5. INTRODUCTION
• Prostate cancer is one of the most common cancers that affect men,
especially those > 50 years of age.
• Prostate cancer is typically diagnosed and monitored using prostate-
specific antigen (PSA) testing
• nce the decision to treat has been made, therapeutic options
include radical prostatectomy, radiation therapy, androgen
deprivation therapy (ADT), and chemotherapy.
• ince all treatment options may adversely affect the patient's quality of
life, shared decision-making with the patient is strongly encouraged in
all current guidelines.
6. EPIDEMIOLOGY
• Incidence: following skin cancer (i.e., melanoma and nonmelanoma
combined) most common cancer in men in the US
• The lifetime risk of prostate cancer for men living in the US is one in
nine.
• Mortality: in 2020, second leading cause of cancer deaths in men in
the US (after lung cancer)
7. Risk factors
• Advanced age (> 50 years)
• Family history
• African-American descent
• Genetic disposition (e.g., BRCA2, Lynch syndrome)
8. Clinical features
• Typically asymptomatic
• Early prostate cancers are typically detected during screening tests.
• Some prostate cancers are found incidentally (incidental prostate
cancer)
• Patients may present with features of complicated lower urinary tract
symptoms (LUTS), including:
• Urinary retention
• Hematuria
• Incontinence
• Flank pain (due to hydronephrosis)
9. Cont’
• Advanced prostate cancer can manifest with:
Constitutional symptoms: fatigue, loss of appetite, clinically significant
unintentional weight loss
Features of metastatic disease; examples include:
• Bone pain (due to bone metastasis, especially in the lumbosacral spine)
• Neurological deficits (e.g., due to vertebral fracture causing spinal cord compression)
• Lymphedema (caused by obstructing metastases in the lymph nodes)
10. Cont’
• Digital rectal examination
A DRE should be performed in individuals with elevated
serum PSA levels and as part of the comprehensive evaluation of
male LUTS.
it has a low positive predictive value for detecting prostate cancer
and should not be performed as the sole screening modality.
May be normal in early disease or if the cancer is located in areas of
the gland that are not palpable on DRE.
12. Cont’
• Features suggestive of prostate cancer include:
Localized indurated nodules on an otherwise smooth surface
Prostatomegaly, lobar asymmetry, obliteration of the sulcus
Hard non tender nodules
• ??Most prostate cancers are located in the peripheral zone
(posterior lobe) of the prostate. In contrast, BPH occurs in
the transitional zone of the prostate.
• ??Even patients with advanced prostate cancer may have a
normal DRE; if clinical suspicion is high, continue diagnostic
evaluation for prostate cancer!
14. Diagnosis
• Suspect prostate cancer in patients with elevated PSA levels detected on
routine screening and/or abnormal findings on DRE
• Consider adjunctive PSA testing before performing a biopsy.
• Confirm the diagnosis after performing prostate biopsy.
• Stage prostate cancer to determine the appropriate management and
prognosis
• Total PSA levels PSA > 4 ng/mL: Prostate cancer is likely
• ??A PSA level ≤ 4 ng/mL does not exclude prostate cancer
• Other causes of elevated total PSA: BPH, UTI, prostatitis, prostatic trauma
or manipulation (including
15. Cont’
• ??5-alpha reductase inhibitors (5-ARIs) can suppress PSA production,
resulting in spuriously low PSA levels.
• This should be taken into consideration in patients on long-term 5-
ARIs (e.g., for BPH).
16. Evaluation of tumor extent
• Cross-sectional imaging (CT, MRI, or PET-CT scan) is recommended to
identify:
• The spread of cancer beyond the prostatic capsule
• Pelvic and distal lymph node involvement
• Hepatic and osseous metastasis
• Assessment of bone metastases:
• Serum alkaline phosphatase may be elevated bone metastases.
• PET scan is more sensitive than other modalities and may become the new
standard.
• X-rays (e.g., spinal x-ray) may be appropriate to evaluate undifferentiated
bone pain or if pathological fractures are suspected.
17. Cont’
• Skeletal metastases are the most common non-nodal sites
of metastasis in prostate cancer.
• Vertebral metastases commonly occur due to the spread of malignant
cells through the Batson vertebral venous system.
• Skeletal metastases are predominantly osteoblastic but osteolytic
metastases can also occur.
18. Management
• Watchful waiting
• Indications: recommended approach if all of the following apply
• Limited life expectancy (≤ 5 years)
• Slow-growing tumor
• Asymptomatic or minimal symptoms
• Regular monitoring with scheduled DRE and serum PSA levels
• Initiate definitive management according to cancer stage only when
symptoms occur
19. Cont’
• Active surveillance :
• indications Very low-risk and low-risk localized prostate cancers in
patients with a life expectancy > 5 years
• Regular monitoring with scheduled DRE, PSA, prostate biopsies,
and MRI
• Initiate definitive management according to cancer stage if disease
progression is demonstrated
20. Cont’
• Androgen deprivation
• Androgen deprivation therapy (ADT)
• therapy designed to decrease testosterone production by the testes
• Indications
• Locally advanced and metastatic prostate cancer: primary treatment modality
• Options
• Medical castration: decreases pituitary stimulation of androgen production by the testes
• Gonadotropin-releasing hormone (GnRH) agonists (e.g., leuprolide, relugolix)
• Gonadotropin-releasing antagonist (e.g., degarelix)
• Surgical castration: bilateral orchiectomy
• Adverse effects: increased risk of osteoporosis and fractures
• Androgen synthesis inhibitors and androgen receptor antagonists
21. Cont’
• Radiation therapy
• Indications
• Localized prostate cancer: primary treatment option
• Metastatic prostate cancer, high-risk localized prostate cancer, local recurrence
following prostatectomy: as an adjunct to androgen deprivation
• After prostatectomy: adjuvant therapy if adverse features are detected
• Options: brachytherapy and/or external beam radiation therapy (EBRT)
• Complications
• Radiation prostatitis, enteritis (e.g., diarrhea),
• Cystitis, urethritis, and urinary incontinence
• Erectile dysfunction
• Increased risk of rectal cancer
22. Cont’
• Radical prostatectomy
• Indications
• Localized prostate cancer in patients who are not candidates for active surveillance
• Following unsuccessful primary radiation therapy
• Technique
• Removal of the entire prostate gland, including the prostatic capsule, the seminal
vesicles, and the vas deferens
• Pelvic lymph node dissection may be performed during prostatectomy.
• Important consideration: PSA levels should drop to undetectable levels
after a successful prostatectomy.
• Complications: erectile dysfunction , urinary incontinence , infertility
23. cont’
• ???Radical prostatectomy involves the removal of the vas deferens,
resulting in infertility.
• Chemotherapy
• Indication: Consider as an adjunct to ADT in patients with metastatic
prostate cancer.
• Commonly used agent: docetaxel (a cytotoxic agent)
25. Cont’
• PSA level remains the standard screening tool.
• A PSA of ≥ 4 ng/mL is the most common threshold used to prompt referral to
urology and possible biopsy.
• Lower thresholds are used in:
• Patients receiving a 5-ARI
• DRE is not recommended as the sole screening tool
for prostate cancer.
• A screening interval of 2 years (or more) is recommended.
26. Prognosis
•
The most important prognostic indicator for prostate cancer is the
histological grade (i.e., grade group or Gleason score).
• Broadly, patients with cancer confined to the prostate and
pretreatment PSA levels < 10 ng/mL have a favorable prognosis.
•
