From the Guidelines
As a top-notch PG resident, it is crucial to prioritize prostate cancer management based on the most recent guidelines, such as the 2023 NCCN Clinical Practice Guidelines in Oncology 1. When managing prostate diseases, it is essential to consider the complexity of the disease and the various treatment options available. The most common prostate diseases include benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer.
Key Considerations
- For BPH, initial management includes alpha-blockers like tamsulosin (0.4mg daily) or alfuzosin (10mg daily), which relax smooth muscle to improve urinary flow.
- 5-alpha reductase inhibitors such as finasteride (5mg daily) or dutasteride (0.5mg daily) can be added for larger prostates (>40g) to reduce prostate size over 3-6 months.
- For acute bacterial prostatitis, ciprofloxacin 500mg twice daily or trimethoprim-sulfamethoxazole 160/800mg twice daily for 2-4 weeks is recommended.
- Chronic bacterial prostatitis requires longer antibiotic courses of 4-12 weeks.
Prostate Cancer Management
Prostate cancer management should be tailored to the individual patient, considering factors such as adjusted life expectancy, disease characteristics, predicted outcomes, and patient preferences, as outlined in the 2023 NCCN Clinical Practice Guidelines in Oncology 1.
- Active surveillance is recommended for low-risk disease.
- Radical prostatectomy or radiation therapy is suitable for intermediate-risk disease.
- Multimodal approaches, including androgen deprivation therapy, are necessary for high-risk disease.
Diagnostic Tools
- Digital rectal examination and PSA testing are crucial diagnostic tools.
- PSA velocity and density provide additional diagnostic value. By understanding the pathophysiology of prostate diseases, including hormonal influences in BPH, infectious processes in prostatitis, and genetic/environmental factors in cancer, healthcare providers can guide appropriate therapeutic approaches and improve patient outcomes.
From the FDA Drug Label
- 1 Monotherapy Finasteride tablets 5 mg/day was initially evaluated in patients with symptoms of BPH and enlarged prostates by digital rectal examination in two 1-year, placebo-controlled, randomized, double-blind studies and their 5-year open extensions Patients in A Long-Term Efficacy and Safety Study had moderate to severe symptoms at baseline (mean of approximately 15 points on a 0 to 34 point scale). Patients randomized to finasteride tablets who remained on therapy for 4 years had a mean (± 1 SD) decrease in symptom score of 3.3 (± 5. 8) points compared with 1.3 (± 5.6) points in the placebo group. Compared with placebo, finasteride tablets was associated with a significantly lower risk for acute urinary retention or the need for BPH-related surgery [13.2% for placebo vs 6. 6% for finasteride tablets; 51% reduction in risk, 95% CI: (34 to 63%)]. Finasteride tablets decreased prostate volume by 17.9% (from 55. 9 cc at baseline to 45.8 cc at 4 years) compared with an increase of 14.1% (from 51.3 cc to 58.5 cc) in the placebo group (p<0.001).
Diseases of the prostate such as Benign Prostatic Hyperplasia (BPH) can be effectively managed with finasteride tablets. The medication has been shown to:
- Decrease symptom score by a mean of 3.3 points compared to 1.3 points in the placebo group
- Reduce the risk of acute urinary retention or the need for BPH-related surgery by 51%
- Increase maximum urinary flow rate by 1.9 mL/sec compared to 0.2 mL/sec in the placebo group
- Decrease prostate volume by 17.9% compared to an increase of 14.1% in the placebo group These effects are beneficial for patients with moderate to severe symptoms of BPH and enlarged prostates 2.
From the Research
Diseases of the Prostate
As a top-notch PG resident, it is essential to understand the various diseases that affect the prostate gland. Some of the common diseases include:
- Benign prostatic hyperplasia (BPH)
- Prostate cancer
Diagnosis and Management of BPH
According to 3, BPH is a common condition that increases in prevalence with age. The diagnosis of BPH involves a history of onset, duration, and severity of lower urinary tract symptoms and medication use to rule out other causes of symptoms. Physical examination includes a digital rectal examination and assessment for bladder distention or neurologic impairment. Recommended tests include serum prostate-specific antigen measurement and urinalysis to help identify infection, genitourinary cancer, or calculi as an alternative cause of lower urinary tract symptoms.
Role of Digital Rectal Examination in Prostate Cancer Diagnosis
The role of digital rectal examination (DRE) in prostate cancer diagnosis has been debated in recent years. According to 4, the COVID-19 pandemic has resulted in the rapid adoption of virtual consultations, making clinical examination difficult. However, 5 suggests that DRE has a limited role in the modern prostate cancer diagnostic pathway due to the widespread adoption of MRI. Additionally, 6 found that DRE had a statistically significant effect on the serum PSA concentration, but the clinical significance of this effect was inconsequential.
Screening for Prostate Cancer
According to 5, the screening performance of digital rectal examination for detection of prostate cancer is not particularly impressive, suggesting that it might not be necessary to conduct this examination routinely. However, 7 found that DRE demonstrated prognostic usefulness when prostate-specific antigen was greater than 3 ng/ml, limited usefulness for less than 2 ng/ml, and marginal usefulness for 2 to 3 ng/ml. These findings support the restriction of digital rectal examination to men with higher prostate-specific antigen as a reflex test to improve specificity.
Key Findings
Some key findings from the studies include:
- BPH severity is assessed using validated, self-administered symptom questionnaires such as the American Urological Association Symptom Index or International Prostate Symptom Score 3.
- DRE has a limited role in the modern prostate cancer diagnostic pathway 4, 5.
- The screening performance of digital rectal examination for detection of prostate cancer is not particularly impressive 5.
- DRE demonstrated prognostic usefulness when prostate-specific antigen was greater than 3 ng/ml 7.