Clinical Notes : Urology

109. Prostate Cancer

 

Presentation

Currently, most cases of prostate cancer are identified by screening in asymptomatic men.

Symptoms of prostate cancer include the following:

  • Urinary complaints or retention

  • Back pain

  • Hematuria

However, such symptoms are often from diseases other than prostate cancer (eg, urinary complaints from benign prostatic hyperplasia [BPH]).

Physical examination alone cannot reliably differentiate benign prostatic disease from cancer.

 

Findings in patients with advanced disease may include the following:

  • Cancer cachexia

  • Bony tenderness

  • Lower-extremity lymphedema or deep venous thrombosis

  • Adenopathy

  • Overdistended bladder due to outlet obstruction

Diagnosis

Elevated prostate-specific antigen (PSA) level

  • No PSA level guarantees the absence of prostate cancer

  • The risk of disease increases as the PSA level increases, from about 8% with PSA levels of ≤1.0 ng/mL [1] to about 25% with PSA levels of 4-10 ng/mL and over 50% for levels over 10 ng/mL (1)

 

Abnormal digital rectal examination (DRE) findings

  • DRE is examiner-dependent, and serial examinations over time are best

  • Most patients diagnosed with prostate cancer have normal DRE results but abnormal PSA readings

 

Biopsy

  • Biopsy establishes the diagnosis

  • False-negative results often occur, so multiple biopsies may be needed before prostate cancer is detected

 

Screening

Men should decide whether to be screened for prostate cancer based on a discussion with their health care provider about the uncertainties, risks, and potential benefits of screening. (2)

The recommended age for starting screening is as follows:

  • 50 years of age for men at average risk who have at least a 10-year life expectancy

  • 40 or 45 years of age for men of African descent and men who have had a first-degree relative diagnosed with prostate cancer before age 65 years

  • 40 years of age for men with several first-degree relatives who had prostate cancer at an early age

 

A  2017 guideline, advises that

  • in men aged 55 to 69 years, the decision of whether or not to undergo screening should be individualized

  • for men aged 70 years and older, PSA-based screening for prostate cancer is not recommended. (3,4,5)

 

Men who decide to be screened should be tested with a PSA test. A digital rectal exam (DRE) may also be done as a part of screening.

If screening does not detect cancer, the time between subsequent screenings depends on the results of the blood test, as follows:

  • PSA <2.5 ng/ml – Retesting may be done every 2 years

  • PSA ≥2.5 ng/ml – Retesting should be done annually

Even after the decision to screen has been made, the discussion about the risks and benefits of testing should be repeated as new information becomes available.

Treatment

Localized prostate cancer

Standard treatments for clinically localized prostate cancer include the following:

  • Radical prostatectomy

  • Radiation therapy

  • Active surveillance

  • Androgen deprivation therapy (ADT)

 

Metastatic prostate cancer

Metastatic prostate cancer is rarely curable, and management of these cases typically involves the following:

  • Therapy directed at relief of particular symptoms (eg, palliation of pain)

  • Attempts to slow further progression of disease

In the OOH setting management should focus on

  • treatment of acute presenting condition such as infection, pain 

  • evaluation of patient's fears and anxiety

  • initial education about investigations necessary 

  • referral back to own GP for initial workup

 
 
 
NICE.jpg

1. Thompson IM, Pauler DK, Goodman PJ, Tangen CM, Lucia MS, Parnes HL, et al.

Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter.

N Engl J Med. 2004 May 27. 350 (22):2239-46. 

View/Access

2.  Wolf AM, Wender RC, Etzioni RB, Thompson IM, et al.

American Cancer Society guideline for the early detection of prostate cancer: update 2010.

CA Cancer J Clin. 2010 Mar-Apr. 60(2):70-98.

View/Access

 

3. Draft Recommendation Statement

Draft Recommendation Statement: Prostate Cancer: Screening. U.S. Preventive Services Task Force.

 April 11, 2017; Accessed: February 16, 2018.

View/Access

4.  Chustecka Z.

'Individualize,' Says Prostate Cancer Screening From USPSTF.

Medscape Medical News.

View/Access

.

5.  American Urological Association.

AUA Disputes Panel’s Recommendations on Prostate Cancer Screening.

May 21, 2012. 

View/Access

Prostate cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up

European Society for Medical Oncology.

July 2015

View/Access

Prostate cancer: diagnosis and management.

NICE Clinical guideline [CG175]

January 2014

View/Access

Screening for prostate cancer: US Preventive Services Task Force recommendation statement

US Preventive Services Task Force

May 2018

View/Access

Guidelines on prostate cancer

European Association of Urology

EAU Guidelines. Edn. presented at the EAU Annual Congress Barcelona 2019. ISBN 978-94-92671-04-2.

May 21, 2012. 

View/Access

 

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