Prostate cancer

doi:10.1016/j.mpmed.2015.10.001

Medicine

Volume 44, Issue 1, January 2016, Pages 47-51

https://doi.org/10.1016/j.mpmed.2015.10.001 Get rights and content

Abstract

Prostate cancer is a major health problem. In the UK, it is the commonest male cancer and the second commonest cause of male cancer death. Increasing age is its strongest predeterminant. Virtually all cancers are adenocarcinomas, the grade being indicated by the Gleason score. There are often no presenting symptoms. Investigations such as serum prostate-specific antigen, digital rectal examination, biopsy and, increasingly, magnetic resonance imaging (MRI) are required for diagnosis. Local staging consists of MRI, with computed tomography, bone scanning and, increasingly, positron emission tomography for detecting metastases. Management depends on disease stage, the patient's fitness and their wishes regarding treatment. Active surveillance is increasingly used for low-volume and low-grade cancers. For localized prostate cancer, radical prostatectomy can offer a cure. Curative treatment can be given as external-beam radiotherapy or brachytherapy. The survival rate at 10 years may be as high as 90% for a well-differentiated, localized prostate cancer. Hormonal therapy, which lowers or blocks testosterone, is used in locally advanced and metastatic disease. Hormonal therapy slows but does not cure metastatic disease. Cytotoxic chemotherapy is increasingly used for castrate-refractory prostate cancer and has recently been shown to significantly improve overall survival in hormone-naive patients with metastatic prostate cancer.

Section snippets

Epidemiology

Prostate cancer is a significant international health problem and the second leading cause of cancer death in men in the UK.¹ For men in developed countries, the lifetime risk of developing microscopic prostate cancer is 30%,² and of developing clinical disease is 13%.¹

In 2012, 43,436 men in the UK were diagnosed with prostate cancer.¹ The incidence is increasing; this is thought to be a result of greater disease awareness and increased detection due to the prostate-specific antigen (PSA) serum

Aetiology and risk factors

Several risk factors have been implicated. The most important are age, ethnicity and genetic factors.

Age: this is the strongest predetermining factor for the development of prostate cancer, which is increasingly common with advancing age. In the UK between 2009 and 2011, only 1% of cases were diagnosed in men under 50 years of age, with 36% of cases diagnosed in men aged 75 years and over.¹
Ethnicity: the highest incidences are found in African–American men and the lowest in Chinese men.
Familial:

Pathology

Over 95% of prostate cancers are adenocarcinomas; other less common types include sarcomas and neuroendocrine tumours. The majority (90%) of adenocarcinomas are acinar, with ductal carcinomas being less common. Characteristic prostate adenocarcinoma cells have hyperchromatic, enlarged nuclei with prominent nucleoli and abundant cytoplasm. The basal cell layer is absent in prostate cancer. Prostate cancer is often multifocal. About 70% of cancers are found in the peripheral zone, 20% in the

Grading and staging

Prostate cancer is graded using the Gleason system, which is based on the microscopic appearance of the glandular architecture of the prostate. A grade between 1 and 5 is given first to the most dominant pattern, and then to the second commonest pattern. The two grades are added together to give the Gleason score, which ranges from 2 to 10. The grade indicates the degree of glandular differentiation: grade 1 indicates a well-differentiated tumour, whereas grade 5 is a poorly differentiated

Diagnosis

Early low-grade prostate cancer is usually asymptomatic, unlike locally advanced or metastatic disease, which is usually symptomatic. Local growth can cause obstructive or irritative urinary symptoms, and metastatic spread can present with bone pain and even compression of the spinal cord. Patients may also present with systemic symptoms such as anorexia, weight loss and fatigue.

The main investigations used to diagnose prostate cancer are discussed below.

Prostate-specific antigen: many cases of

Other investigations

If a biopsy is positive for adenocarcinoma, a decision must be made regarding suitability for radical treatment before proceeding with additional investigations.

MRI: the role of MRI is evolving and MRI of the pelvic area (or CT if MRI is contraindicated) is recommended prior to treatment.⁴ This gives information about the local extension of the cancer and nodal involvement, which is important if radical prostatectomy or radiotherapy is planned.

Whole-body bone scintigraphy: this is recommended

Differential diagnosis

Induration of the prostate apparent on DRE is also associated with prostatitis, previous transurethral resection of the prostate, needle biopsy and prostatic calculi. The main differential diagnoses are BPH, prostatic calculi and prostatitis.

Management

Once staging investigations and biopsy have been performed the results should be reviewed in a multidisciplinary team (MDT) meeting attended by all the relevant teams (urology, oncology, radiology, histopathology, nurse specialists). The MDT will make a recommendation for treatment that will be discussed with the patient at their next consultation.

Prognosis

The survival rate at 10 years for a well-differentiated, localized prostate cancer is over 90%; for a poorly differentiated tumour it is 60% or less. Prostate cancer is one of the few solid cancers that is readily curable, if it is detected early. Metastatic disease remains incurable and a lethal illness for most men with this stage of disease.

Practice points

•
All cases should be discussed in a multidisciplinary team meeting before a treatment recommendation is made
•
Active surveillance is being

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