• Clinical science

Prostate cancer

Summary

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.

Epidemiology

  • Following skin cancer, most common cancer in men
    • Mostly affects elderly men
  • Third leading cause of cancer deaths in American men (after lung cancer)

References:[1][2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors

  • Advanced age (> 50 years)
  • Family history
  • African-American race
  • Genetic disposition (BRCA-2, Lynch syndrome)
  • Obesity and diet high in animal fat

Advanced age is the main risk factor for developing prostate cancer! Sexual activity and benign prostatic hypertrophy (BPH) are not associated with developing prostate cancer !; ; ;
References:[1][5][2][3]

Clinical features

Early-stage prostate cancer

Advanced-stage prostate cancer

References:[2][6]

Diagnostics

Approach

  • 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

Normal PSA values do not exclude the presence of prostate cancer!

Inflammation, manipulation of the prostate, and other malignant or benign prostate disease causing elevated enzyme levels may lead to false-positive PSA results.

Confirmatory test

Staging

References:[5][2][7][8][9][10][11]

Pathology

References:[12][2]

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Approach

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

Radical prostatectomy involves removal of the vas deferens, resulting in infertility!

Management of disseminated disease

Management of castration-resistant prostate cancer (CRPC)

CRPC is characterized by disease progression (elevated serum PSA levels, progression of pre-existing metastasis, or new metastases) despite ADT (surgical or medical castration).

References:[2][11][13][14][15][16][17][18][19][20][21][22][23]

Complications

References:[24][25][2][26][27][20]

We list the most important complications. The selection is not exhaustive.