Prostate Cancer

Pt <77 years old with family h/o prostate cancer presents with gradual onset unintentional weight loss, urinary frequency/hesitancy, hematuria, and bony back pain. Denies h/o HTN, chest pain, heart failure, MI, stroke, lung disease, GI ulcer, IBD, DM, depression. Lower extremity weakness and enlarged prostate with asymmetry/nodularity on DRE.

  • CBC shows anemia

  • PSA > 10 ng per L indicating intermediate risk or higher; repeat in 1 month for confirmation

  • Consider monitoring with yearly DRE and PSA every 3 to 6 months

  • Consider MRI for prostate visualization

  • Consider referral for 12-core prostate biopsy (sensitivity 80%) to determine Gleason score and quantify disease risk

  • Treatment per disease risk and Charlson comorbidity index

    • Low risk disease: Observation vs. active surveillance vs. brachytherapy

    • Intermediate risk: Treat as low vs. high risk s/p shared decision making

    • High risk prostate cancer: Consider treatment plan that may include

      • Androgen deprivation therapy with Lupron (leuprolide) depot 7.5 mg q monthly

      • External beam radiation therapy (EBRT) vs. radical prostatectomy

  • Refer to urology

  • Pt counseled about risks and benefits of observation vs. treatment

Notes

  • Epidemiology

    • Affects 1 in 7 men

    • 1 in 39 affected men will die from the disease (3rd most common cause of cancer-related death in men)

  • The reason for the debate about screening:

    • Treatment may not greatly change the course of the disease and will almost certainly result in undesirable adverse effects.

    • Patients who present with symptoms as described above (e.g. bony pain and LE weakness due to spinal cord compression) have metastatic disease and will likely not benefit from treatment.

  • Disease risk

    • Determined using a Gleason score (requires biopsy) and PSA level

    • Gleason scores range from 2 to 10

    • PSA

      • 10 ng per L or greater indicates intermediate risk or higher

      • 20 ng per L or greater indicates high risk

  • Adjusted life expectancy

    • Performed using Charlson Comorbidity Index with 1 point each for the following: HTN, chest pain, heart failure, MI, stroke, lung disease, GI ulcer, IBD, DM, depression

    • Do not treat very low or low risk patients if

      • 62+ years old with 3 or more comorbidities

      • 77+ years old with any comorbidities

  • Observation/treatment modalities

    • PSA rise >0.75 ng/dL in one year is concerning

    • Brachytherapy: Implanted radioisotopes (fewer adverse effects)

    • EBRT: Precision radiation of prostate (risk for urinary incontinence, erectile dysfunction, scarring of urethra/GI tract)

    • Radical prostatectomy: Removal of prostate that limits disease progression (almost certain urinary incontinence, ED)

Prostate cancer staging

Prostate cancer staging