Prostate Cancer

Question 1

A 56 year old male has an annual health check and his PSA has increased from 1.2 to 6.5ng/ml (NR<1.5mg.ml) in 12 months. He has noted reduced urinary flow over the past 5 years. How would you investigate and manage him?

Answer 1

Introductory
Given increasing PSA in the context of reduced urinary flow, the most important differential to exclude is prostate cancer. Flag that PSA is a poor screening test for prostate cancer, one single positive result has a low PPV. Most likely this man’s symptoms and elevated PSA is related to BPH given the slow growth over time

Ddx - causes of elevated

• acute prostatitis
• trauma: sexual intercourse, DRE
• ejaculation

Goals

• perform targeted assessment including Hx/Ex/Ix
• refer to Uro for further investigation if significant patient concern + other factors like fam hx
• For prostate biopsy and histological diagnosis

Question 2

Prostate cancer - History

Answer 2

History

• sx: obstructive LUTS, time course,
• REDS: haematuria, fevers, sweats, weight loss, sx of local invasion (bowel changes, erectile dysfunction
• HPI: past PSAs, abnormal biopsies in the past, previous investigations
• Risks: older age, black ethnicity, smoking, alcohol, irradiation
• Medications, allergies
• SNAP

Question 3

Prostate cancer - Examination

Answer 3

Examination:

• general appearance + vitals
• abdo exam + DRE: assess size, shape, consistency, character of prostate, nodularity suggestive of Ca whilst diffuse enlargement BPH (median sulcus intact)
• systems review for mets (bone, lung, brain)

Question 4

Prostate cancer - Investigations

Answer 4

Investigations
Key/diagnostic
- prostate biopsy; transcutaneous or trans-rectal US guided needle biopsy: Apply Gleasons score to histologically grade cancer 
- staging imaging if appropriate
- PSA trend

Other

• Bedside: urinalysis, UA
• Bloods: CMP, LFT (ALP and Ca for bony mets), FBC, CRP/ESR
• Imaging: Staging imaging (MRI, PET, CT)

Question 5

Prostate cancer - Management

Answer 5

Management

• Uro referral
• MDT for cancer, acquire appropriate grading and staging before determining appropriate management plan; Mx depends on patient, disease factors as well as treatment intent.

Otherwise;
- active surveillance with Hx, Ex, PSA trend; initiate definitive management if suggestion of disease progression

Definitive;
- TURP +/- pharmacological (androgen deprivation) and radiological adjuvant therapy
+/- brachytherapy
- palliation