Prostate Cancer Flashcards
Discuss the anatomy of the prostate gland
It is at the base of the bladder, at the beginning of the urethra. Any growth will prevent urinary flow
What are the risk factors for prostate cancer?
- exogenous testosterone
- age
- family history
- afro-caribbean origin
- smokers
- androgen levels
- dietary influences
- weight
- infections with STDs, multiple partners
- increased frequency of ejaculation
How is prostate cancer screened for?
Prostate specific antigen testing or digital rectal examination
What are common presentations of prostate cancer?
- benign prostate hyperplasia mimics prostate cancer
URINARY SYMPTOMS: increased frequency of urination, nocturia, urgency, hesitancy, reduced urinary flow, incomplete bladder emptying, infection
- elevated PSA
- blood in ejaculate
- many men are asymptomatic
What are symptoms of advanced disease associated with prostate cancer?
bone pain, anaemia, other symptoms of metastatic spread
Which investigations are carried out for prostate cancer?
TRUS - takes tissue from the prostate gland, can sometimes miss the cancer so multiple biopsies are taken
- CT scan, bone scan, MRI scan
- digital rectal exam
How is prostate cancer staged?
Using the gleason scale, first number is the most predominant cell type and second is the second most predominant cell type
What are the T stages for prostate cancer?
T1 - small tumour within the prostate gland, too small to be detected and generally causes no symptoms
T2 - tumour is still within the prostate, but is large enough to be detected
T3 AND 4 - tumour has spread to surrounding tissue
Which T stages related to localised prostate cancer?
T1 and 2
Which T stages relate to locally advanced prostate cancer?
T3 and 4
What are the N stages for prostate cancer?
N1 - cancer in nearby lymph nodes
What are the M stages for prostate cancer?
M1a - cancer has spread to other lymph nodes
M1b - cancer in the bones
Which stages relate to metastatic prostate cancer?
N1, any M
Which stages of prostate cancer are classed as low risk?
T1-T2a, gleason less than 6
Which stages of prostate cancer are classed as intermediate risk?
T2b, gleason 7
Which stages of prostate cancer are classed as high risk?
T2c and 8-10 gleason
How are low risk prostate cancers treated?
Active surveillance, watchful waiting, radical prostactomy or radiotherapy
How is intermediate risk prostate cancer treated?
Patients offered radical treatment.
If gleason score is more than 8 then adjuvant hormonal therapy recommended for 2 years post RT.
Check prostate stimulating hormone levels
How is high risk prostate cancer treated?
Radical prostectamy/radiotherapy
6 months of androgen deprivation therapy
radiotherapy
high dose brachytherapy
What are the options for radical radiotherapy?
Radiotherapy focused on the prostate, radioactive seeds to prostate, cryotherapy
What are the adverse effects of radical radiotherapy?
- problematic as the urethra runs through the prostate
- incontinence
- loss of sexual function
- impotence
- bowel problems
How is locally advanced prostate cancer treated?
Leutenising hormone releasing hormone antagonists
Give some examples of LHRHA
buserelin, goserelin, triptorelin, leuprorelin
How is goserelin administerd?
Zoladex is administered as a prefilled syringe, available as 4/12 weekly implants or nasal sprays
How do 4/12 weekly implants of zoladex work?
Pellet is implanted into the empidermis and leeches out the drug
What is the normal process of the prostate cell cycle?
hypothalamus reduces LHRH to pituitary gland, which releases LH to the testes, which releases testosterone and signals to to prostate to regulate cell cycle, cells die and grow normally, but in prostate cancer prostate cells proliferate uncontrollably. There is also a release of adrenal corticotrophic hormone from pituitary gland which stimulates the adrenal gland, producing adrenal androgens, that stimulate the prostate.
What can LHRAa cause initially?
Initial surge in testosterone, causing a tumour flare. Anti androgens can be given 3 days prior to giving LHRHa and continued for up to 3 weeks after. Degarelix does not cause this as it is a LHRH antagonist
What are the adverse effects of LHRAa?
Hot flushes, inplantation site reactions, loss of libido
When are anti-androgens added in to treatment?
When men are not responding well enough to LHRAa/to prevent tumour flare
Give some examples of anti-androgens
Flutamide, bicalutamide, cyproterone
How do anti-androgens work?
Competitiively inhibit the androgen receptors, which inhibits testosterone release. Has similar adverse effects to LHRHa
How does hormone resistant disease occur?
There is not just one way to produce testosterone. Cell signalling systems change and this leads to an up regulation of the androgen receptor in cells, anti androgens can even become agonists
How is advanced prostate cancer treated?
- Dexamethasone
- radiotherapy
- bisphosphonates or strontium for bone pain
- chemotherapy
Which further treatments can be given to patients that stop responding to hormonal therapies but have not had chemotherapy?
- enzalutamide and arbiratone
Which chemotherapy drugs are given for prostate cancer and when are they indicated?
Docetaxel, mitoxantrone, estramustine. Given in advanced hormone refractory disease
How do LHRHa agonists work?
LHRHa agonists stimulate the pituatry to produce LH which results in increased testosterone which leads to a negative feedback loop, as the hypothalamus decreases the release of LHRH, and this leads to a fall in testosterone and the tumour shrinks
