Prostate cancer

Question 1

What is the normal prostate function?

Answer 1

Produces seminal fluid, this is stored in the seminal vesicles. This is what keeps the sperm mobile and nourished.

Question 2

Epidemiology of prostate cancer- how common is it and what is the age group that commonly gets it?

Answer 2

Most common cancer in men. 1in 8 men experience prostate cancer and there are over 50% of cases over the age of 75.

Question 3

What is the pathophysiology of prostate cancer and how is it different from benign prostatic hyperplasia?

Answer 3

Cancer is due to the hyperplasia of the peripheral zones of the prostate gland.

BPH is due to hyperplasia of the transition (middle zone) of the prostate.

Question 4

Why do prostate tumours grow and what is their histology?

Answer 4

1. They grow due to production of androgens e.g. testosterone
2. 95% are adenocarcinomas

Question 5

Where are the most common metastatic sites for prostate cancer?

Answer 5

1. Bone mets
2. Lymph nodes

1 in 5 patients present with mets. Usually bone mets.

Question 6

What are the risk factors for prostate cancer?

Answer 6

1. Advancing age (50+)
2. More common in afro-caribbean men
3. Family hx, if their mother has had breast cancer, their risk is more than doubled
4. BRCA
5. Anabolic steroids (due to altered testosterone levels)

Question 7

How does prostate cancer present (symptoms)

Answer 7

Lower urinary tract symptoms e.g.
1. poor stream
2. nocturia
3. straining
4. hesitation
5. dribbling
6. increased frequency
7. impotence

Question 8

Screening programme for prostate cancer

Answer 8

Men aged 50-69 with a PSA over 3.0 and a hard, nodular prostate on PR exam is the criteria for a 2 week wait referral.

Question 9

Investigations for diagnosis of prostate cancer

Answer 9

1. Digital rectal exam and full examination
2. Multiparametric MRI is first line for suspected prostate cancer (transurethral ultrasound is no longer used due to complications of infection, pain and rectal bleeding)

Question 10

What factors affect PSA levels?

Answer 10

1. exercise (increases with more vigorous exercise)
2. UTI
3. Ejaculation

Question 11

Differential diagnoses of raised PSA

Answer 11

1. prostatic hypertrophy
2. prostate cancer
3. prostatitis
4. post-biopsy
5. catheterisation

Question 12

Surgical intervention for management of prostate cancer

Answer 12

Radical prostatectomy with curative intent is indicated when stage is T2 or less. Usually for patients under 70 with no co-morbidity.

Palliative surgery e.g. trans-urethral resection may be used to relieve prostatic symptoms or urinary obstruction.

Question 13

Why is radiotherapy delayed until 6 weeks after surgery?

Answer 13

Post Trans-urethral resection, wait 6 weeks to prevent stricture formation

Question 14

Side effects of radiotherapy

Answer 14

Dysuria, rectal bleeding, diarrhoea, impotence

Question 15

Grade of prostate cancer and management (stage and according treatment)

Answer 15

1. Localised (T1/ T2) = Conservative/ radical prostatectomy/ radiotherapy (treatment depends on life expectancy & patient choice)
2. Localised advanced (T3/ T4) = hormone therapy/= radiotherapy
3. Metastatic = hormone therapy

Question 16

Hormone therapy for metastatic disease - how does it work?

Answer 16

Inhibition of the growth-stimulatory effect of endogenous androgens may effectively treat prostate cancer – 80% response rate.

Question 17

Leutenising hormone releasing hormone agonists - what are they and how do they work?

Answer 17

Leuprolide and goserelin

• Interferes with the normal release of gonadotropins from the pituitary.
• Reduce the level of circulation testosterone
  (i.e. medical castration)

Question 18

GnRH antagonists - what are they and how do they work?

Answer 18

e.g. Degarelix

• Leads to castrate levels of testosterone within 3 days
• Doesn’t cause a flare
• Block the pathway superiorly at the level of the pituitary.

Question 19

Anti-androgens - how do they work in prostate cancer management?

Answer 19

e.g. bicalutamide
act by blocking the pathway of androgens produced by the adrenals. This stops prostate cancer cells from growing.

Question 20

Which are the most common chemotherapy agents used in prostate cancer treatments?

Answer 20

Docetaxel (in combination with prednisolone)
Cabazitaxel

Both cytotoxic agents

Question 21

What is the survival rate/prognosis of prostate cancer?

Answer 21

1. Survival of men with low risk localised prostate cancer is 99% in 10 years
2. 10 year survival rate is around 84% and in metastatic disease the median survival rate is 3.5 years.