prostate%20cancer
PROSTATE CANCER

Prostate cancer is the cancer that occurs in the male's prostate.

It is the most common cancer in men >50 years of age.

Signs and symptoms include weak urinary stream, polyuria, nocturia, hematuria, erectile dysfunction, pelvic pain, back pain, chest pain, lower extremity weakness or numbness and loss of bowel or bladder control.

Monitoring

Observation

  • Based on the premise that it may be more beneficial to provide palliative therapy at the time when local or metastatic progression occurs
  • Management option for:
    • Patients who prefer not to undergo treatments
    • Elderly men or immunocompromised patients with comorbidities and/or poor prognostic features
    • Patients who will not benefit but will only incur harm from definitive treatments
  • Preferred for patients with low risk prostate cancer with life expectancy of <10 years
  • Recommended for patients with non-metastatic castration-resistant prostate cancer (CRPC), with continued androgen deprivation therapy
  • Includes monitoring of prostate-specific antigen (PSA) and digital rectal examination (DRE) every 6 months

Advantages:

  • Potential harm from different unnecessary therapies may be avoided

Disadvantages:

  • Increases the risk for urinary retention and pathologic fracture

Active Surveillance

  • Watchful waiting while actively monitoring the disease course to be able to intervene when the disease progresses
  • Preferred for patients with very low-risk prostate cancer with life expectancy of <20 years
  • Treatment option for those with low-risk localized disease and candidates for radical prostatectomy or radiotherapy
    • May also be suggested to asymptomatic patients, elderly men, and those with comorbidities

Inclusions:

  • Initial: Multiparametric MRI (mpMRI)  if not performed previously
  • 1st year: Monitoring of  prostate-specific antigen (PSA) every 3-4 months and digital rectal examination (DRE) every 6-12 months, and repeat prostate biopsy at 12 months
    • Repeat needle biopsy within 6 months from initial diagnosis is indicated for patients with <10 cores
    • Repeat biopsy may not be performed if the life expectancy is <10 years
  • 2nd-4th year: Prostate-specific antigen (PSA) monitoring every 3-6 months and digital rectal examination (DRE) every 6-12 months
  • 5th year and yearly thereafter: Prostate-specific antigen (PSA) every 6 months and digital rectal examination (DRE) every 12 months
  • Prostate-specific antigen (PSA) kinetics (doubling time and velocity) should be monitored all throughout active surveillance duration

Advantages:

  • Potential harm from different treatment modalities may be avoided
  • Patient may go back to their normal activities and may retain present quality of life
  • Smaller/undiagnosed malignancies will remain therapy-naive, thereby preventing future treatment resistance
  • Expenses may be reserved for more definitive treatments

Disadvantages:

  • Chance for early treatment and cure may be missed
  • High propensity for disease progression and metastasis
  • Tumor size may increase, making surgery and medical management more difficult
  • Preservation of function may be more difficult for more aggressive and bigger tumors
  • Increased anxiety due to untreated malignancy and uncertainty of disease progression
  • Intermittent monitoring with diagnostics and clinic visits are required

Follow Up

Local Recurrence

  • Initial prostate-specific antigen (PSA) levels of >0.2 ng/mL and subsequent confirmatory levels of >0.2 ng/mL signifies biochemical recurrence
  • Endorectal ultrasound may be considered to rule out recurrence after radical prostatectomy

Follow-up Examinations

Prostate-Specific Antigen (PSA) Monitoring

  • Prostate-specific antigen (PSA) levels should be significantly lower after radical prostatectomy, radiation therapy, cryotherapy and other treatments
  • Should be done every 3-6 months x 5 years, then every 6-12 months x 5 years, then annually

Digital Rectal Exam (DRE)

  • Timing of DRE after radiotherapy: Every 6-12 months
  • Timing of DRE after radical prostatectomy: Every 1-3 years

Bone Scan

  • May be done if prostate-specific antigen (PSA) levels rise after local therapy
  • Bone densitometry measurement by dual-energy x-ray absorptiometry (DEXA) scans should be obtained regularly especially in patients at high risk for skeletal side effects and for monitoring of treatment response to Denosumab or bisphosphonates

Computed Tomography (CT) Scan/Magnetic Resonance Imaging (MRI) Scan

  • May be considered if the following occurs after radical prostatectomy:
    • Prostate-specific antigen (PSA) levels still detectable
    • Previously undetectable prostate-specific antigen (PSA) is suddenly detected
    • Recorded prostate-specific antigen (PSA) increases in >2 prostate-specific antigen (PSA) level examinations
    • Increasing prostate-specific antigen (PSA) or positive digital rectal examination (DRE) after radical prostatectomy
  • Spinal magnetic resonance imaging (MRI) to detect cord compression is recommended in castration-resistant prostate cancer (CRPC) patients with vertebral metastases and neurological symptoms

Castration-Resistant Prostate Cancer (CRPC)

  • Recurrence or disease progression despite medical or surgical castration
  • Criteria for defining castration-resistant prostate cancer (CRPC):
    • Prostate-specific antigen (PSA) progression [prostate-specific antigen (PSA) level >2 ng/mL, listed 3 consecutive increases 1 week apart, resulting in 25% increase over the nadir value]
    • Serum testosterone levels <50 ng/dL or <1.7 nmol/L
    • Anti-androgen withdrawal of >4-6 weeks

 

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