Prostate Cancer

Question 1

Prostate Specific Antigen

Answer 1

• A protein produced by the prostate
• Measured by a blood test
• Primary screening modality for PRCA (Digital rectal exam)

Question 2

What is the screening for prostate cancer?

Answer 2

• Individualized, informed decision-making for males between 55 to 69 yo

Question 3

What are the treatment options for localized disease?

Answer 3

• Surgery (radical prostatectomy)
• ADT (Androgen deprivation therapy)
• Radiation (external beam radiation therapy EBRT)
• AS (active surveillance)

Question 4

Androgen Deprivation Therapy (ADT)

Answer 4

• Bilateral orchiectomy
• LHRH agonist
• LHRH agonist + 1st gen antiandrogen
• LHRH antagonist

Question 5

LHRH agonist

Answer 5

• MOA:
  
  • Initial: Increase LH/ACTH production
  • Later: Continued LHRH stimulation shuts down LH/ACTH production
• Leuprolide/Goserelin/Triptorelin

Question 6

What is the route of administration of Leuprolide?

Answer 6

IM

Question 7

What is the route of administration of Goserelin?

Answer 7

SQ

Question 8

What is the route of administration of Triptorelin?

Answer 8

IM

Question 9

1st Generation Antiandrogen

Answer 9

MOA: Inhibits androgen receptor binding and uptake by prostate cancer
* NOT used as monothreapy
* Should be used when starting LHRH agonist to prevent testosterone flare

Nilutamide/Flutamide/Bicalutamide
* All PO

Question 10

RxADT Toxicities

Answer 10

• Increase osteoporosis, risk for fractures
• Decrease muscle mass and strength
• Decrease size of penis and testicles
• Increase breast size and soreness, hot flush
• Increase risk for CV events, insulin resistance, lipid changes, obesity

Question 11

LHRH antagonist

Answer 11

Degarelix and Relugolix

Question 12

What is the route of administration of Degarelix?

Answer 12

SQ

Question 13

Relugolix

Answer 13

• PO
• DDIs
• Increase QTc

Question 14

What is the difference between LHRH agonist vs LHRH antagonist?

Answer 14

• No initial INCREASE LH/ACTH (testosterone flare)
• Quicker drop in testosterone
• Lower risk of cardiac events

Question 15

Abiraterone (Zytiga)

Answer 15

• Potent, selective, and irreversible CYP17 inhibitor; interferes with androgen biosynthesis in adrenals and peripheral tissues
• PO

Question 16

What are the side effects of Abiraterone?

Answer 16

• Excess mineralocorticoids (HTN, decrease K+, edema)
• Fatigue
• Hot flush
• Liver toxicity
  Always given with low dose prednisone 5mg

Question 17

2nd Generation antiandrogens

Answer 17

• Stronger, broader
• Oral daily
• Apalutamide, enzalutamide, darolutamide

Question 18

Castration-resistant prostate cancer

Answer 18

Progression despite castrate levels of testosterone (< 50 ng/dl)

Question 19

What is the treatment of M0 CRPC?

Answer 19

PSADT > 10 months
* Monitoring preferred
* Other secondary hormone therapy

PSADT <= 10 months
* 2nd generation antiandrogen

Question 20

What is the treatment of M1 CRPC?

Answer 20

• Continue ADT
• Add RANKL inhibitor or a bisphosphate if metastatic to bone
• Palliative XRT for painful bone mets
• Best supportive care

Question 21

What is the pharmacist’s role in prostate cancer?

Answer 21

• Support pharmacy team members (independent double check)
• Support providers (DDIs)
• Support patients (counseling and side effect management)