The Diagnosis of Prostate Cancer

Part of the “Enhancing Prostate Cancer Care” MOOC

Catherine HolbornSenior Lecturer in Radiotherapy & Oncology

Sheffield Hallam University

Learning Outcomes (week 1)By the end of week 1, you should be able to:

1. Explain the factors that place men at a higher risk of having or developing a prostate cancer

2. Describe the steps and tests undertaken, in order to diagnose prostate cancer and discuss their pros and cons

3. Discuss the benefits and limitations of PSA testing in asymptomatic men

4. Discuss how information and support relating to prostate cancer and prostate cancer testing might be improved

Why are these important?In Europe, prostate cancer is the most common cancer

in men. Worldwide it is the second most common¹.In the UK, it is the second most common cause of male

cancer death. In Europe, the third and Worldwide, the fourth most common cause¹.

Arguably, increased awareness about prostate cancer is needed. More importantly, awareness of the risk factors that can place a man at a higher risk of having or developing prostate cancer.

Why else?The diagnosis of prostate cancer is not straightforward and

the tests involved can be unpleasant and uncomfortableIt involves a number of different tests, each of these with their

own benefits, limitations and even risksTesting an asymptomatic man for prostate cancer is not a

straightforward decisionThere is currently no definitive test that can tell us whether a

man with an early stage prostate cancer has a slow growing and indolent cancer, or a more aggressive and fast growing one

Men must be well informed about the procedures and be supported to make informed choices that are right for them, based on their individual risk and preferences

Risk Factors: AgeRisk increase with ageIn the UK, it is rare under the age of 50, accounting for

1% of cases. 36% of cases are in men aged 75yrs and over¹.

In many countries, asymptomatic men, around the age of 45-55yrs (recommendations vary), are encouraged to talk to their primary care physician/GP about their ‘individual’ risk of developing prostate cancer, and the pros and cons of being tested based on this, and other relevant individual factors.

Risk Factors: Familial LinksIf one first line relative has had prostate cancer, a man’s risk is

doubledIf two or more first line relatives have had prostate cancer, the

risk increases 6-11 fold²Asymptomatic men to whom this applies, must be informed of

their increased risk and the potential value of being tested in this context.

Some genetic links have been identified e.g. the breast cancer susceptibility gene (BRCA2)

Much more research in this area is needed and is ongoing

Risk Factors: EthnicityAgain, asymptomatic men to whom this applies, must be

informed of their increased risk and the potential value of being tested.

Black men are at a higher risk of developing prostate cancer than white men

In the UK, Black men have a 1 in 4 lifetime risk³. In the US, they are 1.6 times more likely to develop prostate cancer and 2.4 times more likely to die from it ⁴.

Men present more frequently with high grade and aggressive cancers, increased tumour volume at each clinical stage and increased PSA levels⁵⁶

A Genetic-Environment LinkGenetic and biochemical differences are thought to pre-dispose Black

men to prostate cancerAdditional environmental factors may then act as a trigger to its

development⁵⁶Genetic; certain genes may be responsible, but research is ongoing in

this area. Those identified to-date are involved in promoting androgen metabolism, enabling prostate growth and providing a driving force for prostate cancer initiation and progression⁵

Biochemical; factors such as decreased serum vitamin D levels, Insulin Growth Factor (IGF) levels and ratios (high level of IGF-1), increase serum LDL cholesterol levels and decreased serum lycopene levels; are some that have been investigated⁵

Environmental e.g. a westernised lifestyle characterised by a high calorific diet, rich in fat, refined carbohydrates and animal protein.

PSA testing asymptomatic menAsymptomatic men who fall into one of the three risk

categories, may want to consider being tested for prostate cancer

Why don’t we (the UK and other countries) do this as routine?A benefit to being tested can be the detection of a prostate

cancer, hopefully at an early stage, when it is very treatableHowever, there are also limitations and risks associated with

being testedMany countries feel that these are too significant and that the

benefits do not outweigh these (for the population)However, on an individual basis, they might do…

Men should be well-informedSo PSA testing in asymptomatic men should be

undertaken after an informed decision has been made by the individual, after discussion with their physician/GP about their ‘individual’ risk and health preferences

The resources this week provide an overview of the key issues associated with PSA testing/screening

References1. Cancer Research UK. Prostate Cancer Statistics. Available at

www.cancerresearchuk.org/cancer-info/cancerstats/types/prostate (last accessed 01/06/2014)

2. Heidenreich A, Bastian PJ, Bellmunt J, Bolla M, Joniau S, Mason MD et al (2013) Guidelines on Prostate Cancer. European Association of Urology. Available at www.uroweb.org/guidelines/online0guidelines

3. Prostate Cancer UK. About the risk in Black men (webpage). Available at www.prostatecanceruk.org/information/who-is-at-risk (last accessed 01/09/2014)

4. Prostate Cancer Foundation. Prostate Cancer: straight talk for African-American men and their families. Available at www.pcf.org/site (last accessed 01/09/2014)

5. Chornokur G, Dalton K, Corysova ME, Kumar NB (2010) Disparities at presentation, diagnosis, treatment and survival in African American men affected by prostate cancer. The Prostate. 71(9) pp.985-997

6. Wu I and Modlin CS (2012) Disparities in prostate cancer in African-American men: what primary care physicians can do. Cleveland Clinical Jounral of Medicine. 79(5) pp.313-320

So what next?You should now start to read through the learning

resources and information supporting this weeks learning outcomes.

This includes the videos with those who have been affected by prostate cancer.

And of course, try to engage with this weeks activities as much as possible, to help consolidate and enhance your learning