Prostate Cancer

1. Epidemiology
   1. Histologic evidence of Prostate Cancer on autopsy
      1. Men over age 50 years: 30%
      2. Men over age 80 years: 70%
   2. Clinical Incidence
      1. Incidence (2007 in U.S.): 218,890 new cases
      2. Incidence tripled in 10 years prior to 1997 (PSA detection)
      3. Lifetime diagnosis occurs in 17% of men
   3. Mortality
      1. Second leading cause of cancer death in men (Second to Lung Cancer)
      2. However, only 3% of men die of Prostate Cancer (27,050 deaths per year in U.S.)
2. Risk Factors
   1. Age (Incidental finding on Autopsy)
      1. Age 50 years: 30% incidence Prostate Cancer
      2. Age 60 years: 35% incidence Prostate Cancer
      3. Age 70 years: 40% incidence Prostate Cancer
      4. Age 80 years: 55% incidence Prostate Cancer
      5. Age over 90 years: 100% incidence Prostate Cancer
   2. Ethnicity
      1. Black Men: 64 per 100,000 (confers twice risk of caucasian men)
      2. Caucasian Men: 26 per 100,000 (confers twice risk of asian men)
      3. Lower risk ethnicity: Asian and hispanic
   3. Family History (Relative risk of Prostate Cancer)
      1. First degree relative with Prostate Cancer: Relative Risk of 2.5 to 3
      2. Brother with Prostate Cancer before age 63: Relative Risk of 4
      3. Sister with Breast Cancer: Relative Risk of 2
      4. Other Family History that increases Prostate Cancer risk
         1. More than one first degree relative is affected
         2. Affected relative was under age 55 at diagnosis
   4. Miscellaneous risk factors
      1. Vitamin E Supplementation (400 units/day)
         1. Prostate Cancer risk increases 1 new case in 625 men
         2. Klein (2011) JAMA 306:1549-56.
   5. Factors not with additional cancer risk
      1. Ejaculation frequency not associated with cancer risk
      2. Leitzmann (2004) JAMA 291:1578-86
3. Screening
   1. Frequency
      1. Annual exam for men aged 50 years and older
      2. Annual exam for high risk men aged 40 years and older
      3. Screening can stop when age >75 (USPSTF) or when <10 years life expectancy (ACS/AUA)
         1. See Charlson Comorbidity Index (CALE)
   2. Testing
      1. See Prostate Specific Antigen (PSA)
      2. Digital Rectal Exam (evaluate for asymmetry, nodularity)
         1. Test Sensitivity: <60%
         2. Test Specificity: >83%
         3. Positive Predictive Value: <28%
         4. Summary: Poor efficacy with high false positive and false negative rate
         5. Hoogendam (1999) Fam Pract 16(6): 621-6
4. Diagnosis
   1. Transrectal Ultrasonography-guided Prostate biopsy
      1. Biopsy cores (6-12 are taken)
         1. Twelve cores are significantly more sensitive than 6 without increased complication risk
         2. Eichler (2006) J Urol 175(5): 1605-12
5. Classification
   1. See Prostate Cancer Staging (TNM)
   2. See Prostate Cancer Histologic grading (Gleason Score)
6. Complications: Metastasis
   1. Spine Metastasis (90% of Prostate Cancer metastasis)
      1. Involves Vertebral Column in 85% of cases
      2. Most often affects lumbar spine
      3. Identified 19 months from initial diagnosis
      4. Recurrence is common (45% risk within 2 years)
   2. Lung Metastasis (50% of Prostate Cancer metastasis)
      1. Identified 35 months from initial diagnosis
   3. Liver Metastasis (25% of Prostate Cancer metastasis)
   4. Brain Metastasis (rare)
      1. Identified 60 months from initial diagnosis
      2. Poor prognosis (average survival 7.6 months)
   5. References
      1. Benjamin (2002) Am Fam Physician 65(9): 1834-40
7. Management
   1. See Prostate Cancer Management
8. Prevention: Possibly Protective Factors
   1. Exercise (walking)
   2. Soy Protein
   3. Flaxseeds (Phytoestrogens)
   4. Lycopones (tomatoes)
   5. Selenium
   6. Green Tea
   7. Vitamin D Supplementation
   8. Calcium Supplementation
   9. Garlic
   10. PC-SPES
   11. Grape seed extract
   12. Zinc
9. References
   1. Cooner (1994) Am Fam Physician
   2. Wilbur (2008) Am Fam Physician 78(12): 1377-84