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This chapter addresses the following Curriculum Geriatric Fellowship Milestone: #19

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LEARNING OBJECTIVES

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Learning Objectives

  • List the risk factors for the development of prostate cancer.

  • Understand the screening recommendations for prostate cancer in older men.

  • Describe the treatment options for localized and advanced prostate cancer in older patients.

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Key Clinical Points

  1. There is no Food and Drug Administration (FDA)-approved treatment shown to reduce the risk of developing prostate cancer.

  2. Life expectancy and comorbidities should be considered before initiating prostate cancer screening.

  3. Localized prostate cancer in an older patient can be effectively treated with a range of therapies including watchful waiting, active surveillance, surgery, and/or radiation.

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EPIDEMIOLOGY AND RISK FACTORS

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Prostate cancer remains the most common noncutaneous malignancy diagnosed in American men and is the second leading cause of cancer-related deaths. Currently about 233,000 U.S. men per year are diagnosed with prostate cancer and about 29,000 U.S. men per year die of the disease.

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The only undisputed risk factors for prostate cancer are older age, African-American race, and positive family history. Prostate cancer is generally a disease of older men; risk increases exponentially with age, with a median age at presentation of 66 years. More than half of prostate cancer diagnoses and 90% of prostate cancer deaths occur in men older than 65. The incidence rates of the disease among African-American men are higher than rates for men in any other racial or ethnic background. African-American men are more likely to be diagnosed with prostate cancer and to die from it than their Caucasian counterparts. The estimated lifetime risk of prostate cancer is 17.6% and 20.6%, respectively for Caucasians and African-Americans, while the estimated lifetime risk of death is 2.8% and 4.7%. Early-onset prostate cancer may be inherited in an autosomal dominant fashion, and it is estimated that approximately 10% of all prostate cancer cases are hereditary. A large twin study suggests that genetic factors may account for as much as 42% of prostate cancer risk, although the absence of clear, highly penetrant markers suggests that in the majority of men, prostate cancer risk involves a complex interaction of multiple genetic and environmental factors.

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Additional factors such as diet, obesity, hormones, inflammation and sexually transmitted diseases, and occupational exposure have all been implicated in prostate carcinogenesis, but without consistent results. Dietary fat may be a risk factor for prostate cancer. Multiple epidemiologic, case-control, and cohort studies have suggested a moderate-to-strong increased risk of developing prostate cancer, particularly advanced disease, associated with total dietary fat, saturated fat, α-linolenic fatty acid, and cooked red meat. Two large prospective studies and a smaller case-control study suggest that fish intake may be protective, possibly owing to marine omega-3 fatty acids—known antagonists of arachidonic acid, which suppress the production of proinflammatory cytokines. Evidence for the association with dietary fat is further correlated with worldwide incidence patterns; prostate cancer is more common ...

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