Prostate cancer

Question 1

Prostate cancer is the most common cancer in?

Answer 1

men

Question 2

Prostate cancer is almost always androgen-dependent, meaning ?

Answer 2

they rely on androgen hormones (e.g., testosterone) to grow. The majority are adenocarcinomas and grow in the peripheral zone of the prostate.

Question 3

The key risk factors for prostate cancer are:

Answer 3

Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids

Question 4

Presentation of prostate cancer

Answer 4

Prostate cancer may be asymptomatic. It may also present with lower urinary tract symptoms (LUTS), similar to benign prostate hyperplasia. These symptoms include hesitancy, frequency, weak flow, terminal dribbling and nocturia.

Other symptoms include:

Haematuria
Erectile dysfunction
Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)

Question 5

What is the Prostate-Specific Antigen?

Answer 5

The epithelial cells of the prostate produce prostate-specific antigen (PSA). PSA is a glycoprotein that is secreted in the semen, with a small amount entering the blood. Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation. It is specific to the prostate, meaning it is not produced anywhere else in the body. A raised level can be an indicator of prostate cancer.

Question 6

Is PSA testing reliable?

Answer 6

Prostate-specific antigen testing may lead to the early detection of prostate cancer, potentially leading to effective treatment and preventing significant problems. However, research has failed to show that the benefits of using PSA for screening outweigh the risks. In the UK, men over 50 can request a PSA test if they would like one.

PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

Question 7

Common causes of a raised PSA are:

Answer 7

Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation

Question 8

A benign prostate feels?

Answer 8

smooth, symmetrical and slightly soft, with a maintained central sulcus (the dip in the middle between the right and left lobe). There may be generalised enlargement in prostatic hyperplasia.

Question 9

An infected or inflamed prostate (prostatitis) feels?

Answer 9

enlarged, tender and warm.

Question 10

A cancerous prostate feels?

Answer 10

firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule. Any of these features can indicate prostate cancer and warrant further investigation. In primary care, these findings require a two week wait urgent cancer referral to urology.

Question 11

What is Multiparametric MRI?

Answer 11

Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a Likert scale, scored as:

1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer

Question 12

Prostate Biopsy?

Answer 12

Prostate biopsy is the next step in establishing a diagnosis. The decision to perform a biopsy depends on the MRI findings (e.g., Likert 3 or above) and the clinical suspicion (i.e. examination and PSA level).

Prostate biopsy carries a risk of false-negative results if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate. The MRI scan results can guide the biopsy to decide the best target for the needles.

Question 13

There are two options for prostate biopsy:

Answer 13

Transrectal ultrasound-guided biopsy (TRUS)

Transperineal biopsy

Question 14

Transrectal ultrasound-guided biopsy involves?

Answer 14

an ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.

Question 15

Transperineal biopsy involves?

Answer 15

needles inserted through the perineum. It is usually under local anaesthetic.

Question 16

The main risks of a prostate biopsy are?

Answer 16

Pain (particularly lower abdominal, rectal or perineal pain)
Bleeding (blood in the stools, urine or semen)
Infection
Urinary retention due to short term swelling of the prostate
Erectile dysfunction (rare)

Question 17

Isotope Bone Scan?

Answer 17

An isotope bone scan (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.

A radioactive isotope is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton. Metastatic bone lesions take up more of the isotope, making them stand out on the scan.

Question 18

Gleason Grading System

Answer 18

The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).

The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):

The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy

Question 19

A Gleason score of:

Answer 19

6 is considered low risk
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
8 or above is deemed to be high risk

Question 20

TNM Staging for Prostate Cancer

Answer 20

T for Tumour:

TX – unable to assess size
T1 – too small to be felt on examination or seen on scans
T2 – contained within the prostate
T3 – extends out of the prostate
T4 – spread to nearby organs

N for Nodes:

NX – unable to assess nodes
N0 – no nodal spread
N1 – spread to lymph nodes

M for Metastasis:

M0 – no metastasis
M1 – metastasis

Question 21

Depending on the grade and stage of prostate cancer, treatment can involve:

Answer 21

Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery

Question 22

A key complication of external beam radiotherapy is?

Answer 22

proctitis (inflammation in the rectum) caused by radiation affecting the rectum. Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.

Question 23

Brachytherapy involves?

Answer 23

implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

Question 24

Hormone therapy aims to?

Answer 24

Reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible

Question 25

Options of hormone therapy?

Answer 25

Androgen-receptor blockers such as bicalutamide

GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)

Bilateral orchidectomy to remove the testicles (rarely used)

Question 26

Side effects of hormone therapy include:

Answer 26

Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis

Question 27

Radical prostatectomy involves ?

Answer 27

a surgical operation to remove the entire prostate. The aim is to cure prostate cancer confined to the prostate. Key complications are erectile dysfunction and urinary incontinence.