Prostate Cancer

Question 1

Prostate Cancer Risk Factors

Answer 1

Age
FH (5-10%)
Ethnicity

Question 2

What is mpMRI?
What is bpMRI

Answer 2

mpMRI - T2 (Anatomy), DWI - Diffusion Weighted Imaging(Specificity), ADC - Apparent Diffusion Coefficient, DCE - Dynamic Contrast Enhancement (Sensitivity)

bpMRI - T2, DWI

bpMRI - Cheaper, Quicker, Doesn’t require gadolinium, Similar sensitivity/specificity

Question 3

What does the PROMIS trial show

Answer 3

Paired Cohort Study: MRI + TRUS versus TRUS

mpMRI - Higher sensitvity (93% vs 48%) but lower specificity (41% versus 96%) compared to TRUS
mpMRI - Good NPV but inferior PPV

Indicated that men should have MRI before Biopsy

Question 4

Staging of Prostate Cancer

Answer 4

T1 (non-visible/papable)
T1a<5%
T1b>5%
T1c - from biopsy

T2 (Organ Confined)
T2a <Half a lobe

T2b>Half a lobe
T2c Both Lobes

T3 (Extracapsular)
T3a Extracapsublar
T3b (Involving Seminal Vesicle

T4 Local Spread)

Nx, N0, N1 (regional LN)

Mx, M0
M1(Metastatic)
M1a (Non-regional LN)
M1b (bone)
M1c (other sites)

Question 5

Risk Groups in Prostate Ca

Answer 5

NCCN Risk Stratifiaction (now replaced by CPG)

Low
PSA < 10
Gleason 6 or less
<T2a Disease

Intermediate
PSA 10-20
Gleason 7
T2b Staging

High
PSA>20
Gleason>8
>T2C

Question 6

Evidence for Radical Prostatectomy vs WW

Answer 6

Scandinavian Prostate Cancer Group (2014)
11% Reduction in overal mortality with 12 year follow up

Question 7

Who is eligible for AS

Answer 7

Low Risk Prostate Ca (gl 6)
Low Volume Indtermediate Risk Prostate Ca (3+4 and low volume)

Question 8

What did PROTECT trial show

Answer 8

No SD between AS, RT, RALP in terms of mortality

Radical Treatment reduced metastases and disease progression by half

56% men on AS received treatment by 10 years

Question 9

When should you consider bone scan?

Answer 9

Kandaswamy et al 2017

100% NPV for bone scan if PSA <20, Primary Gleason pattern 3 (i.e. 3+4 or 3+3)

Therefore bone scan if PSA >20 and Gleason 4+3

Question 10

Side Effects of hormone treatment

Answer 10

Hot flushes, ED, Libido, Weight Gaine, Fatigue, Developing female characteristics, Osteoporosis, Heart Disease

Question 11

Non ADT drugs improving overall survival in advanced PCa

Answer 11

Docetaxel, Cabazitaxel, Abiraterone, Enzalutamide, Sipleucel-T, Alpharadin

Question 12

What does abiraterone do?

Which trials demonstrated increased survival?

Answer 12

Inhibits androgen synthesis - Given with prednisolone.

Inhibits CYP17 and CY 17 (prevents cortisol and testosterone production)

Latitude + Stampede demonstrated increased survival in metastatic pCA
COU-AAA demonstrated increased suurvival both pre and post docetaxel

Question 13

How do enzalutamide and bicalutamide differ?

What trial looked at enzalutamide?

Answer 13

Enzalutamide binds with greater affinity than bicalutamide to Androgen Receptors. Bicalutamide can be cnosidered a partial AR Agonist.

Affirm trial demonstrated increased survival in metastatic CRpCa post docetaxel

Prevail trial demonstrated increased survival in metastatic CR pCa pre docetaxel

Question 14

PSA Range by Age

Answer 14

40-49 <2.5
50-59 <3.5
60-69 <4.5
70-79 - >6.5
>79 - Use clinical judgement

Question 15

Who do you need contrast enhanced MRI Scan for?

Answer 15

People with hip/pelvic prosthesis

Question 16

Answer Q:

How is prostate cancer stratified by risk?

Answer 16

Traditionally it was:
Low
Intermediate
High Risk

Now the Cambridge Prognostic group risk stratification is widely used.