What does active surveillance mean, and who is eligible?

Active surveillance means monitoring low-risk or selected favourable-intermediate-risk prostate cancer closely rather than treating it immediately. It is appropriate for ISUP Grade Group 1 (Gleason 3+3=6) and selected ISUP 2 disease with PSA density under 0.15 and fewer than 50% biopsy cores positive. The protocol involves PSA every 3–6 months, annual digital rectal examination, annual MRI, and repeat biopsy at 1 year then every 2–3 years. The 15-year ProtecT follow-up confirmed non-inferior cancer-specific survival compared with surgery or radiotherapy, with significantly less treatment-related morbidity. Triggers for conversion to active treatment include pathological upgrade on biopsy, MRI progression, or PSA-doubling time under 3 years.

What are the main side effects of androgen deprivation therapy that GPs should manage?

ADT — LHRH agonists or antagonists used alone or with ARPIs — produces a predictable cluster of effects requiring active GP management. Bone loss (ADT triples osteoporotic fracture risk): perform DEXA at baseline and every 1–2 years; supplement calcium 1,000–1,300 mg/day plus vitamin D 1,000–2,000 IU/day; prescribe bisphosphonate or denosumab (Prolia) per PBS Authority criteria. Cardiovascular risk: annual BP, lipids, and HbA1c. Sarcopenia and fatigue: resistance plus aerobic exercise via exercise physiologist under the chronic disease management plan. Hot flushes: venlafaxine 37.5–75 mg/day or escitalopram 10 mg/day. Mood disturbance and sexual dysfunction each justify a Mental Health Care Plan referral.

When is cord compression a concern in prostate cancer patients, and what should a GP do?

New bone pain in a man with any prostate cancer history — especially nocturnal back, hip, or pelvic pain — indicates a metastatic workup. Back pain with bilateral leg weakness, saddle anaesthesia, urinary retention, or altered anal tone is a neurosurgical emergency: call 000, start dexamethasone 16 mg IV loading dose, and transfer to ED with pre-notification to neurosurgery. This cannot wait for a GP referral appointment. Request urgent MRI whole spine if available locally before transfer in stable patients, but do not delay transfer if in doubt.

Which patients with advanced prostate cancer qualify for PARP inhibitors or Lu-177-PSMA therapy?

PARP inhibitors (olaparib) are PBS Authority-listed for metastatic castration-resistant prostate cancer (mCRPC) with BRCA1/2 or other homologous recombination repair (HRR) alterations — confirmed on MBS items 73436 and 73437 via specialist testing. Lu-177-PSMA-617 (Pluvicto) is PBS Authority Section 100 for PSMA-PET-positive mCRPC that has progressed on both a taxane and a novel ARPI — based on the VISION trial (Sartor, NEJM 2021). Both require specialist initiation through urology or medical oncology. The GP's role is to refer promptly when these states are reached.

Why should all men with metastatic prostate cancer have HRR genetic testing?

Approximately 12–25% of metastatic prostate cancers carry pathogenic variants in HRR genes — most importantly BRCA2, but also ATM, CHEK2, PALB2, and CDK12. These variants predict response to PARP inhibitors (olaparib, talazoparib) and — for BRCA2 in particular — confer more aggressive disease biology. The Cancer Council Australia 2024 PSA guidelines recommend HRR germline plus somatic testing in all metastatic prostate cancers. MBS items 73436 and 73437 are listed specifically to enable this and gate PBS PARP inhibitor access. Identified variants also prompt cascade testing of female first-degree relatives for breast and ovarian cancer risk.

Prostate adenocarcinoma

Prostate cancer staging, treatment, and GP survivorship care

By Dr HB Lo, FACRRM Reviewed 8 September 2026 7 min read

Prostate cancer is the most commonly diagnosed cancer in Australian men — approximately 25,500 new cases per year — with overall 5-year survival of approximately 96%.

The GP role has shifted to risk stratification and survivorship. Low-risk disease (ISUP Grade Group 1) is managed with active surveillance; the 15-year ProtecT trial confirmed equivalent cancer-specific survival to treatment. Intermediate- and high-risk localised disease requires surgery or radiotherapy.

For metastatic hormone-sensitive disease, ADT combined with an androgen-receptor pathway inhibitor is now standard. The GP manages the full ADT side-effect burden during long-term survivorship.

Prostate cancer is the most commonly diagnosed cancer in Australian men and the second leading cause of male cancer death, yet overall 5-year survival sits at approximately 96% because the majority of tumours are low-risk and indolent at diagnosis. For localised disease detected through PSA testing, the GP’s central task is not simply to refer — it is to facilitate an informed decision between active surveillance, surgery, and radiotherapy, all of which produce equivalent cancer-specific survival in low-risk disease but carry meaningfully different side-effect profiles.

This article covers post-diagnosis management. PSA screening and the shared decision around PSA testing in asymptomatic men are covered separately.

A. Core clinical — the AU general-practice framework

Grading and risk stratification

After biopsy confirms prostate adenocarcinoma, the Cancer Council Australia 2024 PSA guidelines and NCCN v4.2024 anchor management to the ISUP Grade Group system (derived from Gleason score) and clinical risk category:

ISUP Grade Group	Gleason	Risk implication
1	3+3=6	Indolent; active surveillance preferred
2	3+4=7	Favourable-intermediate
3	4+3=7	Unfavourable-intermediate
4	4+4 or 3+5 or 5+3 = 8	High-grade
5	4+5 or 5+4 or 5+5 = 9–10	Highest-grade

Risk groups:

Low: PSA under 10 ng/mL, ISUP 1, clinical stage T1c–T2a
Favourable-intermediate: one intermediate factor, fewer than 50% cores positive
Unfavourable-intermediate: two or more intermediate factors, ISUP 3, or ≥50% cores positive
High: PSA over 20 or ISUP 4–5 or cT3a
Metastatic: nodal or distant spread — systemic therapy is the priority

History and examination

Many men are diagnosed after an incidentally raised PSA with no symptoms. When symptoms are present: LUTS (overlap with BPH); haematuria or haematospermia (uncommon but red-flag); bone pain (new, persistent, nocturnal back, hip, or pelvic pain in a man with prostate cancer history = metastatic workup); and neurological symptoms from cord compression.

Examination includes: digital rectal examination (size, consistency, nodules — document at every visit); abdominal examination for bladder distension; lymph nodes; bony tenderness; and a neurological screen if back pain is present (lower-limb power, tone, reflexes, plantar response, saddle sensation, anal tone).

Pitfalls: 5α-reductase inhibitors (finasteride, dutasteride) halve the measured PSA — double the value when interpreting. Testosterone replacement is generally contraindicated during and after prostate cancer treatment (specialist decision only).

Staging investigations

PSMA-PET CT is now the preferred staging modality for high-risk localised disease and biochemical recurrence, replacing conventional bone scan plus CT per Cancer Council Australia 2024 and the PRIMARY trial (Hofman, Lancet 2020), which demonstrated superior accuracy (92% versus 65%) and 27% management change rate. MBS item 61628. For cord compression suspicion: urgent MRI whole spine.

B. Treatment by risk group

Active surveillance (low-risk and selected favourable-intermediate)

The ProtecT trial 15-year follow-up (Hamdy, NEJM 2023) confirmed no cancer-specific survival difference between active surveillance, radical prostatectomy, and radical radiotherapy in low-risk disease. Active surveillance avoids the urinary, sexual, and bowel morbidity of active treatment in men who may never need it. Protocol: PSA every 3–6 months; digital rectal examination annually; MRI annually; confirmatory biopsy at 1 year then every 2–3 years. Trigger for conversion: pathological upgrade, MRI progression, or PSA-doubling time under 3 years.

Radical prostatectomy

Robot-assisted radical prostatectomy dominates AU practice in 2026. Side effects: erectile dysfunction (50–80%); urinary incontinence (5–20% at 12 months); shortened penile length; ejaculatory loss. Pelvic-floor physiotherapy before and after surgery accelerates continence recovery.

Radical radiotherapy

External beam IMRT or IGRT (typically 78–80 Gy or moderate hypofractionation). Combined with ADT for intermediate (4–6 months) and high-risk (24–36 months) disease per eviQ protocols. Stereotactic body radiotherapy (5-fraction regimens) is emerging for low- and intermediate-risk disease.

Androgen deprivation therapy

LHRH agonists (leuprorelin, goserelin) require a short course of bicalutamide (50 mg daily for 2–4 weeks) at initiation to prevent the testosterone flare. The LHRH antagonist degarelix avoids flare and achieves faster castration — useful when cord compression risk, urinary obstruction, or symptom urgency make rapid testosterone suppression important. Castrate level is testosterone under 1.7 nmol/L.

Metastatic hormone-sensitive disease (mHSPC)

ADT alone is no longer standard. Combining ADT with an ARPI is now the evidence-based approach across multiple phase-III trials: abiraterone plus prednisone (LATITUDE, NEJM 2017); enzalutamide (ENZAMET, NEJM 2019); apalutamide; and darolutamide plus docetaxel for high-volume disease (ARASENS, NEJM 2022). All ARPIs are PBS Authority Section 100 HSD. Docetaxel added to ADT for high-volume mHSPC is supported by the CHAARTED trial and remains part of the triplet approach.

Metastatic castration-resistant disease (mCRPC)

Olaparib 300 mg twice daily for BRCA1/2-mutated or HRR-altered mCRPC (MBS testing items 73436 and 73437; PBS Authority Section 100), based on the PROfound trial (de Bono, NEJM 2020). Lu-177-PSMA-617 (Pluvicto) for PSMA-PET-positive mCRPC after taxane and novel ARPI, based on the VISION trial (Sartor, NEJM 2021); PBS Authority Section 100 since 2023.

C. ADT side-effect management — the GP’s ongoing role

ADT produces a recognisable cluster of effects requiring active management at every review:

Bone: ADT triples fracture risk. Obtain DEXA at baseline and every 1–2 years. Supplement calcium 1,000–1,300 mg/day plus vitamin D 1,000–2,000 IU/day. Prescribe denosumab (Prolia) or bisphosphonate if T-score criteria met (PBS Authority). Pre-treatment dental review before denosumab or bisphosphonate.

Cardiovascular: Annual assessment of BP, lipids, and HbA1c. Exercise referral via GPCCMP.

Sarcopenia and fatigue: Resistance plus aerobic exercise 2–3 sessions per week via exercise physiologist under the GPCCMP. The RANGER trial (Galvão, JCO 2018) demonstrated significant improvements in lean mass, fatigue, and cardiovascular parameters.

Hot flushes: Venlafaxine 37.5–75 mg/day or escitalopram 10 mg/day are effective per AMH.

Mood and cognition: ADT-related depression, anxiety, body-image concerns, fear of recurrence, and sexual or partner-relationship distress routinely justify a Mental Health Care Plan (MBS item 2715). Prostate cancer has one of the highest rates of psychological comorbidity among cancer types.

Sexual and urinary function: Post-prostatectomy urinary incontinence — pelvic-floor physiotherapy first; artificial urinary sphincter for persistent cases. Erectile dysfunction — PDE5 inhibitors (sildenafil, tadalafil), intracavernosal injection, or vacuum erection device.

D. Australian operations

Standard GP attendances use items 23, 36, and 44. PSA is item 66655. Testosterone is item 66536. FBC is item 65070. DEXA is item 12306 (baseline and during ADT). Multiparametric MRI prostate is item 63461. PSMA-PET CT is item 61628. HRR germline testing is items 73296 and 73297; advanced prostate cancer-specific HRR items are 73436 and 73437 (listed ~2023). GPCCMP plan is item 965 (review 967) — almost every man with prostate cancer on ADT qualifies post-July 2025 given the chronic condition plus comorbidity bundle. Telehealth item 91790 is appropriate for survivorship PSA reviews; new symptoms or DRE require in-person review.

PBS key items: LHRH agonists (leuprorelin, goserelin) are Authority Streamlined. ARPIs (enzalutamide, abiraterone, apalutamide, darolutamide) are Authority Required Section 100 HSD. Olaparib is Authority Required Section 100. Lu-177-PSMA-617 is Authority Required Section 100 from 2023. Bisphosphonate and denosumab are Authority Required. Denosumab Prolia (osteoporosis) requires T-score criteria. Hot-flush medications are General Schedule.

Post-treatment monitoring (summary)

Active surveillance: PSA every 3–6 months; annual DRE and MRI; repeat biopsy. Post-prostatectomy: PSA at 6 weeks then 3-monthly in year 1, 6-monthly in years 2–5, annual thereafter; nadir target under 0.1 ng/mL. Post-radiotherapy: PSA 3-monthly years 1–2, 6-monthly years 3–5; Phoenix definition failure = nadir plus 2 ng/mL. ADT: 3-monthly PSA and testosterone; annual metabolic panel, DEXA, cardiovascular assessment.

E. Special populations

Aboriginal and Torres Strait Islander men: Lower incidence but higher case fatality due to later-stage presentation. Engage Aboriginal Liaison services; ATSI health assessment (item 715). Veterans: DVA Gold or White Card covers all aspects; SOP accepted for Vietnam-era herbicide and firefighting exposures.

Family history and genetics: First-degree relatives of men with BRCA2-related prostate cancer — particularly female relatives — are eligible for cascade BRCA testing. Familial cancer clinic referral when BRCA2, BRCA1, PALB2, ATM, or Lynch syndrome identified.

Younger men (under 60): Higher probability of familial or hereditary aetiology; germline testing priority. Fertility counselling if relevant before definitive treatment.

When to escalate

Emergency (same day): Suspected cord compression — back pain plus neurology — immediate transfer plus dexamethasone 16 mg IV loading plus pre-notification to neurosurgery and ED. Obstructive uropathy with renal failure. Pathological hip fracture.

Urgent (within 2 weeks): Newly diagnosed cancer for MDT staging. Rapid PSA rise on treatment. New metastases on imaging.

Routine: Survivorship co-management; long-term ADT toxicity; biochemical recurrence after curative therapy; genetics referral for BRCA or family clustering.

What this article is and is not

This is general health information based on current Australian guidelines — Cancer Council Australia 2024 PSA guidelines, USANZ, PCFA, eviQ, eTG, and AMH — and pivotal international trials including ProtecT, PRIMARY, LATITUDE, ENZAMET, ARASENS, PROfound, and VISION. It is not personal medical advice and does not create a doctor–patient relationship. Clinical decisions, including treatment modality choice for any individual, are made with the patient’s treating specialists.

For Australian consumer resources: PCFA; Cancer Council 13 11 20; HealthDirect — Prostate cancer; Healthy Male.

Sources cited

Frequently asked questions

What does active surveillance mean, and who is eligible?

Active surveillance means monitoring low-risk or selected favourable-intermediate-risk prostate cancer closely rather than treating it immediately. It is appropriate for ISUP Grade Group 1 (Gleason 3+3=6) and selected ISUP 2 disease with PSA density under 0.15 and fewer than 50% biopsy cores positive. The protocol involves PSA every 3–6 months, annual digital rectal examination, annual MRI, and repeat biopsy at 1 year then every 2–3 years. The 15-year ProtecT follow-up confirmed non-inferior cancer-specific survival compared with surgery or radiotherapy, with significantly less treatment-related morbidity. Triggers for conversion to active treatment include pathological upgrade on biopsy, MRI progression, or PSA-doubling time under 3 years.
What are the main side effects of androgen deprivation therapy that GPs should manage?

ADT — LHRH agonists or antagonists used alone or with ARPIs — produces a predictable cluster of effects requiring active GP management. Bone loss (ADT triples osteoporotic fracture risk): perform DEXA at baseline and every 1–2 years; supplement calcium 1,000–1,300 mg/day plus vitamin D 1,000–2,000 IU/day; prescribe bisphosphonate or denosumab (Prolia) per PBS Authority criteria. Cardiovascular risk: annual BP, lipids, and HbA1c. Sarcopenia and fatigue: resistance plus aerobic exercise via exercise physiologist under the chronic disease management plan. Hot flushes: venlafaxine 37.5–75 mg/day or escitalopram 10 mg/day. Mood disturbance and sexual dysfunction each justify a Mental Health Care Plan referral.
When is cord compression a concern in prostate cancer patients, and what should a GP do?

New bone pain in a man with any prostate cancer history — especially nocturnal back, hip, or pelvic pain — indicates a metastatic workup. Back pain with bilateral leg weakness, saddle anaesthesia, urinary retention, or altered anal tone is a neurosurgical emergency: call 000, start dexamethasone 16 mg IV loading dose, and transfer to ED with pre-notification to neurosurgery. This cannot wait for a GP referral appointment. Request urgent MRI whole spine if available locally before transfer in stable patients, but do not delay transfer if in doubt.
Which patients with advanced prostate cancer qualify for PARP inhibitors or Lu-177-PSMA therapy?

PARP inhibitors (olaparib) are PBS Authority-listed for metastatic castration-resistant prostate cancer (mCRPC) with BRCA1/2 or other homologous recombination repair (HRR) alterations — confirmed on MBS items 73436 and 73437 via specialist testing. Lu-177-PSMA-617 (Pluvicto) is PBS Authority Section 100 for PSMA-PET-positive mCRPC that has progressed on both a taxane and a novel ARPI — based on the VISION trial (Sartor, NEJM 2021). Both require specialist initiation through urology or medical oncology. The GP's role is to refer promptly when these states are reached.
Why should all men with metastatic prostate cancer have HRR genetic testing?

Approximately 12–25% of metastatic prostate cancers carry pathogenic variants in HRR genes — most importantly BRCA2, but also ATM, CHEK2, PALB2, and CDK12. These variants predict response to PARP inhibitors (olaparib, talazoparib) and — for BRCA2 in particular — confer more aggressive disease biology. The Cancer Council Australia 2024 PSA guidelines recommend HRR germline plus somatic testing in all metastatic prostate cancers. MBS items 73436 and 73437 are listed specifically to enable this and gate PBS PARP inhibitor access. Identified variants also prompt cascade testing of female first-degree relatives for breast and ovarian cancer risk.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.