Pocket Oncology (Pocket Notebook Series), 1st Ed.

LOCALIZED PROSTATE CANCER

Eric L. Smith

Epidemiology

• Incidence: 240000, Most common non-skin CA in US men

• Annual Mortality: 28000, 2nd most common cause of CA death in men

• Elevated risk: Increasing age, AA, & + FHx

Screening

• Mortality benefit from screening the general population has not been established

• PLCO CA Screening Trial: Screening detected a higher incidence of CA, but no difference in OS after 13 y of follow-up, suggesting overtreatment of indolent CA (J Natl Cancer Inst 2012; 104:125)

• ERSPC: Screening detected a higher incidence of CA, a lower prostate CA specific mortality rate, no difference in overall mortality after 11 y of follow-up (NEJM 2012;366:981)

• USPTF concluded that for every 1000 pts routinely screened w/PSA:

Prevent 0–1 D from prostate CA

Cause 100–120 men to undergo Bx for FP results, 1/3 of w/c would experience mod. sx from the Bx

Diagnose 110 men w/prostate CA

Cause ∼50 serious complications from tx, including ED (29 men), incontinence (18 men), CV events (2 men), VTE (1 man), & death due to the tx (<1 man)

Thus, they recommend against PSA based screening for prostate CA in any population (grade D recommendation) (Ann Intern Med 2012; 157:120)

• Other groups have concluded o/w, the ACS recommends annual–biannual PSA screening after a discussion of the risks/benefits to men ≥50 y if nl risk, ≥45 y if elevated risk (see above), ≥40 y w/multiple 1st-deg relatives w/prostate CA, in all cases only if pt has a predicted life expectancy of ≥10 y

Initial Workup

• For PSA >4 or abnl DRE: Transrectal u/s guided bx, w/12 cores (J Urol 2006;175:1605)

• Histology: Gleason Score is sum of the 1° + 2° histologic grade (range of each is grade 1–5, or well- to poorly differentiated), grade 1–2 is rarely if ever classified from a needle bx so effective scale is 3+3 to 5+5 = 6–10

• Clinical Grade

T1: Not palpable (T1c is diagnosed on PSA screening alone)

T2: W/n the prostate (T2c is involving both lobes)

T3: Extends through the prostatic capsule (T3b invades seminal vesicle)

T4: Invades adjacent structure other then seminal vesicle, ie, bladder, levator muscles, pelvic wall

Staging

Prognosis

• 5y Prostate Ca specific (relative to aged matched controls) Survival Rates at Time of Dx:

Local (stage I-II) nearly 100%

Regional (stage III, T4, N1) nearly 100%

Distant (M1) 29%

• Prognosis for localized disease varies based on risk stratification w/validated nomograms to aid decision making

Initial Treatment (by Recurrence Risk) of Localized Disease

• Positive surgical margins after RP, consider adjuvant RT (NCCN guidelines version 1.2013)

Monitoring

• After Definitive Rx: PSA q6–12 mos ×5 y then q12mos; DRE q12mos, may be omitted if PSA undetectable

Metastatic Work Up for Newly Diagnosed Disease

• Determined by risk based on: DRE (clinical grade), PSA, & Gleason Score

• If high-risk disease based on above, consider eval for:

Distant mets w/CT A/P

Bone mets w/bone scan if:

T1 + PSA >20

T2 + PSA >10

Gleason ≥8

T3–T4 or

Sx