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Prostate Cancer

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•most common cancer in men •second most deadly cancer

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Number of cases diagnosed each year

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~180,000 •30 million men suffer from (BPH) •every 3 mins a new case....

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odds of getting PC

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•odds are 2 to 1 a male will have prostate problems by age 60

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how common?

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second most common cancer in men

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Prostatic Symptoms

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•difficulty initiating urination •weak urinary stream •frequent urination - often with urgency - often accompanied with incontinence •waking several times a night to urinate •sexual dysfunction and decreased libido •blood in urine •pain or stiffness low back, upper thigh, hips

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symptoms in early stages

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often asymptomatic (no symptoms)

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prostate

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•two lobes •part of reproductive system •in front of rectum, below the bladder •conical shape, size of walnut •purpose: produce fluid for semen, which transports sperm during the male orgasm

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underlying cause of prostatic symptoms

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•Benign Prostatic Hypertrophy (BPH) •prostatitis •prostate cancer - increased risk with age

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Benign Prostatic Hypertrophy (BPH)

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- non cancerous enlargement

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prostatitis

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- inflammation - infection (Chlamydia)

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Lower urinary tract symptoms

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•weak urine stream •hesitancy (difficulty initiating/starting) •incomplete bladder emptying •intermittent flow ('start-stop') •prolonged micturation •straining to void •frequency •Urgency •Urge incontinence •Nocturia (night time urination •Splitting or spraying •Terminal dribbling •Post-micturition dribble

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Prostate Ca vs. BPH - DRE exam induration or nodules

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•PC - yes •BPH - no

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Prostate Ca vs. BPH - Symmetrical enlargement, prostate firmness

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• PC - no • BPH - yes

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Prostate Ca vs. BPH - nocturia, urgency, frequency, hesitancy

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• PC - possible • BPH - more likely

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Prostate Ca vs. BPH - erectile dysfunction

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•PC - advanced Ca •BPH - increased incidence

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Prostate Ca vs. BPH - hematuria, hematopermia

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•PC - uncommon •BPH - possible with UTI

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PRostate Ca vs. BPH - bone pain

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•PC - small % (metastatic) •BPH - No

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Prostate Cancer rates by location

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•US has most cases •followed by Sweden, then Canada •may have better detection, may be lifestyle

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what is pc more common in

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prostate cancer is most common in men over 50

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prostate cancer death rates

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declining since ~ 1994 •differences by state - Tennessee has highest incidence while Utah has lowest •differences in healthcare

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historical trends

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seem to be declining since early 1990s

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Gleason Score Histologic Grading

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1. Small, uniform glands 2. More stroma between glands 3. distinctly infiltrative margins 4. irregular masses of neoplastic glands 5. only occasional gland formation

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risk factors

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•age •race - black men 2.5 times rate for white men •family history •diet - high animal fat increases risk •geography •occupations •genetics

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Family History

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•approximately 1 out of every 10 men diagnosed with prostate cancer will be a member of a family with hereditary prostate cancer •if a man has 1 close relative with prostate cancer, his risk is 2x as high as the general population to develop prostate cancer •2 close relative and his risk is increased by 5x •3 or more close relatives and risk is 11x higher

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Digital Rectal Exam (DRE)

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•gloved finger in rectum •crude, more has to do with getting lucky

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Prostatic Specific Antigen (PSA)

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•protein originating from the prostate •detected in blood •PSA testing detects elevated PSA levels - elevated or rising PSA levels are used as a signal that there is something wrong with the prostate •nonspecific test - high false positive rate •PSA screening recommendations - AUA; all men over age 50 PSA + DRE - ACP, USPTSF; no routine screening •Elevated PSA - > 4ng/mL = 25% chance prostate cancer - >10ng/mL = 67% chance prostate cancer

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is variability in PSA normal?

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there is some variability with race and age

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Normal PSA Variability with race and age

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can go from 0-5.5 ng/mL depending on race and age •least - 40-49 Asian •most - 70-79 white •increases with age •lowest (asian), middle (african-american), high (white)

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adverse effects of screening

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•false positive •false negative •inconvenience •labeling

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Treatment Considerations

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•age and expected life span •other serious medical/health conditions •sage and grade of cancer •individual's feelings (and doctor's opinion) about the need to treat the cancer •Likelihood of cure from each type of treatment (or provide some other measure of benefit) •Individual feelings about side effects common with each treatment

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Prostatectomy rates

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rates have gone up

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brachytherapy

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•hollow needles are used to insert radioactive seeds into the prostate gland near the tumor to emit low-dose radiation to kill cancer cells over six to seven months

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surgical treatment options

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remove entire prostate gland in patients with early diagnosed organ confined prostate cancer 1. robotic radical prostatectomy 2. laparoscopic radical prostatectomy 3. traditional open radical prostatectomy

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how many men undergo prostate surgery annually?

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400,000 •surgery often results in incontinence and impotence

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adverse effects of Rx

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•impotence •incontinence •death •overtreatment

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treatments for prostate cancer

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•radiation •prostatectomy

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want to screen if

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>50 years or age >40 with positive family history or African American

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reasons for PSA test (non-preventative)

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•back ache •previous treatment for prostate •problems passing urine

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reasons for PSA test (preventative reasons)

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•prostate cancer in family •age •precaution

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the iceberg effect

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extent to which PSA reaches into latent reservoir (15%) •based on overdiagnosis estimates of 29% for whites

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lifetime risk of clinical prostate cancer (iceberg effect)

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•9 of every 100 men

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lifetime risk of autopsy detectable cancer (iceberg effect)

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•36 of every 100 men •latent detected by PSA screening •latent not detected by PSA screening

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Screening for Prostate Cancer - the Controversy that Refuses to Die

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controversy over whether PSA is beneficial •many physicians recommend but don't get it themselves •evidence and guidelines do not recommend routine screening -no proven benefit and some risk •death rate has decline 4% per year since PSA introduced in 1992 though

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US Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial

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PSA and DRE exame with 11 yr f-u • not difference in mortality

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European Randomized Study of Screening for Prostate Cancer (ERSPC)

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•PSA screening without DRE •20% reduction in the death

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ACS Screening Guidelines

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•Men should only be screened "after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening..." •Informed decision making -Age 50- men at average risk start receiving facts about prostate cancer and screening - Age 45 - Men at higher risk (African American, first-degree relative with prostate cancer <age 65) •PSA -PSA with or without DRE -PSA value of 4.0 ng/mL to trigger further evaluation -PSA 2.5-4.0 ng/mL (25% of cancers) -Individualized risk assessment -PSA <2.6 ng/mL repeat every 2 yrs

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AUA Guidelines

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"The AUA feels there is no single PSA standard that applies to all men, nor should there be ... Although prostate cancer risk correlates with serum PSA, there is no PSA value below which a man may be reassured that he does not have biopsy-detectable prostate cancer..." •PSA recommendations -baseline PSA test at the age of 40 -subsequent rescreening that evaluates, among other risk factors, free and total PSA, PSA velocity, and PSA density.

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Informed Decision Making

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"One Third of Men Undergo PSA Test Without Discussion" Core elements: •PSA screening detects cancer earlier than without •Conflicting evidence if screening prevents/delay death from PC •Early detection cannot predict who benefits from treatment •PSA and DRE can produce false-positive or false-negative results •Abnormal results from screening (PSA and DRE) require prostate biopsies, which can be painful and lead to complications (infection or bleeding) •Treatment complications (urinary, bowel, sexual, and other health problems) can be significant or minimal, permanent or temporary •Not all men whose prostate cancer is detected through screening require immediate treatment •Some require periodic blood tests and prostate biopsies to determine the need for future treatment

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Gothenburg Study

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PSA Screening Halves Mortality From Prostate Cancer •(PSA) in men between 50 and 69 years of age reduced prostate cancer mortality by almost half during a follow-up period of 14 years •Low levels PSA screening in Sweden

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Chochrane review Prostate Cancer Screening

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Findings: •"No statistically significant difference in prostate cancer-specific mortality between men randomised to the screening and control groups (RR 1.00/95%) •"A diagnosis of prostate cancer was significantly greater in men randomised to screening" •"Localized prostate cancer was more commonly diagnosed in men randomised to screening" •"Screeenig resulted in a range of harms... minor to major.."

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Chemoprevention

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•Use of medication to prevent development •Reduction by Dutasteride of Prostate Cancer Events (REDUCE ) - High risk population •50 to 75 years of age •elevated (PSA) or •Hx prostate biopsy because of suspicion of PC 4 year - Placebo-control - Relative risk reduction 22.8%

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Drugs for Prostate Cancer Prevention

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1) 5-alpha-reductase (5-ARI) inhibitors • Finasteride (Proscar, generic) • Dutasteride (Avodart) 2) Block enzyme that converts testosterone to dehydroepiandrosterone (DHEA) • DHEA stimulates the prostate.

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AUA Recommendations for Drugs

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•PSA score of 3.0 or below •Annual screen for prostate cancer •No signs of prostate cancer

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Treatment options

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1) brachytherapy 2) external beam radiation 3) open radical prostatectomy 4) Da Vinci robotic-assisted laparoscopic radical prostatectomy 5) hormone therapy 6) continuous observation

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external beam radiation

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High energy X-rays are used to kill cancer cells. The therapy is conducted over seven weeks.

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open radical prostatectomy

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Open surgery to remove the whole prostate gland and nearby lymph nodes.

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DaVinci robotic-assisted laparoscopic radical prostatectomy

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Robotic surgery where the prostate is removed with five or six tiny incisions. Robotic arms enter these holes with a camera and surgical instruments.

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hormone therapy

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Lowers the level of male hormones such as testosterone using injections or oral medication as they fuel cancer growth.

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continuous observation

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Patient does not undergo any active treatment. Instead, the doctor monitors the patient's condition with regular Prostate Specific Antigen (PSA) blood tests, biopsies and rectal exams

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adverse effects of androgen deprivation therapy

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•Hot flashes •Gynecomasti •Osteoporosis •Sexual Dysfunction •Fatigue •Insulin resistant •Decreased muscle mass •Abnormal lipid panel •Increased risk CVD •Cognitive changes - Poor memory - Poor concentration •Psychological changes - Mood swings - Depression

GERO 416 – Prostate Cancer 1 – Flashcards

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