8 - Prostate Flashcards
What is the epidemiology of prostate cancer?
- Most common malignancy in men (2nd most common in UK)
- 1 in 6 men
- Peak incidence 75-79
- More common and higher mortality in black men
What are some risk factors for prostate cancer?
Remember prostate cancer is androgen dependent
- Increasing age
- Family history
- Black African or Caribbean origin
- Obesity
- Anabolic steroids
- BRCA mutation
What are the two most common sites of prostate cancer metastases?
- Bone
- Lymph nodes
Majority of prostate cancer is slow growing!
What are the different types of prostate cancer and where do they occur in the prostate?
Most common (95%): adenocarcinomas
Rarer: transitional cell, squamous cell and neuroendocrine cancers
Majority in the peripheral zone!!!
How may prostate cancer present?
- Asymptomatic
-
LUTS:
- Nocturia
- Frequency
- Hesitancy
- Urgency
- Dribbling
- Overactive bladder
- Retention
- Visible haematuria
- Abnormal DRE (hard, nodular, enlarged, asymmetrical)
What are some symptoms of advanced prostate cancer?
- Haematuria
- Blood in semen
- Lower back pain/bone pain secondary to bony metastasis
- Weight loss
- Anorexia
What should prompt you to do a DRE and how would it feel if there was prostate cancer?
DRE should be considered in men with:
- LUTS (e.g. nocturia, frequency, hesitancy, urgency or retention)
- Haematuria
- Unexplained symptoms that may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss)
- Erectile dysfunction
- Other reasons to be concerned of prostate cancer (e.g. elevated PSA)
What is PSA and why may it be raised?
Prostate specific antigen produced by epithelial cells of prostate to liquefy semen
Common causes of a raised PSA are:
- Prostate cancer
- Benign prostatic hyperplasia
- Prostatitis
- UTIs
- Vigorous exercise (notably cycling)
- Recent ejaculation or prostate stimulation
Any man over the age of 50 can request a PSA. What do you need to counsel men on before a PSA test?
- May be raised for many other reasons (false positives 75%)
- May provide false reassurance if not raised (false negatives 15%)
What do men need to avoid before a PSA test?
- Active or recent UTI (last 6 weeks)
- No ejaculation, anal sex or prostate stimulation for 48 hours
- No vigorous exercise for 48 hours
- Had a urological intervention in the past 6 weeks
What should prompt a PSA test?
- Asymptomatic but man >50 requests it
- LUTS (e.g. nocturia, frequency, hesitancy, urgency or retention)
- Visible haematuria
- Erectile dysfunction
- Unexplained symptoms (e.g lower back pain, bone pain, weight loss)
What are the first line investigations in the GP if somebody presents with symptoms of prostate cancer?
- DRE
- Urine Dip
- PSA
What is the referral criteria for a two week wait for prostate cancer?
- Abnormal prostate (‘feels malignant’) on DRE
- PSA level is elevated above age-specific range (>4)
Clinician discretion must be used, a normal PSA and normal DRE do not exclude prostate cancer
What investigation is done for suspected prostate cancer on the two week wait and how is it scored?
Multiparametric MRI
Likert scale
- 1 – very low suspicion
- 2 – low suspicion
- 3 – equivocal
- 4 – probable cancer
- 5 – definite cancer
3 or more then need a biopsy
If the Likert score is 3 or more, what is the next investigation offered for suspected prostate cancer?
Prostate Biopsy
- Transperineal
- Transrectal (TRUS)
What are the complications of a prostate biopsy?
- Pain (particularly lower abdominal, rectal or perineal pain)
- Bleeding (blood in the stools, urine or semen)
- Infection
- Urinary retention due to short term swelling of the prostate
- Erectile dysfunction
What are some further investigations done to grade prostate cancer if metastases are suspected?
- Bone isotope scan
- CT
- Gleason grading
What is the Gleason grading score and how do you interpret it?
Based on the histology from the prostate biopsies
Less differentiation means higher grade and poorer prognosis
The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7)
- First number is grade of the most prevalent pattern in biopsy
- Second number is grade of second most prevalent pattern in biopsy
What are the three ways of predicting prognosis with prostate cancer?
- TNM staging
- Gleason grade
- Risk stratification
What is the risk stratification in local disease with prostate cancer?
PSA, Gleason, TNM
What information do you need to give men who are about to undergo treatment for prostate cancer?
- Discuss all relevant management options.
- Inform men that treatment may result in:
– altered physical appearance
– altered sexual experience
– possible loss of sexual function, ejaculation and fertility
– changes in urinary function
What are the different treatment options for localised prostate cancer?
- Active surveillance
- Radical prostatectomy
- Radical radiotherapy
Offer adjuvant hormonal therapy for a minimum of 2 years to men receiving radiotherapy who have a Gleason score of ≥ 8
What is watchful waiting/active surveillance in the treatment of prostate cancer and who is this suitable for?
Active Surveillance
- Regular annual PSA measurements, DRE, multiparametric MRI and biopsies
- Done to avoid over treatment and side effects of radio/surgery
- Candidates: low risk local disease
Watchful waiting
- No interventions, only if symptoms
- Elderly and many comorbidities
How is intermediate/high risk locally advanced prostate cancer managed?
- Radical prostatectomy: removal of the entire prostate gland and surrounding tissues. Can be completed as open, laparoscopic or robotic procedure
- Radical radiotherapy: external beam radiotherapy (EBRT) and brachytherapy
- Adjuvant hormone therapy if having radiotherapy as radical treatment
