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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
There is no Food and Drug Administration (FDA)-approved treatment shown to reduce the risk of developing prostate cancer.
Life expectancy and comorbidities should be considered before initiating prostate cancer screening.
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 248,000 US men per year are diagnosed with prostate cancer and about 34,000 US 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 White counterparts. The estimated lifetime risk of prostate cancer is 17.6% for White and 20.6% for 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. Approximately 10% of all prostate cancer cases are hereditary, with an onset 6 to 7 years earlier than nonhereditary cases. Several germline mutations such as BRCA1/2, HOXB13, or ATM may also identify families at high risk. BRCA1/2 germline mutations are present in up to 6% of unselected prostate cancer patients. The prospective Identification of Men With a Genetic Predisposition to Prostate Cancer targeted screening study confirmed a higher incidence of prostate cancer, at a younger age and with more clinically significant tumors, only in BRCA2 mutation carriers compared with noncarriers.
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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. ...