Prostate Cancer: A Complete Guide for International Patients in Shanghai

Introduction

Prostate cancer is the most commonly diagnosed cancer in men in many Western countries and is rapidly increasing in incidence in China and across Asia. While historically less prevalent in Asian populations, urbanization, dietary westernization, and improved detection through PSA testing have driven a significant rise in prostate cancer diagnoses in China over the past two decades.

The critical message about prostate cancer is one of optimism: when detected at an early, localized stage, prostate cancer is highly curable. The five-year survival rate for localized prostate cancer approaches 100%. Even metastatic prostate cancer, once considered rapidly fatal, has been transformed by modern hormonal therapies and targeted agents into a condition that many men live with for years or even decades.

For international patients and expatriates in Shanghai, understanding prostate cancer — from screening and diagnosis to treatment options and survivorship — is essential. This guide provides a comprehensive overview tailored to the needs of the international community in Shanghai.

Understanding the Prostate

The prostate is a walnut-sized gland located below the bladder and in front of the rectum in men. It surrounds the urethra (the tube that carries urine and semen out of the body) and produces fluid that forms part of semen. The prostate naturally enlarges with age — a benign process called benign prostatic hyperplasia (BPH) — which is distinct from prostate cancer but can cause similar urinary symptoms.

Types of Prostate Cancer

• Adenocarcinoma: Accounts for more than 95% of prostate cancers. Arises from the glandular cells of the prostate. This guide focuses primarily on adenocarcinoma.
• Small cell carcinoma / neuroendocrine prostate cancer: A rare, aggressive variant that does not produce PSA and requires different treatment. May arise de novo or develop from adenocarcinoma after prolonged hormonal therapy.
• Ductal adenocarcinoma, mucinous carcinoma, signet ring cell carcinoma: Rare variants with distinct behavior.

Risk Factors

• Age: The most important risk factor. Prostate cancer is rare before 50; risk increases sharply with age. The majority of cases are diagnosed in men over 65.
• Family history: Having a first-degree relative (father, brother) with prostate cancer doubles the risk. Multiple affected relatives confer higher risk.
• Hereditary cancer syndromes: BRCA2 mutations (and to a lesser extent BRCA1) significantly increase prostate cancer risk and are associated with more aggressive disease. Lynch syndrome also increases risk. Genetic testing is increasingly recommended for men with high-risk or metastatic prostate cancer.
• Ethnicity: Prostate cancer is more common and more aggressive in men of African descent. Asian men historically have lower incidence, but risk increases significantly with adoption of Western lifestyle and diet.
• Diet: High consumption of red meat and high-fat dairy products may increase risk. Diets rich in vegetables, particularly lycopene-containing foods (tomatoes), may be protective.
• Obesity: Associated with more aggressive prostate cancer and worse outcomes.

Symptoms

Early prostate cancer typically causes no symptoms. This is why PSA screening is so important — by the time symptoms develop, cancer may have spread beyond the prostate.

When symptoms do occur, they may include:

• Urinary symptoms: frequent urination (especially at night), weak or interrupted urine flow, difficulty starting or stopping urination, a feeling of incomplete bladder emptying
• Blood in the urine (hematuria) or semen (hematospermia)
• Erectile dysfunction
• Pain or discomfort in the pelvic area

Note: These urinary symptoms are more commonly caused by benign prostatic hyperplasia (BPH) than by prostate cancer. However, they warrant medical evaluation to exclude cancer.

Symptoms of advanced or metastatic prostate cancer include:

• Bone pain (particularly in the back, hips, or pelvis) — reflecting bone metastases
• Unexplained weight loss and fatigue
• Leg weakness or swelling (from spinal cord compression or lymph node involvement)

Screening: The PSA Test

Prostate-specific antigen (PSA) is a protein produced by both normal and cancerous prostate cells. A blood PSA test is the primary screening tool for prostate cancer. Elevated PSA can indicate prostate cancer, but also BPH, prostatitis (prostate infection), or other benign conditions.

PSA Screening Recommendations

• Average risk men: Discuss PSA screening with your doctor starting at age 50. Screening is most beneficial for men with a life expectancy of at least 10–15 years.
• Higher risk men (family history of prostate cancer, BRCA2 mutation carriers): Consider starting screening at age 40–45.
• PSA interpretation: A single PSA value must be interpreted in context. PSA velocity (rate of rise over time), PSA density (PSA relative to prostate volume), and free-to-total PSA ratio all provide additional diagnostic information.
• PSA thresholds: A PSA above 4.0 ng/mL is traditionally considered elevated, but cancer can occur at lower levels, and many men with PSA 4–10 ng/mL do not have cancer. Clinical judgment and further investigation are required.

PSA testing is widely available at Shanghai hospitals and international clinics. CMCS can coordinate PSA testing and specialist interpretation as part of a comprehensive men’s health check-up.

Diagnosis

When PSA is elevated or prostate cancer is suspected, the diagnostic workup includes:

• Digital rectal examination (DRE): Manual examination of the prostate through the rectum to assess size, consistency, and any palpable nodules. A hard, irregular prostate raises suspicion for cancer.
• Multiparametric MRI (mpMRI) of the prostate: The most important pre-biopsy investigation. Provides detailed imaging of the prostate to identify suspicious lesions and guide targeted biopsy. Reported using the PI-RADS scoring system (1–5). Available at major Shanghai hospitals.
• Prostate biopsy: Tissue sampling is required to confirm the diagnosis. Modern approaches include:
  • MRI-targeted (fusion) biopsy: MRI images are fused with real-time ultrasound to guide needles precisely to suspicious lesions. Significantly improves detection of clinically significant cancer. Available at leading Shanghai urology centers.
  • Systematic transrectal ultrasound (TRUS) biopsy: The traditional approach, taking multiple random cores from the prostate. Being replaced by targeted approaches at leading centers.
  • Transperineal biopsy: Needles are inserted through the perineum (skin between scrotum and anus) rather than through the rectum, reducing infection risk. Increasingly preferred at leading centers.
• Pathological assessment — Gleason score and Grade Group: The biopsy specimen is examined by a pathologist and assigned a Gleason score (2–10) and Grade Group (1–5). Higher grades indicate more aggressive cancer. Grade Group 1 (Gleason 6) is low-risk; Grade Group 5 (Gleason 9–10) is very high-risk.
• Staging investigations: For intermediate-to-high risk cancer, staging scans are performed to assess for spread beyond the prostate:
  • CT scan of abdomen and pelvis (lymph node assessment)
  • Bone scan (technetium-99m) or PSMA PET-CT (increasingly preferred — more sensitive for detecting metastases)
  • PSMA PET-CT: A highly sensitive nuclear medicine scan using prostate-specific membrane antigen (PSMA) as a target. Rapidly becoming the standard of care for staging and detecting recurrence. Available at leading Shanghai hospitals.
• Germline genetic testing: Recommended for men with high-risk, very high-risk, or metastatic prostate cancer to identify BRCA1/2, ATM, and other mutations that influence treatment decisions and family risk.
• Somatic tumor molecular testing: Tumor tissue or liquid biopsy testing for homologous recombination repair (HRR) gene mutations (BRCA2, ATM, CDK12) and microsatellite instability (MSI) to guide eligibility for PARP inhibitors and immunotherapy.

Staging

Prostate cancer is staged using the TNM system and risk-stratified into groups that guide treatment decisions:

• Localized (Stage I–II): Cancer confined to the prostate. Further classified as low, intermediate (favorable/unfavorable), or high risk based on PSA, Grade Group, and clinical stage.
• Locally advanced (Stage III): Cancer has extended beyond the prostate capsule or into seminal vesicles or adjacent structures, but has not spread to lymph nodes or distant organs.
• Metastatic (Stage IV): Cancer has spread to lymph nodes (N1) or distant organs, most commonly bone (M1b) and less commonly liver or lungs (M1c).

Treatment

Treatment decisions in prostate cancer are complex and depend on cancer stage and risk group, patient age and life expectancy, comorbidities, and patient preferences regarding side effects. A multidisciplinary team (MDT) approach involving urologists, radiation oncologists, and medical oncologists is essential.

Active Surveillance

For men with low-risk or favorable intermediate-risk localized prostate cancer, active surveillance (AS) — close monitoring without immediate treatment — is a guideline-recommended option. It avoids or delays the side effects of treatment while maintaining the option to treat if the cancer progresses.

Active surveillance involves regular PSA testing (every 3–6 months), repeat prostate MRI (annually), and repeat biopsy (at 1–2 years and periodically thereafter). Strict adherence to the surveillance protocol is essential. CMCS can coordinate active surveillance programs at Shanghai’s leading urology centers.

Radical Prostatectomy

Surgical removal of the entire prostate gland (radical prostatectomy) is a curative treatment for localized and selected locally advanced prostate cancer. Modern approaches include:

• Robot-assisted laparoscopic radical prostatectomy (RALP): The gold standard surgical approach at leading centers worldwide. Offers superior precision, reduced blood loss, faster recovery, and better preservation of urinary continence and erectile function compared to open surgery. Robotic surgery (da Vinci system) is available at major Shanghai hospitals including Zhongshan Hospital and Ruijin Hospital.
• Laparoscopic radical prostatectomy: Minimally invasive but without robotic assistance. Widely performed in China.
• Open radical prostatectomy: The traditional approach, still performed at some centers.

Key side effects of radical prostatectomy include urinary incontinence (usually temporary, resolving within weeks to months) and erectile dysfunction (risk depends on nerve-sparing technique and pre-operative function).

Radiation Therapy

Radiation therapy is an equally effective curative option for localized prostate cancer, with different side effect profiles compared to surgery:

• External beam radiation therapy (EBRT): Modern techniques including intensity-modulated radiation therapy (IMRT) and volumetric arc therapy (VMAT) deliver high doses of radiation precisely to the prostate while minimizing exposure to surrounding structures. Typically delivered over 4–8 weeks. Available at major Shanghai hospitals.
• Stereotactic body radiation therapy (SBRT): Ultra-hypofractionated radiation delivered in 5 sessions over 1–2 weeks. Increasingly used for low-to-intermediate risk prostate cancer. Available at leading Shanghai radiation oncology centers.
• Brachytherapy: Radioactive seeds (low-dose rate) or a temporary high-dose rate source are placed directly into the prostate. Used for low-to-intermediate risk disease, often in combination with EBRT for higher-risk disease.
• Androgen deprivation therapy (ADT) combined with radiation: For intermediate-to-high risk localized and locally advanced disease, ADT is combined with radiation to improve outcomes.

Androgen Deprivation Therapy (ADT)

Prostate cancer cells are driven by male hormones (androgens), primarily testosterone. ADT reduces testosterone to castrate levels, suppressing cancer growth. It is the cornerstone of treatment for locally advanced and metastatic prostate cancer.

• LHRH agonists (e.g., leuprolide, goserelin): Monthly or 3-monthly injections that suppress testosterone production. Available in China.
• LHRH antagonists (e.g., degarelix, relugolix): Faster testosterone suppression without the initial testosterone flare of LHRH agonists. Relugolix is an oral option. Availability in China is expanding.
• Bilateral orchiectomy (surgical castration): Permanent and cost-effective; less commonly chosen in the modern era of medical castration.

Side effects of ADT include hot flashes, fatigue, loss of libido, erectile dysfunction, weight gain, muscle loss, bone density loss (osteoporosis), metabolic syndrome, and increased cardiovascular risk. Proactive management of these side effects is essential.

Novel Hormonal Agents (NHAs)

A major advance in prostate cancer treatment, NHAs are now used across all stages of the disease:

• Enzalutamide: An androgen receptor inhibitor. Approved and available in China for metastatic castration-resistant prostate cancer (mCRPC) and metastatic hormone-sensitive prostate cancer (mHSPC).
• Abiraterone acetate: Blocks androgen synthesis. Used with prednisone. Approved and available in China for mCRPC and mHSPC.
• Apalutamide, darolutamide: Androgen receptor inhibitors approved for non-metastatic CRPC and mHSPC. Availability in China is expanding.

PARP Inhibitors

For men with metastatic castration-resistant prostate cancer (mCRPC) harboring BRCA1/2 or other HRR gene mutations, PARP inhibitors offer targeted therapy:

• Olaparib: Approved in China for BRCA-mutated mCRPC.
• Niraparib, rucaparib: Availability in China is evolving.

Germline and somatic molecular testing is essential to identify patients eligible for PARP inhibitor therapy.

Chemotherapy

• Docetaxel: First-line chemotherapy for metastatic prostate cancer, used in combination with ADT for high-volume metastatic hormone-sensitive disease, and for mCRPC. Available in China.
• Cabazitaxel: Second-line chemotherapy for mCRPC after docetaxel. Available in China.

PSMA-Targeted Radioligand Therapy

Lutetium-177 PSMA (Lu-177 PSMA-617 / Pluvicto): A revolutionary targeted radiotherapy that delivers radiation directly to PSMA-expressing prostate cancer cells. Approved for PSMA-positive mCRPC after prior NHA and taxane therapy. Availability in China is expanding rapidly. CMCS can advise on current access options.

Immunotherapy

Pembrolizumab (anti-PD-1) is approved for MSI-H/dMMR prostate cancer — a small subset. Immunotherapy has limited efficacy in unselected prostate cancer.

Bone-Targeted Therapy

• Denosumab and zoledronic acid: Reduce skeletal-related events (fractures, spinal cord compression) in patients with bone metastases. Also used to prevent bone loss from ADT.
• Radium-223 (Xofigo): An alpha-emitting radiopharmaceutical that targets bone metastases and improves survival in mCRPC with symptomatic bone metastases. Availability in China is limited.

Survivorship & Side Effect Management

Prostate cancer treatment side effects significantly impact quality of life. Proactive management is essential:

• Urinary incontinence: Pelvic floor exercises (Kegel exercises) before and after surgery improve recovery. Most men regain continence within 3–12 months.
• Erectile dysfunction: Penile rehabilitation (PDE5 inhibitors, vacuum erection devices) should begin early after surgery or radiation. Discuss options with your urologist.
• Bone health: ADT causes bone loss. Calcium, vitamin D supplementation, weight-bearing exercise, and denosumab or bisphosphonates are used to prevent osteoporosis and fractures.
• Cardiovascular health: ADT increases cardiovascular risk. Regular exercise, healthy diet, and cardiovascular monitoring are essential.
• Psychological impact: Anxiety, depression, and body image concerns are common. Psychological support and peer support groups are valuable.
• PSA monitoring: Regular PSA testing after curative treatment detects biochemical recurrence early, allowing salvage treatment before clinical progression.

Prostate Cancer Care in Shanghai

• Surgical expertise: Robotic radical prostatectomy (da Vinci) is available at Zhongshan Hospital, Ruijin Hospital, and other leading centers. Shanghai’s urological surgeons have extensive experience with high-volume prostate cancer surgery.
• PSMA PET-CT: Available at major Shanghai hospitals — one of the most important advances in prostate cancer staging and recurrence detection.
• Multidisciplinary tumor boards: Leading Shanghai hospitals conduct MDT meetings for prostate cancer, ensuring treatment decisions reflect the latest evidence.
• Novel therapies: Enzalutamide, abiraterone, olaparib, and docetaxel are available in China. Access to newer agents (Lu-177 PSMA, darolutamide) is expanding. CMCS can advise on current availability.
• Genetic testing: Germline BRCA and HRR testing is available at major Shanghai hospitals and commercial laboratories.

How China Medical Concierge Shanghai (CMCS) Can Help

A prostate cancer diagnosis — or the decision about whether to screen — requires expert guidance and seamless coordination. CMCS provides:

• PSA screening coordination: Arranging PSA testing and specialist interpretation as part of men’s health check-ups
• Specialist matching: Connecting you with leading urologists, radiation oncologists, and medical oncologists at Shanghai’s top hospitals
• MDT coordination: Facilitating access to multidisciplinary tumor board review
• Appointment booking: Priority scheduling across multiple specialties
• Medical interpretation: Professional interpreters for all consultations, biopsy procedures, and treatment discussions
• Second opinion coordination: Arranging second opinions from leading specialists, including remote consultations with international centers
• Genetic testing coordination: Facilitating germline and somatic molecular testing
• Insurance coordination: Liaising with your international health insurer for treatment approvals and claims, including for novel agents and robotic surgery
• Survivorship support: Coordinating ongoing PSA surveillance, side effect management, and specialist follow-up

📩 Contact CMCS today for a free initial consultation.

Frequently Asked Questions

Should I have a PSA test?
PSA screening is a personal decision that should be made in discussion with your doctor, weighing the benefits of early detection against the risks of overdiagnosis and overtreatment. Most guidelines recommend discussing PSA screening starting at age 50 for average-risk men, and at 40–45 for those with a family history of prostate cancer or BRCA2 mutations. CMCS can coordinate a consultation with a urologist to discuss your individual risk and screening options.

Is prostate cancer always aggressive?
No. Prostate cancer exists on a wide spectrum. Low-grade (Grade Group 1) prostate cancer grows very slowly and may never cause symptoms or require treatment. High-grade (Grade Group 4–5) cancer is aggressive and requires prompt treatment. Accurate risk stratification — using PSA, Grade Group, MRI, and staging — is essential to guide the right treatment decision.

What is active surveillance and is it safe?
Active surveillance is close monitoring of low-risk prostate cancer without immediate treatment. It is a guideline-recommended option for carefully selected men with low-risk disease. Studies show that the majority of men on active surveillance do not require treatment within 10 years, and those who do progress can be treated successfully. It requires strict adherence to a monitoring protocol.

Is robotic prostatectomy available in Shanghai?
Yes. Robot-assisted radical prostatectomy (da Vinci system) is available at major Shanghai hospitals including Zhongshan Hospital and Ruijin Hospital. Shanghai’s urological surgeons have extensive experience with this procedure. CMCS can facilitate access to leading robotic surgeons.

Are novel hormonal agents (enzalutamide, abiraterone) available in China?
Yes. Both enzalutamide and abiraterone are approved and available in China for metastatic prostate cancer. PARP inhibitors (olaparib) are also available for eligible patients with BRCA mutations. CMCS can assist with accessing these therapies and navigating insurance pre-authorization.

Is prostate cancer treatment covered by international health insurance?
Yes. Prostate cancer diagnosis and treatment — including surgery, radiation, hormonal therapy, and chemotherapy — are covered by most international health insurance plans. Coverage for novel agents (PARP inhibitors, Lu-177 PSMA) and robotic surgery may require pre-authorization. CMCS can verify your coverage and manage the authorization process.