Editing Prostate Cancer: Diagnosis and evaluation (section)

=== <span style="color:#ff0000">History and physical exam</span> ===
* '''<span style="color:#ff0000">History'''
*# '''Signs and symptoms of prostate cancer'''
*#* '''Localized disease is usually asymptomatic'''
*#* '''Advanced disease may be associated with signs and symptoms'''
*#** '''Regional symptoms: lower urinary tract symptoms, hematuria, hematospermia, bladder outlet obstruction causing renal failure, decreased ejaculate volume, and rarely, impotence'''
*#** '''Metastatic symptoms: bone pain, lethargy, anemia, weight loss, pathologic fractures, and lower extremity edema; less common are malignant retroperitoneal fibrosis, paraneoplastic syndromes, disseminated intravascular coagulation, and paralysis'''
*# '''[[Prostate Cancer: Epidemiology and Pathogenesis|Risk factors]] for prostate cancer'''
*# '''Eligibility for investigations/treatment'''
*#* '''PMHx, FHx, Meds, All, Social, etc.'''
*#** '''Will patient benefit from investigations/treatment (age, competing risk (comorbidity))?'''
*#*** '''Is a TRUS biopsy of benefit in a 95 year-old male with a PSA 400 ng/mL ?'''
*#** '''Is the patient a candidate for treatment ([[AUA: Clinically Localized Prostate Cancer (2017)|contraindications to radiotherapy]], for example)?'''
*#** '''<span style="color:#ff0000">Family history</span>'''
*#***'''<span style="color:#ff0000">Criteria for "strong" family history (2):</span>'''
*#***# '''<span style="color:#ff0000">≥1 brother or father OR ≥2 male relatives with one of the following (3):</span>'''
*#***##'''<span style="color:#ff0000">Diagnosed with prostate cancer at age <60 years</span>'''
*#***##'''<span style="color:#ff0000">Any of whom died of prostate cancer</span>'''
*#***##'''<span style="color:#ff0000">Any of whom had metastatic prostate cancer.</span>'''
*#***# '''<span style="color:#ff0000">Family history of other cancers with ≥2 cancers in hereditary breast and ovarian cancer syndrome or Lynch syndrome spectrum.</span>'''
*#***#* '''<span style="color:#ff0000">Hereditary breast and ovarian cancer syndrome</span>'''
*#***#**'''<span style="color:#ff0000">Associated cancers (5):[https://www.ncbi.nlm.nih.gov/books/NBK1247/]</span>'''
*#***#*#'''<span style="color:#ff0000">Breast (male and female)</span>'''
*#***#*#'''<span style="color:#ff0000">Ovarian</span>'''
*#***#*#'''<span style="color:#ff0000">Prostate</span>'''
*#***#*#'''<span style="color:#ff0000">Pancreatic</span>'''
*#***#*#'''<span style="color:#ff0000">Melanoma</span>'''
*#***#*'''<span style="color:#ff0000">Lynch syndrome</span>'''
*#***#**'''<span style="color:#ff0000">Associated cancers (11)</span>[https://www.ncbi.nlm.nih.gov/books/NBK431096/]'''
*#***#**#'''<span style="color:#ff0000">Colorectal (20-80%) (most common)</span>'''
*#***#**#'''<span style="color:#ff0000">Gynecologic</span>'''
*#***#**## '''<span style="color:#ff0000">Endometrial (15-60%) in females (second most common)</span>'''
*#***#**##'''<span style="color:#ff0000">Ovarian cancer (1-38%) in females</span>'''
*#***#**#'''<span style="color:#ff0000">Urologic</span>'''
*#***#**##'''<span style="color:#ff0000">Urothelial (1-18%), includes upper urinary tract and bladder</span>'''
*#***#**##'''<span style="color:#ff0000">Prostate</span>'''
*#***#**##'''<span style="color:#ff0000">Adrenal[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3739861/ §]</span>'''
*#***#**#'''<span style="color:#ff0000">Other gastrointestinal</span>'''
*#***#**##'''<span style="color:#ff0000">Gastric cancers (1-13%)</span>'''
*#***#**##'''<span style="color:#ff0000">Hepatobiliary</span>'''
*#***#**##'''<span style="color:#ff0000">Small bowel</span>'''
*#***#**#'''<span style="color:#ff0000">Skin</span>'''
*#***#**#*'''<span style="color:#ff0000">Sebaceous adenoma, sebaceous epithelioma, sebaceous adenocarcinoma, keratoacanthoma, and squamous cell carcinoma[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423888/]</span>'''
*#***#**# '''<span style="color:#ff0000">Brain</span>'''
*#***#**#'''<span style="color:#ff0000">Inconsistent: Pancreas, breast, (prostate)</span>'''
*#**'''<span style="color:#ff0000">Patients with a "strong" family history should ideally be genotyped</span>[https://pubmed.ncbi.nlm.nih.gov/37096582/]'''
*#***'''Genotype is to ascertain whether there is presence of a pathogenic variant (e.g., BRCA1/2, Lynch Syndrome, ATM, CHEK2) or one or more of a growing set of identified germline DNA damage-repair mutations found in patients with metastatic prostate cancer diagnoses.'''
*# '''Patient preference for investigations/treatment'''
*#* '''Benefits/harms of treatment (sexual function, for example)'''
* '''<span style="color:#ff0000">Physical exam</span>'''
** '''Body habitus'''
*** '''Determine candidacy for intervention'''
** '''<span style="color:#ff0000">Digital rectal examination</span>'''
*** '''A palpable tumour and the extent is associated with local disease extent (clinical T stage)'''
****'''Can both overestimate and underestimate the extent of disease because of its poor sensitivity and lack of reproducibility'''
***** '''Consider useful to detect presence, but not useful to assess stage'''
*** '''In a screened population, an abnormal DRE is associated with an increased risk for detecting high-grade (Gleason 8 to 10) prostate cancer'''
***'''<span style="color:#ff0000">Indications (2023 AUA Guidelines on Early Detection of Prostate Cancer[https://pubmed.ncbi.nlm.nih.gov/23659877/])</span>'''
****'''<span style="color:#ff0000">Screening</span>'''
*****'''<span style="color:#ff0000">Should not use DRE as the sole screening method.</span>'''
******'''The primary screening modality recommended for the early detection of prostate cancer is a PSA blood test.'''
*****'''<span style="color:#ff0000">Insufficient evidence to support adding DRE to PSA-based prostate cancer screening.</span>'''
******For various reasons, clinicians may choose to complement PSA screening with DRE based on SDM.
*******When DRE and PSA tests are used in prostate cancer screening, detection rates are higher with PSA testing alone vs. DRE alone, and highest with the tests together[https://pubmed.ncbi.nlm.nih.gov/28012755/]
*****[[AUA: Prostate Cancer Screening (2018)|2018 AUA]] and [[CUA: Prostate Cancer Screening (2017)|2017 CUA]] Guidelines support the role of DRE in screening
****'''<span style="color:#ff0000">Elevated PSA[https://pubmed.ncbi.nlm.nih.gov/23659877/]</span>'''
*****'''<span style="color:#ff0000">If PSA ≥ 2 ng/mL, strongly consider supplementary DRE to establish risk of clinically significant prostate cancer.</span>'''
******Highest utility of DRE in randomized trials is demonstrated in the workup of patients with an elevated PSA.*******In contrast to a screening application, use of DRE subsequent to the screening encounter may be of value.
********In patients undergoing prostate biopsy for an elevated PSA during screening, abnormal DRE improves the PPV for any prostate cancer and GG2+ detection