Prostate Cancer

Prostate Cancer
Elsevier Point of Care (ver detalles)Actualizado August 8, 2022. Copyright Elsevier BV. All rights
reserved.
Synopsis
Urgent Action
 Consider metastatic prostate cancer in patients with acute neurologic
symptoms (eg, lower-extremity weakness or paralysis), urinary or fecal
incontinence, or urinary retention
Key Points
 Prostate cancer is common and potentially lethal
 Prostate-specific antigen screening is controversial; recommendations

vary depending on organization issuing guidance 1 2
o Individualized and shared decision-making regarding prostate-
specific antigen screening is recommended for most patients aged
55 to 69 years 1 2
o For most patients aged 70 years or older, no screening is
recommended 1 2
o American Urological Association recommends individualized
decision-making of younger patients (aged 40-54 years) at higher
risk (eg, first-degree relative with prostate cancer, Black people)
regarding prostate-specific antigen screening 2
o National Comprehensive Cancer Network recommends earlier
baseline testing, with subsequent frequency determined by risk
estimated from age-specific percentile in which initial test result
falls 2
 In most patients, disease progresses slowly; treatment strategy is
determined by risk stratification based on histologic characteristics and
extent of tumor, risk factors associated with demographics and family
history, and by life expectancy
 For patients with very-low-risk and low-risk disease, active surveillance is

recommended with intent to provide definitive treatment if evidence of
tumor progression develops
 Definitive treatments include radical prostatectomy and radiation therapy

(external beam or brachytherapy); these are recommended as initial
treatment in patients with intermediate- to higher-risk disease and life
expectancy of 10 years or more, and they may be offered as initial
therapy (instead of active surveillance) to patients in lower-risk groups
 Androgen deprivation therapy is added as adjuvant treatment in patients

with high-risk disease or if resected tissue shows adverse features and is
used as initial therapy for patients with metastatic disease
 Observation is usually recommended for asymptomatic patients with life
expectancy of less than 10 years; treatment is introduced when
symptomatic disease arises or is thought to be imminent
 Chemotherapy, radiation therapy, and radiopharmaceutical treatments

are available for symptomatic metastatic disease
 Prostate cancer and its treatment have significant potential effect on

quality of life, including adverse effects of sexual dysfunction and urinary
incontinence
Pitfalls
 Clinical benign prostatic hypertrophy may coexist with prostate cancer
 Prostate-specific antigen testing can lead to diagnosis of clinically

insignificant prostate cancer. In such patients, curative treatment options
may yield more harm than benefit
Terminology
Clinical Clarification
 Prostate cancer is adenocarcinoma of the prostate gland
 Most common nondermatologic cancer in male population worldwide and

the second most common cause of cancer death in male population in
the United States 3
 Marked clinical heterogeneity exists
o Tumors range from indolent and clinically irrelevant to virulent and

rapidly lethal
Classification
 2 types of prostate cancer staging 4
o Clinical staging: based on findings from physical examination,
laboratory tests, imaging, and biopsy
o Pathologic staging: combines clinical staging information with

information from surgical removal of prostate and microscopy
 Both clinical and pathologic staging use same classification system,

which incorporates 5 elements: characteristics of primary tumor (T),
lymph node involvement (N), evidence of metastasis (M), prostate-
specific antigen level, and Gleason score, which is a description of the
glandular architecture of the prostate 4
o Higher Gleason score and prostate-specific antigen level imply a
more aggressive tumor and worse prognosis 5
 Gleason grading system
 Used to quantify prostate cancer aggressiveness
 Gleason score is based on sum of histologic grades

of the 2 most dominant tumor patterns seen on
biopsy
 Gleason grades range from 1 to 5
 Grades 1 and 2 are rarely diagnosed
 Patients are given the following 2 Gleason

grades: 6
 Primary grade describes predominant
glandular pattern
 Secondary grade describes the second

most predominant glandular pattern
 Total Gleason scores (primary grade

plus secondary grade) range from 6 to
10 in most patients
 2 numerically equivalent total Gleason

scores may confer different degrees of
risk, depending on order of component
histologic patterns (eg, Gleason 7 [3 +
4] is associated with lower risk than
Gleason 7 [4 + 3] based on difference
in dominant cellular pattern)
 National Comprehensive Cancer

Network groups Gleason scores into
histologic grade groups, which are
incorporated into risk stratification to
guide treatment selection
 Grade group 1: Gleason score 6

or less; Gleason pattern 3 or
less + 3
 Grade group 2: Gleason score

7; Gleason pattern 3 + 4

7; Gleason pattern 4 + 3
8; Gleason patterns 4 + 4, 3 + 5,
5+3
 Grade group 5: Gleason score 9

or 10; Gleason patterns 4 + 5, 5
+ 4, 5 + 5
 Clinical TNM categories according to American Joint Committee on

Cancer 2018 staging 4
o Primary tumor, clinical
 TX: primary tumor cannot be assessed
 T0: no evidence of primary tumor
 T1: clinically inapparent tumor neither palpable nor visible

by imaging
 cT1a: tumor incidental histologic finding in 5% or

less of tissue resected
 cT1b: tumor incidental histologic finding in more than

5% of tissue resected
 cT1c: tumor identified by needle biopsy (eg, owing to

elevated prostate-specific antigen level)
 Tumor found in 1 or both lobes by needle

biopsy but not palpable or reliably visible by
imaging is classified as T1c
 T2: tumor palpable and confined within prostate
 cT2a: tumor involves half of 1 lobe or less
 cT2b: tumor involves more than half of 1 lobe but not

both lobes
 cT2c: tumor involves both lobes
 T3: tumor extends through prostate capsule but is not fixed

or does not invade adjacent structures
 cT3a: extracapsular extension (unilateral or bilateral)
 cT3b: tumor invades seminal vesicle(s)

 T4: tumor is fixed or invades adjacent structures other than
seminal vesicles, such as external sphincter, rectum,
bladder, levator muscles, and/or pelvic wall
o Primary tumor, pathologic
 pT2: organ-confined disease
 pT3: extraprostatic extension
 pT3a: extraprostatic extension or microscopic

invasion of bladder neck
 pT3b: seminal vesicle invasion
 pT4: tumor is fixed or invades rectum, bladder, levator

muscles, and/or pelvic wall
o Regional lymph nodes
 NX: regional nodes not assessed
 N0: no regional node metastasis
 N1: metastasis in regional node(s)
o Distant metastases
 M0: no distant metastasis
 M1: distant metastasis
 M1a: nonregional lymph node(s)
 M1b: bone(s)
 M1c: other site(s) with or without bone disease
 Stage grouping based on TNM categories 4

o Stage I is defined as follows:
 cT1a-c or cT2a or pT2, N0, M0
 Gleason grade group 1
 Prostate-specific antigen level lower than 10 ng/mL
o Stage IIA is defined as follows:

 cT1a-c or cT2a, N0, M0
 Prostate-specific antigen level between 10 and 20 ng/mL
o Stage IIA is also defined as follows:
 cT2b-c, N0, M0
o Stage IIB is defined as follows:
 T1-2, N0, M0
o Stage IIC is defined as follows:
 T1-2, N0, M0
 Gleason grade group 3 or 4
o Stage IIIA is defined as follows:
 T1-2, N0, M0
 Gleason grade group 1 to 4
 Prostate-specific antigen level 20 ng/mL or more
o Stage IIIB is defined as follows:
 T3-4, N0, M0
 Gleason grade group 1 to 4
 Any prostate-specific antigen level
o Stage IIIC is defined as follows:

 Any T, N0, M0
o Stage IVA is defined as follows:
 Any T, N1, M0
 Any Gleason grade group
o Stage IVB is defined as follows:
 Any T, N0, M1
 Any Gleason grade group
 Risk stratification (specifics vary slightly between guidelines; American

Urological Association combines the prior risk categories of "very-low-risk" and
"low-risk" disease together) 8 9 7
o Very low risk
 Clinical stage T1c and

 Grade group 1 (Gleason score of 6 or less) and
 Prostate-specific antigen level lower than 10 ng/mL and
 Disease present in fewer than 3 biopsy cores and
 Disease occupies 50% or less of any core and
 Prostate-specific antigen density lower than 0.15 ng/mL/cc
o Low risk
 Clinical stage T1 or T2a and

 Grade group 1 (Gleason score of 6 or less) and
o Intermediate risk
 Has no high-risk factors and 1 or more of the following

intermediate risk factors:
 Clinical stage T2b to T2c but not qualifying for high

risk
 Grade group 2 or 3 (Gleason score of 7)
 Prostate-specific antigen level greater than 10 to 20

ng/mL
 Further stratified into favorable intermediate or unfavorable

intermediate based on number of intermediate risk factors
and percentage of positive biopsy specimens
o High risk
 Clinical stage T3a or

 Grade group 4 or 5 (Gleason score of 8-10) or
 Prostate-specific antigen level greater than 20 ng/mL
o Very high risk (locally advanced)
 Clinical stage T3b to T4 or

 Primary Gleason pattern of 5 or
 More than 4 biopsy cores with grade group 4 or 5 (Gleason
score of 8-10)
Diagnosis
Clinical Presentation
History
 Organ-confined cancer (stage T0, T1, or T2N0M0)
o Most are asymptomatic
 Locally advanced prostate cancer (T3N0M0)
o Urinary tract symptoms
 Dribbling, hesitancy, and slowing of stream
 Frequency, nocturia, and dysuria
 Incomplete emptying of bladder and incontinence
 Hematuria
o Ejaculatory complaints and erectile dysfunction
o Perineal discomfort or pain
o Back pain
 Metastatic prostate cancer (any T, any N, M1x)
o Symptoms depend on site of metastasis
 Key examples include acute neurologic symptoms (eg,

lower extremity weakness or paralysis), urinary or fecal
incontinence, or urinary retention, but others (eg, bone
pain) may occur
 Obtain personal and family history of cancer and/or known germline

variants; history should include prostate and other cancers that may
suggest variants associated with early or aggressive disease or with
familial cancer syndromes, including:
o Gastric, bile duct, pancreatic, small bowel, colorectal
o Breast, ovarian, endometrial
o Kidney, urothelial
o Melanoma
o Lymphoma
Physical examination
 Palpable nodule may be detected on digital rectal examination
Causes and Risk Factors

Causes
 No known cause
Risk factors and/or associations

Age
 Prevalence increases with age through eighth decade 10

 Uncommon before age 50 years
 Most frequently diagnosed in males aged 65 to 74 years 10
 Lifetime risk is 12.6% 10

Sex
 Males only
Genetics
 9% of all cases are familial 11

 Family history of prostate cancer increases risk; prostate cancer in first-
degree relative whose disease occurred before age 60 years conveys
2.1- to 2.5-fold increased risk of developing disease 12
 A number of germline variants are associated with prostate cancer, and
these cancers tend to occur earlier and be more aggressive 12
o Some are also associated with other malignancies (eg, breast and
ovarian cancers, pancreatic cancer, melanoma, colorectal cancer)
and hereditary syndromes of multiple malignancies (eg, Lynch
syndrome)
o Most commonly recognized include:
 HOXB13
 BRCA1 and BRCA2
 FH
 ATM
 CHEK2
 RAD51D
 PALB2
 ATR
Ethnicity/race
 Incidence of prostate cancer is 60% higher in Black people of African

ancestry compared with White people 13
 Disease tends to occur earlier and progresses more rapidly in Black
people than in White people 12
 Certain germline variants are prevalent in people of Ashkenazi Jewish
descent 7
Other risk factors/associations
 Factors associated with higher rates of prostate cancer 14

o High intake of animal fat and red meat 15
o Low intake of vegetables and fruit, vitamins, and coffee
o Obesity
o Physical inactivity
o Exposure to high doses of ionizing radiation or environmental

carcinogens (agent orange) 12
o Chronic inflammation/prostatitis
o Sexually transmitted infection
 Higher ejaculatory frequency is correlated with lower prostate cancer risk

in some studies 14
 No convincing relationship has been found between vasectomy and
prostate cancer risk 14
 Baseline prostate-specific antigen levels above age-specific median
(even if within reference range) in males aged 40 to 55 years are
associated with eventual development of prostate cancer and with
aggressive forms of disease 16
Diagnostic Procedures
Primary diagnostic tools

 Workup for prostate cancer may be triggered by symptoms, by incidental
discovery of prostate nodules on physical examination, or through
prostate-specific antigen screening
o In patients undergoing transurethral resection of prostate for

symptoms of urinary obstruction, prostate cancer is occasionally
diagnosed on basis of pathology evaluation of submitted tissue
 Goal of workup is to detect cancer if present, assess extent, and

characterize nature of disease and likelihood of progression in context of
patient's age, health status, life expectancy, family history, and other
parameters 12
o Asymptomatic patients with life expectancy of 5 years or less may
not benefit 17
o Life expectancy calculators are available from US Social Security
Administration 18 and WHO 19
 Adjustments to calculated figure may be appropriate based
on clinician's judgement of patient's health status 7
 Excellent health (top 25%): add 50%
 Poor health (lowest 25%): subtract 50%
 In patients with prostate-specific antigen level higher than 3 ng/mL,

repeat testing for confirmation and perform digital rectal examination and
workup for benign disease; assess cancer risk factors based on personal
and family history 12
o Other parameters that may provide guidance include: 12
 Several derivatives of prostate-specific antigen testing,
including free prostate-specific antigen level
 Prostate-specific antigen velocity
 Prostate-specific antigen density
 May be appropriate in cases in which indications for biopsy

are unclear (eg, strong family history and equivocal
prostate-specific antigen level) or to determine need for
repeat biopsy in patients with elevated prostate-specific
antigen level and negative initial biopsy result 20
 Several scoring systems incorporating biomarkers (eg
4Kscore, PHI, PCA3) have been validated and may help
predict clinically significant prostate cancer and provide
additional information for patients with moderately elevated
prostate-specific antigen 20
 Prostate risk calculators (prostate cancer prevention trial
risk calculator and European randomized study prostate
cancer risk calculator) can be used to estimate the risk of
clinically significant prostate cancer in males with an
elevated prostate-specific antigen 20
 For patients with elevated prostate-specific antigen level and/or abnormal
digital rectal examination findings, prostate biopsy (12 core specimens)
can be considered 12 21
o Advisable in patients with digital rectal examination findings
suggestive of malignancy (eg, palpable nodule) even with normal
prostate-specific antigen levels 12
o Multiparametric MRI may be considered to aid in identifying
clinically significant lesions and potentially avoid unnecessary
biopsy 12 22
o Biopsy is usually guided by imaging, most commonly transrectal
ultrasonography; MRI is increasingly used in conjunction with
ultrasonography 12
 Staging and other pretreatment evaluations in patients with positive
biopsy results 7
o Pelvic imaging with or without abdominal imaging by CT or MRI is
recommended in select patients with intermediate- or higher-grade
malignancies
o Radionuclide bone scan is recommended to detect bone

metastases in select patients (eg, patients with unfavorable
intermediate- or high-risk disease)
o Germline testing is recommended for all patients with high-risk or

very-high-risk cancers and for all other patients with known or
suggestive family history of germline variant; this should be
directed by a genetic counselor
 Family history indicators that suggest possibility of germline

variant include:
 First-degree relative or multiple relatives diagnosed

with prostate cancer before age 60 or who died of
prostate cancer
 Ashkenazi Jewish ancestry
 3 or more cancers on same side of family, especially

if occurring at age 50 years or younger
 Germline testing is also recommended for patients whose

biopsy or resected tissue shows intraductal or cribriform
histology 9or who have either regional or distant metastases
o Molecular and biomarker analysis of tissue may be helpful in
guiding further management in patients with low or favorable
intermediate risk with life expectancy of 10 years or more. It is
also recommended in patients who are found to have regional or
distant metastases
Laboratory
 Prostate-specific antigen may be used to screen asymptomatic patients
and to evaluate those with lower urinary tract symptoms that suggest
prostate disease; it is also an important element in staging and follow-up
of confirmed malignancy
o Prostatitis, urinary tract infection, and benign prostatic hypertrophy

may produce elevated prostate-specific antigen levels and
prostate abnormalities that may mimic prostate cancer. Any
diagnostic abnormality that persists despite therapy for these
benign conditions is reason to consider prostate biopsy
 When prostate cancer develops, prostate-specific antigen level usually

exceeds 4 ng/mL 23
o Level below 4 ng/mL does not guarantee that patient does not
have cancer
 About 15% of patients with level below 4 ng/mL will have

prostate cancer on biopsy 24
o Patients with level between 4 and 10 ng/mL have about 1 in 4
chance of having prostate cancer 25
o If level is more than 10 ng/mL, chance of having prostate cancer is
more than 50% 25
 Prostate-specific antigen derivatives 12
o Prostate-specific antigen velocity
 Rate of change in prostate-specific antigen level over time,

minimally defined by 3 separate measurements over 18
months
 Rate of 0.35 ng/mL/year or more may indicate presence of

malignancy with lethal potential
 Most useful at low or equivocal prostate-specific antigen

levels; do not use as sole indicator for biopsy
 Not useful or necessary in patients with prostate-specific

antigen values greater than 10 ng/mL
 May be elevated by occurrence of prostatitis
o Prostate-specific antigen fractions

 Total prostate-specific antigen exists as free prostate-
specific antigen and bound, or complexed, prostate-specific
antigen
 Free prostate-specific antigen
 Percentage of free prostate-specific antigen (free

prostate-specific antigen ÷ by total prostate-specific
antigen × 100) tends to be significantly lower in
patients with prostate cancer
 For ratio of less than 10%, likelihood of cancer is

about 50%; ratio of greater than 25% signifies
probability of less than 10% 16
 Sensitivity is 95% and specificity is 20% 26
 FDA approved for use in patients with prostate-
specific antigen levels between 4 and 10 ng/mL and
normal digital rectal examination findings
 Prostate health index
 Combines total prostate-specific antigen, free

prostate-specific antigen, and proPSA (precursor to
prostate-specific antigen) results in mathematical
prediction model
 Value less than 24 correlates with absence of

aggressive malignancy (ie, high likelihood of either
no cancer or of indolent form) 27
 FDA approved for use in patients with prostate-
specific antigen levels of 4 to 10 ng/mL and normal
digital rectal examination findings
o Prostate-specific antigen density
 Prostate-specific antigen value divided by prostate volume

(latter determined by transrectal ultrasonography)
 Value less than 0.15 ng/mL/cc correlates with low likelihood

of malignancy
 Useful in identifying patients in whom elevated prostate-

specific antigen level and prostate enlargement can be
explained by benign prostatic hypertrophy
 Germline, molecular, and biomarker analyses are used primarily for

prognostic information; discovery of germline variants may have
significant implications for patient's relatives
Imaging
 Transrectal ultrasonography 12
o Not a good screening test owing to its low sensitivity and
specificity
o Use is generally reserved to facilitate transrectal biopsy of

prostate
o May also be used to measure prostate volume to determine

prostate-specific antigen density 12
 Multiparametric MRI 28
o Noninvasive method of assessing prostate for suspicious lesions
o May better characterize clinically significant lesions and reduce

unnecessary biopsies 22 28
o Standardized reporting (Prostate Imaging Reporting and Data
System) has been developed; currently on second iteration 28
 Lesions with Prostate Imaging Reporting and Data System
version 2 score of 4 or 5 have high likelihood of malignancy
and should be biopsied
 Lesions with score of 1 or 2 have low likelihood of

malignancy, and biopsy is not indicated based on imaging
findings alone
 Lesions with a score of 3 are considered equivocal, and

decision to biopsy is subjective
o Reported results may use 5-point Likert scale 21

 Consider omitting prostate biopsy for patients whose
multiparametric MRI Likert score is 1 or 2, but only after
discussing risks and benefits and reaching shared
decision 21
 Offer biopsy for patients whose Likert score is 3 or more 21
 CT scan of abdomen and pelvis
o Does not provide good visualization of gland itself but can detect
advanced local or metastatic disease 12
o Can detect grossly enlarged or abnormal lymph nodes but cannot
detect presence of pathologic tissue in lymph nodes 12
o Recommended in patients with intermediate- or higher-risk
disease and more than 10% likelihood of lymph node involvement
(determined by nomogram 29) 7
o Not routinely recommended in asymptomatic patients with low- or
intermediate-risk prostate cancer 9
 MRI of abdomen and pelvis
oMay be appropriate in some cases to guide prostate biopsy,
especially in patients in whom initial biopsy result is negative and
cancer is strongly suspected 12
o May be used for staging to determine extent of local disease,
especially if CT findings are equivocal 7
o American College of Radiology favors MRI over CT for staging of
intermediate-risk disease 12
 Prostate-specific membrane antigen PET-CT 7
o New modality that uses radiopharmaceuticals targeting prostate-
specific membrane antigen on the surface of prostate cells to
detect extraprostatic spread of prostate cancer
oAlternative to standard imaging for initial staging and for detection

of recurrent disease or progression 7
o Higher sensitivity and specificity than conventional imaging with
CT and whole-body bone scan, but outcome data to guide
subsequent management is lacking 30
o Recommended imaging modality after both radiotherapy and
radical prostatectomy for patients with biochemical evidence of
recurrence or persistently elevated prostate-specific antigen if the
findings would alter management 31
o May also have a role in primary staging; however, guidelines
currently recommend treatment decisions be primarily based on
the extent of disease seen on conventional imaging 31 32
o Consider in patients with prostate cancer who are at high risk for
metastatic disease with negative conventional imaging 9
 Bone scan is recommended for patients with unfavorable intermediate-
and high-risk disease 7
o Not routinely recommended in asymptomatic patients with low- or
intermediate-risk prostate cancer 9
Procedures
Transrectal biopsy of prostate
General explanation
o Multiple core biopsies are taken, usually in a systematic pattern

that includes specimens obtained bilaterally from apex, lateral
apex, midgland, lateral midgland, base, and lateral base, for a
total of 12 cores 12
o Biopsy guidance 7 12
 Transrectal ultrasonography or transperineal-guided biopsy
with MRI targeting is recommended 12
 MRI-targeted biopsy improves diagnostic accuracy
compared with transrectal biopsy guided by
ultrasonography 33 34
 MRI-transrectal ultrasonographic fusion biopsy techniques
may be superior for cancer detection compared with
transrectal ultrasonography alone 28
Indication
o Digital rectal examination results suggestive of disease
o Abnormal prostate-specific antigen level greater than 4 ng/mL or

greater than 3 ng/mL with digital rectal examination findings highly
suggestive of disease 12
o Prostate lesion identified on multiparametric MRI (Prostate
Imaging Reporting and Data System version 2 score of 4 or 5) 28
o Repeated biopsy is indicated per protocol for patients under active
surveillance for known prostate cancer 7
Contraindications
o Active urinary tract infection
o Surgical absence of rectum
Complications
o Urinary tract infection and sepsis
o Hematuria and hematospermia
o Rectal bleeding
Interpretation of results
o Pathologic confirmation of malignancy
o Gleason grades and score
Differential Diagnosis
Most common
 Other causes of urinary tract symptoms can mimic locally advanced prostate
cancer
o Benign prostatic hypertrophy (Related: Benign Prostatic Hypertrophy)
 Can mimic locally advanced prostate cancer by causing
hematuria, urinary retention, and voiding symptoms
 May cause elevated prostate-specific antigen levels
 Can be differentiated from locally advanced prostate cancer

by prostate-specific antigen density (less than 0.15
ng/mL/cc) and prostate biopsy if performed
 Nodularity, if present, suggests malignancy, but

absence of nodularity does not rule it out
o Prostatitis
 Can mimic locally advanced prostate cancer by causing an
elevated prostate-specific antigen level, hematuria, urinary
retention, and voiding symptoms
by urinalysis result suggestive of infection (eg, leukocytes),
positive culture, and, if performed, prostate biopsy

o Prostatic calculi
 Can mimic locally advanced prostate cancer by causing

hematuria, urinary retention, and voiding symptoms

by cystoscopy and, if performed, prostate biopsy

Treatment
Goals
 For patients with localized disease and significant life expectancy, cure is
desired outcome; timing of intervention depends on risk stratification and
patient preferences
 For patients in whom curative approach is not deemed suitable (eg,

advanced age, comorbidities, locally advanced disease), prevent
progression of disease and related symptoms
 Maximize quality of life
o Relieve lower urinary tract symptoms, pain, and complications (eg,

fractures)
Disposition
Admission criteria
Admit patients with advanced prostate cancer presenting with anuria, acute
renal failure, urinary clot retention, or spinal cord compression secondary to
metastatic disease
Criteria for ICU admission
 Admit patients with acute renal failure plus congestive heart failure or
hemodynamic instability
Recommendations for specialist referral

 Refer patients with suspected prostate cancer to a urologist to assess
need for biopsy and further surgical intervention and to guide further
management
 Refer patients with newly diagnosed prostate cancer to a medical and/or

radiation oncologist
Treatment Options
Owing to frequency of prostate cancer in the population (particularly in older
patients), slow progressive pace of most prostate cancers, and potential for
significant adverse effects of treatment (eg, urinary incontinence, erectile
dysfunction, radiation proctitis), several strategies for initial management have
emerged 8 35
 Definitive therapy with intent to cure
o 2 primary modalities: radical prostatectomy and radiation therapy

(external beam radiation therapy, proton radiation therapy, or
interstitial brachytherapy)
 Cryosurgery and high-intensity focused ultrasonography

have gained public interest, but they are not yet endorsed
by guidelines as standard care
o Intervention may be indicated at time of diagnosis or at a point

during active surveillance when evidence suggests increasing risk
of progression
Large clinical trial that randomized male patients aged 50 to 69

o
years with localized prostate cancer detected by prostate-specific
antigen screening to active monitoring, surgery, or external beam
radiation therapy showed no differences in 10-year prostate-
associated mortality. Rates of progression and metastasis were
higher in patients in active monitoring group 36
 Observation
o Active surveillance
o Watchful waiting
 Palliative management to relieve symptoms and maintain quality of life
o Androgen deprivation therapy, radiation therapy, chemotherapy,

immunotherapy, or radiopharmaceutical therapy
Selection of approach depends on the following: 8 35

 Tumor staging and risk category
 Presence of genetic or demographic risk factors

 Patient age, life expectancy, and overall health
 Presence or absence of symptoms
 Patient preference regarding prognosis potential and effect of treatment

options on quality of life
Definitive therapy
 Recommended for the following groups: 7

o Intermediate-risk patients with life expectancy of 10 years or more
o High-risk and very-high-risk patients with life expectancy of 5

years or more
Several trials show significantly lower prostate-specific


mortality rates in high-risk patients treated with early
prostatectomy compared with watchful waiting/observation;
active surveillance was not a comparator 37 38
 May be offered to the following groups: 7
o Very-low-risk patients with life expectancy of 20 years or more
o Low-risk patients with life expectancy of 10 years or more
 Radical prostatectomy (perineal, retropubic, laparoscopic, or robot-

assisted) 7
o May include pelvic lymph node dissection in patients with 2% or
greater chance of lymph node involvement
Risk is assessed by nomogram 29 9


o Most common adverse effects
 Stress urinary incontinence
 Erectile dysfunction
 Lymphedema and/or lymphocele may occur if

lymphadenectomy is performed
o Systematic review of laparoscopic, robot-assisted, and open

prostatectomy found no high-quality evidence comparing long-
term oncologic outcomes 39
 Overall complication rate and urinary and sexual quality of
life were similar
 Length of hospital stay and transfusion requirements were

greater in open procedures
 Definitive radiation therapy

o External beam radiation therapy 7
 Several techniques are available: intensity modulated,
stereotactic, or hypofractionated
 Hypofractionation entails delivery of higher doses

per fraction (ie, session), thus shortening duration
needed to administer total dose; it may be offered to
patients in lower-risk categories who have opted for
treatment with selected external beam radiation
therapy 40
 Associated with small increased risk of early
gastrointestinal adverse effects, but long-term
toxicity appears similar to conventional
external beam radiation therapy 41
 Long-term efficacy data are not yet available,
but 5-year outcomes for hypofractionation
appear similar to conventional radiation
therapy
 May be an appropriate choice in the following additional

groups:
 Select patients with unfavorable intermediate-risk

disease and life expectancy of fewer than 10 years
 Select patients with high-risk or very-high-risk

disease and life expectancy of 5 years or fewer
 May be considered with androgen deprivation therapy with

or without brachytherapy for patients with high-risk and
very-high-risk disease who are currently symptomatic or
who are expected to have complications within next 5 years
 Most common adverse effects
 Stress urinary incontinence
 Urinary urgency, frequency, and hematuria
 Rectal bleeding and diarrhea
o Interstitial prostate brachytherapy 7

 Low-dose (delivered via implanted radioactive seeds) and
high-dose (delivered via temporary implanted catheter)
protocols exist
 May also be used as adjunct to boost external beam
radiation therapy in the following cases:
 Patients with unfavorable intermediate-risk disease

and life expectancy of fewer than 10 years
 Patients with high-risk or very-high-risk disease and

life expectancy of more than 5 years or who are
symptomatic
 Most common adverse effects include:
 Dysuria, urinary retention, and hematuria
 Perineal bruising
o Proton beam radiation therapy 7

 Delivers highly focused radiation doses to prostate while
minimizing radiation to surrounding normal tissues
 Cost of treatment is high, and there is currently no clear

evidence of benefit of this form of radiation therapy
Observation
 Active surveillance
o Typically involves follow-up with periodic prostate-specific antigen

tests, digital rectal examination, and prostate biopsies, with intent
to intervene with definitive treatment when test results suggest
increasing risk 42
o Consider for:
 Low- or intermediate-risk disease regardless of life

expectancy or age
 Recommended for patients with localized very-low-

risk disease ("best option") and localized low-risk
disease ("preferable option") 8
 At 15-year follow-up in patients with very-low-
risk disease, fewer than 1% experience
metastatic progression 35
 For patients with low-risk disease, rates of
progression are not as well defined are but
thought to be higher; for such patients,
presence of demographic or genetic risk
factors may influence decision 8
May be offered to those with favorable localized
intermediate-risk disease, but risk of metastases is
higher than with definitive therapy 8
 Patients who wish to defer definitive treatment for any
reason
 Watchful waiting 8
o Observation with intent to provide palliative therapy when
symptoms arise
o Consider in patients with significant comorbidities or in those with

life expectancy of fewer than 5 years
 For intermediate-risk and lower-risk malignancies, National

Comprehensive Cancer Network extends acceptable time
frame for this strategy to patients with life expectancy of 10
years or less 7
Adjuvant or palliative therapy for locally advanced, metastatic, or recurrent
prostate cancer
 Androgen deprivation therapy 43

o Prostate cancer has been shown to grow in presence of
testosterone until or unless cellular adaptation results in hormonal
resistance
o Considered mainstay of treatment of advanced hormone-sensitive

prostate cancer and can be initiated in asymptomatic patients with
biochemical evidence (prostate-specific antigen level) of disease
progression or in patients who develop symptoms of metastatic
disease 44
 Early initiation of treatment may extend survival and reduce
rate of skeletal events; however, this must be balanced
against risk of adverse effects
o May be considered as adjuvant therapy for localized high-risk and

very-high-risk disease in which complications (eg, hydronephrosis,
metastasis) are expected within next 5 years or in cases in which
pathology results in resected tissue shows adverse features 7
o Agents include luteinizing-releasing hormone antagonists (eg,
degarelix) or agonists (eg, leuprolide, goserelin, triptorelin) that
reduce circulating testosterone levels
o Oral nonsteroidal antiandrogens (eg, bicalutamide, flutamide,

nilutamide) can be added to androgen deprivation therapy as
follows:
 To block testosterone flare associated with gonadotropin-

releasing hormone agonist therapy
 In patients with metastatic disease to bone
o Other second line hormonal agents include enzalutamide,

abiraterone, and apalutamide
 Often combined with continuation of androgen deprivation

therapy or chemotherapy to enhance treatment response
Darolutamide or abiraterone in combination with

docetaxel and androgen deprivation therapy, both
have been shown to improve overall survival in
patients with metastatic hormone-sensitive prostate
cancer 45 46
o Low levels of testosterone similar to those seen in androgen
deprivation therapy can also be achieved with surgical castration
(bilateral orchiectomy)
Bilateral orchidectomy may be associated with fewer


adverse effects than treatment with luteinizing-releasing
hormone agonists 7
o Over time, most patients eventually stop responding to standard
androgen deprivation therapy 7
 When prostate cancer is no longer sensitive to chemical or
surgical castration, it is referred to as castration-resistant
prostate cancer 47
 Variety of secondary hormone therapy options are available
for castration-resistant prostate cancer, including second
line hormone agents described above, ketoconazole,
corticosteroids, estrogens, and diethylstilbestrol 47
o Patients treated with androgen deprivation therapy are at risk for
osteoporosis and should receive supplemental calcium (500 mg)
and vitamin D (400 international units) 7
 Patients with osteoporosis or bone metastases may benefit
from use of zoledronic acid or denosumab;
bisphosphonates may also be used. However, these have
not been proven to reduce fractures in this population 48 49
 Baseline bone density measurement is recommended to
determine fracture risk and need for pharmacologic
therapy 49
 Bone-targeted drugs are not recommended for prevention
of bone metastasis in patients with nonmetastatic disease 49
 Chemotherapy 50
o Typically given to patients with castration-resistant prostate cancer
who have progressive (metastatic) disease 17 51
o Some identifiable variants appear to correlate with responsiveness
to specific agents
o Clinicians should not offer systemic chemotherapy or

immunotherapy to noncastration-resistant prostate cancer patients
outside the context of a clinical trial 21
 Immunotherapy 52
o For patients with castration-resistant prostate cancer who have
progressive (metastatic) disease and specific tumor
characteristics
 Radiation therapy
o Adjuvant radiation therapy may be delivered to prostatic bed and

surrounding tissues after radical prostatectomy in patients with
intermediate or high risk of recurrence and those with evidence of
recurrence but without distant metastases (ie, salvage radiation
therapy) 53 54
 In males with a detectable prostate-specific antigen after
prostatectomy for prostate cancer, salvage prostate bed
radiotherapy improves progression-free survival at 5
years 53
 In patients with unfavorable intermediate-risk prostate
cancer, it is recommended that short-term androgen
deprivation therapy (4-6 months) be added to
radiotherapy 54 55 56
 In patients with high-risk prostate cancer, it is
recommended that long-course androgen deprivation
therapy (18-36 months) be added to radiotherapy 55
 Pelvic lymph node radiation may also be offered
Postprostatectomy and salvage radiation therapy are given in form

o
of external bean radiation therapy; salvage brachytherapy is
option for local recurrence 7
 Radiopharmaceutical therapy 57
o For patients with castration-resistant prostate cancer who have
symptomatic bone metastases but no visceral metastases
 Radium Ra 223 dichloride
o For patients with metastatic castration-resistant prostate cancer

who have not responded to androgen deprivation therapy and a
taxane and who have 1 or more metastatic lesions that highly
express prostate-specific membrane antigen on the diagnostic
radiolabeled prostate-specific membrane antigen PET/CT
scan 30 58
 Lutetium-177 vipivotide tetraxetan (also known as Lu-177
prostate-specific membrane antigen-617)
 Bone-directed therapy
o Denosumab or zoledronic acid is recommended to prevent or

reduce skeletal-related events (eg, fractures, spinal cord
compression) in patients with castration-resistant prostate cancer
and bone metastases 7 21 49 59
Treatment with radium Ra 223 is recommended to palliate pain
o
and reduce risk of skeletal-related events in patients with
symptomatic bone metastases; may extend overall survival in
those with isolated bone metastases 49
 Isolated external beam radiation therapy is alternative 7
o Oral or intravenous bisphosphonates may be used for pain relief
for people with bone metastases when other treatments, including
analgesics and palliative radiation therapy, are inadequate 21
 Cochrane review indicated probable reduction in skeletal
events and progression of bone disease in patients with
bone metastases from prostate cancer 60
Recommendations for initial therapy by risk stratification 7 12
 Very low risk
o Life expectancy fewer than 10 years: observation
o Life expectancy 10 to 20 years: active surveillance
o Life expectancy 20 years or more: active surveillance, radiation

therapy (external beam or brachytherapy), or radical
prostatectomy
 Low risk
o Life expectancy fewer than 10 years: observation
o Life expectancy 10 years or more: active surveillance, radiation

therapy (external beam or brachytherapy), or radical
prostatectomy
 Favorable intermediate risk
o Life expectancy fewer than 10 years: observation or radiation

therapy (external beam or brachytherapy)
o Life expectancy 10 years or more: active surveillance, radical

prostatectomy, or radiation therapy (external beam or
brachytherapy)
 Unfavorable intermediate risk
o Life expectancy fewer than 10 years: observation or external

electron beam radiation therapy, with or without brachytherapy
and with or without androgen deprivation therapy
o Life expectancy 10 years or more: radical prostatectomy or

external electron beam radiation therapy, with or without
brachytherapy and with or without androgen deprivation therapy
 High and very high risk
o Appropriate options that may be selected according to patient's

age, overall health, and preferences are as follows:
 External beam radiation therapy with or without androgen

deprivation therapy
 External beam radiation therapy plus brachytherapy plus

androgen deprivation therapy
 Radical prostatectomy (if adjacent organs are not involved)
 Androgen deprivation therapy
 Nodal and metastatic disease
o Androgen deprivation therapy with or without external beam

radiation therapy
Salvage protocols consisting of radiation therapy, androgen deprivation therapy,

and/or chemotherapy exist for patients with recurrence after initial treatment 7
Outcomes
For patients treated with radical prostatectomy, 15-year cancer-specific


mortality is 12% overall and 5% in lowest-risk group 61
 For patients with early disease treated with radiation therapy, 25-year
disease-free survival is more than 70% 62
Nondrug and supportive care
Palliative care for symptomatic patients with metastatic disease focuses on
emotional support, relief of bone pain, nutritional support, and relief of other
patient-specific symptoms
Procedures
Radical prostatectomy
General explanation
 Complete surgical removal of prostate
o May be done by perineal or retropubic approach
o Use of laparoscopy and robotic assistance has replaced open

procedure in many centers
o Length of hospital stay and transfusion requirements are lower in

laparoscopic and robot-assisted procedures than in open
procedures 39
Pelvic lymph node dissection may be done in conjunction if risk of nodal

metastasis is calculated (by nomogram 29) to be 2% or more 7 63
o Provides staging information but not consistently associated with
improvement in metastasis-free or overall survival 63
Indication
Potentially curable disease in patients with life expectancy of 10 years or

more 7
Contraindications
 Poor functional status
 Presence of comorbidities that pose unacceptable anesthesia risk
 Locally invasive disease (eg, involvement of adjacent organs)
Complications
 Erectile dysfunction
 Urinary incontinence
External beam radiation therapy
General explanation
 Use of image-guided external beam radiation therapy to destroy
malignancy
 Rapidly evolving newer techniques may reduce collateral tissue damage

and duration of treatment
Indication
 Potentially curable disease
 Palliative therapy for bone metastases
Contraindications
 Previous radiation therapy to pelvic area
 Active inflammatory disease of rectum (eg, ulcerative colitis)
 Permanent indwelling urinary catheter
Complications
 Urinary incontinence
 Lower urinary tract symptoms (eg, urgency, frequency, hematuria)

 Rectal bleeding and diarrhea; latter may become chronic
Brachytherapy
General explanation
 Placement of radiation-emitting implants into prostate to destroy
malignancy
Indication
 Potentially curable disease
 May be used as adjunct to boost external beam radiation therapy
Complications
 Lower urinary tract symptoms (eg, urgency, frequency, hematuria)
 Perineal bruising
Comorbidities
 Poor overall health with life expectancy of fewer than 10 years; increases
risk of adverse events from prostate cancer treatments
Monitoring
 In patients who have received definitive treatment, monitor prostate-
specific antigen levels every 6 to 12 months for 5 years, then annually;
perform digital rectal examination annually 7
o 6-month intervals are recommended for monitoring prostate-
specific antigen level for first 5 years after external beam radiation
therapy
o 3-month intervals may be appropriate for patients with high-risk

disease treated by either modality
 In patients with node-positive or metastatic disease, monitor every 3 to 6

months with history and physical examination (including digital rectal
examination) and prostate-specific antigen level 7
o Periodically perform bone imaging, especially once doubling time
of prostate-specific antigen level reaches 8 months
 Active surveillance entails scheduled prostate-specific antigen

measurements, digital rectal examinations, and prostate biopsies;
guidelines differ on frequency of testing patients in active surveillance
o National Comprehensive Cancer Network 7

 Prostate-specific antigen testing no more frequent than
every 6 months
 Digital rectal examination no more frequent than every 12

months
 Multiparametric MRI no more frequent than every 12

months
 Repeat biopsy at outset or within 6 months if uncertain

about appropriateness of active surveillance versus
intervention; after that, no more frequent than every 12
months unless clinically indicated by significant clinical
change
 May be triggered by increasing prostate-specific

antigen level, change in examination findings, or
change in MRI findings
 Progression of disease is suggested by presence of

grade group 4 or 5 if malignant changes are found in
a greater number of cores or appear to be
anatomically more extensive
o American Urological Association 35

 Prostate-specific antigen testing every 3 months for first
year, then every 3 to 6 months
 Digital rectal examination; frequency not specified
 Repeat biopsy within 2 years (even without biochemical or

physical evidence of progression) to confirm
appropriateness of continued surveillance (versus definitive
treatment) and every 3 to 5 years thereafter
 Use of multiparametric MRI may be considered, but role

and frequency are undefined
 In patients under observation, assess for relevant symptoms every 6 to

12 months with laboratory tests and imaging at discretion of physician 7
Complications and Prognosis
Complications
 Prostate cancer treatments have potential for local and systemic adverse
effects that may greatly affect quality of life. Most common include:
o Depression and anxiety

o Erectile dysfunction
Urinary incontinence 64
o
Fecal incontinence 21
o
 Androgen deprivation therapy may result in complications that include: 21
o Hot flashes
o Sexual dysfunction
o Gynecomastia
o Osteoporosis and fractures
 Progressive prostate cancer can cause:
o Urinary obstruction, leading to urinary retention and renal failure
o Preferential metastasis to lumbar vertebral bodies with potential

for vertebral body fracture and collapse leading to possible
neurologic compromise as follows:
 Compromise to motor and sensory function of lower limbs,

including paralysis
 Compromise to urinary and gastrointestinal systems,

resulting in fecal and urinary incontinence or retention
Prognosis
 5-year survival for localized and regional prostate cancer is 100% and
drops to about 32% with metastatic disease 10
Screening and Prevention
Screening
At-risk populations
 All males are at risk, and risk increases with age
 Higher-risk groups, for whom earlier or more frequent screening may be

recommended, include: 12
o Black people of African ancestry
o People with first-degree relative with prostate cancer (eg, brother,

father, uncle), especially if diagnosed before age 60 years
o People with germline variant(s) that increase risk for prostate

cancer, including BRCA1, BRCA2, HOXB13, ATM, and several
mismatch repair genes 12
Screening tests
 Best screening test, if screening is elected, is prostate-specific antigen
test 12
 Digital rectal examination is not sufficient as stand-alone screening test,
but it should be considered in addition to prostate-specific antigen testing
because early malignancy occasionally presents as palpable nodule
before prostate-specific antigen level is elevated 12
 Screening with prostate-specific antigen testing is controversial, and
medical organizations differ on recommendations for its use 2 12
o American Urological Association recommendations 2
 Younger than 40 years: do not routinely screen
 Aged 40 to 54 years at average risk: do not routinely

screen
 Aged 40 to 54 years at higher risk (eg, positive family

history or Black people): explain harms and benefits to
patient and individualize screening decision based on
discussion
 Aged 55 to 69 years: explain harms and benefits to patient

and individualize screening decision based on discussion
 Screening every 2 or more years may be preferred

over annual screening, because it preserves most
benefits of screening and reduces overdiagnosis and
false-positive results
 Patients aged 70 years or older and any patient with life

expectancy of less than 10 to 15 years: no routine
screening
o US Preventive Services Task Force recommendations 1

 Aged 55 to 69 years: explain harms and benefits to patient
and individualize screening decision based on discussion
 Aged 70 years or older: do not screen
 High-risk groups: US Preventive Services Task Force does

not make separate specific recommendations for prostate
cancer screening in Black patients or those with family
history of prostate cancer, but does acknowledge that it is
possible that screening may offer greater potential benefits
for these patients compared with those in general
population
o National Comprehensive Cancer Network recommends earlier

baseline testing with subsequent frequency determined by risk
estimated on basis of initial test result 12
 Begin informed testing at age 45 years and continue to age
75 years unless current life expectancy is less than 10
years; testing may be continued in very healthy patients
after age 75 years
Some authorities stress significance of baseline

testing in fifth or sixth decade in predicting
probability of developing cancer based on
observation that results above age-specific median
(even within reference range) are associated with
eventual development of cancer of aggressive
nature 16
 For patients in high-risk groups (eg, Black people, strong
family history, known germline variant), begin screening
discussions earlier (eg, 40 years) and consider annual
screening; however, there is no evidence that this will
reduce morbidity or mortality compared to testing beginning
at age 45 years 12
 For patients with prostate-specific antigen value lower than
1 ng/mL, repeat testing at 2- to 4-year interval
 1 ng/mL is above 75th percentile for males younger

than 50 years
 Results that fall within higher percentiles convey

greater risk for developing prostate cancer
 For patients with initial prostate-specific antigen value of 1

to 3 ng/mL, repeat testing at 1- to 2-year interval
 For patients with initial prostate-specific antigen value of 3

ng/mL or greater, continue evaluation with multiparametric
MRI and possible transrectal biopsy guided by
ultrasonography
European guidelines suggest first repeating

prostate-specific antigen before undertaking
additional investigations in asymptomatic males with
prostate-specific antigen level between 3 and 10
ng/mL and a normal digital rectal examination 30
o Canadian Urological Association guidelines suggest starting
prostate-specific antigen testing at age 50 years in most males
and at age 45 years in males with an increased risk of prostate
cancer 20
 American Urological Association guidelines provide the following
framework for informative discussion with patients contemplating
screening: 2
o Many prostate cancers are indolent; although likelihood of
developing prostate cancer is significant, only minority of prostate
cancers progress to advanced disease
o Test results may be falsely positive or falsely negative
o Prostate-specific antigen elevations may occur owing to a number

of factors other than cancer
o Biopsy and treatment carry risks, including both harms and lack of
benefit
 American Cancer Society 65 and other organizations provide free decision

aids written for patients
 Most guidelines recommend further evaluation for patients with
confirmed prostate-specific antigen value greater than 3 to 4 ng/mL 1 2 12
o May include calculation of prostate-specific antigen kinetics,
testing for biomarkers, and, ultimately, biopsy
Prevention
 Lifestyle measures, such as limiting intake of animal fats, red meat, and
high-fat food and increasing fruit and vegetable intake as well as physical
exercise, may be associated with reduced risk of prostate cancer 14 15
Referencias
1.US Preventive Services Task Force: Prostate Cancer: Screening. USPSTF website.
Updated May 8, 2018. Accessed July 29, 2022.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-
screening
Ver en el Artículo|Referencia cruzada
2.Carter HB et al: Early Detection of Prostate Cancer (2018). American Urological
Association website. Published 2013. Reviewed and Confirmed 2018. Accessed July
29, 2022. https://www.auanet.org/guidelines/prostate-cancer-early-detection-guideline
3.Nieto M et al: Prostate cancer: re-focusing on androgen receptor signaling. Int J
Biochem Cell Biol. 39(9):1562-8, 2007
4.Buyyounouski MK et al: Prostate. In: Amin MB et al, eds: American Joint Committee
on Cancer: AJCC Cancer Staging Manual. 8th ed. Springer; 2018:715-26
Ver en el Artículo
5.Chen N et al: The evolving Gleason grading system. Chin J Cancer Res. 28(1):58-64,
2016
6.Prostate Conditions Education Council: Gleason Score: Prostate Cancer Grading and
Prognostic Scoring. Prostate Conditions Education Council website. Accessed July 29,
2022. https://www.prostateconditions.org/about-prostate-conditions/prostate-cancer/
newly-diagnosed/gleason-score
7.National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in
Oncology (NCCN Guidelines): Prostate Cancer. Version 4.2022. NCCN website.
Updated May 10, 2022. Accessed July 29, 2022. https://www.nccn.org/
8.Sanda MG et al: Clinically localized prostate cancer: AUA/ASTRO/SUO guideline.
Part I: risk stratification, shared decision making, and care options. J Urol. 199(4):990-
7, 2018
9.Eastham JA et al: Clinically localized prostate cancer: AUA/ASTRO guideline, part I:
introduction, risk assessment, staging, and risk-based management. J Urol. 208(1):10-8,
2022
10.National Cancer Institute: Surveillance, Epidemiology, and End Results Program:
Cancer Stat Facts: Prostate Cancer. NIH SEER Program website. Accessed July 29,
2022. https://seer.cancer.gov/statfacts/html/prost.html#prevalence
11.Stanford JL et al: Familial prostate cancer. Epidemiol Rev. 23(1):19-23, 2001
12.National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in
Oncology (NCCN Guidelines): Prostate Cancer Early Detection. Version 1.2022.
NCCN website. Updated February 16, 2022. Accessed July 29, 2022.
https://www.nccn.org/
13.Powell IJ. Epidemiology and pathophysiology of prostate cancer in African-
American men. J Urol. 177(2):444-9, 2007
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Prostate Cancer

 Prostate-specific antigen screening is controversial; recommendations

 For patients with very-low-risk and low-risk disease, active surveillance is

 Definitive treatments include radical prostatectomy and radiation therapy

 Androgen deprivation therapy is added as adjuvant treatment in patients

 Chemotherapy, radiation therapy, and radiopharmaceutical treatments

 Prostate cancer and its treatment have significant potential effect on

 Prostate-specific antigen testing can lead to diagnosis of clinically

 Most common nondermatologic cancer in male population worldwide and

o Tumors range from indolent and clinically irrelevant to virulent and

o Pathologic staging: combines clinical staging information with

 Both clinical and pathologic staging use same classification system,

 Used to quantify prostate cancer aggressiveness

 Gleason score is based on sum of histologic grades

 Gleason grades range from 1 to 5

 Grades 1 and 2 are rarely diagnosed

 Patients are given the following 2 Gleason

 Secondary grade describes the second

 Total Gleason scores (primary grade

 2 numerically equivalent total Gleason

 National Comprehensive Cancer

 Grade group 1: Gleason score 6

 Grade group 2: Gleason score

 Grade group 3: Gleason score

 Grade group 5: Gleason score 9

 Clinical TNM categories according to American Joint Committee on

 TX: primary tumor cannot be assessed

 T0: no evidence of primary tumor

 T1: clinically inapparent tumor neither palpable nor visible

 cT1a: tumor incidental histologic finding in 5% or

 cT1b: tumor incidental histologic finding in more than

 cT1c: tumor identified by needle biopsy (eg, owing to

 Tumor found in 1 or both lobes by needle

 T2: tumor palpable and confined within prostate

 cT2a: tumor involves half of 1 lobe or less

 cT2b: tumor involves more than half of 1 lobe but not

 cT2c: tumor involves both lobes

 T3: tumor extends through prostate capsule but is not fixed

 cT3a: extracapsular extension (unilateral or bilateral)

 cT3b: tumor invades seminal vesicle(s)

o Primary tumor, pathologic

 pT2: organ-confined disease

 pT3: extraprostatic extension

 pT3a: extraprostatic extension or microscopic

 pT3b: seminal vesicle invasion

 pT4: tumor is fixed or invades rectum, bladder, levator

o Regional lymph nodes

 NX: regional nodes not assessed

 N0: no regional node metastasis

 N1: metastasis in regional node(s)

 M0: no distant metastasis

 M1: distant metastasis

 M1a: nonregional lymph node(s)

 M1c: other site(s) with or without bone disease

 Stage grouping based on TNM categories 4

 cT1a-c or cT2a or pT2, N0, M0

 Gleason grade group 1

 Prostate-specific antigen level lower than 10 ng/mL

o Stage IIA is defined as follows:

 Gleason grade group 1

 Prostate-specific antigen level between 10 and 20 ng/mL

o Stage IIA is also defined as follows:

 Gleason grade group 1

 Prostate-specific antigen level lower than 20 ng/mL