Prostate Cancer Aria F Olumi M D Division

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 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 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

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

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 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 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: 2215, 1992

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, 1973 -1997, NCI, 2000 14

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 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 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

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, 111: 58, 1974

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

Staging of Prostate Cancer 22

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