prostate cancer

Question 1

epidemiology of prostate cancer

RFs

Answer 1

most common cancer in males in UK

RFs
- Family history:
 Prostate cancer in 1st/2nd degree
relative
 Breast cancer in mother
- Genetics: BRCA2 mutation and
Lynch syndrome (HNPCC)
- Diet: Red meat, fat, dairy,
calcium; Obesity
- Chemicals: High pesticide
exposure
- Hormones: High levels of IGF-1
- afro-carribean ethinicity

peripheral zone of the prostate is what is commonly involved in prostate cancer

Question 2

stages of prostate cancer

Answer 2

stage 1 - cancer is small and only in the prostate

stage 2 - cacner is larger and in both lobes of the prostate

stage 3 - spread to close lymph galnds or seminal vesicles

stage 4 - spread to distant organs

• bladder
• bone
• liver

Question 3

what is the gleason score

Answer 3

grading of the cancer - 5

Increasing number shows increasing dysplasia

Question 4

when will one be referred via cancer pathway

Answer 4

PSA and DRE
PSA > 3.0mg/ml age 50-69
- LUT Sx - nocturia, urinary frequency, hesitancy, urgency or retention or
erectile dysfunction or
visible haematuria.

Question 5

Ix for prostate cancer

Answer 5

PSA

FIRST LINE multiparametric MRI as a first-line investigation.

Biopsy Gold Standard

• TRUS - transrectal US, increased infection risk
• Template/transperineal - front anterior cancer

bone mets -> bone synctiography, technicium 99

Question 6

Mx of low-intermediate- high risk prostate cancer

Answer 6

LOW RISK -T1/2

• active surveillance - young patients
• watchful waiting - old ppl where surgery is risky
• 1st year 3-4ms measure PSA, DRE - 12 m
• 2nd year and onwards - 6m PSA, 12m DRE

intermediate risk

• radical prostatectomy
• radical radiotherapy -> external beam and brachytherapy w neo adjuvant androgen deprivation

intermediate - high risk OPTION

• hormonal therapy
• radical prostatectomy: erectile dysfunction is a common complication, infertility, urinary incontinence

radiotherapy: external beam and brachytherapy. Patients are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer, erectile dysfucntion, urinary Sx, bowel probs, infertility

HORMONES
- synthetic GnRH agonist
ie Goserelin
- cover initially with anti-androgen to prevent rise in testosterone - hot flushes
- leuproelin
used in palliative care 

Anti-androgen
- cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes
bigalutmide
both cause gynaecomastia

Orchidectomy

castrate resistant/mets
abiratereone acetate - ADT always give w prednisolone

Question 7

Sx of prostate cancer

Answer 7

• bladder outlet obstruction: hesitancy, urinary retention
• haematuria, haematospermia
• pain: back, perineal or testicular
• digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

Question 8

what else increases PSA levels

Answer 8

• benign prostatic hyperplasia (BPH)
• prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
• ejaculation (ideally not in the previous 48 hours)
• vigorous exercise (ideally not in the previous 48 hours)
• urinary retention
• instrumentation of the urinary tract
• DRE

Question 9

what is metastatic CaP

Answer 9

Bone metastases
 Sclerotic (Osteoblastic)
‘Hot spots’ on bone scan
 Highly unlikely if PSA <10

Treatment
 Hormones (+ Upfront docetaxel chemotherapy if
good performance status)
 Surgical castration
 Medical castration
- LHRH agonists

Palliation
 Single-dose radiotherapy
 Bisphosphonates
 Zoledronic acid

If docetaxel-resistant and PS 0-2
 Consider
 Enzalutamide (5x stronger antagonist of androgen
receptor than bicalutamide)
 Prednisolone + Abiraterone (abiraterone irreversibly
blocks cytochrome P17 [involved in the production of
testosterone])

Question 10

classification in terms of risk

Answer 10

low tisk
PSA <10
Gleason score - 6
no DRE felt

intermediate
PSA 10-20
Gleason score 7
T2b-T2c