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FRCSC 2020 Guidelines > Clinically Localized Prostate Cancer AUA Guideline 2017 > Flashcards

Clinically Localized Prostate Cancer AUA Guideline 2017 Flashcards

1
Q

what does AUA say for number of cores that can be positive for the very low risk localized prostate cancer?

A

no more than 1/3 positive.
so for extended template no more than 4.
the 2 that is mentioned in the text is in a sextant biopsy. targeted biopsies should not be included in this count

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2
Q

if someone has a tumor that is more than 0.2 ml on imaging does that mean they are not very low risk?

A

they can still be if they meet other criteria

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3
Q

what is very low risk localized prostate ca as per this guideline?

A

PSA <10 ng/ml AND Grade Group 1 AND clinical stage T1-T2a AND <34% of biopsy cores positive AND no core with >50% involved, AND PSA density <0.15 ng/ml/cc

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4
Q

what is low risk localized prostate ca as per this guideline?

A

PSA <10 ng/ml AND Grade Group 1 AND clinical stage T1-T2a

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5
Q

what is intermediate risk localized prostate ca as per this guideline?

A

PSA 10-<20 ng/ml OR Grade Group 2-3 OR clinical stage T2b-c

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6
Q

what is favorable intermediate risk localized prostate ca as per this guideline?

A

Favorable: Grade Group 1 (with PSA 10-<20) OR Grade Group 2 (with PSA<10)

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7
Q

what is unfavorable intermediate risk localized prostate ca as per this guideline?

A

Unfavorable: Grade Group 2 (with either PSA 10-<20 or clinical stage T2b-c) OR Grade Group 3 (with PSA < 20

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8
Q

what is high risk localized prostate ca as per this guideline?

A

PSA >20 ng/ml OR Grade Group 4-5 OR clinical stage >T3*

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9
Q

what should counselling of the patient include?

A

Cancer severity
Patient values and preferences
Life expectancy
pre-treatment general functional and GU symptoms
expected post treatment functional status
potential for salvage treatment

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10
Q

what are some patient related factors that are modifiable and patient should be counselled about?

A

smoking
obesity
associated with higher prostate cancer death and worse functional outcomes after.
Patients can delay therapy for a few months if appropriate to work on above.
frailty also associated with poor outcomes
functional status

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11
Q

Should physicians order CT or bone scan for staging of very low risk patients?

A

No

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12
Q

what should be the recommended treatment for men with very low risk prostate cancer?

A

Active surveillance

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13
Q

what is the metastatic progression rate of patients with very low risk prostate ca? what about low risk?

A

<1%

3%

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14
Q

what is the recommended option for most low risk patients?

A

Active surveillance

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15
Q

Which low risk patients should be offered RT or RP>

A

PSAD>0.15
Obesity (BMI)( >35)
Africa american race
Extensive GS 6 cancer on systematic biopsies
men with family history of aggressive prostate cancer

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16
Q

Can you use ADT in treatment of low risk localized prostate cancer?

A

not routinley
BUT can be used to shrink gland for Brachy
in RTOG 9408 addition of ADT for 4 months did not confer an OS benefit at 9 years. 2000 men in the study

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17
Q

List side effects of cryosurgery? does it work in comparison to AS?

A 
survival benefit has not been shown in comparison to AS
Side effects:
ED should be expected (90%) 
Urinary retention 
irritative symptoms
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18
Q

Clinicians should inform low-risk prostate cancer patients who are considering focal therapy or high intensity focused ultrasound (HIFU)

A

that these interventions are not standard care options because comparative outcome evidence is lacking

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19
Q

Clinicians should recommend ——— for men with a life expectancy ≤5 years with low-risk localized prostate cancer.

A

observation or watchful waiting

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20
Q

Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers

A

have not shown a clear role in the selection of candidates for active surveillance.

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21
Q

what are three genetic tissue assays approved by FDA for men with prostate cancer?

A

GEnomic classifier(GC): risk of mets
Genomic Prostate Score (GPS): risk of non organ confined disease
Cell Cycle Progression(CCP) : risk of death

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22
Q

What is the recommended staging for unfavorable intermediate risk prostate cancer?

A

CT scan/MRI and Bone scan

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23
Q

Clinicians should recommend ……….. as standard treatment options for patients with intermediate-risk localized prostate cancer

A

radical prostatectomy or radiotherapy plus androgen deprivation therapy (ADT)

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24
Q

what were the findings of the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) and PIVOT? ( relating to intermediate risk disease)

A

SPCG-4: most patients were intermediate risk disease and there was a reduction of death from prostate cancer from 21% to 15% with RP at 10 years in comparison to watchful waiting.

PIVOT: no difference as per trial but subgroup analysis of intermediate risk patients should there was a benefit in RP vs watchful waiting.

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25
Q

what were the findings of ProtecT?

A

Active surv vs RT vs RP
most patients low risk
AS: 50% got treatment by 10 years
no difference in OS at 10 years

metastasis and prostate cancer progression lower in patients who recieved RT or RP

there are Meta analysis of retrospective data that suggest surgery patients may do better but no good RCT in this domain.

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26
Q

Clinicians should inform patients that favorable intermediate-risk prostate cancer can be treated with radiation alone….

A

but that the evidence basis is less robust than for combining radiotherapy with ADT.

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27
Q

Describe twp RCT that are relevant for ADT + RT for Intermediate risk prostate cancer

A

RTOG 9408:
2000 men, 1000 intermediate
OS improved from 54% to 61% if 6 months of ADT was added to RT(66 gy), these days we use higher doses

EORTC 22991 added ADT to 78Gy RT and PFS improved but not OS. so seems to be beneficial with higher doses of radiation as well.

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28
Q

In which patient with intermediate risk prostate cancer can clinician consider cryosurgery?

A

patients with contraindications to more traditional therapies such as prostatectomy or radiotherapy
There is a lack of evidence for AS, cryosurgery or watchful waiting in this space.

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29
Q

Active surveillance …………. to select patients with favorable intermediate-risk localized prostate cancer;

A

may be offered

however, patients should be informed that this comes with a higher risk of developing metastases compared to definitive treatment.

For these patients MRI and biopsy should be done to make sure you are dealing with what you think you are dealing with.

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30
Q

Patients with small volume cancer on biopsy who have < 10% Gleason pattern 4 may reflect ……..

A

artifactual upgrading due to tangential cut of a Gleason 3 acinus, in which case the lumen is not seen and the pathologist’s impression is of a solid clump of cells (i.e. higher grade)

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31
Q

Clinicians should recommend ….. waiting for men with a life expectancy ≤5 years with intermediate-risk localized prostate cancer.

A

observation or watchful

PIVOT trial subgroup analysis showedd mortality was identical at 4 years for people treated and those who were not

32
Q

Clinicians should inform intermediate-risk prostate cancer patients who are considering focal therapy or HIFU that …..

A

these interventions are not standard care options because comparative outcome evidence is lacking.

HIFU should preferably be only offered in the context of a clinical trial.

33
Q

Clinicians should stage high-risk localized prostate cancer patients with…

A

Cross sectional imaging( CT or MRI) and bone scan.

PSA <10 has NPV of 99.5% for significant findings on bone scan. <1% of patients with PSA <20 have a positive bone scan or CT.

34
Q

Clinicians should recommend ……. as standard treatment options for patients with high-risk localized prostate cancer.

A

radical prostatectomy or radiotherapy plus androgen deprivation therapy

35
Q

For high-risk prostate cancer patients receiving external beam radiotherapy and ADT, ……..should be offered to eligible patients.

A

brachytherapy boost (low-dose rate or high-dose rate)

36
Q

Watchful waiting should only be considered in …… with high risk prostate cancer

A

asymptomatic men with limited life expectancy (≤5 years).

37
Q

both PIVOT And SPCG-4 showed… for high risk prostate cancer

A

reduced mortality esp for younger patients at 15 years.

38
Q

what are recommendations re HIFU, focal therapy and cryosurgery?

A

Not recommended.
One study of intermediate risk patients found Cryo and aDT to be similar. No good study on high risk patients.

no prospective RCTs for HIFU vs traditional treatment

If these are done should be in a clinical trial.

39
Q

should primary ADT be offered to high risk patients?

A

Not unless local symptoms and limited life expectancy.

Studies have failed to find a benefit for ADT

40
Q

what is the incidence of germ line mutation in DNA repair genes in men with mCRPC?

A

somatic mutations 25%
germline mutations 10%
Genes include:
BRCA2, ATM, CHEK2, BRCA1, etc

41
Q

Clinicians may consider referral for genetic counseling for patients (and their families) with high-risk localized prostate cancer and …….

A

and a strong family history of specific cancers (e.g., breast, ovarian, pancreatic, other gastrointestinal tumors, lymphoma).

42
Q

Localized prostate cancer patients who elect active surveillance should have accurate disease staging including….

A

systematic biopsy with ultrasound or MRI-guided imaging.

More than 12-15 cores not beneficial.
consensus these days is 10-12 cores with extra targeted cores as needed

43
Q

what are the downsides of template transperineal saturation biopsy?

A

more resource intensive, more invasive, 10% urinary retention, oversampling and detection of insignificant cancers, requires anesthesia, more pathologist times

44
Q

what percentage of men with negative MRI have clinically significant prostate Ca?

A

10%

an interval of two years bw MRI in men on survailance is proposed by some

45
Q

What percentage of patients can be identified as progressed on AS by DRE alone?

A

3-5%

Do that DRE

46
Q

Localized prostate cancer patients undergoing active surveillance should have routine surveillance PSA testing and digital rectal exams.

A

Correct

47
Q

Localized prostate cancer patients undergoing active surveillance should be encouraged to have a confirmatory biopsy within the initial…….. and surveillance biopsies thereafter.

A

two years

PRAIS trial had initial biopsy, then at 1 year, 4 and 7.

cancercare ontario: also been adopted by ASCO, are for PSA every 3-6 months, DRE each year, and systematic biopsies within 6-12 months after the diagnostic biopsy, and then every 3-5 years until the patient is ‘switched’ to watchful waiting.

48
Q

Can mpMRI be used as a component of active surveillance for prostate cancer?

A

yes(expert opinion)

high NPV for clinically significant prostate ca: a negative MRI would reassure you that a low risk disease is truly low risk, reduces the need for frequent biopsies,
MRI should be performed on 1.5T machine minimum, include DWI with apparent diffucion coeficient( ADC) , intravenous contrast DCE( dynamic contrast enhancement) , T2WI

THE MRI DOES NOT REPLACE BIOPSY!!!! STILL SHOULD DO BIOPSY

49
Q

what is the role of tissue based genomic biomarkers in AS and the FU ?

A

No role

50
Q

Clinicians should offer definitive treatment to localized prostate cancer patients undergoing active surveillance who develop adverse reclassification.

A

if there is adverse reclassification due to the detection of a higher Gleason score than was present at the initiation of surveillance, definitive treatment should be considered.Other factors that may lead to adverse reclassification include growth of lesion on mpMRI and suspicious rises in PSA that may change PSA density.187 In the PIVOT and ProtecT studies, 20% and 50%, respectively, of patients who started on active surveillance received treatment within 10 years

51
Q

who is most likely to benefit cancer control from RP?

A

younger patient <65
Life expectancy>10 years
Localized prostate cancer

Numerous studies exploring its natural history have suggested that, even if high-grade and left untreated, disease specific survival is a median of 8-10 years after diagnosis

52
Q

Is there a difference in cancer control, continence recovery and sexual recovery bw RARP and open RP?

A 
NO
RCT Australia: margin status the same
Other studies: no difference in PFS, RFS
No difference in continence
no difference in ED
53
Q

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

A

blood loss

two RCTs have shown lower transfusion rates with MIS approaches.

54
Q

Which one has better post op erectile function? Radical retropubic prostatectomy or perineal prostatectomy?

A

retorpubic

in perineal approach nerve sparing is typically not possible.

55
Q

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.

A

Correct.

A number of trials have shown no benefit for this at 7 years in BCR.

56
Q

………… has been recognized to be a key determinant of post-prostatectomy sexual recovery

A

Patient age

57
Q

Predictive models indicate approximately …….. reduction in probability for recovery of erections firm enough for intercourse for each decade of life from age 50 to 70

A

15-20%

58
Q

studies evaluating patient-reported pad-use, as a measure of urinary incontinence, showed that the relative risk of incontinence increases………( how much) for men 70 years of age compared to men at 60 years of age

A

by two fold

59
Q

Pelvic lymphadenectomy can be considered for ……… undergoing radical prostatectomy and is recommended for those with ……….. disease.

A

any localized prostate cancer patients

unfavorable intermediate-risk or high-risk

60
Q

About …..of the primary lymph nodes are contained within a standard dissection limited to the obturator fossa; about……… of the primary nodes are contained within an extended template that includes the obturator fossa and the tissue medial and lateral to the internal iliac vessels

A

40%
two-thirds

but there is conflicting evidence regarding PLND. it is impossible to remove all LNs that remove prostate as these are sporadic including some nodes by aorta and IVC.

61
Q

what is the most common complications of PLND?

A

lymphocele 60%( treatment not needed most of the time, when it is put a perc drain and can use sclerosing agents)

62
Q

Clinicians should inform localized prostate cancer patients with ………. prostate cancer about benefits and risks related to the potential option of adjuvant radiotherapy when locally extensive prostate cancer is found at prostatectomy.

A

unfavorable intermediate-risk or high-risk

63
Q

Clinicians may offer single modality …….. for patients who elect radiotherapy for low-risk localized prostate cancer.

A

external beam radiotherapy(IMRT, SBRT(hypofractionated) ) or brachytherapy( low dose rate, high dose rate)

64
Q

Clinicians may offer …….. for favorable intermediate-risk localized prostate cancer.

A

external beam radiotherapy or brachytherapy alone or in combination

65
Q

what is the rationale for combining two modalities of radiotherapy?

A

improved coverage of the periprostatic space and/or planned coverage of the pelvic lymph nodes in patients with unfavorable intermediate risk disease

66
Q

Clinicians should offer …..months of ADT as an adjunct to ……….to patients electing radiotherapy for high-risk localized prostate cancer.

A

24-36 ( this is thought to confer a 5-10% improved surivival based on RCTs comparing short term vs long term ADT )

either external beam radiotherapy alone or external beam radiotherapy combined with brachytherapy

  • There is little data on SBRT in high risk setting and not recommended
  • ongoing trials whether addition of PLN to radiation field is benefitial. previous trials have not shown a benefit but these can be electively added as nodes are shown to harbor micro-metastatic disease on previous studies
67
Q

List side effects of ADT

A 
Hot flashes
decreased bone mineral density
sexual side effects ( in an RCT even at 6 years patients who had radiation +ADT had poorer sexual function than RP, some other studies suggest no difference long term, there is 1 risk of non recovery of testosterone after ADT( 5-7% complete, 28% incomplete recovery) 
gynecomastia
depression 
fatigue
weight gain
osteoporosis
68
Q

Is hypofractionation better than regular fractionation for prostate cancer??

A

Could be because prostate cancer has lower alpha beta ratio

Studies so far have shown 3Gy to be non inferior to 2Gy per fraction

69
Q

Contraindications for brachytherapy

A 
absolute:
previous TURP( if the defect prevents adequate placement of seeds)

Relative:
irritative and obstructive LUTS
gland>60 cc

70
Q

Does Proton therapy offer any advantage over other forms of treatment?

A

Nope

71
Q

Clinicians may consider ……..localized prostate cancer patients who are not suitable for either radical prostatectomy or radiotherapy due to comorbidities yet have >10 year life expectancy.

A

whole gland cryosurgery in low- and intermediate-risk

evidence is limited. one single centre RCT showed that cryosurgery had similar PFS as EMRT(non dose escalated (<70Gy) ) with ADT in this populaiton

in a study of high risk patients cryosurgery was inferior to EBRT

72
Q

Contraindications to cryosurgery

A

Surgical absence of rectum(cant do a TRUS to monitor things)
Previous TURP bc risk of urethral sloughin and necrosis as the warming catheter will not be in full contact with urethra

73
Q

principles of cyrosurgery

A

third generation argon system
urethral warming catheter
real-time US monitoring of advancing Iceball
ftwo cycles of freeze and thaw
temperature at prostate capsule to ensure complete cell kill -40

74
Q

Who has more GI toxicity? EBRT or Cryo?

A

EBRT
they can also have urinary retention lasting for weeks, tx would be with SP or urethral foley
they also have less incontinence but comparable urinary function and urinary bother

75
Q

Clinicians should inform those localized prostate cancer patients considering focal therapy or HIFU that these treatment options …….

A

lack robust evidence of efficacy

HIFU is approved by the FDA for the destruction of prostate tissue, it is not approved explicitly for the treatment of prostate cancer.

FRCSC 2020 Guidelines (49 decks)

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