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Last Updated: 6/5/2015  

Prostate Cancer

Prevention
  • Tell patients who ask that the risks of finasteride and dutasteride may outweigh the potential benefits for prostate cancer prevention.

Screening
  • Discuss the benefits and harms of PSA testing in standard-risk men aged 50 to 69, beginning at age 40 to 45 in men with risk factors.

  • Do not offer screening for most men over age 69 or with a life expectancy of less than 10 to 15 years.

Diagnosis
  • Obtain a prostate biopsy in patients with a serum PSA level >4.0 ng/mL or with a nodule or suspicious induration on digital rectal examination (DRE).

  • Obtain serum PSA levels and DRE in men with obstructive urinary symptoms, impotence, hematospermia, or pelvic pain or signs of metastatic prostate cancer.

  • Perform staging evaluation to exclude regional or metastatic disease in select patients with biopsy-confirmed prostate cancer.

Therapy
  • Note that the therapy of prostate cancer can be complex and is best made with involvement of the patient and a multidisciplinary team.

  • Therapeutic options are informed by cancer stage and risk of progression based upon PSA levels and Gleason score; general options include:

    • Watchful waiting or active surveillance for low-risk disease

    • Radical prostatectomy or external-beam radiation therapy for early-stage disease and a life expectancy of 10 or more years

    • Brachytherapy for localized low-risk disease and minimal obstructive symptoms

    • Androgen deprivation therapy (ADT) for metastatic disease

    • Bilateral orchiectomy for patients who fail ADT if serum testosterone is at castrate levels

    • Combined androgen blockade (ADT plus nonsteroidal anti-androgen) for metastatic hormone-sensitive prostate cancer

    • ADT for a rising PSA level following therapy for localized disease or high risk disease after prostatectomy

  • Monitor serum PSA following local therapy for prostate cancer; begin ADT if the PSA level rises from the post-treatment nadir.

  • Recommend palliative external-beam radiation therapy for castration-resistant prostate cancer and painful bone metastases.

  • Administer chemotherapy for metastatic castration-resistant prostate cancer that is symptomatic or rapidly progressing, generally with docetaxel as first-line therapy.

  • Screen patients with prostate cancer who are undergoing androgen deprivation therapy for osteoporosis, and administer bisphosphonate to patients with low bone-mineral density or osseous metastases.

DOI: 10.7326/d188
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Timothy Gilligan, MD has nothing to disclose. William K. Oh, MD has nothing to disclose. Bilal Chughtai, MD has nothing to disclose. James Stulman, MD has nothing to disclose.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD; Richard Lynn, MD, FACP.

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