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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
Key points
- USPSTF: PSA screening is an individual decision for men aged 55-69; do not screen routinely age 70 or older
- Diagnosis requires prostate biopsy; PSA is not diagnostic by itself
- Localized low-risk disease may be managed with active surveillance
- Definitive local options include radical prostatectomy or radiation therapy depending on risk and patient factors
- Metastatic prostate cancer commonly spreads to bone with osteoblastic lesions and elevated alkaline phosphatase
Overview
Prostate cancer is usually adenocarcinoma arising in the peripheral zone of the prostate. It is biologically heterogeneous: many tumors are indolent, while high-grade or metastatic disease can be lethal. Risk assessment integrates PSA, digital rectal examination, MRI, biopsy grade group/Gleason score, tumor stage, number of cores, and imaging.
Epidemiology
Prostate cancer is one of the most common cancers in men in the United States. Risk increases with age, Black ancestry, family history, BRCA2 and other DNA repair mutations, and Lynch syndrome. Many patients die with prostate cancer rather than from it, making overdiagnosis and overtreatment central screening issues.
Clinical Features
Symptoms
Usually asymptomatic when localized
Lower urinary tract symptoms may occur but are more often due to BPH
Bone pain, weight loss, fatigue suggesting metastatic disease
Back pain with weakness, saddle anesthesia, or urinary retention suggesting spinal cord compression
Hematuria or obstructive uropathy in locally advanced disease
Signs
DRE may reveal hard, nodular, asymmetric prostate
Normal DRE does not exclude prostate cancer
Focal neurologic deficits or spinal tenderness with metastases
Lymphadenopathy or lower extremity edema in advanced disease
Investigations
First-line
PSA with shared decision-makingScreening decision individualized ages 55-69; PSA can be elevated by BPH, prostatitis, ejaculation, and procedures
Digital rectal examinationAssesses nodularity/asymmetry but is not sufficiently sensitive as sole screen
Repeat PSA and risk assessmentConfirm unexpected elevation and incorporate age, prostate size, family history, race, and prior PSA trend
Second-line
Multiparametric prostate MRIUsed before biopsy in many modern pathways to target lesions and improve risk stratification
Prostate biopsyTransrectal or transperineal biopsy confirms diagnosis and provides Gleason grade group
Staging labsAlkaline phosphatase may rise with bone metastases; renal function if obstruction
Specialist
PSMA PET/CT or conventional staging imagingUsed for unfavorable intermediate, high-risk, recurrent, or metastatic disease depending on availability and guideline pathway
Germline testingConsider in metastatic, high-risk, strong family history, or DNA repair-associated cancer patterns
Management
USPSTF Prostate Cancer Screening Recommendation; NCCN Prostate Cancer Guidelines; ASCO guidance1
Screening
- Ages 55-69: shared decision-making about PSA screening, balancing mortality benefit against false positives, biopsy harms, and overtreatment
- Age >=70: routine PSA screening is not recommended by USPSTF
- Higher-risk men may discuss screening earlier with clinicians, especially Black men or strong family history
2
Localized disease
- Very low/low-risk: active surveillance is preferred for many patients
- Intermediate/high-risk: radical prostatectomy, radiation therapy, and/or androgen deprivation depending on risk group
- Use grade group, PSA, clinical stage, MRI, and patient preference to select therapy
3
Advanced and metastatic disease
- Androgen deprivation therapy is foundational for metastatic hormone-sensitive disease
- Add androgen receptor pathway inhibitors, docetaxel, radiation to primary, PARP inhibitors, radioligand therapy, or immunotherapy in selected settings
- Treat spinal cord compression urgently with steroids, MRI, and radiation/surgery evaluation
Complications
- Bone metastases: Osteoblastic lesions, pain, fractures, spinal cord compression
- Urinary obstruction: Hydronephrosis or renal dysfunction in advanced disease
- Treatment adverse effects: Erectile dysfunction, incontinence, bowel symptoms, hot flashes, osteoporosis, metabolic syndrome
- Overdiagnosis: Detection of indolent cancer that may never become clinically significant
USMLE Step 2 CK Exam Tips
- 1PSA screening age 55-69 is shared decision-making; age >=70 do not routinely screen
- 2PSA is organ-specific, not cancer-specific; prostatitis and BPH can elevate it
- 3Diagnosis requires biopsy, not PSA alone
- 4Low-risk localized prostate cancer often gets active surveillance
- 5Prostate cancer bone metastases are typically osteoblastic; myeloma lesions are lytic
- 6Back pain plus neurologic deficits in cancer patient = spinal cord compression emergency
- 7Androgen deprivation causes hot flashes, osteoporosis, metabolic syndrome, and sexual dysfunction
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