History and exam
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
Recommendations nationales de bonne pratique pour la prise en charge du cancer localisé de la prostate: première partiePublished by: KCELast published: 2014Nationale praktijkrichtlijn voor de aanpak van gelokaliseerde prostaatkanker: deel 1Published by: KCELast published: 2014Key diagnostic factors
common
presence of risk factors
Key factors include age over 50 years, black ethnicity, and family history of prostate cancer.
elevated prostate-specific antigen (PSA)
Most common presenting finding.
Elevated PSA levels should be correlated with patient age as PSA typically increases with age regardless of presence of prostate cancer.[59]
Other non-malignant conditions (e.g., prostatitis and benign prostatic hyperplasia) may increase PSA levels. PSA levels may also vary according to race.[53]
Other diagnostic factors
common
abnormal digital rectal examination (DRE)
Less common presenting finding since prostate-specific antigen (PSA) screening has been widely adopted.
An asymmetric and/or indurated or nodular prostate suggests cancer and should prompt further evaluation.
The overall size of the prostate may be noted. However, estimating the size of the prostate on examination is inaccurate and unreliable.
uncommon
nocturia
Uncommon in low-risk (early-stage) disease. If present, may indicate more advanced disease or (more commonly) benign prostatic hyperplasia.
urinary frequency
Uncommon in low-risk (early-stage) disease. If present, may indicate more advanced disease or (more commonly) benign prostatic hyperplasia.
urinary hesitancy
Uncommon in low-risk (early-stage) disease. If present, may indicate more advanced disease or (more commonly) benign prostatic hyperplasia.
dysuria
Uncommon in low-risk (early-stage) disease. If present, may indicate more advanced disease or (more commonly) benign prostatic hyperplasia.
haematuria
Uncommon in low-risk (early-stage) disease. If present, may indicate more advanced disease or (more commonly) another unrelated urinary tract disorder.
weight loss/anorexia
Associated with metastatic disease.
lethargy
Associated with metastatic disease.
bone pain
Associated with metastatic disease.
palpable lymph nodes
Associated with metastatic disease.
Risk factors
strong
age >50 years
Of the known risk factors for prostate cancer, age is the most important.[32][33] It is most commonly reported in men aged over 50 years; median age at diagnosis in the US is 68 years (based on 2018-2022 data).[1]
Autopsy data indicate that 70% of men over 80 years of age and 40% of men over 50 years of age have pathological evidence of prostate cancer.[34]
black ethnicity
The incidence of prostate cancer in the US is highest among non-Hispanic black men (194.8 per 100,000).[1]
In the UK, prostate cancer incidence rates are approximately twice as high in black men (African, Caribbean, or other black ancestry) compared with white men, and peak at a younger age (2.9 times higher in black men aged <65 years and 1.9 times higher in those aged ≥65 years, based on data from 2013 to 2017).[11]
Analysis of incidence data suggests that black men have a higher risk of developing pre-clinical prostate cancer and a higher risk of progression to metastatic disease.[25][26]
Northern European, Caribbean, Australian, New Zealand, North American, and Southern African populations
Incidence is highest in Northern Europe, Australia and New Zealand, the Caribbean, Northern America, Southern Africa, and Southern Africa.[8]
positive family history/genetic factors
Risk of prostate cancer is increased in men with a positive family history of prostate cancer.[20]
One meta-analysis reported a pooled relative risk (RR) of 2.48 in men with one first-degree relative (brother or father) with prostate cancer compared with no first-degree family history.[20] Risk was higher if the first-degree relative was a brother (RR 3.14) than a father (RR 2.35). A RR of 4.39 was reported in men with two or more first-degree relatives with a history of prostate cancer.
The genetic basis for this hereditary cause is unclear, but prostate-cancer specific germline mutations (e.g., HOXB13) have been implicated.[21] Germline mutations that increase the risk of prostate and other cancers have been identified:
homologous recombination DNA repair gene mutations (e.g., BRCA1, BRCA2, ATM, CHEK2, PALB2, RAD51D)
DNA mismatch repair gene mutations (e.g., MLH1, MSH2, PMS2, MSH6)
Estimates of risk associated with BRCA mutations vary and may be influenced by age, ethnicity, and variant location; cumulative lifetime risk estimates for prostate cancer are 19% to 61% for BRCA2 carriers and 7% to 26% for carriers of a BRCA1 mutation.[23][35]
Germline BRCA2 mutations are associated with a high risk of early-onset prostate cancer, more aggressive disease, and poor survival outcomes; whether BRCA1 variants are associated with similarly poor outcomes requires further research.[36][37][38]
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