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Prostate cancer

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OS AI Engine

Medicine > Renal

Background Knowledge ????

Definition

  • A malignant tumour that originates in the prostate gland.
  • Typically, it arises from prostatic acinar epithelial cells (accounts for up to 90% of cases).
  • For total new cases, prostate cancer is currently the 2nd most common cancer in the UK and 4th most globally (2022).

Epidemiology

  • Most common cancer in men in the UK (1 in 4 lifetime risk in Black men, 1 in 8 in White men).
  • 2nd most common cause of cancer-related death for men in the UK.
  • Risk increases with age, especially after age 50, with the disease most commonly diagnosed in the age group 65-69 years old.
  • Higher prevalence in the Black population and those with a family history.

Aetiology & Risk Factors

  • Increasing age: People aged 50 years old or over are at a higher risk.
  • Black ethnicity: Higher incidence has been recorded in the Black population when compared to the White population, though the cause for this is not clear.
  • Genetics: Germline mutations such as HOXB13 and BRCA2 implicated in development.
  • Despite the common belief of association, studies around BMI and prostate cancer often do not consider missed diagnosis, likely leading to biased results.

Types

  • Adenocarcinomas (most common type, arising from glandular cells):
    • Acinar adenocarcinoma: Arising from acinar epithelium (fluid-secreting), accounts for 90-95% of cases.
    • Ductal adenocarcinoma: Originating in primary and secondary prostatic ducts, accounts for 0.4-0.8% of all cases, but faster growing.
  • Transitional cell carcinoma: Starting from urothelium, accounts for 2-4% of cases.
  • Squamous cell carcinoma: Beginning in squamous cells covering the prostate, much faster growing than adenocarcinomas, 0.5-1% of cases.
  • Small cell/neuroendocrine prostate cancer: Rare and often diagnosed late-stage, arising from neuroendocrine cells of prostate, <2% of cases.
  • Sarcoma & lymphoma (rare, less than 0.1% each).

Clinical Features 🩺

Clinical Presentation

  • Often asymptomatic in early stages.
  • Lower urinary tract symptoms (LUTS): Urinary hesitancy, increased frequency, nocturia.
  • Erectile dysfunction.
  • Visible haematuria or haematospermia.
  • General symptoms: Lower back/bone pain, anorexia, lethargy.

Investigations 🔍

Tests

  • Digital rectal examination (DRE): Prostate may feel hard, with/without nodules, but a normal prostate doesn’t exclude tumour suspicion.
  • PSA testing: Elevated in prostate cancer, but non-specific (can also be seen in BPH, prostatitis and UTI) and can be raised from normal activity alone (e.g. vigorous exercise in past 48 hours).
  • Prostate biopsy: Transrectal/transperineal, ultrasound-guided; confirms diagnosis and grades the tumour.
  • MRI (mpMRI) and bone scans: Evaluate spread.

Staging

  • Based on TNM staging (advanced/metastatic will always be M1).
  • Grading is based on:
    • Gleason score: Based on biopsy sample histology, using the most common and highest tissue grades to score between 6-10 which describes speed of growth.
    • Grade Group: Using Gleason score, scores the likelihood of the cancer growing and spreading.
  • Localised, locally advanced, metastatic cancer categories dictate treatment.

Management 💊

Management

  • Depends on staging, grade, and patient’s health and age.
  • Localised: Radical curative therapy (e.g. radical prostatectomy) or active surveillance.
  • Locally advanced: Androgen deprivation & radiotherapy.
  • Metastatic: Androgen deprivation/chemotherapy or palliative care.
  • Radiotherapy includes external beam or brachytherapy, used for radical treatment.

Complications

  • Local invasion: Can lead to patient experiencing symptoms of LUTS, urinary retention, dysuria.
  • Bone metastasis: Most commonly metastasises to bones, leading to pain and risk of pathological fracture, along with spinal cord compression.
  • Other metastasis: Includes lymph nodes, lungs and liver.
  • Urinary incontinence and erectile dysfunction post-treatment.

Prognosis

  • Generally good survival rates for localised prostate cancer.
  • In metastatic prostate cancer, the five-year survival rate is ~49% (2022).
  • Depends on Gleason score, PSA levels, and stage at diagnosis.

Prevention

  • Due to the non-modifiable risk factors, prevention is centred more on early diagnosis and treatment.
  • Maintaining general health is always beneficial, particularly in those otherwise susceptible to developing cancers:
    • Smoking cessation.
    • Regular exercise.
    • Eat a well-balanced diet.

Key Points

  • Prostate cancer is a very common cancer, affecting up to 1 in 4 men in the Black population and is a leading cause of cancer-related deaths.
  • Risk factors are mostly non-modifiable, with age being the biggest contributor.
  • Adenocarcinomas account for the majority (90-95%) of cases.
  • Diagnosis made with mpMRI and prostate biopsy; grading uses Gleason score and Grade Groups based on biopsy.
  • Metastasises often to bone, but can also spread to lymph nodes, lung and liver.

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