Xavier University - Ateneo de Cagayan

Jose P Rizal School of Medicine

Corrales Avenue, Cagayan de Oro City, Philippines

PROSTATE CANCER AWARENESS

Public Health Care Paper

In partial fulfillment of the requirements for the Clinical Clerkship A.Y. 2023 - 2024

Members
Aquino, Janica
Betaganso, Leda Beth
Calago, Pearl Mariam
Dable, Clyde Van
Leal, Tisha Nicole
 I. INTRODUCTION

Prostate cancer represents the most commonly diagnosed male malignancy worldwide and
stands as the sixth leading cause of cancer-related mortality among men. Predominantly
affecting older individuals, prostate cancer is diagnosed in 99% of cases in men over the age
of 50, with a median diagnosis age of 66 years. While rare in men under 45, its incidence is
rising due to factors such as prior underdiagnosis, increasing obesity, trends in metabolic
syndrome, and heightened environmental carcinogenic exposure. Notably, studies indicate
that prostate cancer tends to be more aggressive in younger men, with approximately 80% of
men developing the disease by the age of 80.

In the Philippines, prostate cancer is an emerging health concern among men, with
GLOBOCAN 2020 data estimating that 8,242 males are diagnosed annually. This rising
incidence underscores the pressing need for effective prevention, early detection, and
management strategies. The impact of prostate cancer extends beyond the individual,
affecting families and imposing significant economic burdens on the healthcare system.
Therefore, understanding the epidemiology, etiology, symptoms, and clinical management of
prostate cancer is crucial for developing comprehensive public health policies and clinical
guidelines to address this growing challenge.

II. OBJECTIVES
1. To provide an overview of the epidemiology and etiology of prostate cancer.
2. To discuss the clinical manifestations of prostate cancer, including its signs and
symptoms.
3. To discuss the diagnostic modalities used to diagnose prostate cancer.
4. To discuss the different ways to manage prostate cancer and its prognosis.
5. To disseminate information on leprosy to the public
III. EPIDEMIOLOGY

Prostate cancer is the most commonly diagnosed male malignancy worldwide and the 6th
leading cause of cancer death in men. Prostate cancer occurs in 99% of individuals >50 years
old (median age 66 years old). Though uncommon in < 45-year-olds, its incidence increases
due to prior underdiagnosis, increasing obesity trends, increasing metabolic syndrome
trends, and increased environmental carcinogenic exposure. Studies suggest that the disease
 tends to be more aggressive in younger individuals and 80% will develop prostate cancer by
age 80.

The Global Cancer Network Observatory or GLOBOCAN 2020 data show that in the
Philippines, an estimated 8242 males are diagnosed with this dreaded disease annually. It is
an emerging health concern for Filipino men.

IV. RELEVANCE

Prostate cancer is one of the most common cancers among Filipino men. According to the
Global Cancer Observatory, prostate cancer is one of the most common cancers in the
Philippines, contributing significantly to the overall cancer burden in the country. The
increasing incidence rates highlight the need for effective prevention strategies.
Prostate cancer, particularly in its advanced stages, can severely impact the quality of life of
affected individuals due to symptoms and complications like pain, urinary issues, and sexual
dysfunction. Preventive measures and early treatment can help maintain a better quality of
life for men.

Treating prostate cancer, especially in advanced stages, can be very costly and
resource-intensive. Prevention and early detection can reduce the economic burden on the
healthcare system by lowering the need for expensive treatments, hospitalizations, and
long-term care associated with advanced prostate cancer.

There is a general lack of awareness about prostate cancer among Filipino men. Early
detection significantly improves the prognosis of prostate cancer. Government agencies such
as the DOH have developed programs to promote awareness to the masses by providing.
awareness campaigns to educate men about the importance of regular screenings, such as
prostate-specific antigen (PSA) tests and digital rectal exams (DRE).

V. DISCUSSION

A. INCIDENCE
Prostate cancer is one of the most commonly diagnosed cancers among Filipino men.
According to data from the Global Cancer Observatory, it is one of the most common
cancers in the Philippines, with an increasing trend in incidence rates over recent
 years. The incidence of prostate cancer in the Philippines is reflective of global trends
where developed countries typically report higher incidence rates due to better
diagnostic capabilities and higher awareness. However, mortality rates in the
Philippines remain high due to late-stage diagnosis and limited access to advanced
treatment options​.

B. ETIOLOGY
The etiology of prostate cancer is multifactorial, involving a combination of genetic,
environmental, and lifestyle factors. These Include:

Older Age
Prostate cancer incidence increases with age, with most cases diagnosed in men
over 65 years. The aggressiveness of the cancer tends to decrease with age,
suggesting that older men may develop less aggressive forms of the disease.

Ethnicity
Ethnicity significantly influences prostate cancer risk. African-American men have
the highest incidence and mortality rates, possibly due to genetic predispositions
and socio-economic factors affecting healthcare access. In contrast, Asian men
generally have lower incidence rates​.

Obesity
Obesity is a well-established risk factor for prostate cancer. It is associated with an
increased risk of advanced prostate cancer and mortality. Adipose tissue can
influence hormone levels, including increased estrogen and insulin, which may
promote cancer development.

Hypertension
Hypertension has been linked to a higher risk of prostate cancer. The exact
relationship is not fully understood, but it is hypothesized that hypertension may
influence cancer development through chronic inflammation and changes in blood
flow to the prostate.
​
Sedentary lifestyle
Physical inactivity is associated with an increased risk of prostate cancer. Regular
exercise may reduce this risk by improving immune function, reducing
inflammation, and regulating hormone levels​

Persistently elevated testosterone levels

Elevated levels of testosterone over long periods may increase the risk of
developing prostate cancer. Testosterone can stimulate prostate cell growth, which
might lead to cancerous changes​.

History of STIs
Infections with sexually transmitted infections (STIs) like chlamydia, gonorrhea, and
syphilis have been associated with an increased risk of prostate cancer. These
infections may cause chronic inflammation, which can contribute to cancer
development.
 Strong family history of cancers
A family history of prostate cancer, as well as breast and ovarian cancer, significantly
increases risk. Men with a first-degree relative with prostate cancer have twice the
risk, and this risk is even higher if the relative had early-onset disease or if multiple
first-degree relatives are affected. Genetic mutations such as BRCA1 and BRCA2,
which are linked to breast and ovarian cancers, also contribute to the risk of
prostate cancer​

C. SIGNS & SYMPTOMS

Prostate cancer often presents with a variety of symptoms, which can be categorized
into early and advanced stages. The symptoms are primarily related to urinary and
reproductive functions due to the prostate's anatomical location.

Urinary Issues
Frequent Urination
Especially at Night (Nocturia): One of the earliest signs of prostate cancer is an
increased need to urinate, particularly during the night. This occurs because the
prostate gland's enlargement can press against the urethra, causing bladder
irritation​.

Difficulty Starting or Stopping Urination

Men may experience trouble initiating or halting the urine stream, which is a
result of the tumor obstructing the flow of urine through the urethra​.

Weak or Interrupted Urine Flow

A weak urine stream or intermittent flow is also common, as the growing
prostate can impede the normal passage of urine​.

Pain or Burning Sensation During Urination

This symptom can be indicative of an infection or inflammation of the prostate,
often seen in conjunction with prostate cancer​.

Inability to Urinate
In severe cases, the obstruction caused by the tumor can lead to acute urinary
retention, where the individual is unable to urinate at all​.

Blood in Urine (Hematuria) or Semen (Hematospermia)

The presence of blood can be alarming and is a sign that warrants immediate
medical evaluation as it might indicate cancer progression​.

Erectile dysfunction
Prostate cancer can interfere with sexual function, leading to difficulties in achieving or
maintaining an erection. This is due to both the physical obstruction caused by the
tumor and the psychological impact of the diagnosis.

Pain and Discomfort

Painful Ejaculation
Men may experience pain during ejaculation, which is another symptom that
 arises due to the proximity of the prostate to the reproductive organs​.

Discomfort in the Pelvic Area

General discomfort or pain in the pelvic region can be an early sign of prostate
issues, including cancer​.

Pain or Stiffness in the Lower Back, Hips, or Thighs

This can occur if the cancer spreads to surrounding tissues or bones, leading to
localized pain and stiffness​.

Swelling in the Legs or Pelvic Area

Lymph node involvement can lead to edema, or swelling, in the lower extremities and
pelvic area due to impaired lymphatic drainage​.

Bone Pain
Metastatic prostate cancer often spreads to the bones, causing significant pain,
particularly in the hips, spine, and pelvis​.

Weight Loss and Fatigue

Unintentional weight loss and persistent fatigue are common systemic symptoms of
advanced cancer, reflecting the body's response to the malignancy and its metabolic
demands​.

D. CLINICAL DIAGNOSIS
The diagnosis of prostate cancer involves a combination of clinical evaluation and diagnostic
tests. This comprehensive approach ensures accurate detection and appropriate staging of
the disease.

Medical History and Physical Examination

Medical History
The initial step involves taking a detailed medical history, including any urinary
symptoms, family history of prostate cancer, and other risk factors such as age and
ethnicity. This helps in identifying individuals at higher risk.
Physical Exam
Digital Rectal Exam (DRE): A DRE is a common clinical method where a healthcare
provider inserts a gloved, lubricated finger into the rectum to feel the prostate gland.
This helps detect abnormalities such as lumps or hard areas that may indicate cancer.
Diagnostic Tests
Prostate-Specific Antigen (PSA) Test
The PSA test measures the level of PSA in the blood. Elevated PSA levels can indicate
prostate cancer, though benign conditions such as prostatitis or benign prostatic
 hyperplasia (BPH) can also cause high PSA levels.

According to the Philippines CPG on prostate cancer, regular PSA screening is

recommended for men aged 50 and above, or younger for those at high risk (e.g.,
with a family history of prostate cancer).

Transrectal Ultrasound (TRUS)

TRUS involves the use of sound waves to create an image of the prostate gland. It is
often used to guide needle biopsies. A probe is inserted into the rectum to capture
detailed images of the prostate.

Prostate Biopsy
A prostate biopsy is considered the definitive method for diagnosing prostate cancer.
Under TRUS guidance, multiple tissue samples are taken from different areas of the
prostate and examined microscopically for cancer cells.

In the Philippines, the CPG recommends a systematic biopsy approach, where 12

core samples are taken to ensure a comprehensive evaluation.

Magnetic Resonance Imaging (MRI)

Multiparametric MRI (mpMRI) can provide detailed images of the prostate and
surrounding tissues, helping to identify suspicious areas that may need further
investigation or biopsy. MRI is particularly useful for staging and assessing the extent
of cancer.

The integration of MRI with biopsy techniques (MRI-TRUS fusion biopsy) is gaining
popularity for its accuracy in detecting clinically significant prostate cancer.

Gleason Score
The Gleason score is a grading system used to evaluate the aggressiveness of
prostate cancer based on biopsy samples. It ranges from 6 (least aggressive) to 10
(most aggressive). This score helps guide treatment decisions.

Advanced Diagnostic Techniques

 Prostate Health Index (PHI)
PHI is a newer blood test that combines total PSA, free PSA, and [-2]proPSA levels to
provide a more accurate risk assessment of prostate cancer. It is particularly useful in
differentiating between benign and malignant prostate conditions.

Genomic Testing
Genomic tests analyze the DNA of prostate cancer cells to identify specific mutations
and predict the behavior of the cancer. Examples include the Oncotype DX Prostate
Test and Prolaris. These tests can help tailor personalized treatment plans.

E. TREATMENT
The management and treatment of prostate cancer depend on the stage and grade of the
cancer, the patient's age, overall health, and personal preferences. In the Philippines, the Clinical
Practice Guidelines (CPG) for prostate cancer provide a framework for clinicians to offer
evidence-based care tailored to the individual needs of patients.

Active Surveillance
Active surveillance is a strategy for managing low-risk prostate cancer that involves close
monitoring of the disease without immediate intervention. This approach is suitable for
men with low-grade, limited-size cancer and aims to avoid or delay the side effects of
treatment while keeping a close watch on the cancer’s progression.

Periodic PSA Testing

Patients under active surveillance undergo regular PSA tests to monitor for any changes
in PSA levels that might indicate cancer progression.

Repeat Biopsy
An additional biopsy is typically performed 12-18 months after the initial diagnosis to
reassess the cancer’s grade and extent. This helps determine if the cancer remains
low-risk or if it has become more aggressive.

MRI
MRI can be used as a non-invasive alternative to repeated biopsies, reducing discomfort
and potential complications associated with frequent biopsies .

Localized Disease Treatment

For patients with localized prostate cancer who are expected to live for 10 years or
longer, definitive treatment options are considered to eradicate the cancer and prevent
recurrence. These treatments include:

External Beam Radiation Therapy (EBRT)

This method uses high-energy rays to target and kill cancer cells. It is less
invasive than surgery and associated with fewer immediate side effects.

Brachytherapy
Involves the placement of radioactive seeds directly into the prostate. This
 method delivers a high dose of radiation to the prostate with minimal impact on
surrounding tissues.

Radical Prostatectomy
Surgical removal of the entire prostate gland and some surrounding tissues. This
option is suitable for patients with a higher risk of cancer spread. While it can
offer a definitive cure, it is associated with potential side effects such as urinary
incontinence and erectile dysfunction.

Cryotherapy

Cryotherapy involves freezing prostate tissue to kill cancer cells. It is an option

for men who are not candidates for surgery or radiation therapy. This minimally
invasive procedure can be effective but may have side effects like urinary issues
and erectile dysfunction.

Advanced Disease Management

For patients with advanced prostate cancer that has spread beyond the prostate,
treatment options aim to control the disease, relieve symptoms, and improve quality of
life.

Androgen Deprivation Therapy (ADT)

Reduces levels of male hormones (androgens) to slow the growth of prostate
cancer. This can be achieved through medications or surgical removal of the
testes (orchiectomy).

Chemotherapy
Used for cancers that do not respond to hormone therapy. Chemotherapy
involves drugs that kill rapidly dividing cancer cells. It can help manage
symptoms and prolong life but is associated with significant side effects.

Targeted Therapy and Immunotherapy

These newer treatments target specific molecules involved in cancer growth or

enhance the body's immune response against cancer cells. Options include
drugs like enzalutamide and abiraterone, and immune checkpoint inhibitors.

Integrative and Palliative Care

Integrative care involves combining standard medical treatments with complementary
therapies to manage symptoms and side effects, improve quality of life, and support
emotional well-being.

Palliative Care
Focuses on relieving symptoms and improving the quality of life for patients
with advanced cancer. This includes pain management, nutritional support, and
psychological counseling.

F: RECOMMENDATIONS
The Department of Health (DOH) in the Philippines has established comprehensive guidelines
 and strategies for the prevention and management of prostate cancer, reflecting the significant
health burden it poses. Here are some key recommendations and strategies:

● Prevention Strategies
○ Awareness Campaigns
The DOH leads annual observances such as Prostate Cancer Awareness Month
to promote public awareness and understanding of prostate cancer. Activities
include webinars, distribution of educational materials, and collaborations with
various agencies and specialty societies to disseminate accurate information
about prostate cancer prevention and early detection​.

○ Lifestyle Modifications
Encouraging healthy lifestyle choices such as maintaining a healthy weight,
regular physical exercise, and managing conditions like hypertension and
diabetes are crucial. These recommendations align with global practices to
reduce the risk factors associated with prostate cancer.

○ Screening and Early Detection

Regular screening is particularly emphasized for high-risk groups, such as men
over the age of 50 and those with a family history of prostate cancer.

● Management and Treatment

The Philippine Clinical Practice Guidelines (CPG) provide detailed protocols for managing and
treating prostate cancer, ensuring a structured approach to patient care:
○ Active Surveillance
○ Localized Disease Treatment:
■ Radiation Therapy
■ Radical Prostatectomy
■ Cryotherapy
○ Advanced Disease Management:
■ Hormone Therapy
■ Chemotherapy
○ Palliative Care

Overall, the Philippine DOH's recommendations for the prevention and management of prostate
cancer reflect a comprehensive, multi-faceted approach, combining public awareness, lifestyle
interventions, and structured clinical management to address this significant health issue
effectively.

VII. REFERENCES
● Leslie SW, Soon-Sutton TL, R I A, et al. Prostate Cancer. [Updated 2023 Nov 13]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470550/
● https://www.who.int/philippines/news/detail/14-02-2024-doh--who-launch-2024-2028-nati
onal-integrated-cancer-control-program-(niccp)-strategic-framework
● https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2022.811044/full
● https://www.wjon.org/index.php/wjon/article/view/1191/915