 4 without cribriform or intraductal growth patterns.

Key recommendations for active surveillance:

-
**All patients with low-risk prostate cancer (ISUP GG 1)** should primarily undergo active surveillance. Neither surgery nor radiotherapy is recommended for these patients.
- Active surveillance is recommended only with a prostate MRI that meets current quality criteria and an MRI-guided biopsy, to avoid misclassification.
- During active surveillance, PSA should be checked every **3 months** (for ISUP GG 2) or every **6 months** (for ISUP GG 1) for the first two years.
- An MRI-guided **re-biopsy** is recommended at **12–18 months**.

A critical distinction: active surveillance should be discontinued in favor of surgery or radiotherapy in the event of **histological progression** (worsening of the cancer grade on biopsy) — but NOT based on a PSA increase alone. Purely MRI-guided active surveillance without re-biopsy is possible but has not yet been sufficiently evaluated to be recommended as standard practice.

## Surgery and Radiation Therapy

When treatment is needed — for men with higher-risk cancers or those who prefer definitive treatment — the guideline provides specific recommendations:

**Radical prostatectomy (RP)** is recommended for patients with localized prostate cancer who require treatment. It remains a cornerstone of definitive therapy.

For patients who experience **biochemical recurrence** (a rising PSA after surgery), the approach depends on the risk profile:

- For patients with a **high-risk profile**: **delayed percutaneous salvage radiotherapy** is recommended if biochemical recurrence from the nadir (PSA below the detection limit) is detected after surgery.
- For patients with **biochemical recurrence and a favorable risk profile** (PSA doubling time greater than 12 months, ISUP GG less than 4): **watchful waiting** is an acceptable approach.
-
**PSMA-PET/CT** examinations may be useful if PSA levels rise above **0.2 ng/mL** to locate the recurrence and assist in treatment planning.

**Primary curative radiation therapy** should be delivered using **intensity-modulated percutaneous radiotherapy (IMRT)** with **image guidance (IGRT)** — meaning the radiation is shaped precisely to the tumor and its position is verified at each treatment session. The standard dose is at least **74 Gy to 80 Gy** in normofractionated form (standard daily doses).

For localized intermediate-risk and localized high-risk prostate cancer, either **moderate hypofractionation** (for example, treatment over four weeks instead of eight) or normofractionated radiotherapy is indicated. The shorter course is more convenient for patients and has been shown to be equally effective.

## What This Means for Patients

The shift described in this article represents a fundamental change in prostate cancer care. For patients, the practical implications are substantial:

**Fewer unnecessary tests and procedures.** The old model had men getting annual PSA tests indefinitely. The new model means a single baseline PSA at age 45 tells you a lot about your personal risk. Most men (about 9 out of 10) will need no further testing for 5 years. When PSA is elevated, the routine next step is no longer an immediate biopsy — it's an MRI, which eliminates the need for up to 70% of biopsies.

**More accurate detection.** MRI-guided fusion biopsy nearly doubles the chance that a biopsy, when performed, will find a real, clinically significant cancer (42% positive predictive value compared to about 25% for traditional biopsy). Fewer men will go through the discomfort and anxiety of a biopsy that finds nothing — or, worse, finds a harmless cancer that leads to unnecessary treatment.

**Less overtreatment.** The ProtecT trial's 15-year results provide powerful reassurance: for localized prostate cancer, cancer-specific survival exceeds 97% regardless of whether men choose surgery, radiation, or active monitoring. Half of men with localized prostate cancer are now candidates for active surveillance, avoiding the side effects of surgery and radiation (such as incontinence and erectile dysfunction) without compromising their survival.

**Better staging for high-risk disease.** PSMA-PET/CT can detect lymph node and distant metastases far more accurately than older imaging methods (92% vs 65% accuracy), ensuring that men who actually need systemic treatment get it, while those with truly localized disease aren't over-treated.

The authors note that patients can be expected to **benefit greatly** from the new PSA-MRI algorithm. It eliminates unnecessary diagnostic testing and treatment while enabling necessary treatment to be initiated earlier — and therefore with fewer side effects.

However, there is a significant challenge ahead. The need for high-quality diagnostic testing, including MRI with broad geographic coverage, will be a major challenge to the health care system — especially regarding accessibility. Not every community will automatically have access to Q2-certified prostate MRI.

## Study Limitations

This article is a narrative review, not a new clinical trial. It synthesizes existing evidence, which means its conclusions depend on the quality of the underlying studies. Important limitations to keep in mind:

- The recommendations primarily reflect the German health care system, where the guideline was developed. Some recommendations (such as specific PSA thresholds and screening intervals) may not translate perfectly to other countries with different health care structures.
- The ProtecT trial, while landmark, enrolled a specific population and follow-up of 15 years — while prostate cancer can be slow-growing, longer-term differences between treatment approaches could emerge over 20–25 years.
- Active surveillance protocols vary between health systems, and the optimal monitoring intensity continues to evolve. Pure MRI-guided surveillance without re-biopsy hasn't been fully validated yet.
- PSMA-PET/CT data, while compelling for staging accuracy, represents "initial evidence" for some uses in primary diagnostics. Long-term outcome data showing that PSMA-PET/CT changes survival are still accumulating.
- Overdiagnosis cannot be completely avoided — no diagnostic test can perfectly predict which cancers will become life-threatening. The strategies described reduce overdiagnosis but don't eliminate it.

## Recommendations for Patients

Based on the guideline changes described in this article, here is what men should consider discussing with their doctors:

1.
**Start early detection at age 45.** If you're in the 45–50 age range and choose to be screened, request a baseline PSA test rather than waiting until later decades, when results are harder to interpret.
1.
**Know your baseline PSA number.** A value below 1.5 ng/mL is reassuring — you likely need no repeat testing for 5 years. Values of 1.5–3 ng/mL mean testing every 2 years. Values above 3 ng/mL require confirmation and a full urological risk assessment.
1.
**Don't panic over an elevated PSA.** Remember: 3 out of 4 biopsies done after an elevated PSA alone show no cancer. The new approach uses MRI before biopsy, avoiding invasive procedures in half of men with elevated PSA.
1.
**Ask about the quality of your MRI.** If you need a prostate MRI, ask whether the radiologist is specially certified (Q2 special certificate) and whether the scanner meets current quality standards. This significantly affects accuracy.
1.
**If diagnosed with low-risk prostate cancer, consider active surveillance.** The evidence is clear that most low-risk cancers don't threaten your life. All patients with ISUP grade group 1 should primarily undergo active surveillance rather than immediate surgery or radiation.
1.
**If you have intermediate-risk cancer, ask whether you qualify for "favorable intermediate risk" active surveillance.** If you have ISUP grade group 2 with less than 25% Gleason pattern 4 and no cribriform or intraductal growth patterns, monitoring may be a valid option.
1.
**Make treatment decisions based on the full picture.** The ProtecT trial shows no difference in cancer-specific survival between surgery, radiation, and active monitoring at 15 years. Weigh side effects, your overall health, and your preferences — not just fear of the diagnosis.
1.
**If you have high-risk or metastatic prostate cancer, ask about genetic testing.** More than 10% of men with metastatic disease carry pathogenic variants in DNA repair genes, which may affect treatment options.
1.
**Don't start screening at age 75+.** Most men currently have their first screening after age 75, which is the wrong time — it leads to overdiagnosis of harmless tumors and overtreatment. If you're older, discuss whether screening is appropriate with your doctor based on your life expectancy.

## Frequently Asked Questions

### Why should I have my first PSA test at age 45?

A baseline PSA at age 45 helps predict your lifelong risk of metastatic prostate cancer. Most men (about 9 out of 10) have a PSA below 1.5 ng/mL and need no further testing for at least 5 years. This personalized approach reduces unnecessary tests and overdiagnosis compared with annual screening.

### What does my PSA number mean after the baseline test?

A PSA below 1.5 ng/mL means low risk and no repeat testing for at least 5 years. A PSA between 1.5 and 3.0 ng/mL means intermediate risk and testing every 2 years. A confirmed PSA of 3.0 ng/mL or above means high risk, and your doctor will recommend MRI to decide if a biopsy is needed.

### Why is a digital rectal exam no longer recommended for prostate cancer screening?

The digital rectal exam (DRE) has a sensitivity of only 5%, meaning it misses the vast majority of prostate cancers. New guidelines recommend PSA testing combined with MRI when indicated, which is far more accurate. DRE is no longer part of routine early detection for prostate cancer.

### If my PSA is elevated, do I need a biopsy right away?

No. First, your PSA is confirmed and your overall risk is assessed using factors like prostate size, inflammation, and family history. If risk is increased, you undergo a prostate MRI. An MRI-ultrasound fusion biopsy is indicated only for findings rated PI-RADS 4 or 5. This approach avoids up to 70% of unnecessary biopsies.

### What is active surveillance and can I choose it instead of surgery or radiation?

Active surveillance means closely monitoring low-risk prostate cancer instead of treating it immediately. All patients with low-risk cancer (ISUP grade group 1) should primarily have active surveillance. Even some favorable intermediate-risk patients (less than 25% Gleason pattern 4) can be monitored. PSA is checked regularly and MRI-guided re-biopsy is recommended at 12–18 months.

### Does treatment choice affect survival for localized prostate cancer?

In the ProtecT trial, after 15 years, cancer-specific survival exceeded 97% whether men chose surgery, radiation, or active monitoring. There was no difference in cancer-specific death among the three approaches. This means patients should be informed neutrally about all options, weighing side effects and personal preferences.

### Should I have genetic testing if I have prostate cancer?

Genetic counseling and germline testing are recommended for all patients with metastatic prostate cancer. More than 10% of these men carry pathogenic variants in DNA repair genes. Knowing about these changes can influence treatment decisions, especially regarding newer targeted therapies. Discuss this with your doctor.

### Should I get a second opinion before deciding between active surveillance and surgery or radiation for localized prostate cancer?

Yes, a second opinion is valuable because the ProtecT trial showed that for localized prostate cancer, cancer-specific survival exceeds 97% whether you choose surgery, radiation, or active monitoring. The new guideline recommends that low-risk (ISUP grade group 1) cancers be managed with active surveillance, and some favorable intermediate-risk cases may also qualify. A second opinion can confirm your risk group and ensure you are not over-treated. Diagnostic Detectives Network provides independent expert second opinions.

## Source Information

**Original article:** "The Early Detection, Diagnostic Evaluation, and Local Treatment of Prostate Cancer: A Paradigm Shift"

**Publication:** Deutsches Ärzteblatt International | Dtsch Arztebl Int 2025; 122: 420–6

**DOI:** 10.3238/arztebl.m2025.0099

This article was based on the systematic literature searches carried out for the 2025 update of the German S3 clinical practice guideline on prostate cancer (AWMF registration number 043–022OL).

*This patient-friendly article is based on peer-reviewed research and is intended for educational purposes. It does not replace individualized medical advice. Always consult your physician about screening, diagnosis, and treatment decisions.*


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