Question

1. Risk assessment and screening procedure of:Prostate

2. Relevant information of Prostate cancer based on:
a. Chief complaints
b. Functional patterns
c. Physical examination of patient with Prostate cancer

3. Pathophysiologic mechanics of prostate cancer is it a Solid tumor or Liquid tumors

Answer 1

QUESTIONS:

1. Risk assessment and screening procedure of:Prostate

2. Relevant information of Prostate cancer based on:
a. Chief complaints
b. Functional patterns
c. Physical examination of patient with Prostate cancer

3. Pathophysiologic mechanics of prostate cancer is it a Solid tumor or Liquid tumors

ANSWERS

1. Risk assessment and screening procedure of:Prostate

Prostate

1. Size and shape of walnut on average

2. Function is the release of fluid to protect and nourish sperm

3. As men age prostate gets bigger and some patients will experience lower urinary tract symptoms

4. As men age likelihood of prostate cancer is higher 1. 22-55% by age 50-60 2. 48-90% by age over 80 .

Prostate Cancer Incidence

• 5th most common worldwide cancer

• 2nd most common cancer in men

• 11.7% of new cancers, due to screening 19% of cancers detected in the united states in comparison to 5.3% in developing countries

Prostate cancer and race

• African Americans have incidence 1.6 times white Americans

• Death rates 2.4 times greater than white Americans

PSA

• Prostate Specific Antigen:

• Protein
• Secreted in high concentrations into seminal fluid
• Bound and unbound forms
• Levels in blood can vary by age, prostate volume, and race
• It is influenced by androgen
• Prostate disease- bph, prostatitis, prostate manipulation, urinary tract infection and prostate cancer can all elevate psa

Screening

• The Examination of a group to separate well persons from those who have an undiagnosed pathologic condition or who are at high risk.
• Benefits of diagnosis at earlier stage of disease to increase better survival and reduce morbidity.
• "Screening" means testing for a disease even if you have no symptoms. The prostate specific antigen (PSA) blood test and digital rectal examination (DRE) are two tests that are used to screen for prostate cancer. Both are used to detect cancer early. However, these tests are not perfect. Abnormal results with either test may be due to benign prostatic enlargement (BPH) or infection, rather than cancer.
• The American Urological Association (AUA) recommends talking with your healthcare provider about whether or not you should be screened. To find out if prostate cancer screening is a good idea, use our Prostate Cancer Screening Assessment Tool [pdf]. Share your results with your healthcare provider when you talk about the benefits and risks of screening.

DRE

• The digital rectal examination (DRE) helps your doctor find prostate problems. For this examination, the healthcare provider puts a lubricated gloved finger into the rectum. The man either bends over or lies curled on his side on a table. During this test, the doctor feels for an abnormal shape or thickness to the prostate. DRE is safe and easy to do. But the DRE by itself cannot detect early cancer. It should be done with a PSA test.

PSA Blood Test

• The prostate-specific antigen (PSA) blood test is one way to screen for prostate cancer. This blood test measures the level of PSA in the blood. PSA is a protein made only by the prostate and prostate cancers. The test can be done in a lab, hospital or healthcare provider's office.
• Very little PSA is found in the blood of a man with a healthy prostate. A low PSA is a sign of prostate health. A rapid rise in PSA may be a sign that something is wrong. Prostate cancer is the most serious cause of a high PSA result. Another reason for a high PSA can be benign (non-cancer) enlargement of the prostate. Prostatitis, inflammation of the prostate, can also cause high PSA results.
• A rise in PSA level does not tell us the type of cancer cells present. The rise tells us that cancer may be present.

Since the beginning of PSA

• From 1993 to 2008 after the onset of widespread PSA testing, the mortality rate from prostate cancer declined by 40%(Surveillance, Epidemiology, and End Results [SEER] Program),
• 75% reduction in the proportion of advanced-stage disease at diagnosis.
• Compared to United Kingdom screening is only performed in 10% of people
•    Prostate cancer deaths only decreased by 12% in UK
• ESPRC- 20% reduction in mortality in screened population over 9 years.
•    However to prevent one prostate cancer death- 1410 people need to be screened and 48 people need to be treated
• PLCO trial- Showed no difference in mortality between screened and unscreened population.
• Highly controversial trial- contamination of patients
• Bottom line over-treatment risk is high

Interpretation of PSA

• Only way to confirm diagnosis is by tissue from prostate biopsy
• Triggers for biopsy:
  • Abnormal digital rectal examination
  • Traditionally 4 ng/ml was used but 25% of prostate cancers were detected below 4
  • Now a baseline can be established and reconfirmed depending on age
  • Rapidly rising psa (psa velocity), elevated psa in comparison to prostate size (psa density) are markers
• PSA density >0.15 for pts with psa between total values of 4 and 10
• PSA velocity- >0.75 ng/ml/year for psa 4-10. Some say even lower threshold for lower psa.
• % free psa- cancer pts have lower free psa as psa is complexed

Biopsy

• Traditionally performed by transrectal ultrasound
• Performed in office
• Tolerated well
• Main risk is infection which is reduced by antibiotics
• Other risks of bleeding, blood in urine, trouble urinating
•    Risk of hospitalization across the board is low at 4%

Plus and Minus of Biopsy

• Only 26% biopsy will return with cancer diagnosis
• May return with low grade low volume cancer.
• If did not use screening picks up cancers 5-7 years prior to it becoming symptomatic.

Adjunct Markers and Tests

• Alternative blood tests
  • PCA3
  • Prostate Health Index
  • 4k score
• Prostate MRI
  • May be useful in patients for repeat biopsies
  • May be useful in patients on surveillance
  • No standardization in interpretation at this time

Guidelines- US Preventative Task Force

• 2012- Panel gave PSA screening grade D
  •    Recommends against Prostate Cancer Screening in general population
  •    They do not have recommendation for people of certain ethnicity known for higher incidence of prostate cancer
  •     No recommendation for use of psa screening for positive family history
  •     Prior recommendation was there was insufficient data for general population but definitely no benefit for individuals over age of 75.
• Same task force in 2009 that recommended against mammography screening for breast cancer which was later rescinded
• Conclusions were made based on large trial data that had contamination.

Guidelines- American Cancer Society

• Age 50 and above for average risk
• Age 45 for men at high risk
• Age 40 for men at even higher risk
• Men screened every 2 years below PSA 2.5
• Men screened annually for PSA > 2.5
• Thorough history including family history, previous psa, previous examinations and biopsy
• Start discussion risks and benefits for screening
• Age 45-49: obtain baseline psa
  • If > 1 obtain repeat test 1-2 years
  • If < 1 obtain repeat testing at age 50
• Age 50-70 or >70 in specific healthy population
  • 1-2 year testing. Trigger for biopsy is abnormal digital rectal examination or psa >3
• The Panel recommends against PSA screening in men under age 40 years.
• The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. – This does not include increased risk population such has family history and African Americans
• For men ages 55-69 Recommendation to screen after discussion of weighing benefits of prostate cancer mortality of 1 man for 1000 screened
• Possible to screen PSA every 2 years instead of 1
• No screening in population above 70 unless 10 to 15 year life expectancy
• Societies against screening
  • US Preventative Task Force
• Societies for screening
  • American Cancer Society
  • National Comprehensive Cancer Network
  • American Urological Association
• In accordance with the American Urological Association

1. PSA screening does yield survival benefit

2. PSA screening picks up cancers 5-7 years prior to symptomatic disease

3. PSA screening may represent over diagnosis in 25% of people

• Each individual is different once the risks of screening are explained and results are individually tailored • If diagnosis is confirmed, treatment is also custom planned
• Guidelines are tools in recommending plan and are not certainly rigid for each individual.  Certainly overtreatment of prostate cancer but if aggressive cancers are caught early, early treatment can be curative rather than palliative.

Stages

Grading (with the Gleason Score) and staging defines the progress of cancer and whether it has spread:

Grading

When prostate cancer cells are found in tissue from the core biopsies, the pathologist "grades" it. The grade is a measure of how quickly the cells are likely to grow and spread (how aggressive it is).

The most common grading system is called the Gleason grading system. With this system, each tissue piece is given a grade between three (3) and five (5). In the past, we assigned scores of one (1) and two (2). A grade of less than three (3) means the tissue is close to normal. A grade of three (3) suggests a slow growing tumor. A high grade of five (5) indicates a highly aggressive, high-risk form of prostate cancer.

The Gleason system then develops a "score" by combing the two most common grades found in biopsy samples. For example, a score of grades 3 + 3 = 6 suggests a slow growing cancer. The highest score of grades 5 + 5 = 10 means that cancer is present and extremely aggressive.

The Gleason score will help your doctor understand if the cancer is as a low-, intermediate- or high-risk disease. Generally, Gleason scores of 6 are treated as low risk cancers. Gleason scores of around 7 are treated as intermediate/mid-level cancers. Gleason scores of 8 and above are treated as high-risk cancers.

Staging

Tumor stage is also measured. Staging describes where the cancer is within the prostate, how extensive it is, and if it has spread to other parts of the body. One can have low stage cancer that is very high risk. Staging the cancer is done by DRE and special imaging studies.

The system used for tumor staging is the TNM system. TNM stands for Tumor, Nodes and Metastasis. The "T" stage is found by DRE and other imaging tests such as an ultrasound, CT scan, MRI or bone scan. The imaging tests show if and where the cancer has spread, for example: to lymph nodes or bone.

These staging imaging tests are generally done for men with a Gleason grade of 7 or higher and a PSA higher than 10. Sometimes follow-up images are needed to evaluate changes seen on the bone scan.

2. Relevant information of Prostate cancer based on:
a. Chief complaints
b. Functional patterns
c. Physical examination of patient with Prostate cancer

a. Chief complaints

In its early stages, prostate cancer often has no symptoms. When symptoms do occur, they can be like those of an enlarged prostate or BPH. Prostate cancer can also cause symptoms unrelated to BPH. If you have urinary problems, talk with your healthcare provider about them.

Symptoms of prostate cancer can be:

• Dull pain in the lower pelvic area
• Frequent urinating
• Trouble urinating, pain, burning, or weak urine flow
• Blood in the urine (Hematuria)
• Painful ejaculation
• Pain in the lower back, hips or upper thighs
• Loss of appetite
• Loss of weight
• Bone pain

b. Functional patterns

• The prostate is roughly 3 centimeters long, about the size of a walnut, and weighs approximately 20 grams. Its function is to produce about a third of the total seminal fluid.
• The prostate gland is located in the male pelvis at the base of the penis. It is below (inferior) to the urinary bladder and immediately anterior to the rectum.
• The prostate surrounds the posterior part of the urethra, but this can be misleading. The posterior urethra, prostatic urethra, and proximal urethra all describe the same anatomy as there is no difference between the internal lining of the prostate and the urethra; they are the same entity.
• The prostate is primarily made up of glandular tissue which produces fluid that constitutes about 30% to 35% of the semen. This prostatic portion of the semen nourishes the sperm and provides alkalinity which helps maintain a high pH. (The seminal vesicles produce the rest of the seminal fluid.)
• The prostate gland requires androgen (testosterone) to function optimally. This is why hormonal therapy (testosterone deprivation) is so effective. Castrate resistant tumors are thought to generate intracellular androgens.
• Cancer begins with a mutation in normal prostate glandular cells, usually beginning with the peripheral basal cells.
• Prostate cancer is most common in the peripheral zone which is primarily that portion of the prostate that can be palpated via digital rectal examination (DRE).
  • Prostate cancer is an adenocarcinoma as it develops primarily from the glandular part of the organ and shows typical glandular patterns on microscopic examination.
  • The cancer cells grow and begin to multiply, initially spreading to the immediately surrounding prostate tissue forming a tumor nodule.
  • Such a tumor may grow outside the prostate (extracapsular extension) or may remain localized within the prostate for decades.
  • Prostate cancer commonly metastasizes to the bones and lymph nodes.
  • Metastases to the bone are thought to be at least partially a result of the prostatic venous plexus draining into the vertebral veins.
• The prostate accumulates zinc and produces citrate. However, increased dietary or supplemental zinc and citrate do not appear to have any influence on prostatic health or the development of prostate cancer.

c. Physical examination of patient with Prostate cancer

Symptoms

Prostate cancer may cause no signs or symptoms in its early stages.

Prostate cancer that's more advanced may cause signs and symptoms such as:

• Trouble urinating
• Decreased force in the stream of urine
• Blood in the urine
• Blood in the semen
• Bone pain
• Losing weight without trying
• Erectile dysfunction

Risk factors

Factors that can increase your risk of prostate cancer include:

• Older age. Your risk of prostate cancer increases as you age. It's most common after age 50.
• Race. For reasons not yet determined, Black people have a greater risk of prostate cancer than do people of other races. In Black people, prostate cancer is also more likely to be aggressive or advanced.
• Family history. If a blood relative, such as a parent, sibling or child, has been diagnosed with prostate cancer, your risk may be increased. Also, if you have a family history of genes that increase the risk of breast cancer (BRCA1 or BRCA2) or a very strong family history of breast cancer, your risk of prostate cancer may be higher.
• Obesity. People who are obese may have a higher risk of prostate cancer compared with people considered to have a healthy weight, though studies have had mixed results. In obese people, the cancer is more likely to be more aggressive and more likely to return after initial treatment.

Complications

Complications of prostate cancer and its treatments include:

• Cancer that spreads (metastasizes). Prostate cancer can spread to nearby organs, such as your bladder, or travel through your bloodstream or lymphatic system to your bones or other organs. Prostate cancer that spreads to the bones can cause pain and broken bones. Once prostate cancer has spread to other areas of the body, it may still respond to treatment and may be controlled, but it's unlikely to be cured.
• Incontinence. Both prostate cancer and its treatment can cause urinary incontinence. Treatment for incontinence depends on the type you have, how severe it is and the likelihood it will improve over time. Treatment options may include medications, catheters and surgery.
• Erectile dysfunction. Erectile dysfunction can result from prostate cancer or its treatment, including surgery, radiation or hormone treatments. Medications, vacuum devices that assist in achieving erection and surgery are available to treat erectile dysfunction.

Screening for prostate cancer

Digital rectal examination Open pop-up dialog box

• Testing healthy men with no symptoms for prostate cancer is controversial. There is some disagreement among medical organizations whether the benefits of testing outweigh the potential risks.
• Most medical organizations encourage men in their 50s to discuss the pros and cons of prostate cancer screening with their doctors. The discussion should include a review of your risk factors and your preferences about screening.
• Prostate screening tests might include:
  • Digital rectal examination (DRE). During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of the gland, you may need further tests.
  • Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein in your arm and analyzed for PSA, a substance that's naturally produced by your prostate gland. It's normal for a small amount of PSA to be in your bloodstream. However, if a higher than usual level is found, it may indicate prostate infection, inflammation, enlargement or cancer.

Diagnosing prostate cancer

Transrectal biopsy of the prostateOpen pop-up dialog box

If prostate cancer screening detects an abnormality, your doctor may recommend further tests to determine whether you have prostate cancer, such as:

• Ultrasound. During a transrectal ultrasound, a small probe, about the size and shape of a cigar, is inserted into your rectum. The probe uses sound waves to create a picture of your prostate gland.
• Magnetic resonance imaging (MRI). In some situations, your doctor may recommend an MRI scan of the prostate to create a more detailed picture. MRI images may help your doctor plan a procedure to remove prostate tissue samples.
• Collecting a sample of prostate tissue. To determine whether there are cancer cells in the prostate, your doctor may recommend a procedure to collect a sample of cells from your prostate (prostate biopsy). Prostate biopsy is often done using a thin needle that's inserted into the prostate to collect tissue. The tissue sample is analyzed in a lab to determine whether cancer cells are present.

Determining whether prostate cancer is aggressive

• When a biopsy confirms the presence of cancer, the next step is to determine the level of aggressiveness (grade) of the cancer cells. A doctor in a lab examines a sample of your cancer cells to determine how much cancer cells differ from the healthy cells. A higher grade indicates a more aggressive cancer that is more likely to spread quickly.
• Techniques used to determine the aggressiveness of the cancer include:
• · Gleason score. The most common scale used to evaluate the grade of prostate cancer cells is called a Gleason score. Gleason scoring combines two numbers and can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer), though the lower part of the range isn't used as often.
• Most Gleason scores used to assess prostate biopsy samples range from 6 to 10. A score of 6 indicates a low-grade prostate cancer. A score of 7 indicates a medium-grade prostate cancer. Scores from 8 to 10 indicate high-grade cancers.
• · Genomic testing. Genomic testing analyzes your prostate cancer cells to determine which gene mutations are present. This type of test can give you more information about your prognosis. But it's not clear who might benefit most from this information, so the tests aren't widely used. Genomic tests aren't necessary for every person with prostate cancer, but they might provide more information for making treatment decisions in certain situations.

Determining whether the cancer has spread

Once a prostate cancer diagnosis has been made, your doctor works to determine the extent (stage) of the cancer. If your doctor suspects your cancer may have spread beyond your prostate, one or more of the following imaging tests may be recommended:

• Bone scan
• Ultrasound
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET) scan

3. Pathophysiologic mechanics of prostate cancer is it a Solid tumor or Liquid tumors

• The prostate is roughly 3 centimeters long, about the size of a walnut, and weighs approximately 20 grams. Its function is to produce about a third of the total seminal fluid.
• The prostate gland is located in the male pelvis at the base of the penis. It is below (inferior) to the urinary bladder and immediately anterior to the rectum.
• The prostate surrounds the posterior part of the urethra, but this can be misleading. The posterior urethra, prostatic urethra, and proximal urethra all describe the same anatomy as there is no difference between the internal lining of the prostate and the urethra; they are the same entity.
• The prostate is primarily made up of glandular tissue which produces fluid that constitutes about 30% to 35% of the semen. This prostatic portion of the semen nourishes the sperm and provides alkalinity which helps maintain a high pH. (The seminal vesicles produce the rest of the seminal fluid.)
• The prostate gland requires androgen (testosterone) to function optimally. This is why hormonal therapy (testosterone deprivation) is so effective. Castrate resistant tumors are thought to generate intracellular androgens.
• Cancer begins with a mutation in normal prostate glandular cells, usually beginning with the peripheral basal cells.
• Prostate cancer is most common in the peripheral zone which is primarily that portion of the prostate that can be palpated via digital rectal examination (DRE).
  • Prostate cancer is an adenocarcinoma as it develops primarily from the glandular part of the organ and shows typical glandular patterns on microscopic examination.
  • The cancer cells grow and begin to multiply, initially spreading to the immediately surrounding prostate tissue forming a tumor nodule.
  • Such a tumor may grow outside the prostate (extracapsular extension) or may remain localized within the prostate for decades.
  • Prostate cancer commonly metastasizes to the bones and lymph nodes.
  • Metastases to the bone are thought to be at least partially a result of the prostatic venous plexus draining into the vertebral veins.
• The prostate accumulates zinc and produces citrate. However, increased dietary or supplemental zinc and citrate do not appear to have any influence on prostatic health or the development of prostate cancer.