Urology · Prostate cancer
Prostate cancer: what has actually changed in treatment
More has changed in how prostate cancer is found than in how it is cut out. Scans now decide who needs a biopsy at all, some cancers are deliberately not treated, and a new radioactive treatment has moved earlier in advanced disease. Here is what the 2026 guidelines say — including which of these fit a patient travelling from abroad, and which do not.
The short answer
- MRI before biopsy is now standard, so fewer men have an unnecessary biopsy.
- PSMA PET is the most sensitive scan for finding spread, and it changes treatment plans.
- Low-risk cancer is often monitored, not treated. This is the guideline position, not a compromise.
- HIFU and focal therapy are still investigational under EAU 2026 and AUA/ASTRO 2026 — heavily marketed, but not yet proven against standard treatment.
- Robotic surgery gives better continence recovery, while cancer control is comparable to open surgery in randomised trials.
1. Diagnosis: the biggest change of all
For decades a raised PSA led more or less straight to a biopsy of the prostate. That is no longer the case. The guidelines now recommend a multiparametric MRI first, specifically to avoid unnecessary biopsies. If the MRI is reassuring, many men can be spared the procedure entirely; if it is not, the biopsy can be aimed at the suspicious area rather than sampling blindly.
For finding out whether a cancer has spread, PSMA PET is now described as the most sensitive technique available. This matters practically: a man who would once have been treated as having localised disease is sometimes found to have spread — and a man feared to have widespread disease is sometimes found to have only one or two spots, which changes the plan completely.
The 2026 EAU update also introduced a new five-tier risk classification, replacing the older low / intermediate / high grouping with something more granular.
Bring your MRI images on a disc or USB, not just the report, and bring the biopsy pathology report with the Gleason or ISUP grade. Without these, a second opinion is guesswork and scans may simply be repeated.
2. Sometimes the right treatment is no treatment
Active surveillance — regular PSA tests, scans and repeat biopsies, with treatment held in reserve — is the recommended management for low-risk prostate cancer, and for selected patients with favourable intermediate-risk disease (ISUP grade group 2).
This is not a way of saving money or avoiding effort. Many prostate cancers grow so slowly that they never threaten the man who has them, while surgery and radiotherapy carry real risks to continence and erections. Monitoring avoids paying that price for a cancer that was never going to cause harm.
Active surveillance is the one option that does not travel well. It depends on regular tests and repeat biopsies over years, with the same team watching the trend. If your cancer is suitable for surveillance, the honest advice is to be monitored where you live — not to fly somewhere for an operation you may not need.
If you are told abroad that your low-risk cancer needs immediate surgery, that is worth a second opinion.
3. Surgery: the robot, honestly assessed
Robot-assisted surgery is now the usual way a prostate is removed in most high-volume centres. Randomised trials comparing it with traditional open surgery found similar cancer control, and similar urinary and sexual function at two years. More recent pooled analyses favour the robotic approach for recovery of urinary continence and for the ability to spare the nerves that control erections.
So the robot is a genuine advantage — a modest and real one, mostly in recovery rather than in cure. What it is not is a substitute for experience. The number of these operations a surgeon performs each year remains one of the strongest predictors of the outcome.
4. Radiotherapy: fewer sessions than before
Radiotherapy cures prostate cancer as effectively as surgery in many men. The change worth knowing about is hypofractionation — delivering the treatment in fewer, larger sessions. The 2026 guidelines recommend considering it for intermediate-risk patients.
For patients with cancer in the pelvic lymph nodes (cN1), the guidelines advise radiotherapy to the prostate itself combined with long-term intensified hormone treatment — not hormones alone.
Radiotherapy and travel: do the arithmetic first
Even shortened radiotherapy is a course of treatment, not a single visit, and hormone treatment continues for months or years afterwards. Before travelling for radiotherapy, get three things in writing: how many sessions, over how many weeks, and what has to continue at home — and confirm that a doctor where you live will prescribe and monitor it.
A course abandoned halfway because someone had to fly home is worse than one never started.
5. HIFU and focal therapy: what the guidelines actually say
Focal treatments aim to destroy only the part of the prostate containing cancer — using high-intensity focused ultrasound (HIFU), cryotherapy or similar — and to leave the rest intact, preserving continence and erections. The idea is genuinely attractive, and it is one of the most heavily advertised treatments in medical tourism.
The guidelines are more cautious than the advertising:
- EAU 2026: whole-gland or focal ablative therapy should only be offered within a clinical trial or registry. This is a strong recommendation.
- AUA/ASTRO 2026: patients must be told that ablation remains investigational, without high-quality data comparing it to standard treatment. The panel cautions against wide adoption of HIFU, noting there are no randomised trials comparing it with surgery, radiotherapy or surveillance.
Safety is reasonably established; what is missing is long-term proof that the cancer is controlled as well as by standard treatment. That is a real distinction, and it is the one a patient deserves to have explained before choosing.
If you are considering focal therapy, ask directly: is this being offered inside a trial or registry, and what are this centre's own results at five years? Those two questions separate a serious programme from a sales pitch.
6. Advanced disease: targeted radiation from the inside
For cancer that has spread and stopped responding to hormone treatment, lutetium-177 PSMA-617 is a treatment given into a vein that seeks out prostate cancer cells and irradiates them from within. It has been established in castration-resistant disease, and in March 2025 its approved use was extended to an earlier setting on the basis of the PSMAfore trial.
It is given as a course of several cycles, spaced weeks apart, and requires a nuclear medicine department. For a patient living in another country, that means either staying for the full course or arranging the remaining cycles at home before starting — a logistics question that has to be settled first, not discovered halfway through.
| Situation | Usual direction in 2026 | Suits travelling? |
|---|---|---|
| Low-risk, small volume | Active surveillance | No — needs long-term local follow-up |
| Localised, treatment indicated | Surgery (often robotic) or radiotherapy | Surgery yes, with recovery time; radiotherapy needs weeks on site |
| Node-positive (cN1) | Radiotherapy + long-term intensified hormone treatment | Only with a doctor at home to continue treatment |
| Considering HIFU / focal | Trial or registry setting | Ask which trial before booking anything |
| Spread, hormone-resistant | May include lutetium-177 PSMA-617 | Several cycles — plan the whole course in advance |
Every one of these decisions should be made in a multidisciplinary discussion — urologist, radiation oncologist and medical oncologist together — not by whichever specialist the patient happens to reach first.
Medically reviewed by Assoc. Prof. Dr. Bekir Voyvoda
Urologist at Florence Nightingale Hospital, Istanbul; Associate Professor since 2025. This guide was prepared by the BookingHospital medical team from the 2026 EAU and AUA/ASTRO prostate cancer guidelines and reviewed for accuracy. Treatment for each patient is planned by the treating team after their own imaging and pathology are assessed.
Send your MRI and pathology report for a second opinion
Send your MRI images, biopsy pathology report and PSA history. A physician will review them and explain which treatment paths are reasonable in your situation — including when monitoring at home is the better answer.
Medical disclaimer. This article is general information based on published international guidelines. It is not personal medical advice, it does not establish a doctor–patient relationship, and it cannot replace assessment by the physicians treating you. Decisions about prostate cancer treatment depend on individual pathology, imaging, age and other health conditions.
References
- EAU–EANM–ESTRO–ESUR–ISUP–SIOG Guidelines on Prostate Cancer — 2026 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. European Urology, March 2026.
- American Urological Association / ASTRO. Clinically Localized Prostate Cancer Guideline, 2026.
- Coughlin GD, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. Lancet Oncology 2018.
- Sartor O, et al. Lutetium-177–PSMA-617 for metastatic castration-resistant prostate cancer. New England Journal of Medicine 2021; and the PSMAfore trial, on the basis of which the indication was extended in March 2025.