DRJAY.UK / URO60 / FRCS REVISION
Prostate cancer diagnostic & prognostic toolkit
PSA → MRI/PSAD → biopsy reasoning → Cambridge Prognostic Groups → CAPRA → TNM
Educational prototype — not patient-facing decision support. Risk estimates are cohort-specific; local referral pathways and multidisciplinary assessment prevail. No patient data are stored or transmitted.
Age-related PSA: Oesterling, Roobol and NICE
PSA generally increases with age and prostate volume. Age-specific reference limits describe population distributions, not a PSA level below which clinically significant cancer is excluded.
| Age (years) | Oesterling et al. 1993: 95th-percentile PSA (ng/mL) | NICE NG12 symptomatic referral threshold (ng/mL) |
|---|
| 40–49 | 2.5 | >2.5 |
| 50–59 | 3.5 | >3.5 |
| 60–69 | 4.5 | >4.5 |
| 70–79 | 6.5 | >6.5 |
| <40 or ≥80 | Not established in this four-band table | Clinical judgement |
Oesterling: These age-specific values came from a community-based reference population; they are not cancer-exclusion cut-offs. Oesterling et al., JAMA 1993.
Roobol / ERSPC: Screening research emphasises that PSA is a continuous risk marker: sensitivity, specificity, overdiagnosis and the balance of benefit and harm depend on the threshold and screening population. Screening-study results should not be conflated with NICE NG12 symptomatic referral criteria. Roobol / ERSPC research.
NICE NG12: The right-hand column is for possible symptomatic prostate cancer and is not a population-screening recommendation. An abnormal DRE, symptoms, family history, genetic predisposition and overall clinical suspicion require independent assessment. NICE NG12.
1. MRI + PSA density: risk-adapted biopsy matrix
Enter PSA and MRI-measured prostate volume to calculate PSA density. The EAU PI-RADS matrix applies to biopsy-naïve men. NICE uses a separately reported 1–5 Likert assessment; the two scores are not interchangeable.
NICE uses a 1–5 Likert assessment of MRI suspicion. PI-RADS is a separate standardised reporting system used by the EAU matrix. If your radiology report uses Likert, select it here for the separate NICE pathway; do not assume numerical equivalence with PI-RADS.
Calculated PSA density (PSAD)
Enter PSA and prostate volume above to calculate PSA density.
NICE Likert: select a score if reported.
Clinical judgement: Clinical suspicion, DRE findings, family history, genetic risk and other relevant risk factors must be considered by the clinician. The matrix is intended for biopsy-naïve men and is not an automatic biopsy instruction. Follow the separate NICE pathway where applicable.
Guideline distinction: NICE offers biopsy for MRI Likert ≥3 and considers omission for Likert 1–2 after shared decision-making. EAU uses PI-RADS and PSA-density risk stratification. The table below reproduces the EAU 2026 risk-adapted decision matrix alongside the detection proportions.
Schoots & Padhani (BJUI 2021): biopsy-avoidance evidence matrix
Compiled cohort proportions of ISUP grade group ≥2 cancer from the figure you supplied. These are observed detection proportions, not individual risk predictions; cohorts, definitions and prevalence differ. Displayed as an evidence heatmap, not a rule that supersedes NICE/EAU.
| PI-RADS | PSAD <0.10 | 0.10–<0.15 | 0.15–<0.20 | ≥0.20 |
|---|
| 1–2 | 3% | 7% | 8% | 18% |
|---|
| 3 | 4% | 13% | 29% | 29% |
|---|
| 4–5 | 31% | 54% | 69% | 77% |
|---|
EAU 2026 Table 5.5 — biopsy decision matrix
Scope and interpretation: The EAU table is for biopsy-naïve men and should be interpreted alongside the separate NICE pathway, not as an automatic biopsy instruction. Incorporate DRE, family history, prior testing, individual risk and shared decision-making. A prior negative biopsy requires a different assessment.
This is the EAU risk-adapted matrix for biopsy-naïve men; it is not a stand-alone instruction for an individual patient. “Strongly consider” is preserved as a distinct EAU category.
| PI-RADS | PSAD <0.10 | 0.10–<0.15 | 0.15–<0.20 | ≥0.20 |
|---|
| 1–2 | Do not biopsy | Do not biopsy | Do not biopsy | Consider biopsy |
|---|
| 3 | Do not biopsy | Consider biopsy | Strongly consider biopsy | Biopsy |
|---|
| 4–5 | Biopsy | Biopsy | Biopsy | Biopsy |
|---|
EAU table wording: “No biopsy”, “Consider biopsy”, “Strongly consider biopsy”, “Perform biopsy”. Decisions must also account for family history, DRE, prior biopsy and overall suspicion. EAU diagnostic evaluation, Table 5.5.
Schoots IG, Padhani AR. Risk-adapted biopsy decision based on prostate magnetic resonance imaging and prostate-specific antigen density for enhanced biopsy avoidance in first prostate cancer diagnostic evaluation. BJU Int. 2021;127:175–178. DOI 10.1111/bju.15277. Matrix percentages cross-checked against the pooled EAU table reproducing Schoots & Padhani; these are study-level detection proportions, not personalised predictions.
EAU diagnostic guidance: PI-RADS ≤2 and PSAD <0.20 with no family history: biopsy may be omitted with PSA monitoring (weak); PI-RADS 3 and PSAD <0.10 with no family history: biopsy may be omitted (weak); PI-RADS ≥4: targeted with perilesional sampling. EAU diagnostic evaluation.
NICE NG131: offer MRI-influenced biopsy for Likert ≥3; consider omission after shared decision-making for Likert 1–2. For negative MRI without biopsy, PSAD >0.15 is among features prompting consideration of biopsy. NICE §§1.2.3–1.2.12.
2. Cambridge Prognostic Group (CPG) — NICE
Applies after prostate cancer is diagnosed. Uses PSA, Gleason grade group and integrated T stage; it is not a pre-biopsy risk model.
Shared with the MRI/PSA density and CAPRA sections.
The rows reproduce the combinations in your teaching table, with the favourable/unfavourable risk categories added. OR/AND conditions are read across the row; in CPG 4–5 the feature columns describe alternatives, not simultaneous requirements. NICE uses PSA 10–20 inclusively. Enter PSA above, then select Grade Group and T stage to highlight the applicable CPG rows.
| Cambridge Prognostic Group | Risk classification | Gleason score / qualifying feature | ISUP Grade Group | PSA (ng/mL) | Clinical T stage |
|---|
| CPG 1 | Low risk | ≤6 (3+3) | 1 | <10 | T1–T2 |
|---|
| CPG 2 | Favourable intermediate | 3+4=7 OR PSA 10–20 | 2 OR 1 with PSA 10–20 | 10–20 if GG1; <10 if GG2 | T1–T2 |
|---|
| CPG 3 | Unfavourable intermediate | 3+4=7 AND PSA 10–20 | 2 | 10–20 | T1–T2 |
|---|
| CPG 3 | Unfavourable intermediate | OR 4+3=7 | 3 | ≤20 | T1–T2 |
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| CPG 4 | High risk | Exactly one high-risk feature: Gleason 8 OR PSA >20 OR T3 | 4 if Gleason feature | >20 if PSA feature | T3 if stage feature |
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| CPG 5 | Very high risk | Two or more of Gleason 8, PSA >20, T3 | 4 if Gleason feature | >20 if PSA feature | T3 if stage feature |
|---|
| CPG 5 | Very high risk | OR Gleason 9–10 OR T4 | 5 if Gleason feature | Any | T4 if stage feature |
|---|
NICE NG131 Table 1, recommendation 1.2.15. NICE Table 1 uses PSA 10–20 ng/mL inclusively for CPG 2/3, and PSA >20 ng/mL for a high-risk feature. The calculator applies these exact boundaries. Primary guidance.
3. UCSF-CAPRA (0–10) — pretreatment prognostic score
Separate from CPG. CAPRA combines PSA, Gleason score, age, clinical stage and percentage of positive biopsy cores. It is a prognostic score, not a biopsy-indication tool.
Cooperberg MR et al. The UCSF Cancer of the Prostate Risk Assessment (CAPRA) score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. Primary publication search. Score bands: 0–2 low, 3–5 intermediate, 6–10 high. The age cut-off is ≥50 years. Original CAPRA validation categories begin at PSA 2 ng/mL; values below that range are not scored by this educational implementation.
4. Prostate cancer TNM staging
Clinical T stage, MRI stage and pathological T stage are distinct. The schematic below illustrates the T/N/M categories; use the definitions and radiological staging reference beneath it.
Primary tumour (T)
T1: clinically inapparent, not palpable (T1a ≤5% of resected tissue, T1b >5%, T1c needle biopsy).
T2: organ-confined (T2a ≤half one lobe; T2b >half one lobe; T2c both lobes, in traditional clinical subdivisions).
T3a: extraprostatic extension, including microscopic bladder neck invasion.
T3b: seminal vesicle invasion.
T4: fixed or invading adjacent structures other than seminal vesicles.
Regional lymph nodes (N)
N0: no regional nodal metastasis.
N1: regional pelvic lymph node metastasis.
Distant metastases (M)
M0: no distant metastasis.
M1a: non-regional nodes.
M1b: bone.
M1c: other distant sites, with or without bone disease.
Radiological staging reference: Radiopaedia: prostate cancer staging. Schematic supplied by the user; schematic is educational and not a substitute for the staging definitions.
STRATCANS — Active Surveillance Follow Up Calculator
Explore the independent STRATCANS calculator. This is a third-party tool and is not affiliated with DrJay.uk. The embedded view depends on STRATCANS permitting iframe display; if the panel is blank or blocked, use the direct link.
Open STRATCANS in a new tab ↗
Sources and release notes
NICE NG131 recommendations · EAU prostate diagnostic evaluation · Schoots & Padhani 2021 · Your uploaded Prostate Cancer – 2 PSA and Staging and Risk Stratification teaching presentations.
This is an FRCS teaching prototype with independently tested numerical logic. No MDT mode, no copy buttons, no external script dependencies, no patient-data persistence. Confirm CAPRA primary-source implementation; independently test edge cases and visually audit the paper-derived heatmap before public deployment.