Prostate Cancer: From Diagnosis to Treatment Decision
Prostate cancer is not a single disease. A roadmap through your risk group, your treatment options and what actually determines the decision.
Last medically reviewed: October 4, 2026 — Assoc. Prof. Dr. Müslüm Ergün
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About the condition
Prostate cancer is one of the most common cancers in men. An important feature is that in most cases it PROGRESSES SLOWLY. For that reason not every prostate cancer carries the same urgency, and not every patient receives the same treatment.
The purpose of this page is not to sell you a treatment but to make the decision process understandable. In prostate cancer the most common mistake is to think "there is cancer, take it out now" without looking at the risk group — or, conversely, to delay a disease that genuinely requires treatment.
HOW THE DIAGNOSIS IS MADE: the process usually begins with a rising PSA or a firmness found on digital rectal examination. Today a biopsy is not performed straight away; a multiparametric prostate MRI is done first. If the MRI shows a suspicious area, a targeted sample is taken from it (fusion biopsy). This approach reduces unnecessary biopsies and helps avoid missing significant cancers.
WHAT THE BIOPSY RESULT TELLS YOU: the pathologist scores how aggressive the cancer cells look under the microscope using the Gleason score; this is simplified into the ISUP grade, five groups from 1 to 5. ISUP 1 is the most indolent group, ISUP 5 the most aggressive. The number of cores involved and which areas they come from are also recorded.
RISK GROUP: the PSA value, the ISUP grade and the stage of the tumour are assessed together, and the disease is classified as low, intermediate or high risk. This classification forms the basis of the treatment decision. If needed, further imaging (such as a bone scan or PSMA PET) is requested to look for spread.
WHAT DETERMINES THE DECISION: your risk group alone is not enough. Your age, life expectancy, accompanying conditions, urinary and sexual function and your own priorities are weighed together. Two patients in the same risk group may be offered different treatments; this is not an inconsistency but the natural result of deciding case by case.
Who is it suitable for?
May be suitable
- Men with a rising PSA or a suspicious finding on rectal examination
- Patients diagnosed with prostate cancer on biopsy who wish to review their treatment options
- Patients who have been offered treatment elsewhere and are seeking a second opinion
- Low-risk patients who have been offered active surveillance and want to understand the process
- Patients whose PSA is rising again after treatment (biochemical recurrence)
May not be suitable
- People who have not yet had a PSA test or examination — basic assessment comes first
- Patients with urinary symptoms only and no suspicion of cancer — benign prostatic enlargement should be assessed instead
- Situations requiring urgent intervention (inability to pass urine, signs of kidney failure) — urgent treatment takes priority
- People with a single high PSA value and no confirmed diagnosis — PSA alone does not make a diagnosis
Technology used
- Multiparametric prostate MRI — identifying the suspicious area before biopsy
- MRI fusion biopsy — targeted sampling
- PSMA PET (in selected cases) — assessment of spread
- da Vinci robotic system — if surgery is chosen
Surgeon's experience
Verifiable information
- Surgeon's experience
- Assoc. Prof. Dr. Müslüm Ergün121270
Step-by-step journey
- Step 1
PSA and examination
A rising PSA or an examination finding starts the process. A single high PSA does not make a diagnosis; infection and benign enlargement can also raise it, so the value is repeated.
- Step 2
Multiparametric MRI
Performed BEFORE biopsy. If there is a suspicious area it shows its location and its relationship to the capsule; if there is not, an unnecessary biopsy may be avoided.
- Step 3
Targeted biopsy
A sample is taken from the area marked on MRI using the fusion technique. The result is reported as an ISUP grade.
- Step 4
Risk group and staging
PSA, ISUP grade and stage are assessed together to determine the risk group. If necessary, a search for spread is carried out.
- Step 5
Treatment decision
The decision is reached by discussing your risk group, age, accompanying conditions and priorities together. Seeking a second opinion at this stage is entirely reasonable.
Method comparison
| Risk group | Typical findings | Prominent options | Points to watch |
|---|---|---|---|
| Low risk | Low PSA, ISUP 1, limited involvement | Active surveillance first; surgery and radiotherapy also options | Avoiding overtreatment; adherence to follow-up is essential |
| Intermediate risk | ISUP 2–3 or moderately raised PSA | Radical prostatectomy or radiotherapy | The possibility of nerve-sparing is assessed separately in this group |
| High risk | ISUP 4–5, high PSA or advanced stage | Surgery or radiotherapy, often with additional treatment | Oncological safety takes priority; a search for spread is needed |
This table summarises the logic of the decision; it is not individual advice. The final decision is made together with your age, accompanying conditions and priorities.
Risks
- OVERTREATMENT: treating a low-risk, slow-growing cancer with unnecessary surgery or radiotherapy; side effects occur while the gain in life expectancy is limited
- UNDERTREATMENT: leaving a disease that genuinely needs treatment under surveillance, or delaying it
- Deciding on the basis of a single PSA value — PSA also rises with infection and benign enlargement
- Going straight to biopsy without an MRI — the chance of missing significant tumours increases
- Not discussing the side effects of treatment (urinary leakage, changes in sexual function) before surgery
Alternatives
- Active surveillance — close follow-up with regular PSA, MRI and biopsy in selected low-risk patients
- Radical prostatectomy — surgical removal of the prostate (robotic or open)
- Radiotherapy — external beam treatment or brachytherapy
- Focal therapies — targeting the tumour-bearing area in selected cases; the evidence base is developing
- Hormone therapy — in advanced disease, usually alongside other treatments
Recovery
Diagnostic phase
What is most needed in this period is time and accurate information. Most forms of prostate cancer progress slowly enough to allow you a few weeks to decide; you do not have to decide in haste.
Decision phase
Compare the side effects of the options with your own priorities in life. Discuss your expectations about continence and sexual function openly; this prevents most of the disappointment experienced later.
After treatment
Whichever treatment is chosen, regular PSA follow-up is carried out. A PSA that stays at the expected level is the most practical measure that the treatment is working.
Frequently asked questions
I have been diagnosed with prostate cancer — do I need surgery straight away?
In most cases, no. A large proportion of prostate cancers progress slowly and you have a few weeks to decide. Your risk group needs to be established first. In low-risk patients, active surveillance may be more appropriate than immediate treatment.
My PSA came back high — do I have cancer?
Not necessarily. PSA is a protein produced by prostate tissue, and inflammation, benign enlargement or even some recent procedures can raise it. A diagnosis is therefore not made on a single high value; the test is repeated and, if needed, an MRI follows.
Why is an MRI done before biopsy?
A multiparametric MRI shows the suspicious area in advance. The biopsy can then be targeted rather than random; the chance of missing significant cancers falls, and in some patients an unnecessary biopsy can be avoided.
Which is better, surgery or radiotherapy?
In intermediate- and high-risk localized disease both are accepted options and neither has a definitive advantage over the other. The difference lies in their side-effect profiles: with surgery, urinary leakage is more prominent early on; with radiotherapy, bowel and bladder symptoms can appear over time. The choice is made together with your age, accompanying conditions and priorities.
Does active surveillance mean "doing nothing"?
No. Active surveillance is a planned programme: PSA measurement at set intervals, MRI and, when needed, repeat biopsy. The aim is to move to treatment in good time if the disease shows signs of progression, while avoiding unnecessary side effects in the meantime. It is not suitable for patients who cannot keep to the follow-up.
Will my sexual function and continence be affected?
Both main treatments can affect these functions. In surgery, if a nerve-sparing technique can be applied the chance for sexual function improves; continence usually recovers within weeks. It is important to discuss your expectations clearly before treatment.
I would like a second opinion — how do I send my file?
Sharing your MRI images, your biopsy/pathology report and your PSA values is enough. You may send your file for a second opinion only; this does not oblige you to receive treatment.
What if my PSA rises again after treatment?
This is called biochemical recurrence and can appear before the disease is visible on imaging. The rate of rise, the initial treatment and the risk group are assessed, and either additional treatment or close surveillance is planned. Detecting it early widens the options.
There is prostate cancer in my family — what should I do?
In men with a first-degree relative affected by prostate cancer, starting assessment earlier is advised. At what age to begin and how often to repeat it depends on your personal risk profile; this is worth discussing with your physician.
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This page is for general information only and is not a substitute for medical advice.
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