overview of prostate cancer Flashcards
describe the prostate gland
- walnut-sized gland located behind the base of the penis, in - front of the rectum and below the bladder
- surrounds the urethra
what is the primary function of the prostate gland?
produce seminal fluid, the liquid in semen that protects, supports, and helps transport sperm
what are risk factors for prostate cancer?
- AGE
- race (more common in african american men)
- family history
- nationality (more common in N America and NW Europe)
- genetics (BRCA1+2 gene esp)
- diet, exercise, obesity
1:___ men in the UK are diagnosied in the UK with prostate cancer
1:8
prostate cancer survival?
84% of men survive for 10 or more years (prostate cancer v prevalent but survival rates are good)
what are symtpoms of prostate cancer?
> local (LUTS = low urinary tract symptoms) — obstructive, irritative
metastatic — pain etc
systemic — fatigue, weight loss
describe some obstructive LUTS
- feel as though not emptying bladder properly
- terminal dribbling
- get up to pee lots during the night
- not good flow of urine
describe some irritative LUTS
- a lot of urianry frequency
- discomfort
- possible blood in urine
how is prostate cancer diagnosed?
- history
- DRE = digital rectal exam
- PSA = prostate specific antigen
- multiparametric MRI
- biopsy
what can increase PSA?
- BPH = benign prostatic hypertrophy
- age (increasing)
- prostatitis
- ejaculation
- DRE
what can decrease PSA?
- drugs — finasteride/dutasteride
- obesity
- herbal preparations
screening for prostate cancer
- no UK screening programme
- screening can lead to over diagnosis, over treatment
- consider targeted PSA screening in high risk populations eg. African American, strong family history
describe multiparametric MRI
> T1 and t2 images
functional imaging
—> dynamic contrast enhanced (DCE) DWI
—> diffusion weighted imaging (DWI)
describe prostate biopsy
> transrectal ultrasound guided (TRUS) biopsy
—> biopsy taken throguh the rectal wall under ultrasound guidance
—> about 12 samples taken
> more recently, template biopsy
—> transperineal
—> multiple samples taken
—> can potential target areas seen on MRI that you cant reach via transrectal approach
reasons for doing a prostate biopsy
- type of tumour
- grade of tumour
- percentage of tumour
- T Stage of cancer
what type of tumour are the vast majority of prostate cancers?
adenocarcinoma
what is the grading score for tumour grade of prostate cancer?
gleason score
descirbe the gleason score
- grading system used to define aggressiveness
- score of 3-5 are considered cancerous
- addition of 2 most common scores = Gleason score
2 scores out of 5 to give a score out of 10
lowest score can get it 3+3 (below is benign)
highest score is 5+5 = 10
descirbe grade group 1
- gleason score 3+3
- 96% 5 years RFS
describe grade group 2
- gleason score 3+4 = 7
- 88% 5 years RFS
describe grade group 3
- gleason score 4+3 = 7
- 63% 5 years RFS
describe grade group 4
- gleason score 4+4 = 8
- 48% 5 years RFS
describe grade group 5
- gleason score : 4+5=9, 5+4=9, 5+5=10
- 26% 5 years RFS
what does RFS stand for?
relapse free survival
describe staging
- a way of describing cacner — size and extent
- TNM system
- helps doctor to determine prognosis
- formulation of treatment plan
describe stage I prostate cancer
- cancer confined to prostate T1a-2a
- PSA < 10
- grade group 1 (3+3 = 6)
confined to prostate, usually less than half of gland
describe stage II prostate cancer
still localised to prostate
> stage IIA
-T1a-2a
- PSA 10-20
- grade group 2
> stage IIB
- T1-2
- PSA <20
- grade group 2
> stage IIC
- T1-2
- PSA <20
- grade group 3-4
describe stage III prostate cancer
= locally advanced cancer
> stage IIIA
- T1-2
- PSA >20
- grade group 1-4
> stage IIIB
- T3-4
- grade group 1-4
> stage IIIC
- grade group
describe stage IV prostate cancer
have spread outside of prostate locally (eg. pelvis) or beyond (liver, lungs, bones, pelvic lymph nodes etc)
what are the most common places of spread of prostate cancer?
lymph nodes and the bones
what are the 3 prognostic groups for localised prostate cancer
- low risk — T1-T2a and Gleason score 6 and PSA < 10ng/ml
- intermediate risk — T2b-T2c or Gleason score 7 or PSA 10-20
- high risk — T3a or Gleason score 8-10 or PSA >20
treatment for low/intermediate risk disease
available for all treatment
- active surveillance
- external beam radiotherapy
- brachytherapy
- radical prostatectomy
what might influence treatment choice?
> tumour factors — PSA, stage, grade
patient factors — age, LUTs, sexual function, choice, family or friends experience, media
pathway factors — urologists, nurses, support groups
describe active surveillance
- regular monitoring = PSA every 3 months, DRE 6 months, after a year repeat MRI and biopsy
- PSA
- DRE
- mpMRI
- biopsy
v. different to watchful waiting
what is brachytherapy?
aka internal radiotherapy, close therapy
2 types
- low dose rate = good for low or intermediate risk — implanting radioactive source into the prostate. under general anaesthetic, well tolerated, half life of 30 days
- high dose rate = god for intermediate/high risk disease — used as mono therapy, or in combination wiht ERBT. radioactive source taken out
describe external beam radiotherapy
- OP treatment
- 5-37 fractions (treatments) depending on risk
- no anaesthetic
- no catheter
- often in combination with ADT
describe surgery for prostate cancer
Robotic Assisted Laparoscopic Prostatectomy (RALP)
- surgeon operates from a. console with a 3D screen
- grasp controls to manipulate surgical tools within the patient
- robotic arms translate finer, hand and wrist movements
- very high-precision
intermediate/high risk disease treatment
- localised disease with higher risk of disease progression
- important to adequately stage disease
- radiotherapy + ADT
- RALP with lymph node dissection
what is ADT?
= androgen depravation therapy
- >95% newly diagnosed prostate cancer will respond to treatment with ADT
- 2 mechansims for preventing androgens :
—> reduce the level of androgens
—> block the androgens from binding
describe reducing level of testosterone in ADT
injections : gonadotropin releasing hormone agonists (GnRHa) / Luteinising hormone releasing hornier agonists (LHRHa)
- stimulate pituitary to produce LH
- LH stimulates testicles to produce testosterone
- chronic exposure to LHRH leads to desensitisation and a drop in LH —> subsequent drop in testosterone
- may cause testosterone flare so need to give with androgen blocker
what LHRH agonists are available?
- Zoladex
- Prostap — 4/54 or 12/52
- Decapeptyl — 4/52, 12/52, 6/12
describe GnRG/LGRG antagonists
- prevent LHRH binding to pituitary gland — decrease LH — decrease testosterone
- no testosterone flare
- Degarelix — 240mg initial dose (2 x 120mg SC), 80mg 4/52
- very expensive and has to be given every 4 weeks
- only really used for men in hospital presenting with symptoms of disease such as malignant spinal cord compression
describe androgen blockers
- prevent testosterone from being able to stick to cell surface
- often used for 3 or 4 weeks prior to and after LHRH agonist injections
- used to reduce testosterone flare
- Bicalutamide, Cyproterone Acetate
ADT side effects
‘ male menopause ‘
describe metastatic prostate cancer
- disease has spread outside the prostate
- not curable
- aim of treatment = disease control
- median survival is 5 years
- hormone sensitive —> castrate resistant
- ADT is backbone of treatment
treatment for hormone sensitive metastatic prostate cancer
- ADT always
- chemotherapy — Docetaxel
- novel hormones — Abiraterone, Apalutamide, Darolutamide, Enzalutamide
- radiotherapy
describe castrate resistant metastatic prostate cancer
- 12-18 months post ADT initiation
- rising PSA despite castrate levels of testosterone (<0.5mmol/L)
- androgen receptor amplification
- androgen receptor mutations
- intraluminal androgen production
- other growth signals take over
- median survival - 3 years
treatment for castrate resistant metastatic prostate cancer
- ADT
- supportive care — analgesia, antiemetics, psychological etc
- chemotherapy — Docetaxel, Cabazitaxel
- novel hormones — Abiraterone, Apalutamide, Darolutamide, Enzalutamide
- radioisotopes — Radium 223, Lu-PSMA
- radiotherapy — to painful bone metastases
describe radium 223
similar to calcium
- preferentially taken up into bones where the bones are working overtime — where cancer is active
- Ra 223 then emits alpha particles — directly damage DNA
