Prostate Cancer

Question 1

What is the 10 year survival rate of Prostate Cancer?

Answer 1

Over 80%

Question 2

What is the pathophysiology of Prostate Cancer?

Answer 2

Aetiology- ongoing research

Growth of prostate cancer is influenced by androgens (testosterone and dihydrotestosterone)

Majority adenocarcinoma and arise in the peripheral zone of the prostate. Often multifocal.

Question 3

What are the two categories of adenocarcinomas in Prostate Cancer?

Answer 3

Acinar adenocarcinoma- orginates in the glandular cells that line the prostate gland. Most common form of prostate cancer.

Ductal adenocarcinoma - orginates in the cells that line the ducts of the prostate gland. Tends to grow and metastasise faster than acinar adenocarcinoma.

Question 4

What are the risk factors for Prostate Cancer?

Answer 4

Increasing age

Ethnicity - black african or caribbean twice as likely

FH

Rarely BRAC1 OR BRAC2 gene

Modifiable risk factors - obesity, DM, smoking, degree of exercise.

Question 5

What are the clincial features of Prostate Cancer?

Answer 5

Localised- LUTS

Advanced localised - haematuria, dysuria, incontinence, haematospermia, suprapubic pain, loin pain and even rectal tenesumus.

Meatstatic disease - bone pain, lethargy, anorexia and unexplained weight loss.

DRE - asymmetrical, nodularity or a fixed irregular mass.

Question 6

What is the differential diagnosis for Prostate Cancer?

Answer 6

BPH
Prostatitis

Causes of haematuria: Bladder cancer, urinary stones, UTI and pyelonephritis

Question 7

What investigation could intially be used in suspected Prostate Cancer?

Answer 7

PSA

Question 8

How can PSA be artificially raised?

Answer 8

BPH 
Prostatitis
Vigorous exercise   
Ejaculation 
Recent DRE

Question 9

What further calculations using PSA can be done to make it more useful in Prostate Cancer?

Answer 9

Free:total PSA ratio - 4-10 increased chance of diagnosing prostate cancer.

PSA density - serum PSA level dividedby prostate volume which is determined by imaging (TRUS, CT or MRI) - higher the PSA density the increased likelihood of prostate cancer.

Question 10

What is essential for men who are offered a PSA screening test?

Answer 10

Counselling prior to testing is essential

Question 11

What further investigations are performed in suspected Prostate Cancer with elevated PSA?

Answer 11

Biopsies:

Transperineal (templete) biopsy - under GA, day case, lower risk of infection

TransRectal Ultrasound-guided (TRUS) biopsy - under LA, 12 cores are taken, 1-2% risk of sepsis

Repeat prostate biopsy after negative previous biopsy is recommended for men with rising or persistently elevatd PSA and/or suspicious DRE.

Question 12

What is the grading system for Prostate Cancer?

Answer 12

Gleason Grading system - based upon histological appearance

TNM staging

Question 13

What imaging may be done in Prostate Cancer?

Answer 13

Multi-parametric MRI (mp-MRI) - aid diagnosis - identify abnormal ares of prostate that can be targetted for biopsy

CT abdo-pelvis and Bone scan

Question 14

What is done with all cases of Prostate Cancer?

Answer 14

Discussed at specialist prostate cancer MDT

Management relates risk stratification based upon PSA, gleason score and T staging

Question 15

What treatment is offered to low risk disease in Prostate Cancer?

Answer 15

Active surveillance, radical treatment offered if show evidence of disase progression

Question 16

What treatment should be offered to those at intermediate or high risk disease in Prostate Cancer?

Answer 16

Radical treatment options should be discussed with all men with intermediate risk disease and high risk disease with realistic disease control. Those with intermediate risk can also be offered active surveillance (should not be offered for high risk disease)

Question 17

What treatment should be ofered to those who show metastaic disease in prostate cancer?

Answer 17

Chemotherapy agents and anti-hormonal agents can be used in metastatic prostate cancer

Question 18

What treatment should be offered to those with castrate-resistant disease in prostate cancer?

Answer 18

Those who demonstrate evidence of hormone-relapsed disease can be considered for further chemotherapy agents, such as Docetaxel. Corticosteroids can be offered as third-line hormonal therapy after androgen deprivation therapy and anti-androgen therapy to men with hormone-relapsed prostate cancer

Question 19

What is invloved in active surveillance in proatate cancer?

Answer 19

Active surveillance requires monitoring of patients with 3-monthly PSA, 6 month to yearly DRE, and re-biopsy at 1-3 yearly intervals assessing for progression and intervening at the appropriate time. Mp-MRI is also being used increasingly in such protocols.

Question 20

What is watchful waiting in prostate cancer?

Answer 20

Symptom guided apporoach

Question 21

What is the mainstay surgical treatment for prostate cancer?

Answer 21

Radical prostatectomy - open, laparoscopically or robotically

Question 22

What is removed in radical prostatectomy?

Answer 22

Prostate gland
Seminal vesicles
Surrounding tissue
+/- pelvic lymph nodes

Question 23

What are th side effects of radical prostatectomy?

Answer 23

ED (60-80%)
Stress incontinence
Bladder neck stenosis

Question 24

What are two forms of curative radiotherapy used in localised prostate cancer?

Answer 24

External-beam radiotherapy - focused radiotherapy to target prostate gland and limit damge to surrounding structures

Brachytherapy- tranperineal implementation of radicoacive seeds

Question 25

When is chemotherapy indicated in prostate cancer?

Answer 25

Metastatic prostate cancer

Question 26

What are the chemothearpy options in prostate cancer?

Answer 26

Some examples of chemotherapy drugs used include docetaxel (recommended in men with testosterone-resistant cancer) and cabazitaxel (used with prednisolone, recommended for treating relapsed prostate cancer which has progressed after using docetaxel chemotherapy).

As prostate cancer growth is stimulated by circulating androgens (testosterone), androgen deprivation therapies are regularly used, such as via gonadotrophin-releasing hormone (GnRH) receptor agonists (e.g. goserelin)

Newer hormone therapies now exist, such as the drugs enzalutamide and abiraterone, acting to lower levels of serum testosterone. Both of these drugs are reserved for patients with metastatic prostate cancer.