ProstateCancer

Information about ProstateCancer

Published on January 14, 2008

Author: Tommaso

Source: authorstream.com

Content

Carcinoma of Prostate: issues of screening 2005:  Carcinoma of Prostate: issues of screening 2005 David R. Rudy, MD,MPH Professor in Chair, Family and Preventive Medicine Chicago Medical School/ RFUMS Preventive Medicine MTD 601 Relative significance of Prostate Ca :  Relative significance of Prostate Ca Tumor Incidence Cause specific mortality Lung 172,570 163,510 M:F =55%:45% CRC 145,290 56,290 Breast 212,930 40,870 Prostate 232,090 30,350 Jemal A, Tiwari RC, Murry T, Ward E , Samuels A, TiwariRC, Ghafoor A, Feuer EJ, Thun M: Cancer Statistics, 2005. CA: Cancer J. for Clin 2005; 55(1): 10-30 Case mortality prostate Ca:  Case mortality prostate Ca Prostate Ca deaths/US 2002 30,350 ÷ incidence/ US 232,090 = 13%; compare to 21% 1998 Ca Prostate: burden of suffering 1 (epidemiology, incidence):  Ca Prostate: burden of suffering 1 (epidemiology, incidence) Most common cancer in males (and pop.); second cause cancer death (men) after lung Incidence: 147.6/100,000/yr males), 1000/100,000/yr by age 80; 28,900 deaths 189,000 new expected US 2002:spurious increase due to increased screening during the 1980s (lead time bias)] Jemal A, et al: Cancer Statistics, 2002. CA - Cancer Journ Clin. 2002; 52(1): 23-45 Ca Prostate: burden of suffering 2 (mortality):  Ca Prostate: burden of suffering 2 (mortality) 15.7 /100,000/year mortality (1998) Case mortality increased nearly 20% from 1976 (22.1%) to 1994 (26.0%), possibly due to increasing life expectancy. Cause of mortality in 3.6% (i.e. lifetime risk of dying of Ca prostate, comparable to breast Ca deaths for women) Ca Prostate: burden of suffering 3 (geography, ethnicity):  Ca Prostate: burden of suffering 3 (geography, ethnicity) African-Americans: lifetime death risk is 66% higher in African Americans than white Americans (4.5% vs 3.6%), though lifetime incidence is only mildly higher than in whites (18.8% vs 18.5%) Ca Prostate:  Ca Prostate Pathophysiology: multicentric carcinoma of varying aggressiveness; increasingly incident and prevalent; decreasingly aggressive with age. Causation: incidence directly related to testosterone production. 2nd’y causes may include inadequate vegetables/fruit, vitamins D, A; also obesity. Ca Prostate: presentation (how discovered) (1) :  Ca Prostate: presentation (how discovered) (1) Prostatism (symptoms of obstruction), (Causes of prostatism = BPH, prostatitis, Ca) or finding a (stony hard palpable) nodule on DRE; > 50% have metastases; asymmetrical DRE finding; 50% have Ca; bone metastases; or screened w/ elevated PSA. CA prostate presentation 1A::  CA prostate presentation 1A: If PSA ≥ 4ng/mL once, 66% are organ confined; nearly 75% if screened by serial determinations for rate of rise, i.e. latter more sensitive; i.e., going from ≥ 1 ng/mL/yr. Prostatism::  Prostatism: the syndrome of urinary obstruction of varying degrees Nocturia, urgency, hesitancy, decreased size of stream; susceptibility to acute retention Causes: BPH, ± prostatitis, carcinoma Ca Prostate: presentation (2): staging:  Ca Prostate: presentation (2): staging A = non-palpable (always confined to one lobe) B = palpable, confined to capsule C = penetration of capsule, to seminal vesicles or bladder D = lymph node involvement D1 = without distant mets; D2 = distant mets, e.g. bone, lung Ca Prostate: presentation (3): Work-up:  Ca Prostate: presentation (3): Work-up PSA height correlates roughly with stage (see Table III - 6) IVP to r/o involvement of ureters, kidneys Cystoscopy to r/o bladder (contiguous) involvement Ca Prostate: presentation (4): Work-up:  Ca Prostate: presentation (4): Work-up Chest XR to r/o lung (i.e. distant) metastases Staging exploration lymphadenectomy (as many as 2/3 of cases initially diagnosed as stages A,B may become C or D after lymph exploration) Therapeutic approaches prostate Ca:  Therapeutic approaches prostate Ca Prostatectomy Irradiation Hormone (orchiectomy/estrogen) Ca prostate treatment 1: Organ confined:  Ca prostate treatment 1: Organ confined Patient < 70 y.o., life exp. 10 years or >: Radical prostatectomy Patient =/> 70 y.o., life expectancy < 10 years : Radiotherapy. Prognosis same as surgery for the first 10 years Patients =/> 70 y.o. with decreased life expectancy or w/ small, low grade cancer: Watchful waiting (Naitoh J et al: AFP 1998; 57:1131-39) Survival Ca Prostate:  Survival Ca Prostate 78% overall survival [Journal CA, 43(1)] (only 1/380 with histologic dx Ca prostate will die of it) Stage A 87% Stage B (5-10% of total) 81% Stage C 65% Stage D 30% [CA 1993 43(2)] Ca Prostate: prevalence in different settings:  Ca Prostate: prevalence in different settings 1% in a primary care practice 23% in a urologist’s practice 33% of men over the age of 50; 50% in 70 y.o. 70% by 80 y.o. (autopsy studies, i.e. indolent) (Guide to Clinical Preventive Services, 1989) Ca Prostate: burden of suffering 6 (geography, ethnicity):  Ca Prostate: burden of suffering 6 (geography, ethnicity) -much less frequent in Asians. Japanese men have less Ca prostate but Japanese-American men’s rates approximate those of other American men. Pathophysiology 1::  Pathophysiology 1: Carcinoma of prostate produces increased serum PSA (normal upper limit 4.0 ng/mL, rising normally with age or size of gland as in BPH PSA elevation is lacking in 20% ± of cases (but less if rate if rise or proportion of bound PSA are considered) Pathophysiolgy 2::  Pathophysiolgy 2: Ca exists in proportion to proportion of BOUND PSA. Corollary: PSA in carcinoma of prostate occurs in lesser proportion as FREE form (unbound). a cutoff of < 27% free PSA 2.6-4.0 allows 90% sensitivity, 18% specificity (avoid bx in 18%: Cutoff of < 25% in patients with 4 -10 ng/mL allows 95% sensitivity, 20% specificity: Cataloña: J.A.M.A. 1997; 277: 1452-55 Dx 3: PSA sens. (> 4.0 ng/mL) by stage of prostate cancer:  Dx 3: PSA sens. (> 4.0 ng/mL) by stage of prostate cancer Stage A: 38.0% Stage B 52.2% Stage C 68.4% Stage D 79.9% from USN Hosp Great Lakes Lab 1997 (Table III - 6, Syllabus] Ca prostate screening/ diagnosis 1: PSA:  Ca prostate screening/ diagnosis 1: PSA PSA elevation (> 4ng/mL) is =/>80% sensitive for prostate cancer, and 90% specific ±. Thus, with average risk there are many false positives Thus, PSA not an ideal screen test Ca prostate diagnosis 2: PSA :  Ca prostate diagnosis 2: PSA Normal PSA defined according to age group. (See Table III-7): 40-49 years: 0.0-2.5 ng/mL (median 0.7) 50-59 years: 0.0-3.5 ng/mL (median 1.0) 60-69 years: 0.0-4.5 ng/mL (median 1.4) 70-79 years: 0.0-6.5 ng/mL (median 2.0) (Oesterling et al: J.A.M.A. 1993; 270: 860-64) Another criterion: rise PSA > 0.7 ng/mL/yr Ca prostate Dx ::  Ca prostate Dx : Percent of free PSA < 27% Free PSA < 10% carries 56% risk of carcinoma Free PSA > 25% cuts risk to 8% “Free PSA measurement is most useful when total PSA = 4 -10 ng/mL Cataloña et al: Patient Care 1998; Sept 30: 58-83 Ca prostate diagnosis 4: Spurious causes of PSA elevation: :  Ca prostate diagnosis 4: Spurious causes of PSA elevation: cystoscopy, prostate biopsy, prostate massage, prostatitis, urethral instrumentation; large volume of gland as in BPH Criteria for screenability satisfied?:  Criteria for screenability satisfied? 1. Condition has significant effect on life (yes) 2. Treatment available (sort of) 3. Asymptomatic period of diagnoseability (yes) 4. Treatment in asymptomatic yields result superior to delaying until symptoms appear (maybe) 5. Tests of reasonable cost- sensitivity and specificity appropriate for population risk (not perfect) 6. Incidence sufficient to justify cost (yes) Screening recommendations for prostate Ca, conservative view::  Screening recommendations for prostate Ca, conservative view: ACS (June 6, 1997) and NCI: annual DRE from the age of 50 if life expectancy of at least 10 years); at 45 years of age for those at high risk (≥ 2 1st degree relatives with prostate cancer, African-American). Urological association = same except start at 40 y.o. Ca prostate Screening, liberal (aggressive) view::  Ca prostate Screening, liberal (aggressive) view: PSA screening annually recommended when: 1. male> 50 y.o., < 75 y.o. 2. > 40 y.o. African American male 3. male > 35 y.o. if 1st degree F.H. Ca prostate x 3 at early ages If 2.5- < 4- ng/mL, check q 6 mo. If 4 -10, obtain free PSA; if ≤ 25, biopsy Ca prostate Dx 5: Indications for Biopsy::  Ca prostate Dx 5: Indications for Biopsy: Abnormal DRE Elevated PSA [> 4] PSA for age (e.g. > 2.5 for < 50 y.o.; > 3.5 for < 60 y.o.) Percent of free PSA {< 27%} Rate of rise with age{≥ 0.7/yr}) Ca prostate Dx 5 A: Other Indications for Biopsy::  Ca prostate Dx 5 A: Other Indications for Biopsy: PSA 4 -10 ng/mL with free PSA < 25% PSA > 10 ng/mL! Cataloña et al: Patient Care 1998; Sept 30: 58-83 Ca prostate definitive diagnosis::  Ca prostate definitive diagnosis: Transrectal ultrasonic study Transurethral resection biopsy Transrectal biopsy Therapy of Ca Prostate 1: stages A or B:  Therapy of Ca Prostate 1: stages A or B Patient < 70 y.o., life exp 10 years or >: Radical prostatectomy Patient =/> 70 y.o., life exp 10 years or >: Radiotherapy. Prognosis same as surgery for the first 10 years Patients =/> 70 y.o. with decr. life expectancy or w/ small, low grade cancer: Watchful waiting Therapy of Ca Prostate 2: Stages C or D::  Therapy of Ca Prostate 2: Stages C or D: Testosterone deprivation: i.e., orchiectomy, estrogen therapy Irradiation of prostate (49%) or of pelvic nodes f/b prostate (45.5%) Complications of Radical Prostatectomy 1: Impotence:  Complications of Radical Prostatectomy 1: Impotence 40-50 years: 0 % 51-60 years: 45% 61-70 years: 57% > 70 years: 100%: Complications of Radical Prostatectomy 2: Incontinence :  Complications of Radical Prostatectomy 2: Incontinence None: 81.5% Mild: (one pad/d) : 14% Moderate (multiple pads): 3% Severe (total): 1.5%

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