Prostate

Question 1

List 4 causes of an elevated PSA?

Answer 1

Prostate cancer
BPH
Prostatitis
Perineal trauma/sexual activity

Question 2

How common is prostate cancer?

Answer 2

2 in 100 men by 55 may have prostate cancer

by 85 years old, 20% may have prostate cancer

Question 3

What are the current RACGP recommendations for PSA screening?

Answer 3

not recommended unless at risk patient requests it. but need to counsel the patient on the pros and cons of screening.

Question 4

At what age should you continue screening for prostate cancer?

Answer 4

in 2013 prostate cancer world conference, a baseline reading of PSA in their 40’s may be useful in predicting cancer in the future
Generally may consider PSA testing once in their 50’s.
don’t screening in men with life expectancy no greater than 10 years due to a comorbidity.
Remember age is the primary determinant of risk.

Question 5

What is the sensitivity and specificity of the PSA blood test?

Answer 5

Low sensitivity - high false negative
Higher specificity = lower false positive

For people who test positive to the test, they are likely to have the disease - higher PPV.

Low NPV - high false negative- people who test negative may infact have disease. So a person who tests negative mays till have prostate acncer.

Question 6

What advice should you give before a patient gets a PSA test?

Answer 6

Avoid sex, masturbation for 2 days prior to test.

Question 7

What range of PSA is the free to total PSA test validated in?

Answer 7

PSA range > 4

Question 8

What would you do with a PSA result that is within his age related reference range but above the median for a patients age?

Answer 8

Above the median for the age means that may be at higher risk.
Many would consider repeat the test within 12 months with a free to total.
If a patient had a family history of the disease and had a PSA above median for his age after a repeated test in 3 months with urine MCS- should consider referral to a urologist, although his PSA is with age related reference range.
As we know the PSA test had a low sensitivity - ie high false negatives - ie people with negative test result may still have cancer.

Question 9

What is the difference between gleason grade and score?

Answer 9

A pathology will used the gleason grading system to architecturally describe how well differentiated a prostate cancer is. Gleason grades range from 1-5. Grade being most well differentiated. grade 5 being most poorly differentiated.

For each sample of biopsy, the pathology will grade 2 regions of the biopsy. Ie gleason grade of 2 and 3 in the one sample = gleason score of 5.

Question 10

How would you interpret a gleason score of 2,3,4?

Answer 10

low grade, well differentiated cancers.

Question 11

How would you interpret a gleason score of 5 and 6?

Answer 11

moderately differentiated cancers

Question 12

How would you interpret a gleason score of 7 and above?

Answer 12

High grade, poorly differentiated cancers.

Question 13

What would be the management of a patient with low grade prostate cancer?

Answer 13

Low grade = PSA

Question 14

What management options are available for prostate cancer?

Answer 14

radical prostatectomy
External beam radiation - cystitis and proctitis.
brachytherapy - urethral stricture - less able to do salvage surgery for local recurrence.

Question 15

How common is erectile dysfunction and urinary incontinence after prostatectomy?

Answer 15

2/3 may get ED

1/3 may have ongoing urinary problems.

Question 16

What advice would you give to a patient about time to recovery from incontinence and ED?

Answer 16

90% will return to normal continence by 12 months post surgery.
Approximately 50% will report ED 2 years post surgery. Optimal time to recovery of ED is 2-3 post surgery.

Question 17

Outline a typical active surveillance program for low grade prostate cancer?

Answer 17

A typical active surveillance program includes PSA testing every 4 months for the first year after diagnosis and every 6 months thereafter. A surveillance biopsy should be performed by a urologist at 12 months to exclude histological progression of disease despite stable PSA levels, then every 2–3 years thereafter. A DRE is not usually incorporated into an active surveillance program.

Question 18

Outline 1 risk and 1 protective factor for prostate cancer?

Answer 18

Family history is the strongest risk factor

Tomato consumption. Lyocpenes.

Question 19

What is the rate of false positive PSA results?

Answer 19

1 in 10 will be a false positive.

Question 20

What is the rate of complication for a false positive result?

Answer 20

87 men out 1000 who have a false positive, 28 of those will have a serious complication from the biopsy.

Question 21

What is the mortality benefit from PSA testing?

Answer 21

2 out of every 1000 men tested will avoid death from prostate cancer before 85 years old.