Prostate cancer: symptoms, causes, and diagnosis

A cancer with no warning signs

This point deserves to be made right away, as it is the source of a frequent misunderstanding. Many men think they will know how to recognize the signs. In reality, waiting for symptoms to appear most often amounts to missing the window where the cancer is most easily curable.

This is precisely why the diagnosis is based on PSA test and on the'imaging, and not on listening to symptoms. A perfectly asymptomatic man can have cancer, whereas a man with severe difficulty urinating most often has a simple prostate adenoma, which is not cancerous at all.

Urinary symptoms: what they really mean

Nevertheless, urinary disorders can accompany prostate cancer. Two situations occur: either the tumor has progressed enough to compress the urethra, or—and this is by far the most frequent case—an adenoma coexists with the cancer.

The signs involved are the same as those of benign hypertrophy:

• Frequent urges to urinate, especially at night
• Difficulty starting or to interrupt the stream
• Weak jet or interrupted
• Pain or burning during urination
• Pelvic pain or perineal

In other words, these symptoms warrant a consultation, but they in no way allow for a conclusion. Only an evaluation, combining a clinical examination, a PSA test, and imaging, can distinguish between an adenoma, prostatitis and cancer. These three conditions can also coexist in the same patient.

In detail: prostate symptoms and their evaluation

The signs of advanced cancer

When the disease progresses beyond the gland, other manifestations may appear. They then reflect local or distant extension.

Bone pain

The skeleton is the primary site of prostate cancer metastasis. Persistent pain in the pelvis, spine, or hips, without an obvious mechanical cause, should prompt a medical consultation.

They do not necessarily mean a spread: back pain is common after 50. But combined with a high PSA, they require an evaluation.

Other signs may accompany an advanced disease:

• Worsening of urinary symptoms, until retention
• Blood in the urine or semen
• Persistent fatigue and unusual
• Unexplained weight loss
• Erectile dysfunction recently appeared

However, it should be remembered that the vast majority of prostate cancers are now detected before this stage, thanks to PSA testing. These signs correspond to situations that have become less frequent.

Causes and risk factors

The exact mechanisms that trigger prostate cancer remain poorly understood. On the other hand, several risk factors are firmly established, and they determine the screening strategy.

• Age — this is the primary factor. The risk increases significantly after age 50 and continues to grow thereafter.
• Family medical history — a father or brother approximately doubles the risk. Several cases in the family, or cases occurring before age 60, reinforce this indication.
• African or West Indian ancestry — men from sub-Saharan Africa and the French West Indies have a higher incidence and often earlier forms.
• Genetic predispositions — certain mutations, particularly BRCA2, are associated with an increased risk and more aggressive forms.

Specifically, these factors modify the age at which screening is discussed. In the presence of a family history or African or West Indian ancestry, it is generally offered earlier, around age 45 rather than 50.

The diagnostic pathway

Diagnosis is never done in a single step. It proceeds by progressive elimination, from the simplest to the most invasive.

1. Consultation and digital rectal examinationThe clinical examination assesses the volume and consistency of the gland and checks for a suspicious hard area. Simple and fast, it provides information that imaging does not always give.
2. PSA testPSA is a protein produced by the prostate. Its elevation indicates a prostate abnormality, without implying its nature. Its interpretation takes into account age, the volume of the gland, and the change in the level over time.
3. multiparametric MRIIt now constitutes an essential step before First-ever biopsy. Acquired and interpreted according to PI-RADS standards, it localizes suspicious areas and guides the samples. A normal MRI in a low-risk patient may lead to deferring the biopsy.
4. Targeted prostate biopsyPerformed under local anesthesia, it takes small tissue fragments from the areas identified on the MRI. It is the only examination that confirms the diagnosis.

This sequence is important. For a long time, biopsies were performed immediately when PSA levels were high, without guidance. Prior MRI now makes it possible to avoid unnecessary biopsies and better target the ones that are needed.

In detail: the prostate biopsy · The transperineal approach · The complete check-up in one day

Interpret the PSA level

PSA naturally increases with age and prostate volume. Therefore, there is no single threshold, but rather orders of magnitude to be interpreted in context.

Three elements significantly refine this reading. The PSA density, which relates the level to the prostate volume: a PSA of 7 in a 100-gram prostate does not have the same value as in a 30-gram prostate. The kinetics, that is to say, the rate of evolution between two dosages. And the free-to-total PSA ratio, useful in the zone of uncertainty.

What the biopsy says: adenocarcinoma and Gleason score

The vast majority of prostate cancers are adenocarcinomas, that is to say, tumors developed from glandular cells. The analysis of the samples does not merely confirm or rule out the diagnosis: it evaluates its aggressiveness.

This is the role of Gleason score, today translated into ISUP prognostic grade groups from 1 to 5. The lower the score, the more differentiated the tumor and the slower its progression. An ISUP grade 1 corresponds to a low-aggressiveness cancer, often compatible with simple active surveillance; conversely, a grade 4 or 5 requires rapid management.

This distinction is fundamental because it explains why two men with prostate cancer may receive radically different treatment proposals—or even, for one of them, no immediate treatment at all.

After the diagnosis: what is being discussed

A prostate cancer diagnosis does not automatically lead to surgery. The strategy depends on the aggressiveness of the tumor, its spread, the PSA level, age, general health status, and the patient's priorities.

• Active surveillance — for low-aggressiveness forms, with close monitoring of PSA and imaging
• Surgery radical prostatectomy
• Radiotherapy — external or by brachytherapy
• Focal treatments — cryotherapy or high-intensity focused ultrasound, in selected patients
• Medication treatments — in certain situations

Focal therapies target the tumor area rather than the entire gland, with the aim of preserving urinary and sexual functions. They are not suitable for all cancers, and their long-term results remain less established than those of standard treatments: the 2026 European guidelines place them within the framework of a prospective registry.

In detail: minimally invasive treatments for prostate cancer

Frequently asked questions

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Send your latest PSA dosage, your MRI report if you have one, and your previous examinations. We will tell you what is missing and what the available items already allow us to conclude.

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