This document provides an overview of prostate cancer including epidemiology, risk factors, screening recommendations, clinical presentation, diagnosis, staging and risk stratification. Some key points: - Prostate cancer is the second most common cancer in men worldwide. Incidence and mortality increases with age. - Risk factors include age, family history, metabolic syndrome, certain dietary factors and medications. - Screening is recommended for men aged 55-69 with a PSA test and digital rectal exam. Screening intervals depend on PSA levels. - Diagnosis involves PSA testing, digital rectal exam, and biopsy. Staging uses the Gleason score and TNM system to determine risk level and treatment options

2. Prostate Cancer
Presenter: Dr. Muhammad Jalal
Urology Resident, SIUT, Karachi.

3. Introduction
1: Epidemiology
2: Risk Factors
3: Screening, Why, Why Not?
4: Clinical Presentation
5: Diagnosis
6: Staging

4. Epidemiology
• Second most frequent malignancy (after lung cancer) in men
worldwide, counting 12.76 m new cases and causing 0.35 m deaths
(3.8% of all deaths by cancer) in 2018.
• Incidence and mortality increases with age and varies across regions
and population.
• Average age at diagnosis is 66 years.

5. Incidence
• In 2018, (1,276,106) new cases of prostate cancer were registered
worldwide, representing 7.1% of all cancers in men.
• Though diagnosis is 1 in 350 men under 50 years, it increases up to 1
in every 52 for ages 50 to 59 years.
• The incidence rate is nearly 60% in men over the age of 65 years.

6. Mortality
• In 2018, the highest mortality rates were recorded in Central America
(10.7 per 100,000 people), followed by Australia and New Zealand
(10.2) and Western Europe (10.1).
• The lowest rate was reported in the countries of Asia (South-Central,
3.3; Eastern, 4.7 and South-Eastern, 5.4) and Northern Africa (5.8).
• The mortality rises with age, and almost 55% of all deaths occur after
65 years of age.

8. Risk Factors
• Age
• Family History
• Metabolic Syndrome (Obesity, Diabetes/Metformin)
• Dietry Factors
• Hormonally actie medication(5-ARI, Testosterone)
• Others: IBD, Balding, Gonorrhea, Smoking, HPv infection.

9. Age
Incidence rates by age at diagnosis, all cancer types.
Source: SEER 21 2013–2017, all races, both sexes.

10. Family History
Family History and Risk for Prostate Cancer

11. Metabolic Syndrome
Diabetes/Metformin
On a population level, metformin users were found to be at a
decreased risk of PCa diagnosis compared with never-users.
Obesity
Obesity is associated with lower risk of low-grade PCa in multivariable
analyses, but increased risk of high-grade Pca.

12. Dietry factors
Dairy
A weak correlation between high intake of protein from dairy products
and the risk of PCa was found.
Fat
No association between intake of long-chain omega-3 poly-unsaturated
fatty acids and PCa was found .
A relation between intake of fried foods and risk of PCa may exist

13. Vitamin D
Both low- and high vitamin-D concentrations being associated with an
increased risk of PCa, and more strongly for high-grade disease.
Vitamin E/Selenium
An inverse association of blood, but mainly nail selenium levels
(reflecting long-term exposure) with aggressive PCa have been found.
Selenium and Vitamin E supplementation were, however, found not to
affect PCa incidence

14. Hormonally active medication
5-alpha-reductase inhibitors (5-ARIs)
Testosterone

15. Screening
• Screening refers to testing for disease in healthy, asymptomatic
populations,
• whereas diagnosis is the identification of disease among individuals
with signs or symptoms.
• The principal goal of screening is to improve overall health outcomes
by identifying and treating disease at an earlier stage

16. • Population or mass screening is defined as the ‘systematic
examination of asymptomatic men (at risk)’ and is usually initiated by
health authorities.
The co-primary objectives are:
*Reduction in mortality due to PCa;
*A maintained QoL as expressed by QoL-adjusted gain in life years
(QALYs).

17. Screening in Prostate Cancer
• Men 55 to 69 years of age
• Age 50 for men who are at average risk of prostate cancer and are
expected to live at least 10 more years.
• Age 45 for men at high risk of developing prostate cancer. This
includes men who have a first-degree relative (father or brother)
diagnosed with prostate cancer at an early age (younger than age 65).
• Age 40 for men at even higher risk (those with more than one first-
degree relative who had prostate cancer at an early age).

18. • If no prostate cancer is found as a result of screening, the time
between future screenings depends on the results of the PSA blood
test:
*Men who choose to be tested who have a PSA of less than 2.5 ng/mL
may only need to be retested every 2 years.
*Screening should be done yearly for men whose PSA level is 2.5
ng/mL or higher.

19. • Because prostate cancer often grows slowly, men without symptoms
of prostate cancer who do not have a 10-year life expectancy should
not be offered testing since they are not likely to benefit.

20. Clinical Presentation
• Symptoms during the early stages of prostate cancer
• (Non Specific)
• Difficulty starting to urinate or emptying bladder.
• A weak flow.
• A feeling that bladder hasn’t emptied properly
• Dribbling urine after urinating
• Increase Frequency, Nocturia
• Urgency, Urge Incontinence.

21. Symptoms during the advanced stage (Specific may/may not)
• Back pain, hip pain or pelvis pain
• Problems getting or keeping an erection
• Blood in the urine or semen
• Unexplained weight loss

22. Diagnosis
Digital Rectal Examination:
• Before the availability of PSA testing, physicians relied solely on DRE
for early detection of prostate cancer.
• Needs expertise.
• Limited use for screening at PSA level <3.0 ng.
• Most Urologists prefer combinig both tools.
• PSA is superior, but combining both detects well.

23. Prostate-Specific Antigen
• PSA is a member of the human kallikrein gene family, is secreted in
high concentrations (milligrams per milliliter) into seminal fluid, and
circulates in blood in bound and free form.
• Serum PSA levels vary with age, race, and prostate volume.

24. The interpretation of PSA values should always take into
account:
• Age.
• UTI or prostate disease.
• Recent diagnostic procedures.
• Prostate-directed treatments.

25. PSA level (ng/mL) Risk of PCa (%) Risk of ISUP grade > 2 PCa (%)
0.0–0.5 6.6 0.8
0.6–1.0 10.1 1.0
1.1–2.0 17.0 2.0
2.1–3.0 23.9 4.6
3.1–4.0 26.9 6.7
Risk of PCa identified by systemic PCa biopsy in relation to low PSA values

26. Biomarkers in prostate cancer:
Blood Based:
PHI (Prostate Health Index (PHI) test (combining free and total PSA and the [-
2]pro-PSA isoform [p2PSA]).
4K four kallikrein (4K) score test (measuring free, intact and total PSA and
kallikrein-like peptidase 2 [hK2] in addition to age, DRE and prior biopsy
status).
IsoPSA utilises a novel technology which focuses on the structure of PSA

27. Urine Based:
PCA3 Prostate cancer gene 3 is a prostate-specific, non-coding
microRNA (mRNA) biomarker that is detectable in urine sediments
obtained after three strokes of prostatic massage during DRE.
SelectMDX test is similarly based on mRNA biomarker isolation from
urine

28. The role of imaging in clinical diagnosis
TRUS and US-based techniques:
• New sonographic modalities such as micro-Doppler, sonoelastography
contrast-enhanced US or high-resolution micro-ultrasound provided
promising preliminary findings, either alone, or combined with so-
called ‘multiparametric US’.

29. Multiparametric magnetic resonance imaging
• Good sensitivity for the detection and localisation of ISUP grade > 2
cancers.
• MRI is less sensitive in identifying ISUP grade 1 PCa.

30. Baseline biopsy:
• The need for prostate biopsy is based on PSA level, other biomarkers
and/or suspicious DRE and/or imaging.
• Age, potential co-morbidity and therapeutic consequences should
also be considered and discussed beforehand.
• Risk stratification is a potential tool for reducing unnecessary
biopsies.

31. • Limited PSA elevation alone should not prompt immediate biopsy.
• Prostate-specific antigen level should be verified after a few weeks, in
the same laboratory using the same assay under standardised
conditions (i.e. no ejaculation, manipulations, and UTIs).
• Empiric use of antibiotics in an asymptomatic patient in order to
lower the PSA should not be undertaken

32. • (US)-guided biopsy is now the standard of care.
• Prostate biopsy is performed by either the transrectal or transperineal
approach.
• Some evidence suggests reduced infection risk with the transperineal
route.
• TURP should not be used as a tool for cancer detection.

33. • Repeat biopsy
Repeat biopsy after previously negative biopsy
• The indications for repeat biopsy are:
• Rising and/or persistently elevated PSA.
• Suspicious DRE, 5–30% PCa risk.
• Intraductal carcinoma as a solitary finding, > 90% risk of associated
high-grade PCa.
• Positive mpMRI findings.

35. Definition
Low-risk Intermediate-risk High-risk
PSA < 10 ng/mL PSA 10-20 ng/mL PSA > 20 ng/mL any PSA
and GS < 7 (ISUP grade 1) or GS 7 (ISUP grade 2/3) or GS > 7 (ISUP grade 4/5) any GS (any ISUP grade)
and cT1-2a or cT2b or cT2c cT3-4 or cN+
Localised Locally advanced
EAU risk groups for biochemical recurrence of localised and locally advanced prostate cancer

36. Gleason score ISUP grade
2-6 1
7 (3+4) 2
7 (4+3) 3
8 (4+4 or 3+5 or 5+3) 4
9-10 5
International Society of Urological Pathology 2014 grade (group) system