B8.048 Prework 1: Screening for and Diagnosis of Prostate Cancer

Question 1

what is the prostate

Answer 1

a gland in the pelvis

Question 2

purpose of the prostate

Answer 2

reproduction
makes the seminal fluid (non-sperm) portion of the ejaculate to nourish sperm
stored in the seminal vesicles

Question 3

composition of the prostate

Answer 3

glands: source of adenocarcinoma of the prostate
stroma: contains the suportive tissues such as the smooth muscle, vessels, and autonomic nerves, source of the non-adenocarcinoma prostate cancers (sarcomas)
seminal vesicles

Question 4

risk factors for prostate cancer

Answer 4

increasing age
AA race/ethnicity
fam history of prostate, breast, ovarian, and pancreatic cancers
genetic syndromes/conditions: lynch, BRCA2

Question 5

AUA screening guidelines

Answer 5

40-54: men at risk

55-69: shared decision making

Question 6

american cancer society screening guidelines

Answer 6

50+: average risk with life expectancy > 10 years
45+: men at high risk
40+: men at highest risk, more than 1 first degree relative

Question 7

NCCN screening guidelines

Answer 7

45-75

Question 8

USPSTF screening guidelines

Answer 8

55-69

Question 9

should you screen men >70 for prostate cancer?

Answer 9

depends on their sitch

if they are going to live a while, yes

Question 10

PSA

Answer 10

protein produced by the prostate and secreted into seminal fluid to liquify semen

Question 11

how does PSA get into the serum

Answer 11

loss of the basal cell layer (hallmark of prostate cancer histologically) results in leakage of PSA into blood stream > thus returning elevated levels

Question 12

2 components of prostate cancer screening

Answer 12

PSA and DRE

Question 13

DRE

Answer 13

palpation of the prostate for nodularity

palpable lesion = 40% risk of incident prostate cancer

Question 14

prostate zones

Answer 14

transition zone = 20%
central zone = 5%
peripheral zone = 70-80%

Question 15

accuracy of a PSA screening

Answer 15

PSA > 4 used
-PPV 30%
-NPV 85%
unfortunately with PSA < 4, 15% of men will have high grade disease

Question 16

why can people with PSA < 4 have high grade prostate cancer

Answer 16

younger men have smaller glands; less BPH driven PSA, so lower PSAs can be more concerning
prostate cancer cells can make less PSA by volume than normal prostate cells (not normally functioning cells)

Question 17

risks of prostate biopsy

Answer 17

discomfort
pain
bleeding (urine, stool, semen)
transient ED
infection (2-4% get post biopsy sepsis)

Question 18

contemporary schema for assembling of screening info

Answer 18

concern > shared decision making > PSA and DRE
if PSA elevated: biomarker or MRI > biopsy if abnormal
if abnormal DRE: prostate biopsy

Question 19

additional tests for prostate cancer screening

Answer 19

4K score
PHI
PCA3
MRI

Question 20

4K score

Answer 20

total PSA, free PSA, intact PSA, kallikrein-related peptide 2
clinical factors
AUC for clinically significant prostate cancer: 0.77-0.82 (better than PSA)

Question 21

PCA3

Answer 21

PCA3 ad PSA RNA in post DRE urine samples
approved in men with a negative prior biopsy
NPV 90%

Question 22

multi-parametric MRI with fusion biopsy

Answer 22

T2 weighted
dynamic contrast enhanced
diffusion weighted imaging
approved for men with a prior negative biopsy
-NPV: 90%
-PPV: 60%

Question 23

advantage of MRI over blood tests

Answer 23

approved (get coverage) and offers ability to target

Question 24

targeted biopsy

Answer 24

uses US and MRI fusion software
targets lesions identified on MRI for biopsy
tracks where biopsies were obtained

Question 25

lifetime risk of prostate cancer death across population

Answer 25

2.8%

Question 26

does PSA screening decrease mortality?

Answer 26

21% RR in cancer mortality
29% when adjusted for noncompliance
1.07 deaths per 1000 men

Question 27

NTT of PSA screening

Answer 27

781 men screened
12 cancers detected
to prevent 1 death at 13 years

Question 28

why not screen for prostate cancers?

Answer 28

large number screened to avert 1 death
false positive PSA values result in unnecessary biopsies
some men who receive treatment don’t need it