What is the protocol for screening, diagnosing, and treating prostate cancer?

Protocol for Screening, Diagnosis, and Treatment of Prostate Cancer

Population-based PSA screening for prostate cancer reduces prostate cancer mortality at the expense of overdiagnosis and overtreatment and is not recommended for general population screening. 1 Instead, a risk-adapted approach with individualized decision-making is the current standard of care.

Screening Protocol

Who to Screen

• Men aged 55-69 years: Discuss benefits and harms of screening through shared decision-making 1, 2
• High-risk men (African American men or those with first-degree relative diagnosed with prostate cancer before age 65): Begin screening at age 45 2
• Very high-risk men (multiple family members diagnosed with prostate cancer before age 65): Begin screening at age 40 2
• Men over 70 years: Screening not recommended 1, 2
• Men with life expectancy <10-15 years: Screening not recommended 2

Screening Method

• PSA blood test with digital rectal examination (DRE) 2
• A single elevated PSA should not prompt a prostate biopsy and should be verified by a second value 1
• Screening intervals based on PSA level 2:
  • PSA <1.0 ng/mL: Every 2-4 years
  • PSA 1.0-2.5 ng/mL: Every 2 years
  • PSA ≥2.5 ng/mL: Annually

Diagnostic Protocol

Indications for Biopsy

• Decision for biopsy should consider:
  • DRE findings
  • Ethnicity
  • Age
  • Comorbidities
  • PSA values
  • Free/total PSA ratio
  • History of previous biopsy
  • Patient values 1

Biopsy Procedure

• Transrectal ultrasound-guided prostate biopsy under antibiotic cover and local anesthesia
• Minimum of 10-12 cores should be obtained 1
• Before repeat biopsy, multi-parametric MRI is recommended with a view to MRI-guided or MRI-TRUS fusion biopsy 1

Pathology Reporting

• Report the extent of involvement of each biopsy core
• Report the commonest and worst Gleason grades 1
• Use International Society of Urologic Pathology recommendations for reporting 1

Staging Protocol

Risk Assessment

• General health and comorbidities should be assessed 1
• Patients not suitable for curative treatment due to poor health do not normally require staging investigations 1

Imaging for Staging

• Patients with intermediate or high-risk disease should be staged for metastases using:
  • Technetium bone scan
  • Thoraco-abdominal CT scan or
  • Whole-body MRI or
  • Choline PET/CT 1

Treatment Protocol

Localized Disease

1. Watchful waiting with delayed hormone therapy

   • For men not suitable for or unwilling to have curative treatment 1

2. Active surveillance

   • For low-risk disease
   • Involves close monitoring with PSA, repeat biopsies, and/or MRI
   • Curative treatment reserved for those with disease progression 1, 3

3. Radical prostatectomy

   • Curative option for localized disease
   • Potential side effects include erectile dysfunction (affects 2 in 3 men) and urinary incontinence (affects 1 in 5 men) 4

4. External beam radiotherapy or brachytherapy

   • Alternative curative options
   • Side effects include bowel and urinary problems 1

Metastatic Disease

1. Androgen deprivation therapy (ADT)

   • Primary treatment for metastatic disease
   • Usually through medical castration with gonadotropin-releasing hormone agonists 3

2. Combination therapy

   • Addition of androgen receptor pathway inhibitors (e.g., darolutamide, abiraterone) to ADT improves survival
   • Abiraterone improved median overall survival from 36.5 months to 53.3 months compared with ADT alone 3

3. Chemotherapy

   • Docetaxel may be considered, especially for patients with extensive disease 3
   • Cabazitaxel (25 mg/m²) can be used after docetaxel failure 5

4. Novel hormonal therapies

   • Enzalutamide has shown efficacy in both metastatic and non-metastatic castration-sensitive prostate cancer 6

Common Pitfalls and Caveats

• PSA screening: While it reduces prostate cancer mortality by approximately 21%, it leads to overdiagnosis and overtreatment, with 781 men needing to be invited for screening and 27 patients needing treatment to prevent one death 1

• False positives: PSA is not specific for prostate cancer and can be elevated in benign conditions, leading to unnecessary biopsies 2

• Age considerations: Testing for prostate cancer in asymptomatic men should not be done in men over 70 years due to limited benefit and increased harms 1

• Treatment decisions: Given the range of treatment options and side effects, men should be offered consultation with both a urologist and radiation oncologist 1

• Treatment complications: Men should be counseled that treatment may cause sexual dysfunction, infertility, bowel and urinary problems 1