Receiving a prostate cancer diagnosis can bring up many questions about what comes next. Understanding the typical journey, or “path,” of the disease can help provide clarity during a confusing time. This guide breaks down the common progression of prostate cancer, explaining each stage as a medical specialist would.
The journey for nearly every patient begins with diagnosis. For many men, this process is initiated by routine screening or the emergence of urinary symptoms. Specialists follow a clear process to confirm the presence of cancer and determine its characteristics.
The vast majority of men are diagnosed when the cancer is still confined to the prostate gland. This is called localized prostate cancer. At this point, the path often splits into two main directions, depending on the risk level determined by the PSA level, Gleason score, and clinical stage.
For men with a low Gleason score (typically 6) and a small amount of slow-growing cancer, the most common recommendation is often not immediate treatment. Instead, specialists recommend a program called active surveillance. This is not the same as doing nothing; it is a proactive approach to closely monitor the cancer.
Active surveillance typically involves:
The goal is to avoid or delay the side effects of treatment for as long as possible, since many of these low-risk cancers grow so slowly they may never cause a problem in a man’s lifetime. Treatment is only initiated if there are signs the cancer is becoming more aggressive.
For men with more aggressive or higher-volume localized cancer (e.g., Gleason score of 7 or higher), specialists usually recommend definitive treatment aimed at curing the disease. The two primary treatment options are:
The choice between these treatments depends on a man’s age, overall health, and personal preferences after a detailed discussion with his medical team.
After treatment with surgery or radiation, some men experience what is called a “biochemical recurrence.” This is not a clinical diagnosis of visible cancer but is defined by a rising PSA level.
For a man who had a prostatectomy, any detectable PSA can signal a recurrence. For a man who had radiation, doctors look for a specific rise in PSA over its lowest point. A rising PSA suggests that some cancer cells remained in the body and are starting to grow again. The next step is usually imaging scans, like a PSMA PET scan, to try and locate where the cancer is. Treatment at this stage, called salvage therapy, might involve radiation (if surgery was the first treatment) or other systemic therapies.
If prostate cancer spreads beyond the prostate gland, it is considered advanced or metastatic. The most common place for it to spread is to the lymph nodes and bones. The goal of treatment at this stage shifts from a cure to controlling the cancer’s growth, managing symptoms, and extending life.
The cornerstone of treatment for advanced prostate cancer is Androgen Deprivation Therapy (ADT), also known as hormone therapy. Prostate cancer cells use testosterone (an androgen) as fuel to grow. ADT works by dramatically lowering the testosterone levels in the body, which effectively starves the cancer cells and causes them to shrink or stop growing for a period of time. This is usually administered through injections.
While ADT is very effective, most prostate cancers eventually adapt and start to grow again even with very low testosterone levels. This is known as Castration-Resistant Prostate Cancer (CRPC). When this happens, the path involves moving to other treatments, such as more advanced hormone therapies (like abiraterone or enzalutamide), chemotherapy, targeted therapies, or radiopharmaceuticals, to continue controlling the disease.
What are the most common symptoms of prostate cancer? In its early stages, prostate cancer often has no symptoms. As it grows, it can cause issues like difficulty urinating, a weak urine stream, blood in the urine or semen, and erectile dysfunction. However, these symptoms are more commonly caused by non-cancerous conditions like an enlarged prostate (BPH).
Is prostate cancer always a slow-growing disease? No. While many prostate cancers are slow-growing and may not require immediate treatment, some forms are very aggressive and can spread quickly. The Gleason score from a biopsy is the best tool specialists use to determine how aggressive a particular cancer is.
Does every man with prostate cancer follow this exact path? This guide describes the most common progression, but every patient’s journey is unique. The specific path depends on the cancer’s characteristics, the patient’s age and overall health, and decisions made in consultation with a team of medical specialists, including urologists and oncologists.