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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Commonest cancer in males in the UK (~52,000 new cases/year). Lifetime risk ~1 in 8. Adenocarcinoma arising from the peripheral zone (~70%)
- Risk factors: age (>50), Black ethnicity (2× risk), family history, BRCA2 mutations
- PSA: useful but imperfect screening tool (false positives: BPH, UTI, prostatitis, cycling. False negatives: ~15% of prostate cancers have normal PSA)
- Investigation pathway: PSA raised → mpMRI prostate (PI-RADS scoring) → targeted biopsy (transperineal, NICE NG131)
- Management spectrum: active surveillance (low-risk) → radical prostatectomy/radiotherapy (localised) → ADT ± docetaxel (advanced/metastatic)
Overview
Prostate cancer is the commonest cancer in males in the UK. The vast majority (~95%) are adenocarcinomas arising from the peripheral zone of the prostate gland. The disease has an extremely variable natural history — ranging from indolent microscopic tumours (found incidentally in >50% of men aged >80 at autopsy) to aggressive metastatic disease. Histological grading uses the Gleason scoring system (recently updated to the Grade Group system 1–5). The disease is androgen-dependent, forming the basis for androgen deprivation therapy (ADT) in advanced disease. Prostate cancer has a predilection for bony metastases (characteristically osteosclerotic/osteoblastic).
Epidemiology
Approximately 52,000 new cases per year in the UK — the most common cancer in males. Second most common cause of cancer death in men (after lung). Five-year survival is approximately 86% overall (>99% for localised disease, <30% for metastatic). Incidence increases sharply with age (rare <50 years). Black men have approximately double the risk, and present at a younger age with more aggressive disease. BRCA2 mutation carriers have ~3–5× increased risk.
Clinical Features
Symptoms
Often asymptomatic — detected by PSA testing or incidental finding
Lower urinary tract symptoms (LUTS): frequency, nocturia, hesitancy, poor stream — often due to co-existing BPH rather than the cancer itself
Haematuria (rare at presentation)
Erectile dysfunction
Bone pain (especially back, pelvis, proximal limbs — from bony metastases)
Weight loss, fatigue (advanced disease)
Spinal cord compression: bilateral leg weakness, urinary retention, saddle anaesthesia (ONCOLOGICAL EMERGENCY)
Signs
Hard, irregular, nodular prostate on DRE (peripheral zone tumour)
Loss of median sulcus (advanced local disease)
May have normal DRE (anterior or small tumours)
Bony tenderness (metastases)
Lower limb lymphoedema (pelvic lymph node metastases)
Neurological signs of spinal cord compression (late)
Investigations
First-line
PSA (prostate-specific antigen)Raised PSA warrants further investigation. Age-adjusted reference ranges (e.g. >3.0 ng/mL in 50–59 years). False positives: BPH, UTI, prostatitis, recent ejaculation, catheterisation, vigorous exercise
Digital rectal examination (DRE)Assess prostate size, texture, symmetry, nodularity. Hard, irregular, craggy prostate = suspicious for malignancy
Second-line
Multiparametric MRI (mpMRI) prostateFirst-line investigation BEFORE biopsy (NICE NG131). PI-RADS scoring 1–5: PI-RADS ≥3 = likely significant cancer → proceed to biopsy. Avoids unnecessary biopsies
Transperineal prostate biopsyTargeted (MRI-guided) + systematic. Transperineal approach preferred over transrectal (lower sepsis risk). Provides Gleason score and Grade Group
Specialist
Staging investigationsBone scan (isotope) or PSMA PET-CT for intermediate/high-risk disease — detect bone and lymph node metastases. CT chest/abdomen/pelvis
Gleason score and Grade GroupGleason 6 (GG1) = low-risk. Gleason 3+4=7 (GG2) = favourable intermediate. Gleason 4+3=7 (GG3) = unfavourable intermediate. Gleason 8 (GG4) and 9–10 (GG5) = high-risk
Management
NICE NG131 (Prostate cancer), 20191
Localised low-risk (GG1, PSA <10, T1–T2a)
- Active surveillance: PSA monitoring (every 3–6 months), repeat mpMRI (12–18 months), rebiopsy if concern
- Suitable for men with low-volume, low-grade disease — avoids overtreatment
- Switch to radical treatment if evidence of progression
2
Localised intermediate/high-risk
- Radical prostatectomy: open, laparoscopic, or robotic. Includes pelvic lymph node dissection for high-risk
- Radical radiotherapy: external beam (EBRT) ± brachytherapy boost, with concurrent ADT (6 months for intermediate, 2–3 years for high-risk)
- Side effects of surgery: erectile dysfunction (~50%), urinary incontinence (~5–20%). Side effects of radiotherapy: bowel toxicity, erectile dysfunction, urinary symptoms
3
Locally advanced/metastatic
- Androgen deprivation therapy (ADT): LHRH agonists (goserelin, leuprorelin) or antagonists (degarelix), or bilateral orchidectomy
- Advanced hormone-sensitive: ADT + abiraterone, or ADT + docetaxel, or ADT + enzalutamide (triplet/doublet therapy)
- Castration-resistant prostate cancer (CRPC): abiraterone, enzalutamide, docetaxel, cabazitaxel, radium-223 (bone metastases), olaparib (BRCA-mutated)
- LHRH agonist flare prevention: co-prescribe anti-androgen (bicalutamide) for first 2 weeks to prevent testosterone flare
4
Supportive care
- Bone health: zoledronic acid or denosumab for bone metastases (prevent skeletal events)
- ADT side effects: hot flushes, osteoporosis, metabolic syndrome, cardiovascular risk, fatigue, sexual dysfunction — counsel and manage proactively
- Spinal cord compression: emergency — high-dose dexamethasone + urgent MRI + neurosurgical/oncological review
Complications
- Bone metastases: Characteristically osteosclerotic (osteoblastic) — back pain, pathological fractures, spinal cord compression. Raised ALP
- Spinal cord compression: Oncological emergency — dexamethasone + urgent imaging and treatment
- Urinary obstruction: Locally advanced disease can cause bilateral ureteric obstruction → AKI
- Treatment side effects: Radical prostatectomy: incontinence, erectile dysfunction. ADT: osteoporosis, metabolic syndrome, cardiovascular risk, loss of libido
UKMLA Exam Tips
- 1Prostate cancer arises from PERIPHERAL zone (70%). BPH arises from TRANSITIONAL zone. This is why BPH causes LUTS but early prostate cancer does not
- 2mpMRI prostate BEFORE biopsy (NICE NG131) — this changed practice. PI-RADS ≥3 = biopsy. PI-RADS 1–2 = avoid unnecessary biopsy
- 3PSA is organ-specific NOT cancer-specific — raised in BPH, prostatitis, UTI, catheterisation, ejaculation
- 4Bone metastases from prostate cancer are characteristically OSTEOSCLEROTIC (unlike most cancers which are osteolytic). Raised ALP
- 5LHRH agonist flare: initial testosterone surge can worsen symptoms (bone pain, cord compression). Prevent with anti-androgen cover (bicalutamide) for 2 weeks
- 6Gleason 3+4=7 ≠ Gleason 4+3=7. The PRIMARY pattern matters more: 4+3 is worse than 3+4
- 7Active surveillance ≠ watchful waiting. AS = curative intent with monitoring. WW = palliative intent in elderly/comorbid
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