↑PSA / abnormal DRE
Confirm: MRI + biopsy (Gleason score)
Treat: Low-risk → active surveillance; localized → prostatectomy/radiation; metastatic hormone-sensitive → ADT + ARPI doublet (abiraterone/apalutamide/enzalutamide/darolutamide) for most; triplet (ADT + docetaxel + darolutamide or abiraterone) for fit, high-volume/de novo (ARASENS, PEACE-1) — ADT ± first-gen antiandrogen alone is substandard for mHSPC
Order set
- PSA + DRE
- MRI prostate
- Biopsy (Gleason)
- Staging by risk
Criteria
AdmitCord compression, obstruction, or severe pain
ICURarely
DischargeRisk-stratified plan; emergencies (cord/obstruction) managed
Key
- PSA screening (USPSTF 2018): individualized shared decision-making age 55–69 (Grade C); do NOT screen ≥70 (Grade D).
- Long-term ADT → bone protection (denosumab/zoledronate); metastatic disease → germline/somatic BRCA/HRR testing → PARP inhibitors.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Bone pain
- Cord compression
- Obstructive uropathy
Differentials
- BPH
- Prostatitis
- Bladder pathology
Common mistakes
- Over-screening low-risk men
- Missing metastatic cord compression
Disposition & follow-up
Risk-stratified: surveillance vs surgery/RT vs ADT.
Discharge package
MedicationsADT/therapy per plan
Follow-upUrology/oncology; PSA monitoring
Warning symptomsBone pain, urinary retention, leg weakness (cord compression)
💊 Treatment detail — doses & preparation
GoserelinGnRH agonist
Dose3.6 mg SC q28 d or 10.8 mg q12 wk (prostate/breast)
PreparationDepot implant SC anterior abdominal wall
MonitorTumour flare in first weeks (add bicalutamide cover in prostate), testosterone level
Bicalutamideanti-androgen
Dose50 mg OD (with GnRH agonist; 150 mg monotherapy in some settings)
Preparation50/150 mg tablets
MonitorGynaecomastia, LFTs; flare protection at initiation
Docetaxeltaxane chemotherapy
Dose75 mg/m² IV q3 wk (prostate) with dexamethasone premedication
PreparationDilute per protocol, infuse 1 h; premed dexamethasone 8 mg BD ×3 d (from day before)
MonitorNeutropenia (nadir day 7), fluid retention, neuropathy
📖 EAU / NCCN Prostate CancerReviewed July 2026