When Your Eyes Are Trying to Tell You Something Your Brain Already Knows

Prostate cancer is an increasingly important health concern among Pakistani men. The risk increases with age, and assessing men who are at higher risk can help identify clinically significant prostate cancer at a stage when treatment may still be curative.

Diagnosis may involve assessing a man's individual risk, a prostate-specific antigen (PSA) blood test, imaging and, when needed, a biopsy. Treatment depends on the cancer's risk category and stage, as well as the patient's overall health and preferences.

In Pakistan, prostate cancer accounted for 5,198 new cases among men in 2022, making it the fourth most commonly diagnosed cancer among Pakistani men, according to the International Agency for Research on Cancer (IARC) Global Cancer Observatory.

Advances in diagnosis and treatment are making it possible to detect prostate cancer earlier in appropriate patients and treat it with increasing precision.

Who Is at Higher Risk of Prostate Cancer?

Age is the most important risk factor for prostate cancer. The risk increases substantially after the age of 50.

Family history also matters. Men whose father or brother has had prostate cancer, particularly at a younger age, may have a higher risk of developing the disease.

Inherited genetic changes, particularly mutations in BRCA2 and other DNA-repair genes, can increase the risk of developing prostate cancer and may be associated with more aggressive disease.

Some lifestyle factors, including obesity, smoking, physical inactivity and diets high in processed or red meat, have also been associated with prostate cancer risk.

Maintaining a healthy weight, exercising regularly, avoiding tobacco and following a balanced diet are important for overall health. However, these measures cannot completely eliminate the risk of prostate cancer.

What Does a PSA Test Tell You About Prostate Cancer?

The prostate-specific antigen (PSA) blood test is an important tool for assessing the risk of prostate cancer, but it cannot diagnose cancer on its own.

PSA levels can also increase because of benign prostate enlargement, inflammation, infection and other prostate conditions. This means that an elevated PSA does not necessarily mean that a man has prostate cancer. Similarly, a normal PSA level does not completely rule out cancer.

The decision to have a PSA test should be based on an individual's circumstances, including age, family history, general health, life expectancy and previous PSA results. Depending on the situation, doctors may also consider the digital rectal examination (DRE), PSA density, risk assessment tools and prostate MRI.

If the PSA level is moderately elevated, the doctor may sometimes recommend repeating the test before proceeding with further investigations. The goal is risk-based early detection, rather than testing every man without considering his individual risk.

How Is Prostate Cancer Diagnosed with MRI and Biopsy?

When prostate cancer is suspected, doctors combine PSA results and clinical assessment with imaging and, when indicated, a biopsy.

Multiparametric MRI (mpMRI) has become an important part of prostate cancer assessment. It can help identify areas that appear suspicious and guide decisions about whether a biopsy is needed.

When a biopsy is recommended, MRI-targeted biopsy, often combined with systematic sampling, can improve the detection of clinically significant prostate cancer. Transperineal biopsy is increasingly used and has a favourable infection profile compared with some other biopsy approaches.

A biopsy is used to determine whether cancer is present and provides important information about how aggressive it is. The biopsy findings, including the Grade Group/Gleason score, are considered alongside PSA levels, examination findings and imaging results to determine the cancer's risk category.

How Is Prostate Cancer Treated?

Treatment for prostate cancer depends on several factors, including the cancer's risk category and stage, the patient's age and overall health, and personal preferences.

Treatment options range from active surveillance for selected low-risk cancers to surgery, radiotherapy and systemic treatments for higher-risk or advanced disease.

Active Surveillance

For some men with low-risk, localised prostate cancer, active surveillance may be appropriate. This involves closely monitoring the cancer through regular PSA tests, MRI scans and clinical assessments.

The aim is to avoid or delay treatment and its potential side effects when the cancer is unlikely to cause problems in the short term, while allowing treatment to begin if there are signs that the disease is progressing.

Surgery and Radiotherapy

For men with clinically significant, localised prostate cancer, potentially curative treatment options include radical prostatectomy and radiotherapy.

Modern minimally invasive and robotic-assisted surgery may be suitable for selected patients. Advances in radiotherapy, including image-guided radiotherapy and intensity-modulated radiotherapy (IMRT), allow doctors to deliver treatment more precisely while limiting exposure to surrounding healthy tissues.

Treatment for Higher-Risk or Advanced Cancer

Higher-risk and locally advanced prostate cancers may require a combination of radiotherapy and androgen-deprivation therapy (ADT) or newer hormonal treatments.

For metastatic prostate cancer, treatment may include modern hormonal therapies and chemotherapy, which can help control the disease and improve outcomes for many patients.

PSMA PET/CT has also improved the detection and staging of prostate cancer in selected patients. For some men with advanced prostate cancer, PSMA-targeted radioligand therapies, such as lutetium-177 PSMA therapy, may provide another treatment option.

What Does Prostate Cancer Care Mean for Men in Pakistan?

For men in Pakistan, improving prostate cancer outcomes involves greater awareness, appropriate risk-based testing, timely diagnosis and access to quality treatment.

Men who may be at higher risk—particularly older men and those with a strong family history of prostate cancer—should discuss their individual risk with a doctor. Early specialist assessment can help identify clinically significant disease at a stage when potentially curative treatment may still be possible.

Key Takeaways

• Age and family history matter: Talk to your doctor about your individual risk of prostate cancer.

• PSA is not a cancer diagnosis: An abnormal PSA result does not necessarily mean cancer and needs to be interpreted in context.

• MRI can help with diagnosis: Prostate MRI is increasingly used to assess suspicious findings and guide biopsy decisions.

• Not every prostate cancer needs immediate treatment: Active surveillance may be appropriate for some men with low-risk disease.

• Treatment options are expanding: Depending on the cancer's stage and risk, treatment may include surgery, radiotherapy, hormonal therapy, chemotherapy and PSMA-based treatments.

• Timely specialist assessment matters: Early evaluation can help identify clinically significant prostate cancer when potentially curative treatment may still be possible.

Prostate cancer is an increasingly important health concern among Pakistani men. It is more common with increasing age, and early assessment of men at higher risk can help identify clinically significant disease at a stage when treatment may still be potentially curative. Diagnosis involves risk assessment, PSA testing, imaging and, when indicated, a prostate biopsy. Treatment depends on the cancer’s risk group, stage, the patient’s overall health, and individual preferences.

In Pakistan, prostate cancer accounted for 5,198 new cases among men in 2022, making it the fourth most commonly diagnosed cancer among Pakistani men, according to the International Agency for Research on Cancer (IARC) Global Cancer Observatory.

Prostate cancer is increasingly detectable at an earlier stage and treatable with greater precision.

 Who Is at Higher Risk of Prostate Cancer?

Age is the most important risk factor for prostate cancer, with risk increasing substantially after the age of 50. Family history is also significant. Men whose father or brother has had prostate cancer, particularly at a younger age, are at increased risk.

Inherited genetic changes, especially BRCA2 and other DNA-repair gene mutations, may increase the likelihood of aggressive disease. Lifestyle factors such as obesity, smoking, physical inactivity and diets high in processed or red meat have also been associated with prostate cancer risk.

Maintaining a healthy weight, exercising regularly, avoiding tobacco and following a balanced diet are sensible measures for overall health, although they cannot eliminate the risk of prostate cancer.

What Does a PSA Test Tell You About Prostate Cancer?

The prostate-specific antigen (PSA) blood test is an important tool for assessing prostate cancer risk, but it does not by itself diagnose cancer. PSA is not specific for cancer screening - it can also be elevated by benign prostate enlargement, inflammation, infection and other prostate conditions.

Therefore, an elevated PSA does not necessarily mean cancer, and a normal PSA does not completely exclude it.

The decision to have a PSA test should be individualised according to age, family history, general health, life expectancy and previous PSA results. Doctors may also consider PSA density, digital rectal examination, risk calculators and prostate MRI.

In men with a moderately elevated PSA, repeating the test may sometimes be appropriate before proceeding to further investigations. The aim should be risk-based early detection rather than indiscriminate testing.

How Is Prostate Cancer Diagnosed with MRI and Biopsy?

When prostate cancer is suspected, diagnosis involves combining PSA results and clinical assessment with imaging and, when indicated, biopsy. Multiparametric MRI (mpMRI) has become an important diagnostic tool. It can identify suspicious areas and help guide biopsy decisions.

Where biopsy is indicated, MRI-targeted biopsy, often combined with systematic sampling, improves the detection of clinically significant cancer. Trans-perineal biopsy is increasingly used because of its favourable infection profile.

A biopsy determines whether cancer is present and provides information about its aggressiveness. PSA, Grade Group/Gleason score, examination and imaging findings are then combined to determine the cancer's risk category.

How Is Prostate Cancer Treated?

Treatment for prostate cancer depends on the cancer's risk and stage, the patient's age and overall health, and personal preferences. Treatment options can range from active surveillance for selected low-risk cancers to surgery, radiotherapy and systemic treatments for higher-risk or advanced disease.

For selected men with low-risk localised cancer, active surveillance may be the best approach. Regular PSA testing, MRI and clinical assessment allow doctors to monitor the disease while avoiding or delaying unnecessary treatment.

For clinically significant localized cancer, potentially curative options include radical prostatectomy and radiotherapy. Modern minimally invasive and robotic-assisted surgery may be appropriate in selected centres. Advanced radiotherapy techniques, including image-guided and intensity-modulated radiotherapy (IMRT), allow increasingly precise treatment while limiting exposure to surrounding tissues.

Higher-risk and locally advanced cancers may require combinations of radiotherapy and androgen-deprivation therapy (ADT) or newer hormonal treatments.

For metastatic disease, systemic treatments including modern hormonal agents and chemotherapy can significantly improve disease control. PSMA PET/CT has enhanced the detection and staging of prostate cancer in selected patients. PSMA-targeted radioligand treatments such as lutetium-177 PSMA therapy have also opened new treatment possibilities for appropriately selected men with advanced disease.

What Does Prostate Cancer Care Mean for Men in Pakistan?

For men in Pakistan, the priority is to combine medical advances with earlier awareness, appropriate risk-based testing and equitable access to quality diagnosis and treatment.

Key Takeaways for Patients

• Age and family history matter: discuss your individual risk with your doctor.

• PSA is not a cancer diagnosis: an abnormal result requires appropriate interpretation.

• MRI can improve diagnosis: it is increasingly important before prostate biopsy.

• Not every prostate cancer requires immediate treatment: active surveillance may be appropriate for low-risk disease.

• Modern treatments are expanding: surgery, precision radiotherapy, hormonal therapy, chemotherapy and PSMA-based approaches offer multiple options.

• Early specialist assessment matters: timely evaluation can identify clinically significant cancer when curative treatment may still be possible.

About the Author: Dr Sehrish Momin, Senior Instructor and Consultant in the Department of Ophthalmology and Visual Sciences​ at the Aga Khan University Hospital, Karachi.