PROSTATE CANCER
Lipi Shukla
Key Statistics:
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1/9 men in Australia will develop Prostate Ca
Most common cancer in Australian males
Around 20,000 cases are dx each year
Chance of dx of Prostate Ca:
– 1/1000 for a man in his 40’s  80/1000 in his 70’s
• Deaths:
– Around 3,300 men die of Prostate Ca each year
– 2nd most common cause of cancer related deaths
Overview of the Prostate:
• Walnut sized, roughly 20g.
• Lies below the bladder and
anterior to the rectum.
• TZ - 5-10%: surrounds the
urethra.
• CZ - 25%: forms a funnel and
contains the ejaculatory ducts
• PZ - 70%: peripheral secretions of
the prostate
Functions:
• Secretions:
– thin, pH 6.4, spermine,
prostaglandins, Ig, Proteases.
• Acts as a valve:
– preventing flow of urine
during ejaculation
Prostate Cancer
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99% Adenocarcinoma
Involves the peripheral zone
BPH usually co-exists
Commonest symptom: Asymptomatic
Family History is VERY important
Screening: PSA + DRE
– >50 with no FHx
– >40 with FHx
• Progression of Cancer:
– Local + Lymphatic: bladder base  seminal vesicles
– Hematogenous: vertebrae/bones (sclerotic lesions)
Risk Factors:
• Increased Age
• Family History
– 1 x 1st degree relative = 30% risk
– 2 x 1st degree relatives = 50% risk
– 3x 1st degree relatives = almost 100% risk!
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BPH
Lower incidence in Asians, increased in Africans
Vasectomy maybe linked to increased Ca
High monounsaturated fat diet; has been linked
to increased incidence
Presentation:
• Most commonly: No Symptoms/Signs
• PSA testing shows:
– Increased PSA for age bracket OR increased PSA velocity
>0.6ng/ml/yr
• Signs of urinary obstruction:
– Hesitancy, poor stream, nocturia, frequency.
• Extremely late (uncommon signs):
– Hypercalcemia, spinal cord compression, pathological
fractures
– Edema, renal failure
– Weight loss, fevers, night sweats, unexplained DVT
– New onset of erectile dysfunction
Examination
Findings with Ca:
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Firm + Enlarged
Assymetrical
Areas of induration
Irregular/ Nodular
Loss of Median
Sulcus
Interpreting the PSA
• Prostate Specific Antigen
– Serum Protease that is almost specifically produced by the
prostate
– Liquefies the sperm and cervical mucous cap
• PSA Value (absolute and median)
• PSA Velocity: >0.6ng/ml/yr suggestive of Ca
• Free PSA: Total PSA ratio <9% is suggestive of Ca
REMEMBER THERE ARE OTHER CAUSES OF ELEVATED PSA
Investigations
• Blood Tests:
– PSA, FBE, EUC, CMP, ALP
• Urine MCS +/- Urethral Swabs
– Rule out infection
• Transrectal US guided biopsy:
– 12-core peripherally weighted
– 25% false negative rate
– If ++ PSA elevation and –ve biopsy:
repeat with peripherally saturated
24-core biopsy.
• Staging:
– CT/MRI/Bone Scans
Gleason Score
• Looks at the architecture of
the glandular & stromal
cells.
• Histopathology based
grading:
– 1-5
(5 beingscore
the highest
So
which
is better? 4 + 3 = 7 OR 3 + 4 = 7
grade + poorest prognosis)
– Least differentiated to most
differentiated
• Minimal score is 6 
maximum 10.
• % of cores affected out of 12
makes an impact
Staging
• T0: no evidence of tumor
• T1: tumor present, but not detectable clinically or with
imaging
– Clinically normal feeling prostate
• T2: Confined to the prostate
– Can be palpated clinically
• T3: the tumor has spread through the prostatic capsule
(if it is only part-way through, it is still T2)
– Can be palpated clinically
• T4: the tumor has invaded other nearby structures
Risk Stratification
Normal
Palpation
Abnormal
Palpation
Treatment
• For most cancers depends on:
– Grade
– Stage
– Histological Subtype
• Surgery
– Laparoscopic vs. Open vs. Robotic
• Hormonal
• e.g. leuprolide or goserelin
• Radiotherapy
– EBRT vs (LDR) Brachytherapy vs HDR
• Chemotherapy
• Palliative: Analgesia, TURP, RTx, IV bisphosphonates
Some examples of regimes:
• Young/Middle Aged + >10yr expected survival
with low risk:
– ACTIVE SURVEILLANCE
• 3 monthly PSA, 18 month repeat TRUS
• Old + <10 year expected survival with any risk:
low/int/high:
– WATCHFUL WAITING
• Hormonal Therapy with PSA >20
• Given intermittently (every 3 months)
• Defers palliative therapy
• Young + >10 years life expectancy with
intermediate or high risk:
– Radical Prostatectomy + Gosrelin (Zoladex)
• Older + >10 year life expectancy with
intermediate or high risk:
– Radiotherapy + Hormonal Therapy
• Metastatic Disease
– Usually hormone insensitive
– Can give Gosrelin every 12 weeks, withdraw when PSA
plateaus to decrease hormone resistance
– Palliative measures:
• Rtx for spinal cord compression
• TURP to relieve obstruction
• IV fluids, bisphosphonates, Calcitonin for Hypercalcemia
QUESTIONS?
References
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Prostate Cancer Australia http://www.prostate.org.au/articleLive/
Up to date: Overview of treatment of prostate cancer. Nancy Dawson et al
Up to date: Clinical presentation, diagnosis and staging of prostate cancer.
Phillip Kantoff et al.
Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal
examination and serum prostate specific antigen in the early detection of
prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol
1994; 151:1283.
Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J
Clin 2011; 61:69.