Prostate Cancer: the basics

When to Screen

Prostate cancer is slow growing and patients should only be screened if they have a life expectancy >10-15yrs (calculator here) to see the benefits of cancer diagnosis and treatment, otherwise do not screen.

Overall lifetime risk of prostate cancer mortality is 3%

ERSPC: if 1000 men screened for prostate cancer, rate of death decreases from 5 to 4

Elevated PSA and its nuances

Causes of elevated PSA

PSA density

Risk of finding high grade cancer on prostate biopsy

Prostate Biopsy

Technique recommendations:

Risks of biopsy:

Prostate MRI

Prostate Cancer AUA Risk Classifications

Risk Group Grade Group Clinical Stage PSA # Cores Positive % Core Involvement PSA Density Further Workup Treatment Recommendations Risk of Metastasis
Very Low GG1 cT1-T2a < 10 < 1/3 < 50% < 0.15 none Active Surveillance < 1% @ 10-15yrs
Low GG1 cT1-T2a < 10 none Active Surveillance
(unless high risk for progression)
~3% @ 10-15yrs
Intermediate Favorable GG1
GG2
cT2b-c 10-20
<10
* RALP +/- PLND
XRT w/o ADT
Intermediate Unfavorable GG2
GG3
cT2b-c 10-20
< 20
* RALP + PLND
XRT w/o ADT
High GG4-5 cT3-T4 > 20 CT +/- MR
bone scan
RALP + PLND
XRT + ADT

*Indications/Notes for Further Staging after Diagnosis

AUA: stage w/ MR/CT if 2/3 are present - palpable nodule on DRE, GG2-3, PSA > 10

NCCN: stage if life expectancy > 5yrs, get bone scan if cT2 + PSA > 10, get CT if T2 and nomogram predicts > 10% nodal involvement

Bone scans

Active Surveillance

There is no unified recommendation for frequency of PSA checks, biopsy, MRI. 50-73% patients end up undergoing treatment by 10yrs.

Watchful waiting: good if high risk and life expectancy < 5yrs or low/intermediate risk and life expectancy < 10yrs

Surgery (RALP) vs Radiation (XRT): a short summary

At this time, surgery and radiation have equivalent chance of cure. The choice comes down to patient comorbidities, age, and personal preferences regarding side effects. Studies have shown patients usually prefer one vs another prior to discussion, but discussion is worth having.

Surgery

Radiation

Surgery

Goals of Surgery

  1. Cure prostate cancer
  2. Maintain continence
  3. Maintain erectile function

Obtaining cancer cure may require sacrificing erectile function. If patients are adamant about nerve-sparing, can perform with the risk of not obtaining cancer cure.

Younger/healthier patients see greater long-term benefit with surgery. Open and robotic have same risks/benfits, depends on surgeon experience.

MSK nomograms

Specific surgical risks for counseling

Radiation (XRT)

General XRT options

Risk-Based Options

Risks, Side Effects, and Other Considerations

Androgen Deprivation Therapy

Mechanism:

Medication Groups:

Cancer Recurrence

Risk factors: positive margins, SVI, EPE, higher GG - recurrence rates 60+% for high risk features after RP w/o ART

PSAdt < 10-12mo, 50% die within 10-13yrs

"Pound Study" (Pound 1999)

Adjuvant vs Salvage XRT

Benefits of adjuvant XRT (aXRT)

Locally Invasive Prostate Cancer (T3-T4)

The gist is that these patients can be managed with surgery and/or radiation but all treatments have a higher risk of failure and may require adjuvant therapy.

Metastatic Prostate Cancer

Sources: