Prostate cancer

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The most common cancer in men with in England and Wales producing second highest number of deaths of male cancer, causing 13% of all cancer deaths in men[1].

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Prostate cancer: diagnosis and treatment - NICE guidelines, 2014 are more comprehensive than this article and freely available]

Contents

Diagnosis

We could screen for it, if we had a reliable screening test, and we knew what best to do about it when we find it

  • Local disease is almost always diagnosed incidentally as a result of a presentation with prostatism
  • Metastatic disease is often diagnosed late and classically is manifest by bony spread
  • PSA screening without symptoms is a controversial area and international practice may vary. The main point is that early diagnosis by this means may not influence net morbidity or mortality.

Histology

Graded according to the Gleason grade.

Malignant cells with macronucleoli and loss of gland formation. Further histological pictures available at the Johns Hopkins pathology site

Genetics

There is a variation in the incidence of prostatic cancer between races. As a hormone sensitive cancer, one hypothesis is that the length of a CAG trinucleotide repeat may affect androgen receptor expression with shorter repeats showing a higher risk of cancer. A meta-analysis of this confirmed a small difference of only about 1 repeat and concluded that this is unlikely to have biological significance.[2]

There are additional associations with the pathways of androgen metabolism and growth factor expression. These include polymorphisms and mutations of the CYP17A1, CYP3A4, CYP19A1, SRD5A2, IGF1, and IGFBP3 genes.[3]

Prognosis

  • Local disease may be very good
    1. Low-risk men
    2. Intermediate risk men
    3. High-risk men

The Cancer research UK site gives prognostic and other information.[4] Prognosis is easily confounded by easily confounded by lead time bias and this can lead to ill informed assumptions based on analogy with other cancers without such bias[1].

Staging

Staging of disease in those where treatment decisions may alter, is a combination of isotope bone scan and prostate MRI. The order of investigation varies, but often bone scan generally first as metastatic disease would alter the requirement for local staging in most centres.

Treatment

  • Prostatectomy
  • Hormone manipulation
    • Most men with recurrent prostate cancer initially respond to androgen deprivation therapy
    • Long term androgen deprivation therapy increases risk atheroclerosis and cardiovascular disease.
  • Chemotherapy and radiotherapy

Advanced Disease

In metastatic castration-resistant prostate cancer a number of options:

References