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Y4 Cancer Care: Oncology > Prostate Cancer > Flashcards

Prostate Cancer Flashcards

1
Q

Which cancer is the most common in men?

A

Prostate cancer is the most common cancer in men.

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2
Q

What are the risk factors for prostate cancer?

A

The key risk factors for prostate cancer are:

  • Increasing age
  • Family history
  • Black African or Caribbean origin
  • Tall stature
  • Anabolic steroids
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3
Q

What hormones does prostate cancer rely on to grow?

A

Prostate cancer is almost always androgen-dependent, meaning they rely on androgen hormones (e.g., testosterone) to grow.

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4
Q

What is the most common form of prostate cancer?

A
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5
Q

What are the clinical features of prostate cancer?

A

Prostate cancer may be asymptomatic. It may also present with lower urinary tract symptoms (LUTS), similar to benign prostate hyperplasia. These symptoms include hesitancy, frequency, weak flow, terminal dribbling and nocturia.

Other symptoms include:

  • Haematuria
  • Erectile dysfunction
  • Symptoms of advanced disease or metastasis (e.g. weight loss, bone pain or cauda equina syndrome)
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6
Q

Briefly describe prostate specific antigen

A

The epithelial cells of the prostate produce prostate-specific antigen (PSA). PSA is a glycoprotein that is secreted in the semen, with a small amount entering the blood. Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation. It is specific to the prostate, meaning it is not produced anywhere else in the body. A raised level can be an indicator of prostate cancer.

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7
Q

Briefly describe the use of prostate specific antigen testing

A

Prostate-specific antigen testing may lead to the early detection of prostate cancer, potentially leading to effective treatment and preventing significant problems. However, research has failed to show that the benefits of using PSA for screening outweigh the risks. In the UK, men over 50 can request a PSA test if they would like one.

PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

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8
Q

Other than prostate cancer, what else can cause elevate prostate specific antigen?

A

Common causes of a raised PSA are:

  • Prostate cancer
  • Benign prostatic hyperplasia
  • Prostatitis
  • Urinary tract infections
  • Vigorous exercise (notably cycling)
  • Recent ejaculation or prostate stimulation
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9
Q

What is the problem with PSA false positives?

A

False positives may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. Additionally, it may lead to the unnecessary diagnosis and treatment of prostate cancer that would never have caused problems (the patient would have died of other causes before experiencing any adverse effects of the prostate cancer).

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10
Q

What is the problem with PSA false negatives?

A

False negatives may lead to false reassurance.

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11
Q

How does a benign prostate feel on examination?

A

A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus (the dip in the middle between the right and left lobe). There may be generalised enlargement in prostatic hyperplasia.

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12
Q

How does an infected or inflammed prostate feel on examination?

A

An infected or inflamed prostate (prostatitis) may be enlarged, tender and warm.

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13
Q

How does a cancerous prostate feel on examination?

A

A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule. Any of these features can indicate prostate cancer and warrant further investigation. In primary care, these findings require a two week wait urgent cancer referral to urology.

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14
Q

What is the first-line investigation for prostate cancer?

A

Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer.

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15
Q

What scale is used to assess prostate cancer following an MRI?

A

Likert scale.

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16
Q

Briefly describe the Likert scale

A

The results are reported on a Likert scale, scored as:

  • 1: very low suspicion
  • 2: low suspicion
  • 3: equivocal
  • 4: probable cancer
  • 5: definite cancer
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17
Q

What score using the Likert scale would require a patient to undergo a biopsy of the prostate?

A

Patients with suspicious lesions on MRI (Likert 3 or more) will then go on to a biopsy (which can be several different forms).

18
Q

If metastatic prostate cancer is suspected, what other investigations need to be ordered?

A

If metastatic disease is suspected, the patient will require further imaging. This includes:

  • CT
  • Bone isotope scans
19
Q

Briefly describe the role of prostate biopsy in investigating prostate cancer

A

Prostate biopsy is the next step in establishing a diagnosis. The decision to perform a biopsy depends on the MRI findings (e.g., Likert 3 or above) and the clinical suspicion (i.e. examination and PSA level).

Prostate biopsy carries a risk of false-negative results if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate. The MRI scan results can guide the biopsy to decide the best target for the needles.

There are two options for prostate biopsy:

  • Transrectal ultrasound-guided biopsy (TRUS)
  • Transperineal biopsy
20
Q

Briefly differentiate between transrectal ultrasound-guided biopsy (TRUS) and transperineal biopsy

A

Transrectal ultrasound-guided biopsy involves an ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.

Transperineal biopsy involves needles inserted through the perineum. It is usually under local anaesthetic.

21
Q

What are the risks of prostate biopsy?

A

The main risks of a prostate biopsy are:

  • Pain (particularly lower abdominal, rectal or perineal pain)
  • Bleeding (blood in the stools, urine or semen)
  • Infection
  • Urinary retention due to short term swelling of the prostate
  • Erectile dysfunction (rare)
22
Q

Briefly describe the use of isotope bone scanning

A

An isotope bone scan (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.

A radioactive isotope is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton. Metastatic bone lesions take up more of the isotope, making them stand out on the scan.

23
Q

Briefly describe the Gleason Grading System

A

The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).

The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):

  • The first number is the grade of the most prevalent pattern in the biopsy
  • The second number is the grade of the second most prevalent pattern in the biopy
24
Q

Briefly interpret the following Gleason scores:

  • 6
  • 7
  • 8
A

A Gleason score of:

  • 6 is considered low risk
  • 7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
  • 8 or above is deemed to be high risk
25
Q

Briefly describe the TNM staging of prostate cancer

A

The TNM staging system can be used for prostate cancer, rating the T (tumour), N (lymph nodes) and M (metastasis).

T for tumour:

  • TX: unable to assess size
  • T1: too small to be felt on examination or seen on scans
  • T2: contained within the prostate
  • T3: extends out of the prostate
  • T4: spread to nearby organs

N for nodes:

  • NX: unable to assess nodes
  • N0: no nodal spread
  • N1: spread to lymph nodes

M for metastasis:

  • M0: no metastasis
  • M1: metastasis
26
Q

What are the various treatment options for prostate cancer?

A

Depending on the grade and stage of prostate cancer, treatment can involve:

  • Surveillance or watchful waiting in early prostate cancer
  • External beam radiotherapy directed at the prostate
  • Brachytherapy
  • Hormone therapy
  • Surgery
27
Q

Briefly describe the role of active surveillance in prostate cancer

A

This is suitable for people with low grade prostate cancer and involves repeating investigations such as PSA, DR and biopsies over a number of years. If the cancers grade or stage increases, then the clinician and patient can reassess their treatment options. This option reduces the chances of over treating patients.

28
Q

Briefly describe the role of external beam radiotherapy in prostate cancer

A

Radiotherapy can be either curative or palliative. In palliation it can help reduce the tumour bulk as well as reduce pain of bony metastasis.

29
Q

What are the complications of external beam radiotherapy?

A

Local effects:

  • Proctitis (inflammation in the rectum
  • Bowel fibrosis
  • Bladder fibrosis
  • Radiation cystitis
  • Diarrhoea

Systemic effects:

  • Nausea
  • Tiredness
  • Loss of hair in treatment area
30
Q

A key complication of external beam radiotherapy is proctitis (inflammation in the rectum) caused by radiation affecting the rectum.

How does it present and how can it be prevented?

A

Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge.

Prednisolone suppositories can help reduce inflammation.

31
Q

Briefly describe the role of brachytherapy in prostate cancer

A

Brachytherapy involves implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate.

32
Q

What are the complications of brachytherapy?

A

The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

33
Q

Briefly describe the role of hormonal therapy in prostate cancer

A

Hormone therapy aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible. The options are:

  • Androgen-receptor blockers such as bicalutamide
  • GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
  • Bilateral orchidectomy to remove the testicles (rarely used)
34
Q

When is hormonal therapy used in prostate cancer?

A

Hormonal therapy is used for patients with metastatic disease.

35
Q

What is the mechanism of action of:

  • GnRH analogues
  • Androgen antagonists
  • GnRH antagonists
A

GnRH analogues: these paradoxically result LH & FSH blockade at the pituitary by causing over stimulation.

Androgen antagonists: these can be offered in addition to GnRH analogues to prevent an increase in disease activity following a transient surge in LH & FSH.

GnRH antagonists: these block the GnRH receptors which results in decreased LH & FSH levels and thus testosterone.

36
Q

What are the side effects of hormonal therapy for prostate cancer?

A

Side effects of hormone therapy include:

  • Hot flushes
  • Sexual dysfunction
    • Decreased labido
    • Impotence
    • Infertility
  • Gynaecomastia
  • Fatigue
  • Osteoporosis
  • Weight gain
  • Diabetes
  • Ischaemic heart disease
37
Q

Which hormonal treatment causes a transient rise in testosterone?

A

GnRH analogues.

38
Q

How is the transient rise in testosterone caused by GnRH analogues prevented?

A

GnRH analogues cause a transient increase in testosterone before LH, FSH blockage is achieved which can increase the disease activity. This can result in malignant cord compression if there is a disease in the spine.

The chances of this can be reduced by using an androgen receptor antagonist. This prevents an increase in disease activity following a transient surge in LH & FSH.

39
Q

What is the role of radical prostatectomy in prostate cancer?

A

Radical prostatectomy involves a surgical operation to remove the entire prostate. The aim is to cure prostate cancer confined to the prostate.

40
Q

What are the key complications of radical prostatectomy?

A

Key complications are erectile dysfunction and urinary incontinence.

Y4 Cancer Care: Oncology (7 decks)

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