Prostate Cancer

Question 1

What do the guidelines state for who should be sent for genetic counseling? For full list refer to NCCN guidelines and the screenshot you took.

Answer 1

If you have 1st degree relative with prostate cancer less than age 60, two close relatives with history of breast or prostate (regardless of age), any patient with metastatic or regional prostate cancer that is high risk or very high risk. Ashkenazi jewish ancesty.

Question 2

What age group per the USPTF task force do they recommend that you could do screening for prostate cancer?

Answer 2

You can have an individualized discussion with those aged 55-69, they don’t recommend for 70 or older. NCCN recommends starting screening at age 45 for normal risk patients.

Question 3

What is the def of T1 lesions?

Answer 3

Lesions not palpable on exam and only incidentally discovered. T1a-less than 5% in tissue resected. T1b-more than 5% of tissue resected. T1c-tumor actually identified by needle biopsy in one or both sides.

Question 4

What is the def of T2 lesions?

Answer 4

T2a-palpable and takes less than 1/2 of a lobe
T2b-palpable and takes more than 1/2 of a lobe
T2c-occupies both lobes

Question 5

What is the def of a T3 lesion?

Answer 5

Extracapsular tumor, locally advanced. T3a-extraprostatic extension on one side or both sides. T3b-invades seminal vesicle

Question 6

When there is seminal vesicle involvement what stage do they automatically have? Grade group 5? Lymph Node? Distant mets?

Answer 6

Stage IIIB which is locally advanced disease. Grade Group 5-Stage IIIC. Lymph Node-Stage IVA. Distant Mets-Stage IVB.

Question 7

What is the difference between Gleason 3+4 vs 4+3?

Answer 7

3+4 is considered favorable intermediate risk disease while 4+3 is considered unfavorable intermediate risk.

Question 8

What defines a very low risk prostate cancer case? Based off of this what defines low risk?

Answer 8

Very low risk (must have all of the following): Less than 3 biopsy cores +, with less than or equal to 50% cancer w/ PSA density less than 0.15, Gleason 6 and T1c, PSA<10. Low risk-cT1-T2a, grade group 1, PSA<10, they must have the all of the above (and either PSA density>0.15, more than 3 cores that are positive, or any core w/positive tumor >50%)

Question 9

What is the management for a very low risk and low risk prostate cancer?

Answer 9

For those with 10-20 year life expectancy you do active surveillance (preferred!) for very low risk. If less than this you just observe for very low risk and low risk. For low risk and 10 year life expectancy you can treat w/brachytherapy, EBRT, or prostatectomy. For low risk if they have a 10+ expectancy you can treat these patients.

Question 10

For low risk patients with prostate cancer, how do you manage these patients?

Answer 10

If life expectancy less than 10 years, you observe. If the life expectancy is 10 years or more, the preferred option is active surveillance. But it says you can do RT or surgery.

Question 11

What defines unfavorable intermediate risk group?

Answer 11

Gleason of 4+3=7, % of cores w/ cancer is greater or equal to 50%, or 2-3 IRFs: cT2b-c, PSA 10-20, GS of 7 (grade group 3)

Question 12

What defines intermediate favorable risk group?

Answer 12

% of cores less than 50% AND Grade group 1 or 2, and only ONE IRF: cT2b-c, PSA 10-20, GS of 7

Question 13

What is the management of unfavorable intermediate risk patients? Favorable group?

Answer 13

If patient a has a life expectancy greater than 10 years-RP+PLND, EBRT+ADT (4-6 months). If life expectancy is 5-10 years you can do EBRT+ADT or you can do observation. Remember the adjuvant therapy after definitive tx to be given if lymph node+ or adverse features (RT and ADT). Favorable group-if greater than 10 years active surveillance is an option! In addition to RT or surgery. If less than 10- RT or observation.

Question 14

For those patients who have favorable intermediate risk prostate cancer if they have adverse features (seminal vesicle invasion, extracapsular ext, or detectable PSA) what do you do? What if they have no adverse features but positive lymph nodes?

Answer 14

Adverse features: preferred option is to wait and do salvage RT+/-ADT once the PSA>0.1. For lymph node positive dx: ADT+/-RT

Question 15

What defines very high risk prostate cancer? Can you remember based off of this what defines high risk disease?

Answer 15

Must have one feature: cT3b-T4, primary Gleason pattern 5, >4 cores Gleason 8-10, 2 or more high risk features. High risk features: grade group 4 or 5 (8-10), PSA>20, cT3a

Question 16

What is the management of very high risk or high risk disease?

Answer 16

If life expectancy greater than 5 years OR they are symptomatic-EBRT+ADT (2 years) or +Abiraterone (very high risk only!), RP+PLND. If 5 years or less and asymptomatic you do observation, ADT, or EBRT.

Question 17

What is the tx of high risk or very high risk prostate cancer if life expectancy is 5 years or less?

Answer 17

Observation, ADT, or EBRT.

Question 18

When do you in the diagnostic workup get a bone scan and a CT or MRI scan?

Answer 18

For those who have intermediate unfavorable, high/very high risk patients

Question 19

When should you consider getting a PSMA PET?

Answer 19

For high risk patients before you decide on whether they will get RP or EBRT to rule out mets. Also you do this for patients with a BCR.

Question 20

For patients with early stage prostate cancer what are adverse risk features that can be found and what do you do for these patients?

Answer 20

Positive margins, seminal vesicle invasion, extracapsular extension, or detectable PSA after def tx. Tx-EBRT+/-ADT

Question 21

Be mindful that in high risk patients Grade Group 4/5, Gleason of 7 or higher what should you not do for these patients who develop a BCR?

Answer 21

For these patients you should start immediate ADT rather than delayed until PSA for instance goes over 10. Also as opposed to intermittent, you should do continuous ADT.

Question 22

What are the tx options for lymph node positive early stage prostate cancer? Locally advanced/Stage III dx

Answer 22

If life expectancy is>5 years or symptomatic-Preferred option is EBRT+Abi+ADT. Other options are EBRT+ADT or ADT+/-Abi or RP+PLND. 5 years or less and asymptomatic-observation or ADT.

Question 23

What are the tx options for a biochemical recurrence or PSA persistence after RP if the imaging is negative +/-positive fossa recurrence? (for those with life expectancy>5 years)

Answer 23

Make sure to calculate the PSA doubling time to risk stratify them! If the imaging is neg for mets preferred option is EBRT+/- ADT or you can also monitor them.

Question 24

What is the tx for a biochemical recurrence after RP if the imaging is positive for pelvic nodal recurrence? If life expectancy is less than or equal to 5 years?

Answer 24

Life expectancy>5 years-EBRT+ADT+/-Abiraterone. If life expectancy is less than or equal to 5 years you do observation.

Question 25

What is the treatment of a PSA recurrence or resistance following RT? This is only for those with life expectancy greater than 5 years, if it’s less you observe.

Answer 25

If imaging is neg for recurrence and patient has a high PSA doubling time you can do ADT. If the imaging is positive for nodal recurrence in the pelvis you can do ADT+/-Abiraterone. An option in both scenarios is seminal vesicle biopsy and monitoring.

Question 26

Relugolix is a GNRH antagonist just like Degarelix, what is the benefit to using Relugolix over Degarelix and Lupron?

Answer 26

Relugolix is assoc with less major cardiovascular events.

Question 27

What are the tx options for progressive castrate sensitive disease that is M0 and has gotten maximal therapy?

Answer 27

Observation (preferred), ADT (can be intermittent or continuous), or Enzalutamide+/- Leuprolide (only to be given in patients w/PSADT less than or equal to 9 months, PSA 2 or more than the nadir after RT or 1 or more after RP w or w/o RT), and not considered a candidate for maximal pelvic therapy.

Question 28

What are the tx options for castrate resistant M0 prostate cancer?

Answer 28

All patients must continue ADT. If the PSA DT is greater than 10 months you can observe (preferred) or you can use secondary hormone agents (e.g. Biclutamide). If PSA DT<10 months: Apalutamide, Darolutamide, Enzalutamide (all cat 1).

Question 29

What is the treatment of low volume castrate sensitive M1 prostate cancer? This is for metachronous dx

Answer 29

ADT w/Abiraterone, Apalutamide, Enzalutamide (all cat 1 options). Remember there is no OS benefit in this setting to give w/Docetaxel!

Question 30

What is defined as high risk disease in castrate sensitive M1 prostate cancer? How do you treat high volume synchronous metastasis?

Answer 30

Visceral metastasis or 4 or more bone lesions with at least one outside the vertebral body and pelvis. So for a fit patient you can give them ADT w/Docetaxel and Darolutamide or Abiraterone. OR you can do ADT w/Abi, Darolutamide, or Enzalutamide.

Question 31

How do you treat high volume metachronous or low volume synchronous castrate sensitive M1 prostate cancer?

Answer 31

You can do triplet therapy or you can do ADT w/Abi, Darolutamide, and Enzalutamide or you can do ADT with EBRT to the metastatic site +/-Abiraterone or Docetaxel (Cat2B) (this is only for low disease burden).

Question 32

How does Sipulecel-T work? Who does this work best for? When is this indicated?

Answer 32

After undergoing leukopheresis the infusion is combined with G-CSF and PAP to help APCs and T cells target PAP on tumor cells. Those with low volume disease and low PSA. There is a OS benefit. This is only for castrate resistant disease.

Question 33

What are some side effects of Abiraterone? What CNS syndrome can occur?

Answer 33

Fluid retention, edema, Afib, hypokalemia, LFTs, HTN, arthralgias, fatigue, back/bone pain.

Question 34

What are the side effects seen with Enzalutamide?

Answer 34

Fatigue, diarrhea, hot flash, joint pain, HTN, headache, seizure, cardiac, PRESS

Question 35

When giving Sipulecel-T who can you not give this to?

Answer 35

If they have visceral metastasis you can’t give it, so can only have bone metastatic disease.

Question 36

Beyond primary therapy options (ARIs) in metastatic castrate resistant disease what are your options?

Answer 36

Sipulecel-T, Cabazitaxel, Xofigo, and Pluvicto.

Question 37

What are some side effects of Xofigo?

Answer 37

Bone pain, anemia, thrombocytopenia, neutropenia, N/V/D, constipation.

Question 38

Xofigo is indicated for who?

Answer 38

Those with bone only disease and non-bulky adenopathy (less than 3cm).

Question 39

More so for informational knowledge when a patient fails Enzalutamide or Abiratertone what is the benefit of giving Cabazitaxel? In a patient who has failed Docetaxel and Abiraterone what do you give?

Answer 39

You can see an OS benefit with Cabazitaxel. Remember there is cross reactivity with Enzalutamide and Abiraterone so if you fail one you will fail the other. For this reason you give Cabazitaxel if they failed taxane and Abi.

Question 40

When using Olaparib when can you use it and with what novel hormone agent can you combine it with?

Answer 40

So you use Olaparib alone only after progression with first line treatment using novel hormone agent (for BRCA or other HRR mutation e.g. PALB2, ATM). Or you can combine it with Abiraterone in those who have not been treated in the mCR setting and have not received novel hormone therapy (ONLY for BRCA mutation!).

Question 41

What is the indication to using Niraparib and Abiraterone?

Answer 41

For patients who haven’t received treatment for castrate resistant metastatic disease with BRCA mutation ONLY (germ line or somatic). Can consider if they have received novel hormone agent, but this Cat 2B

Question 42

Talazoparib with Enzalutamide can be used when?

Answer 42

In those with castrate resistant metastatic cancer if they haven’t started tx for castrate resistant dx and also have a HRR mutation (so BRCA and others-ATM, CHEK2, PALB2, ATR, CDK12). Can consider if they have received novel hormone agent, but this Cat 2B

Question 43

You give Pluvicto when?

Answer 43

After failing both a taxane and AR antagonist therapy.

Question 44

What is the indication of Pembrolizumab in prostate cancer?

Answer 44

MSI-H or dMMR or TMB high

Question 45

What bone directed therapy do we use for prostate cancer?

Answer 45

For those with castrate resistant disease we use Zometa or Denosumab.

Question 46

What is the indication to use Rucaparib in castrate resistant metastatic dx?

Answer 46

It is used for for those with BRCA 1/2 and have progressed on a taxane and anti-androgen therapy. Conversely, you can give it those who have anti-androgen, but are not fit to receive a taxane.