Prostate Cancer

Key Features

Essentials of Diagnosis

• Prostatic induration on digital rectal examination (DRE) or elevated level of serum prostate-specific antigen (PSA)

• Most often asymptomatic

• Rarely, systemic symptoms (weight loss, bone pain)

General Considerations

• Most common cancer detected in American men

• Second leading cause of cancer-related death in men

• In 2020 in the United States, an estimated 191,930 new cases of prostate cancer were diagnosed and 33,330 deaths resulted

• At autopsy, > 40% of men aged > 50 years have adenocarcinoma of the prostate, most often occult

• Incidence increases with age: autopsy incidence is ~30% of men aged 60–69 years versus 67% of men aged 80–89 years

• Risk factors

  • African American race

  • Family history of prostate cancer

  • History of high dietary fat intake

• A 50-year-old American man has lifetime risks of 40% for latent cancer, of 16% for clinically apparent cancer, and of 2.9% for death from prostate cancer

• Majority of prostate cancers are adenocarcinomas

Clinical Findings

Symptoms and Signs

• Most prostate cancers are asymptomatic

• However, some cases will be diagnosed based on discrete nodules or areas of induration within the prostate on a DRE

• Obstructive voiding symptoms

• Lymph node metastases

• Lower extremity lymphedema

• Back pain or pathologic fractures

• Rarely, signs of urinary retention (palpable bladder) or neurologic symptoms as a result of epidural metastases and spinal cord compression

Diagnosis

Laboratory Tests

• The serum PSA level is typically low and correlates with the total volume of prostate tissue and tends to increase with age

• Measurement of serum PSA is useful in

  • Detecting and staging prostate cancer

  • Monitoring response to treatment

  • Identifying recurrence before it becomes clinically evident

• As a screening test, PSA is elevated (> 4.0 ng/mL [4.0 mcg/L]) in 10–15% of men

• Approximately 18–30% of men with PSA 4.1–10 ng/mL (4.1–10 mcg/L) and 50–70% of men with PSA > 10 ng/mL (10 mcg/L) will be diagnosed with prostate cancer

• Patients with PSA < 10 ng/mL usually have localized and therefore potentially curable cancers

• Interestingly, approximately 20% of patients who undergo radical prostatectomy for localized prostate cancers have normal levels of PSA

Imaging Studies

• Transrectal ultrasound (TRUS): most prostate cancers are hypoechoic

• MRI of the prostate

• CT imaging can be useful in detecting regional lymphatic and intra-abdominal metastases

• Conventional radionuclide (99-technetium) bone scan is recommended for patients with a PSA level > 20 ng/mL

• PET (eg, ¹⁸F-sodium fluoride [¹⁸F-NaF] PET) and hybrid [¹⁸F-NaF] PET/CT imaging appear to be more sensitive than conventional bone scans

• PET imaging using fluciclovine (Axumin) has been approved for suspected cancer recurrence based on elevated PSA after prior treatment

• Small molecules targeting PSMA (prostate-specific membrane antigen) also show significant promise as ...