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Prostate cancer

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Prostate cancer

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Malignant neoplasm of the prostate gland
 ( PCa is a widely used acronym to denote prostate cancer )

How common- Second most prevalent cancer in men worldwide ( Lung cancer is first ) Happens more in developed countries – incidence of PCa is less in Asian countries compared to Western nations In 2014 there were 46000 new diagnosis of PCa – this accounts for 13 % of all new cancers diagnosed ( NICE 2019 ) 1 in 8 men will get prostate cancer at some point in life More than 1/2 the cases of PCa in UK each year are in men aged 70 ( 2012 ) and over – incidence is highest in men aged 90 and over Mortality rate has been falling worldwide Inversely associated with deprivation with higher incidence in affluent areas in the UK

Risk factors-Age – affects predominantly older men Black ethnicity Family history Obesity High levels of dietary fat

Anatomy-The gland is about 3 cm long , about the size of a walnut and weighs approximately 20 gms About 2/3 rd is glandular and remaining 1/3rd is fibromuscular- cancer normally begins with a mutation in normal prostate glandular cells -usually starting with the peripheral basal cells Anatomical division

Histologically into 3 zones

Central
Transitional
Peripheral-Most cancers happen in the peripheral zone

This is the area which can be felt by a digital rectal examination

Presentation-Patients often asymptomatic ( early prostate cancer ) A raised PSA on screening / testing often the commonest cause which brings the patient to the attention of the physician LUTS symptoms – can also happen with benign prostatatic hyperplasia Also think of PCa in patients with problems with sexual function and performance e.g ED or painful ejaculation Advanced disease – can present with symptoms of metastasis

Prostate specific antigen ( PSA ) Serine protease- produced by the prostate gland and secreted into the seminal fluid Recognised biomarker for the diagnosis and monitoring of PCa Elevated PSA alone can identify PCa correctly only in about 25-30 % of time PSA test can also miss about 15 % of cancers About 3 in 4 men with a raised PSA will not have cancer PSA can be elevated without cancer for e.g in
○ benign prostatic hypertrophy
○ prostatitis
○ UTI PSA increases with age- regardless of cancer

Discuss the pros and cons of testing and give written advice Men older than 50 who request a PSA test Men with 
○ LUTS symptoms as nocturia , urinary frequency , hesitancy , urgency or retention
○ erectile dysfunction
○ visible haematuria
○ unexplained symptoms which could be due advanced disease for e.g LBP, bone pain , weight loss In the UK PSA testing screening is not a national policy In the US , PSA screening can be offered to men over the age of 50 with a life expectancy of atleast 10 yrs Men with increased risk of PCa can be tested from 45 yrs Prostate cancer UK also advice’s that if a man has no symptoms of a prostate problem and is clearly unlikely to live for less than 10 or more yrs – his GP or the practice nurse should advice him not to have a PSA test

when not to do the psa test –an active urinary infection ejaculated in previous 48 hrs exercised vigorously in previous 48 hrs had a prostate biopsy in previous 6 weeks



Digital rectal examination-Done routinely May detect abnormalities, asymmetry and suspicious hard nodules An abnormal DRE can detect 18-20 % of cancers Recommended by CKS and Prostate Cancer UK , NICE

Management –Specialists will guide the patient on diagnosis and management Most patients will undergo biopsy- which is US guided ( TRUS )- MRU- TRUS fusion guided biopsy is becoming more widely available now Gleason score is used to grade prostate tumours
score 6 or less – low grade
score 7 – intermediate grade
score 8-10 is high grade Treatment may include
◘◘ observation
◘◘ active surveillance
◘◘ androgen deprivation therapy
◘◘ external beam radiotherapy
◘◘ brachytherapy
◘◘ radical prostatectomy

NIE guidance on prostate cancer

References Prostate Cancer Stephen W Leslie et al StatPearls last Updated September 2019 BMJ Best Practice Prostate Cancer Systemic treatment for metastatic prostate cancer Gwenaelle Gravis – Asian Journal of Urology ( 2019 ) 6, 162-168 Dynamed Prostate Cancer Prostate cancer screening with prostate-specific antigen : A guide to the guidelines Sonja Cabarkapa et al prostate Int 4
( 2016 ) 125-129 Prostate Cancer UK www.prostatecanceruk.org CKS NHS Prostate Cancer Risk calculator -https://uroweb.org/prostate-cancer-risk-calculator-offers-men-individual-risk-assessment/ PCRMP Sheet- Advising well men aged 50 and over about the PSA test for prostate cancer : information for GPs NICE Prostate cancer diagnosis and management May 2019

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