The Early Detection, Diagnostic Evaluation, and Local Treatment of Prostate Cancer: A Paradigm Shift

Abstract

Background: Approximately 75 000 men receive a diagnosis of prostate cancer in Germany each year. New data on the early detection, diagnostic evaluation, and treatment of prostate cancer provide the basis for a paradigm shift in the management of locally confined prostate cancer.

Methods: This narrative review is based on the systematic literature search that was carried out for the 2025 update of the German clinical practice guideline on prostate cancer.

Results: Risk-adapted early detection is now recommended. This involves the measurement of a baseline PSA value at age 45 whose magnitude determines the interval of follow-up testing: once every 5 years for baseline values below 1.5 ng/mL, and once every two years for baseline values between 1.5 and 3 ng/mL. Patients with PSA levels above 3 ng/mL should undergo a repeat PSA test and, if these levels are confirmed, receive a urological risk assessment including prostatic volume, family history, and past medical history. High risk patients should undergo magnetic resonance imaging (MRI) and, if necessary, prostate biopsy. This new PSA-MRI algorithm increases accuracy in detecting clinically significant prostate cancers, enabling the previously recommended annual testing and digital rectal examination to be avoided. Another novelty is that the indication for an active surveillance strategy for men with low-risk prostate cancer has been expanded to ISUP grade group 1 and 2 cancers with favorable risk.

Conclusion: The need for high-quality diagnostic testing, including MRI, with broad geographic coverage will be a major challenge to the health care system, especially with regard to accessibility. Patients can be expected to benefit greatly from the new PSA-MRI algorithm, as it eliminates unnecessary diagnostic testing and treatment while enabling necessary treatment to be initiated earlier and therefore with fewer side effects.

Figure

Algorithm for risk-adapted early detection ERSPC, European Randomized Study of Screening for Prostate Cancer; MRI, magnetic resonance imaging; PSA, prostate-specific antigen

Figure 1

Multiparametric magnetic resonance imaging (MRI) The patient is a 73-year-old man with a confirmed elevated PSA level of 9.5 ng/mL. In the peripheral zone of the mid-prostate, right anterior to posterolateral, there is a suspect area of highly probable carcinoma (arrows) with a PI-RADS of 5. Subsequent targeted MRI-ultrasound fusion biopsy led to the diagnosis of prostate cancer with a Gleason score of 3+4 (60%/40%).

Figure 2

PSMA-PET/CT in a 55-year-old man with an initial diagnosis of prostate cancer (iPSA 25.8 ng/mL). 18F-PSMA positron emission tomography (PET) for primary staging. The images in the upper row include coronal sections from computed tomography (CT) scans, a PET scan, and a fused PET/CT scan. The images in the lower row include a transaxial CT and a fused PET/CT. The PSMA PET/CTs show focal, intensified PSMA uptake in the prostate, without uptake in the lymph nodes or other organs (miTNM codeline: mT3b [LM, RM, LSV] N0 M0).

eFigure

Targeted MRI/ultrasound fusion biopsy system Computer used to combine MRI images with ultrasound images (left), high-resolution ultrasound scanner (middle), exam table with leg support (right, foreground)