Prostate Cancer

The Prostate Gland

Clip
Male sex gland
Size of a walnut
Helps control urine
flow
Produces fluid
component of semen
Produces Prostate
Specific Antigen (PSA)
and Acid Phosphatase

Four Areas of the Prostate
Transition Zone
Peripheral Zone
Anterior Zone
Central Zone
Factors Increasing Risk of Prostate
Cancer
Age
Lifestyle
Hormones
Race
Genetics
2006 Estimated US Cancer Deaths*
ONS=Other nervous system.
Source: American Cancer Society, 2006.
Men
291,270
Lung & bronchus 31%
Colon & rectum 10%
Prostate 9%
Pancreas 6%
Leukemia 4%
Liver & intrahepatic 4%
bile duct
Esophagus 4%
Non-Hodgkin 3%
lymphoma
Urinary bladder 3%
Kidney 3%
All other sites 23%

Prostate Cancer Risk factors:
Increased risk
Family history
10% CaP genetic
Multiple DNA Loci being
examined
High fat diet
African-American race
Increasing age

Multiple Risk Factors Amplify
Risk
Decreased risk
Low fat diet
Lycopene
Vit E, Selenium
Finasteride (Proscar)
Decreased total
incidence
Increased high grade
disease

Challenges of prostate cancer
screening and treatment
Goal: Find clinically significant cancer at a point
when a cure is possible
Goal: Avoid excessively aggressive treatment in
clinically insignificant disease
Examine prognostic factors of diagnosed
disease to predict if it will be significant
Consider patient medical issues, age,
philosophy
Prostate Cancer: Not to be confused with
Benign Prostatic Hypertropy (BPH)
BPH is age related enlargement of benign tissue
Enlarged tissue can cause urinary symptoms
Treatment initiated if symptoms are bothersome, infections or
incomplete bladder emptying
In contrast, Prostate cancer in early stages has no symptoms
Diagnostic triad for early detection of prostate cancer
Traditional indication for Prostate Biopsy:
Usually with LE >10yrs
Abnormal DRE regardless of PSA
Abnormal PSA velocity (.75 ng/dL/yr)
PSA > 4.0 or age appropriate range
Consider decreasing in men in 40s, 50s or with
risk factors (FH/AAmerican)

Elevated PSA does not mean prostate cancer
Screening Guidelines for the Early Detection of Prostate
Cancer
American Cancer Society

The prostate-specific antigen (PSA) test and the digital rectal examination
(DRE) should be offered annually, beginning at age 50, to men who have a
life expectancy of at least 10 years.
Men at high risk (African-American men and men with a strong family history
of one or more first-degree relatives diagnosed with prostate cancer at an
early age) should begin testing at age 45. Starting at age 40 can be
considered.
For men at average risk and high risk, information should be provided about
what is known and what is uncertain about the benefits and limitations of
early detection and treatment of prostate cancer so that they can make an
informed decision about testing.

Staging prostate cancer:
Treatment and outcomes of treatment
are the same for high risk population
Gleason grading system:
Prognostic indicators
PSA
Stage
Grade
#positive biopsy cores
%biopsy core positive

This helps us predict what cancer may be significant vs.
insignificant

When stratified by these indicators, patients in high risk groups
have the same treatment outcome
DAmico et al risk stratification for clinically
localized prostate cancer

Low risk Diagnostic PSA < 10.0 ng/mL and
Highest biopsy Gleason score < 6 and
Clinical stage T1c or T2a

Intermediate risk Diagnostic PSA > 10 but < 20 ng/mL or
Highest biopsy Gleason score = 7 or
Clinical stage T2b

High risk Diagnostic PSA > 20 ng/mL or
Highest biopsy Gleason score > 8 or
Clinical stage T2c/T3
PSA = prostate-specific antigen

Treating Prostate Cancer
Early Disease: Success depends on prognostic factors
Surgery
External Beam Radiation
With or without Androgen Deprivation (hormonal therapy)
Brachytherapy (Low risk disease)
Cryotherapy
Watchful Waiting (Low risk disease)
Risks, Pros and Cons of each
Advanced Disease
Hormone Therapy
Chemotherapy
Pain Management

PSA will indicate status of disease
Traditional Treatment Suggestions:
Age 30 60 radical prostatectomy (RP),
WWaiting if appropriate candidate
Age 60 70 XRT, seeds, RP, wwaiting if
appropriate candidate
Age >70 if LE>10yrs XRT, seeds, wwaiting if
appropriate, delayed androgen deprivation
LE<10yrs: WWaiting, delayed androgen
deprivation
Radiation Therapy (RT)
High-Powered X-Rays that damage DNA and
kill prostate cancer cells.

1. External Beam Radiation Therapy (EBRT): X-
rays aimed at prostate.

2. Brachytherapy: Radioactive seed implants
into prostate.
External Beam Radiation
Goal: Maximize damage to the prostate
and minimize damage to surrounding
tissues (i.e. bladder and rectum)
Prostate
Seminal
Vesicles
Watchful Waiting
A.K.A. observation, with an eye towards
curative therapy or palliative therapy.
Diagnosis of an early-stage (T1-T2), low-grade
tumor. Low risk disease.
No medical treatment is provided.
PSA quarterly, Rebiopsy yearly
Consider treatment if PSA changes or Biopsy
differs significantly
Removing Androgens
1. Orchiectomy (castration): surgical removal of the
testicles.
2. Oral drug which has the same effect as castration.
Blocks testosterone production. Include LHRH
agonists and antagonists and oral estrogens.
3. Anti-androgens which block the effects of
testosterone.
4. Combination therapies.
Results of Androgen Removal
Impotence
Loss of sexual desire (libido)
Hot flashes
Weight gain
Fatigue
Reduced brain function
Loss of muscle and bone mass
Some cardiovascular risks