Onc - Prostate

Question 1

What are key risk and age groups relevant to making an initial recommendation for PSA screening?

Answer 1

Family history, brother, uncle.
African American race
Age 55-69 (AUA), 45-75 (NCCN)

Question 2

How often should PSA screening be repeated?

Answer 2

Every 2 years, depending on baseline PSA

Question 3

Which low risk groups may not benefit from PSA screening?

Answer 3

<10-15 years life expectancy
Age <40
Age >75 years

Question 4

What are the benefits of PSA screening expressed as number of deaths averted per 1000 men from a key RCT? What RCT refutes this?

Answer 4

ERSPC - 1 death fewer per 1000 men screened

PLCO - showed no benefit in screening (however >90% of “control” patients had at least one PSA

Question 5

How do you improve the specificity of the PSA test?

Answer 5

Combining with secondary biomarkers:

4K, PHI, Exosome, Select MDX

Question 6

What are the potential harms (and approximate percentage of each) for screening patients for prostate cancer?

Answer 6

Over diagnosis: 66% (ERSPC), 23-43% (SEER)
Hematuria/hematospermia: 20-50%
Fever, pain, bleeding, urinating problems: 33%
Sepsis: 3-4%
Psychological impact

Question 7

What factors may trigger a prostate biopsy?

Answer 7

PSA >3 (ERSPC)
Age (55-69)
Abnormal DRE

Question 8

Is there any evidence in favor of trying to lower PSA with antibiotics in an asymptomatic patient?

Answer 8

No

Question 9

Why is PSA not recommended for men between 40-54 years old?

Answer 9

ERSPC and PLCO trials did not study this age group sufficiently

Question 10

For a motivated man >70 years old who wants to be screened, what may be additional guidance on triggers?

Answer 10

Increase threshold to PSA >10 (PIVOT study).

Stop screening if PSA <3.

Question 11

Describes steps to prepare for a biopsy and biopsy scheme.

Answer 11

Informed consent: include risk of bleeding, hematuria, hematospermia, infection, sepsis and discomfort.
Blood thinners: discuss which should be held
Antibiotic prophylaxis for all patients: Single dose fluoroquinolone is effective as 3d dosing or Bactrim
12-13 core bx: sextant including lateral biopsies
Use lidocaine for local anesthesia

Question 12

When is MRI fusion biopsy indicated?

Answer 12

Indicated after a negative biopsy but persistently elevated PSA.
May consider at first biopsy.
If MRI visible lesions are present, MRI targeted bx may be performed.

Question 13

What is the associated prostate cancer risk with positive mpMRI lesion?

Answer 13

34-68%

Question 14

What are the two RCT that looked at MRI guided biopsy in detecting prostate cancer?

Answer 14

PROMIS

PRECISION

Question 15

What did PROMIS and PRECISION (RCTs) show in terms of detecting significant cancer with mpMRI as compared with standard TRUS bx?

Answer 15

mpMRI had a higher sensitivity and was more effective in detecting high risk disease than standard TRUS bx. mpMRI bx detected fewer indolent cancers

Question 16

What did the PROMIS RCT show?

Answer 16

mpMRI may allow 27% of men to avoid primary bx and diagnose 5% fewer clinically insignificant cancers. mpMRI was more sensitive (93%) and less specific (41%) at detecting clinically significant G4+3 cancer

Question 17

What did PRECISION RCT show?

Answer 17

Clinically significant cancer was detected in 38% of men in the MRI targeted bx group as compared with 26% in the standard biopsy group.

Question 18

How would you manage a patient who is at high risk for sepsis (on chronic antibiotics)

Answer 18

Consider preprocedure rectal swab culture and tailor ppx abx.

Question 19

Describe management considerations for an orthopedic joint prosthesis:

Answer 19

Abx: single dose fluoroquinolone +am/gent

• use in first 2 years of joint replacement
• use in immunocompromised patient with prosthetic joint
• use if prosthetic joint and comorbidities ie HIV, DM

Question 20

Describe risks/recommendation for a fluoroquinolone

Answer 20

• associated with increased risk of tendinitis and tendon rupture
• higher risk in patients over 60, or transplant patient on steroids
• stope med at first sign of tendon pain/swelling/inflammation

Question 21

How would you manage post prostate biopsy patient with gross hematuria, lower abdominal pain and fever >101.5, chills and rigors?

Answer 21

Send to ED
Empiric broad spectrum abx, assuming fluoroquinolone-resistant sepsis
Admission with 1-2 weeks abx per cultures
Rule out clot retention