Prostate Cancer Analysis

The average age at diagnosis of prostate cancer is 73 years. The age-adjusted death rate from prostate cancer has not changed appreciably in 35 years. The prevalence of prostate cancer is 30% in men over the age of 50. One in six men will be diagnosed with prostate cancer during their lifetimes.

Clinical evaluation

Some patients with prostate cancer may have obstructive urinary symptoms similar to benign prostatic hypertrophy; some patients may have weight loss and bone pain. Most patients have no symptoms, only an elevated prostate specific antigen found on routine screening.

Physical exam. Digital rectal exam is used to assess the prostate nodule for extension beyond prostate edge, firmness, fixation, or induration.

Prostate specific antigen ( PSA)

Prostate specific antigen (PSA) is a glycoprotein specific for prostate tissue (although not necessarily prostate cancer). Elevated serum levels of PSA correlate closely with an increased likelihood of prostate cancer, especially when increases from baseline levels are observed. An elevated age-specific PSA level is usually an indication to consider transrectal ultrasonography and biopsy of the prostate.

PSA screening detects prostate cancer at an earlier stage. However, an improvement in survival has not been documented.

Transrectal ultrasonography

Transrectal ultrasound is more sensitive than digital rectal exam, but still misses about 30% of known cancers.

The main indication of ultrasound is to guide transrectal prostate biopsy.

Urological evaluation of suspected prostate cancer

The prostate nodule should be evaluated by transrectal ultrasound and prostate needle biopsies. If no transrectal ultrasound lesion is identified, then random sextet biopsies should be performed.

Indications for biopsy:

(1) Abnormal digital rectal exam (discrete, firm nodule),

(2) Elevated prostate-specific antigen (regardless of digital rectal exam).

Metastatic evaluation. SMA 18, chest x-ray, intravenous pyelogram or ultrasound (optional), and bone scan.

Therapy of early stage prostate cancer

Stage I and II disease are best managed surgically with radical prostatectomy (radiation therapy is another option). Radical prostatectomy consists of removal of the prostate and seminal vesicles, and a staging pelvic lymph node dissection.

Stage III disease is managed with radiotherapy or surgery.

Stage IV disease is managed with endocrine manipulation.

There is no firm evidence that any of these therapies is better than any other: therefore, “watchful waiting” is also a legitimate option in selected patients.

Endocrine therapy of advanced prostate carcinoma

Treatment of advanced malignancy (Stage IV) involves surgical or medical castration.

Total blockade with leuprolide plus flutamide is slightly better than leuprolide alone.

Orchiectomy is an outpatient procedure that is the safest and least expensive option. The incidence of impotence with orchiectomy is no different than with medical castration therapies.

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