Pocket Medicine

HEMATOLOGY-ONCOLOGY

PROSTATE CANCER

Epidemiology and risk factors (NEJM 2003;349:366)

•  Most common cancer in U.S. men; 2nd most common cause of cancer death in men

•  Lifetime risk of prostate cancer dx ~16%; lifetime risk of dying of prostate cancer ~3%

•  More common with ↑ age (rare if <45 y), in African Americans and if  FHx

• ↑ risk w/ BRCA2 (4.7) and BRCA1 (1.8) (JNCI 1999;91:1310 & 2002;94:1358)

Clinical manifestations (usually asymptomatic at presentation)

•  Obstructive sx (more common with BPH): hesitancy, ↓ stream, retention, nocturia

•  Irritative sx (also seen with prostatitis): frequency, dysuria, urgency

•  Periprostatic spread: hematuria, hematospermia, new-onset erectile dysfunction

•  Metastatic disease: bone pain, spinal cord compression, cytopenias

Screening (NEJM 2012;367:e11)

•  Digital rectal exam (DRE): size, consistency, lesions

•  PSA: 4 ng/mL cut point neither Se nor Sp; can ↑ with BPH, prostatitis, acute retention, after bx or TURP, and ejaculation (no significant ↑ after DRE, cystoscopy); 15% of men >62 y w/ PSA <4 & nl DRE have bx-proven T1 cancer (NEJM 2004;350:2239)

•  Per American Cancer Soc. men ≥50 y (or ≥ 45 y if African-Am or  FHx) should discuss PSA screening w/ their MD; USPSTF rec. against screening in asx males (no reduction in prostate cancer-related mortality) (NEJM 2009;360:1310; Annals 2012;157:120)

Diagnostic and staging evaluation

•  Transrectal ultrasound (TRUS) guided biopsy, with 6–12 core specimens

•  HistologyGleason grade (2–10; low grade ≤6) = sum of the differentiation score (1 = best, 5 = worst) of the 2 most prevalent patterns in the bx; correlates with prognosis

•  Imaging: to evaluate extraprostatic spread bone scan: for PSA >10 ng/mL, high Gleason grade or clinically advanced tumor abdomen-pelvis CT: inaccurate for detecting extracapsular spread and lymph node mets endorectal coil MRI: improves assessment of extracapsular spread

Prognosis

•  PSA level, Gleason grade and age are predictors of metastatic disease

•  In surgically treated Pts, 5-y relapse-free survival >90% if disease confined to organ, ~75% if extension through capsule, and ~40% if seminal vesicle invasion

•  PSA doubling time, Gleason, & time to biochemical recurrence predict mortality following recurrence. For local recurrence following RP, salvage RT may be beneficial if low PSA.

•  Metastatic disease: median survival ~24–30 mo; all become castrate resistant (in 15–20% discontinuation of antiandrogens results in paradoxical ↓ in PSA)

•  Long-term consequences of antiandrogen therapy include osteoporosis

Prevention

•  Finasteride and dutasteride ↓ total prostate cancers detected by bx, but ↑ number of high Gleason grade tumors (NEJM 2003;349:215 & 2010;362:1192)



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!