- Clinical science
Prostate cancer is the second most common cancer in men after skin cancer and the third leading cause of cancer death in men after lung cancer. The risk of developing prostate cancer increases with age. It is more common in African Americans. In early stages, prostate cancer generally causes no symptoms and is typically detected by screening. The preferred diagnostic procedures are digital rectal examination (DRE), PSA testing, and ultrasound-guided transrectal prostate biopsy. Bone metastases are common in advanced prostate cancer and can be diagnosed using a bone scan. Because most patients with prostate cancer are of advanced age, life expectancy and the histological evaluation of a tumor biopsy should be taken into account when planning treatment. Radical prostatectomy and radiotherapy are indicated in young patients. In older patients, “watchful waiting” (i.e., purely symptomatic treatment) and “active surveillance” (i.e., continuous restaging and initiation of curative measures if tumor progresses) are also a treatment option since localized prostate cancer typically has a slower growth rate and a better prognosis compared to other malignancies.
- Advanced age (> 50 years)
- Family history
- African-American race
- Genetic disposition (BRCA-2, Lynch syndrome)
- Obesity and diet high in animal fat
Early-stage prostate cancer
Advanced-stage prostate cancer
- Loss of appetite → weight loss
- Urinary symptoms
- Erectile dysfunction
- Metastatic disease
- Physical examination and a digital rectal examination (DRE) are performed to screen for prostate cancer.
- Measurement of prostate-specific antigen levels for screening is controversial because of the risk of overdiagnosis and overtreatment.
- An irregular and nodular prostate in DRE is suspicious for malignancy.
- Since DRE or PSA irregularities are not specific to prostate cancer, multiple ultrasound-guided biopsies are collected to confirm the diagnosis.
- In cases of confirmed prostate cancer, staging is used to assess the extent of disease and plan adequate treatment.
Screening and basic diagnostics
Digital rectal examination (DRE)
- Findings upon palpation
Measure prostate-specific antigen levels : indications
- If prostate cancer is suspected
- Marker to monitor metastasis or cancer recurrence following treatment of PSA-positive prostate cancer
- For potential screening
- Benefit is controversial
- Usefulness should be evaluated on a case-by-case basis by the physician and patient.
- Interpretation: a total PSA > 4 ng/mL suggests malignancy
- ↑ Alkaline phosphatase in bone metastases
- ↑ Prostatic acid phosphatase (PAP)
- Measure prostate-specific antigen levels : indications
- Urine: urinalysis and urine culture to rule out hematuria or urinary tract infection
Normal PSA values do not exclude the presence of prostate cancer!
- Indication: histological confirmation of suspicious findings on DRE, suspicious PSA levels or velocities, or clinically suspected prostate cancer
- Technique: ∼ 12 prostate samples are biopsied; from different areas of the prostate guided by transrectal ultrasonography (TRUS) under local anesthesia and prophylactic antibiotics.
- Interpretation: When prostate cancer is present in the biopsy, the tumor is graded using the Gleason score.
- Complications: UTI, prostatitis, hematuria, hematospermia, acute urinary retention
- Indication: in confirmed prostate cancer to assess the extent of the disease
- Other tumors
The differential diagnoses listed here are not exhaustive.
The treatment plan is based upon the patient's age, life expectancy, medical condition, and preferences. Results of imaging studies, PSA levels, and the Gleason score are taken into consideration when evaluating the different treatment options.
Management of localized disease
Active surveillance: regular follow-ups with cancer restaging instead of treating
- Preferred option for most early-stage cancers)
- Treatment is only started if the tumor progresses.
Watchful waiting: less intensive type of follow-up than active surveillance
- Best approach in elderly patients with slow-growing tumors, a life-limiting comorbidity, or a life expectancy < 10 years who are more likely to die from other causes.
- Systemic or local treatment to relieve symptoms is initiated if symptomatic progression of the tumor occurs.
Definitive treatment: radiation therapy and/or prostatectomy
- Radiation therapy
- Postoperative monitoring of PSA levels: PSA level should drop to undetectable levels.
- Indication: androgen sensitive localized high-grade or metastatic prostate cancer
- Gonadotropin-releasing hormone (GnRH) agonists (e.g., leuprolide) or antagonist (e.g., degarelix)
- May be combined with an antiandrogen (e.g., flutamide, bicalutamide) for complete androgen blockade.
- Surgical castration: bilateral
Management of disseminated disease
- Chemotherapy with docetaxel
- Osteoclast inhibitors (e.g., bisphosphonates, denosumab) in bone metastases
Management of castration-resistant prostate cancer (CRPC)
- General approach
- CRPC + asymptomatic bone metastases: IV zoledronic acid; every 3–4 weeks or denosumab
- CRPC + symptomatic bone metastases
- Regional metastasis → pelvic lymph nodes
- Distant metastasis → bone metastases (most common location)
- Complications following surgery or radiotherapy
We list the most important complications. The selection is not exhaustive.