Prostate Cancer Overview

• Prostate cancer is primarily adenocarcinoma affecting the prostate gland
• It often develops in the peripheral zone
• Diagnosis rates are increasing annually
• There is a 12% (1 in 8) lifetime risk of developing prostate cancer
• Prostate cancer is the most common diagnosed cancer in men, and the 3rd most common cause of cancer death in men
• Survival rates are improving: 5-year survival was 65% in 1998, and 91.5% in 2013

Clinical Manifestations

• Storage issues: urgency, frequency, nocturia, urinary incontinence
• Voiding difficulties: hesitancy, weak flow, straining, terminal dribble, incomplete emptying
• Other symptoms: blood in urine/semen, dysuria, dysejaculation
• Metastases may cause bone pain, pathological fractures, and hypercalcemia

Prostate-Specific Antigen (PSA)

• PSA helps liquefy ejaculate, enabling fertilization
• PSA is excreted in semen, urine, and blood
• The role of serum PSA levels are clinically unclear
• Multiple conditions, including prostate cancer, benign prostatic hyperplasia, UTI/prostatitis, and post-DRE, can elevate PSA
• PSA testing has allowed for earlier prostate cancer diagnosis
• A PSA test is not an ideal test, and not specific to prostate cancer, and high for other reasons. Discussion needs to happen before taking the test
• If the PSA is checked and high consider the following. DRE - cannot palpate all of gland. TRUS - sampling only of gland, can miss P.Ca. MRI – 17% chance of missing clinically significant P.Ca

PSA Levels & Risk

• PSA level of 0-0.5 ng/ml carries a 6.6% risk of PCa and a 0.8% risk of ISUP Grade >2 PCa
• PSA level of 0.6-1 ng/ml carries a 10.1% risk of PCa and a 1.0% risk of ISUP Grade >2 PCa
• PSA level of 1.1-2 ng/ml carries a 17.0% risk of PCa and a 2.0% risk of ISUP Grade >2 PCa
• PSA level of 2.1-3 ng/ml carries a 23.9% risk of PCa and a 4.6% risk of ISUP Grade >2 PCa
• PSA level of 3.1-4 ng/ml carries a 26.9% risk of PCa and a 6.7% risk of ISUP Grade >2 PCa
• PSA level of 4.1-10 ng/ml carries a 27% risk of PCa
• PSA level >10 ng/ml carries a >50% risk of PCa

Risk Factors

• Age: 75% of diagnoses occur in men > 65 years
• Ethnicity: Higher incidence in Black men, followed by White and Asian men; westward migration increases risk
• Heredity: 9% of cases are hereditary with multiple defects implicated
• Diet: Alcohol and smoking
• Obesity: Lower risk of low-grade, higher risk of high-grade
• Exercise may protect against prostate cancer

Screening

• PSA screening is controversial and not currently recommended by any association due to its lack of specificity (only 40%) and sensitivity
• Prostate cancer often has a long latent period, so death is often caused by other causes

Prostate Cancer Diagnosis

• NICE Guidelines: Refer if >3ng/ml
• NCCP Guidelines still use age-adjusted cut-offs

Digital Rectal Examination (DRE)

• Any irregular DRE should be referred for assessment, regardless of PSA
• Hard, craggy, nodular prostates are more concerning
• Significant inter- and intra-observer variability; can be as low as 17%

Imaging and Biopsy

• Magnetic Resonance Imaging (MRI) is increasingly important in the diagnosis and local staging of prostate cancer
• Report with PIRADS
• Must be a multiparametric MRI like T2-weighted images, Diffusion weighted images, and Dynamic Contrast Enhancement
• Biopsies can be preformed transrectal and transperineal routes

Gleason Score

• Gleason score is a classification of the histological pattern based on the degree of glandular de-differentiation. the calculation is the most common histological pattern score + the second most common histological pattern score

Staging

• Staging may involve: Bone Scan, СТ ТАР, PSMA (prostate-specific membrane antigen) PET scanning

Treatment Options

• Early disease with life expectancy >10 years: Radical prostatectomy (T1, T2, T3), Radical radiotherapy (T1, T2, T3), and Brachytherapy (T1, T2)
• Early disease with life expectancy <10 yrs: Watchful waiting/conservative treatment if no signs of disease progression (monitor PSA). Consider TURP if obstructive symptoms are an issue
• Metastatic Disease: Palliation needed and Hormonal therapy in androgen-dependent tumours

Active Surveillance

• Active surveillance is also known as "Treatment Deferral"
• Active surveillance may be suitable for low-risk prostate cancer ("clinically insignificant")
• The aim is to avoid side effects of treatments of prostate cancer
• Active surveillance requires strict and regular monitoring of patient - protocol based like Regular PSA + DRE
• Repeat biopsy is usually mandated in protocols
• Active surveillance is not suitable for patients who would never be radical therapy candidates