Prostate cancer is the most common noncutaneous cancer in men in the United States. An estimated one in six white men and one in five African-American men will be diagnosed with prostate cancer in their lifetime, with the likelihood increasing with age.

The image below depicts the anatomy of the male pelvis and genitourinary tract.

Signs and symptoms

Currently, most cases of prostate cancer are identified by screening in asymptomatic men. Symptoms of prostate cancer include the following:

• Urinary complaints or retention
• Back pain
• Hematuria

However, such symptoms are often from diseases other than prostate cancer (eg, urinary complaints from benign prostatic hyperplasia [BPH]). Physical examination alone cannot reliably differentiate benign prostatic disease from cancer.

Findings in patients with advanced disease may include the following:

• Cancer cachexia
• Bony tenderness
• Lower-extremity lymphedema or deep venous thrombosis
• Adenopathy
• Overdistended bladder due to outlet obstruction

Diagnosis

Elevated prostate-specific antigen (PSA) level

• No PSA level guarantees the absence of prostate cancer.
• The risk of disease increases as the PSA level increases, from about 8% with PSA levels of ≤1.0 ng/mL ^[1] to about 25% with PSA levels of 4-10 ng/mL and over 50% for levels over 10 ng/mL ^[1]

Abnormal digital rectal examination (DRE) findings

• DRE is examiner-dependent, and serial examinations over time are best
• Most patients diagnosed with prostate cancer have normal DRE results but abnormal PSA readings

Biopsy

• Biopsy establishes the diagnosis
• False-negative results often occur, so multiple biopsies may be needed before prostate cancer is detected

Screening

The American Cancer Society (ACS) recommends that men decide whether to be screened for prostate cancer based on a discussion with their health care provider about the uncertainties, risks, and potential benefits of screening. ^[2]

The recommended age for starting screening is as follows:

• 50 years of age for men at average risk 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

The US Preventive Services Task Force (USPSTF) recommends against any routine PSA-based screening for prostate cancer. This recommendation is considered controversial.

Management

Localized prostate cancer

Standard treatments for clinically localized prostate cancer include the following:

• Radical prostatectomy
• Radiation therapy
• Active surveillance
• Androgen deprivation therapy (ADT)

Metastatic prostate cancer

Metastatic prostate cancer is rarely curable, and management of these cases typically involves the following:

• Therapy directed at relief of particular symptoms (eg, palliation of pain)
• Attempts to slow further progression of disease