Risk Factors and Assessment of Prostate Cancer

1
Risk Factors and Assessment of Prostate Cancer

• Andy Linsenmeyer MS III

2
Epidemiology

• Most commonly diagnosed visceral cancer
• 3rd most common cause of cancer death in men
• Represents 33 of cancers diagnosed annually

3
Risk Factors

• Age-most important
• Race and ethnicity
• Genetics
• Diet

4
Race and Ethnicity

• African American men have higher risk than white
  or Hispanic men
• African American men also have earlier age of
  onset, worse Gleason score, and more advanced
  stage at the time of diagnosis

5
Prostate cancer is more common in black men
SEER Database
6
Genetic Factors

• Double the risk if a first degree relative is
  affected (brother, father)
• 8q24 allele was found to confer a strong risk of
  developing prostate cancer
• BCRA 1/2 mutation increases risk 2-5 fold

7
Genome-wide association study identifies a second
prostate cancer susceptibility variant at 8q24

• 7 genetic risk factors on 8q24 reliably predicted
  ones probability of prostate cancer
• Almost all risk factors seen more frequently in
  African Americans
• Could explain higher rate of disease in African
  Americans

8
Dietary Factors

• High animal fat, low vegetable intake
• Ca and Vitamin D
• Possibly protective
• Selenium
• Vitamin E
• Zinc
• Soy intake

9
Age-specific (crude) SEER incidence rates by
'expanded' race for prostate cancer, males SEER
17 registries for 2000-2003
10
Clinical presentation

• Usually asymptomatic, diagnosed by elevated PSA
• Urinary urgency, nocturia, hesistancy, frequency
  more likely BPH
• Uncommon sx include new onset erectile
  dysfunction, hematuria, hematospermia, or
  symptoms of metastatic disease

11
Digital Rectal Exam

• Can detect tumors in lateral and posterior
  aspects of gland
• Those not detected include T1s and the 25-35 in
  other parts of the gland
• Areas of induration or frank nodules on digital
  rectal examination suggestive of cancer
• PPV of 5-30
• Consider biopsy even without elevated PSA

12
Anatomy
13
Physiology

• Secretes milky alkaline fluid to protect and
  nourish sperm
• 30-50 glands arranged into acini
• Free testosterone converted to DHT by 5 alpha
  reductase
• 2.5 time more potent than testosterone
• Binds to androgen receptor in glandular cells
  stimulating growth
• Divided into central, peripheral, and transition
  zones
• Peripheral zone contains 65 of glandular tissue
  and therefore cancer most commonly originates
  there

14
PSA

• Elevations can be caused by BPH most commonly,
  cancer, perineal trauma, prostatic inflammation,
• 1. PSAgt10
• Over 50 have cancer
• 24-50 percent increase in having extraprostatic
  spread
• BIOPSY

15
PSA

• 2. PSA 4-10
• Biopsy still recommended
• Lower specificity
• About 1 in 5 biopsies will reveal cancer
• PPV of about 20

16
PSA

• 3. PSAlt4
• In 3 studies of men 50 or older with prostate
  cancer, 43 had PSA values of lt4
• Higher likelihood of finding organ confined
  disease if PSA lt4
• Biopsy should be considered in men with PSA as
  low as 2.6 if rate of increase is gt.75
  ng/ml/year.

17
Diagnosis

• Biopsy is gold standard
• Transrectal, office procedure, ultrasound guided
• Either take 6 or 10-12 cores of tissue
• 10-12 cores associated with higher rates of
  detection

18
Staging

• Clinical staging-radionucliotide bone scan, CT
  scan, endorectal coil MRI
• Major means of determining prognosis and
  selecting therapy
• Gleason grade
• Analyzes tumor histology, rates it 1 (well
  differentiated) to 5 poorly differentiated and
  then sum scores
• TNM
• Assigned c or clinical stage and p or
  pathological stage
• T reflects size and location of tumor, N is nodal
  involvement, and M is metastasis

19
What treatment?

• Consider
• General medical condition
• Gleason score and PSA
• Clinical stage
• Outcomes of alternative treatment
• Side effects of treatment

20
General classes of therapy

• Surgery
• Radiation therapy
• Androgen deprivation therapy
• Active surveillance (watchful waiting)

21
Indications for Active Surveillance (ie watchful
waiting)

• Old man (over 70-75)
• Nonpalpable cancer
• PSA density lt0.15 ng/ml per gram
• Gleason scorelt6
• Cancer in less than half of biopsy cores

22
Indication for operation

• Radical prostatectomy, perineal prostatectomy,
  laparoscopic radical prostatectomy
• Significant morbidity
• Impotence, urinary incontinence
• RT vs Operation dependent on patient preference
• Younger men encouraged to have prostatectomy
  because of high recurrence risk with RT

23
Take Home Points

• Very common
• Age and African American race important risk
  factors
• PSA useful for diagnosis
• Best therapy dependent on patient to patient
  basis
• No consensus on whether RT or surgery is better