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.

Question 3

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

Answer 3

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

Question 4

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

Answer 4

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

Question 5

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

Answer 5

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 (if they have this w/ PSA<10 and Gleason 6 they are low risk).

Question 6

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

Answer 6

For those with 10-20 year life expectancy you do active surveillance (preferred!). If less than this you just observe. If more than 20 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 7

What defines unfavorable intermediate risk group?

Answer 7

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

Question 8

What defines intermediate favorable risk group?

Answer 8

% of cores less than 50% AND Gleason of 3+4=7 and only ONE IRF: cT2b-c, PSA 10-20, GS of 7

Question 9

What is the management of unfavorable intermediate risk patients?

Answer 9

If patient a has a life expectancy of 10 years or more-RP+PLND, EBRT+ADT (4-6 months), EBRT+Brachytherapy +/-ADT (4-6 months)

Question 10

What is the management for favorable intermediate risk patients?

Answer 10

If life expectancy is greater than 10 year-EBRT or brachytherapy or RP +/- pelvic lymph node dissection

Question 11

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

Answer 11

Must have one feature: If cT3b-T4, Gleason >5, >4 cores Gleason 8-10, 2 or more high risk features. High risk features: GS 4 or 5, PSA>20, cT3a

Question 12

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

Answer 12

EBRT+ADT (2 years)+Abiraterone (very high risk only!), RP+PLND, EBRT+Brachytherapy+ADT (1-3 years) (Cat 1 for the last option).

Question 13

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

Answer 13

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

Question 14

When should you consider getting a PSMA PET?

Answer 14

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 15

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 15

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

Question 16

In a patient who undergoes a RP with PLND and is found to have lymph node positive disease what is the best next step?

Answer 16

For those with a life expectancy of 5 years or more the preferred option is EBRT+ADT+Abiraterone (2 years) or you can do EBRT+ADT or ADT +/-Abiraterone.

Question 17

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 17

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 18

What are the options for castrate resistant metastatic disease?

Answer 18

For those with a PSADT less than or equal to 10 months you give Apalutamide, Darolutamide, or Enzalutamide with ADT. You can do ADT+Docetaxel. For those with a PSADT greater than 10 months you monitor (preferred) or give secondary hormonal agent.

Question 19

What are the non-chemo options for patients with castrate sensitive metastatic prostate cancer?

Answer 19

ADT with apalutamide, Abiraterone, or Enzalutamide.

Question 20

What are the options involving chemo to give for patients with castrate sensitive metastatic prostate cancer? Who qualifies for this?

Answer 20

Triplet: ADT+Docetaxel with either abiraterone or Darolutamide. You only do this for very fit patients who have high burden disease: visceral metastasis and 4 or more bone lesions with 1 being outside the axial skeleton.

Question 21

For castrate sensitive metastatic disease with low tumor burden what is an option for these patients?

Answer 21

ADT+EBRT to the area involved or ADT alone.

Question 22

How does Sipulecel-T work? Who does this work best for?

Answer 22

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.

Question 23

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

Answer 23

Fluid retention, edema, Afib, hypokalemia, LFTs, HTN, arthralgias, fatigue, back/bone pain. PRESS syndrome can occur.

Question 24

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

Answer 24

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

Question 25

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

Answer 25

Sipulecel-T, Cabazitaxel, Xofigo, and Pluvicto.

Question 26

What are some side effects of Xofigo?

Answer 26

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

Question 27

Xofigo is indicated for who?

Answer 27

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

Question 28

More so for informational knowledge when a patient fails Enzalutamide or Abiratertone what is the benefit of giving Cabazitaxel?

Answer 28

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.

Question 29

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

Answer 29

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 or have not received novel hormone therapy (ONLY for BRCA mutation!).

Question 30

What is the indication to using Niraparib and Abiraterone?

Answer 30

For patients who haven’t received treatment for castrate resistant metastatic disease or for those who have received Docetaxel but no novel hormone therapy with BRCA mutation ONLY. Can consider if they have received novel hormone agent, but this Cat 2B

Question 30

Talazoparib with Abiraterone can be used when?

Answer 30

In those with castrate resistant metastatic cancer if they haven’t started tx or if they have received Docetaxel but not novel AR antagonist for HRR mutation (so BRCA and others). Can consider if they have received novel hormone agent, but this Cat 2B

Question 30

You give Pluvicto when?

Answer 30

After failing both a taxane and AR antagonist therapy.

Question 30

What is the indication of Pembrolizumab in prostate cancer?

Answer 30

MSI-H or dMMR or TMB high

Question 31

What bone directed therapy do we use for prostate cancer?

Answer 31

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