Prostate Cancer Aria F Olumi M D Division

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Prostate Cancer Aria F. Olumi, M. D. Division of Urologic Surgery Beth Israel Deaconess Prostate Cancer Aria F. Olumi, M. D. Division of Urologic Surgery Beth Israel Deaconess Medical Center 1

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Probability of developing clinically significant prostate cancer by age Probability 1/6 1/10, 000 <39 Probability of developing clinically significant prostate cancer by age Probability 1/6 1/10, 000 <39 1/78 40 -59 Age 60 -79 3 Cancer Statistics, 1996, Parker SL et

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Prostate Cancer in African Americans • 30 -35% higher incidence of prostate cancer than Prostate Cancer in African Americans • 30 -35% higher incidence of prostate cancer than whites • 223% higher mortality rate than whites • Causes: screening, environmental, biologic, hormonal • Socioeconomic status and education have not been important differentiating factors Demers, RY et al , Arch Int Med, 154, 1994 Morton, RA Jr. , Urology, 44, 1994 Pienta, KJ, Urology, 45, 1995 Baquet, CR et al, JNCI, 83, 5 1991

6 Parker SL, et al. CA Cancer J Clin 47: 5, 1997 6 Parker SL, et al. CA Cancer J Clin 47: 5, 1997

Hereditary Prostate Cancer • Cluster of three or more affected immediate relatives • Occurrence Hereditary Prostate Cancer • Cluster of three or more affected immediate relatives • Occurrence of prostate cancer in three generations • Cluster of two relatives affected at 55 years of age 7

Genetic links in familial prostate cancer Nature Medicine 7: 153, 2001 8 Genetic links in familial prostate cancer Nature Medicine 7: 153, 2001 8

Hereditary vs. Sporadic Prostate Cancer • Only difference is younger age of onset • Hereditary vs. Sporadic Prostate Cancer • Only difference is younger age of onset • Higher histologic grade with linkage to HPC -1 • No difference in prostate cancer recurrence Gronberg H, et al. JAMA, 278: 1251, 1997 Bova GS, et al. J Urol. , 160: 660, 1998 9

Dietary factors in prostate cancer • High fat consumption correlates with high rates of Dietary factors in prostate cancer • High fat consumption correlates with high rates of death from prostate cancer • Dietary factors affect progression as opposed to initiation of prostate cancer • Lycopene (tomato-based foods) related with lower risk of prostate cancer 10

Prostate Specific Antigen (PSA) • Serine protease • Produced by the prostatic epithelial cells Prostate Specific Antigen (PSA) • Serine protease • Produced by the prostatic epithelial cells and peri-urethral glands • Elevated in both BPH and prostate cancer • In prostate cancer PSA value is higher and more rapid rate of rise than in BPH 11

PSA in BPH and Prostate Cancer 12 Carter HB et al. , JAMA, 16: PSA in BPH and Prostate Cancer 12 Carter HB et al. , JAMA, 16: 2215, 1992

Screening for Prostate Cancer with PSA • Controversial – Lack of randomized trials – Screening for Prostate Cancer with PSA • Controversial – Lack of randomized trials – Lifetime risk of prostate cancer: 16% – Lifetime risk of prostate cancer death: 3. 4% • Screening reserved for those with greater than 10 year life expectancy. 13

Incidence and Mortality from Prostate Cancer Ries L, et al. SEER Cancer statistics review, Incidence and Mortality from Prostate Cancer Ries L, et al. SEER Cancer statistics review, 1973 -1997, NCI, 2000 14

Rationale for early cancer detection • Reduce mortality • Prevent Morbidity – Urinary obstruction Rationale for early cancer detection • Reduce mortality • Prevent Morbidity – Urinary obstruction – Bleeding – Painful bony metastasis 15

Estimated Probability of Prostate Cancer with Normal Digital Rectal Exam PSA, ng/ml Probability of Estimated Probability of Prostate Cancer with Normal Digital Rectal Exam PSA, ng/ml Probability of Prostate Cancer 0 -2. 4 ? 2. 5 -4. 0 12 -23% 4. 1 -10. 0 25% >10. 0 >50% 16

Screening for Prostate Cancer • ACS and AUA recommendations: – PSA and Digital Rectal Screening for Prostate Cancer • ACS and AUA recommendations: – PSA and Digital Rectal Exam Annually – Begin at age 50 – For men with at least 10 year life expectancy – Begin screening earlier for men at high risk of prostate cancer 17

Prostatic Anatomy 18 Prostatic Anatomy 18

Diagnosis of Prostate Cancer • Prostate Needle Biopsy by Transrectal Ultrasound Guidance done for: Diagnosis of Prostate Cancer • Prostate Needle Biopsy by Transrectal Ultrasound Guidance done for: – Abnormal DRE – and/or elevated PSA (> 4 ng/ml) – and/or abnormal PSA velocity (> 0. 75 ng/ml/year) – and/or abnormal age-adjusted PSA 19

Gleason Histologic Grading of Prostate Cancer Gleason D et al. , 20 J Urol, Gleason Histologic Grading of Prostate Cancer Gleason D et al. , 20 J Urol, 111: 58, 1974

Gleason Histologic Grading of Prostate Cancer Gleason 3+3 Prostate Adenocarcinoma 21 Gleason Histologic Grading of Prostate Cancer Gleason 3+3 Prostate Adenocarcinoma 21

Staging of Prostate Cancer 22 Staging of Prostate Cancer 22

Treatment Options for Prostate Cancer • • • Radical Prostatectomy External beam radiation therapy Treatment Options for Prostate Cancer • • • Radical Prostatectomy External beam radiation therapy Radioactive seed implantation (Brachytherapy) Anti-androgen hormonal ablation therapy Generally not responsive to chemotherapy 23




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