Prostate cancer

Question 1

Prostate cancer pathophysiology

Answer 1

Growth of prostate cancer is influenced by androgens

Question 2

Prostate cancer types

Answer 2

Majority are adenocarcinomas

• > 75% of adenocarcinomas arise from the peripheral zone, 20% in the transitional zone & 5% central zone
• Acinar adenocarcinoma - originates in the glandular cells that line the prostate gland (most common)
• Ductal adenocarcinoma - originates in the cells that line the ducts of the prostate gland (tends to grow & metastasise faster than acinar adenocarcinoma)

Other types include small cell, squamous cell, transitional cell carcinoma

Question 3

Prostate cancer risk factors

Answer 3

Age - incidence of prostate cancer increases with age

Ethnicity - men of black African/Caribbean ethnicity

Family history of prostate cancer

Genetic predisposition - BRCA2/BRCA1 gene

Modifiable risk factors - obesity, diabetes mellitus, smoking

Question 4

Prostate cancer clinical features

Answer 4

LUTS - weak urinary stream, increased urinary frequency & urgency

More advanced localised disease → haematuria, dysuria, incontinence, haematospermia, suprapubic pain, loin pain & rectal tenesmus

Bone pain

Lethargy

Anorexia

Unexplained weight loss

Question 5

Prostate cancer Ix

Answer 5

DRE

PSA

Multi-parametric MRI scan of prostate

Biopsy

• transperineal biopsy - preferred due to decreased risk of infection
• transrectal biopsy

Staging - CT C/A/P and PET-CT

Question 6

Prostate cancer grading

Answer 6

Gleason grading system

Sample of prostate tissue is assigned a score according to its differentiation & Gleason score is calculated from this

Higher Gleason, poorer prognosis

Used is conjunction with PSA levels & TNM staging

Question 7

Prostate cancer general management

Answer 7

Discussion at a specialist prostate cancer MDT
Low-risk disease - active surveillance, radical treatments offered to those who show evidence of disease progression

Intermediate & high risk disease - radical treatment options (low intermediate can be offered active surveillance)

Metastatic disease - chemotherapy & anti-hormonal agents can be used

Castrate-resistant disease - evidence of hormone-relapsed disease patients can be considered for further chemo, corticosteroids can be offered as a third-line hormonal therapy

Question 8

Prostate cancer watchful waiting & active surveillance

Answer 8

Watchful waiting - symptom-guided approach to prostate cancer management where therapy is deferred & initiated at time of symptomatic disease; intent not curative

Active surveillance - can be offered to select patients with curable low-risk disease

• 3-monthly PSA, 6 month to yearly DRE, re-biopsy at 1-3 yearly intervals assessing for progression

Question 9

Prostate cancer surgical management

Answer 9

Radical prostatectomy - open, laparoscopically or robotically

SE: ED, stress incontinence & bladder neck stenosis

Question 10

Prostate cancer radiotherapy

Answer 10

External-beam radiotherapy - focused radiotherapy to target the prostate gland & limiting damage to surrounding tissues

Brachytherapy - transperineal implantation of radioactive seeds directly into the prostate gland

Question 11

Prostate cancer anti-androgen therapy & chemotherapy

Answer 11

Androgen deprivation therapy - mainstay of management of metastatic prostate cancer & improves outcomes in patients undergoing radiotherapy

• anti-androgens
• GnRH receptor agonists (goserelin)
• GnRH receptor antagonists (degarelix)
• surgical castration

Chemo is only indicated in metastatic disease