Prostate cancer was diagnosed in 186,320 men in 2008 in the United States-an incidence comparable to that of breast cancer. About 28,660 men died of prostate cancer in 2008. The early diagnosis of cancers in mildly symptomatic men found on screening to have elevated serum levels of PSA has complicated management. Like most other cancers, incidence is age-related. The disease is more common in blacks than whites. Symptoms are generally similar to and indistinguishable from those of prostate hyperplasia, but those with cancer more often have dysuria and back or hip pain. On histology, 95% are adenocarcinomas. Biologic behavior is affected by histologic grade (Gleason score).

In contrast to hyperplasia, prostate cancer generally originates in the periphery of the gland and may be detectable on DRE as one or more nodules on the posterior surface of the gland, hard in consistency and irregular in shape. An approach to diagnosis is shown in Fig. 79-1. Those with a negative DRE and PSA ≤4 ng/mL may be followed annually. Those with an abnormal DRE or a PSA >10 ng/mL should undergo transrectal ultrasound (TRUS)-guided biopsy. Those with normal DRE and PSA of 4.1-10 ng/mL may be handled differently in different centers. Some would perform TRUS and biopsy any abnormality or follow if no abnormality were found. Some would repeat the PSA in a year and biopsy if the increase over that period were >0.75 ng/mL. Other methods of using PSA to distinguish early cancer from hyperplasia include quantitating bound and free PSA and relating the PSA to the size of the prostate (PSA density). Perhaps one-third of persons with prostate cancer do not have PSA elevations.

Lymphatic spread is assessed surgically; it is present in only 10% of those with Gleason grade 5 or lower and in 70% of those with grade 9 or 10. PSA level also correlates with spread; only 10% of those with PSA <10 ng/mL have lymphatic spread. Bone is the most common site of distant metastasis. Whitmore-Jewett staging includes A: tumor not palpable but detected at TURP; B: palpable tumor in one (B1) or both (B2) lobes; C: palpable tumor outside capsule; and D: metastatic disease.

Figure 79-1
The use of the annual digital rectal examination (DRE) and measurement of prostate-specific antigen (PSA) as guides for deciding which men should have transrectal ultrasound (TRUS)-guided prostate biopsy. There are at least three schools of thought about what to do if the DRE is negative and the PSA is equivocal (4.1 to 10 ng/mL).