Prostate Cancer: Disease Ranging from Slow-Growing to Aggressive

Prostate cancer covers a wide spectrum. Some cancers grow so slowly that careful monitoring is safer than immediate treatment, while others spread early and require intensive therapy. PSA, MRI, biopsy grade and stage must be interpreted together because no single result determines the cancer's behaviour.

What prostate cancer is Prostate cancer develops when abnormal cells within the prostate grow without normal control. The prostate is a gland below the bladder and in front of the rectum. It surrounds the first part of the urethra. The gland contributes fluid to semen. It is present in men, trans women and non binary people who have not had it removed. Most prostate cancers are adenocarcinomas arising from gland forming cells. One diagnosis covers a wide behavioural spectrum Prostate cancer is not one uniformly aggressive disease. Some small, low grade cancers grow slowly and may never cause symptoms or shorten life. Other cancers grow quickly, invade nearby structures or spread to lymph nodes and bones. Two cancers with similar PSA levels can behave differently because their grade, volume, stage and molecular features differ. This variation explains why treatment ranges from structured monitoring to multimodal cancer therapy. Indolent does not mean imaginary An indolent cancer is a genuine cancer with a low expected risk of progression. Its cells usually have a lower grade and remain confined to the prostate. Immediate radical treatment may cause more harm than the cancer would have caused during that person's lifetime. Monitoring is therefore an evidence based management strategy for appropriately selected disease. The cancer is still reviewed carefully so that treatment can begin if its risk changes. Aggressive prostate cancer Aggressive cancers contain cellular patterns associated with faster growth and greater metastatic potential. They may have a higher grade group, extend beyond the prostate or involve lymph nodes. Some produce a rapidly rising PSA, although aggressive disease can occasionally occur without a very high PSA. Higher risk disease usually requires radical treatment, hormone therapy or systemic treatment rather than surveillance alone. Rare prostate cancer types Adenocarcinoma accounts for the great majority of prostate cancers. Rare forms include small cell neuroendocrine cancer, ductal adenocarcinoma, urothelial carcinoma and sarcoma. These cancers can behave differently and may not produce PSA in the usual way. Their treatment does not necessarily follow the standard adenocarcinoma pathway. The pathology report must therefore establish the actual tumour type. Risk increases with age Prostate cancer risk rises substantially with age. Most diagnoses occur after age 50, although younger people can develop the disease. Age changes risk but does not determine whether testing or treatment is appropriate by itself. Life expectancy, health, health problems in the family and personal preferences also matter. Ethnicity and inherited risk People from Black African and Black Caribbean backgrounds have a higher prostate cancer risk. A father or brother with prostate cancer also increases risk, especially when diagnosed young. Family histories involving breast, ovarian, pancreatic or prostate cancer can suggest an inherited cancer predisposition variant. BRCA2 is particularly important because it can increase prostate cancer risk and may be associated with more aggressive disease. Most prostate cancers are not explained by a known inherited variant. Early prostate cancer often causes no symptoms Cancer confined to the prostate frequently causes no noticeable symptoms. The outer part of the gland is a common cancer site and does not immediately obstruct urine flow. Some cancers are discovered after an informed choice PSA test rather than because of symptoms. The absence of urinary symptoms does not exclude clinically important disease. Lower urinary tract symptoms Possible symptoms include a weak stream, hesitancy, urgency, frequency and getting up at night to urinate. Incomplete emptying or urinary retention can also occur. These symptoms are far more commonly caused by benign prostate enlargement than by prostate cancer. Cancer can still coexist with benign enlargement, so persistent or changing symptoms deserve assessment. Symptom severity does not reliably indicate tumour grade or stage. Blood and sexual symptoms Visible blood in urine requires assessment because it can arise from the bladder, kidney, prostate or urinary tract. Blood in semen is usually benign but should be reviewed when persistent, recurrent or accompanied by other concerns. Erectile dysfunction has many vascular, neurological, hormonal, psychological and medicine related causes. It can be considered within prostate assessment but is not specific for cancer. Symptoms of advanced disease Prostate cancer commonly spreads to bone when it becomes metastatic. Persistent back, hip, pelvic or rib pain can occur, particularly when pain is progressive or disturbs sleep. Advanced disease can also cause weight loss, fatigue, anaemia or reduced mobility. These symptoms have many more common explanations and do not prove metastatic cancer. New neurological symptoms with back pain require emergency assessment for spinal cord compression. What PSA is Prostate specific antigen, usually called PSA, is a protein made by prostate cells. A small amount normally enters the bloodstream. Cancer can increase PSA by disrupting normal prostate architecture. However, normal and benign prostate cells also produce PSA. The test measures prostate activity rather than cancer specifically. PSA is not a diagnostic test by itself A raised PSA does not prove prostate cancer. Many people with a raised result have benign enlargement, inflammation or another non cancer cause. A PSA within an expected range does not completely exclude cancer. The result cannot reliably distinguish an indolent tumour from an aggressive one. MRI and sometimes biopsy are needed to investigate the underlying cause. Benign prostate enlargement and PSA The prostate commonly enlarges with age through benign prostatic hyperplasia. More benign prostate tissue can produce more PSA. A moderately raised level may therefore reflect gland size rather than cancer. PSA density compares the blood PSA with prostate volume measured on imaging. A higher density can increase concern but remains one component of a wider assessment. Infection and inflammation Urinary infection and prostatitis can substantially raise PSA. Testing during active infection can produce a misleading result. The PSA is usually delayed until several weeks after infection has resolved. Painful urination, fever, pelvic pain or sudden urinary symptoms may suggest infection and require assessment first. Prostatitis and cancer can coexist, so persistent PSA elevation still needs review. Ejaculation and exercise Ejaculation can temporarily increase PSA in some people. Vigorous exercise, especially cycling and activities placing pressure near the prostate, can also affect the result. Current NHS advice is to avoid ejaculation, vigorous exercise, cycling and receptive anal sex for 48 hours before testing. These precautions reduce avoidable variation but do not make the test perfectly accurate. Prostate examination and procedures Prostate biopsy, urinary instrumentation and significant prostate manipulation can raise PSA. Testing should be timed appropriately after a biopsy or invasive procedure. A routine gentle digital rectal examination usually has little clinically important effect on PSA. Some laboratories still take the blood sample before examination to standardise the result. A DRE should not be treated as equivalent to infection or biopsy as a PSA confounder. Medicines can lower PSA Finasteride and dutasteride reduce prostate size and can lower PSA substantially. This can make an apparently low value misleading unless the clinician knows the medicine is being taken. Testosterone suppressing cancer treatments also reduce PSA. Herbal supplements and other medicines should be disclosed before interpretation. A result must be assessed against previous values and the clinical context. The benefits of PSA testing PSA testing can identify a prostate problem before symptoms develop. It may lead to diagnosis of aggressive cancer while curative treatment remains possible. Repeating measurements can reveal a changing pattern over time. The potential benefit is greatest when the person would be eligible for further investigation and treatment. The limitations and harms of PSA testing PSA can lead to MRI, biopsy, anxiety and diagnosis of cancer that would never have caused harm. This is called overdiagnosis. Overdiagnosis can lead to overtreatment with permanent urinary, sexual or bowel effects. The test can also miss cancer and create false reassurance. The decision to test should therefore follow a balanced discussion of benefits and risks. There is no routine population screening programme The UK does not currently offer routine population wide PSA screening. People with a prostate can ask a GP about testing after discussing its limitations. Testing may also be offered because of symptoms, increased inherited risk or clinical concern. A screening style PSA in someone without symptoms differs from diagnostic assessment of urinary or cancer related symptoms. Digital rectal examination A digital rectal examination allows a clinician to feel the back surface of the prostate through the rectum. A hard, irregular or nodular prostate can raise concern and trigger urgent referral. A normal examination cannot exclude cancer because much of the gland cannot be felt. Modern pathways rely more heavily on PSA and MRI than on examination alone. Declining an examination should not prevent discussion of PSA testing or appropriate referral. Primary care assessment The clinician asks about urinary symptoms, visible blood, pain, weight change and erectile function. They review infection, medicines, catheterisation, health problems in the family, ethnicity and previous PSA results. A urine test may identify infection. Kidney function and other blood tests may be needed when obstruction or advanced disease is possible. The decision to refer combines PSA, symptoms, examination, health and preferences. The suspected cancer referral pathway NICE recommends urgent referral when the prostate feels malignant on examination. For symptomatic people, referral is considered when PSA exceeds the age specific NICE threshold. An urgent referral means cancer needs prompt exclusion. It does not mean cancer has been diagnosed. A markedly abnormal result, progressive symptoms or concern for metastatic disease can change the urgency and investigation route. PSA trends and repeat testing PSA naturally varies between tests. A borderline result may be repeated after temporary causes have been addressed. PSA velocity describes how quickly the value changes over time. PSA doubling time describes how long it takes to double. Trends can inform risk but should not replace MRI, biopsy or specialist judgement. Multiparametric MRI comes before biopsy NICE recommends multiparametric MRI as the first line specialist investigation for suspected localised prostate cancer. The scan combines several MRI sequences to examine prostate anatomy, tissue density and blood flow characteristics. It identifies suspicious areas and estimates whether disease may extend outside the gland. MRI can help avoid unnecessary biopsy when the scan is low risk and the overall suspicion is low. It also guides biopsy towards abnormalities most likely to contain significant cancer. MRI scoring Prostate MRI is commonly reported using a five point suspicion scale. NICE uses a Likert scale, while many services also use PI RADS terminology. A higher score means clinically significant cancer is more likely. A low score MRI reduces risk but does not make cancer impossible. The result must be considered with PSA density, family what the person describes, examination and previous tests. When biopsy is recommended NICE recommends MRI influenced biopsy when the MRI score is 3 or higher. Biopsy may also be considered after a low risk MRI when PSA density, PSA trend or health problems in the family remains concerning. The decision should include the chance of detecting significant cancer and the risk of finding insignificant disease. A person should have time to discuss benefits, limitations and complications. Prostate biopsy A biopsy removes small tissue samples for microscopic examination. Many NHS biopsies now pass needles through the skin between the scrotum and anus using a transperineal approach. Transrectal biopsy through the rectum may still be used in some settings. MRI targeted samples examine suspicious areas, while systematic samples assess other parts of the prostate. Biopsy is required for histological confirmation in most people considered for radical treatment. Biopsy risks Blood in urine or semen is common after biopsy and usually settles. Temporary discomfort and urinary difficulty can occur. Infection is possible, particularly after transrectal biopsy. Acute urinary retention, heavy bleeding and sepsis are uncommon but serious complications. Written post biopsy instructions should explain when emergency help is required. Biopsy can miss disease A biopsy samples selected areas rather than every prostate cell. A clinically important tumour can occasionally be missed or undergraded. MRI targeting improves accuracy but does not remove all sampling uncertainty. Persistent concern after a negative biopsy may lead to repeat PSA, MRI review or another biopsy. A negative biopsy is reassuring but not an absolute lifetime guarantee. Gleason grading A pathologist examines how prostate cancer glands are arranged under the microscope. The visible patterns are assigned Gleason grades. Modern diagnosed cancers usually contain patterns graded 3, 4 or 5. Higher patterns look less like normal prostate glands and generally behave more aggressively. The grade describes microscopic appearance rather than tumour size. The Gleason score The Gleason score adds two important patterns found in the sample. The first number represents the predominant pattern, and the second represents the next important higher grade pattern. A score of 3 plus 4 equals 7, as does 4 plus 3. However, 4 plus 3 is usually more concerning because pattern 4 predominates. The order of the numbers therefore matters, not only their total. Grade groups Grade groups translate Gleason patterns into five broader categories. Grade group 1 corresponds to Gleason 3 plus 3. Grade group 2 corresponds to Gleason 3 plus 4, while grade group 3 corresponds to 4 plus 3. Grade group 4 includes Gleason score 8, and grade group 5 includes scores 9 to 10. Higher groups are associated with greater risk of growth and spread. Grade is not stage Grade describes how aggressive the cells appear. Stage describes where cancer is located and how far it has spread. A small cancer confined to the prostate can have a high grade. A larger local tumour can have a lower grade. Treatment decisions combine grade, stage, PSA, cancer volume and health rather than using one feature alone. TNM staging The TNM system describes anatomical extent. T describes the primary tumour and whether it remains within the prostate. N describes regional lymph node involvement. M describes distant metastases, most commonly involving bone. These components help classify disease as localised, locally advanced or metastatic. Localised prostate cancer Localised cancer remains within the prostate and is generally staged T1 or T2. Management options can include active surveillance, radical prostatectomy or radical radiotherapy. The appropriate choice depends on risk group, life expectancy, fitness and preferences. Many localised cancers are curable, but some low risk cancers do not need immediate treatment. Locally advanced prostate cancer Locally advanced disease has grown through the prostate capsule, reached nearby structures or involved pelvic lymph nodes. It has not spread to distant organs. Treatment can still aim for long term control or cure. Options commonly include radical radiotherapy with androgen deprivation therapy and selected surgical approaches. The exact plan depends on local extent and overall risk. Metastatic prostate cancer Metastatic cancer has spread beyond the prostate region. Bone is the most frequent distant site, but lymph nodes, liver and lungs can also be affected. Treatment is usually not curative, although it can control disease for prolonged periods. Hormone therapy forms the treatment backbone and is commonly intensified with additional systemic therapy. Palliative care supports symptoms alongside active oncology treatment. Cambridge Prognostic Groups NICE uses Cambridge Prognostic Groups for localised and locally advanced prostate cancer. The system combines PSA, grade group and T stage. CPG 1 represents the lowest risk category, while CPG 5 represents the highest risk. The group helps guide surveillance, surgery, radiotherapy, hormone therapy and staging investigations. It estimates population risk and cannot predict one person's future with certainty. Additional staging investigations Low risk localised cancer does not routinely need every staging scan. Higher risk disease may require imaging of lymph nodes and bones. CT, bone scanning, MRI or modern molecular imaging can be selected according to the clinical question and local pathway. Unnecessary scans can identify harmless abnormalities and create further uncertainty. Treatment intent Curative treatment aims to eradicate cancer within the prostate and surrounding risk area. Non curative treatment aims to control disease, prevent complications and prolong life. Active surveillance retains curative treatment as a future option if risk increases. Watchful waiting usually has a symptom control intention rather than a planned curative pathway. The treatment goal should be explained clearly. Active surveillance Active surveillance is a deliberate treatment strategy for selected localised cancers with a low expected risk. It avoids or delays radical treatment side effects while preserving the chance of cure if the cancer changes. Monitoring includes regular PSA tests, clinical review, repeat MRI and biopsy when indicated. The schedule is structured rather than passive. Active surveillance is explicitly not doing nothing. Who may be offered active surveillance NICE offers active surveillance as the preferred option for CPG 1 localised cancer. It is also an option for selected CPG 2 disease. Some people with CPG 3 disease may choose surveillance when they do not accept immediate radical treatment. It is not recommended for CPG 4 or 5 disease. Selection depends on the complete risk profile and the person's ability to attend monitoring. What surveillance looks for Clinicians monitor PSA level, density and rate of change. MRI assesses whether a lesion has enlarged or developed more concerning features. Repeat biopsy can identify increased cancer volume or a higher grade. Treatment is reconsidered when there is evidence of biological or anatomical progression. An isolated PSA fluctuation does not automatically mean treatment is required. The psychological impact of surveillance Living with untreated cancer can cause anxiety even when surveillance is medically appropriate. Some people prefer immediate treatment despite a low expected benefit. Others value avoiding urinary, sexual and bowel effects for as long as possible. Decision support and access to the specialist team are important. Choosing surveillance should not be presented as less courageous than choosing surgery or radiotherapy. Active surveillance and watchful waiting differ Active surveillance monitors potentially curable cancer and plans radical treatment if risk increases. Watchful waiting usually suits people whose age or health makes radical treatment unlikely to improve survival. Watchful waiting focuses on symptoms rather than repeated biopsies and intensive imaging. Hormone therapy can begin later if the cancer causes symptoms or progression. The terms should not be used interchangeably. Radical prostatectomy Radical prostatectomy removes the prostate and seminal vesicles, usually using robotic keyhole surgery. Pelvic lymph nodes may also be removed when nodal risk is significant. Surgery provides the entire gland for detailed pathological staging. PSA should fall to a very low or undetectable level afterwards. Further radiotherapy or hormone therapy may be needed when pathology or follow up suggests residual risk. Urinary effects of surgery Urinary leakage is common immediately after catheter removal and usually improves over time. A minority develop persistent stress incontinence during coughing, lifting or exercise. Pelvic floor rehabilitation can support recovery. Severe persistent leakage may require specialist devices or further surgery. Surgery can also cause bladder neck narrowing or altered urinary flow. Sexual effects of surgery The nerves controlling erections run close to the prostate. Nerve sparing surgery may preserve them when cancer position and safety allow. Erectile function can still take months or years to recover and may remain impaired. Orgasm can continue, but ejaculation is absent because the prostate and seminal vesicles have been removed. Natural conception through intercourse is no longer possible after radical prostatectomy. Radical external beam radiotherapy External beam radiotherapy directs radiation at the prostate and surrounding risk areas. Modern planning shapes the dose while limiting exposure to the bladder and rectum. Treatment may be delivered over several weeks or using shorter hypofractionated schedules. Higher risk localised and locally advanced disease usually receives androgen deprivation therapy with radiotherapy. Brachytherapy Brachytherapy places radioactive sources within or near the prostate. Low dose rate treatment uses permanent seeds, while high dose rate treatment uses temporary sources. It can be used alone for selected lower risk disease or combined with external radiotherapy for higher risk disease. Prostate size, urinary symptoms, anatomy and cancer risk influence suitability. Urinary effects of radiotherapy Radiotherapy can irritate the bladder and urethra. Frequency, urgency, discomfort and a weaker stream can develop during or shortly after treatment. Rarely, bleeding or narrowing occurs later. People with significant obstruction may need urinary treatment before radiotherapy. Urinary incontinence is generally less common than after surgery but can still occur. Bowel effects of radiotherapy The rectum lies directly behind the prostate. Radiotherapy can cause loose stool, urgency, mucus, discomfort or rectal bleeding. Most early symptoms improve, but a minority develop persistent radiation related bowel injury. New bleeding after treatment still requires assessment rather than being assumed to be radiation damage. Bowel side effects are generally more associated with radiotherapy than prostatectomy. Sexual effects of radiotherapy Erectile dysfunction can develop gradually after radiotherapy. Radiation can affect blood vessels, nerves and surrounding tissues. Hormone therapy given with radiotherapy can further reduce libido and erections. Ejaculation often reduces and fertility may be impaired. Sexual rehabilitation and fertility discussion should occur before treatment where relevant. Comparing surgery and radiotherapy For suitable localised cancers, radical prostatectomy and radical radiotherapy provide broadly comparable cancer control outcomes. Neither option is universally superior for every person. Surgery more commonly causes early urinary incontinence and immediate erectile dysfunction. Radiotherapy more commonly causes bowel irritation and can produce later urinary or sexual effects. Personal anatomy, health, risk group and priorities guide the choice. Why treatment comparisons require caution Side effect rates depend on baseline function, age, technique, experience and follow up duration. Radiotherapy is often combined with hormone therapy in higher risk disease, adding separate effects. Surgery can be followed by radiotherapy when adverse pathology or recurrence appears. A person may therefore experience effects from more than one modality. Decision aids are more useful than declaring one treatment simply better. Androgen deprivation therapy Most prostate adenocarcinomas depend on androgen signalling, particularly testosterone. Androgen deprivation therapy, usually called ADT, lowers testosterone or blocks its production. It can be delivered through injections, tablets or surgical removal of the testicles. ADT usually shrinks or slows hormone sensitive cancer. It does not remove the prostate and does not usually cure metastatic disease by itself. ADT with radiotherapy NICE recommends combining ADT with radical radiotherapy for CPG 2 to 5 localised or locally advanced disease. Hormone treatment can begin before radiotherapy and continue during or afterwards. It reduces cancer cell stimulation and improves outcomes in appropriate higher risk disease. The duration depends on the risk group, treatment plan and tolerance. ADT for metastatic disease ADT is the backbone of treatment for hormone sensitive metastatic prostate cancer. Modern care commonly adds another treatment rather than relying on ADT alone. Options can include androgen receptor pathway inhibitors, abiraterone or docetaxel, according to eligibility and current guidance. Some people receive two additional treatments as triplet therapy. The choice depends on disease burden, health, interactions and preferences. Hormone sensitive and hormone relapsed disease Hormone sensitive cancer still responds to testosterone suppression. Over time, some cancers progress despite testosterone remaining at a suppressed level. This is called castration resistant or hormone relapsed prostate cancer. ADT is usually continued while additional treatments target other growth pathways. Progression can be detected through PSA, imaging, symptoms or a combination. Side effects of hormone therapy ADT can cause hot flushes, loss of libido, erectile dysfunction and fatigue. Reduced muscle mass and increased body fat can occur. Long term treatment can reduce bone density and increase fracture risk. It can also affect mood, cognition, glucose, cholesterol and cardiovascular risk. Exercise, bone assessment and metabolic monitoring form part of safer treatment. Chemotherapy Docetaxel can be combined with ADT for selected newly diagnosed metastatic cancers. It may also treat disease that has progressed after earlier hormone treatment. Chemotherapy targets dividing cells throughout the body. Possible effects include infection risk, fatigue, hair loss, neuropathy and nail changes. The expected benefit must be balanced against health and treatment tolerance. Targeted and precision treatments Some advanced prostate cancers carry DNA repair changes such as BRCA alterations. PARP inhibitors can treat selected cancers with appropriate biomarkers. Genomic testing may examine tumour tissue, blood or an inherited sample. A tumour mutation does not always mean that the change was inherited. Genetic counselling is important when a germline variant may affect relatives. Radiotherapy for metastatic symptoms Focused radiotherapy can reduce pain from bone metastases. It can also treat selected spinal, pelvic or lymph node problems. Radioisotope treatments can target widespread bone dominant disease in appropriate situations. Palliative radiotherapy aims to improve symptoms and function rather than eradicate all cancer. Bone health Prostate cancer commonly spreads to bone, and ADT can weaken otherwise unaffected bone. Calcium, vitamin D, exercise and fracture risk assessment may be needed. Bisphosphonates or denosumab can be used in selected advanced disease or osteoporosis pathways. New focal bone pain should be assessed rather than assumed to be ordinary arthritis. Metastatic spinal cord compression Cancer within the spine can press on the spinal cord or cauda equina. Warning symptoms include severe or progressive back pain, leg weakness and difficulty walking. Numbness around the buttocks or genitals, urinary retention and loss of bowel control are emergencies. Immediate assessment and MRI protect the best chance of preserving movement and continence. Urinary obstruction The prostate surrounds the urethra, so cancer or benign enlargement can obstruct urine flow. Acute retention causes a painful inability to pass urine and requires urgent catheterisation. Advanced pelvic disease can obstruct the ureters and damage kidney function. A nephrostomy or internal stent may be needed to drain an obstructed kidney. Treatment follow up PSA is an important monitoring test after treatment. After prostatectomy, PSA should become extremely low because most PSA producing tissue has been removed. After radiotherapy, the prostate remains present and PSA usually falls more gradually. A single PSA rise does not always mean recurrence. Serial values, treatment type and imaging determine the next step. Biochemical recurrence Biochemical recurrence means PSA has risen according to defined criteria after radical treatment. It may occur before cancer is visible on a scan or causes symptoms. Some people need salvage radiotherapy, hormone therapy or further imaging. Others can be monitored because immediate treatment would add little benefit. A rising PSA should be interpreted through the specialist pathway rather than in isolation. Prognosis is individual Prognosis depends on stage, grade group, PSA, tumour volume, biology and response to treatment. Many low risk cancers never threaten life. Many localised and locally advanced cancers can be treated with curative intent. Metastatic disease is usually not curable but can often be controlled for years using sequential treatments. Population statistics cannot predict exactly what will happen to one person. Emotional and practical effects A diagnosis can affect identity, sexuality, continence, relationships and confidence. Active surveillance can create anxiety despite avoiding physical treatment effects. Radical treatment can alter ejaculation, fertility and sexual experience. Hormone therapy can affect mood, energy and body composition. Specialist nursing, continence care, psychosexual support and peer support can help. What this lesson should not be used for This lesson cannot diagnose prostate cancer from urinary symptoms or a PSA value. It cannot determine grade, stage or treatment suitability without MRI, biopsy and specialist assessment. Do not start antibiotics, hormone treatment or supplements solely to alter PSA without clinical advice. Do not interpret active surveillance as neglect or assume every diagnosed cancer needs immediate radical treatment. Seek urgent help for urinary retention, neurological deterioration or symptoms suggesting spinal cord compression.

Prostate cancer ranges from low grade disease that may never cause harm to aggressive cancer requiring intensive treatment. PSA identifies possible prostate abnormality but does not diagnose or grade cancer. MRI, biopsy grade, stage and risk grouping determine whether active surveillance, surgery, radiotherapy, hormone therapy or systemic treatment is appropriate.