Prostate Flashcards
epidemiology -3
most common cancer in US
2nd leading cause of cancer death
african am»_space;caucasian both incidence and death
etiology -2
increased exposure to testosterone
genetic (45% of dz if age <55)
risk factors -3
age (median 67),
race (more in blacks, less in asians),
family history
pathophysiology of sx -3
urethra passes through prostrate
THUS sx when hypertrophy
inc freq, inability to start/stop, dyuria, hematuria, nocturia, incomplete emptying, dribbling
Screening -2
- DRE (25-50% of masses are cancer), PPV 26-35%
- PSA, specific to prostate, not to cancer, PPV 40-49%
- TRUS (transrectal u/s) indicated after abnormal PSA or DRE
PSA concepts -6
> 4.0 abnormal.
between 4-10 could be BPH or CA.
free PSA >25% likely BPH, no bx
free PSA between 15-25%, consider bx
PSA velocity 0.35 per year higher RR death
PSA density: PSA/prostate volume by TRUS
Factors affecting PSA -5
finasteride, dutasteride (50% dec),
saw palmetto (unpredictable),
androgen receptor blockers (variable, usually inc),
ejaculation (inc),
bx OR DRE (inc)
Screening recommendations -3
DO GUIDELINES AGREE?
US PSTF lack of evidence that PSA saves lives -> unnecessary testing and tx
European Randomized Study of Prostate CA 20% red in death
US PLCO study no survival advantage
Screening Guidelines -5
ACS start annual PSA when age 50,
NCCN, AUA start when 40, if 75y
Prevention - prostate CA prevention trial (PCPT) -6
NOTE: dutasteride no diff in gleason 7-10 CA
finasteride vs placebo for 7 yrs;
30% reduction;
nonsig 14% inc in high-grade (gleason 7-10)->thus no FDA approval;
ASCO/AUA guideline consider for asymptomatic with PSA <3.0,
if taking for BPH discuss benefits/risks,
NOTE prevelance dec but morbidity/mortality NOT assessed
Prevention - selenium - SELECT trial
4 arms: selenium, vit e, selenium + vit e, placebo
no sig benefit
Prevention - vitamin e - SELECT trial
nonsig (p=0.6) inc risk of prostate CA,
other trials show varying doses of vit e but high dose may be worse
Signs and Symptoms -6
asymptomatic early;
advanced -
alterations in micturition,
impotence,
lower extremity edema,
anemia,
wt loss
Natural hx -3
indolent early,
spreads via local extension (lymphatics, lymph nodes, hematogenously),
met to bone (80%), liver, lung
Diagnosis -8
PE, PSA, TRUS, serum chem, bone scan, CT/MRI, Bx via TURP, 99% adenocarcinoma
Staging -3
Gleason 1-5 two sections added,
higher the score greater probability of extracapsular spread;
T1: clinically undectable tumor (either palpation or imaging)
T2: confined within prostate
T3: extends through prostate capsule
T4: invades bladder, levator muscles, pelvic wall
NOTE: N1: mets in regional lymph node
Treatment - localized disease - general concepts
depend primarily on stage and grade but also on pt’s age, health, and preferences
Treatment - localized disease - active surveillance
inc anxiety
Treatment - localized disease - XRT -3
equivalent to surgery in outcomes
complications (impotence (30%), rectal/bladder sx).
choice external beam or brachytherapy (not choice for high risk, large or sx dz)
Treatment - localized disease - radical prostatectomy (RP) + pelvic lymph node dissection (PLND) tox. -4
complications (early mortality (0.3%),
bladder contacture (1-22%),
incontinence,
impotence (nerve sparing available)
Treatment - localized disease - ADT -3
LHRH agonist +/- antiandrogen or orchiectomy,
goal serum testosterone <20ng/dl 1 mo after initiation of tx; &&&
ADT/XRT 62% vs 57% 10 yr OS vs XRT alone.
Treatment - localized disease - dutasteride
in active surveillance pts, 38% vs 48% with placebo CA progression at 3 ys
short term vs long term ADT
4-6 months versus 2-3 years
androgen deprivation therapy -2
serum testosterone levels <50 ng/ml.
medical castration or surgical castration are equivalent.
Management of localized dz with low recurrence risk - NCCN -2
· T1-T2a
· Gleason score <10 ng/mL
2 RT or brachy
10yr: #1 AS (· PSA at least as often as every 6 mo · DRE at least as often as every 12 mo · Repeat prostate biopsy as often as every 12 mo)
Adverse features: positive margins, seminal vesicle invasion, extracapsular extension, or detectable PSA