History

Fact Explanation
Hesitancy (difficulty initiating the stream) , poor and/or intermittent stream, straining, prolonged micturition, feeling of incomplete bladder emptying, dribbling [1] Voiding or obstructive type of lower urinary tract symptoms (LUTS) due to bladder outflow obstruction caused by enlarged prostate [1]
Frequency, urgency (compelling need to void that cannot be deferred), urge incontinence (sudden and strong need to urinate which cannot be controlled) and nocturia (voiding at night) [1] Storage or irritative symptoms of LUTS due to secondary detrusor instability causing an overactive bladder [2]
Hematuria [1] Gross hematuria / microscopic hematuria can be a result of cancer itself, a side effect of previous treatments (acute or chronic toxicity of radiotherapy, stone formation on a suture after surgery) [1]
Progressive back pain [2] Prostate can be spread to bones ( lumbar vertebrae through venous plexus, hip/ pelvic bones) . Back pain occur due to bone metastasis [2]
Numbness of feet [2] Lower extremity neurologic impairment can occur due to bone metastasis [2]
Old age [1] Prostate cancer is very rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. About 6 in 10 cases of prostate cancer are found in men over the age of 65 [1]
Family history of prostate cancer [1] Prostate cancer seems to run in some families, which suggests that in some cases there may be an inherited or genetic factor. Some inherited gene changes raise the risk for more than one type of cancer. For example, inherited mutations of the BRCA1 or BRCA2 genes are the reason that breast and ovarian cancers are much more common in some families. Mutations in these genes may also increase prostate cancer risk in some men, but they account for a very small percentage of prostate cancer cases. [2]
Incidental discovery [1] Some countries have prostate cancer screening programmes as prostate cancer is a common cancer in men, with a lifetime prevalence of 17 percent. Prostate cancer symptoms generally occur in advanced stages, making early detection desirable. Digital rectal examination and prostate-specific antigen testing are the most commonly used screening tools. Some patients detect the cancer incidentally due to prostatic resection for benign prostatic hyperplasia ( biopsy report) [1]
References
  1. WILBUR J. Prostate cancer screening: the continuing controversy. Am Fam Physician [online] 2008 Dec 15, 78(12):1377-84 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19119557
  2. NAITOH J, ZEINER RL, DEKERNION JB. Diagnosis and treatment of prostate cancer. Am Fam Physician [online] 1998 Apr 1, 57(7):1531-9, 1541-2, 1545-7 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9556643

Examination

Fact Explanation
Digital rectal examination [1] Prostate is enlarged, asymmetric, nodular, or tender. A firm nodule, generalized nodularity, and asymmetry are more concerning; whereas, symmetric enlargement is common in aging men [1]
Neurological examination [2] Lower extremity neurological impairment (low power, reduced sensation) occur due to bone metastasis (Spinal cord compression caused by metastasis) [2]
References
  1. WILBUR J. Prostate cancer screening: the continuing controversy. Am Fam Physician [online] 2008 Dec 15, 78(12):1377-84 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19119557
  2. NAITOH J, ZEINER RL, DEKERNION JB. Diagnosis and treatment of prostate cancer. Am Fam Physician [online] 1998 Apr 1, 57(7):1531-9, 1541-2, 1545-7 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9556643

Differential Diagnoses

Fact Explanation
Benign prostatic hyperplasia [1] Present with lower urinary tract symptoms. Digital rectal examination- Enlarged prostate,firm and smooth without nodules. The median sulcus should be clearly defined. Elevation of PSA is not as high as in prostate cancer most of the time. [1]
Prostatitis [1] Fever, suprapubic or low back pain, along with the presence of a tender, enlarged prostate gland is consistent with prostatitis. Supportive investigation results include leukocytosis, presence of an abnormal urinary sediment; elevation of PSA may also be noted [1]
References
  1. WILBUR J. Prostate cancer screening: the continuing controversy. Am Fam Physician [online] 2008 Dec 15, 78(12):1377-84 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19119557

Investigations - for Diagnosis

Fact Explanation
Prostate specific antigen (PSA) [1] PSA as a serum marker that is 70 to 80 percent sensitive for prostate cancer.However, the PSA test is not very specific, since only one third of men with an abnormal serum PSA level actually have cancer. Low-risk: PSA < 10 Intermediate-risk: PSA 10-20 High-risk: PSA > 20 [1]
Trans rectal ultra sound scan (TRUS) [2] To identify the prostatic enlargement, solid areas and the echogenicity. Almost all prostate carcinomas arise in the outer gland. The outer gland is located in the posterior, lateral, and apical portions of the gland. This is fortuitous, as these portions s of the gland are most easily imaged by TRUS [2]
References
  1. NAITOH J, ZEINER RL, DEKERNION JB. Diagnosis and treatment of prostate cancer. Am Fam Physician [online] 1998 Apr 1, 57(7):1531-9, 1541-2, 1545-7 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9556643
  2. MURRAY DJ, COOPERBERG PL, GOLDENBERG SL, TOI A. Transrectal Ultrasound of Prostatic Carcinoma: A new way to evaluate benign and malignant conditions Can Fam Physician [online] 1991 Jun:1479-1483 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2145402

Investigations - Fitness for Management

Fact Explanation
X ray lumbar spine [1] Plain radiographs (X-rays) demonstrate characteristic osteoblastic lesions in lumbar vertebrae due to bone metastasis [1]
Serum creatinine [1] Serum creatinine determination to evaluate renal function as urinary obstruction can give rise to kidney damage [1]
Serum electrolytes [1] To evaluate renal function as urinary obstruction can give rise to kidney damage [1]
References
  1. NAITOH J, ZEINER RL, DEKERNION JB. Diagnosis and treatment of prostate cancer. Am Fam Physician [online] 1998 Apr 1, 57(7):1531-9, 1541-2, 1545-7 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9556643

Investigations - Followup

Fact Explanation
alkaline phosphatase level [1] Elevated alkaline phosphatase level due to bone metastasis [1]
Prostate specific antigen (PSA) [2] PSA levels of 4 to less than 10 ng per mL, 10 to 20 ng per mL (10 to 20 mcg per L), and greater than 20 ng per mL are associated with a low, intermediate, and high risk of prostate cancer recurrence after treatment, respectively [2]
References
  1. NAITOH J, ZEINER RL, DEKERNION JB. Diagnosis and treatment of prostate cancer. Am Fam Physician [online] 1998 Apr 1, 57(7):1531-9, 1541-2, 1545-7 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9556643
  2. MOHAN R, SCHELLHAMMER PF. Treatment options for localized prostate cancer. Am Fam Physician [online] 2011 Aug 15, 84(4):413-20 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21842788

Investigations - Screening/Staging

Fact Explanation
transrectal ultrasonography-guided prostate biopsy [1] The most recent guideline from the American Cancer Society recommends transrectal ultrasonography-guided prostate biopsy as a reasonable option in men with PSA levels of 4 ng per mL (4 mcg per L) or greater. GX: cannot assess grade G1: the tumor closely resembles normal tissue (Gleason 2–4) G2: the tumor somewhat resembles normal tissue (Gleason 5–6) G3–4: the tumor resembles normal tissue barely or not at all (Gleason 7–10) [1]
CT / MRI pelvis, PET scans / bone scans [1] To stage the cancer ( to detect the extent of spread ) TNM staging: TX: cannot evaluate the primary tumor T0: no evidence of tumor T1: tumor present, but not detectable clinically or with imaging T1a: tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons) T1b: tumor was incidentally found in greater than 5% of prostate tissue resected T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate T2a: the tumor is in half or less than half of one of the prostate gland's two lobes T2b: the tumor is in more than half of one lobe, but not both T2c: the tumor is in both lobes but within the prostatic capsule T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2) T3a: the tumor has spread through the capsule on one or both sides T3b: the tumor has invaded one or both seminal vesicles T4: the tumor has invaded other nearby structures It should be stressed that the designation "T2c" implies a tumor which is palpable in both lobes of the prostate. Tumors which are found to be bilateral on biopsy only but which are not palpable bilaterally should not be staged as T2c. Evaluation of the regional lymph nodes ('N') NX: cannot evaluate the regional lymph nodes N0: there has been no spread to the regional lymph nodes N1: there has been spread to the regional lymph nodes Evaluation of distant metastasis ('M') MX: cannot evaluate distant metastasis M0: there is no distant metastasis M1: there is distant metastasis M1a: the cancer has spread to lymph nodes beyond the regional ones M1b: the cancer has spread to bone M1c: the cancer has spread to other sites (regardless of bone involvement) [1]
References
  1. MOHAN R, SCHELLHAMMER PF. Treatment options for localized prostate cancer. Am Fam Physician [online] 2011 Aug 15, 84(4):413-20 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21842788

Management - General Measures

Fact Explanation
Patient education [1] Because of long-term side effects, the integration of survival outcomes with quality of life is important. One recent study used decision modeling to estimate quality-adjusted life years (QALYs) for patients with clinically localized prostate cancer. Patients with Gleason 2 to 4 cancer had a decreased number of QALYs following treatment; conversely, patients with Gleason 7 to 10 cancer had an increased number of QALYs following treatment. Outcomes for patients with Gleason 5 to 6 cancer were less clear. Long term side effects of treatment- Bowel dysfunction: Estimated risk after prostatectomy (%) - 2-7 Estimated risk after external radiation therapy (%) - 0-30 Estimated risk after brachytherapy (%) - 1-10 Erectile dysfunction: Estimated risk after prostatectomy (%) - 50-90 Estimated risk after external radiation therapy (%) - 30-85 Estimated risk after brachytherapy (%) - ∼ 20 at 2 to 3 years, ∼ 50 at 5 to 6 years Urinary dysfunction: Estimated risk after prostatectomy (%) - 15-60 Estimated risk after external radiation therapy (%) - 2-30 Estimated risk after brachytherapy (%) - 12-30 [1]
References
  1. BHATNAGAR V, KAPLAN RM. Treatment options for prostate cancer: evaluating the evidence. Am Fam Physician [online] 2005 May 15, 71(10):1915-22 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15926407

Management - Specific Treatments

Fact Explanation
Conservative management [1] Conservative management, with or without androgen ablation reserved for symptomatic disease, is one option for prostate cancer patients. Compared with an age-matched cohort of men without prostate cancer, patients with well-differentiated prostate cancer (i.e., Gleason score of 2 to 4) did not have an increased risk of death; patients with Gleason scores of 8 to 10, however, had about a two- and threefold increase in the risk of death, respectively [1]
Prostatectomy [1] Surgical removal of the prostate is an option for patients with clinically localized cancer. Several case series have suggested that patients with early prostate cancer have a good disease-free survival rate following radical prostatectomy. [1] Among patients in whom cancer was detected clinically (not by PSA screening), those who underwent radical prostatectomy (RP) had fewer prostate cancer–related deaths than patients who chose watchful waiting, although this benefit was limited to patients younger than 65 years [2]
External beam radiotherapy treatment (EBRT) [1] Another treatment for patients with localized prostate cancer is external or interstitial radiation. Conformal external beam radiation generally has replaced conventional external radiation because higher doses of radiation can be directed to the prostate with less radiation to the surrounding tissues. Differences between radiation and radical prostatectomy were attributable to pretreatment PSA and T-stage (lead time) and biopsy Gleason score (length time). Several case series also have shown that disease-free survival following radiation is comparable with radical prostatectomy [1] A systematic review found that surgery and external beam radiation therapy (EBRT) were equivalent in effectiveness, especially if the baseline PSA level was greater than 10 ng per mL. EBRT is given over eight to nine weeks and is associated with more bowel adverse effects than surgery. Surgery is more difficult if cancer recurs after EBRT [2]
Brachytherapy [2] The efficacy of brachytherapy is comparable with external radiation. In patients with low-risk cancer, brachytherapy using iodine-125 or palladium-103 pellet implantation is recommended as monotherapy. It is a preferred option in these patients because it controls the cancer as effectively as surgery or EBRT, and patients experience much less urinary incontinence and erectile dysfunction. [2]
Active surveillance [2] Compared with observation and watchful waiting, active surveillance is a more structured program to track the progression of prostate cancer, allowing for earlier intervention if the patient's risk is found to increase on follow-up. Active surveillance is recommended for low- and very low-risk patients. Men following this have been found to have favorable levels of anxiety and distress. [2]
References
  1. BHATNAGAR V, KAPLAN RM. Treatment options for prostate cancer: evaluating the evidence. Am Fam Physician [online] 2005 May 15, 71(10):1915-22 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15926407
  2. MOHAN R, SCHELLHAMMER PF. Treatment options for localized prostate cancer. Am Fam Physician [online] 2011 Aug 15, 84(4):413-20 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21842788