Prostate Cancer

 

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Taylor Carta, Devin Conway, Shaimaa Eldib, Lucinda hampton, Kim Jackson, Vidya Acharya, Nicole Sandhu, Tony Lowe, Evan Thomas, Mandy Roscher, Jess Bell, Kirenga Bamurange Liliane, Elaine Lonnemann, 127.0.0.1, Rosie Swift, Tarina van der Stockt, Venugopal Pawar and WikiSysop  

Definition/Description

Prostate cancer is the most common type of cancer in men after skin cancer, and is the second leading cancer related cause of death in men. It is slow growing and affects one third of all males by the age of 50.  Prostate cancer is a common metastatic cancer that spreads primarily to bone, which frequently causes lumbar pain. (TEXT) Even with such a high mortality and metastasis rate, microscopic changes occur in the prostate which often cause no signs or symptoms, and they may be so slow growing that they may never cause a health threat. (TEXT) Variations in the rate of prostate cancer progression and spreading suggests genetic involvement along with familial predisposition and diet.Overall, prostate cancer has become a significant issue due to the fact that it is so prevalent, more men are being diagnosed due to an increase in routine screenings, more men are living longer with the disease, and because there is a higher incidence of the disease with an increase in age. (TEXT)

Prevalence

Prostate cancer is more common in African-American males compared to white or Hispanic males, and is least common in Asians and Native American men.¹ It most commonly affects men over the age of 50 with an increasing incidence with age. It is rare in men under 45.¹

Characteristics/Clinical Presentation

Clinical Signs and Symptoms^1,2:

• Urinary retention or other urinary complaints
• Low back pain, inner thigh or perineal pain or stiffness
• Hematuria
• Suprapubic or pelvic pain
• Sexual dysfunction

Early prostate cancer may be asymptomataic. Most screenings of prostate cancer are being done in asymptomatic men. The listed signs and symptoms may also be present with other prostate related disease processes such as benign prostatic hyperplasia or prostatitis.²

Manifestations of Metastasized Prostate Cancer^1,2:

• Sciatica
• Bone pain and lower extremity pain
• Lymphedema of groin or lower extremities 
• Neurological changes from spinal cord compression
• Anemia
• Weight loss and loss of appetite

Associated signs and symtoms to ask the patient about include:

• Melena
• Sudden moderate to high fever
• Chills
• Changes in bowel or bladder function

Associated Co-morbidities

A retrospective study entitled “Comorbidities, Treatment and Ensuing Survival in Men with Prostate Cancer” looked at men diagnosed with prostate cancer and how cormorbidities affected their mortality and treatment.

Survival differences corresponding to 5-year and 10-year survival rates were studied. “The respective 5-year and 10-year survival for those without any comorbid conditions were 88% and 75%; men with moderate-severe COPD were 50% and 12%; diabetes with end-organ damage were 57% and 36%.” So, just based off of this one studied it can be speculated that comorbidities such as, COPD and diabetes could factor into the mortality of those diagnosed with prostate cancer. (STUDY)

Also, some studies have shown that there is a lower risk of getting a less dangerous form of prostate cancer and an increased risk of getting a more advanced form of it in obese men. Some studies have also found that obesity may create a greater risk of dying from prostate cancer. (ACS)

Medications

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Diagnostic Tests/Lab Tests/Lab Values

Screening:

Prostate-specific antigen (PSA) test: 

• A blood test used to test for elevated levels of PSA, which occurs with any changes in the prostate.
• The risk of disease increases as the PSA level increases; however, a normal level of PDA has not been determined. 1
• If prostate cancer develops the PSA levels will typically increase past 4 ng/mL of blood (American cancer society)

        -PSA level between 4 and 10: 25% chance of having prostate cancer

        -PSA greater than 10: over 50% chance of having prostate cancer

• No PSA level guarantees the absence of prostate cancer. (medscape)

         -Approximately 15% of men with a PSA below 4 will be positive for prostate cancer when biopsied (American cancer society)

• There are several factors that may increase PSA levels (American Cancer Society)

The U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer due the test often producing false positives, which then can lead to harmful side effects from proceeding diagnostic tests or treatment. (Medscape) This recommendation is considered controversial and is currently in the process of being updated according to the U.S. Preventive Services Task Force website. (USPSTF)

Digital rectal examination (DRE):

• A DRE is an exam in which the doctor inserts a finger into the rectum to allow the ability to palpate the back of the prostate gland, which allows for the ability to feel possible cancers or bumps (american cancer society)
• Majority of patients diagnosed with prostate cancer have abnormal PSA levels, but normal DRE results (medscape)
• This test may still be included in screening because even though it is less effective than a PSA blood test overat may still be able to detect cancer in men that may demonstrate normal PSA levels

Prostate cancer often grows slowly; therefore, men without symptoms of prostate cancer who do not have a 10-year life expectancy may not be screened. Overall health status, and just age, is important when making decisions, and patients should talk to their healthcare provider about the pros and cons of being tested and treated for prostate cancer. (CDC, American Cancer Society)

Recommended age to start screening for prostate cancer according to the American Cancer Society:
• 50 years of age for men with an average risk, and who have at least a 10-year life expectancy
• 40 or 45 years of age for African Americans and men who have had a first-degree relative diagnosed with prostate cancer before age 65 years
• 40 years of age for men with several first-degree relatives who had prostate cancer at an early age

Diagnosis:

Biopsy:

• The diagnosis of prostate cancer is established via a biopsy of the prostate gland, and may be indicated for individuals who have elevated PSA levels. (medscape)
• A small piece of the prostate gland is removed and examined under a microscope for cancer cells. If cancer cells are found a Gleason score will be determined from the biopsy.
• Gleason score: indicates how likely the cancer is to spread.

        -Ranges from 2–10: the lower the score the less likely it is that the cancer will spread (cdc)

• False-negative results often occur; therefore, multiple biopsies may be done before prostate cancer can be detected (medscape)

Transrectal Ultrasound (TRUS):

• A small probe is inserted into the rectum and it uses sound waves (ultrasound) to create a picture of the prostate.
• TRUS is not utilized as a screening tool because it cannot always differentiate between normal tissue and cancerous tissue. Instead, it is often used in conjunction when a prostate biopsy to help guide the biopsy needles into the right area of the prostate.
• TRUS can also be utilized to determine the PSA density and can also be used to tell which treatment choices are appropriate. (American Cancer Society)

Etiology/Causes

The cause of prostate cancer is not yet known; however, there are several known risk factors that have been shown to indicate an increase in the risk of developing cancer. (ACS)

Non modifiable:

• Advancing Age

     -Most men who acquire prostate cancer are 65 years or older
     -It is very rare to develop prostate cancer before 45 years of age

• Race/Ethnicity

     -African-American men have an increased risk of developing prostate cancer compared to white or Hispanic men, and the risk is less                common in men of Asian and Native American descent. (TEXT)
     -The mortality rates in African-American men are more than twice as high as in any other racial group. (MEDSCAPE)

• Geography

     -Prostate cancer occurs more frequently in North America, northwestern Europe, Australia, and on the Caribbean islands, and it is less common in Asia, Africa, Central America, and South America. (ACS)

• Family History

     -There is an increased risk of developing prostate cancer if a brother or father had the disease, and the risk increases the more first degree relatives that are affected. (TEXT)

• Gene Mutations (ACS)
• Viruses (TEXT)
• Hormones
  -A study performed showed a possible correlation between elevated levels of luteinizing hormone and of testosterone:dihydrotestosterone and a mild increase in risk of prostate cancer (MEDSCAPE)
  

Modifiable:

• Diet

     -A diet high in animal fat, red meat, and high-fat dairy products may be attributed to an increase risk in developing prostate cancer.

• Occupational exposures (TEXT, ACS)

     -Such as chemicals (herbicides, pesticides, and toxic combustable products), cadmium, and other metals (TEXT, ACS)

• Multiple sex partners (TEXT)
• Low levels of vitamins or selenium (TEXT)
  
  

Systemic Involvement

Early prostate cancer is often asymptomatic and is often diagnosed because men seek medical attention for issues regarding urinary dysfunction (i.e. retention) or low back, hip or leg pain. Prostate cancer almost exclusively metastasizes to bone of the pelvis, spine or femur via the bloodstream or lymphatic system and spreads in the early stages. It has also been known to spread to the bladder, rectum and distant organs such as the liver, lung and brain via the lymphatics¹. 

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Differential Diagnosis

• Obstruction of lower urinary tract
• Prostatitis
• Benign Prostatic Hyperplasia

Case Reports/ Case Studies

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Glode, LM. Case Reports on Prostate Cancer. Reviews in Urology 2004;6(Suppl 7):S39-S45. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472886/ (accessed 8 April 2016).

Resources

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Recent Related Research (from Pubmed)

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References

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