Prostate Cancer

A Case Report

Gilles Plourde

• Publisher: Academic Press
• Year: 2018
• ISBN:
  9780128159675
• Topic: Biological Sciences
• Subtopic: Biology
• Index: Biological Sciences

Prostate Cancer: A Case Report discusses the prevention, treatment modalities, and side effects of the medications used to treat prostate cancer. The book presents the most appropriate information, allowing patient empowerment to make informed decisions on their choice of treatments. Through the analysis of a real case report, the book also discusses the main complication associated with prostate cancer—bone metastasis—and provides information on treatment modalities for lung and liver metastasis. Diet, physical activities and the management of stress are also discussed, as is palliative care and the use of palliative sedation when other treatment modalities have failed. Cannabis, the pros and cons of euthanasia, and concerns raised by society are also covered. Esteemed author Dr. Plourde has more than 12 years' experience working on drug safety, especially for biologic products involved in the treatment of various cancers. For more than 4 years he has suffered from prostate cancer with metastasis to the lungs and bones. During this time he has learned a lot on prostate cancer from the medical literature and from discussions with various specialists. The case report presented in this book represents his own medical history. Prostate Cancer: A Case Report provides the most relevant and up to date information on the various aspects involved in the screening, diagnosis and treatment of prostate cancer.

• Helps readers more rapidly identify the signs and symptoms of prostate cancer in order to provide early detection and treatment of the disease
• Provides health care providers and patients with relevant information to make informed decisions on the most appropriate methods to screen, prevent, diagnose and treat prostate cancer
• Discusses best practices on the most optimal diet, physical activity, and ways of dealing with the stress associated with advanced cancer

Chapter 1

Case Report #1—Presentation of the Patient

Abstract

This first case discusses the main signs and symptoms associated with prostate disease so that patients might identify when something is not functioning properly with their urinary system, thus a screening is required. The author discusses bone pain, which is another signal that patients should see their primary care providers immediately. The author explains screening procedures such as the digital rectal examination (DRE) and the prostatic specific antigen (PSA) to rule out the possibility of prostatitis, benign prostate hypertrophy, or prostate cancer. These differential diagnoses are discussed in this case report. The author also comments on the controversies surrounding the use of PSA as a screening and diagnostic tool. Then the author discusses the diagnostic procedure (i.e., transrectal ultrasound with prostate biopsies) that allows us to determine that the patient had a poorly differentiated prostate adenocarcinoma. With the abdominal ultrasound and the CT scan the oncologists was able to confirm that the cancer has spread to other organs (i.e., the staging). With the bone scintigraphy the oncologist was able to find the presence of bone metastasis. Unfortunately, this confirms that our patient has an aggressive form of cancer associated with a very bad prognosis. Finally, when the cancer is classified as stage IV, it has become metastatic, which is commonly known as generalized cancer as in our patient. The oncologist gives the patient a very short life expectancy, from 2 to 4 years, knowing that cancers with this stage are incurable.

Keywords

Prostatism; Prostatitis; Benign prostate hyperplasia; Prostate cancer; Gleason score; Transrectal ultrasound; Prostate biopsies; Staging; Bone scintigraphy; CT scan; Magnetic resonance imaging; Prognostic; ECOG scale

Introduction

A 52-year-old man with a 5-month history of urinary symptoms (e.g., difficulty initiating urination, reduced urinary flow, incomplete emptying of the bladder, frequent urination especially at night [prostatism]) visited a walk in clinic at the end of March 2014 due to the onset of pelvic, abdominal, lower back (lumbar) and hip pain. The health care provider performed a digital rectal examination (DRE) and found that the volume and consistency of the prostate was normal. According to the description made by the health care provider the prostate was similar to what was seen during the routine physical examination performed 5 years ago by patient's family doctor.

Question #1: Based on this preliminary information what should be the most probable diagnostic?

1. (A) Chronic prostatitis
2. (B) Benign prostate hyperplasia (BPH)
3. (C) Prostate cancer

Answer: C.

(A) Chronic prostatitis. Prostatitis represents the swelling and inflammation of the prostate gland, a walnut-sized gland located directly below the bladder in men. Prostatitis often causes painful or difficult urination. Other symptoms include pain in the groin, pelvic area, or genitals, as well as flu-like symptoms in some cases. Prostatitis affects men of all ages but tends to be more common in men aged 50 or younger. This condition can be due to many causes, which often are unidentified. If prostatitis is caused by a bacterial infection, it can usually be treated with antibiotics. Depending on the cause, prostatitis can come on gradually or suddenly. It might improve quickly, either on its own or with treatment. Some types of prostatitis last for months or keep recurring (chronic prostatitis).

For our patient a diagnosis of chronic prostatitis was suggested considering the duration of symptoms. The patient was prescribed Levaquin 750 mg per day for 1 month to treat this suggested chronic prostatitis and Rapaflo 8 mg per day to allow for a relief of urinary symptoms. The health care provider told the patient to take nonsteroidal antiinflammatory drugs (NSAIDs) to relieve his pain.

A prostate-specific antigen (PSA) level and a urinary analysis and culture were requested. The PSA level came back to 25.6 ng/mL; normal is between 0 and 4 ng/mL for a patient this age. At this level the PSA was already strongly evocative of prostate cancer. Due to the symptoms and high PSA level the health care provider made a consultation with an urologist.

On June 9, 2014 a urologist performed a prostate physical examination and surprisingly noted that the prostate was enlarged mainly on the right side. Then he decided to prescribe another month of antibiotics (i.e., Ciprofloxacin 500 mg twice a day), claiming that this antibiotic is better at treating prostatitis than the previous one. He also prescribed a continuation of the NSAIDs for the pain. Obviously it was very unlikely that he dealt with a case of chronic prostatitis, nevertheless, this urologist did nothing immediately to eliminate the possibility of prostate cancer being more concerned about a chronic prostatitis. For more information on the use of PSA as a screening and management tools for prostate cancer, please see Item C and consult Case Report #9 on biomarkers.

(B) Benign prostate hyperplasia (BPH). Also called benign prostatic hypertrophy. BPH is an enlargement of the prostate gland due to an increased number of cells (hyperplasia). Most of the growth occurs in the transition zone of the prostate. The prostate naturally gets larger as men age; in fact, almost all men will have some prostate enlargement by the age of 70. Other than increasing age, there are no risk factors for BPH. For now, researchers cannot confirm whether BPH increases the risk of prostate cancer. With the rapid progression in PSA levels (see C) in such a limited period of time, it is highly unlikely that the patient had BPH.

(C) Prostate cancer. Prostate cancer is a malignant tumor that starts in the cells of the prostate. Malignant means that it can spread, or metastasize, to other parts of the body. Prostate cancer is the second-most common cancer in Canadian men [1,2]. It usually grows slowly and can often be completely removed or managed successfully. Cells in the prostate sometimes change and no longer grow or behave normally. These changes may lead to noncancerous or benign conditions such as prostatitis and BPH [1,2]. Changes to the cells of the prostate can also cause precancerous conditions. This means that while the cells do not yet indicate cancer, there is a higher chance these abnormal changes will become cancerous.

The precancerous conditions that can develop in the prostate are prostatic intraepithelial neoplasia (PIN), proliferative inflammatory atrophy (PIA), and atypical small acinar proliferation (ASAP). Most often, prostate cancer starts in the glandular cells of the prostate. This type of cancer is called adenocarcinoma of the prostate. Rare types of prostate cancer can also develop; these include transitional cell carcinoma and sarcoma. In mid-April 2014, another blood test was requested and came back normal for the patient’s hemoglobin, white blood cells, and platelets, as well as for the liver and urinary functions. However, the PSA had jumped to 79.3, which was increasingly evocative of prostate cancer, in which case the PSA continues to rise very quickly.

Comment #1: For the reader’s information the PSA is an enzyme, a protease, and its gene is dependent on androgens [3]. The rise in levels observed in prostate cancer are likely due to an increase in the passage of the antigen through the basal membrane, which is broken by the cancer. This protease is produced, in theory, exclusively by the prostate; however, special situations have been described in the course of which the PSA concentration is increased [3]. For example, there is a rise in the PSA in about a third of breast cancer diagnoses and its concentration can also be increased significantly in the case of hepatitis, though not at the level observed in our patients.

Comment #2: About 70% of total serum PSA that circulates is bound to the blood proteins form, and 30% is in free form. The free form increases in the case of BPH, while the bound form increases in the case of prostate cancer [3]. The PSA free/total ratio changes greatly in the case of prostate cancer (see Case Report #9). For men under 70 a PSA level < 3 ng/mL is considered to be normal. For men over 70 the PSA levels rise slightly with age so that a value of 6.5 ng/mL can be considered reassuring. The PSA alone does not allow the exact diagnosis of prostate cancer, but it is certainly one of the most important risk factors for prostate cancer according to Mondo et al. [3]. For example the PSA can be high in various prostate pathologies including prostate adenoma and prostatitis (prostate inflammation/infection). It can be elevated after a rectal examination (but not in a significant way), cystoscopy, establishment of a house probe, or intervention on the prostate.

Comment #3: For the benefits of the reader, PSA is the most widely used biomarker for the early detection of prostate cancer. Since the introduction of PSA testing, prostate cancer diagnoses have increased, but at the same time the number of patients dying from the disease has decreased [3]. Furthermore, higher PSA levels are associated with a higher risk of cancer, high-grade disease, high tumor stage, and the presence of metastatic disease as in our patient [3].

However, according to the medical literature PSA, does not represent an ideal biomarker [3]. First, commercial assays measuring PSA are not standardized for direct comparison, so repeat testing is usually necessary. Second, PSA levels are not specific to prostate cancer and can be modulated by many factors, such as age, infection, trauma, ejaculation, instrumentation, and medication use (e.g., 5-alpha-reductase inhibitors and corticosteroids). Third, there is no absolute value below which there is a negligible risk of prostate cancer, and PSA levels cannot distinguish between indolent and aggressive diseases. In the prostate cancer prevention trial, approximately 15% of men with a PSA below 4 ng/mL were at risk for prostate cancer, while 15% of these men had a high-grade disease [3].

However, when the PSA level was < 1 ng/mL, the risk of high-grade disease is very low. Moreover, PSA levels above the traditional cutoff of 4–10 ng/mL reveal the presence of cancer on biopsies in only 25%–30% of patients. Hence there is no PSA cutoff point with high sensitivity and specificity for prostate cancer monitoring in healthy men, but there is rather a continuum of prostate risk at all values of PSA [3]. However, a rapid and continuous increase in PSA levels (short doubling time) as seen with our patient is always alarming.

Prostate cancer screening with PSA levels has been a subject of debate and controversy due to its potential toward overdetection and overtreatment, which can induce patient anxiety. Indeed the ability of PSA levels to reduce mortality has produced mixed results in recent randomized screening trials. Uncertainty also exists in the practical considerations of testing, such as the age at which to initiate and discontinue the testing, along with its frequency [3].

Various guidelines addressing prostate screening have highlighted these issues of uncertainty, prompting the US Preventive Services Task Force to recommend against the use of PSA levels for screening in 2012 [4]. Nonetheless, PSA levels still remain the first-line biomarker option for the detection of prostate cancer. In a recent review of the Canadian Task Force on Preventive Health Care, for which our patient act as an external reviewer has recommended: not screening with PSA in patients of < 55 years-old and patients older than 70 years old. This suggests that the PSA is not recommended as a screening tool in patients without symptoms or prostate disease [5].

On the other hand the higher the PSA, the higher the possibility of a cancer expansion beyond the prostate. Therefore it is important to remember that clinical examination remains irreplaceable in the case of this disease. In order to increase the sensitivity of this test, it is suggested to use the PSA free/total ratio [3]. Thus for a PSA ranging between 4 and 10 ng/mL and a ratio < 5% the probability of a prostate cancer is strongly suspected. Conversely a ratio > 30% is more in favor of a benign prostate disease such as benign prostate hypertrophy [3]. Although this ratio has not been measur...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• About the Author
• Foreword
• Introduction
• Chapter 1: Case Report #1—Presentation of the Patient
• Chapter 2: Case Report #2—Other Differential Diagnoses
• Chapter 3: Case Report #3—Treatment Options
• Chapter 4: Case Report #4—External and Internal Risk Factors
• Chapter 5: Case Report #5—Paraneoplastic Syndromes Associated With Prostate Cancer
• Chapter 6: Case Report #6—Bone Metastasis and Its Treatment
• Chapter 7: Case Report #7—How to Improve Quality of Life
• Chapter 8: Case Report # 8—Treatment Modalities in Development
• Chapter 9: Case Report #9—Biomarkers of Prostate Cancer
• Chapter 10: Case Report #10—Euthanasia (Assisted Suicide) or Palliative Sedation
• Resources for the Readers
• Index