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  • Writer's pictureFrancesco Bruno Tagliaferro

Prostate cancer: epidemiology, diagnosis and treatment

Prostate cancer is the second most common cancer in the male population. There are three well-recognized risk factors for prostate cancer:

  • advanced age

  • genetic predisposition

  • ethnic origin


Prostate cancer represents 22% of all neoplasms after the fifth decade of life and is the third cancer for mortality in Italy, determining 8% of all men deaths for tumors.

Currently, there is no high-level scientific evidence that identifies preventive measures to reduce the risk of prostate cancer.

Life expectancy has gradually risen, and is now 92% at five years; this increase was mainly determined by the improvement of diagnostic thecniques, which allowed to anticipate the diagnosis (pre-clinical stage) and, therefore, allowed to anticipate the therapy, making it more effective.


PROSTATE CANCER DIAGNOSIS

Esplorazione rettale
Rectal exploration

Prostate cancer is usually suspected following positive rectal examination and/or elevated PSA levels. The definitive diagnosis is always histological. Therefore, in the suspicion of prostate cancer, prostate biopsy is mandatory. Before proceeding with a prostate biopsy, multiparametric prostate MRI is strongly recommended. In fact, it has a very high negative predictive power, i.e. if the MRI is negative, it is highly unlikely that there is a prostate cancer, and if the clinical suspicion is low, the biopsy can possibly be avoided. Conversely, if the MRI shows suspicious areas, the images can be used to perform a targeted sampling of the lesions, thus increasing the precision of the biopsy. Ultrasound, transrectal and suprapubic, has no role in the diagnosis of prostate cancer, nor can it be used as a screening tool. If the ultrasound shows one or more suspicious areas for cancer, these will still need to be confirmed with the MRI. If, on the other hand, the ultrasound is negative, this result cannot be considered satisfactory, as the method is not powerful enough. In case of suspicion, an MRI should still be performed. The guidelines of international scientific societies define prostate biopsy with fusion technique (RM + ECO) as the most reliable approach among the various biopsy techniques still in use . For a more in-depth discussion of diagnostic techniques, please refer to the specific articles.





STAGING AND GRADING


For the clinical staging of prostate cancer, the 2017 TNM (Tumor Node Metastasis) classification is used. Here is the table of the guidelines of the European Society of Urology of 2022, the most recent:


The histopathological grading of prostate cancer is defined by the Gleason score, which assigns a score from 1 to 5 based on the degree of the neoplastic disease (1 normal cells, 5 advanced cancer). To obtain the score, it is necessary to add the score of the two most represented tumor patterns. The number obtained is the Gleason score (e.g. 4+4 = Gleason 8). The most represented pattern is written first (eg 7 can be 3+4 or 4+3). The most recent ISUP grading assigns a grade from 1 to 5 to tumor patterns, essentially differentiating Gleason 7: 3+4 from Gleason 7: 4+3, the latter assigned to a higher grade.


NOTES OF THERAPY


Treatment of prostate cancer depends on several factors, including the stage of the cancer, its severity, the patient's general health and personal preferences. Here is a non-exhaustive list of common treatment options for prostate cancer (it is advisable to ALWAYS refer to your trusted doctor to take the most suitable path)

  1. Active surveillance: this approach is usually taken for slow-growing prostate cancers or for elderly patients with medical problems that may not require immediate treatment. During active surveillance, doctors closely monitor the cancer with periodic tests (for example, blood tests for PSA levels and prostate biopsies) to evaluate its progression. If the cancer starts to grow or get worse, people may switch to other treatments.

  2. Surgery: radical prostatectomy is surgery in which the entire prostate and surrounding tissue is removed. This procedure is often recommended for prostate cancers that are confined to the gland and are not metastatic. It can be performed through a traditional abdominal incision or with the help of less invasive techniques such as laparoscopic prostatectomy or robotic prostatectomy.

  3. Radiation therapy: this treatment option uses high-energy ionizing beams to destroy cancer cells. It can be given externally (external beam radiation) or internally (brachytherapy), which involves inserting small radioactive sources directly into the prostate. Radiation therapy can be used as a primary treatment or as a complement to surgery.

  4. Hormone therapy: since testosterone stimulates the growth of prostate cancer cells, hormone therapy aims to reduce testosterone levels in the body. This can be done through the use of drugs that block testosterone production or that prevent testosterone receptors from binding to cancer cells. Hormone therapy can be used as a primary treatment or as a complement to other treatments such as surgery or radiation therapy.

  5. Chemotherapy: This is mainly used when prostate cancer is metastatic and does not respond to other treatments. Chemotherapy uses drugs to kill cancer cells or slow their growth.

  6. Cryotherapy: cryotherapy is a therapeutic procedure that uses extreme cold to destroy prostate cancer cells. It is used as a treatment option for prostate cancer in a few selected cases.


Importantly, treatment options may vary depending on the patient's individual circumstances. The choice of the best treatment must be based on an accurate assessment of the case by a specialized medical team, which takes into account the clinical features, the patient's preferences and the potential complications or side effects of the different therapeutic approaches.

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