Prostate Cancer:

Men at risk & diagnosis

Marc Laniado

Prostate cancer is a big issue

Q: Which ethnic group is at the HIGHEST

risk of developing prostate cancer?

Life time risk of diagnosis

Black men 1 in 4 life time risk

Asian men 1 in 20 life time risk

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White men 1 in 8 life time risk

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Life time risk of dying

Black men 1 in 12

Asian men 1 in 44

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White men 1 in 24

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Risk of PCa within 10, 20 and

30 years by age

percentage of men (how many out of 100) who will get prostate cancer over different time periods. The time periods are based on the man’s current age.

Current age Within 10 y Within 20 y Within 30 y

30 0.01% 0.32% 2.3

40 0.3% 1% 7%

50 2% 7% 13%

60 6% 11% 14%

70 7% 10% n/a

(A) Prostate cancer is more likely than benign disease

(B) Benign disease is more likely than cancer

Q: In a 50 year old white man

with moderate lower urinary

tract symptoms (LUTS) & PSA

4 mcg/L,

A man with a high PSA and no LUTS is

MORE likely to have prostate cancer

Prostate cancer grows from the outside and

only late presses on the urethra

BPH grows around urethra

causing symptoms early

• Test for PSA & do prostate examination for [1.6.2]

• Lower urinary tract symptoms OR urinary retention

• Erectile dysfunction

• Haematuria -

• DVT - test for urological cancers

• 2WW suspected cancer referral [new 2015]

• PSA > age specific reference range PSA

• Abnormal DRE

NICE Guideline 12

prostate cancer

testing & referral

Q: A 50 y.o. man is concerned: his prostate feels

benign & you test his PSA. On follow up, you advise

him that his PSA is 4 mcg/L Do you refer now

A) yes, even though he remembers he

ejaculated 2 nights before the blood was taken

B) No, because urine culture suggests a UTI

C) Yes, as his prostate felt small

D) Yes, as his prostate felt enormous

E) No, because he exercised vigorously the

day before the blood was taken

Half of abnormal PSA results

return to normal on retest

PSA values in one man over a time

Fre

quency

Always repeat the PSA after 2 weeks, please

Avoid exercise and ejaculation

for 2 days before PSA

If PSA high with UTI, give quinolone for 2

weeks, wait 2 weeks or more before retest

But don’t routinely give antibiotics

just repeat after 2 weeks

Prostate examination▪ Prostate

▪ Size

▪ Normal – golf ball

▪ > 50 cc – tennis ball

– Consistency

▪ Nodule/asymmetric? Cancer

– Anatomical limits

▪ Should be able to feel median sulcus, lateral

and cranial borders

▪ Seminal vesicles impalpable

– Normal anal tone and sensation

T1: feels benign

T2: hard but mobile

T3: hard, not mobile

T4: fixed

Refer immediately if

the prostate feels

hard

Q Your patient: 63 year-old, white man, PSA

6.5 & 7 mcg/L, benign-feeling prostate

What should you NOT tell him next?

A) His chance of any prostate cancer is

70% & significant prostate cancer 40%

B) a multiparametric MRI is the next test

and can avoid the need for prostate

biopsies in 25% of men

C) His chance of urosepsis after a

transrectal biopsy is <1%

Men aged 50 to 75; PSA 3- 15 mcg/L:

71% have prostate cancer

Reference standard

40%

31%

0%

25%

50%

75%

100%

Transperineal mapping biopsy

% o

f m

en w

ith s

ignific

ant ca

ncer

Significant Insignificant

mpMRI can “see”

prostate cancer that

cannot be felt or

reached by

transrectal biopsy

‘suspicion score’ or PI-RADS score:

1 (very low risk) to 5 (very high risk)

Cancer in

prostate

Bladder

Rectum

Anus

mpMRI found 93% of significant

prostate cancers

Reference standard

40% 37%

0%

25%

50%

75%

100%

Transperineal mapping biopsy mpMRI +ve

% o

f m

en w

ith s

ignific

ant ca

ncer

Significant

TRUS biopsy identified less than

half of significant cancers

Reference standard

40% 37%

19%

0%

25%

50%

75%

100%

Transperineal mapping biopsy mpMRI +ve TRUS biopsy +ve

% o

f m

en w

ith s

ignific

ant ca

ncer

Significant

1 in 4 men have low suspicion score

MRI (i.e. 1 or 2) & can avoid biopsy

Ahmed 2017 Lancet

But even low suspicion score MRI scan

may require biopsies if other high risk factors

e.g. PSA density, FH of PCa, Afro-Caribbean origin, low free/total PSA ratio

Transrectal prostate biopsies

are ‘transfaecal’ biopsies

Prostate

RectumUltrasound probe

significant infection in 1 to 4% of men

Transperineal biopsies accurate, reach

front & back of prostate, no sepsis

Front

Cancer

Prostate

Perineal skin

Grid

Back

Cancer

Can be done under local anaesthetic

Q: 47 y.o. man, father had prostate cancer,

benign-feeling prostate, PSA 2.7 mcg/L

A. You admonish him for having had his PSA test and

tell him never to do it again

B. you advise him that his PSA is normal, and to

forget about

C. you tell him to repeat his PSA & will make a

Suspected Cancer Referral only if the PSA is the

same or more

D. You give him two weeks of an antibiotic

(ciprofloxacin/trimethoprim) & repeat his PSA in

another 2 weeks

E. You tell him that randomised studies have shown

no benefit in PSA testing and treatment makes no

difference anyway

PCRMP guidance states that

"The PSA test is available free to any

man aged 50 or over who requests

it, after careful consideration of the

implications".

https://www.gov.uk/guidance/prostate-cancer-risk-management-programme-overview

PSA testing in asymptomatic men

Prostate Cancer Risk Management Programme,

Public Health England 2016

Relatives with prostate or breast

cancer increase the risk

Pancreatic

Prostate

Prostate PancreaticBreast

Breast

ProstateProstate

Ovary

Colon

https://prostatecanceruk.org/for-health-professionals/our-

projects/psa-consensus-for-health-professionals

Prostate Cancer Diagnostic Pathway with mpMRI and transperineal biopsies

31

PSA > 3 or > 2.5 with risk

factorsmpMRI

Suspicion score 3, 4 ,5

Suspicion score 1, 2

Targeted transperineal

prostate biopsies

transperineal systematic biopsies

PSA surveillance & repeat mpMRI

Biomarker?

No mpMRI

PSAD = PSA density (PSA/prostate volume)

Q: Man 63 y, fit & well on finasteride for 7 years &

negative transrectal biopsy. He wants testosterone

supplementation & you check his PSA graph.

A. His PSA is below age -

specific reference

range, so all good

B. Doubling his PSA is

still less than before,

so all is good

C. Switch him to

dutasteride &

prescribe testosterone

D. Refer to a urologist

0

1.5

3

4.5

6

PS

A

Finasteride

Finasteride shrinks benign prostate tissue;

significant cancer continues to still grow

Low risk tumour

High-risk tumour

Proportion occupied by the tumour

increased after background prostate shrinks

Proportion occupied by the growing tumour

increases even more after background prostate shrinks

After starting finasteride/dutasteride PSA

drops and stays low in BPH

0.

1.5

3.

4.5

6.

PSA

5ARI started

BPH

PSA drops starting finasteride/dutasteride with

low risk prostate cancer

0.

1.5

3.

4.5

6.

PSA

5ARI started

Low risk PCa

BPH

Rising PSA after starting

finasteride/dutasteride suggests high risk

prostate cancer

0.

1.5

3.

4.5

6.

PSA

5ARI started

High risk

PCa

Low risk PCa

BPH

New blood and urinary biomarkers predict

high-grade PCa on TRUS biopsy

•

FDA approved

Not available in UK

Not FDA approved

Available in UK as part of corporate screens

Available in UK

Prostate Cancer Diagnostic Pathway with mpMRI and transperineal biopsies

38

PSA > 3 or > 2.5 with risk

factorsmpMRI

Suspicion score 3, 4 ,5

Suspicion score 1, 2

Targeted transperineal

prostate biopsies

transperineal systematic biopsies

PSA surveillance & repeat mpMRI

Biomarker?

No mpMRI &

PSA < 15

SelectMDxPSA surveillance & repeat Biomarker

No mpMRI