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Therapeutics P3 Spring > Prostate Cancer > Flashcards

Prostate Cancer Flashcards

1
Q

Prostate Cancer Clinical Presentation

A

Localized disease:
- asymptomatic

Locally invasive disease:
- ureteral dysfunction, urinary frq, urinary hesitancy, incomplete bladder emptying

Advanced disease:
- back pain, cord compression, lower extremity edema, pathologic fractures, anemia, weight loss

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2
Q

Prognostic factors

A

Prostate specific antigen (PSA)
- normal < 4
- >10 high risk
Tumor size
Histologic grade (Gleason Score)
- 2 to 4: less aggressive
- 7 to 10: more aggressive

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3
Q

When you see this card review the local disease initial therapies chart

A

Do it, Bitch >:/

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4
Q

Androgen Deprivation Therapy

A

Gold standard treatment for advanced prostate cancer
- Surgical castration (not common anymore)
- Medical castration: LHRH agonist +/- antiandrogen, OR LHRH antagonist

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5
Q

LHRH agonists

A
  • reversible method of androgen ablation
  • goal serum testosterone < 50 ng/dL one month after starting therapy
    Agents:
  • Goserelin (Zoladex)
  • Leuprolide (Lupron IM, Eligard SQ)
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6
Q

LHRH agonist acute ADE

A

tumor flare
hot flashes
erectile dysfunction
edema
gynecomastia
injection site reaction

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7
Q

LHRH agonist chronic ADE

A

Osteoporosis
clinical fracture
obesity
insulin resistance
increased risk of diabetes
CV events
hyperlipidemia

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8
Q

LHRH agonists counseling points

A

Initial tumor flare caused by LH/FSH surge
- presents clinically as bone pain or increased urinary sx
- resolves after about 2 weeks
- management: first gen antiandrogen before the administration of LHRH agonist and continuing for 2-4 weeks

Baseline bone mineral density test before starting long term ADT
- calcium and Vit D supplementation

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9
Q

LHRH antagonists

A

Agents:
- degarelix (Firmagon)
- relugolix (Orgovyx)

Faster effects than LHRH agonists

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10
Q

Antiandrogens

A

MOA: inhibit androgen uptake and/or binding of androgen to target tissues

First Gen:
- Biculatamide
- Flutamide
- Nilutamide
- ADE: diarrhea, gynecomastia, inc LFTs, hot flashes

2nd gen: (more potent, preferred)
- Apalutamide (M0)
- Enzalutamide (M0 or M1)
- Darolutamide (M0)

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11
Q

Combined Androgen Blockade

A

LHRH agonist or antagonist + antiandrogen
higher risk of ADE
Controversial: can be used as an initial therapy or add after several months if androgen ablation is incomplete (testosterone not < 50)

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12
Q

Castration Sensitive Prostate Cancer

A

ADT + Abiraterone or Apalutamide or Enzalutamide

ADT w/ Docetaxel x6 cycles + Abiraterone or Darolutamide
- good for high volume castration sensitive metastatic prostate cancer

high volume = visceral metastases, and/or 4 bone metastases with at least 1 metastases beyond pelvis

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13
Q

M0 Castration Resistant Prostate Cancer (CRPC) treatment

A

if PSADT > 10 months:
- monitor (preferred)
- other secondary hormone therapy

if PSADT </= 10 months:
- Apalutamide
- Enzalutamide
- Darolutamide
- other secondary hormone therapy

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14
Q

Secondary Hormone Therapies

A

2nd gen antiandrogen:
- Apalutamide
- Darolutamide
- Enzalutamide

Androgen metabolism inhibitor:
- abiraterone + prednisone or methylprednisone (M1 only)

Other secondary hormone therapy:
- First gen antiandrogen (nilutamide, flutamide, or bicalutamide)
- corticosteroids
- antiandrogen withdrawal
- ketoconazole + hydrocortisone

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15
Q

Apalutamide (Erleada)

A

MOA: nonsteroidal androgen receptor inhibitor

ADE: fatigue, HTN, rash, diarrhea, nausea, arthralgias, fracture risk, peripheral edema, seizure

CI: seizure hx, DC if seizure occurs

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16
Q

Darolutamide (Nubeqa)

A

MOA: competitive androgen receptor inhibitor

ADE: fatigue, HTN, Rash

Pearls:
- take with food
- no increase in seizure risk

17
Q

Enzalutamide (Xtandi)

A

MOA: pure androgen receptor signaling inhibitor

ADE: diarrhea, fatigue, HA, myalgia, edema, seizures

18
Q

M1 CRPC treatment: No prior Docetaxel or novel hormone therapy

A

Preferred:
- Abiraterone
- Docetaxel
- Enzalutamide

Other:
- Radium-233 (for symptomatic bone metastases)
- Sipuleucel-T
- other secondary hormone therapy

19
Q

M1 CRPC treatment: prior novel hormone therapy / no prior docetaxel

A

Preferred:
- docetaxel
Other:
- cabizataxel/carboplatin
- Olaparib (for HRRm)
- Rucaparib (for BCRA)
- Radium 223 (sx bone metastases)
- Sipuleucel-T
- abiraterone +/- dexamethasone
- other secondary hormone therapy

20
Q

M1 CRPC treatment: prior docetaxel / no prior novel hormone therapy

A

Preferred:
- Abiraterone
- Cabazitaxel
- Enzalutamide

Other
- Cabazitaxel/Carboplatin
- Mitoxantrone (for sx patients who can’t tolerate other therapies)
- Radium 223 (sx bone metastases)
- Sipuleucel-T
- other secondary hormone therapy

21
Q

M1 CRPC treatment: prior docetaxel and novel hormone therapy

A

Preferred:
- Cabazitaxel
- Docetaxel rechallenge

Other:
- Lutetium Lu 177 (for PSMA positive metastases)
- Cabazitaxel/carboplatin
= Olaparib for HRRm
- Mitaxantron for palliation
- Rucaparib for BRCA
- Radium223 for sx bone metastases
- Pembrolizumab
- Abiraterone
- Enzalutamide
- Other secondary hormone therapy

22
Q

Docetaxel (Taxotere)

A

MOA: inhibition of DNA, RNA, and protein synthesis
ADE: myelosuppression, alopecia, edema, peripheral neuropathy, hypersensitivity rxn

Caution with hepatic impairment, avoid if:
- Tbili > ULN
- AST +/- ALT > 1.5x ULN AND alk phos > 2.5x ULN

Pearls: co-administer with prednisone

23
Q

Abiraterone (Zytiga, Yonsa)

A

MOA: inhibits formation of the testosterone precursors DHEA and androstenedione

ADE: diarrhea, edema, hypoK, HTN, hepatotoxicity, hypertriglyceridemia

Pearls: admin with prednisone or methylprednisolone)
- Zytiga should be given on empty stomach (1hr before or 2 hrs after food)
- Yonsa may be administered with or without food

24
Q

Radium-223 (Xofigo)

A

MOA: radiopharmaceutical -> breaks DNA

ADE: peripheral edema, nausea, myelosuppression

Pearls:
- do not give with chemo
- used for symptomatic bone metastases

25
Q

Cabazitaxel (Jevtana)

A

MOA: microtubule inhibitor
ADE: febrile neutropenia, hypersensitivity rxn, mucositis, edema

26
Q

Lu-177-PSMA-617 (Pluvicto)

A

beta-emitting radiopharmaceutical that selectively binds to PSMA receptors on prostate cancer cells

Indicated for PSMA+ M1 CRPC

ADE: fatigue, dry mouth, nausea, myelosuppression

27
Q

Prostate Cancer Supportive care

A

Screen for diabetes and CVD in all patients receiving ADT

Yearly bone mineral density monitoring
- Calcium 1000-1200 mg QD
- Vitamin D 400-800 IU daily
- androgen induced bone loss: Denosumab
- osteoporosis: Zoledronic acid

Therapeutics P3 Spring (32 decks)

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