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
What are the side effects of radical prostatectomy and radical radiotherapy?
Prostatectomy
- Urinary incontinence
- Erectile dysfunction
- If open post op issues like pain, post op ileum, pneumonia, atelectasis but robotic avoids this
Radiotherapy
Local effects:
- Proctitis
- Urinary incontinence
- Erectile dysfunction (less than above)
- Risk of bowel/bladder cancer
- Bowel fibrosis
- Bladder fibrosis
- Radiation cystitis
- Diarrhoea
Systemic effects:
- Nausea
- Tiredness
- Loss of hair in treatment area
Proctitis and Bowel cancer are a common complication of external beam radiotherapy for prostate cancer. How can this be managed?
Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge
When is hormone therapy given in prostate cancer, what are the different types and how do they work?
Given alongside radical radiotherapy in local disease or to slow progression in metastatic disease
Aim is to lower androgens as prostate cancer is androgen dependant
How does Goserelin act as chemical castration?
GnRH agonist that stimulates LH/FSH release from the anterior pituitary. Initially it causes an increase in LH/FSH release. However, the persistent presence of an agonist causes downregulation of receptors on the pituitary gland leading to reduced LH/FSH release
If Goserelin is given this can cause a short term increase in testosterone. If there is any metastases in the spine this can lead to spinal cord compression from rapid growth. How can we prevent this?
Give a androgen receptor antagonist
e.g Bicalutamide and Enzalutamide
What are the side effects of hormone therapy in prostate cancer?
Sexual
- Decreased libido
- Erectile dysfunction
- Infertility
- Gynecomastia
Metabolic
- Weight gain
- Osteoporosis
- Diabetes
- Ischaemic heart disease
Haematological
- Anaemia
- Fatigue
When may chemotherapy be used in prostate cancer treatment?
Docetaxel
- Locally advanced
- Metastatic
How is metastatic prostate cancer managed?
- Docetaxel chemotherapy
- Androgen deprivation therapy
- Bilateral orchidectomy offered as an alternative to androgen deprivation therapies
- Palliative care
How often should you check PSA levels of a man with prostate cancer being treated?
Watchful waiting in primary care: at least annually
Radical treatment:
– at least 6 weeks after treatment
– at least every 6 months for the first 2 years
– at least once a year after the first 2 years.
How can ED from prostate cancer treatment be managed?
How can urinary incontinence from prostate cancer treatment be managed?
How can the side effects from prostate cancer hormonal treatment be managed?
- Progestogens for hot flushes
- Radiotherapy or tamoxifen for gynacomastia
How can painful bone metastases in prostate cancer be managed?
- Strontium 98 radiotherapy
- Bisphosphonates
What is the 5 year survival with prostate cancer?
86%
Why is screening not done for prostate cancer?
- No evidence it decreases mortality
- Overdiagnosis
This patient has prostate cancer, what could be the differentials for this presentation?
Look for cachexia and anaemia
What investigations should you do for Mr Warren when suspecting progression of prostate cancer?
Bone scan to look for bone metastases, MRI to rule out spine compression, CT lumbosacral spine to rule out compression fracture
What is the difference between transperineal and TRUS biopsy?
TRUS is LA and transperineal is GA template biopsy
How can you account for a large prostate in the PSA test?
PSA density
When should you do a bone scan in prostate cancer?
- PSA>20
- Gleason >8
- T>3
What screening is done for prostate cancer?
Opportunistic when requested or when symptoms
What is the referral criteria for renal and bladder cancer and what investigations are done at the 2 week wait?
NB image
Bladder Cancer
- Over 45 with….
- Unexplained visible haematuria without UTI or
- Visible haematuria that persists or recurs after treatment of UTI
- Over 60 with….
- Unexplained non-visible haematuria and dysuria or raised WCC or
- Persistent or recurrent UTI
Renal Cancer
- Over 45 with….
- Unexplained visible haematuria without UTI or
- Visible haematuria that persists after treatment of UTI
What are some differentials for haematuria?
Visible: Urological
Non visible: Nephrological
What is the referral criteria for testicular cancer and what investigation is done?
- Non-painful enlargement or change in shape or texture of the testis
- Direct access US and AFP, bhCG, LDH
What is the referral criteria for penile cancer?
- A penile mass or ulcerated lesion where a STI has been excluded or treated
- Unexplained or persistent symptoms affecting the foreskin or glans e. recurrent phimosis and balantitis
What are the treatment options for bladder TCC?
- TURBT: diagnosis and management
- Radical Cystectomy with reconstruction: see image
- Intravesical chemotherapy
- Palliative radio
- Immunotherapy
What is the treatment for upper urinary tract TCC?
How does RCC present and what are some risk factors for this?
- Haematuria
- Palpable mass
- Incidental finding on imaging
What are the treatment options for RCC?
- Surveillance
- Radical nephrectomy
- Palliative immunotherapy
What are the different histological types of testicular cancer?
What are the risk factors for penile cancer?
Metastatic prostate cancer treatment
need LHRH agonist
Bicalutamide oral 28 days
In 2 weeks time offer first injection monthly
so essentially castrated the patient for the first dose
if experiencing bone pain and give bisphosphonates and can offer localised single dose of chemo to the area that is affected
