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.

Prostate%20cancer Management

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, thereby maintaining quality of life
    • Also prompts a change in diagnostic tests when symptoms suggest disease progression
  • 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 very low-risk or 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

Advantage

  • Potential harm from different unnecessary therapies may be avoided

Disadvantage

  • 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, delaying the potential side effects of treatments
  • Recommended for patients with very low-risk prostate cancer with life expectancy of 10-20 years
    • Preferred in patients with very low-risk prostate cancer with life expectancy of ≥20 years
  • Recommended for patients with low- and favorable intermediate-risk prostate cancer with life expectancy of ≥10 years
  • Criteria for the use of active surveillance include: Clinical stage T1c or T2a, grade group 1, <3 positive cores with ≤50% cancer involvement in any core, PSA <10 ng/mL, PSA density <0.15 ng/mL/g
    • Decision to use active surveillance should not be based solely on above criteria 
  • 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
  • Presence of any of the following pathology should prompt exclusion for active surveillance: Predominant ductal carcinoma, sarcomatoid carcinoma, small cell carcinoma, EPE or LVI in needle biopsy, perineal invasion

Inclusions

  • Initial: Multiparametric MRI (mpMRI) if not performed previously
  • 1st year: Monitoring of PSA every 6 months and DRE, prostate biopsy and mpMRI 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: PSA monitoring every 3-6 months and DRE every 6-12 months
  • 5th year and yearly thereafter: PSA every 6 months and DRE every 12 months
  • 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 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

  • 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 EBRT or radical prostatectomy: Annual

Bone Scan

  • May be done if 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:
    • PSA levels still detectable
    • Previously undetectable PSA is suddenly detected
    • Recorded PSA increases in >2 PSA level examinations
    • Increasing PSA or positive DRE after radical prostatectomy
  • Spinal MRI to detect cord compression is recommended in CRPC patients with vertebral metastases and neurological symptoms
  • For patients without any evidence of metastases, the following imaging studies may be considered:
    • For further soft tissue and bone evaluation: C-11 choline PET/CT, PET/MRI, F-18 fluciclovine PET/CT or PET/MRI
    • For further bone evaluation: F-18 sodium fluoride PET/CT or PET/MRI

Gallium 68-PSMA PET/CT Scan  

  • Has comparable sensitivity and specificity with other FDA-approved imaging agents in detecting recurrences at lower PSA levels 
  • Has good sensitivity in prostate cancer restaging
  • Useful in identifying CRPC and in predicting response to therapy

Castration-Resistant Prostate Cancer (CRPC)

  • Recurrence or disease progression (clinical, radiographical or biochemical) despite medical or surgical castration
  • Criteria for defining CRPC:
    • PSA progression [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

Salvage Treatments

  • Salvage radiotherapy is a treatment option for patients with increasing PSA levels after radical prostatectomy and no presence of distant metastasis; should be given once biochemical recurrence has been confirmed
    • May consider hormone therapy if PSA is 0.20 ng/mL postoperatively
  • Salvage radical prostatectomy may be used for patients with treatment failure after radiotherapy

 

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