Prostate Cancer

20,000 new cases each year

 

Prostate is a very slowly growing cancer.

 

 

Causes and Risk Factors

Incidence is rising due to aging population

PIN incidence is 30% in men age 30-39, and is the same across the world.

Clinical incidence is very high in North America and Europe, though low in Asia.

So there are environmental factors leading to clinical manifestations. The Japan Effect:

 

Increased risk

 

Decreased risk

 

Sunlight/Vit D

survival is dependent on season of diagnosis. PSA levels are lower in the summer. The Iowa Study showed a 60% reduction in Cancer Mortality over 4 years. There is increased riskthe further you are away from the equator.

 

Extensive media coverage leads to confusion among patients and physicians.

 

 

Prevention

Finasteride appears to reduce incidence (Thompson et al, NEJM, 2003)

 

diet and lifestyle modifications

Vitamin E

selenium 200 ug

lycopene 10 mg

vitamin 1 gm/day

decrease fat intake and BMI

green tea

alcohol

 

 

Signs, Symptoms, and Diagnosis

 

Local, curable disease is frequently asymptomatic.

 

Advanced disease leads to weight loss,

 

Early detection should include DRE and PSA

 

Digital Rectal Examination (DRE)

Very easy

 

PSA

Maybe a better term would be prostate non-specific antigen.

PSA screening led to a large increase.

PSA is found in ejaculate, used to liquify semen.

Detects more tumours and detects tumours at an earlier age

 

Factors altering PSA include age, race, manipulation (catheter, DRE), BPH, infection, cancer

Age-adjusted PSAs

An abnormal rate of rise (Ie >0.75 /year) is worrying.

PSA circulates freely and is also bound to blood proteins. ....

 

absence of basal cells.

 

 

Transrectal Utrasound

TRUS can be used to guide biopsy, but is not useful on its own to find cancer

 

Screening

high risk populations: men over 50, black men in NA, people with family history

 

 

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Pathophysiology

Doubling time is in months (Johansson et al, JAMA, 2004)

Stage T1c - can't be felt by DRE

Stage T2a - involves one lobe

 

Gleason score - sum of two most common grades seen - rated from 2-10

 

 

 

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Treatments

used to be 'seek and destroy', not 'target and control'

Treatments reduce mortality, but also morbilidity, ie from bone mets

 

watchful waiting

activiation

 

external beam radiotherapy

side effects

early: radiation cystitis or proctitis, retention

late: irritative symptoms, chronic proctitis,

 

androgen deprivation therapy

LHRH agonists

bilateral orchiectomy

ketoconazole - chemical castration

 

Comorbidity is a significant predictor of outcome (Charlson)

Factors involved in selecting therapy

age and health

 

tumor - stage, grade, PSA

 

 

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Consequences and Course

Most men will survive 10 years without treatment

Even though prostate cancer incidence is increasing rapidly, the rates of mortality are rising very slowly.

Prostate cancer is slowly growing.

 

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The Patient

 

Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med 2008;358(12):1250-1261.

Direct comparisons of different approaches to the treatment of prostate cancer are uncommon in the literature. This study identified patients undergoing brachytherapy (n = 306), external beam radiation (n = 292), and radical prostatectomy (n = 603). Some patients underwent more than 1 treatment (ie, 35 patients received brachytherapy and radiation or androgen suppression) and most patients undergoing surgery had nerve-sparing procedures. A range of quality of life and satisfaction outcomes were measured at 2, 6, 12, 24, and 30 months by asking both patients and their spouses. A clinically meaningful change was defined as a change of at least one half standard deviation. Patients had a median age of 59 years and 9% were black. Groups differed in a number of ways: white patients were more likely to choose surgery; black patients had more comorbidities, a larger mean prostate size, and a higher mean prostate-specific antigen (PSA). Patients choosing brachytherapy were more likely to have a low risk cancer and a Gleason score of less than 7 points. The results are fairly complex, and the graphs of symptoms versus time since treatment may be helpful when counseling patients. A few patterns emerged, though. Nerve-sparing surgery was significantly better than nonnerve sparing surgery with regard to sexual and urinary incontinence scores. Patients receiving radiation plus neoadjuvant hormone therapy had significantly worse sexual outcomes than those receiving radiotherapy only. Although sexual function and urinary incontinence scores declined precipitously after surgery, some recovery occurred over the next 2 years. Worse outcomes were associated with obesity, black race, a larger prostate volume, and a higher pretreatment PSA. Spousal and patient concerns over urinary and sexual adverse effects were correlated, as were outcome satisfaction among patients and symptoms related to sexual function, vitality, and urinary function. The study is limited by the relatively short (2-year) follow-up period.

 

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Health Care Team

 

 

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Community Involvement

 

 

 

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References