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Last Updated: 9/18/2014  

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.
Authors and Disclosures:
Timothy Gilligan, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. William K. Oh, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Bilal Chughtai, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. James Stulman, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.

The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, FACP, Editor.

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