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Prostate Cancer

Practice Essentials

Prostate cancer represents the second most common cancer in men worldwide and the fifth most common cause of cancer death in men; in the United States, it is the most common cancer in men and the second most common cause of cancer deaths in men.
Acinar adenocarcinoma of the prostate comprises 90-95% of prostate cancers diagnosed.
Ductal carcinoma and neuroendocrine carcinoma account for the majority of additional cases. The 2016 World Health Organization classification provides a comprehensive listing of prostate tumors, including acinar adenocarcinoma subtypes.
In this article, the term prostate cancer refers to prostatic acinar adenocarcinoma.

The image below depicts the anatomic associations of the male urinary tract. The prostate lies between the bladder and the urogenital diaphragm. Owing to its anatomic location, the prostate may be palpable transrectally and accessed for biopsy via either the rectum or the perineum. For a more detailed description of prostate biopsy, see Workup/Prostate Biopsy

Prostate cancer. This diagram depicts the relevant

Prostate cancer. This diagram depicts the relevant anatomy of the male pelvis and genitourinary tract.

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For additional information please see Prostate Cancer: Diagnosis and Staging, a Critical Images slideshow, to help determine the best diagnostic approach for this potentially deadly disease and/or Advanced Prostate Cancer: Signs of Metastatic Disease, a Critical Images slideshow, for help identifying the signs of metastatic disease.

Signs and symptoms

Most patients presenting with prostate cancer do so with screen-detected cancer and are asymptomatic. Local symptoms associated with prostate cancer can include:

Lower urinary tract symptoms (LUTS)

Hematuria

Hematospermia

Erectile dysfunction

Urinary retention

However, those symptoms are generally not caused by prostate cancer. Physical examination alone cannot reliably differentiate benign prostatic disease from cancer.

Findings in patients with advanced disease may include the following:

Cancer cachexia

Bony tenderness

Lower-extremity lymphedema or deep venous thrombosis

Adenopathy

Overdistended bladder due to outlet obstruction

Neuropathy

See Presentation for more detail.

Diagnosis

Elevated prostate-specific antigen (PSA) level

No PSA level guarantees the absence of prostate cancer.

The risk of disease increases as the PSA level increases, from about 8% with PSA levels of ≤1.0 ng/mL
 to about 25% with PSA levels of 4-10 ng/mL and over 50% for levels over 10 ng/mL

Abnormal digital rectal examination (DRE) findings

DRE is examiner-dependent, and serial examinations over time are best

Most patients diagnosed with prostate cancer have normal DRE results but abnormal PSA readings

Biopsy

Biopsy establishes the diagnosis

False-negative results often occur, so multiple biopsies may be needed before prostate cancer is detected

Screening

Multiple institutions and collaborative groups have addressed prostate cancer screening. The United States Preventive Services Task Force (USPSTF) recomended against prostate cancer screening in 2011-2012, but in 2018 reversed the recommendation to include screening after an informed discussion. 

The evidence for and against screening, a summary of screening guidelines, and the observed impact of the USPSTF guidelines on prostate cancer incidence and mortality are presented in full detail in Workup/Prostate Cancer Screening

Management

Localized prostate cancer

Standard treatments for clinically localized prostate cancer include the following:

Watchful waiting 

Active surveillance

Radical prostatectomy

Radiation therapy

Emerging treatments with limited long-term data include targeted therapy and whole-gland ablation. 

Non-localized or recurrent prostate cancer

Prostate cancer may recur in up to a third of men after definitive local therapy. This disease state is now subdivided into castrate-sensitive or castrate-resistant locally recurrent prostate cancer and castrate-sensitive or castrate-resistant metastatic prostate cancer. These disease states are rarely curable, but recent advances in the understanding of salvage radiation therapy, chemohormonal therapy, androgen blockade, and poly(ADP-ribose) polymerase (PARP) inhibition has greatly prolonged survival for these men. For full discussion of this rapidly developing field, see Metastatic and Advanced Prostate Cancer.

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