Prostate cancer: screening, PSA, MRI, biopsy and treatments — how can care be personalised?

A raised PSA does not automatically mean cancer

PSA is a protein produced by the prostate. Its level can rise in case of cancer but also with benign enlargement, inflammation, infection or after certain examinations. There is therefore no single figure that “proves” cancer. Age, prostate volume, PSA trend, family history and clinical examination are taken into account.

Early detection: an individual decision

The French AFU 2024–2026 guidelines propose a strategy adapted to individual risk. Digital rectal examination still has a role in the assessment, and a suspicious examination may lead to an MRI even if the PSA is not very high. The decision to look for cancer must take into account life expectancy, personal risks and the patient’s preferences, because detecting an indolent tumour can lead to overdiagnosis and overtreatment.

Men of African descent have a higher risk of prostate cancer, sometimes at a younger age. The European Association of Urology (EAU) guidelines recommend offering them, as for men with a family history, information about PSA testing earlier, from the age of 45, instead of 50 in the general population, as part of a shared decision.

Why has MRI become central before biopsy?

Multiparametric MRI helps identify suspicious areas, estimate prostate volume and calculate PSA density. Lesions are classified according to PI-RADS. The AFU recommends MRI before a first set of biopsies as part of the diagnostic strategy. An MRI with low suspicion combined with low clinical risk may, in some patients, lead to postponing a biopsy after shared decision-making.

How are biopsies performed?

When indicated, systematic samples may be combined with biopsies targeted at the lesions visible on MRI. Transperineal or transrectal approaches are possible depending on practice. Pathology analysis determines the tumour type and the ISUP grade group, derived from the Gleason score, which contributes to risk assessment.

The transperineal route is increasingly used because of its infection profile, but the strategy depends on the centre and the context.

Must a localised cancer always be treated immediately?

No. For some low-risk cancers, active surveillance is a standard strategy: the patient is monitored with PSA, examination, MRI and sometimes biopsies, with curative treatment if the disease is reclassified. This strategy aims to avoid the side effects of unnecessary treatment without losing the possibility of treating the cancer if it progresses.

What are the main treatment options?

Depending on risk and stage: radical prostatectomy, external beam radiotherapy, brachytherapy, combined hormone therapy in some situations, or surveillance. For advanced disease, additional systemic treatments may be needed (chemotherapy, new hormone therapies, targeted treatments or radiopharmaceuticals depending on the characteristics of the disease).

In metastatic disease, hormone therapy remains a cornerstone; the biological profile and the course of the disease then guide successive choices.

Side effects and shared decision-making

Surgery and radiotherapy can affect urinary, sexual and sometimes bowel function, with different profiles. The decision is therefore not based only on expected survival, but also on age, other illnesses, urinary and sexual function before treatment, and the patient’s priorities.

Frequently asked questions