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Prostate Cancer

Last updated 31 May 2026 · Oncology clinical guideline

📋 Key Information Summary

📋
  • Prostate cancer is the most common non-skin cancer in Australian men, with 1 in 6 diagnosed by age 85.
  • Risk is increased by age, family history (especially BRCA1/2 mutations), and African ancestry.
  • Diagnosis hinges on a combination of PSA level, digital rectal examination (DRE), and prostate biopsy.
  • Multiparametric MRI (mpMRI) is a key staging and risk-stratification tool, widely available in Australia.
  • The Gleason score (and newer ISUP Grade Groups) is the primary histopathological prognostic factor.
  • TNM staging, PSA level, and Gleason score combine to define risk groups (low, intermediate, high) that guide management.
  • Active surveillance is the standard of care for most men with low-risk, localised disease to avoid overtreatment.
  • Definitive treatment options include radical prostatectomy (open/robotic) and radiotherapy (external beam or brachytherapy).
  • Androgen deprivation therapy (ADT) is used in combination with radiotherapy for intermediate/high-risk localised disease and as first-line for metastatic disease.
  • Novel imaging with PSMA-PET/CT has revolutionised staging for intermediate and high-risk disease, replacing many conventional scans.
  • Treatment decisions are complex and require shared decision-making, considering cancer risk, patient age, comorbidities, and quality-of-life preferences.
  • Aboriginal and Torres Strait Islander men have higher prostate cancer mortality and face significant barriers to timely diagnosis and care.

Introduction & Australian Epidemiology

Prostate cancer is the most commonly diagnosed cancer in Australian men and the third most common cause of cancer death. It is a significant public health challenge, with management evolving from a one-size-fits-all approach to highly personalised, risk-stratified care. The cornerstone of modern management is accurate staging and risk assessment, guiding the critical decision between active surveillance, curative-intent therapy, and palliative management.

In Australia, the age-standardised incidence rate is approximately 180 per 100,000 men, with a lifetime risk of about 1 in 6. Mortality has been steadily declining due to earlier detection and improved treatments. However, significant disparities exist, particularly for Aboriginal and Torres Strait Islander men, who are often diagnosed at a later stage and have poorer survival outcomes.

Epidemiology & Risk Factors

Age is the strongest risk factor, with incidence rising sharply after age 50. Other established risk factors include:

  • Family History: Having a first-degree relative (father, brother) with prostate cancer doubles the risk. Risk increases further with multiple affected relatives or early onset in relatives. Germline mutations in BRCA1, BRCA2, and HOXB13 confer a significantly elevated lifetime risk.
  • Ethnicity: Men of African ancestry have the highest global incidence. In Australia, incidence is slightly lower in men of Asian descent.
  • Other Factors: Obesity is associated with higher-grade, more aggressive disease. There is no definitive evidence linking vasectomy, BPH, or specific dietary factors to causation, though lifestyle factors may influence progression.
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Familial/Hereditary Cancer: Consider referral to a familial cancer service for men with a strong family history (e.g., ≥3 first-degree relatives, or BRCA2 carrier) for discussion of earlier PSA screening (from age 40) and genetic testing implications.

Pathology & Gleason Grading

Over 95% of prostate cancers are adenocarcinomas. Histological grading is the single most important prognostic factor for localised disease.

The Gleason Score is determined by the pathologist assessing the two most prevalent glandular patterns (1-5) in the biopsy sample. The primary and secondary patterns are added to give a score (e.g., 3+4=7). Pattern 5 is the most poorly differentiated and aggressive.

ISUP Grade Groups (2014): To improve clinical clarity, Gleason scores have been condensed into five prognostic Grade Groups:

ISUP Grade GroupGleason ScorePrognosis
1≤ 6 (3+3)Low risk, excellent prognosis
27 (3+4)Favourable intermediate risk
37 (4+3)Unfavourable intermediate risk
48High risk
59-10Very high risk

Investigations (PSA, Biopsy & Imaging)

ESSENTIAL
Prostate-Specific Antigen (PSA) & Digital Rectal Examination (DRE)
PSA is a serum tumour marker. An elevated PSA (>3.0 ng/mL in some risk-stratified approaches) or abnormal DRE warrants further investigation. PSA density, velocity, and free-to-total ratio can improve specificity. MBS Item 66645.
ESSENTIAL
Transperineal or Transrectal Ultrasound-Guided Prostate Biopsy
The transperineal approach is now preferred in Australia to reduce sepsis risk. A systematic biopsy is performed, often with fusion targeting of MRI-identified lesions. Provides Gleason score and Grade Group.
WIDELY AVAILABLE
Multiparametric MRI (mpMRI) of the Prostate
Used for local staging (PI-RADS score), guiding targeted biopsies, and planning surgery/radiotherapy. Standard of care prior to biopsy for most patients. MBS Item 63464.
WIDELY AVAILABLE
PSMA-PET/CT
Revolutionised staging for intermediate-risk (unfavourable) and high-risk disease. Superior to conventional bone scan and CT for detecting nodal and distant metastases. PBS Authority Required.
SPECIALIST
Bone Scan & CT Chest/Abdomen/Pelvis
Largely superseded by PSMA-PET/CT for initial staging. May still be used where PSMA-PET is unavailable or for follow-up in specific settings.

Management (Surveillance, Surgery, Radiotherapy & ADT)

Management is determined by risk stratification, patient fitness, and life expectancy.

Low Risk
ISUP 1, PSA <10, T1-T2a
Active Surveillance is the recommended standard. Involves regular PSA, DRE, MRI, and repeat biopsies to monitor for progression, deferring treatment with curative intent unless indicated.
Setting: Primary care & Urology outpatient
Intermediate Risk
ISUP 2-3, PSA 10-20, T2b-T2c
Active treatment recommended. Choice between Radical Prostatectomy and Radiotherapy + ADT (4-6 months) is based on patient preference, tumour location, and morbidity profiles.
Setting: Multidisciplinary team (MDT) discussion
High / Very High Risk
ISUP 4-5, PSA >20, T3-T4 or N1
Multimodal therapy required. Often Radical Prostatectomy + extended lymph node dissection followed by adjuvant radiotherapy, or Radiotherapy + long-term ADT (18-36 months). PSMA-PET essential for staging.
Setting: Specialist MDT, tertiary centre

Key Treatment Modalities

⚕️
Radical Prostatectomy
Open or Robotic-Assisted (RALP)
Aim Complete removal of prostate and seminal vesicles. Nerve-sparing technique possible for localised disease.
Key Risks Urinary incontinence, erectile dysfunction, anastomotic stricture.
MBS Item 37226 (Robotic)
☢️
Radiotherapy (EBRT)
External Beam Radiotherapy, often IMRT/VMAT
Regimen Typically 37-44 fractions over 7.5-8.5 weeks (conventional) or 20 fractions over 4 weeks (hypofractionated, now standard).
With ADT Short-course (4-6 mo) for intermediate; Long-course (18-36 mo) for high-risk.
💊
Goserelin
Zoladex® · GnRH agonist
Adult dose 3.6 mg SC depot every 28 days, or 10.8 mg SC every 12 weeks.
Role Androgen Deprivation Therapy (ADT). Mainstay of medical castration for locally advanced/metastatic disease.
PBS status ✔ PBS General Benefit
Aboriginal and Torres Strait Islander Health Considerations

Prostate cancer outcomes for Aboriginal and Torres Strait Islander men are significantly worse than for non-Indigenous Australians, driven by later presentation, barriers to accessing specialist care, and higher comorbidity burdens.

Presentation Stage
Higher proportion diagnosed with advanced (metastatic) disease, limiting curative treatment options.
Access to Care
Geographic isolation, cultural safety concerns, and lower referral rates to urologists and radiation oncologists.
Culturally Safe Practice
Utilise Indigenous Health Workers and Liaison Officers. Allow extended consultation times for shared decision-making. Be aware of shame and stigma related to genitourinary examinations.
Systemic Action
Support community-controlled health services. Advocate for equitable access to novel diagnostics (PSMA-PET) and treatments.

📚 References

  1. 1. Cancer Australia. Prostate cancer in Australia statistics. Australian Government. https://www.cancerdata.gov.au/prostate (accessed 2024).
  2. 2. Australian Institute of Health and Welfare (AIHW). Prostate cancer in Aboriginal and Torres Strait Islander people. Cat. no. CAN 133. Canberra: AIHW; 2021.
  3. 3. Prostate Cancer Foundation of Australia and Cancer Council Australia. Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer. 2021.
  4. 4. Mottet N, van den Bergh RCN, Briers E, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer—2023 Update. European Urology. 2023;84(2):208-222.
  5. 5. National Health and Medical Research Council (NHMRC). PSA testing and early management of test-detected prostate cancer: A consumer guide. 2016.
  6. 6. Royal Australian and New Zealand College of Radiologists (RANZCR). Prostate external beam radiotherapy treatment guidelines. 2022.
  7. 7. Hofman MS, Lawrentschuk N, Francis RJ, et al. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA). Lancet. 2020;395(10231):1208-1216.
  8. 8. Department of Health (Australia). Medical Benefits Schedule (MBS) Item 63464, 66645, 37226. Australian Government.
  9. 9. Pharmaceutical Benefits Scheme (PBS). Zoladex (goserelin) and other LHRH analogues. Australian Government.
  10. 10. Urological Society of Australia and New Zealand (USANZ). Position statement on active surveillance for prostate cancer. 2023.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).