Doctors at the Therapeutics Clinic of Alexandra Hospital, part of the Medical School of the National and Kapodistrian University of Athens, have outlined when men should begin discussing prostate-specific antigen (PSA) testing, timed to European Prostate Cancer Awareness Day. Dr. Maria Kaparelou, a pathologist and oncologist, and Thanos Dimopoulos, professor of therapeutics, oncology and hematology, director of the Therapeutics Clinic at Alexandra Hospital and a former rector of the university, said age remains the single most important risk factor, with the disease becoming significantly more common after 50.
Family history also carries particular weight, the doctors said, and genetic predisposition is now an integral part of modern risk assessment. They noted that harmful mutations in DNA-repair genes, most notably BRCA2, are linked both to a higher chance of developing prostate cancer and to more aggressive disease once it appears.
Why early symptoms can be misleading
Prostate cancer often progresses in its early stages without noticeable symptoms, according to Kaparelou and Dimopoulos. When urinary problems do occur, they are not specific to cancer and are frequently linked to benign prostate conditions instead. The doctors said the absence of symptoms should not lead to complacency, and that the modern approach favors early, individualized risk assessment aimed at catching clinically significant tumors while the disease is still potentially curable.
PSA testing remains a key tool for early detection, they said, but a rise in PSA is not specific to cancer and can also occur with benign prostate disease. For that reason, PSA results are evaluated as part of an overall assessment that factors in a man's age, family history and clinical characteristics.
Multiparametric MRI now plays a significant role in diagnosis, the doctors said, helping to pinpoint suspicious areas more precisely, identify clinically significant tumors, and guide decisions on whether and where to perform a biopsy.
The key ages for PSA testing
Current European guidelines recommend an individualized strategy for early diagnosis rather than a single rule for all men, according to the doctors. They said discussion of PSA screening can begin:
- from age 50 for the general male population
- from age 45 for men at increased risk, such as those with a relevant family history
- from age 40 for carriers of harmful BRCA2 mutations
The interval between follow-up checks is not the same for everyone, they said, but is adjusted according to a man's initial risk level.
Avoiding overtreatment
Kaparelou and Dimopoulos stressed that avoiding overtreatment is equally important. For men with localized, low-risk cancer, active surveillance is an established strategy involving systematic monitoring, with intervention only when there are signs the disease is biologically progressing. When radical treatment is needed, radical prostatectomy and radiotherapy, with or without hormone therapy depending on risk, can offer a high chance of long-term control or cure, they said.
Advances in treating advanced disease
The doctors highlighted significant progress in recent years in treating advanced and metastatic prostate cancer, with new treatment options that have changed the natural course of the disease. Androgen deprivation therapy (ADT) remains the foundation of systemic treatment, they said, but modern care now emphasizes intensifying treatment earlier.
Adding newer agents that target the androgen receptor pathway, including abiraterone, enzalutamide, apalutamide and darolutamide, has achieved significant gains in both disease control and overall survival, according to the doctors. In appropriately selected patients, treatment can be intensified further with a triple combination of ADT, newer hormonal therapy and docetaxel chemotherapy, offering additional clinical benefit, particularly for patients with high-volume or high-risk metastatic disease.
Targeting the tumor's molecular profile
Kaparelou and Dimopoulos said the field is gradually shifting from treatment based purely on disease stage to treatment guided by a tumor's molecular identity. Detecting mutations in BRCA1/2 and other homologous recombination genes can lead to the use of targeted therapies, such as PARP inhibitors, in appropriately selected patients.
Targeting PSMA (Prostate-Specific Membrane Antigen) has opened a new field in both imaging, through PSMA PET/CT, and treatment, they said. Therapy with lutetium-177 PSMA is a modern form of targeted treatment that exploits PSMA expression on cancer cells to deliver therapeutic radiation selectively to disease sites, broadening treatment options for selected patients with advanced prostate cancer.
Toward personalized medicine
The doctors described prostate cancer as one of the clearest examples of modern oncology's shift toward personalized and precision medicine. They said the challenge no longer lies only in early diagnosis, but also in accurately assessing a tumor's biological behavior and choosing the treatment strategy best suited to each patient's individual characteristics.
Advances in molecular diagnosis, imaging and treatment have significantly expanded options for managing the disease, aimed at extending survival while preserving quality of life, according to Kaparelou and Dimopoulos. They said early diagnosis, accurate risk assessment and individualized treatment are now the core pillars of optimal prostate cancer care, and that prostate cancer is no longer managed with a single treatment for everyone, but with the right decision for each patient. The earlier that process begins, they said, the greater the opportunity to change the course of the disease.
