BPH and Prostate Cancer, PSA Screening

Question 1

A 51 y/o caucasian male is at his PCP for his annual physical. He has a family hx of prostate cancer (father, diagnosed at age 74). Would you order a PSA screening for this patient?

Answer 1

• Maybe.

Question 2

A 57 y/o healthy caucasian male with no hx of prostate cancer. Should you order a PSA?

Answer 2

• Maybe

Question 3

Should you order a PSA on a 55 y/o African American male with no family history of prostate cancer?

Answer 3

• Maybe

Question 4

What is PSA?

Answer 4

• serine protease of the kallikrein family primarily produced by prostatic luminal epithelial cells. It cleaves seminogelin (semen liquefaction).
• found within serum as bound and unbound forms.

Question 5

What conditions can elevate PSA?

Answer 5

• prostate CA
• BPH
• infections (prostatitis, cystitis)
• ejaculation
• age
• manipulation or trauma

Question 6

What factors can reduce PSA?

Answer 6

• 5-alpha reductase inhibitors
• low serum testosterone
• prostatic surgery
• radiation therapy

Question 7

Is PSA screening recommended in men over age 70?

Answer 7

NO, bc most would die without symptoms due to prostate cancer found at this time.

Question 8

What are the benefits of PSA screening?

Answer 8

• early detection

- may prolong survival

Question 9

What are the disadvantages of PSA screening?

Answer 9

• over-detection of indolent disease
• false positives
• testing associated with morbidity
• over-treatment

Question 10

What did the PLCO trial find?

Answer 10

• no survival benefit for PSA based screening

* flaws however due to pre-screening and contamination in control arm (75% were screened at least once).

Question 11

What did the ERSPC trial in Europe show?

Answer 11

• 21% reduction in death in screened group

* flaws due to contamination issue

Question 12

Is there a universal consensus for threshold for “elevated” PSA?

Answer 12

NO bc there is a trade off between sensitivity and specificity.
*must be adjusted to age and ethnicity.

Question 13

How can we better diagnose the high risk cancers without over treating the low risk cancers?

Answer 13

• genetics
• blood tests
• aka there are other modalities available.

Question 14

What is the prostate health index (PHI)?

Answer 14

• mathematical formula that combines total, free, and proPSA to help in your decision making process.

Question 15

What is the 4K score?

Answer 15

• panel of 4 serum kallikrein markers (tPSA, fPSA, single chain iPSA, and hK2) that can be found in your blood.
• good test but expensive.

Question 16

What is ConfirmMDX?

Answer 16

• epigenetic assay of tissue biopsy looking for methylation changes associated with cancer.
• 96% negative predictive value

Question 17

What is PCA3?

Answer 17

• urine test that looks at non-coding, large chain RNA that is highly over-expressed in prostate cancer compared with noncancerous prostate tissue.
• independent of age, prostate volume, and PSA.

Question 18

** What would we expect to see now that the the newest USPSTF guidelines recommend against PSA testing? (TEST QUESTION)

Answer 18

• higher risk of finding patients with advanced stage prostate cancer

Question 19

** What race has the highest risk for prostate cancer? (TEST QUESTION)

Answer 19

• African Americans

Question 20

** To where does most prostate cancer metastasize? (TEST QUESTION)

Answer 20

• bone (osteoblastic)

* NOT lytic

Question 21

** How do you treat localized vs metastatic prostate cancer? (TEST QUESTION)

Answer 21

• localized= localized treatment (active surveillance, surgery, or radiation)
• metastatic= systemic treatment (chemotherapy)

Question 22

How would you pick up prostate cancer?

Answer 22

• rectal exam (DRE) and abnormal PSA

Question 23

What do symptoms such as bleeding, flank pain, or back pain usually indicate in relation to prostate cancer?

Answer 23

• late stage disease :(

Question 24

What is the trifecta goal of treatment?

Answer 24

• oncologic control
• maintenance of erectile function
• continence

Question 25

What are some newer treatment options for metastatic prostate cancer?

Answer 25

- immunotherapy= sipuleucel - radium 223 - abiraterone= CYP17 lyase inhibitor (must be taken with prednisone) - enzalutamide= ARB with high affinity for androgen receptor

Question 26

Is surgical therapy generally preferred for older or younger patients with localized cancer?

Answer 26

- YOUNGER

Question 27

Is radiation therapy generally preferred for older or younger patients for localized cancer?

Answer 27

- OLDER (70 and up)

Question 28

What is Benign Prostatic Hyperplasia (BPH)?

Answer 28

- a PHYSIOLOGIC increase in the number of prostatic STROMAL and EPITHELIAL cells that commonly contribute to lower urinary tract symptoms (LUTS) in aging men.

Question 29

What are LUTS?

Answer 29

- symptoms that include poor stream, intermittent stream or hesitancy, terminal dribbling, straining, urgency, nocturia, and sensation of incomplete bladder emptying.

Question 30

Does the size of the prostate always correlate with the degree of symptoms?

Answer 30

NO

Question 31

**** Where in the prostate does BPH typically occur? (TEST QUESTION)

Answer 31

- the TRANSITIONAL ZONE | * contrast this to prostate cancer which occurs in the peripheral zone.

Question 32

**** Will alpha blockers (nonselective= terazosin, doxazosin, alfuzosin; or selective= tamsulosin and silodosin) or tadalafil (PDE5 inhibitor; cialis) affect your PSA? (TEST QUESTION)

Answer 32

- NO

Question 33

**** Will 5-alpha reductase inhibitors (finasteride or dutasteride) affect your PSA? (TEST QUESTION)

Answer 33

- YES

Question 34

**** What are the indications for surgical treatment for patients with BPH?

Answer 34

- urinary retention - UTIs - gross hematuria - bladder or renal calculi stones - renal insufficiency or hydronephrosis - failed medical management

Question 35

What is the function of the prostate?

Answer 35

- to secrete certain enzymes into semen to facilitate sperm survival in the female reproductive tract. * prostatic secretions have a large concentration of ZINC compared to blood. - also aids in emission of semen during ejaculation by contracting around the urethra.

Question 36

What are the main receptors found in the prostatic stroma?

Answer 36

- alpha-1A receptors= contraction of smooth muscle and leads to restriction of urine flow

Question 37

What medications can exacerbate urinary retention?

Answer 37

- anticholinergics (atropine, oxybutynin, dicycloamine, glycopyrrolate...) - antihistamines (diphenhydramine, hydroxyzine, chlopheniramine...) - antidepressants (TCAs) - sympathomimetics (alpha-adrenergic agonists; ephedrine, phenylephrine)

Question 38

What should be on your DDx for a patient that comes in with lower urinary tract symptoms (LUTS)?

Answer 38

- BPH - UTI - bladder stones - neurogenic bladder - urethral stricture (scar tissue) - bladder cancer - urethritis

Question 39

What is a complication associated with the use of selective alpha blockers like Tamsulosin (Flowmax) or nonselective alpha blockers?

Answer 39

- intraoperative floppy iris syndrome (IFIS). | * basically not a problem, but if going to the eye doctor, let them know before any eye surgery.

Question 40

When are 5-alpha reductase inhibitors used?

Answer 40

- in men with larger prostates. | * can combine with alpha blocker