Prostate cancer Flashcards
Aetiology of prostate cancer
Malignant tumour of glandular origin - ADENOCARCINOMA
How does prostate cancer evolve/develop
- Localized prostate cancer: confined within the capsule and seldom causes symptoms.
- Locally advanced prostate cancer extends beyond the capsule of the prostate and is often asymptomatic when diagnosed.
- Metastatic prostate cancer most frequently affects the bones, where it causes pain and fragility fractures.
Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease.
Risk factors for prostate cancer
Age >50
Afro-Caribbean/black ethnicity
Family history of prostate (greatest risk >2 first degree relatives)
BRCA2 gene
High fat diet
epidemiology of prostate cancer
Most common cancer in males
Second most common cause of cancer mortality among men
Median age of diagnosis 66
What is PSA
Prostate specific antigen
Protein secreted by epithelial cells of the prostate into the lumen of the duct -> joins seminal fluid -> discharged
Prevented from entering blood via the basement membrane but damage to the gland -> PSA leaks
Concentration > 4 ng/mL indicates possible prostate disease
What can PSA be elevated in
Prostate cancer
BPH
Urinary retention
UTI
Catheterisation/instrumentation of urethra
(Post-biopsy
Post-DRE)
Symptoms of prostate cancer
Asymptomatic in most/early stages
LUTS
- Storage: Frequency, urgency, nocturia,
- Voiding: hesitancy, dribbling, straining, intermittency, dysuria
Pain (lower back)
Erectile dysfunction
Bone pain, weight loss, lethargy, spinal cord compression (mets)
Urinary retention/renal failure
Visible Haematuria
Signs of prostate cancer on examination
Digital rectal examination
Palpable prostate
Cancer - a hard gland, sometimes with palpable nodules
Benign enlargement - smooth, firm, enlarged gland
+/- lymphadenopathy
Investigations for prostate cancer
PSA >4 micrograms/L (do not offer if asymptomatic)
Testosterone (when considering androgen deprivation)
LFTs (when considering androgen deprivation)
FBC (when considering androgen deprivation)
Renal screen (when considering androgen deprivation)
First line: multiparametric MRI
- Report using Likert scale
- Not routinely offered to those who will not be able to have radical treatment
Likert 3 or more -> biopsy
Lower -> consider biopsy
TRUST prostate biopsy
Isotope bone scan: ?mets
Plain x-rays: ?bone mets
Pelvic CT/MRI: lymph nodes, staging
What are the cautions to PSA testing
Should NOT be done within:
6 weeks of a prostate biopsy
4 weeks following a proven urinary infection
1 week of digital rectal examination
48 hours of vigorous exercise
48 hours of ejaculation
How is prostate cancer graded and staged
Staging: TNM
Grading: Gleason score (find 2 largest areas and score with 5 being most aggressive -> quote both scores and the sum)
Management for prostate cancer
Prostate feels like cancer on DRE → Refer for 2ww pathway
MRI/biopsy negative → discuss at MDT meeting
Options:
Active surveillance
Watchful waiting
HIFU
Hormones
Chemotherapy
Radical prostatectomy
Radical radiotherapy
Describe the active surveillance option for prostate cancer
Only tumours showing signs of progressing will be considered for radical treatment
Check the PSA every 3 months, annual DRE and multiparametric MRI
Re-biopsy years 1, 3, 7
Describe the watchful waiting option for prostate cancer
Measure PSA levels at least once a year
Review by urological cancer specialist
Does NOT have repeat biopsies (differentiates from active surveillance)
Describe the surgical options for prostate cancer
Open or laparoscopic radical prostatectomy
Measures PSA 6 weeks prior to treatment and every 6 months for 2 years
Describe hormone therapy for prostate cancer
Prostate is androgen-dependent → i.e. requires testosterone for growth – produced by Testes (& adrenal gland)
Leuprolide - GnRH receptor agonist (synthetic agonist)
very high affinity for this receptor → initial large surge of LH → initial surge effect on testes -> desensitises the system
Flutamide - androgen receptor antagonist
Completely reduces the remaining androgen effect to almost zero
Advantages and disadvantages of PSA testing
Early detection - PSA testing may lead to prostate cancer and detection means treatment before symptoms of progression
Early treatment - May extend life or facilitate a complete cure
15% of people have a normal PSA level but have underlying prostate cancer (False negative)
75% of people with raised PSA level have a negative biopsy (false positive) -> invasive investigations
Complications of prostate cancer treatment
LHRH agonists -> tumour flares: temporary increase in testosterone-> spinal mets to flare → spinal cord compression. Therefore anti-androgens are given to cover for this, then removed when possible
TRUS biopsy
Sepsis (1 in 100)
Acute urinary retention
Severe haematuria
Severe rectal bleeding
Sexual dysfunction
Urinary incontinent
Androgen withdrawal: change in body shape, weight gain, tiredness, hot flushes, loss of libido, erectile dysfunction, gynaecomastia, loss of bone density
Complications of prostate cancer
Local invasion:seminal vesicles, base of the bladder, urethral sphincter, or side wall of the pelvis.
Distant metastases:spreads to the bones, where it can cause pain, pathological fractures, or spinal cord compression.
Lower urinary tract symptoms (LUTS): By the time prostate cancer causes LUTS, it may be advanced and incurable.
Prognosis for prostate cancer
Curable cancer, prognosis depends on stage at diagnosis
Stage 1-3: 5 year survival rate 96-100%
Mets (Stage 4): survival around 18 months
