An introduction to week 1 of a free online course on enhancing prostate cancer care, delivered by Sheffield Hallam University in the UK (Oct-Nov 2014). Week 1 focuses on diagnosis.

1. The Diagnosis of Prostate Cancer
Part of the “Enhancing Prostate Cancer Care” MOOC
Catherine Holborn
Senior Lecturer in Radiotherapy & Oncology
Sheffield Hallam University

2. Learning Outcomes (week 1)
By the end of week 1, you should be able to:
1. Explain the factors that place men at a higher risk of having or
developing a prostate cancer
2. Describe the steps and tests undertaken, in order to diagnose
prostate cancer and discuss their pros and cons
3. Discuss the benefits and limitations of PSA testing in
asymptomatic men
4. Discuss how information and support relating to prostate
cancer and prostate cancer testing might be improved

3. Why are these important?
In Europe, prostate cancer is the most common cancer
in men. Worldwide it is the second most common¹.
In the UK, it is the second most common cause of male
cancer death. In Europe, the third and Worldwide, the
fourth most common cause¹.
Arguably, increased awareness about prostate cancer is
needed. More importantly, awareness of the risk factors
that can place a man at a higher risk of having or
developing prostate cancer.

4. Why else?
The diagnosis of prostate cancer is not straightforward and
the tests involved can be unpleasant and uncomfortable
It involves a number of different tests, each of these with their
own benefits, limitations and even risks
Testing an asymptomatic man for prostate cancer is not a
straightforward decision
There is currently no definitive test that can tell us whether a
man with an early stage prostate cancer has a slow growing
and indolent cancer, or a more aggressive and fast growing
one
Men must be well informed about the procedures and be
supported to make informed choices that are right for them,
based on their individual risk and preferences

5. Risk Factors: Age
Risk increase with age
In the UK, it is rare under the age of 50, accounting for
1% of cases. 36% of cases are in men aged 75yrs and
over¹.
In many countries, asymptomatic men, around the age of
45-55yrs (recommendations vary), are encouraged to talk
to their primary care physician/GP about their ‘individual’
risk of developing prostate cancer, and the pros and cons
of being tested based on this, and other relevant
individual factors.

6. Risk Factors: Familial Links
If one first line relative has had prostate cancer, a man’s risk is
doubled
If two or more first line relatives have had prostate cancer,
the risk increases 6-11 fold²
Asymptomatic men to whom this applies, must be informed of
their increased risk and the potential value of being tested in
this context.
Some genetic links have been identified e.g. the breast cancer
susceptibility gene (BRCA2)
Much more research in this area is needed and is ongoing

7. Risk Factors: Ethnicity
Again, asymptomatic men to whom this applies, must be
informed of their increased risk and the potential value of
being tested.
Black men are at a higher risk of developing prostate cancer
than white men
In the UK, Black men have a 1 in 4 lifetime risk³. In the US,
they are 1.6 times more likely to develop prostate cancer and
2.4 times more likely to die from it ⁴.
Men present more frequently with high grade and aggressive
cancers, increased tumour volume at each clinical stage and
increased PSA levels⁵⁶

8. A Genetic-Environment Link
Genetic and biochemical differences are thought to pre-dispose Black
men to prostate cancer
Additional environmental factors may then act as a trigger to its
development⁵⁶
Genetic; certain genes may be responsible, but research is ongoing in
this area. Those identified to-date are involved in promoting androgen
metabolism, enabling prostate growth and providing a driving force
for prostate cancer initiation and progression⁵
Biochemical; factors such as decreased serum vitamin D levels, Insulin
Growth Factor (IGF) levels and ratios (high level of IGF-1), increase
serum LDL cholesterol levels and decreased serum lycopene levels; are
some that have been investigated⁵
Environmental e.g. a westernised lifestyle characterised by a high
calorific diet, rich in fat, refined carbohydrates and animal protein.

9. PSA testing asymptomatic men
Asymptomatic men who fall into one of the three risk
categories, may want to consider being tested for prostate
cancer
Why don’t we (the UK and other countries) do this as routine?
A benefit to being tested can be the detection of a prostate
cancer, hopefully at an early stage, when it is very treatable
However, there are also limitations and risks associated with
being tested
Many countries feel that these are too significant and that the
benefits do not outweigh these (for the population)
However, on an individual basis, they might do…

10. Men should be well-informed
So PSA testing in asymptomatic men should be
undertaken after an informed decision has been made by
the individual, after discussion with their physician/GP
about their ‘individual’ risk and health preferences
The resources this week provide an overview of the key
issues associated with PSA testing/screening

11. References
1. Cancer Research UK. Prostate Cancer Statistics. Available at
www.cancerresearchuk.org/cancer-info/cancerstats/types/prostate (last
accessed 01/06/2014)
2. Heidenreich A, Bastian PJ, Bellmunt J, Bolla M, Joniau S, Mason MD et al (2013)
Guidelines on Prostate Cancer. European Association of Urology. Available at
www.uroweb.org/guidelines/online0guidelines
3. Prostate Cancer UK. About the risk in Black men (webpage). Available at
www.prostatecanceruk.org/information/who-is-at-risk (last accessed
01/09/2014)
4. Prostate Cancer Foundation. Prostate Cancer: straight talk for African-American
men and their families. Available at www.pcf.org/site (last accessed 01/09/2014)
5. Chornokur G, Dalton K, Corysova ME, Kumar NB (2010) Disparities at
presentation, diagnosis, treatment and survival in African American men
affected by prostate cancer. The Prostate. 71(9) pp.985-997
6. Wu I and Modlin CS (2012) Disparities in prostate cancer in African-American
men: what primary care physicians can do. Cleveland Clinical Jounral of
Medicine. 79(5) pp.313-320

12. So what next?
You should now start to read through the learning
resources and information supporting this weeks learning
outcomes.
This includes the videos with those who have been
affected by prostate cancer.
And of course, try to engage with this weeks activities as
much as possible, to help consolidate and enhance your
learning 