Rung Five

The prostate cancer pathway, step by step

Prostate cancer is common and usually slow, so the biggest decisions are about finding the cancers that matter and not over-treating the ones that don't.

1

Decide about PSA testing, ideally in your mid-to-late 40s

The longest-running screening trial shows a lasting drop in prostate cancer deaths with regular PSA testing, along with real overdiagnosis. U.S. Task Force guidance (2018, under revision) calls screening an individual decision from 55 to 69 and advises against routine screening at 70 and older. The American Urological Association's 2026 guideline says doctors may offer a baseline PSA between 45 and 50. Men with a family history and Black men face higher risk and have more reason to start the conversation early.

13%fewer prostate cancer deaths with screening after 23 yearsERSPC, NEJM 2025, 162,236 men
1 in 456men invited to screening avoided a prostate cancer deathERSPC 23-year follow-up
About 1 in 4men with a raised PSA had cancer on biopsyERSPC Finnish report
2

If PSA is high, confirm before a biopsy

The 2026 AUA guideline advises repeating a newly raised PSA before further markers, imaging or biopsy. MRI before biopsy helps reduce detection of harmless cancers. Ask whether an MRI or a secondary blood or urine test fits your situation.

3

Low-risk cancer: active surveillance is a proven choice

In the ProtecT trial, men with PSA-detected localized prostate cancer were randomly assigned to monitoring, surgery or radiation. At 15 years about 97% in every group had not died of prostate cancer. Monitoring led to more progression, but not more deaths, and a quarter of monitored men never needed treatment. Today's MRI-based surveillance is more precise than the version tested.

3.1%, 2.2%, 2.9%prostate cancer deaths with monitoring, surgery and radiation; no significant differenceProtecT, NEJM 2023
24%of monitored men were alive and never treated at 15 yearsProtecT
4

While on surveillance: what men can do themselves

None of these has yet been shown to change survival in a large trial, but each is low-risk and several show measurable effects on the cancer's biology. In rough order of evidence: keep a healthy weight (strongly linked to advanced prostate cancer), exercise hard and regularly (lowered PSA and PSA velocity in a randomized trial), eat mostly plants (linked to 47% less progression in a large cohort), favor cooked tomatoes and unfermented soy, and ask your urologist before trying a high-omega-3, low-omega-6 diet with fish oil (lowered a tumor growth marker in a small trial).

Skip high-dose vitamin E and selenium pills: no benefit, and vitamin E raised risk. Watch dairy and calcium: the World Cancer Research Fund rates evidence of higher prostate risk as limited.

5

Higher-risk or advanced disease: ask about genetics and PSMA

Standard care is surgery or radiation, often with hormone therapy, and for advanced disease newer hormone drugs and chemotherapy. Three 2025–26 FDA approvals reward testing the tumor: the PSMA-targeted radioligand Pluvicto now covers metastatic hormone-sensitive as well as castration-resistant disease, capivasertib is approved for PTEN-deficient metastatic cancer, and talazoparib with enzalutamide is approved for HRR-mutated metastatic cancer that still responds to hormone therapy. Ask for a PSMA PET scan and tumor plus inherited genetic testing.

Jul 31, 2026Pluvicto approved with hormone pathway drugs for PSMA-positive metastatic hormone-sensitive cancerNovartis and FDA
Jun 12, 2026Capivasertib with abiraterone approved for PTEN-deficient metastatic cancerFDA, CAPItello-281
Oct 26, 2026Talazoparib with enzalutamide approved earlier for HRR-mutated metastatic cancerFDA, TALAPRO-3