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AUA guidelines > Clinically localized prostate cancer > Flashcards

Clinically localized prostate cancer Flashcards

1
Q

What should be obtained for risk stratification of prostate cancer?

A

risk stratification of prostate cancer severity or aggressiveness should include PSA, clinical stage digital rectal exam (DRE), Grade Group, and amount of cancer on biopsy (i.e. number of cores involved, maximum involvement of any single core) PSA density, and imaging

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2
Q

What are the various risk categories for Prostate cancer?

A 
Very low risk
low risk
favorable intermediate
unfavorable intermed
high risk
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3
Q

What are the criteria for very low risk prostate cancers?

A 
2 or fewer cores
less than 50% of a core
Gleason 3+3/GG-1
PSA < 10
PSA density <0.15
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4
Q

What are the criteria for low risk prostate cancer?

A 
PSA <10
and
Grade group 1
and
Stage T1-T2a
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5
Q

What are the criteria for favorable intermediate risk?

A

Grade group 1 with PSA 10-20
or
Grade group 2 with PSA < 10

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6
Q

What are the criteria for unfavorable intermediate risk prostate cancer?

A 
GG 2 with PSA 10-20
or 
Clinical stage T2b-c
or 
GG3 with PSA <20
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7
Q

What are the criteria for high risk prostate cancer?

A 
PSA >20
or 
GG 4-5
or  
clinical stage T3 or greater
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8
Q

How should clinical decision making about prostate cancer treatment be approached

A

With Shared decision making

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9
Q

What behavioral modification should be included in counseling a patient with prostate cancer?

A

Smoking and obesity.

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10
Q

Imaging for low or very low risk prostate cancer?

A

Clinicians should not perform abdomino-pelvic CT or routine bone scans in the staging of asymptomatic very low- or low-risk localized prostate cancer patients.

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11
Q

What is the recommended treatment option for very low risk prostate cancer?

A

Clinicians should recommend active surveillance as the best available care option for very low-risk localized prostate cancer patients

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12
Q

What is the rate of metastatic progression for very low risk prostate cancer at 15 years?

A

<1%

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13
Q

What is the recommended treatment for most low risk prostate cancer patients?

A

Active surveillance is the recommended option. Prostatectomy and radiation may be offered if there seems to be a greater risk of progression.

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14
Q

What are the clinical predictors of increased risk of progression?

A

Clinical predictors for an increased risk of higher grade disease or reclassification of subsequent biopsy include PSA density > 0.15, obesity as measured by BMI, African American race, family history, and extensive Gleason 6 cancer on systematic biopsy cores

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15
Q

Role of ADT for low risk localized prostate cancer?

A

Clinicians should not add ADT along with radiotherapy for low-risk localized prostate cancer with the exception of reducing the size of the prostate for brachytherapy.

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16
Q

What is the role of cyrosurgery in the low risk prostate cancer population?

A

Clinicians should inform low-risk prostate cancer patients considering whole gland cryosurgery that consequent side effects are considerable and survival benefit has not been shown in comparison to active surveillance

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17
Q

What is the role of HIFU and focal therapy for low risk prostate cancer patients?

A

HIFU and focal therapy lack robust evidence and are therefore not considered standard of care.

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18
Q

What are the recommended treatment options for a patient with < 5 years life expectancy and prostate cancer?

A

Men with a life expectancy of ≤5 years do not benefit from prostate cancer screening,79 diagnosis, or treatment. Prostate cancer treatment does not improve survival within five years of follow-up

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19
Q

A patient has unfavorable intermediate risk prostate cancer on biopsy. What additional workup is recommended?

A

Clinicians should consider staging unfavorable intermediate-risk localized prostate cancer patients with cross sectional imaging (CT or MRI) and bone scan

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20
Q

Specifically what findings should guide the physician to seek metastatic staging?

A

metastasis staging for men with two or more of the following features – palpable nodule on DRE (stage T2b/c), Gleason 7 (3+4 or 4+3) or PSA >10.

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21
Q

What are the NCCN/ACR recommendations for obtaining a bone scan?

A

bone scan for T2 and PSA >10 and CT if T2 and have a nomogram probability for nodal involvement >10%

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22
Q

What are the recommended treatment options patient’s with intermediate risk localized prostate cancer?

A

Clinicians should recommend radical prostatectomy or radiotherapy plus androgen deprivation therapy (ADT) as standard treatment options for patients with intermediate-risk localized prostate cancer.

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23
Q

What was the risk reduction of prostatectomy for intermediate risk prostate cancer per the SPCG-4 trial?

A

relative risk of dying after surgery was observed to be reduced at 0.62 (95% CI 0.44 to 0.87, p=0.01) with a reduction of cumulative incidence of death from prostate cancer from 20.7% to 14.6% at fifteen years.

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24
Q

What are the tx options other than prostatectomy for a patient with favorable intermediate risk prostate cancer?

A

Active surveillance
EBRT +/- ADT
Cryosurgery

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25
Q

What are the recommendations for EBRT +/- ADT?

A

Clinicians should inform patients that favorable intermediate-risk prostate cancer can be treated with radiation alone, but that the evidence basis is less robust than for combining radiotherapy with ADT.

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26
Q

What patient’s may benefit most from Cryotherapy?

A

Whole gland ablative therapies such as cryosurgery may be appropriate for patients with contraindications to more traditional therapies, such as prostatectomy or radiotherapy (e.g. medically inoperable patients with either previous pelvic radiotherapy or autoimmune disorders).

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27
Q

What additional work up my be necessary for intermediate risk prostate cancer patients who are considering active surveillance?

A

Patients who are considering surveillance may benefit from an MRI and targeted biopsy

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28
Q

Patient with intermediate risk prostate cancer and less than 5 year life expectancy?

A

Observation or watchful waiting.

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29
Q

Role of HIFU or focal therapy for intermediate risk patients?

A

Not standard of care

30
Q

Patient with high risk prostate cancer. What additional workup would be recommended?

A

Clinicians should stage high-risk localized prostate cancer patients with cross sectional imaging (CT or MRI) and bone scan.

31
Q

Does PSA predict diagnostic efficacy of a bone scan?

A

PSA <10 ng/ml has a negative predictive value of 99.5% for significant findings on bone scan, and <1% of patients with PSA < 20ng/ml have positive bone scans or CTs

32
Q

What are the recommended tx options for high risk prostate cancer?

A

Clinicians should recommend radical prostatectomy or radiotherapy plus androgen deprivation therapy as standard treatment options for patients with high-risk localized prostate cancer.

33
Q

What is the efficacy of radical prostatectomy for high risk patients?

A

The SPCG-4 trial compared radical prostatectomy and watchful waiting.96 At 15 years, all-cause mortality favored radical prostatectomy (46.1% versus 52.7%, RR, 0.75; 95% CI, 0.61 to 0.92), and prostate cancer-specific mortality favored radical prostatectomy (14.6% versus 20.7%, RR, 0.62; 95% CI, 0.44 to 0.87)

34
Q

Patient presents with high risk localized prostate cancer and wants active surveillance?

A

Clinicians should not recommend active surveillance for patients with high-risk localized prostate cancer. Watchful waiting should only be considered in asymptomatic men with limited life expectancy (≤5 years).

35
Q

What is the risk of dying from gleason 8-10 prostate cancer?

A

Men with Gleason 8-10 tumors had a 60-87% chance of dying from prostate cancer within 15 years of diagnosis

36
Q

What is the benefit of prostatectomy vs active surveillance for high risk prostate cancer?

A

PIVOT: Prostate cancer mortality was lower for high-risk patients in the prostatectomy cohort compared to observation (9.1% versus 17.5%, p=0.04)

SPCG-4: prostatectomy was associated with reduced mortality in all groups with the most benefit in the younger men (<65 years, relative risk 0.38).

37
Q

Patient with high risk prostate cancer is interested in Cyrotherapy?

A

Cryosurgery, focal therapy and HIFU treatments are not recommended for men with high-risk localized prostate cancer outside of a clinical trial. Data is lacking.

38
Q

Patient with high risk prostate cancer is interested in ADT?

A

Clinicians should not recommend primary ADT for patients with high-risk localized prostate cancer unless the patient has both limited life expectancy and local symptoms.

39
Q

Why shouldn’t ADT be offered as primary therapy for localized prostate cancer?

A

A randomized prospective study comparing the androgen receptor inhibitor bicalutamide 150 mg to placebo found no significant difference in overall survival or prostate cancer specific survival in men with localized prostate cancer

40
Q

A patient presents with high risk prostate cancer and a strong family history of other cancers?

A

Clinicians may consider referral for genetic counseling for patients (and their families) with high-risk localized prostate cancer and a strong family history of specific cancers (e.g., breast, ovarian, pancreatic, other gastrointestinal tumors, lymphoma)

41
Q

What factors might put the patient at high risk of having a genetic inheritable prostate cancer mutation?

A

High Gleason score (8-10) and family history of cancer (breast, ovarian, pancreatic, other gastrointestinal, lymphoma) in first-degree relatives was associated with germline DNA repair mutations in mCRPC patients (5-10%)

42
Q

What is the next step if a prostate cancer patient elects active surveillance?

A

Localized prostate cancer patients who elect active surveillance should have accurate disease staging including systematic biopsy with ultrasound or MRI-guided imaging

43
Q

What proportion of men getting a targeted biopsy can be expected to have their diagnosis upgraded?

A

30%

44
Q

How should patients on active surveillance be followed?

A

PSA and DRE every 3 months for one year. Then every 6 months thereafter. Repeat prostate biopsy at 1 year then every 3-5 years thereafter.

45
Q

Multiparametric prostate MRI should include what sequences?

A

1.5 Tesla magnet MRI

diffusion weighted imaging (DWI)

apparent diffusion coefficient (ADC)

T2-weighted (T2W) imaging

dynamic intravenous contrast-enhanced (DCE) imaging

46
Q

A patient on active surveillance develops and adverse reclassification on repeat biopsy. What should be done?

A

The patient should be offered treatment.

47
Q

What proportion of patients on active surveillance eventually receive treatment?

A

20% (PIVOT)

50% (ProTect)

48
Q

How do the outcomes compare between open, laparoscopic, and robotic assisted radical prostatectomy?

A

linicians should inform localized prostate cancer patients that open and robot-assisted radical prostatectomy offer similar cancer control, continence recovery, and sexual recovery outcomes.

49
Q

What differences are there between open and robotic radical prostatectomy?

A

Clinicians should inform localized prostate cancer patients that robotic/laparoscopic or perineal techniques are associated with less blood loss than retropupic prostatectomy.

50
Q

A patient is interested in adjuvant therapy in addition to prostatectomy?

A

Clinicians should not treat localized prostate cancer patients who have elected to undergo radical prostatectomy with neoadjuvant ADT or other systemic therapy outside of clinical trials.

51
Q

What is the role of age on erections following prostatectomy?

A

15-20% reduction in erections per decade from 50-70 years old.

52
Q

What is the role of age on incontinence after prostatectomy?

A

Men 70 years old are 2 fold more likely to develop significant incontinence.

53
Q

Who should receive lymphadenectomy during radical prostatectomy?

A

unfavorable intermediate risk disease and high risk disease.

54
Q

A patient with unfavorable intermediate risk disease is found to have locally extensive prostate cancer after prostatectomy. What next?

A

Clinicians should inform localized prostate cancer patients with unfavorable intermediate-risk or high-risk prostate cancer about benefits and risks related to the potential option of adjuvant radiotherapy

55
Q

What are the adverse effects of adjuvant radiotherapy for locally advanced prostate cancer?

A

GI toxicity 59%
Urinary symptoms 37%
No differences in symptoms persisted at 5 years.

56
Q

A patient with high risk prostate cancer is interested in radiotherapy?

A

EBRT + ADT
EBRT + brachy + ADT
ADT should be for 24-36 months

57
Q

What are the adverse effects of ADT?

A 
hot flashes
decrease bone mass
depression
fatigue 
weight gain.
58
Q

What happens when you take ADT with radiotherapy?

A

The adverse effects of ADT are increased.

59
Q

A patient with localized prostate cancer has a previous TURP but is seeking definitive treatment. What is the recommended treatment?

A

Prostatectomy
EBRT
brachy is discouraged.

60
Q

What is one of the theoretical advantages of proton therapy?

A

They stop depositing dose at an energy dependent distance from the source. Good for sparing adjacent tissue.

61
Q

Overall how does proton therapy compare with other treatments?

A

No overall difference

62
Q

What is the difference in adverse effects between proton therapy and IMRT?

A

IMRT actually had lower GI toxicity. Otherwise they were the same.

63
Q

What are the difference between brachytherapy and EBRT?

A

Similar adverse effects except that brachy has a higher risk of obstructive symptoms.

64
Q

Who is the ideal candidate for cryosurgery?

A

low or intermediate risk prostate cancer and not suitable for prostatectomy or radiotherapy.

65
Q

What are some contraindications to cryosurgery for prostate cancer?

A

discouraged for high risk
Prior TURP
unable to have TRUS

66
Q

What is the desired nadir temperature for cryosurgery?

A

-40c with double freeze thaw protocol

67
Q

If considering cryosurgery for a gland greater than 40g what should be done?

A

3-6 months of ADT to shrink the gland.

68
Q

What is the rate of ED after cryotherapy?

A

80-90%

69
Q

What are the rates of ED following various treatments for prostate cancer?

A

Prostatectomy: increased 44%
EBRT: increased 23%
Brachy: increased 21%

70
Q

How should localized prostate cancer patient’s be followed up after treatment?

A

Monitor PSA for at least 10 years

71
Q

What is the overall 5 year relative survival for localized prostate cancer?

A

99%

AUA guidelines (7 decks)

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