Prostate Cancer James B. Benton,M.D.. Prostate Cancer Significant of the clinical problem Early detection/screening Prevention/Management.

Prostate Prostate Cancer Cancer James B. Benton,M.D.James B. Benton,M.D.

Prostate CancerProstate Cancer

• Significant of the clinical problem

• Early detection/screening

• Prevention/Management

Prostate CancerProstate Cancer

• 220,000 new case per year in US

• 380,000 cases projected in 2025

• 40,000 death per year

• Second largest cancer killer after lung cancer.

• Probably #1 in non-smokers.

• Lifetime risk of diagnosis of prostate cancer is 17%

• Lifetime risk of death from prostate cancer is 3.4%

• Autopsy series (22 -55% incidence of prostate cancer)

EpidemiologyEpidemiology• The incidence and mortality of prostate

cancer is quite varied among different populations

• The incidence rate among African Americans is 224/100,000 and American Indians..46/100,000

Epidemiology Cont’dEpidemiology Cont’d

• African-American men have the highest mortality in the world (54/100,000)

• A high mortality rate has also been noted in African heritage in Brazil , Jamaica, and in sub-Saharan Africans.

Epidemiology Cont’dEpidemiology Cont’d

• In 1990, 172,596 cases….33011 deaths

• 149,631 whites….25,281 deaths

• 17,417 blacks….5,181 deaths

• 4,291 Hispanics….727 deaths

• <400 Orientals….<70 deaths

• African American (AA) men historically presented with more advanced disease, and an increased death rate.

• Because of early detection and more aggressive treatments, survival may be equilibrating.

Age Specific PSAAge Specific PSA

Age PSA Age PSA

40 2.0 45 2.4

41 2.1 46 2.5

42 2.2 47 2.6

43 2.3 48 2.6

44 2.3 49 2.7

Age Specific PSA..cont’dAge Specific PSA..cont’d

Age PSA Age PSA

50 2.8 55 3.3

51 2.9 56 3.4

52 3.0 57 3.5

53 3.1 58 3.6

54 3.2 59 3.7

Age Specific PSA..cont’dAge Specific PSA..cont’d

Age PSA Age PSA

60 3.8 65 4.5

61 4.0 66 4.6

62 4.1 67 4.8

63 4.2 68 4.9

64 4.4 69 5.1

Age Specific PSA..cont’dAge Specific PSA..cont’d

Age PSA Age PSA

70 5.3 75 6.2

71 5.4 76 6.4

72 5.6 77 6.6

73 5.8 78 6.8

74 6.0 79 7.0

PreventionPrevention

• Restrict excessive fat and/or carbohydrates

• ?Vitamins/Minerals: Selenium and Vitamin E, and Lycopene

• Annual exam: DRE and PSA at age 40-50

• ? Hormonal…ie. Proscar

Prostate Cancer Prevention TrialProstate Cancer Prevention Trial

• 18,882 men: 55y/o or older: Finasteride(Proscar) or placebo; nl DRE and PSA <3.0: 7 year study

(Thompson NEJM…2003)• CAP developed in 24% of placebo and 18% proscar

(25% reduction)• High grade cancers in 22% of placebo and 37% of

proscar• Side effects: impotence with proscar

Prostate Cancer ScreeningProstate Cancer Screening

• Since introduction of the PSA in the 1980’s, there is evidence that prostate cancer mortality has decreased.

• In countries not using PSA testing, prostate cancer mortality continues to rise (Denmark, Mexico, and Sweden)

American Cancer Society Prostate Cancer American Cancer Society Prostate Cancer Screening GuidelinesScreening Guidelines

• Beginning at age 50, all men with a ten year life expectancy should be offered both PSA and DRE annually

• Men in high risk groups, such as African- Americans or those with a family history should start at age 45

ACS Guidelines Cont’dACS Guidelines Cont’d

• Men at an appreciably higher risk due to multiple first-degree relatives who were dx at an early age could begin at age 40

• If PSA < 1.0, no more until age 45

• If PSA 1.0 – 2.4, annual testing

• If PSA > 2.4, consider biopsy

American Urological Association American Urological Association GuidelinesGuidelines

• All men 50 or older with a ten year life expectancy

• Men 40 – 50 with first degree relative with prostate cancer or of African-American heritage background

• Exams: DRE and PSA

PSA Density and Free PSAPSA Density and Free PSA

• PSA density(PSAD): PSA value divided by the volume of the prostate gland: >0.15 considered abnormal.

• Free PSA: unbound PSA divided by bounded PSA: < 25% is considered abnormal

• Used as factors to determined the need for a biopsy when PSA is 4.0 – 10.0 range

Treatment OptionsTreatment Options

• Surgery• Simultaneous Radiotherapy• External Beam Radiotherapy alone• Seed Implants alone• Cryotherapy• Observation• Hormonal Ablation• ? Vaccines

Treatment cont’dTreatment cont’d

• Combined Radiation and Tumor-specific vaccine regimen.

• Chemotherapy: Doxil +/- hormonal therapy

SurgerySurgery

• Traditional Radical Prostatectomy

• Laparoscopic Prostatectomy

• Robotic Prostatectomy

RadiotherapyRadiotherapy

• Simultaneous: Seeds/XRT

• Sequentially: XRT/Seeds

• Seeds alone

• XRT alone: IMRT- Proton/Neutron/Photons

CryotherapyCryotherapy

• Freezing the prostate

• Limited experience

Hormonal TherapyHormonal Therapy

• Chemical

• Orchiectomy

ExperienmentalExperienmental

• Vaccines

• High energy microwaves therapy

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