You just heard the words no one wants to hear. The hard part is what comes next, because there is not one treatment for prostate cancer. There are many, and they can look very different.

I made this video to help people understand their options and the data behind each of the different treatment choices. It is the same conversation I have in clinic, laid out in one place.

Watch the full guide on YouTube:

Your Gleason score is the single most important number on the pathology report, and it is worth understanding what it actually measures. A pathologist looks at the architecture of the cancer under the microscope, meaning how the cells are arranged, and grades that pattern from 3 to 5. Patterns 1 and 2 are no longer used.

Gleason pattern 3 is the least aggressive pattern and has the lowest risk of spreading. Pattern 4 is where the glands fuse together and lose their neat structure and it is more likely to grow and spread. Pattern 5 is the most aggressive, where the cells barely form glands at all and grow in solid sheets or cords.

Prostate cancer is rarely uniform, so the pathologist reports two numbers: the most common pattern and the second most common. Added together they make the Gleason score, which is why the lowest you will see is 3 + 3 = 6. The order matters. A 3 + 4 = 7 is mostly the less aggressive pattern 3 with some pattern 4, and behaves better than a 4 + 3 = 7, which is mostly the more aggressive pattern 4. Grade Groups were created to help patients better understand the risks of difference Gleason scores.

A few findings buried in the report deserve special attention, because they can turn what looks like a favorable cancer into one that needs treatment.

Cribriform pattern describes pattern 4 cancer that grows as a sheet riddled with holes, like Swiss cheese. It is linked to a higher risk of cancer recurrence and spread, and it is one of the clearest reasons to steer away from active surveillance even when the rest of the report looks reassuring.

Intraductal carcinoma means cancer has filled the normal duct structures of the prostate. It usually travels with aggressive, higher volume disease, so it is a reason to treat rather than watch, and to consider genetic testing, since it is associated with inherited mutations such as BRCA2.

Perineural invasion means the cancer is tracking along a nerve. Nerves run in and out of the prostate, so this is one of the routes the cancer uses to escape the gland. On its own it does not change your grade, and the evidence on how much it predicts outcomes is mixed.

The Gleason score should be evaluated alongside your PSA and the exam to place you in a risk category; in addition, the amount of cancer found on biopsy (i.e number of positive cores and amount of cancer found on a individual core) matters too. One core out of twelve with a tiny amount of cancer is very different from six of twelve biopsies involved, even at the same grade. The full picture, not any single number, is what every option that follows is built on.

An MRI of the prostate is usually done before the biopsy. It finds suspicious areas so we can aim samples directly at them, which catches more of the dangerous cancers and fewer of the harmless ones (Kasivisvanathan et al, N Engl J Med 2018). We still take systematic samples (12 biopsies) from the rest of the gland in the same sitting, because some serious cancers hide in normal looking tissue. One honest caveat: even a targeted biopsy misses the cribriform and intraductal patterns about half the time, so a clean biopsy is reassuring but not provide 100% reassurance that a person does not have aggressive cancer. The MRI also helps decide who is a safe candidate for monitoring.

The MRI comes back as a PI-RADS score from 1 to 5, which rates how suspicious the prostate looks. The higher the score, the higher the chance of finding a cancer worth treating, meaning Grade Group 2 or higher. These are rough ranges, and they shift with your PSA density and the quality of the scan (AUA guideline 2026).

A PI-RADS 3 is the real coin toss, and that is where your PSA density tips the decision to biopsy or wait. A low score is reassuring but not a guarantee, since a small number of serious cancers do not show up on MRI at all.

A PSMA PET scan is a newer whole body scan that lights up prostate cancer cells wherever they are. We use it to stage higher risk disease, to check whether the cancer has spread before choosing treatment. In high risk men it catches spread that standard CT and bone scans miss, and it changes the plan more often (Hofman et al, Lancet 2020). It is not needed for low risk or favorable intermediate risk cancer.

Your Gleason grade and PSA give a solid estimate of risk, but two men with the same numbers can behave very differently. Decipher is a genomic test that reads 22 genes from your biopsy or surgery tissue and estimates how likely the cancer is to spread. The largest review pooled 42 studies and more than 30,000 men, and the national guidelines list it as a useful prognostic tool while cautioning that it has not yet been proven in prospective trials (Jairath et al, Eur Urol 2021). So treat it as a tie breaker, not a verdict. It helps at the edges, where the right move is not obvious. A low score can support watching a borderline cancer rather than treating it. A high score can justify adding hormone therapy to radiation, or choosing a more aggressive plan. It does not replace your grade and PSA. It sharpens the picture when the decision is close.

Decipher looks at the tumor. A separate test, called germline testing, looks at the genes you were born with, usually from a simple blood or saliva sample. It matters because an inherited mutation such as BRCA2 can make prostate cancer more aggressive, can open the door to specific drugs and clinical trials, and flags a risk that may run in the family.

The national guidelines recommend this testing for any man whose cancer is high risk, very high risk, has reached the lymph nodes, or has spread further, regardless of family history. They also recommend it when there is a strong family history of prostate, breast, ovarian, or pancreatic cancer, or Ashkenazi Jewish ancestry, and they suggest considering it for men diagnosed young or with intraductal or cribriform patterns on biopsy. If a mutation turns up, it changes two things at once. Your relatives can be tested and start prostate or breast screening earlier, often with yearly PSA from age 40 for BRCA2 carriers, and your own team can factor it into treatment. A positive result is a reason to sit down with a genetic counselor (NCCN Prostate Cancer Guidelines).

For low risk cancer, the safest first step is often to watch it closely rather than treat it right away. That means a PSA every 3 to 6 months, a repeat MRI, and occasional biopsies. In the Canary PASS program, fewer than 2 percent of men developed spread and fewer than 1 percent died of prostate cancer over 10 years (Newcomb et al). Active monitoring is not ignoring the cancer. It is treating only if and when the cancer shows signs of becoming more aggressive.

Focal therapy treats only the part of the prostate that holds the cancer, instead of the whole gland, to protect the nerves and tissue that control urination and erections. Each tool uses a different kind of energy. Cryotherapy uses cold, freezing the cancer with ice. HIFU uses sound, focusing high intensity ultrasound to heat and destroy the tissue. TULSA uses that same ultrasound heat, delivered from inside the urethra under MRI guidance. And irreversible electroporation, also called NanoKnife, uses electricity, short pulses that kill the cancer cells without heat. These are newer options, and the cancer can return in the untreated tissue, so close follow up afterward is essential: roughly 20 to 30 percent of men need a repeat focal treatment or move on to surgery or radiation within five years, and the long term cancer control data are still maturing. Surgery and radiation stay available as backup if focal therapy does not work.

Radiation can cure prostate cancer without surgery. IMRT shapes photon beams precisely around the prostate across several weeks of daily sessions. SBRT, often delivered on a CyberKnife, gives a higher dose in about five sessions over one to two weeks. Proton therapy uses particles instead of photons. In practice the results are similar, and proton costs far more without a clear advantage.

The side effect pattern is different from surgery. During treatment, most men get temporary bladder irritation, meaning urgency, frequency, and a weaker stream, which usually settles within a few weeks. Lasting problems are less common: about 10 to 15 percent develop ongoing urinary symptoms. A smaller number develop radiation cystitis, an inflamed, irritated bladder that can show up months or even years later and sometimes causes significant blood in the urine. Around 5 to 10 percent develop bowel symptoms such as rectal urgency or bleeding, because the rectum sits right behind the prostate. Erections fade more slowly than with surgery, but 40 to 60 percent develop erectile dysfunction over one to three years, and the risk is higher when hormone therapy is added (Donovan et al, N Engl J Med 2016).

Prostate cancer feeds on testosterone, so androgen deprivation therapy lowers it to starve the cancer. It is added to radiation in higher risk disease and used when the cancer has spread. It works, but the side effects are real: hot flashes, fatigue, muscle and bone loss, and higher cardiovascular risk. Genomic tests like Decipher and ArteraAI can help decide who actually benefits from adding it. One of the most overlooked side effects is bone thinning, which is why men on these drugs need their bone health watched closely. I made a separate video on this:

Surgery removes the whole prostate, usually with a robot. It offers a clear path to taking the cancer out, and it gives exact pathology afterward. The main tradeoffs are urinary leakage and erectile changes. Leakage is worst right after the catheter comes out and then improves: roughly 65 percent of men are pad free by three months, 80 percent by six months, and about 90 percent by a year, helped along by pelvic floor exercises started before surgery. That leaves roughly 5 to 10 percent with lasting leakage that needs a pad, and a smaller number who consider a sling or an artificial sphincter. One thing people forget is that surgery usually improves the blockage symptoms of an enlarged prostate, like a weak stream, even as it introduces the risk of leakage. Erections depend heavily on your age, your starting function, and whether the nerves alongside the prostate can be spared (Donovan et al, N Engl J Med 2016).

You almost certainly know a man who was just told he has prostate cancer and feels rushed into a decision. Please forward this to him. A clear picture of the options is the most useful thing he can have right now. That is how Pareto Life grows.

If this was useful, share it with a friend and subscribe so you do not miss the next issue.

Related reading: Androgen Deprivation Therapy and Your Bones: 81% Have Osteoporosis by Year 10

Hamdy et al, N Engl J Med 2023 (ProtecT, 15 year outcomes) · Hamdy et al, N Engl J Med 2016 (ProtecT, 10 year outcomes) · Donovan et al, N Engl J Med 2016 (ProtecT, patient reported urinary, bowel, and sexual function) · Newcomb et al, J Urol 2016 (Canary PASS active surveillance cohort) · Kasivisvanathan et al, N Engl J Med 2018 (PRECISION, MRI targeted biopsy) · AUA Prostate Cancer guideline 2026 (PI-RADS and csPCa risk) · Hofman et al, Lancet 2020 (proPSMA) · Jairath et al, Eur Urol 2021 (Decipher systematic review) · Cereda et al, Heart Fail Rev 2022 (ADT and cardiovascular risk) · NCCN Prostate Cancer Guidelines (germline genetic testing criteria; Decipher and ArteraAI as advanced prognostic tools)

This issue is for general education and is not medical advice. Treatment decisions should be made with your own urologist based on your individual diagnosis.