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Prostate cancer

Definition
Prostate cancer is a neoplastic disease arising from malignant transformation of cells within the prostate gland, of which adenocarcinoma is the most common subtype.
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Pathophysiology
Risk factors include advanced age, race (African black men, Caucasians), family history, exposure to radiation, UTIs, smoking, obesity, physical inactivity, diet factors (red meat, dairy protein, dietary fat), and elevated endogenous hormones (insulin-like growth factors).
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Epidemiology
The incidence of prostate cancer in the US is estimated at 123-183 cases per 100,000 person-years.
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Disease course
The progression of prostate cancer is impingent on activation of the androgen receptor nuclear receptor, and as such, treatment options for invasive disease rely on targeting this pathway. Progression to castrate-resistant prostate cancer is mediated by aberrant reactivation of the androgen receptor, as well as alterations in cell cycle pathways that result in uncontrolled proliferation.
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Prognosis and risk of recurrence
In men with localized prostate cancer, the 10-year disease-specific mortality ranges from 3% to 18%, depending on the risk category. In men with metastatic prostate cancer, the 5-year survival rate is estimated at 29.3%.
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Key sources
The following summarized guidelines for the evaluation and management of prostate cancer are prepared by our editorial team based on guidelines from the American Urological Association (AUA/SUO 2023), the Canadian Urological Association (CUA 2023), the European Society of Medical Oncology (ESMO 2023; 2020), the American Society of Clinical Oncology (ASCO 2023; 2022; 2021; 2020), the European Association of Urology (EAU 2023), the International Society of Urological Pathology (ISUP/EANM/SIOG/ESUR/EAU/ESTRO 2022), the American Urological Association (AUA/ASTRO 2022; 2019), the Canadian Urological Oncology Group (CUOG/CUA 2022), the American Urological Association (AUA/SUO/ASTRO 2021), the American Urological Association (AUA/ASTRO/ASCO 2018), the U.S. Preventive Services Task Force (USPSTF 2018), and the American Urological Association (AUA/ASCO 2009).
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Guidelines

1.Screening and diagnosis

Indications for screening, general considerations, SUO/AUA: engage in shared decision-making with persons eligible for prostate cancer screening and proceed based on the person's values and preferences.
B
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  • Indications for screening (general population, age < 54 years)

  • Indications for screening (general population, age 55-69 years)

  • Indications for screening (general population, age > 70 years)

  • Indications for screening (high-risk population)

  • Indications for screening (repeat screening)

2.Classification and risk stratification

Risk assessment, undiagnosed, SUO/AUA: consider using validated risk calculators to inform the shared decision-making process regarding prostate biopsy.
C

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  • Risk assessment (newly diagnosed, localized disease)

  • Risk assessment (newly diagnosed, advanced disease)

  • Staging

3.Diagnostic investigations

Prostate magnetic resonance imaging
As per AUA 2023 guidelines:
Consider obtaining prostate MRI before the initial biopsy to increase the detection of grade group ≥ 2 prostate cancer.
C
Use the PI-RADS system in the reporting of multiparametric MRI.
B

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  • Adjunctive biomarkers

  • Imaging for staging (clinically localized)

  • Imaging for staging (metastatic)

  • Germline testing (general indications)

  • Germline testing (positive family history)

  • Germline testing (metastatic disease)

4.Diagnostic procedures

Prostate biopsy, indications, SUO/AUA: perform targeted biopsies of the suspicious lesion
B
and consider performing a systematic template biopsy in biopsy-naïve patients with a suspicious lesion on MRI.
B
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  • Prostate biopsy (pre-biopsy evaluation)

  • Prostate biopsy (approach)

  • Prostate biopsy (antibiotics prophylaxis)

  • Prostate biopsy (technical considerations)

  • Prostate biopsy (reporting)

  • Prostate biopsy (counseling)

  • Prostate biopsy (repeat biopsy)

  • Molecular testing

5.Medical management

Management of local/locoregional disease, initial treatment, low-risk localized disease, ASTRO/AUA: offer active surveillance as the preferred management option in patients with low-risk localized prostate cancer.
A

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  • Management of local/locoregional disease (initial treatment, intermediate-risk localized disease)

  • Management of local/locoregional disease (initial treatment, high-risk localized disease)

  • Management of local/locoregional disease (initial treatment, locally advanced disease)

  • Management of local/locoregional disease (initial treatment, non-curative/palliative intent)

  • Management of local/locoregional disease (technical considerations for radical prostatectomy)

  • Management of local/locoregional disease (technical considerations for radiotherapy)

  • Management of local/locoregional disease (adjuvant therapy after radical prostatectomy)

  • Management of local/locoregional disease (salvage therapy)

  • Management of advanced/metastatic disease (evaluation)

  • Management of advanced/metastatic disease (general principles of management)

  • Management of advanced/metastatic disease (systemic therapy)

  • Management of advanced/metastatic disease (radiotherapy)

  • Management of advanced/metastatic disease (surgery)

  • Management of advanced/metastatic disease (management of metastases)

  • Management of castration-resistant prostate cancer (non-metastatic, pretreatment evaluation)

  • Management of castration-resistant prostate cancer (non-metastatic, surveillance)

  • Management of castration-resistant prostate cancer (non-metastatic, observation and androgen deprivation therapy)

  • Management of castration-resistant prostate cancer (non-metastatic, nonsteroidal antiandrogens)

  • Management of castration-resistant prostate cancer (non-metastatic, chemotherapy and immunotherapy)

  • Management of castration-resistant prostate cancer (metastatic, pretreatment evaluation)

  • Management of castration-resistant prostate cancer (metastatic, general principles of management)

  • Management of castration-resistant prostate cancer (metastatic, hormonal therapy)

  • Management of castration-resistant prostate cancer (metastatic, chemotherapy)

  • Management of castration-resistant prostate cancer (metastatic, PARP inhibitors)

  • Management of castration-resistant prostate cancer (metastatic, immunotherapy)

  • Management of castration-resistant prostate cancer (metastatic, radioligand therapy)

  • Management of castration-resistant prostate cancer (metastatic, prevention of skeletal-related events)

  • Management of castration-resistant prostate cancer (metastatic, surveillance)

  • Management of biochemical recurrence

6.Specific circumstances

Elderly patients: take into account individual life expectancy, health status, and comorbidities in the management of prostate cancer.
A
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  • Patients with premalignant lesions

7.Patient education

General counseling
As per AUA 2022 guidelines:
Counsel patients with prostate cancer that all treatment options carry risk. Incorporate the risks of treatment, in particular to the urinary, sexual, and bowel function, with the risk posed by cancer, patient life expectancy, comorbidities, preexisting medical conditions, and patient preferences in order to facilitate a shared decision-making approach to management.
B
Provide an individualized risk estimate of post-treatment prostate cancer recurrence in patients with prostate cancer.
B

8.Preventative measures

5-alpha reductase inhibitors: consider discussing the benefits of 5-ARIs for 7 years for the prevention of prostate cancer and the potential risks (including the possibility of high-grade prostate cancer) to be able to make a better-informed decision in asymptomatic males with a PSA level ≤ 3.0 undergoing regular screening with PSA or anticipating to undergo annual PSA screening for early detection of prostate cancer, as well as in patients taking 5-ARIs for benign conditions such as LUTS.

9.Follow-up and surveillance

Monitoring for progression, on active surveillance, ASTRO/AUA
Obtain serial PSA values and repeat prostate biopsy in patients with localized disease managed with active surveillance.
E
Obtain multiparametric MRI to augment risk stratification (but not to replace periodic surveillance biopsy) in patients selecting active surveillance.
E

More topics in this section

  • Monitoring for progression (after local treatment)

  • Monitoring for recurrence

  • Surveillance for osteoporosis

  • Multidisciplinary rehabilitation