Prostate Cancer Flashcards
What the RECOMMENDATION for PSA screening < 40 yo?
GUIDELINE STATEMENT 1
Do NOT
Low prevalence of CaP, no evidence of screening benefit
For ages 40-54 what RECOMMENDATIONS for PSA for CaP screening?
GUIDELINE STATEMENT 2
Do NOT perform
*not studied sufficiently in PLCO and ERSPC trials
UNLESS shared decision making d/ higher risk:
- AA race
- Family hx of metastatic/lethal adenocarcinoma(prostate, male/female beast cancer, ovarian, pancreatic) spanning multiple generations, multiple first degree relatives at young ages
What does the panel RECOMMENDED for PSA screening for ages 55-69?
GUIDELINE STATEMENT 3
Shared decision making to proceed
Multiple approaches subsequent to PSA to determine need for second biopsy (no proof of utility as primary screening tests)
**urine, serum biomarkers, imaging, risk calculators to help detect men harboring CaP
What does the panel offer and OPTION for PSA screening frequency?
GUIDELINE STATMENT 4
To reduce harms, interval q 2 years or more may be preferred over annually (can be individualized by baseline PSA)
Goteborg data→rescreening every 4 years not likely to miss curable CaP among men PSA < 1.0
What are the risks of prostate cancer screening?
- Psychological
- Hematuria
- Hematochezia
- Hematospermia
- Dysuria
- Retention
- Pain
- Infection
- Over-diagnosis
- Over treatment
- Transient ED
Describe some elements included in SDM for PSA screening for CaP?
- Putative mortality benefit of screening (overall 3% risk of dying)
- Description of options after abnormal PSA
- Likelihood of FP and FN (no screening test perfect, can be elevated for many reasons, PLCO trial annual screening no advantage over biannual in regards to mortality)
- Description of subsequent tests needed
- Harms of screening (additional procedures, hospitalizations, sepsis)
- Information about prostate gland anatomy an function
- CaP incident and mortality
- Treatment options for early and late CaP
- Complications of treatment options
Current AUA guidelines recommend which abx for prostate biopsy?
1 dose of either FQ OR 1st/2nd Gen Cephalosporin +/- Aminoglycoside OR 3rd Gen Cephalosporin
Aztreonam (if resistance)
Local antibiogram
Rectal swab can be considered (hx of resistance, travel, FQ in past 6 mo, healthcare worker)
List the grade groups for CaP:
- Grade Group 1: Gleason 3+3
- Grade Group 2: Gleason 3+4
- Grade Group 3: Gleason 4+3
- Grade Group 4: Gleason 8 (4+4, 3+5, 5+3)
- Grade Group 5: Gleason 9-10 (4+5, 5+4, 5+5)
Prostate cancer T1 staging
T1a → <5% of tissue removed, incidental during unrelated sx
T1b → >5% of tissue removed, incidental during unrelated sx
T1c → cancer found on biopsy, usually related to elevated PSA
Prostate cancer T2 staging
T2 → prostate cancer completely inside gland
T2a → in only < 50% of one lobe
T2b → in > 50% of one lobe
T2c → cancer in both lobes
Prostate cancer T3 staging
T3 → cancer broken through capsule
T3a → broken through capsule
T3b → spread to SV
Prostate cancer T4 staging
T4 → spread to other organs nearby (rectum, bladder, levator muscles, pelvic wall)
CaP Risk Stratification → Low Risk
CaP Risk Stratification → Intermediate Risk
CaP Risk Stratification → High Risk
At CaP diagnosis, it is a STRONG RECOMMENDATION to utilize SDM, incorporating these key elements:
GUIDELINE STATEMENT 1 (CLINICALLY LOCALIZED CAP)
- Risk category
- Patient values and preferences
- Life expectancy
- Pre-treatment General functional and GU sxs
- Expected post-treatment functional status
- Potential for salvage tx
EXPERTS suggest importance of counseling in regards to what factors at the time of CL CaP Dx?
GUIDELINE STATEMENT 2
Modifiable Health-Related Risk Factors
Smoking
Obesity
(Also consider frailty)
Clinicians are RECOMMENDED to encourage patients to meet with whom at time of dx of CaP?
GUIDELINE STATEMENT 3
Different prostate cancer specialists
Urology
Radiation Oncology
Med Oncology
Effective SDM at time of CaP dx requires clinicians to inform patients of what to make proper treatment decisions?
GUIDELINE STATEMENT 4
Immediate and LT morbidity or side effects of proposed treatment decisions
Active surveillance: preserves QOL until Surgery/XRT necessary, declines in urinary, bowel, sexual function over time with age, anxiety
Sx: (immediate) bleeding, infection, pain, (longer term) ED, UI, stricture, bowel problems, death (<0.1%)
XRT: (immediate) urinary irritation, bowel irrigation, GI effects (longer term) UI, ED, secondary cancer, radiation cystitis
Experts suggest clinicians SHOULD inform patients to participate in what additional measure at time of CaP?
GUIDELINE STATEMENT 5
Clinical trials (based on eligibility and access)
At time of dx for low risk or very low risk CL CAP, what imaging is RECOMMENDED?
GUIDELINE STATEMENT 6
Clinician should NOT perform CT A/P or Bone scans
(no evidence to support need for staging)
Clinicians should RECOMMEND which initial tx for very-low risk CL CaP?
GUIDELINE STATEMENT 7
Active Surveillance
(limited or no metastatic potential, major risk serial bx → at 3-5 year intervals after confirmatory bx)
Reminder:
- PSA <10
- GG1 (Gl 6)
- T1-T2a
- <34% biopsy cores positive
- no core >50% involved
- PSA density <0.15
Clinicians should RECOMMEND which initial tx for low risk CL CaP?
GUIDELINE STATEMENT 8
Active surveillance as preferable care option
(regardless of life expectancy)
**Higher volume disease >50% of cores positive or larger lesions on MRI, while still low risk, may benefit from tx
Reminder:
- PSA < 10
- Grade Group 1
- T1-T2a
Clinicians should RECOMMEND which initial tx for select low risk CL CaP?
GUIDELINE STATEMENT 9
Definitive tx RP or XRT
High probability of progression on AS (PIVOT, ProtecT→small reduction in progression)
Clinical Predictors:
PSA denisty >0.15 (2x risk)
Obesity (3 x risk)
AA race
extensive Gl 6 on systematic cores
FHx of aggressive CaP or early mets
If a patient chooses RT for low-risk CL CAP, what is RECOMMENDATION regarding ADT?
GUIDELINE STATEMENT 10
NO ADT with RT
**Exception → reducing size prostate for brachytherapy
If a patient is considering whole gland cryotherapy for low-risk CL CAP, what is RECOMMENDED counseling?
GUIDELINE STATEMENT 11
A/E are considerable: ED, UI, LUTs, bowel sxs, AUR, urethral sloughing
Survival benefit not shown when compared to AS
If a patient is considering focal therapy of HIFU for low-risk CL CAP, what is RECOMMENDED counseling?
GUIDELINE STATMENT 12
These intervention are NOT the standard of care
*Fails to improve survival outcomes or provide comparable QOL, insufficient data to support
Clinicians should RECOMMEND which initial tx for low risk CL CaP with life expectancy < 5 years?
GUIDELINE STATEMENT 13
Watchful waiting/observation
Palliative, non-aggressive intent→no bx
What is EXPERT consensus for patients with low risk CL CaP considering AS in regards to tissue based genomic biomarkers ?
GUIDELINE STATEMENT 14
Have not shown a clear role in selection of candidates for AS
3 approved by FDA:
- Genomic Classifier (GC)–22 marker based on RNA → high score on bx associated with increased risk of mets
- Genomic Prostate Score (GPS)–12 cancer genes, 20 point increase associated with SS increase HG or non-organ confined dz
- Cell Cycle Progression (CCP)–31 cell cycle genes–increased denotes HR disease
At time of dx for UNFAVORABLE intermediate risk CL CAP, what imaging is should be considered by EXPERT OPINION?
GUIDELINE STATMENT 15
CT A/P or MRI prostate or pelvis and Bone Scan (18F NaFl PET/CT or PMSA considered but not standard in US)
Baseline staging if 2 or more: palpable nodule on DRE (stage T2b/c), Gl 7, or PSA >10
Reminder:
- PSA 10-20 OR
- GG 2-3 OR
- T2b-c
- Favorable GG1 (with PSA 10 - <20) or GG2 (with PSA <10)
- Unfavorable: GG2 (either PSA 10 - <20) or T2b-c OR GG3 (PSA < 20)
At time of dx for intermediate risk CL CAP, what tx is RECOMMENDED?
GUIDELINE STATEMENT 16
RP or XRT+ADT
Patient with FAVORABLE intermediate risk CL CAP, what counseling is RECOMMENDED regarding RT and ADT?
GUIDELINE 17
Can be tx with RT alone, but less evidence than in combination with ADT
Unfavorable should especially be considered for ADT
Reminder:
- PSA 10-20 OR
- GG 2-3 OR
- T2b-c
- Favorable GG1 (with PSA 10 - <20) or GG2 (with PSA <10)
- Unfavorable: GG2 (either PSA 10 - <20) or T2b-c OR GG3 (PSA < 20)
Patients with intermediate risk CL CAP, what other tx options can be considered besides RP or RT?
GUIDELINE 18, 19, 20, 21
MAY consider Cryosurgery (limited to 1 RCT) → whole gland may be appropriate if contraindications to RP or RT
MAY offer AS → favorable int risk CL→ inform higher risk mets compared to definitive tx (benefit MRI + target bx)
Watchful waiting < 5 years life expectancy (no AS, no overall improvement in life expectancy with intervention)
HIFU → not the standard options because comparative evidence lacking
At time of dx for high risk CL CAP, what imaging is A CLINICAL PRINCIPAL?
GUIDELINE STATEMENT 22
CT/MRI and Bone Scan
Reminder:
- PSA >20 OR
- GG 4-5 OR
- _>_T3
Clinicians should RECOMMEND which initial tx options for high risk CL CaP?
GUIDELINE STATEMENT 23
RP or RT + ADT
GUIDELINE STATMENT 24, 25, 26
should NOT recommend AS
Watchful waiting only if asx < 5 life expectancy
NO cryotherapy or HIFU (outside clinical trial)
NO primary ADT (unless limited life expectancy and local sxs)
In addition to treatment, what do EXPERTS suggest for high-risk CL CaP at time of dx?
GUIDELINE STATEMENT 27
consider referral for genetic counseling for patient and families
when high risk and strong fhx of specific cancers (breast, ovarian, pancreatic, GI tumors, lymphoma)
*Germline DNA repair mutations
Describe AS CLINICAL PRICIPALS AND RECOMMENDATIONS:
GUIDELINE STATEMENT 28
CL CaP pts who elect AS should have accurate disease staging including systematic bx with US or MRI
(10-12 core with some targeted per DRE or MRI)
GUIDELINE STATEMENT 29
Routine PSA and DRE
optimal schedule not est, but ProtecT suggests q 3 mo x year 1, q3-6 subsequently
GUIDELINE STATEMENT 30
Confirmatory bx within initial 2 years and surveillance bx thereafter (some protocols recommend repeat bx before committing to AS or w/in 6 mo)
GUIDELINE STATEMENT 31
Consider MP Prostate MRI as part of AS (improve retention by reducing need for bx)
GUIDELINE STATEMENT 32
Tissue based genomic markers have NOT shown clear role in AS and are not necessary for f/up
*(ex. Prolaris, Oncotype Dx, Decipher Score)
GUIDELINE STATEMENT 33
Offer definitive tx when develop adverse reclassification (growth, rises in psa, changes in density, upstaging)
*PIVOT and ProtecT, 20% and 50% pts on AS received definitive tx by 10 years
What is RECOMMENDED that clinicians inform patient’s about outcomes, preparation, and types of RP for CL CaP?
GUIDELINE STATEMENT 34
Younger or healthier men are more likely to experience cancer control from RP than older men
*<65 yo or >10 year life expectancy
GUIDELINE STATEMENT 35
Open and RALP offer similar cancer control, continence, and sexual recovery
GUIDELINE STATEMENT 36
RALP or perineal techniques are associated with less blood loss than RRP
GUIDELINE STATEMENT 37
Nerve-spring is associated with better EF (50-95% erections)
GUIDELINE STATEMENT 38
NOT tx with neoadjuvant ADT or other systemic tx (outside clinical trial)
GUIDELINE STATEMENT 39
Older men experience higher rates of permanent ED and PPI compared to younger men
What do EXPERTS suggest for CL CaP undergoing RP in regards to PLND?
GUIDELINE STATEMENT 40
Consider for any
RECOMMENDED for unfavorable intermediate and high risk
Counsel for complications (i.e. lymphocele→ 0.4-16 % incidence, drain +/- sclerosis, occasional MIS marsupialization)
What is RECOMMENDED for adjuvant ADT after RP?
GUIDELINE STATEMENT 41
unfavorable intermediate and high risk advised of r/b/a of adjuvant ADT when locally extensive CaP found during sx
What types of RT are RECOMMENDED for low risk CL CAP?
GUIDELINE STATEMENT 42
EBRT OR brachytherapy
What types of RT are RECOMMENDED for favorable intermediate risk CL CAP?
GUIDELINE STATEMENT 43
EBRT or brachytherapy ALONE or in combination +/- ADT
Reminder:
- PSA 10-20 OR
- GG 2-3 OR
- T2b-c
- Favorable GG1 (with PSA 10 - <20) or GG2 (with PSA <10)
- Unfavorable: GG2 (either PSA 10 - <20) or T2b-c OR GG3 (PSA < 20)
What protocol of RT and tx are RECOMMENDED for high risk CL CAP? What are a/e?
GUIDELINE STATEMENT 44
24-36 mo of ADT in adjunct to EBRT alone or EBRT + brachytherapy
GUIDELINE STATEMENT 45
use of ADT with RT increases a/e on EF and systemic a/e (hot flashes, dec bone mineral density, gynecomastia, depression, fatigue, and weight gain)
What type of EBRT is RECOMMENDED for any risk category of CL CaP?
GUIDELINE STATEMENT 46
consider moderate hypofractionation (without nodal therapy)
GUIDELINE STATEMENT 48
Proton beam therapy offers no clinical advantage over other forms of therapy
For CL CaP patient with obstructive LUTS which is RECOMMENDED in regards to treatment?
GUIDELINE STATEMENT 47
Surgical approaches
Discourage with volume >60 g
If RT for these patient or they have had previous large TURP, low dose brachytherapy should be discouraged
GUIDELINE 49
Brachytherapy has similar effects as EBRT with regard to EF and proctitis, BUT can exacerbate obstructive sxs
When is whole gland cryosurgery a possibility for treatment per EXPERT opinion? What should patients be informed in regards to this treatment and a/e?
GUIDELINE STATEMENT 50
Low- and intermediate risk CL CaP when RP or RT d/ comorbidities is not possible but > 10 years life expectancy
(max recommended 60 g)
GUIDELINE STATEMENT 51
Cryosurgery has similar PFS as non-dose escalated EBRT + ADTin low- and intermediate-risk dz
Conclusive comparison of mortality lacking
GUIDELINE STATEMENT 52
TURP defects are relative contraindication d/t increased risk of urethral sloughing
GUIDELINE STATEMENT 53
Utilize a 3rd or higher generation, argon-based system (double freeze-thaw cycle)
GUIDELINE STATEMENT 54
Unclear +/- ADT improves cancer control, can reduce prostate size to facilitate tx
(>40g, consider 3-6 mo of ADT)
GUIDELINE 55
ED is expected
GUIDELINE 56
A/E include UI, irritative, and obstructive urinary sxs (sloughing, fistula, bowel effects)
What should clinician inform patient with CL CaP considering focal therapy or HIFU?
GUIDELINE STATEMENT 57
these tx options lack evidence of efficacy
GUIDELINE STATEMENT 58
approved by FDA for destruction of prostate tissue, not explicitly for CaP
GUIDELINE STATEMENT 59
tumor location may influence oncologic outcome (apex avoided for morbidity risks cancer persistence)
GUIDELINE STATEMENT 60
CaP is often multifocal, focal therapy may not be curative and further tx needed
What should clinicians inform patients regarding long term secondary effects of RP, cryotherapy, and RT?
GUIDELINE STATEMENT 61
ED occurs, lacking ejaculate, preserved orgasm (no sexual dysfunction with observation)
GUIDELINE STATEMENT 62
Long term obstructive or irritative sxs for AS, RT whereas RP can relieve LUTs
GUIDELINE STATEMENT 63
Whole gland cryotherapy associated with worse sexual side effects and similar urinary/bowel a/e as RT
GUIDELINE STATEMENT 64
PPI occurs in most patients and persists long-term in small but significant subset (more than AS or RT)
GUIDELINE STATEMENT 65
Temporary proctitis s/p RT persists in some patient in LT (rare in AS or RP)
What is RECOMMENDED for follow up for CL CaP?
GUIDELINE STATEMENT 66
PSA (even though all PSA recurrences are not associated with mets or mortality)
RP < 0.02
RT + ADT nadir PSA < 2 with T recovered (if ADT)
recommended for at least 10 years
What can be used to inform patients of individualized post-treatment prostate cancer recurrence?
GUIDELINE STATEMENT 67
Nomograms taking in to consideration:
tumor grade and stage
race
fhx
age
pathologic stage
etc
+/- genomic testing
What would you tell a patient are the benefits of PSA screening as expressed in the number of deaths averted per 1000 men from a key RCT? What study is this? What study refutes this?
ERSPC (European Randomized Study of Screening for Prostate Cancer): 1 death fewer per 1000
**RRR of CSM 21% at median f/up of 11 years
PLCO (Prostate, Lung, Colorectal, and Ovarian): NO benefit
What are FP and FN in regards to CaP screening?
FP (false positive): elevated PSA with neg bx
FN (false neg): cancer present without elevation in PSA
Potential harms associated with PSA screening?
- Over Diagnosis: ERSPC 66%, SEER 23-43%
- Hematuria/hematospermia: ERSPC 20-50%
- Fever: ERSPC 3.5-4.2%
- Psychological
- Sepsis: 4%
- Pain (pain, fever, bleeding, infection, problems urinating 30%)
Discuss possible patient factors that may trigger prostate biopsy being performed?
- PSA > 3, ERSPC
- Prostate volume
- Inflammation (no benefit of abx in asx man)
- Age (55-69)
What does the panel RECOMMEND for PSA screening > 70 years old or any man with < 10-15 year life expectancy?
GUIDELINE STATEMENT 5
NO screening
If so, increase threshold to PSA > 10 (PIVOT study)
Discontinue if PSA < 3
DDX of elevated PSA (asx)
BPH
UTI
Prostatits
Prostate cancer
Describe some key features of mpMRI prostate?
Key Points
Optimal scanning technique should utilize 3.0T surface coil; an endorectal coil may be necessary for older 1.5T scanners
T2→dark lesion concerning for cancer
DWI (diffusion weighted)→bright lesion corresponding T2 lesion
DCE (dynamic contrast enhanced imaging)→early enhancement with early washout corresponding to T2 lesion
ADC (apparent diffusion coefficient)→dark corresponding to T2 lesion
Identification and reporting of putative tumors uses anatomic and functional images.
The radiographic report should identify up to 4 suspicious lesions with each individual lesion reported and characterized using PI-RAD v2 criteria.
Stratified by PiRADS score, what is correlation to all tumor and Gl_>_7 detection?
All tumor detection:
PI-RADSv2: 2→0-22%, 3→10-16%, 4→30-77% and 5→78-89%
Gleason _>_7
PI-RADSv2: 2→5-6%, 3→0-14%, 4→21-78% and 5→75-100%
Can you use mp MRI in biopsy naïve patients?
Two randomized clinical trials (PROMIS, PIVOT, MRI-FIRST)have provided level 1 data to support use mpMRI prior to biopsy for ALL men
mpMRI-targeted prostate bx in naive patients detects more clinically significant CaP when combined with systematic biopsy (less clinically insignificant CaP, than systematic biopsy alone), but must combine systematic due to risk of missing some clinically significant cancer with targeted alone