- What is prostate cancer (adenocarcinoma of the prostate)?
- Statistics of prostate cancer
- Risk factors for prostate cancer
- Progression of prostate cancer
- Symptoms of prostate cancer
- Clinical examination of prostate cancer
- How is prostate cancer diagnosed?
- Prognosis of prostate cancer
- Treatment of prostate cancer
What is prostate cancer (adenocarcinoma of the prostate)?
The prostate is a gland found only in men. It surrounds the urethra (the tube through the penis that drains urine from the bladder), and sits at the base of the bladder. The prostate is normally about the size of a walnut.
The function of the prostate is to produce fluid that forms part of the semen. This prostatic fluid, in addition to the fluid produced by the seminal vesicles, forms the fluid which carries the sperm when a man ejaculates.
An adenocarcinoma is a type of cancer that arises in the cells of glands. Most cells in the prostate gland are of the glandular type, which means that adenocarcinoma is the most common type of cancer to occur in the prostate. Cancer occurs when the genes of a cell become abnormal (mutation), causing the cell to multiply and interfere with the normal function of a tissue.
Once the cancer reaches a certain size, the abnormal cells can spread to other parts of the body and cause cancerous tumours to grow. This phenomenon is known as metastasis. If a tumour is capable of spreading to other parts of the body in this way, it is called malignant. Adenocarcinoma of the prostate is malignant, however many types grow extremely slowly, and so are unlikely to spread before a man dies of other causes.
Statistics of prostate cancer
Prostate cancer is the sixth most common cancer in the world and the most common form of cancer in Australian men (after nonmelanoma skin cancer) who have the highest incidence of this type of cancer in the world (105 cases per 100,000 males). One in six men will develop prostate cancer at some point in their lives. Although prostate cancer is the second most common cause of cancer in Indigenous Australian males (after lung cancer), the rates are lower in Indigenous men than in non-Indigenous men. It is not clear whether Indigenous Australians are truly less likely to develop prostate cancer, or whether lower rates of screening and diagnostic testing as well as a shorter life expectancy are contributing factors.
There has been a significant increase in the rates of diagnosed prostate cancer since screening asymptomatic men became popular in the 1990s. This screening is carried out via Prostate Specific Antigen (PSA) testing.
The mean age at the time of prostate cancer diagnosis is 68.4 years and 85% of new cases occur in men aged over 60. Following diagnosis, approximately 85% of men survive for 5 years or longer. Up to age 85, a quarter of Australian men will be diagnosed with prostate cancer and 1 in 25 will die from it.
Risk factors for prostate cancer
The main risk factor for prostate cancer is age. Prostate cancer is rarely diagnosed before the age of 40. After 40, the incidence rises rapidly. PSA testing is not generally carried out on men aged under 50 unless they have significant risk factors. The rates of prostate cancer at different ages are as follows:
|Percentage of men|
with prostate cancer
Around 5–10% of prostate cancer is due to genetic defects, so men who have a family history are more at risk of developing it themselves. Men who have a first degree relative (brother, father, son) who have had prostate cancer are two or three times more likely to develop prostate cancer themselves. This risk may be higher if the relative was diagnosed before the age of 60.
Identifying particular genes involved in prostate cancer has proved challenging. The BRCA1 and BRCA2 genes are associated with having a two to five times higher risk of prostate cancer.
In American studies, Black men have higher rates of developing prostate cancer than White or Hispanic men. Indigenous Australians are at lower risk of being diagnosed with prostate cancer than White Australians.
In Caucasians, smoking has been linked to a greater number of deaths due to prostate cancer.
Obesity may be linked with more aggressive forms of prostate cancer, but not with an increased incidence. The link between prostate cancer and diet has been extensively studied. Important findings include:
- A diet high in animal fat may contribute to prostate cancer;
- A diet low in vegetables may be a risk factor for prostate cancer; and
- Soy intake may have a modest protective effect against prostate cancer.
Other men who are at increased risk of prostate cancer are those who have had high PSA levels, or abnormal prostate biopsies in the past.
In the past, testosterone levels were thought to be related to the development of prostate cancer, but this does not appear to be the case.
Progression of prostate cancer
In many cases, prostate cancer spreads so slowly that it never causes illness, and the patient will often die of other causes before the cancer can cause death. However, if the cancer is left untreated, it is possible that it will spread to local pelvic lymph nodes, and eventually spread to other parts of the body (metastasise). This may eventually result in organ failure and death. Bony metastases from prostate cancer are common. For men who choose not to undergo definitive local treatment, their likelihood of survival relates to the aggressiveness of the prostate cancer.
Without treatment, the 10 year disease-specific survival of men with grade 1 prostate cancer (Gleason score 2 to 4) is 87%, with metastases present in 20%. Of men with grade 2 cancer, 42% develop metastases at 10 years. Ten year survival with grade 3 prostate cancer (Gleason 5 to 7) is 34% without treatment.
Another study found that 40% of men who did not have treatment for their prostate cancer died from the disease after fifteen years. About 80% of men who chose radical prostatectomy survived.
Symptoms of prostate cancer
Currently, most prostate cancers diagnosed have no symptoms. The cancer is detected due to abnormal PSA levels. In the past, prostate cancer was diagnosed due to an abnormal digital rectal examination (DRE), or due to the presence of urinary symptoms such as difficulty starting urine stream (hesitancy), urgent rush to get to the toilet (urgency), needing to pass urine frequently at night (nocturia), and dribbling of urine at the end of the stream (terminal dribbling). Remember, though, that these urinary symptoms are more commonly caused by benign prostatic hyperplasia (BPH) or by urinary tract infections.
Other symptoms that may raise suspicions of prostate cancer include new onset erectile dysfunction, blood in the urine (haematuria), blood in the semen (haematospermia), or symptoms of metastatic disease (e.g. bone pain).
Clinical examination of prostate cancer
The doctor will perform a digital rectal examination. This involves inserting a gloved finger into the rectum to feel the prostate and determine if it is enlarged or if there are any lumps. PSA and DRE are generally performed together to check for prostate cancer. PSA testing requires a blood test to be taken.
How is prostate cancer diagnosed?
A blood test is carried out to check the levels of prostate specific antigen (PSA). If a man’s PSA level is higher than 4 ng/mL, it may indicate that he is at increased risk of prostate cancer. However, most men with elevated PSA do not have prostate cancer.
If more investigation is needed, the next stage is usually a prostate biopsy, which is performed using ultrasound, via the rectum. A device is used to pass needles into the prostate, and withdraw them with tissue inside. The prostate tissue is examined under a microscope. If cancer is detected, it is given a Gleason score, which scores the cancer’s aggressiveness.
Serious complications due to prostate biopsy are rare. Hospitalisation (usually for urinary infections) or urinary retention occur in less than 1% of cases. One study found the following complication rates:
- These symptoms were generally short term.Blood in the semen (51%);
- Blood in the urine (23% longer than three days);
- Fever (3.5%); and
- Rectal bleeding (1.3%).
Prognosis of prostate cancer
Due to PSA screening, prostate cancer is generally being diagnosed earlier, and in younger men. The risk of a man being diagnosed with prostate cancer at some point in his life is 1 in 6 (17%), and 3% of men die from prostate cancer. At autopsy, one third of men under the age of 80, and two thirds of men over the age of 80, are found to have prostate cancer. This data suggests that most men die with prostate cancer, rather than from it. At five years, 99% of men diagnosed with prostate cancer are still alive. At 10 years, 95% are still alive.
Determining the degree of spread of the cancer is known as ‘staging’. Cancer that is confined to the prostate gland is generally curable. The prognosis is not as good if the cancer has spread locally. If the cancer has spread to other parts of the body such as the bones, it is very difficult to cure. Treatment is focused on slowing the spread of the disease, and men may still live for many years with a good quality of life.
The prognosis is also related to the grade of the cancer, represented by the Gleason score, which is a measure of how aggressive the cancer is. 40% of men with Gleason scores of 8 to 10 are alive and disease free at 10 years. More than 90% of men with localised tumours and Gleason scores of 2 to 4 are alive at 5 years.
Treatment of prostate cancer
Treatment options for prostate cancer include:
- Active surveillance
- Local treatment
- Palliative treatments
The risk of some small, non aggressive, localised prostate cancers ever spreading is very low. In these cases, the risks of treatment may outweigh the benefits. A doctor may therefore recommend ‘watchful waiting’, also known as ‘active surveillance‘.
In watchful waiting, the cancer and PSA levels are monitored, but no active treatment is carried out. This may be particularly appropriate for men who have a life expectancy of less than 10 or 15 years, due to advanced age or other medical problems.
If a man chooses to have treatment for prostate cancer, the main options in Australia include surgery, radiotherapy and hormone therapy. There is no good quality evidence that one approach is better than another, so treatment choice is based on the following considerations:
- Age, general medical condition and other medical problems. If a man has a life expectancy of less than 10 years, definitive treatment may not be recommended.
- Serum PSA and Gleason score
- Spread of the cancer
- Outcomes associated with treatment options
- Side effects and quality of life implications related to treatment options
Radical prostatectomy (RP) involves removing the prostate via a lower abdominal incision, or via keyhole surgery (laparoscopic). RP generally involves a 4–8 day hospital stay. A urinary catheter (tube through the penis into the bladder) with a urine bag attached remains in place for at least 2 weeks after the operation. Death rates due to radical prostatectomy are 0.5%, increasing to 1% in men over 75 years.
Sexual dysfunction may occur in 20–70% of patients following RP, and urinary problems in 15–50%. Bilateral nerve sparing surgery may be possible in some cases. In some cases, RP may be followed by radiotherapy.
See also Robotic Radical Prostatectomy.
Radiotherapy (External beam radiation therapy)
External beam radiation therapy (EBRT) may be used with RP or hormonal therapy to treat prostate cancer.
Beams of radiation (like x-rays) are targeted at the prostate by a machine that moves around the body. The rays kill the cancer cells. Small tattoos may be placed on the skin to make sure the beam is in exactly the right place, and minimise damage to healthy tissue.
This procedure is performed in an out-patient setting, and men are usually able to maintain their normal activities. Radiotherapy may lead to sexual dysfunction in 20–45% of cases, urinary incontinence in 2–16%, and bowel dysfunction in 6–25% of men who were previously normal in these areas.
For further information on EBRT, see Radiotherapy for Prostate Cancer.
Brachytherapy (internal radiotherapy)
There are two main types of brachytherapy:
- Use of a radioactive pellet: This involves placing a small radioactive pellet into the prostate (seeding). The pellet loses its radioactivity over time, and is not removed. This option may be used for low Gleason score, low PSA, small, localised prostate cancer. Side effects such as painful urination, poor urine flow and bladder irritation are common, and can start a month after treatment; gradually getting better over 12 months.
- Use of wide bore needles: This type of brachytherapy involves inserting wide bore needles into the prostate, through which radioactive sources can be given. After several days of treatment, the needles are removed. This type of brachytherapy is used in conjunction with EBRT for larger, more aggressive tumours. The needles may cause local discomfort, usually relieved by painkillers. Other side effects are similar to those for EBRT.
For further information on brachytherapy, see Radiotherapy for Prostate Cancer.
Hormonal therapy (androgen deprivation therapy)
Hormone therapy may be used in addition to EBRT. It is also used as palliative treatment (i.e. treatment for prostate cancer that cannot be cured). Hormone therapy does not improve outcomes when used before surgical treatment.
Testosterone appears to drive the growth of prostate cancer. Androgen deprivation therapy (ADT) aims to lower levels of testosterone. This may be achieved by removing the testes (often replaced with prosthetic testes) or medical castration with drugs.
Sometimes, prostate cancer is diagnosed and is too advanced to be cured by surgery or radiotherapy. In these cases, treatment is referred to as ‘palliative’. Palliative treatment is designed to relieve symptoms, maintain quality of life and, in many cases, prolong life. It will not cure the disease.
- Transuretheral resection of the prostate (TURP) may be carried out to relieve obstructive symptoms due to the cancer.
- Hormone therapy: ADT is a mainstay of treatment for cancer that is not resectable (removable by surgery). Eventually, the cancer will no longer respond to ADT.
- Bisphosphonates and analgesia may be used to treat cancer spread to bones.
- EBRT may be used to treat pain related to bone metastases.
Relative side effects of different treatments
- Radical prostatectomy and brachytherapy result in higher rates of urinary incontinence and sexual dysfunction than EBRT. Bilateral nerve sparing surgery (not possible in all cases) diminishes this difference.
- RT causes more bowel dysfunction than surgery.
- Brachytherapy causes more obstructive and irritative urinary symptoms.
Good quality evidence of the best approach to prostate cancer is limited, but the following treatment strategies have been suggested:
- Low-risk disease: Radical prostatectomy, brachytherapy monotherapy, or EBRT.
- Intermediate-risk disease: EBRT or surgery. The role of brachytherapy alone is controversial. Brachytherapy plus EBRT may be superior to EBRT alone, though this is also controversial.
- High-risk disease: Radical prostatectomy with or without adjuvant EBRT, or EBRT plus ADT. EBRT or brachytherapy alone are not generally appropriate.
|For more information on prostate cancer, including diagnoses, types of treatments, and some useful tools, videos and animations, see Prostate Cancer.|
- Epstein JI, Yang XJ. Prostate Biopsy Interpretation, 3rd Edition. Philadelphia: Lippincott, Williams, and Wilkins, 2002.
- Braunwald E, Fauci AS, Casper DL, Hauser SL, Longo DL, Jameson JL [eds]. Harrison’s Principles of Internal Medicine, 15th Edition. New York: McGraw-Hill, 2001.
- Cohen RJ, Shannon BA, Phillips M, Moorin RE, Wheeler TM, Garrett KL. Central zone carcinoma of the prostate gland: A distinct tumor type with poor prognostic features. J Urol. 2008; 179(5): 1762-7.
- Jemal A, Siegel R, Ward E, Hao Y, Xu J, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008; 58(2): 71-96.
- The Cancer Council Australia. Prostate cancer screening position statement [online]. 23 May 2005 [cited 12 September 2008]. Available from URL: http://www.cancer.org.au/ File/ PolicyPublications/ PSprostatecancerscreeningAPR2005.pdf
- Roder D. Epidemiology of cancer in Indigenous Australians: Implications for service delivery. Paper presented at the 9th National Rural Health Conference: Standing up for rural health: Learning from the past, action in the future. 7-10 March 2007, Albury, NSW.
- Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, et al [eds]. SEER Cancer Statistics Review, 1973-1999 [online]. National Cancer Institute. Bethesda, MD. 2002 [cited 12 September 2008]. Available from URL: http://seer.cancer.gov/ csr/ 1973_1999/
- Potosky AL, Miller BA, Albertsen PC, Kramer BS. The role of increasing detection in the rising incidence of prostate cancer. JAMA. 1995; 273(7): 548-52.
- Mettlin C, Jones G, Averette H, Gusberg SB, Murphy GP. Defining and updating the American Cancer Society guidelines for the cancer-related checkup: Prostate and endometrial cancers. CA Cancer J Clin. 1993; 43(1): 42-6.
- American Urological Association. Early detection of prostate cancer and use of transrectal ultrasound. In: American Urological Association 1992 Policy Statement Book. Baltimore: Williams & Wilkins, 1992.
- Bouchardy C, Fioretta G, Rapiti E, Verkooijen HM, Rapin CH, et al. Recent trends in prostate cancer mortality show a continuous decrease in several countries. Int J Cancer. 2008; 123(2): 421-9.
- Ries LAG, Melbert D, Krapcho M, Stinchcomb DG, Howlader N, et al [eds]. SEER Cancer Statistics Review, 1975-2004 [online]. National Cancer Institute. Bethesda, MD. 2007. [cited 12 September 2008]. Available from URL: http://seer.cancer.gov/ csr/ 1975_2004/
- Whitmore WF Jr. Natural history of low-stage prostatic cancer and the impact of early detection. Urol Clin North Am. 1990; 17(4): 689-97.
- Mettlin C, Lee F, Drago J, Murphy GP. The American Cancer Society National Prostate Cancer Detection Project. Findings on the detection of early prostate cancer in 2425 men. Cancer. 1991; 67(12): 2949-58.
- Johns LE, Houlston RS. A systematic review and meta-analysis of familial prostate cancer risk. BJU Int. 2003; 91(9): 789-94.
- Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, et al [eds]. SEER Cancer Statistics Review, 1973-1999 [online]. National Cancer Institute. Bethesda, MD. 2002 [cited 12 September 2008]. Available from URL: http://seer.cancer.gov/ csr/ 1973_1999/
- Hankey BF, Feuer EJ, Clegg LX, Hayer RB, Legler JM, et al. Cancer surveillance series: Interpreting trends in prostate cancer – Part 1: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates. J Natl Cancer Inst. 1999; 91(12): 1017-24.
- Delongchamps NB, Singh A, Haas GP. The role of prevalence in the diagnosis of prostate cancer. Cancer Control. 2006; 13(3): 158-68.
- Stamey TA. Making the most out of six systematic sextant biopsies. Urology. 1995; 45: 2-12.
- Thompson D, Easton DF. Cancer incidence in BRCA1 mutation carriers. J Natl Cancer Inst. 2002; 94(18): 1358-65.
- Struewing JP, Hartge P, Wacholder S, Baker SM, Berlin M, et al. The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews. N Engl J Med. 1997; 336(20): 1401-8.
- Cancer risks in BRCA2 mutation carriers. The Breast Cancer Linkage Consortium. J Natl Cancer Inst. 1999; 91(15): 1310-6.
- Edwards SM, Kote-Jarai Z, Meitz J, Hamoudi R, Hope Q, et al. Two percent of men with early-onset prostate cancer harbor germline mutations in the BRCA2 gene. Am J Hum Genet. 2003; 72(1): 1-12.
- Risch HA, McLaughlin JR, Cole DE, Rosen B, Bradley L, et al. Population BRCA1 and BRCA2 mutation frequencies and cancer penetrances: A kin-cohort study in Ontario, Canada. J Natl Cancer Inst. 2006; 98(23): 1694-706.
- Liede A, Karlan BY, Narod SA. Cancer risks for male carriers of germline mutations in BRCA1 or BRCA2: A review of the literature. J Clin Oncol. 2004; 22(4): 735-42.
- Roddam AW, Allen NE, Appleby P, Key TJ. Endogenous sex hormones and prostate cancer: A collaborative analysis of 18 prospective studies. J Natl Cancer Inst. 2008; 100(3): 170-83.
- Huxley R, Asia Pacific Cohort Studies Collaboration. The impact of modifiable risk factors on mortality from prostate cancer in populations of the Asia-Pacific region. Asian Pac J Cancer Prev. 2007; 8(2): 199-205.
- Andersson SO, Wolk A, Bergstrom R, Adami HO, Engholm G, et al. Body size and prostate cancer: A 20-year follow-up study among 135006 Swedish construction workers. J Natl Cancer Inst. 1997; 89(5): 385-9.
- Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003; 348(17): 1625-38.
- Amling CL, Riffenburgh RH, Sun L, Moul JW, Lance RS, et al. Pathologic variables and recurrence rates as related to obesity and race in men with prostate cancer undergoing radical prostatectomy. J Clin Oncol. 2004; 22(3): 439-45.
- Wright ME, Chang SC, Schatzkin A, Albanes D, Kipnis V, et al. Prospective study of adiposity and weight change in relation to prostate cancer incidence and mortality. Cancer. 2007; 109(4): 675-84.
- Schulman CC, Ekane S, Zlotta AR. Nutrition and prostate cancer: Evidence or suspicion? Urology. 2001; 58(3): 318-34.
- Chan JM, Gann PH, Giovannucci EL. Role of diet in prostate cancer development and progression. J Clin Oncol. 2005; 23(32): 8152-60.
- Kolonel LN, Nomura AM, Cooney RV. Dietary fat and prostate cancer: Current status. J Natl Cancer Inst. 1999; 91(5): 414-28.
- Colli JL, Colli A. International comparisons of prostate cancer mortality rates with dietary practices and sunlight levels. Urol Oncol. 2006; 24(3): 184-94.
- Giovannucci E, Rimm EB, Colditz GA, Stampfer MJ, Ascherio A, et al. A prospective study of dietary fat and risk of prostate cancer. J Natl Cancer Inst. 1993; 85(19): 1571-9.
- Cohen JH, Kristal AR, Stanford JL. Fruit and vegetable intakes and prostate cancer risk. J Natl Cancer Inst. 2000; 92(1): 61-8.
- Jian L, Du CJ, Lee AH, Binns CW. Do dietary lycopene and other carotenoids protect against prostate cancer? Int J Cancer. 2005; 113(6): 1010-4.
- Kolonel LN, Hankin JH, Whittemore AS, Wu AH, Gallagher RP, et al. Vegetables, fruits, legumes and prostate cancer: A multiethnic case-control study. Cancer Epidemiol Biomarkers Prev. 2000; 9(8): 795-804.
- Jacobsen BK, Knutsen SF, Fraser GE. Does high soy milk intake reduce prostate cancer incidence? The Adventist Health Study (United States). Cancer Causes Control. 1998; 9(6): 553-7.
- Yan L, Spitznagel EL. Meta-analysis of soy food and risk of prostate cancer in men. Int J Cancer 2005; 117(4): 667-9.
- Catalona WJ, Richie JP, Ahmann FR, Hudson MA, Scardino PT, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: Results of a multicenter clinical trial of 6,630 men. J Urol. 1994; 151(5): 1283-90.
- Pedersen KV, Carlsson P, Varenhorst E, Lofman O. Screening for carcinoma of the prostate by digital rectal examination in a randomly selected population. BMJ. 1990; 300: 1041-4.
- Chodak GW, Keller, P, Schoenberg HW. Assessment of screening for prostate cancer using the digital rectal examination. J Urol. 1989; 141(5): 1136-8.
- Gustafsson O, Norming U, Almgard LE, Fredriksson A, Gustavsson G, et al. Diagnostic methods in the detection of prostate cancer: A study of a randomly selected population of 2,400 men. J Urol. 1992; 148(6): 1827-31.
- Yamamoto T, Ito K, Ohi M, Kubota Y. Diagnostic significance of digital rectal examination and transrectal ultrasonography in men with prostate-specific antigen levels of 4 NG/ML or less. Urology. 2001; 58(6): 994-8.
- Varma M, Lee MW, Tamboli P, Zarbo RJ, Jimenez RE, et al. Morphologic criteria for the diagnosis of prostatic adenocarcinoma in needle biopsy specimens. A study of 250 consecutive cases in a routine surgical pathology practice. Arch Pathol Lab Med. 2002; 126(5): 554-61.
- Johansson J, Andrén O, Andersson S, Dickman PW, Holmberg L, et al. Natural history of early, localized prostate cancer. JAMA. 2004; 291(22): 2713-9.
- Chodak GW, Thisted RA, Gerber GS, Johansson JE, Adolfsson J, et al. Results of conservative management of clinically localized prostate cancer. N Engl J Med. 1994; 330(4): 242-8.
- Aus G, Robinson D, Rosell J, Sandblom G, Varenhorst E, et al. Survival in prostate carcinoma-outcomes from a prospective, population-based cohort of 8887 men with up to 15 years of follow-up: Results from three countries in the population-based National Prostate Cancer Registry of Sweden. Cancer. 2005; 103(5): 943-51.
- Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA. 1997; 277(18): 1445-51.
- Catalona WJ, Smith DS, Ratliff TL, Basler JW. Detection of organ-confined prostate cancer is increased through prostate-specific antigen-based screening. JAMA. 1993; 270(8): 948-54.
- Farkas A, Schneider D, Perrotti M, Cummings KB, Ward WS. National trends in the epidemiology of prostate cancer, 1973 to 1994: Evidence for the effectiveness of prostate-specific antigen screening. Urology. 1998; 52(3): 444-8.
- Amling CL, Blute ML, Lerner SE, Bergstrahl EJ, Bostwick DG, Zincke H. Influence of prostate-specific antigen testing on the spectrum of patients with prostate cancer undergoing radical prostatectomy at a large referral practice. Mayo Clin Proc. 1998; 73(5): 401-6.
- Cooperberg MR, Lubeck DP, Meng MV, Mehta SS, Carroll PR. The changing face of low-risk prostate cancer: Trends in clinical presentation and primary management. J Clin Oncol. 2004; 22(11): 2141-9.
- Dong F, Reuther AM, Magi-Galluzzi C, Zhou M, Kupelian PA, Klein EA. Pathologic stage migration has slowed in the late PSA era. Urology. 2007; 70(5): 839-42.
- Hernandez DJ, Nielsen ME, Han M, Partin AW. Contemporary evaluation of the D’amico risk classification of prostate cancer. Urology. 2007; 70(5): 931-5.
- Lu-Yao GL, Friedman M, Yao SL. Use of radical prostatectomy among Medicare beneficiaries before and after the introduction of prostate specific antigen testing. J Urol. 1997; 157(6): 2219-22.
- Zelefsky MJ, Moughan J, Owen J, Zietman AL, Roach M 3rd, Hanks GE. Changing trends in national practice for external beam radiotherapy for clinically localized prostate cancer: 1999 patterns of care survey for prostate cancer. Int J Radiat Oncol Biol Phys. 2004; 59(4): 1053-61.
- Brenner H, Arndt V. Long-term survival rates of patients with prostate cancer in the prostate-specific antigen screening era: Population-based estimates for the year 2000 by period analysis. J Clin Oncol. 2005; 23(3): 441-7.
- Albertsen PC, Hanley JA, Barrows GH, Penson DF, Kowalczyk PD, et al. Prostate cancer and the Will Rogers phenomenon. J Natl Cancer Inst. 2005; 97(17): 1248-53.
- Jhaveri FM, Klein EA, Kupelian PA, Zippe C, Levin HS. Declining rates of extracapsular extension after radical prostatectomy: Evidence for continued stage migration. J Clin Oncol. 1999; 17(10): 3167-72.
- Chism DB, Hanlon AL, Troncoso P, Al-Saleem T, Horwitz EM, Pollack A. The Gleason score shift: Score four and seven years ago. Int J Radiat Oncol Biol Phys. 2003; 56(5): 1241-7.
- Smith EB, Frierson HF Jr, Mills SE, Boyd JC, Theodorescu D. Gleason scores of prostate biopsy and radical prostatectomy specimens over the past 10 years: Is there evidence for systematic upgrading? Cancer. 2002; 94(8): 2282-7.
- Kondylis FI, Moriarty RP, Bostwick D, Schellhammer PF. Prostate cancer grade assignment: The effect of chronological, interpretive and translation bias. J Urol. 2003; 170(4 Pt 1): 1189-93.
- Cooperberg MR, Moul JW, Carroll PR. The changing face of prostate cancer. J Clin Oncol. 2005; 23(32): 8146-51.
- Miller DC, Hafez KS, Stewart A, Montie JE, Wei JT. Prostate carcinoma presentation, diagnosis, and staging: An update form the National Cancer Data Base. Cancer. 2003; 98(6): 1169-78.
- Crook J, Lukka H, Klotz L, Bestic N. Systematic overview of the evidence for brachytherapy in clinically localized prostate cancer. CMAJ. 2001; 164(7): 975-81.
- Frydenberg M, Wijesinha S. Diagnosing prostate cancer – what GPs need to know. Aust Fam Physician. 2007; 36(5): 345-7.
- Richie JP, Catalona WJ, Ahmann FR, Hudson MA, Scardino PT, et al. Effect of patient age on early detection of prostate cancer with serum prostate-specific antigen and digital rectal examination. Urology. 1993; 42(4): 365-74.
- Crawford ED, Schutz MJ, Clejan S, Drago J, Resnick MI, et al. The effect of digital rectal examination on prostate-specific antigen levels. JAMA. 1992; 267(16): 2227-8.
- Carroll P, Coley C, McLeod D, Schellhammer P, Sweat G, et al. Prostate-specific antigen best practice policy – Part I: Early detection and diagnosis of prostate cancer. Urology. 2001; 57(2): 217-24.
- Smith RA, von Eschenbach AC, Wender R, Levin B, Byers T, et al. American Cancer Society guidelines for the early detection of cancer: Update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: Update 2001 – Testing for early lung cancer detection. CA Cancer J Clin. 2001; 51(1): 38-75.
- Chong CC, Austen L, Kneebone A, Lalak A, Jalaludin B. Patterns of practice in the management of prostate cancer: Results from multidisciplinary surveys of clinicians in Australia and New Zealand in 1995 and 2000. BJU International. 2006; 97(5): 975-80.
- Dorr VJ, Williamson SK, Stephens RL. An evaluation of prostate-specific antigen as a screening test for prostate cancer. Arch Intern Med. 1993; 153(22): 2529-37.
- Harris R, Lohr KN. Screening for prostate cancer: An update of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2002; 137(11): 917-29.
- Abdalla I, Basu A, Hellman S. An evidence-based analysis of the management of localized prostate cancer. Cancer J. 2002; 8(1): 40-6.
- Thompson I, Thrasher JB, Aus G, Burnett AL, Canby-Haginio ED, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007; 177(6): 2106-31.
- Coley CM, Barry MJ, Fleming C, Mulley AG. Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. Ann Intern Med. 1997; 126(5): 394-406.
- Partin AW, Carter HB, Chan DW, Epstein JI, Oesterling JE, et al. Prostate specific antigen in the staging of localized prostate cancer: Influence of tumor differentiation, tumor volume and benign hyperplasia. J Urol. 1990; 143(4): 747-52.
- Lange PH, Ercole CJ, Lightner DJ, Fraley EE, Vessella R. The value of serum prostate specific antigen determinations before and after radical prostatectomy. J Urol. 1989; 141(4): 873-9.
- Hudson MA, Bahnson RR, Catalona WJ. Clinical use of prostate specific antigen in patients with prostate cancer. J Urol. 1989; 142(4): 1011-7.
- Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med. 2003; 349(3): 215-24.
- Thompson IM, Pauler DK, Goodman PJ, Tangen CM, Lucia MS, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level < or = 4.0 ng per milliliter. N Engl J Med. 2004; 350(22): 2239-46.
- Catalona WJ, Smith DS, Ornstein DK. Prostate cancer detection in men with serum PSA concentrations of 2.6 to 4.0 ng/mL and benign prostate examination. Enhancement of specifity with free PSA measurements. JAMA. 1997; 277(18): 1452-5.
- Makarov DV, Humphreys EB, Mangold LA, Walsh PC, Partin AW, et al. Pathological outcomes and biochemical progression in men with T1c prostate cancer undergoing radical prostatectomy with prostate specific antigen 2.6 to 4.0 vs 4.1 to 6.0 ng/ml. J Urol. 2006; 176(2): 554-8.
- NCCN guidelines [online]. National Comprehensive Cancer Network. 2008 [cited 2 October 2008]. Available from URL: www.nccn.org/ professionals/ physician_gls/ default.asp
- Polascik TJ, Oesterling JE, Partin AW. Prostate specific antigen: a decade of discovery – What we have learned and where we are going. J Urol. 1999; 162(2): 293-306.
- Eastham JA, Riedel E, Scardino PT, Shike M, Fleisher M, et al. Variation of serum prostate-specific antigen levels: An evaluation of year-to-year fluctuations. JAMA 2003; 289(20): 2695-700.
- Obek C, Ozkan B, Tunc B, Can G, Yalcin V, Solok V. Comparison of 3 different methods of anesthesia before transrectal prostate biopsy: A prospective randomized trial. J Urol. 2004; 172(2): 502-5.
- Yun TJ, Lee HJ, Kim SH, Lee SE, Cho JY, Seong CK. Does the intrarectal instillation of lidocaine gel before periprostatic neurovascular bundle block during transrectal ultrasound guided prostate biopsies improve analgesic efficacy? A prospective, randomized trial. J Urol. 2007; 178(1): 103-6.
- Giannarini G, Mogorovich A, Valent F, Morelli G, De Maria M, et al. Continuing or discontinuing low-dose aspirin before transrectal prostate biopsy: results of a prospective randomized trial. Urology. 2007; 70(3): 501-5.
- Rodriguez LV, Terris MK. Risks and complications of transrectal ultrasound guided prostate needle biopsy: a prospective study and review of the literature. J Urol. 1998; 160(6 Pt 1): 2115-20.
- Maan Z, Cutting CW, Patel U, Kerry S, Pietrzak P, et al. Morbidity of transrectal ultrasonography-guided prostate biopsies in patients after the continued use of low-dose aspirin. BJU Int. 2003; 91(9): 798-800.
- Herget EJ, Saliken JC, Donnelly BJ, Gray RR, Wiseman D, Brunet G. Transrectal ultrasound-guided biopsy of the prostate: Relation between ASA use and bleeding complications. Can Assoc Radiol J. 1999; 50(3): 173-6.
- Presti JC Jr, Chang JJ, Bhargava V, Shinohara K. The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: Results of a prospective clinical trial. J Urol. 2000; 163(1): 163-6.
- Gore JL, Shariat SF, Miles BJ, Kadmon B, Jiang N, et al. Optimal combinations of systematic sextant and laterally directed biopsies for the detection of prostate cancer. J Urol. 2001; 165(5): 1554-9.
- Emiliozzi P, Scarpone P, DePaula F, Pizzo M, Federico G, et al. The incidence of prostate cancer in men with prostate specific antigen greater than 4.0 ng/ml: A randomized study of 6 versus 12 core transperineal prostate biopsy. J Urol. 2004; 171(1): 197-9.
- Siu W, Dunn RL, Shah RB, Wei JT. Use of extended pattern technique for initial prostate biopsy. J Urol. 2005; 174(2): 505-9.
- Remzi M, Fong YK, Dobrovits M, Anagnostou T, Seitz C, et al. The Vienna nomogram: Validation of a novel biopsy strategy defining the optimal number of cores based on patient age and total prostate volume. J Urol. 2005; 174(4 Pt 1): 1256-60.
- Presti JC Jr, O’Dowd GJ, Miller MC, Mattu R. Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: Results of a community multi-practice study. J Urol. 2003; 169(1): 125-9.
- Epstein JI, Sanderson H, Carter HB, Scharfstein DO. Utility of saturation biopsy to predict insignificant cancer at radical prostatectomy. Urology. 2005; 66(2): 356-60.
- Chang JJ, Shinohara K, Bhargava V, Presti JC Jr. Prospective evaluation of lateral biopsies of the peripheral zone for prostate cancer detection. J Urol. 1998; 160(6 Pt 1): 2111-4.
- Babaian RJ, Toi A, Kamoi K, Troncoso P, Sweet J, et al. A comparative analysis of sextant and an extended 11-core multisite directed biopsy strategy. J Urol. 2000; 163(1): 152-7.
- Naughton CK, Miller DC, Mager DE, Ornsteink DK, Catalon WJ. A prospective randomized trial comparing 6 versus 12 prostate biopsy cores: Impact on cancer detection. J Urol. 2000; 164(2): 388-92.
- Ravery V, Goldblatt L, Royer B, Blanc E, Toublanc M, Boccon-Gibod L. Extensive biopsy protocol improves the detection rate of prostate cancer. J Urol. 2000; 164(2): 393-6.
- Eichler K, Hempel S, Wilby J, Myers L, Bachmann LM, Kleijnen J. Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: A systematic review. J Urol. 2006; 175(5): 1605-12.
- Sajadi KP, Kim T, Terris MK, Brown JA, Lewis RW. High yield of saturation prostate biopsy for patients with previous negative biopsies and small prostates. Urology. 2007; 70(4): 691-5.
- Ravery V, Dominique S, Panhard X, Toublanc M, Boccon-Gibod L. The 20-core prostate biopsy protocol – A new gold standard? J Urol. 2008; 179: 504-7.
- Keetch DW, Catalona WJ, Smith DS. Serial prostatic biopsies in men with persistently elevated serum prostate specific antigen values. J Urol. 1994; 151(6): 1571-4.
- Raaijmakers R, Kirkels WJ, Roobol MJ, Wildhagen MF, Schrder FH. Complication rates and risk factors of 5802 transrectal ultrasound-guided sextant biopsies of the prostate within a population-based screening program. Urology. 2002; 60(5): 826-30.
- Oesterling JE, Martin SK, Bergstrahl EJ, Lowe FC. The use of prostate specific antigen in staging patients with newly diagnosed prostate cancer. JAMA. 1993; 269(1): 57-60.
- Salonia A, Gallina A, Camerota TC, Picchio M, Freschi M, et al. Bone metastases are infrequent in patients with newly diagnosed prostate cancer: Analysis of their clinical and pathologic features. Urology. 2006; 68(2): 362-6.
- Lee N, Fawaaz R, Olsson CA, Benson MC, Petrylak DP, et al. Which patients with newly diagnosed prostate cancer need a radionuclide bone scan? An analysis based on 631 patients. Int J Radiat Oncol Biol Phys. 2000; 48(5): 1443-6.
- Abuzallouf S, Dayes I, Lukka H. Baseline staging of newly diagnosed prostate cancer: A summary of the literature. J Urol. 2004; 171(6 Pt 1): 2122-7.
- Holmberg L, Bill-Axelson A, Helgesen F, Salo JO, Folmerz P, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med. 2002; 347(11): 781-9.
- Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson PO, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2005; 352(19): 1977-84.
- Wilt TJ, Brawer MK. The Prostate Cancer Intervention Versus Observation Trial: A randomized trial comparing radical prostatectomy versus expectant management for the treatment of clinically localized prostate cancer. J Urol. 1994; 152(5 Pt 2): 1910-4.
- Dahm P, Kunz R, Schunemann H. Evidence-based clinical practice guidelines for prostate cancer: The need for a unified approach. Curr Opin Urol. 2007; 17(3): 200-7.
- Haas GP, Delongchamps NB, Jones RF, Chandan V, Serio AM, et al. Needle biopsies on autopsy prostates: Sensitivity of cancer detection based on true prevalence. J Natl Cancer Inst. 2007; 99(19): 1484-9.
- Epstein JI, Walsh PC, Carmichael M, Brendler CM. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA. 1994; 271(5): 368-74.
- Albertsen PC, Hanley JA, Penson DF, Barrows G, Fine J. 13-year outcomes following treatment for clinically localized prostate cancer in a population based cohort. J Urol. 2007; 177(3): 932-6.
- Walz J, Gallina A, Saad F, Montorsi F, Perotte P, et al. A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol. 2007; 25(24): 3576-81.
- Wei JT, Dunn RL, Sandler HM, McLaughlin PW, Montie JE, et al. Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. J Clin Oncol. 2002; 20(2): 557-66.
- Miller DC, Sanda MG, Dunn RL, Montie JE, Pimental H, et al. Long-term outcomes among localized prostate cancer survivors: Health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy. J Clin Oncol. 2005; 23(12): 2772-80.
- Ung JO, Richie JP, Chen MH, Renshaw AA, D’Amico AV. Evolution of the presentation and pathologic and biochemical outcomes after radical prostatectomy for patients with clinically localized prostate cancer diagnosed during the PSA era. Urology. 2002; 60(3): 458-63.
- Begg CB, Riedel ER, Bach PB, Kattan MW, Schrag D, et al. Variations in morbidity after radical prostatectomy. N Engl J Med. 2002; 346(15): 1138-44.
- Lu-Yao GL, Albertsen P, Warren J, Yao SL. Effect of age and surgical approach on complications and short-term mortality after radical prostatectomy – A population-based study. Urology. 1999; 54(2): 301-7.
- Stanford JL, Feng Z, Hamilton AS, Gilliland FD, Stephenson RA, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: The Prostate Cancer Outcomes Study. JAMA. 2000; 283(3): 354-60.
- Hamilton AS, Stanford JL, Gilliland FD, Albertsen PC, Stephenson RA, et al. Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: Results from the Prostate Cancer Outcomes Study. J Clin Oncol. 2001; 19(9): 2517-26.
- Crawford ED, Eisenberger MA, McLeod DG, Spaulding JT, Benson R, et al. A controlled trial of leuprolide with and without flutamide in prostatic carcinoma. N Engl J Med. 1989; 321(7): 419-24.
- Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2010 Cat. no. CAN 56 [online]. Canberra: AIHW 2010. [cited June 18 2011].