Prostate Cancer

Question 1

… cancer is the most common malignancy affecting men in the UK.

Answer 1

Prostate cancer is the most common malignancy affecting men in the UK.

Question 2

1 in … men in the UK will be diagnosed with prostate cancer in their lifetime.

Answer 2

1 in 6 men in the UK will be diagnosed with prostate cancer in their lifetime.

Question 3

Age of onset (prostate cancer)

Answer 3

The prevalence increases with advancing age with incidence peaking between the ages of 75-79. Black men are at greater risk of developing prostate cancer and have a higher mortality when compared to White men.

Question 4

The aetiology of prostate cancer is poorly understood though a number of risk factors have been identified, these are … (4)

Answer 4

Age
Black ethnicity
Family history
Obesity

Question 5

The majority of prostate cancers (95%) are …

Answer 5

The majority of prostate cancers (95%) are adenocarcinomas. Other, much rarer, forms include transitional cell, squamous cell and neuroendocrine cancers.

Question 6

The majority of cancers arise in the … zone of the prostate (around 70%) with 10-20% arising from the … zone and 10-20% arising from the … zone.

Answer 6

The majority of cancers arise in the peripheral zone of the prostate (around 70%) with 10-20% arising from the central zone and 10-20% arising from the transitional zone.

Question 7

Prostate cancer is frequently …

Answer 7

Prostate cancer is frequently asymptomatic, but as disease progresses a number of symptoms may be encountered.

Question 8

LUTS associated with prostate cancer: (7)

Answer 8

Nocturia
Frequency
Hesitancy
Urgency
Dribbling
Overactive bladder
Retention

Question 9

Clinical features of prostate cancer:

Answer 9

LUTS:
Nocturia
Frequency
Hesitancy
Urgency
Dribbling
Overactive bladder
Retention
Visible haematuria
Abnormal DRE (hard, nodular, enlarged, asymmetrical)
Symptoms of advanced disease (e.g haematuria, blood in semen, lower back pain/bone pain secondary to bony metastasis, weight loss, anorexia)

Question 10

… may reveal a malignant feeling prostate.

Answer 10

Digital rectal examination (DRE) may reveal a malignant feeling prostate.

Question 11

Findings of prostate cancer include e.., a.., nodules and h.. of the prostate. It should be noted, many men with prostate cancer will have a normal DRE.

Answer 11

Findings of cancer include enlargement, asymmetry, nodules and hardness of the prostate. It should be noted, many men with prostate cancer will have a normal DRE.

Question 12

Digital rectal examination (DRE) should be considered in men with: (5)

Answer 12

Lower urinary tract symptoms (e.g. nocturia, frequency, hesitancy, urgency or retention)
Haematuria
Unexplained symptoms that may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss)
Erectile dysfunction
Other reasons to be concerned of prostate cancer (e.g. elevated PSA)

Question 13

… … … is a protein produced by prostate epithelial cells.

Answer 13

Prostate specific antigen is a protein produced by prostate epithelial cells.

Question 14

… is produced by normal prostate tissue, however levels in the blood tend to increase in malignancy. As part of normal physiology it is released into prostatic fluid to help liquefy sperm. It may be used both in the diagnosis and surveillance of prostate cancer.

Answer 14

PSA is produced by normal prostate tissue, however levels in the blood tend to increase in malignancy. As part of normal physiology it is released into prostatic fluid to help liquefy sperm. It may be used both in the diagnosis and surveillance of prostate cancer.

Question 15

Before PSA testing men should not have: (4)

Answer 15

Active or recent UTI (last 6 weeks)
Recent ejaculation, anal sex or prostate stimulation
Engaged vigorous exercise for 48 hours
Had a urological intervention in the past 6 weeks

Question 16

Active or recent UTI (last 6 weeks)
Recent ejaculation, anal sex or prostate stimulation
Engaged vigorous exercise for 48 hours
Had a urological intervention in the past 6 weeks

Men should not have had the above before what?

Answer 16

PSA testing

Question 17

Asymptomatic testing - PSA

Answer 17

The indications for PSA are complicated. There have been a number of studies that have tried to establish if a screening programme would be an overall benefit to the population. Currently there are a number of situations where PSA testing would be recommended. A full discussion regarding the PSA test (including the fact there are other causes of an elevated PSA, and a normal PSA does not exclude cancer) should be had with the patient.

PSA testing can be discussed with men over 50, and should be offered to those men over 50 who request it. An information leaflet is available (here) for patients. It makes clear there are both benefits and potential harms from having a PSA test when otherwise well.

Question 18

Specific clinical triggers to consider a PSA test include: (4)

Answer 18

Lower urinary tract symptoms (e.g. nocturia, frequency, hesitancy, urgency or retention)
Visible haematuria
Unexplained symptoms that may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss)
Erectile dysfunction

Question 19

All men with suspected … cancer should be referred on the urgent cancer (two week wait) pathway.

Answer 19

All men with suspected prostate cancer should be referred on the urgent cancer (two week wait) pathway.

Question 20

NICE guidance NG12, Suspected cancer: recognition and referral advise urgent referral on the suspected cancer pathway if the following is found: (2)

Answer 20

Abnormal prostate (‘feels malignant’) on DRE
PSA level is elevated above age-specific range

Question 21

Does a normal PSA and normal DRE exclude prostate cancer?

Answer 21

Clinician discretion must be used, a normal PSA and normal DRE do not exclude prostate cancer. If the diagnosis is suspected the patient should be discussed/referred for further review.

Question 22

What is the first line investigation in the diagnosis of prostate cancer?

Answer 22

Multiparametric MRI is now commonly the first line investigation in the diagnosis of prostate cancer.

Question 23

Multiparametric MRI - used in what?

Answer 23

Recent NICE guidelines (NG 131) advise multiparametric MRI as the first-line investigation in those with suspected localised prostate cancer.

NICE also advise the use of the Likert score - a 5-point score based upon the radiologist’s impression of the scan (adapted from Shin et al):

Question 24

NICE also advise the use of the Likert score - a 5-point score based upon the radiologist’s impression of the scan (adapted from Shin et al): in suspected localised prostate cancer

Answer 24

Clinically significant cancer highly unlikely to be present
Clinically significant cancer is unlikely to be present
Chance of clinically significant cancer is equivocal
Clinically significant cancer is likely to be present
Clinically significant cancer is highly likely to be present

Question 25

Multiparametric MRI-influenced prostate biopsy - Likert score of … or greater

Answer 25

A guided biopsy is offered to patients with a Likert score of 3 or greater. NICE advise considering omitting biopsy in those with Likert score of 1 or 2 - after discussion of benefits and risks of each option and taking into account patient-based factors.

For the most part, the biopsy will be guided by the MRI images previously acquired with the help of USS.

A negative biopsy does not completely exclude a diagnosis of prostate cancer. Many factors, including Likert score, PSA level, DRE findings and medical history may be considered. Cases may be discussed at MDT, if concern remains high they may require repeat biopsy. Others may have ongoing active surveillance.

Those who do not have a biopsy with Likert score 1/2 and a raised PSA should have ongoing active surveillance with repeat PSAs and review.

Question 26

Further imaging for prostate cancer:

Answer 26

Bone isotope scan, CT and further MRI may all be considered to evaluate for distant spread.

Question 27

Stage and grade: prostate cancer

Answer 27

In prostate cancer the TNM classification is used for staging whilst the Gleason score gives the histological grade.

Question 28

TNM classification for prostate cancer:

Answer 28

The tumour, node and metastasis (TNM) classification is used for prostate cancer. It assigns a score for each of the primary tumour, nodal spread (if any) and distant metastasis. The full staging is beyond the scope of this note but can be found on the NICE CKS page (here).

Question 29

Gleason score - prostate cancer:

Answer 29

The Gleason score is a histological grade assigned to prostate cancers. From the biopsy, the most common and second most common tumour pattern is assigned a score of 1 to 5 (5 being the highest grade) to give a combined score of 2 to 10.