8- Prostate cancers

Prostate Cancer Overview

• Most common cancer in the US (excluding skin cancer)
• New cases increased by 50% between 1980 and 1990
• 2009 new cases: ~192,280 (estimated); 80% early disease
• Deaths (estimated): ~27,360
• Increasing number of "non-lethal" tumors diagnosed
• 1 in 6 men will be diagnosed; 1 in 35 will die from it (10% of cancer related deaths in men)

Survival Rates

• 5-year relative survival rate: nearly 100%
• 10-year relative survival rate: 91%
• 15-year relative survival rate: 76%

Cancer Death Rates (Age-Adjusted)

• Prostate cancer death rates saw an increase from 1930 until 1992, when the PSA test was introduced.
• Lung & bronchial cancer death rates continued to increase after 1992.
• Other cancers analyzed include Stomach, Colon & Rectum, Leukemia, Liver and Pancreas.

Prostate Cancer Incidence

• Rates of diagnosis have seen increases over the years (data from SEER program)
• Incidence rates vary by race (all races, white and black).

Prostate Cancer: Incidence and Death Rates (1992-1996), by Age and Race

• Incidence and death rates vary significantly across different age groups for both black and white men. (Note, ages 40-85 are on display, and data is numerical).

Risk Factors for Prostate Cancer

• Age: Rare before 40, 65% over 65
• Race: More common in African Americans (diagnosed later, higher death rates); Less common in Asian and Hispanic Americans
• Family History: 1st degree relatives (father, brother)
• Nationality: North America and NW Europe higher incidence than Asia, Africa, and Central/South America.
• Genetics: BRCA1 and BRCA2 increase risk but are a small percentage
• Diet: Red meat, high-fat dairy. Fruits, vegetables, grains
• Obesity, Exercise, prostatitis, STDs, Vasectomy: no significant effect.

Chemoprevention Studies

• Selenium and Vitamin E trials failed to show that the supplements reduce prostate cancer in healthy men.

Early Detection and Screening

• Digital Rectal Exam (DRE): Feel for nodules.
• Prostate Specific Antigen (PSA): How high? (Note, need additional info to interpret PSA results).
• Transrectal Ultrasound (TRUS): Not for screening

PSA and Prostate Cancer Risk

• PSA levels usually above 4 when cancer develops, but levels below 4 don't rule out cancer; ~15% of men with PSA below 4 have cancer.
• PSA 4-10: ~1 in 4 chance of cancer.
• PSA > 10: Chance of cancer is over 50%.

Confunding Factors for PSA

• Increasing factors: Benign Prostatic Hyperplasia (BPH), Age, Prostatitis, Ejaculation
• Decreasing factors: Finasteride, dutasteride, some herbal mixtures, Obesity

PSA Density, PSA Velocity, % Free PSA

• PSA Density: Normalized to prostate volume.
• PSA Velocity: Change in PSA over time (e.g., more than 15% per year)
• Free PSA/Total PSA: Lower ratio suggests cancer.

Presenting Symptoms of Prostate Cancer

• Decreased urine flow
• Increased urinary frequency
• Hematuria
• Bone pain
• Limb numbness or weakness
• Bowel/bladder incontinence

PSA Levels and Their Predictive Value for Diagnosis (2004 Study)

• Study of men with PSA never above 4ng/ml and no abnormal rectal exam, percentage with prostate cancer varies with PSA levels (3.1 - 4.0, 2.1 - 3.0, etc.).

Effect of Early Diagnosis

• Incidence higher in areas with aggressive screening
• Prostate cancer death rate similar in screened and unscreened populations.
• Randomized trials underway to evaluate screening.
• Conclusion:
  • No screening over 70, unless high family history
  • No screening under 60, unless high family history
  • Recognize limitations (ages 60-70)

Prostate Cancer Survival

• Related to stage, grade, and extent of the tumor
• Local disease: >5 years median survival
• Metastatic disease: 1-3 years median survival, with potential exceptions

Establishing a Diagnosis of Prostate Cancer

• Digital Rectal Exam (DRE)
• PSA/PSA Velocity/Percent-Free PSA
• Transrectal Ultrasound (TRUS)
• U/S-guided biopsy

Evaluation of Abnormal PSA or Prostate Mass

• Ultrasound guided needle biopsies (6-12)
• Gleason score (2-10) (lowest is best) (2 predominant histologies)

Staging and Prognostic Factors

• TNM staging system
• Gleason grading
• DNA analysis by flow cytometry
• PSA level
• Predictive models for organ-confined/non-organ-confined disease

Staging Prostate Cancer

• Abdominal/pelvic CT scans
• Chest x-ray
• Bone scan
• Liver function tests (LFTs)
• Serum PSA and acid phosphatase

Staging Prostate Cancer (Stages I-IV)

• Stage descriptions for clinical staging are presented, including tumor size (T), lymph node involvement (N), metastasis (M), PSA classification, and Gleason score.

Recurrence Risk for Clinically Localized Prostate Cancer

• Low Risk: T1-T2a, Gleason score 2-6, PSA <10 ng/ml
• Intermediate Risk: T2b-T2c, Gleason score 7, PSA 10-20
• High Risk: T3a, Gleason score 8-10, PSA >20
• Very High Risk: T3b-T4 (locally advanced)

Treatment Decisions for Clinically Localized Prostate Cancer

• Based on recurrence risk (low, intermediate, or high)
• Based on life expectancy (<10 years or >10 years)

Prostate - Goals of Therapy

• Primary Therapy:
  • T1a (except very young): No treatment.
  • T1b, T1c, T2: Radical prostatectomy or high-dose radiation (or observation of low-grade)
  • T3 (Stage III): Radiation therapy.
  • Metastatic: Treatment when symptoms
  • High risk: May include hormonal therapy

Radical Retropubic Prostatectomy (RRP)

• "Nerve-Sparing" procedure developed by Walsh
• Modified surgical technique to control blood and improve visibility
• Allows identification and potential preservation of nerves controlling erectile function.

Radiation Therapy (RT)

• High-Powered X-Rays to damage DNA and kill cancer cells
• External beam radiation therapy (EBRT)
• Brachytherapy (radioactive seed implants)

Watchful Waiting

• AKA observation/expectant therapy/deferred therapy.
• Diagnosis of early-stage (T1-T2), low-grade tumor.
• No medical treatment provided; regular follow-up to monitor tumor.

Treatment of Symptomatic Metastatic Disease

• Hormonal Therapies (initial therapy for locally advanced/metastatic diseases): Orchiectomy, Estrogens, LHRH analogs, Antiandrogens,
• Second-line therapy, if needed, may consist of therapies not previously used.

Conclusions

• Risk factors: Age, family history, race, diet and exercise
• Overall survival: Excellent (many years)
• Early detection: Localized cancer identification for benefits; uncertain
• Treatment: Depends on tumor grade, extent, and location.
• Surgery and radiation: Equivalent for localized prostate cancer.
• Hormone-refractory: Responds to chemotherapy, occasional long-term improvement

This quiz provides an overview of prostate cancer, highlighting its prevalence, survival rates, and incidence data. Understand the statistics surrounding this common disease and the trends in diagnosis over the years. Test your knowledge on the impact of PSA testing and demographic variations in incidence rates.