Prostate cancer

Question 1

Where is the prostate gland located

Answer 1

• at the base of the bladder and beginning of the urethra, that’s why its so hard to locate it
• it secretes the milky fluid which a component of semen

Question 2

What are the risk factors for prostate cancer

Answer 2

• male sex
• age >50yrs
• family history
• african-american race
• smoking
• overweight
• dietary influences
• alcohol
• androgen levels - use of exogenous testosterone
• infections with STD/multiple sexual partners
• increased frequency of ejaculation

Question 3

How is prostate cancer screened

Answer 3

• prostate specific antigen (PSA) - high levels indicative of cancer however a patient could have low levels and still have cancer so it is not a great tool
• digital rectal examinations

Question 4

What are the signs and symptoms of prostate cancer

Answer 4

-can present quite late

• increase urination frequency
• nocturia
• urgency, hesitancy, and reduced flow
• incomplete bladder emptying
• infection
• elevated PSA or positive DRE
• blood in ejaculate

other symptoms could suggest more advanced disease

• bone pain
• anaemia
• DIC

Question 5

How is prostate cancer investigated

Answer 5

-Transrectal ultrasound (TRUS)

• CT scanning
• MRI scanning
• radionuclide bone scan

Question 6

What is a side-effect of Transrectal ultrasound (TRUS)

Answer 6

• can cause damage such as faecal and urinary incontinence, infection and erectile dysfunction
• it is also not very accurate

Question 7

what is the Gleason scale staging of prostate cancer

Answer 7

it is the score of 2 most common miscroscopic cellular differentiation pattern of the prostate.

• the higher the first score then the more aggressive the cancer
• has a max score of 10
• a score of 6 could be 3+3 or 4+3

Question 8

What is the TNM staging for prostate cancer

Answer 8

T1- small tumour within prostate gland - generally with no symptoms
T2 - tumour within prostate but large enough to be detec with rectal exam or ultrasound
T3 & 4- cancer spread to surrounding tissues

N1 - cancer spread to nearby lymph nodes

M1a - cancer spread to other lymph nodes not near the gland
M1b - cancer spread to the bones

Question 9

What is localised prostate cancer, locally-advanced prostate cancer and metastatic prostate cancer

Answer 9

-localised prostate cancer - T1 and T2
-locally-advanced prostate cancer - T3 and &
T4
-metastatic prostate cancer - at N stage

Question 10

what is the risk stratification for prostate cancer

Answer 10

Low risk - Gleason score ≤6 and T1-T2a

Intermediate risk - Gleason score 7 and T2b

High risk - Gleason score 8-10 and ≥T2c

Question 11

What is the treatment plan for a low risk prostate cancer patient

Answer 11

• active surveillance

- radical prostatectomy & radiotherapy

Question 12

What is the treatment plan for an intermediate risk prostate cancer patient

Answer 12

• radical prostatectomy & radiotherapy

- if Gleason score is ≥8.0 - then may require adjuvant hormonal therapy for 2 years.

Question 13

What is the treatment plan for a high risk prostate cancer patient

Answer 13

• radical prostatectomy & radiotherapy
• 6 months - 3 years of androgen deprivation therapy
• external beam radiotherapy
• high dose rate brachytherapy

Question 14

What adverse effects are seen with radical therapy

Answer 14

• incontinence
• loss of sexual function - could use sildenafil
• impotence

Question 15

What treatment is used for locally advanced disease of prostate cancer and examples

Answer 15

• lutenising hormone-releasing hormone agonist (LHRHa)

e. g goserelin, leuprorelin

Question 16

What is the MOA of lutenising hormone-releasing hormone agonist (LHRHa)

Answer 16

• a negative feedback loop occurs which leads to a reduction of testosterone so a decrease in tumour occurs
• the Hypothalamus releases LHRH to the pituitary gland
• the pituitary gland releases LH to the testis
• the testsis releases testosterone to the prostate

LHRHa works on the pituitary gland and causes a surge in the testosterone level so the hypothalamus stops releasing LHRH

Question 17

How is lutenising hormone-releasing hormone agonist (LHRHa) treatment initiated

Answer 17

• 3 days of anti-androgen e.g cyproteron BEFORE administering LHRHa.
• it is then continued for 3 week alongside LHRHa

Question 18

What is tumour flare and what can it cause

Answer 18

• it is caused by a surge in testosterone level due to LHRHa which can be elevated for 1-2 weeks.
• it can cause urinary obstruction, bone pain and nerve compression

Question 19

What are the adverse effects of lutenising hormone-releasing hormone agonist (LHRHa)

Answer 19

• loss of libido
• hair loss
• impotence
• weight gain
• muscle loss
• enlargement of man breast
• hot flushes
• mood changes
• implantation site reaction

Question 20

What is an example LHRH antagonist

Answer 20

• degarelix

- does not cause tumour flare

Question 21

What is an example of anti-androgen and how does it work

Answer 21

e.g cyproterone, flutamide

MOA:

• competitively inhibits androgen receptor on prostate gland
• can be used alone or in combo w/ other therapies
• adverse effects similar to LHRHa

Question 22

What is hormone resistant disease

Answer 22

-men will eventually become resistant to treatment at some stage and it leads to advanced disease

Question 23

What is used in for refractory prostate cancer

Answer 23

Abirateron, enzalutamide

Question 24

What is the MOA of anti-androgens

Answer 24

They block androgen receptor and prevents androgens from binding