Assessment & Diagnosis
Key recommendations for diagnosis and risk stratification in primary and secondary care.
MRI and Biopsy Protocols
First-Line Investigation (1.2.2)
Offer multiparametric MRI (mpMRI) as the first-line investigation for people with suspected clinically localised prostate cancer.
Results reported using 5-point Likert scale.
Biopsy Decision Based on Likert Score (1.2.3-1.2.4)
Likert Score 3 or more:
Offer mpMRI-influenced prostate biopsy.
Likert Score 1 or 2:
Consider omitting prostate biopsy, but only after discussing risks and benefits with the patient and reaching a shared decision.
If patient opts for biopsy: offer systematic prostate biopsy.
Clinical Pearl: Between 11-28 out of 100 people with low-risk MRI actually have clinically significant cancer. However, 18-23 out of 100 may be diagnosed with clinically insignificant cancer if biopsied.
Risk Stratification (1.2.6)
For newly diagnosed localised or locally advanced prostate cancer, use the following to stratify risk:
T Stage
Tumour extent (T1/T2 = localised, T3/T4 = locally advanced)
Gleason Grade Group
1 = least aggressive, 5 = most aggressive
PSA Level
Prostate-specific antigen (ng/ml)
Staging Scans: Bone and CT
When to Offer (1.2.7, 1.2.9)
Offer bone scan and CT abdomen/pelvis if:
- • Gleason grade group of 3 or more, OR
- • PSA level ≥10 ng/ml AND Gleason grade group of 2 or more
When NOT to Offer (1.2.8, 1.2.10)
Do NOT routinely offer if:
- • Gleason grade group of 1, OR
- • PSA level <10 ng/ml AND Gleason grade group of 2
GP Role: These scans are typically arranged in secondary care. Understanding these criteria helps with appropriate referral and managing patient expectations.