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AM Report 9/11/09
Prostate Cancer
Julia Rauch
Disease Burden
~220,000 men were diagnosed with prostate cancer in 2007
~1/6 men will receive the disagnosis during their lifetime
~28,000 men died from prostate cancer in 2006 w/ median
age 80 yrs w/ 71% older than 75 yrs
- Interestingly, autopsies of men done in their 70s show
>90% w/ hyperplastic changes & >70% w/malignant changes
Anatomy & Physiology
- Most cancers develop in
peripheral zone which is
area palpated by DRE.
- >95% adenocarcinomas
- Prostate cells express
androgen receptors &
depend on androgens for
growth
Risk Factors
1) Age: Increased with increasing age
2) Race: African Americans have higher incidence & >twice
cancer mortality rate when compared to Caucasians
3) Family history: Increased with family history with double
the risk if one 1st degree relative is affected, and quadruple
the risk if more than two 1st degree relatives are affected
4) Diet: Some thought that red meats, fatty diet increases
risk, & cruciferous vegetables, lycopene (found in tomatoes),
Vit E, and selenium offer protective effect
Typical Presentation
Most commonly related to urinary tract obstruction
including
- urinary urgency, frequency, hesitancy
- nocturia
- new onset impotence
- less firm penile erections
- back pain
- acute urinary retention
- spinal cord compression
-RARELY supraclavicular LAD, or hepatic abnormalities
Prostate Cancer Screening
Remains controversial topic, with recent studies publishing
opposing views: One reporting that PSA did not improve
mortality and the other reporting that PSA screening did
improve mortality.
Current recommendations from US Preventive Services
Task Force is
1) no recommendations regarding PSA screening in men <75
yrs due to insufficient evidence
2) in men 75 years & older, they do NOT recommend
screening as benefits small to none
Prostate Cancer Screening Cont.
Concerns regarding screening include
1) Harm to patient assoc w/ discomfort of biopsy and
pyschological harm of false+ test
2) Morbidity associated with treatment including erectile
dysfunction, urinary incontinence, bowel dysfunction.
3) Indolent vs Aggressive Cancer: Certain % of patients
undergoing treatment for prostate cancer would never have
had developed cancer symptoms in their lifetime
Diagnosis
Established by TRUS-guided needle biopsy = gold standard
Clinical evaluation may also include MRI of abdomen/pelvis
help to evaluate visceral organs, urinary tract, para-aortic &
pelvic adenopathy, CT scan often inaccurate
Metastatic disease evaluation often involves bone scan in
conjunction with plain radiographs for suspicious areas ,
especially if PSA >10, high Gleason grade
GLEASON GRADING SYSTEM
- Core biopsies are measured for histologic
aggressiveness using the above system, correlates
w/prognosis
= 5 histologic patterns, where the primary and
secondary grades are measured then added together to
make Gleason score 2-10, score <6 considered low grade
Staging
Helps to guide treatment
TNM System
T1a-c Nonpalpalpable, detected based on abmornal PSA
T2a-c Palpable but confined to gland
T3a-c Palpable with extension beyond gland
M1: distant mets
Whitmore-Jewitt Stage
A1-2 Well differentiated tumor
B1-2 Palpable involving one or both lobes
C1-2 Palpable with extension beyond capsule/seminal
vesicles
D: Metastatic disease
Management
Localized Disease Options: (stages T1/2)
1) radical surgery
2) radiation therapy
3) watchful waiting
No superiority of one treatment over another, plans based
on symptoms, the chance that untreated cancer will
adversely affect patient during their lifetime
Management Cont
Metastatic Disease:
-Hormonal therapy based on concept that male
hormones/androgens cause prostate CA progression,
elimination of androgens causes regression of disease
1) Bilateral orchiectomy
2) GNRH analogues act to lower testosterone levels
3) Androgen receptor blockade
- Often double therapy for initial 2-4 weeks of therapy w/
GNRH analogue and antiandrogen agent.
- Mets to bone Rx w/ radiation therapy
Follow -up
Increasing levels of PSA after definitive radiotherapy for
localized prostate cancer --> predict residual cancer &
development of mets.
PSA decline to normal after treatment , persistence of
normal levels predicts favorable prolonged response to
therapy
Summary
-Prostate Cancer is a highly prevalent disease, however
screening remains controversial.
- Predicting clinically significant disease is difficult with
many men remaining asymptomatic through the duration of
their life.