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PATIENT STORY

A 55-year-old African-American man in relatively good health comes to the office after having had a prostate-specific antigen (PSA) test performed as part of a workplace health screening. He denies lower urinary tract symptoms, has normal erectile function, and denies weight loss and bone pain. He has no major medical problems, but his father and uncle had prostate cancer. His PSA is 9.3 ng/mL, and he chooses to have a prostate biopsy. Pathology demonstrates prostate cancer with a World Health Organization International Society of Urological Pathology (WHO-ISUP) Grade of 1 (Figure 75-1).

FIGURE 75-1

Microscopic image of biopsy demonstrating glands with enlarged nuclei and prominent nucleoli (hematoxylin and eosin [H&E] staining). The patient was diagnosed with prostate cancer with a Gleason grade of 1. (Reproduced with permission from E.J. Mayeaux, Jr., MD.)

INTRODUCTION

Prostate cancer (Figure 75-2) is the most common non-dermatologic cancer in men.1 The advent of PSA testing and resulting widespread use led to an increase in prostate cancer diagnosis. However, this proved controversial because of uncertain benefits and clear harms. Regardless, PSA testing remains a common test in the evaluation of male urogenital complaints. Once prostate cancer has been diagnosed in a patient, multiple factors such as Gleason score, PSA level, stage at diagnosis, and life expectancy are all considered in risk stratification and treatment options.

FIGURE 75-2

Photograph showing adenocarcinoma on the left lower side of the specimen and bilateral benign prostatic hypertrophy toward the top. (Reproduced with permission from E.J. Mayeaux, Jr., MD.)

EPIDEMIOLOGY

  • Prostate cancer is the third leading cause of cancer death in American men. In 2017 the estimated incidence of new prostate cancer cases in the United States was 161,360, with 26,730 prostate cancer–related deaths.1

  • The relative risk of prostate cancer is 74% higher in black males than non-Hispanic white males. While exact mechanisms are uncertain this is thought to be attributable to inherited susceptibility.1 In 2013, black men had the highest incidence rate of prostate cancer, followed by non-Hispanic white, Hispanic, American Indian/Alaskan Native, and Asian/Pacific Islander men (Figure 75-3).

  • Mortality risk is also greatest in black males. Although cancer deaths have been steadily decreasing since the early 1990s in men of all races, the death rate remains twice as high in black males as in any other group.1 Data from 2010–2014 demonstrate a prostate cancer death rate of 42.8 per 100,000 men in black males, compared with 18.7 per 100,000 in white males and 8.8 per 100,000 in Asian males.2

  • For non-Hispanic white males, the lifetime probability of developing invasive prostate cancer is 12.9%. Incidence increases with age, with the highest probability ...

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