Diagnostic Criteria

PSA testing often detects localized prostate cancers that progress slowly.

Content 12





Content 9


The USPSTF does not recommend screening for prostate cancer unless men express a preference for screening after being informed of and understanding the benefits and risks.

This recommendation applies to adult men in the general US population without symptoms. It also applies to men with an increased risk of death from prostate cancer because of race/ethnicity or family history of prostate cancer.

Screening for prostate cancer in men aged 55 to 69 years offers a small potential benefit of reducing the chance of death. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. The USPSTF does not recommend screening for prostate cancer unless men express a preference for screening after being informed of and understanding the benefits and risks. The USPSTF also concludes with moderate certainty that the potential benefits of PSA-based screening for prostate cancer in men 70 years and older do not outweigh the expected harms.

In 2012, the USPSTF concluded that although there are potential benefits of screening for prostate cancer, these benefits did not outweigh the expected harms enough to recommend routine screening (D recommendation). The change in recommendation grade is based in part on additional evidence that increased the USPSTF's certainty about the reductions in risk of dying of prostate cancer and risk of metastatic disease.

In an editorial commentary, H. Ballentine Carter, MD, from the Department of Urology and the James Buchanan Brady Urologic Institute at the Johns Hopkins University School of Medicine in Baltimore, stated, “The USPSTF has provided a timely and careful approach to reassessment of the benefits and harms of PSA-based screening for prostate cancer. Patients, together with their physicians, should decide whether prostate cancer screening is right for the patient. In this regard, primary care physicians have an important role in reducing the harms associated with screening and could consider a number of factors in this decision process.”


Neal D. Shore, MD, FACS, president of LUGPA, gave an exclusive statement to the Clinical Advisor, in which he states: “LUGPA has always recommended that patient-physician shared decision making requires thoughtful and clear communication with men of all ages who might be at risk for prostate cancer diagnosis. For those patients with newly diagnosed prostate cancer, LUGPA believes a full discussion of all treatment options, which includes active surveillance and appropriate immediate interventions, is required. LUGPA believes that while the current guidelines do represent a step forward, they simply do not go far enough.  LUGPA remains committed to preserving the right of every man to access appropriate screening services after consultation with their healthcare provider.”


  1. US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(18):1901-1913. doi:10.1001/jama.2018.3710
  2. Carter HB. Prostate-specific antigen (PSA) screening for prostate cancer: revisiting the evidence. JAMA. 2018;319(18):1866-1868. doi:10.1001/jama.2018.4914


General considerations include age, and general performance status, Gleason score, initial serum PSA, estimated tumor volume, tumor stage, and patient life expectancy. Options should be explained to patients so that patients can make an informed decision about which treatment best fits their values and goals. Current management can include surveillance, surgery, or radiotherapy.

low-risk individuals (define)- Active surveillance—

likely to die with the disease rather than from the disease. Active surveillance

Treatment is considered if significant disease progression is detected. This involves PSA testing and periodic rebiopsy.

Treatment of choice for patients with organ-defined disease and a life expectancy of more than 10 years. Walsh has shown that the cavernosal nerves that mediate erectile function can be identified and avoided, reducing postoperative erectile dysfunction. Rarely, significant urinary incontinence may be encountered. Radical prostatectomy—

  • Which approach is associated with better outcomes and fewer side effects?
    • Robotic-assisted laparoscopic prostatectomy (RALRP)—RALRP was developed to overcome of the difficulties of the standard laparoscopic prostatectomy. The robotic technique allows for magnified high definition three-dimensional visualization of the operative field and wider range of motion. The majority of men opting for radical prostatectomy in the United States are having RALRP (Figure 73-6).12SOR B
  • External beam radiation therapy (EBRT)—EBRT is also a viable treatment option for localized disease and is the choice treatment option for T3 disease. EBRT utilizes high-energy electrons to destroy cancer cells by damaging cellular DNA. Side effects can include rectal and bladder symptomatology. Short-term androgen deprivation therapy (1 to 3 years) may increase efficacy.13,14SOR B
  • Brachytherapy—Outpatient, ultrasound-guided, transperineal placement of 125I or Pd radioactive seeds into the prostate. Optimal candidates have low-risk prostate cancer. Many centers utilize short-term neoadjuvant hormonal blockade given the difficulty in treated glands larger than 50 gs.15SOR B
  • Androgen ablation in combination with EBRT—There may be some synergy between the apoptotic response induced by androgen deprivation and radiotherapy. Androgen deprivation results in an average 20% decrease in prostate volume to reduce the number of target cells, and thereby improve tumor treatment. Shrinking the prostate can decrease side effects by diminishing the volume of rectum and bladder irradiated.13,16SOR B
  • For recurrent or advanced disease—Docetaxel (Taxotere)-based regimens can be included among the most effective treatment options for the management of patients with advanced, androgen independent prostate cancer. Results with docetaxel as a single agent and in combination regimens with estramustine (Emcyt) have provided patient benefit through an improved palliative response and improvement in quality of life as assessed through quality of life questionnaires. In addition, treatment with Docetaxal based regimens have produced objective responses such as reduced serum PSA levels by 50%, reduction in measurable disease on imaging, pain and health related quality of life. Progression-free survival was significantly increased in patients receiving docetaxel plus estramustine compared to those receiving mitoxantrone and prednisone (6.3 versus 3.2 months).17,18SOR B



Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


Content 3

Content 13

A 65-year-old man in good health comes to the office having had a prostate specific antigen (PSA) test performed at a local health fair. He reports a normal voiding pattern and normal erectile function with no evidence of weight loss or bone pain. He has no major medical problems but does have a strong family history of prostate cancer. His PSA is 9.3 ng/mL and he chooses to have a prostate biopsy. Pathology demonstrates prostate cancer with a Gleason score of 6

Content 11


Question 1 of 1

A 42-year-old African-American man has been diagnosed with hypertension for the past 10 years and treated with medication. One morning, he is found unresponsive by his wife. He is taken to the emergency department and pronounced dead by the physician. An autopsy revealed cardiac hypertrophy and a narrowing of the aorta just distal to the ligamentum arteriosum, with dilation of the intercostal artery's ostia. How could the death have possibly been prevented?



USMLE Reviewer (Subscription Required)