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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Prostate cancer is the home of theranostics: PSMA PET finds it, PSMA radioligands treat it. Hormonal therapy remains the foundation, with PARP and AKT inhibitors added by genotype.
Prostate cancer is the most common cancer in men in most high-income countries and a spectrum: most PSA-detected disease is indolent and safely watched (ProtecT: ~3% prostate-cancer mortality at 15 years whatever the strategy), while de novo metastatic disease, treated with hormonal doublets and triplets and since 2026 with radioligand therapy added, has a median overall survival of about five years in the trial populations behind those regimens, which means half of those men lived longer; it is the second most common cause of cancer death in men. Diagnosis now runs PSA → multiparametric MRI (PRECISION) → targeted biopsy → Grade Group, with germline and somatic HRR testing for advanced disease and PSMA PET for staging (proPSMA) and recurrence. Digital-pathology AI (ArteraAI Prostate, 2025) and gene-expression classifiers (Decipher) refine who needs treatment and who benefits from adding hormone therapy.
Treatment is built on androgen deprivation, the first targeted cancer therapy (Huggins, 1941). Metastatic hormone-sensitive disease is treated with doublets (ADT + abiraterone, enzalutamide, apalutamide or darolutamide) or triplets adding docetaxel (ARASENS, PEACE-1), and since 31 July 2026 with 177Lu-PSMA-617 added to ADT + ARPI (PSMAddition, rPFS HR 0.72). PTEN-deficient disease gained capivasertib + abiraterone in 2026. In castration-resistant disease the sequence includes ARPI switch, PARP inhibitors for HRR-mutant tumours (PROfound, PROpel, TALAPRO-2 with OS benefit), docetaxel and cabazitaxel, radium-223 for bone-only disease, and 177Lu-PSMA-617 before or after chemotherapy (VISION, PSMAfore). Enzalutamide is approved even for high-risk PSA-only recurrence (EMBARK).
| Setting | Approach | Guideline |
|---|---|---|
| Screening | Shared-decision PSA testing from 50 (45 if Black or family history/BRCA), risk-adapted intervals; MRI before biopsy; avoid biopsy if MRI negative and PSA density low. | not mapped |
| Biochemical recurrence | PSMA PET to localise; salvage radiotherapy ± ADT after prostatectomy; metastasis-directed SBRT for oligorecurrence (investigational for survival); enzalutamide ± ADT for high-risk BCR (EMBARK). | not mapped |
| Metastatic hormone-relapsed disease: what is in trials once the approved order runs out | The approved sequence is in the hormone-relapsed row above. After it, the options are trials: actinium-225 PSMA radioligand therapy for men who have progressed on lutetium-177 (AlphaBreak), the STEAP1 T-cell engager xaluritamig (XALUTE) and the KLK2 engager pasritamig, the EZH2 inhibitor mevrometostat with enzalutamide (MEVPRO-1), and, for treatment-emergent neuroendocrine disease, platinum with etoposide outside a trial and the DLL3 and B7-H3 agents borrowed from small cell lung cancer, tarlatamab and ifinatamab deruxtecan. | not mapped |
| Localised prostate cancer: monitoring, surgery or radiotherapy, and what each one costs you | This is the decision the whole of prostate cancer turns on, and it is unusual because the three options are not ranked. NICE NG131 (1.3.8 to 1.3.12) writes one recommendation per Cambridge Prognostic Group: active surveillance is offered first at CPG 1, a choice between all three is offered at CPG 2, radical treatment is offered at CPG 3 with surveillance kept open for men who choose not to be treated immediately, and surveillance is not offered at CPG 4 and 5. If you were given a risk band instead of a number, the bridge is that CPG 1 is low risk, CPG 2 and 3 are intermediate risk and CPG 4 and 5 are high risk; the group is worked out from your Gleason score or grade group, your PSA and your T stage, and a UK pathology report carries the Gleason score and the grade group together. For CPG 1 to 3, NICE (1.3.7) sends the conversation to its box 2, which is a table of what happened to 100 men offered each option in the UK ProtecT trial, and the honest summary of that table is that survival was the same and the harms were not. On survival, box 2 reports that at 10 years, 98 out of 100 men offered monitoring, 99 out of 100 offered prostatectomy and 99 out of 100 offered radiotherapy had not died of prostate cancer, and that the evidence does not show a difference between them. At a median of 15 years the trial found death from prostate cancer in 17 of 545 men (3.1 percent) on monitoring, 12 of 553 (2.2 percent) after prostatectomy and 16 of 545 (2.9 percent) after radiotherapy, with the overall comparison not significant. What treatment changed was spread: metastases in 51 men (9.4 percent) on monitoring against 26 (4.7 percent) and 27 (5.0 percent), and clinical progression in 141 (25.9 percent) against 58 (10.5 percent) and 60 (11.0 percent). A quarter of the monitoring group, 133 men, were alive at the end of follow-up with no prostate cancer treatment of any kind. On continence, box 2 reports moderate to severe incontinence at 6 months in 19 out of 100 men offered prostatectomy against 4 on monitoring and 6 after radiotherapy, and at 6 years in 13, 8 and 5. The trial's own patient-reported figures are blunter: pad use went from 1 percent before treatment to 46 percent at 6 months after surgery, against 4 percent and 5 percent in the other two groups, and was still 17 percent at 6 years and 18 to 24 percent through years 7 to 12. On sexual function, box 2 reports moderate or severe erectile dysfunction at 6 months in 66 out of 100 men offered prostatectomy, 48 after radiotherapy and 29 on monitoring, and at 6 years in 50, 36 and 40. Of the men in the trial, 67 percent could get an erection firm enough for intercourse before anything was done; at 6 months that was 12 percent after surgery, 22 percent after radiotherapy and 52 percent on monitoring, and by year 12 all three groups had converged at a low level. On bowels, radiotherapy is the one that costs: moderate to severe impact of bowel habits on quality of life at 6 months in 10 out of 100 men offered radiotherapy against 3 in each other group, and faecal leakage in 12 percent of the radiotherapy group against 6 percent of the others by year 12. Nothing in this row is a prediction about one man. It is what happened to 1,643 UK men aged 50 to 69 with mostly CPG 1 to 3 disease, and the reason to read it is that it names the trade-off rather than gesturing at it. NICE surrounds the choice with process: a decision aid in the clinic (1.1.6), nomograms with their limits explained (1.1.7), all relevant options discussed even when the local service does not offer them (1.1.9), an assessment by both a specialist surgical oncologist and a specialist clinical oncologist (1.3.5), and an explicit conversation about sexual function, physical appearance, continence and other aspects of masculinity with the man and, if he wishes, his partner (1.1.12). | not mapped |
| If you choose radiotherapy: the schedule, and the hormone therapy that comes with it | Choosing radiotherapy is choosing a schedule and a course of hormone therapy at the same time, and men are often surprised by the second part. On the schedule, NICE NG131 (1.3.19) says to offer hypofractionated radiotherapy, 60 Gy in 20 fractions, using image-guided intensity modulated radiation therapy unless contraindicated, with conventional radiotherapy, 74 Gy in 37 fractions, reserved for people who cannot have the shorter course. Twenty visits over four weeks is therefore the standard rather than a lesser version of it. NG131 (1.3.24) says to consider adding a brachytherapy boost, where radioactive sources are placed in the prostate itself, for CPG 2 to 5, and (1.3.25) not to offer brachytherapy alone at CPG 4 and 5, so whether a boost is available is a question about the centre. On the hormone therapy, NG131 (1.3.21) says to offer radical radiotherapy combined with androgen deprivation therapy rather than either alone for CPG 2, 3, 4 and 5, (1.3.22) six months of it before, during or after the radiotherapy, and (1.3.23) to consider continuing for up to 3 years at CPG 4 and 5 while discussing the benefits and risks of that with the person. This matters because almost everything men describe afterwards as the effect of radiotherapy is the effect of the hormone therapy: the hot flushes, the loss of sex drive, the weight around the waist, the tiredness. The radiotherapy's own signature is in the bowel and the bladder in the weeks around treatment, and in the small late risks: NG131 (1.3.6) asks that people are told about the small increase in the risk of colorectal cancer after radical external beam radiotherapy, and (1.3.42) that anyone with signs of radiation-induced enteropathy is cared for by a team with expertise in it. For high-risk disease starting long-term hormone therapy, NG131 (1.3.26) asks for a separate discussion about adding six cycles of docetaxel, with box 3 setting out both sides plainly: clear evidence that progression is delayed by about a year, a five-year survival difference of 84 against 80 out of 100 that might be chance, and 15 out of 100 developing a fever from a low white count with 1 in 100 dying of an infection they might not otherwise have had. | not mapped |
| Living with hormone therapy: hot flushes, bones, heart, weight and mood, and what is offered for each | Hormone therapy is the longest part of this illness for most men and the least well covered. It works by taking testosterone away, and testosterone was doing a great many other things. The effects last for as long as the treatment does, and Prostate Cancer UK says that after stopping it can take several months to several years for them to settle, while an orchidectomy cannot be reversed at all. Hot flushes are the commonest complaint: NICE NG131 (1.4.3) says to offer medroxyprogesterone 20 mg a day for an initial 10 weeks and to evaluate the effect at the end, and (1.4.4) to consider cyproterone acetate 50 mg twice a day for 4 weeks if that fails or is not tolerated; in a randomised trial of 309 men the median daily hot-flush score fell by 83.7 percent on medroxyprogesterone and 94.5 percent on cyproterone at one month, against 47.2 percent on venlafaxine. NG131 (1.4.5) also says plainly that there is no good-quality evidence for complementary therapies here. Bone thinning starts in the first year and increases with time on treatment: in 50,613 men, 19.4 percent of those on androgen deprivation surviving at least five years had a fracture against 12.6 percent of those not on it. NICE's four bone sentences run in a specific order: (1.4.12) do not routinely offer bisphosphonates to prevent osteoporosis, (1.4.13) consider assessing fracture risk, (1.4.14) offer bisphosphonates to those who have osteoporosis, and (1.4.15) consider denosumab where bisphosphonates are contraindicated or not tolerated. A DEXA scan is how the question is answered. On the heart and the metabolism, in 73,196 Medicare enrollees GnRH agonist use carried adjusted hazard ratios of 1.44 for new diabetes, 1.16 for coronary heart disease, 1.11 for myocardial infarction and 1.16 for sudden cardiac death; in the HERO trial, major adverse cardiovascular events occurred in 2.9 percent of 622 men on oral relugolix against 6.2 percent of 308 on leuprolide over 48 weeks. Prostate Cancer UK suggests general health checks roughly every six months: weight, blood pressure, cholesterol and a diabetes check. Body composition changes: muscle goes, fat arrives, particularly at the waist, and joint and muscle aches follow. NICE NG131 (1.4.18) says to tell people that fatigue is a recognised effect of the therapy and might not be the cancer, and (1.4.19) to offer supervised resistance and aerobic exercise at least twice a week for 12 weeks to reduce fatigue and improve quality of life, which is the single most concrete offer in this section. On mood, Prostate Cancer UK says hormone therapy itself can cause tearfulness, mood swings, low mood, anxiety and depression, and a meta-analysis of 18 studies in 168,756 men found a 41 percent higher risk of depression on androgen deprivation. Memory and concentration change too, though the evidence for a direct cause is weak. Gynaecomastia has its own answer: NG131 (1.4.16) says to offer prophylactic radiotherapy to both breast buds within the first month for people starting long-term bicalutamide monotherapy, a single 8 Gy fraction, with weekly tamoxifen considered if that does not work. And where treatment is long-term and not adjuvant, NG131 (1.4.1) says to consider intermittent therapy, discussing the limited evidence for a reduction in side effects and the effect on progression, with PSA measured every 3 months and treatment restarted at 10 nanogram/ml or above. | not mapped |
| Continence and sexual function: what happens, what help exists, and how to ask for it | These are the two things men do not raise, so this page raises them first. On continence: most men leak when the catheter comes out after a prostatectomy, usually seven to ten days after the operation, because the operation disturbs the sphincter and the pelvic floor. It improves. In ProtecT, pad use after surgery was 46 percent at six months and 17 percent at six years; radiotherapy barely touched continence at 4 to 5 percent. What helps, in the order the guideline puts it: pelvic floor muscle exercises, started four to six weeks before the operation and restarted as soon as the catheter is out; absorbent pads and pants, sheaths, bed protectors and clamps while things settle; bladder retraining for urgency; and, where it does not settle, medicines, an internal male sling for men leaking two to three pads a day at a year, or an artificial urinary sphincter for men still leaking heavily six months on. NICE NG131 (1.3.39) requires access to specialist continence services, (1.3.40) referral for consideration of an artificial urinary sphincter for intractable stress incontinence, and (1.3.41) rules out bulking agent injections. On sexual function: the figures are in the first row of this page, and they are worth reading with someone rather than alone. What is worth knowing is that the services exist and that starting early works better. NICE NG131 (1.3.36) says to offer access to specialist erectile dysfunction services after radical treatment, (1.3.37) to offer PDE5 inhibitor tablets, and (1.3.38) to offer vacuum devices, intraurethral inserts, penile injections or a penile prosthesis where tablets fail or are contraindicated; (1.4.8) extends the same access to men starting hormone therapy and (1.4.10, 1.4.11) repeats the ladder for them. All of it is free on the NHS whether the erection is wanted for sex or for masturbation, and there is no age limit. Prostate Cancer UK says to try each type of tablet at least eight times before moving on, that injections work within 5 to 10 minutes and often work even when desire is low, that about 3 in 100 implants get infected and roughly 5 in 100 inflatable implants need replacing within ten years, and that an erection lasting more than four hours is priapism and means going straight to accident and emergency. Two other things men are rarely told: the penis can become shorter or curved after surgery, and using a vacuum pump early, alone or with tablets, may help preserve it; and orgasm survives even when ejaculation does not, though it feels different, and some men leak urine at orgasm, which pelvic floor exercises help. Beside all of this NICE NG131 (1.1.13) offers the man and his partner the chance to talk to a healthcare professional experienced in psychosexual issues at any stage, and (1.4.9) considers psychosexual counselling for couples on long-term hormone therapy. Taking that offer is not an admission of anything. | not mapped |
| A rising PSA after treatment: what it means, how fast it is rising, and what happens next | After radical treatment the PSA becomes the thing everyone watches, and the waiting for each result has its own name in the clinic. NICE NG131 (1.3.47) says to check it no earlier than 6 weeks after treatment, then at least every 6 months for the first 2 years and at least once a year after that, and (1.3.48) not to do a routine rectal examination while it stays at baseline; (1.3.49) allows remote follow-up after the first 6 months for people with a stable PSA and no significant complications, which for many men means a blood test locally and a phone call. The most useful sentence in the guideline for anyone watching a number go up is (1.3.55): a rising PSA alone should not mean an immediate change in treatment. What matters is the speed, so (1.3.56) asks for the doubling time to be estimated from at least three measurements over at least six months. After a prostatectomy with no known metastases the standard answer is radiotherapy to the prostate bed (1.3.57), often still given with the aim of cure. NG131 (1.3.54) says not to offer routine MRI before salvage radiotherapy but to offer an isotope bone scan if symptoms or PSA trends suggest metastases, and (1.3.58) to consider entry to a clinical trial; in practice a PSMA PET scan is now what localises the disease, and the imaging rows on this page say what it can and cannot see. Hormone therapy is deliberately held back: (1.3.59) says not to offer it routinely for biochemical relapse unless there is symptomatic local progression, proven metastases, or a doubling time of less than three months, which is the guideline protecting men from years of side effects for a number rather than a disease. Where the risk is high, the EMBARK trial is the evidence for adding enzalutamide at this point, and that is a conversation for the multidisciplinary team rather than a default. | not mapped |