Risk Factors For Prostate Cancer
Some risk factors have been linked to prostate cancer. A risk factor is something that can raise your chance of developing a disease. Having one or more risk factors doesnt mean that you will get prostate cancer. It just means that your risk of the disease is greater.
- Age. Men who are 50 or older have a higher risk of prostate cancer.
- Race. African-American men have the highest risk of prostate cancerâthe disease tends to start at younger ages and grows faster than in men of other races. After African-American men, prostate cancer is most common among white men, followed by Hispanic and Native American men. Asian-American men have the lowest rates of prostate cancer.
- Family history. Men whose fathers or brothers have had prostate cancer have a 2 to 3 times higher risk of prostate cancer than men who do not have a family history of the disease. A man who has 3 immediate family members with prostate cancer has about 10 times the risk of a man who does not have a family history of prostate cancer. The younger a mans relatives are when they have prostate cancer, the greater his risk for developing the disease. Prostate cancer risk also appears to be slightly higher for men from families with a history of breast cancer.
- Diet. The risk of prostate cancer may be higher for men who eat high-fat diets.
Biochemical Recurrence Without Metastatic Disease After Exhaustion Of Local Treatment Options
4. Clinicians should inform patients with PSA recurrence after exhaustion of local therapy regarding the risk of developing metastatic disease and follow such patients with serial PSA measurements and clinical evaluation. Clinicians may consider radiographic assessments based on overall PSA and PSA kinetics.
5. In patients with PSA recurrence after exhaustion of local therapy who are at higher risk for the development of metastases , clinicians should perform periodic staging evaluations consisting of cross-sectional imaging and technetium bone scan.
6. Clinicians may utilize novel PET-CT scans in patients with PSA recurrence after failure of local therapy as an alternative to conventional imaging or in the setting of negative conventional imaging.
7. For patients with a rising PSA after failure of local therapy and no demonstrated metastatic disease by conventional imaging, clinicians should offer observation or clinical trial enrollment.
8. ADT should not be routinely initiated in this population . However, if ADT is initiated in the absence of metastatic disease, intermittent ADT may be offered in lieu of continuous ADT.
A Specialist Explains What Patients Can Expect During Treatment
What can patients expect when undergoing treatment for advanced prostate cancer? In this Ask the Expert segment, Scott Tagawa, MD, MS, a professor of medicine and urology at Weill Cornell Medicine in New York City, explains the various types of treatment available, including hormonal therapy, chemotherapy, targeted therapy, and more.
Dr. Tagawa:My name is Scott Tagawa. I am a medical oncologist at Weill Cornell Medicine, near Presbyterian Hospital, Meyer Cancer Center. I focus on the treatment of patients with what I would call genitourinary abnormalities, and the most common of those is prostate cancer.
Graphic: What are the available treatment options for advanced prostate cancer?
Dr. Tagawa:Generally speaking, when someone has advanced prostate cancer, we use what’s called systemic therapy. We can say “medicines,” and they go everywhere, hopefully targeting the cancer more than the patient. But just to take a break from that, there are situations in advanced prostate cancer where we will use local therapy. So that could be surgery or radiation to the prostate. That could be some sort of radiation or ablation to certain areas. Sometimes there are very specific spots, the prostate itself, or other areas that we treat, so I just wanted to mention that.
Graphic: What should patients know about clinical trials for advanced prostate cancer?
More on Your Prostate Cancer Questions Answered
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Surgery For Metastatic Prostate Cancer
Unlike with localized prostate cancer, surgery isnt usually used to treat metastatic cancer. However, it may be used in some cases if it can help improve a patients quality of life, often to resolve urinary problems or stop bleeding.
If your cancer is locally advanced and hasnt spread far, a radical prostatectomy may still be an option. A radical prostatectomy is a surgical procedure in which the prostate is removed, along with any nearby tissue that contains prostate cancer cells.
Chemotherapy For Metastatic Prostate Cancer
Chemotherapy may be used for patients with metastatic prostate cancer, with the aim of slowing any further spread of cancer and improving quality of life.
The most commonly used chemotherapy medications, typically given via an intravenous line, are docetaxel combined with prednisone. However, there are several chemotherapy drugs available, so ask your doctor which types may be most appropriate for your treatment.
In some cases, these treatments are considered palliative, intended to relieve difficult symptoms and improve quality of life.
Prostate cancer treatment: The care you need is one call away
Your multidisciplinary team will work with you to develop a personalized plan to treat your prostate cancer in a way that fits your individual needs and goals.
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During Watchful Waiting Or Active Surveillance
If you choose observation or active surveillance, your PSA level will be monitored closely to help decide if the cancer is growing and if treatment should be considered.
Your doctor will watch your PSA level and how quickly it is rising. Not all doctors agree on exactly what PSA level might require further action . Again, talk to your doctor so you understand what change in your PSA might be considered cause for concern.
How Psa Results Are Used For Diagnosis
In the past, many doctors wanted men with elevated PSA and/or an abnormal digital rectal examination to undergo a prostate biopsy. Today, this is not a course of action recommended by the American Urological Association. In such cases, multiparametric prostate MRI is now recommended as the best front-line test to detector rule outprostate cancer.
If a mpMRI shows a suspicious finding, a MRI-guided biopsy is the most accurate way to perform a biopsy of the prostate. If this is not possible, an MRI can be used with an ultrasound-guided biopsy. This is referred to as a fusion biopsy, and is more accurate than an ultrasound biopsy alone.
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Why You Have The Test
The goal of a prostatectomy is to remove all the cancer, or as much of it as possible. If your cancer hasn’t spread, it might cure you.
But no surgery is perfect. It’s possible that some of the cancer cells spread outside your prostate before your procedure. Or the operation might have left a few cancer cells behind. Those cells could start to grow in the future.
A regular PSA test after a prostatectomy is a way for your doctor to keep tabs on your treatment. It can help your doctor see how well your surgery worked, and if your cancer has come back.
If Treatment Does Not Work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for some people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
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When Is A Psa Test Needed
If you are age 50 to 74, you should discuss the PSA test with your doctor. Ask about the possible risks and benefits.
Men under 50 or over 75 rarely need a PSA test, unless they have a high risk for prostate cancer.
- You are more likely to get prostate cancer if you have a family history of prostate cancer, especially in a close relative such as a parent or sibling.
- Your risks are higher if your relative got prostate cancer before age 60 or died from it before age 75. These early cancers are more likely to grow faster.
- If you have these risks, you may want to ask your doctor about getting the PSA test before age 50.
This report is for you to use when talking with your healthcare provider. It is not a substitute for medical advice and treatment. Use of this report is at your own risk.
Searches And Article Selection
A research librarian conducted searches in Ovid MEDLINE , Cochrane Central Register of Controlled Trials , and Cochrane Database of Systematic Reviews . An updated search was conducted prior to publication through January 20, 2020. The methodology team supplemented searches of electronic databases with the studies included in the prior AUA review and by reviewing reference lists of relevant articles.
The methodology team developed criteria for inclusion and exclusion of studies based on the Key Questions and the populations, interventions, comparators, outcomes, and settings of interest. The population was patients with advanced prostate cancer as described in Table 3. Treatments included first and second line antiandrogens, immunotherapy, chemotherapy, radiation therapy, surgery, radiopharmaceuticals, and surveillance strategies. Comparisons were against placebo, no therapy, or another active intervention and intermittent versus continuous therapy. Outcomes included overall survival , prostate cancer mortality, progression-free survival , prostate-specific antigen progression-free survival , failure-free survival, metastases-free survival, time to metastases, time to progression, skeletal events, and adverse events.
Justification For A New Guideline
Clinicians treating men with advanced prostate cancer are challenged with the rapidly evolving prostate cancer landscape given the approval of new classes of agents for use in various prostate cancer disease states. The increasing complexity of advanced prostate cancer management underscores the need for the current clinical practice guideline, developed to provide a rational basis for treatment of patients with advanced disease, based on currently available published data. To assist in clinical decision-making, guideline recommendations are furnished according to disease state across the entire continuum of advanced prostate cancer.
How Doctors Diagnosed Metastatic Prostate Cancer
When a patient is diagnosed with prostate cancer, the doctor will order tests such as
These tests focuses on the skeleton, the belly and pelvic areas and in the above ways doctors can check for signs that the cancer has spread or if the cancer is metastatic. If ones have symptoms such as bone pain and broken bones for no reason, the doctor may order a bone scan and it may show if you have signs of cancer spread in the bones. The doctor will also ask for blood tests, including a check of PSA levels, to look for other signs that the cancer is spreading.
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Is The Psa Test Recommended For Prostate Cancer Screening
Beginning around 2008, as more was learned about both the benefits and harms of prostate cancer screening, a number of professional medical organizations began to caution against routine population screening with the PSA test. Most organizations recommend that individuals who are considering PSA screening first discuss the risks and benefits with their doctors.
Some organizations do recommend that men who are at higher risk of prostate cancer begin PSA screening at age 40 or 45. These include Black men, men with germline variants in BRCA2 , and men whose father or brother had prostate cancer.
In 2018, the United States Preventive Serves Task Force updated its recommendation statement for prostate cancer screening from a D to a C in men ages 55 to 69. The updated recommendation, which applies to the general population as well as those at increased risk due to race/ethnicity or family history, is as follows:
- For individuals ages 55 to 69 years, the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one. Before making the decision, a person should discuss the potential benefits and harms of screening with their clinician and consider these in the context of their own values and preferences.
- PSA-based screening for prostate cancer is not recommended for individuals 70 years and older.
Pharmacologic Agents In Prostate Cancer
Gonadotropin-releasing hormone analogues suppress ovarian and testicular steroidogenesis by decreasing luteinizing hormone and follicle stimulating hormone levels, whereas GnRH antagonists lower serum testosterone levels by suppressing LH and FSH.
Bisphosphonates are analogues of pyrophosphate that act by binding to hydroxyapatite in bone matrix, thereby inhibiting the dissolution of crystals. These agents prevent osteoclast attachment to the bone matrix and osteoclast recruitment and viability.
Antiandrogens are used as combination agents to treat prostate cancer. Antifungal agents produce a response similar to that of antiandrogens. These drugs inhibit various cytochrome P-450 enzymes, including 11-beta-hydroxylase and 17-alpha-hydroxylase, which in turn inhibit steroid synthesis. The antiandrogen abiraterone is a 17 alpha-hydroxylase/C17, 20-lyase inhibitor that was approved by the US Food and Drug Administration in 2011 for use in combination with prednisone for treatment of metastatic castration-resistant prostate cancer in patients who received prior chemotherapy containing docetaxel.
An ultramicronized abiraterone tablet was approved in May 2018 for CRPC in combination with methylprednisolone. The ultramicronized formulation may be administered with or without food, whereas, the original tablet formulation must be administered 1 hour before or 2 hours after meals.
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What Is Done If A Screening Test Shows An Elevated Psa Level
If someone who has no symptoms of prostate cancer chooses to undergo prostate cancer screening and is found to have an elevated PSA level, the doctor may recommend another PSA test to confirm the original finding. If the PSA level is still high, the doctor may recommend that the person continue with PSA tests and digital rectal exams at regular intervals to watch for any changes over time .
If the PSA level continues to rise or a suspicious lump is detected during a DRE, the doctor may recommend additional tests to determine the nature of the problem. These may include imaging tests, such as magnetic resonance imaging or high-resolution micro-ultrasound.
Alternatively, the doctor may recommend a prostate biopsy. During this procedure, multiple samples of prostate tissue are collected by inserting hollow needles into the prostate and then withdrawing them. The biopsy needle may be inserted through the wall of the rectum or through the perineum . A pathologist then examines the collected tissue under a microscope. Although both biopsy techniques are guided by ultrasound imaging so the doctor can view the prostate during the biopsy procedure, ultrasound cannot be used alone to diagnose prostate cancer. An MRI-guided biopsy may be performed for patients with suspicious areas seen on MRI.
Biomarkers And Other Systemic Therapies
Given the dramatic increase in available therapies for advanced prostate cancer over the past 10 years, there is a renewed urgency to identify predictive biomarkers that can guide treatment selection. A number of promising molecular approaches continue to be investigated, but as of yet there is no assay that has been prospectively demonstrated to lead to improved oncologic outcomes.
In addition to PARP inhibitors, immunotherapies have also emerged as a key therapeutic modality in a large number of solid tumors. Aside from sipuleucil-T, these treatments have generally shown less efficacy in advanced prostate cancer compared to other malignancies, in part related to the relatively low tumor mutational burden of most prostate cancers.171 However, as described in guideline statement 34, there is likely to be a subset of prostate cancer patients who are uniquely sensitive to immunotherapy particularly those patients who have tumors that have a high mutational burden .172 Ongoing trials continue to explore whether immune checkpoint inhibitors, vaccine-based therapies, or oncolytic viruses may have broader utility in men with advanced prostate cancer.
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Screening Tests For Prostate Cancer
Screening is testing to find cancer in people before they have symptoms. Its not clear, however, if the benefits of prostate cancer screening outweigh the risks for most men. Still, after discussing the pros and cons of screening with their doctors, some men might reasonably choose to be screened.
The screening tests discussed here are used to look for possible signs of prostate cancer. But these tests cant tell for sure if you have cancer. If the result of one of these tests is abnormal, you will probably need a prostate biopsy to know for sure if you have cancer.
Radiation Therapy For Metastatic Prostate Cancer
Radiation therapy may be used to treat men with high-risk prostate cancer or stage 4A cancer .
In these instances, external beam radiation therapy is commonly used, also known as EBRT. Using an external machine, your doctor sends targeted beams of radiation to the cancer site. Its administered five days a week in an outpatient facility throughout several weeks.
Radiation may be targeted to cancer that has spread to the bones as well, helping reduce pain.
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