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CDM 4 Exam 3 > Lecture 5 - Prostate Cancer > Flashcards

Lecture 5 - Prostate Cancer Flashcards

1
Q

Risk factors for Prostate Cancer

A

2/3 cases men > 65
Serum Test Lvls = higher lvls higher risk
Agricultural exposures
FH
Diet = High red meat n high-fat dairy, low fruit/veggies
Race = AA> W > His > Pacifici > Native American

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2
Q

Signs n Symptoms of Prostate Cancer

A

weak/interrupted stream
Incomplete bladder emptying
Painful/burning urination
Frequent/urgent urination
Difficulty stopping/starting stream
ED

Distant Disease = bone pin = back/legs/hips

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3
Q

Prostate Cancer screening

A

Age 50 = men at average risk n live 10+ yrs
Age 45 = high risk
Age 40 = higher risk, more than 1 1st degree relative who has

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4
Q

Time until future screen based on PSA

A

< 2.5 = every 2 years
> 2.5 = yearly

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5
Q

Prostate screening tools

A

Digital Rectal Exam
PSA, usually > 20 = cancer
PSA velocity = 3 consecutive measurements over 18-24mnth
PSA doubling time = time for PSA to double

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6
Q

Somatic mutations are associated with….

A

gremline mutations
BRCA1/2 mutations associated w/ inc prostate cancer risk
BRCA2 = 2-6X inc risk

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7
Q

Patients with HRR/BRCA mutations may benefit from….

A

PARP inhibitors

Olaparib, Rucaparib

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8
Q

DNA mismatch repair genes may benefit from….

A

PD-1 inhibitor

Pembrolizumab

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9
Q

Who gets gremline genetic testing

A

+ FH of gremlin mutations BRCA1/2, Lynch mutation
High risk, V High risk, regional or metastatic prostate cancer
Ashkenazi Jewish ancestry
Specific FH cancer

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10
Q

Gleason scores

A

< 6 = well differentiated, less aggressive
7 = moderately differentiated
8-10 = poorly differentiated, highly aggressive

if 2 numbers, 1st is more common

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11
Q

Localized disease is generally stages….

A

1 n 2

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12
Q

Regional disease (locally advanced) generally stage…..

A

3

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13
Q

Advanced/metastatic disease generally stage…..

A

4

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14
Q

active surveillance is…

A

active monitoring course of disease with expectation of applying curative therapy if cancer progresses

Usually, younger men with indolent disease
Delay doesnt affect cure rate

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15
Q

Who is recommended for active surveillance….

A

Very low risk disease and life expectancy greater than or equal to 20 yrs

low risk disease and life expectancy at least 10 yrs

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16
Q

Radical Prostatectomy is…

A

removing all that shit

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17
Q

Radical Prostatectomy post-op complications

A

impotence
incontinence
rectal damage
hemorrhage
infection

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18
Q

External Beam Radiation Therapy Pro vs Cons

A

Pro: avoids surgery issues, no anesthesia, low risk of ED, other urinary issues

Con: 8-9 wk txm, inc risk ED over time, risk of renal symptoms

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19
Q

Brachytherapy Pro vs Cons

A

inserting seeds to area

Pro: txm 1 day, ED unlikely short term, low risk incontinence

Con: anesthesia, limited by size of prostate, acute urinary retention, persistence of irritating voiding symptoms

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20
Q

Goal of Androgen Deprivation Therapy

A

Suppress testosterone to < 50ng/dL

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21
Q

GnRH Antagonists info

A

inhibit production of GnRH

Rapid, no risk of tumor flare

Ex. Degarelix, relugolix

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22
Q

GnRH Agonists info

A

Stimulate production of GnRH

Weeks onset, risk of tumor flare = 1st few days

Ex. Leuprolide, goserelin

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23
Q

Bilateral Orchiectomy Pro vs Con

A

Pro: 1 time deal, cost, avoid inj, immediate benefit

Con: Hot flashes, dec libido, impotence, may not tolerate surgery, psychological

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24
Q

Leuprolide inj info

A

LNRH Agonist
Monthly, Q3, Q4 or Q6 month option

Lupron = IM
Eligard = SubQ

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25
Q

Goserelin (Zoladex) info

A

LNRH Agonist
Monthly or Q3 month
SubQ only

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26
Q

Triptorelin (Trelstar) info

A

LNRH Agonist
Monthly, Q3, Q6 month
IM

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27
Q

Histrelin (Vantas) info

A

LNRH Agonist
SQ every 12 months

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28
Q

LNRH Agonist Pro vs Con

A

Pro: avoid surgery, infrequent admin, low toxicity, as effective as surgery

Con: injection, disease flare, $$$, hot flashes, dec lean body mass n muscle strength, inc fat

29
Q

Androgen flare

A

symptoms worsen in 2-3 weeks

warnings: Severe urethral obstruction, painful vertebral metastases, spinal cord compression, temp inc in bone pain

30
Q

Androgen flare prevention

A

Concurent anti-androgen

Bicalutamide 50mg PO QD for 1st 7 days of therapy

31
Q

Adverse drug reactions of ADTs

A

Osteoporosis/inc fracture risk
Obesity/Diabetes
Fatigue
Lipid alterations
Hot flashes
Inc CVD risk

32
Q

Hot flash management

A

Megestrol 20mg BID
Venlafaxine 12.5-25mg BID
Paroxetine 12.5-37.5mg QD
Gabapentin 600mg QD

33
Q

Flare risk with LNRH Antagonists?

A

nah not really

34
Q

LNRH Agonist vs Antagonists

A

Agonist: Q3-6M, disease flare, few local reaction, delayed onset

Antagonist: may lower CV risk, Rapid onset, Qmonthly, no flares

35
Q

Flutamide unique side effect?

A

turns piss gold or yellow-green

36
Q

Nilutamide unique side effect?

A

Dark adaption difficulties = eyes adjust slower
alc interaction

37
Q

Combined Androgen Blockade (CAB) info

A

More $$$, more ADE
No proven benefit over med/surg castration alone
not much data

38
Q

Combined ADT with novel agents and/or chemotherapy….

A

ADT +…
1. Docetaxel = myelosupression, febrile reactions, neuropathy
2. Abiraterone = hypokalemia, HTN, Hepatotoxicity, edema
3. Enzalutamide = fatigue, lower seizure threshold, falls
4. Apalutamide = fatigue, rash, Hypothyroidism, seizure risk, falls

combo overall improves survival

39
Q

What to give pts with new diagnosed metastatic CSPC

A

ADT + 2nd gen (Docetaxel, Abiraterone, Enzalutamide, Apalutamide)

40
Q

Triplet Therapy info

A

combine 3 drugs but can be very toxic

very few can tolerate effects of these therapies, tend to be younger pts

41
Q

Goal of metastatic setting?

A

palliative intent, not curative

42
Q

Castration-Resistant Prostate Cancer (CRPC)

A

disease progression during treatment with ADT
Test < 50, but cancer progressing

management = continue ADT +/- additional agents
ADT for life

43
Q

M1 (Metastatic CRPC)

A

spread to distant site

44
Q

M0 (Non-metastatic CRPC)

A

only evidence is rising PSA

45
Q

Non-metastatic (M0) CRPC management

A

PSA doubling time > 10 months = continue ADT + observation
PSA dbling time < 10 months = continue ADT + 2ndary hormonal agent

46
Q

2ndary hormonal agents for M0 CRPC

A

Apalutamide = dec seizure threshold, falls, fractures
Darolutamide = less CNS too, renal impairment
Enzalutamide = dec seizure threshold, falls, fractures

47
Q

drugs that interfere with androgenic stimulators of tumor growth (for M1)

A

Enzalutamide
Apalutamide
Darolutamide

48
Q

drugs that cause inhibition of androgen synthesis (for M1)

A

Abiraterone

49
Q

Chemodrugs, rapidly progressive symptomatic disease (for M1)

A

Docetaxel
Cabazitaxel

50
Q

Immunotherapy, asymptomatic or minimally symptomatic (for M1)

A

Sipuleucel-T

51
Q

Bone metastases w/ no visceral disease (for M1)

A

Radium-223

52
Q

MSI-H or dMMR (for M1)

A

Pembrolizumab

53
Q

Mutations in DNA repair genes (for M1)

A

PARP inhibitors

Olaparib
Rucaparib

54
Q

PSMA-targeted therapy (for M1)

A

Lutetium-177-PSMA-617

55
Q

Drugs that require Steroids with dose

A

Abiraterone** req concurent use
Cabazitaxel
Docetaxel

56
Q

Abiraterone (Zytiga) info

A

** food inc bioavailability X 17, higher toxicity..1hr before or 2hr after**
** absence of prednisone = aldosterone overactivity**

CSPC = 1000mg QD + pred 5mg QD
CRPC = 1000mg QD + pred 5mg BID

57
Q

Fine particle formulation Abiraterone (Yonsa)

A

For: Metastatic CRPC
Cant switch from one to other form
500mg QD combo w/ methylpred BID
Can admin w/ or w/o food
generic, dont use hepatic dysfunction

58
Q

Enzalutamide (Xtandi) info

A

indications: Metastatic CRPC, non-metastatic CRPC, metastatic CSPC
Dose: 160mg QD, should also receive LHRH agonist

inc risk of falls, fractures, seizure risk

59
Q

Enzalutamide (Xtandi) info

A

indications: Metastatic CRPC, non-metastatic CRPC, metastatic CSPC
Dose: 160mg QD, should also receive LHRH agonist

inc risk of falls, fractures, seizure risk

60
Q

Apalutamide info

A

Indications: Metastatic CSPC, Non-metastatic CRPC
Dose: 250mg QD

61
Q

Darolutamide info

A

Indications: Non-metastatic CRPC, Metastatic CSPC (combo w/ docetaxel)
Dose: 600mg BID w/ food

Less CNS pen/toxicity

62
Q

Chemotherapy for CRPC

A

Docetaxel = used 1st
Cabazitaxel = after docetaxel failure

63
Q

Docetaxel info

A

75mg/m2 IV Q3 week + pred 5mg BID continuously

V myleosuppressive
CI: ANC < 1,500
Pre-med: Dexamethasone 8mg PO at 12/3/1 hr before txm

64
Q

Cabazitaxel info

A

25mg/m2 IV Q3 week + pred 10mg QD
Low dose = 20mg/m2

Pre-medicate = antihistamine + corticosteroid + h2 antagonist

65
Q

Pre-medicate for Cabazitaxel

A

Benadryl 25mg IV + Dexamethasone 8mg IV + Famotidine 20mg

66
Q

Sipuleucel-T (Provenge)

A

“cancer vaccine”
Indication: asymptomatic or minimally symptomatic mCRPC + > 6 month life expectancy

collect WBC from pt, expose to PAP-GM-CSF -> infuse back into pt to fight cancer

67
Q

Radium-223 (Xofigo) info

A

Indications: CRPC, symptomatic bone metastases, no known visceral metastases

Admin: IV over 1min, 1.35microcuries(50kBq)/kg Q 4 weeks for 6 doses

68
Q

Radium-223 (Xofigo) cautions

A

Dont use with abiraterone

Limited to pts w/ bone metastases without other clinically significant sites of disease

69
Q

Pembrolizumab (Keytruda) info

A

Indication: unresectable or MSI-H or MMR-deficienct solid tumors who have progressed on prior treatment and who have no satisfactory alternative treatment options

Admin = 200mg IV Q3 weeks or 400mg IV Q 6 weeks

CDM 4 Exam 3 (11 decks)

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