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01. Prostate Cancer (1883) > Prostate cancer > Flashcards

Prostate cancer Flashcards

1
Q

What share of male cancer consists of prostate cancer?

A

20%

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2
Q

What is the estimated mortality of prostate cancer out of all male cancers?

A

10%

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3
Q

In autopsy studies, what race had the highest prevalence of prostate cancer?

A 
US Black 
followed by 
US white and european
followed by
Asian
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4
Q

What kind of molecule is Prostate Specific Antigen (PSA)?

A

Serine Protease

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5
Q

When was PSA first used clinically?

and for what?

A

1986

post-treatment follow-up

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6
Q

What is the risk of prostate cancer at PSA 4?

What is the risk of Gleason >7 at PSA 4?

A

26,9%

6,7%

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7
Q

What was the conclusion of the PLCO Trial?

A

There is no evidence of mortality benefit for organized annual screening compared with opportunistic screening

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8
Q

What was did the Göteborg Randomized Population-Based Screening Trial find?

A

42% lower PCa mortality in the organized screening vs the opportunistic testing arm

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9
Q

To avoid 1 PCa death:

How many men have to be screened?
How many PCa’s have to be diagnosed?

A

139 screened

13 PCa found

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10
Q

When does the USPTF (US Preventive Services Task Force) recommend individual (a man can choose for himself after information) screening of prostate cancer?

A

Men aged 55-69

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11
Q

When does the EAU recommend PSA-testing?

A

After counselling the patient on potential risks and benefits

AND

good performance status and a life expectancy of >10-15 years

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12
Q

How should an inital PSA-test be followed?

A

Offer an risk-adapted strategy (based on initial PSA level), with follow-up intervals of 2 years for those initially at risk:

  • PSA >1 at 40 years of age
  • PSA >2 at 60 years of age

Postpone follow-up to 8 years in those not at risk

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13
Q

How does the EAU recommend that you avoid unnecessary biopisies for men with PSA 2-10 and normal digital rectal examination (DRE)?

A

use one of the following tools:

risk-calculator
imaging
additional serum or urine-based test

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14
Q

Which risk calculator is superior when predicting clinicallly significant prostate cancer?

A

ERSPC-RC

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15
Q

What is the risk of prostate cancer if PSA is < 2 but there is a suspect DRE (digital rectal examination)?

A

5-30%

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16
Q

How reliable is TRUS (transrectal ultrasound) for detecting prostate cancer?

A

TRUS in not reliable in detecting prostate cancer.

Thus, there is no evidence that US-targeted biopises can replace systematic biopsies.

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17
Q

How many biopsies should you take in a 30 cc prostate?

A

At least 8 systematic

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18
Q

How many biopsies should you take in a prostate >30cc?

A

10-12

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19
Q

What type of painrelief should be used when performing prostate biopsies?

A

a periprostatic block

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20
Q

What are the top 4 complications of prostate biopsies?

A

Haematospermia 37,4%
Haematuria >1 day 14,5%
Rectal bleeding >2 days 2,2 %
Prostatitis 1%

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21
Q

How common is fewer > 38,5 after prostate biopsies?

A

0,8%

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22
Q

ISUP 1

A

Gleason 2-6

Low risk

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23
Q

ISUP 2

A

Gleason (3+4) =7

Intermediate risk favourable

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24
Q

ISUP 3

A

Gleason (4+3) =7

Intermediate risk unfavourable

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25
Q

ISUP 4

A

Gleason 8

High risk

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26
Q

ISUP 5

A

Gleason 9

High risk

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27
Q

What did the PROMIS trial find?

A

Sensivity of mpMRI for clinically significant PCa is almost double compared to TRUS-biopsy

27% of primary biopsy procedures could be avoided if mpMRI was used as a triage test

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28
Q

What did the PRECISION trial show?

A

That when using MRI-targeted biopsies you can find a greater share of clinically significant PCa

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29
Q

If an MRI is performed that show PI-RADS 3 or more, how should you aim the prostate biopsies?

A

Combine targeted and systematic biopsies

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30
Q

Risk stratification of PCa:

what are the criterias for low risk?

A

PSA <10
Gleason <7 / ISUP1
cT1a-2a

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31
Q

Risk stratification of PCa:

what are the criterias for intermediate risk?

A

PSA 10-20
Gleason 7 / ISUP2-3
cT2b

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32
Q

Risk stratification of PCa:

what are the criterias for high risk?

A

PSA >20
Gleason >7 / ISUP4-5
cT2c

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33
Q

When should you perform a Bone Scan for patients with PCa?

A

Symptomatic patients regardless of PSA

Intermediate unfavourable risk cancer (Gleason 4+3)
High risk cancer (PSA >20)
Locally advanced cancer (T3 or worse)

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34
Q

When should you perform a mpMRI for patients with PCa?

A

Intermediate unfavourable risk cancer
High risk cancer
Locally advanced cancer

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35
Q

Risk stratification of PCa:

what are the criterias for locally advanced PCa?

A

Any PSA
Any Gleason
cT3-4 or N+

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36
Q

When should you perform an abdominal CT for patients with PCa?

A

Intermediate unfavourable risk cancer and worse for N-staging

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37
Q

What is the sensisivity of an abdominal CT for detecting nodal invasion of PCa?

A

<40%

MRI performance is similar

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38
Q

What is the sensivity and specificity for prostate cancer when using PSMA PET/CT?

A

sensitivity 50%

specificity >90%

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39
Q

What is the gold standard for N-staging in prostate cancer?

A

surgery -lymph node dissection

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40
Q

When is surgery the best option for a patient with prostate cancer?

A

<65 years

intermediate risk disease

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41
Q

How likely is it that a patient in monitoring will recieve active treatment within 10 years?

A

54,8%

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42
Q

Number needed to treat with radiotherapy to avoid:
clinical progression?
metastatic disease?

A

9

33

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43
Q

Number needed to treat with surgery to avoid:
clinical progression?
metastatic disease?

A

9

27

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44
Q

What is vital to inform patients of before chosing course of action after a prostate cancer diagnosis?

A

“No active treatment has shown superiority over any other active management options in terms of survival”

“all active treatments have side-effects”

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45
Q

Which side effect(s) is worse with surgery compared to radiation or active-monitoring?

A

Incontinence

Impotence

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46
Q

How many men used incontinence protection after surgery for prostate cancer 6 years postop?

A

17%

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47
Q

How many men had erections firm enough for intercourse at the time of diagnosis of Prostate Cancer?

A

67%

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48
Q

How many men had erections firm enough for intercourse after prostatectomy vs radiotherapy for prostate cancer?

A

12% vs 22%

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49
Q

Number needed to harm with surgery vs radotherapy rather than active monitoring when it comes to urinary incontinence at 2 years:

A

Surgery 5

Radiotherapy 143

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50
Q

When it comes to quality of life how does surgery, radiotherapy and active monitoring compare?

A

No significant differences

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51
Q

Should PLND (Pelvic lymph node dissection) be performed on patients with localized PCa?

A

No (strong recommendation)

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52
Q

Should PLND (Pelvic lymph node dissection) be performed on patients with intermediate risk PCa?

A

No (strong recommendation)

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53
Q

Should PLND (Pelvic lymph node dissection) be performed on patients with high risk PCa?

A

Yes (strong recommendation)

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54
Q

What is the difference between open, laprascopic or robot assisted radical prostatectomy in terms of functional and oncological results?

A

NONE

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55
Q

What is the difference between active surveillance and watchful waiting?

A

Active surveillance focuses on delaying therapy until the tumour becomes progressive and curative treatment can be offered

Watchful waiting focuses on minimising treatment-related toxicity and i palliative

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56
Q

What follow up should Active surveillance include?

A

Digital rectal examination
PSA
Repeated biopsies

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57
Q

What should the neoadjuvant ADT-duration be after radiotherapy?
(ADT = androgen deprivation therapy)

A

intermediate risk 6 months

high risk 3 years

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58
Q

When is brachytherapy as monotherapy recommended?

A 
Stage cT1b-T2a
Gleason 6 <50% of biopsy cores with cancer / Gleason 7 <33% of biopsy cores with cancer
PSA <10
<50cc prostate
IPSS< 12
Urinary flow >15mL/min
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59
Q

What anatomical sites should be included in extended pelvic lymph node dissection (ePLND)?

A

external iliac axis
obturator fossa
around the internal iliac artery

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60
Q

What is standard recommended radiotherapy dose in most European Centers for prostate cancer?

A

≥ 76-78 Gy in 37 fractions

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61
Q

What is the benefit of ADT (androgen deprivation therapy) in addition to radiotherapy?

A

20% added 10-year survival
20% added disease specific survival
No difference in cardiovascular mortality

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62
Q

When should you wait with ADT for patients with high risk prostate cancer that is unable to recieve local treatment?

A

PSA doubling time >12 months and

PSA < 50

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63
Q

What are the possible different courses of action after surgery of a high risk N+ prostate cancer?

A

Offer adjuvant ADT

Offer adjuvant ADT + additional radiotherapy

Offer observation for patients efter eLND and < 2 nodes with microscopic involvement and PSA <0,1

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64
Q

What treatment should be offered for a geriatric patient who presents with metastasised prostatecancer and symptoms?

A

Castration:

  1. bilateral orchiectomy
  2. GnRH agonist with flare protection Bicalutamide
  3. GnRH antagonist

For fit patients castration can be combined with docetaxel or abiraterone acetate
plus prednisolone or prostate radiotherapy

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65
Q

How quickly do you reach castration levels with antiandrogen (degarelix)?

A

By day 3

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66
Q

When should you treat prostate cancer patients with intermittent ADT?

A

Highly motivated asymptomatic patients who have a major PSA response after the induction period

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67
Q

What are the side effects of hormone therapy?

9

A

Loss of libido and sexual interest , erectile dysfunction, impotence
Fatigue
Hot flushes
Decline in intellectual capacity, emotional liability, depression
Decrease in muscular strength
Increase in (abdominal)fat apposition, diabetes, risk of CV events
Osteoporosis
Anaemia

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68
Q

How low is castrations lewel testosteron?

A

<50 ng/dl

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69
Q

When should bone health agents (bisphosponates/denosumab) be used?

A

For men with risk of osteoporotic fractures

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70
Q

What are valid (cytostatic) options for treatment of HSMPC (hormone sensitive metastatic prostate cancer)?

A

Early
Docetaxel
Enzalutamid
Abiraterone

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71
Q

What is the current wiev of prostatectomy and radiation for low volume disease?

A

Radiation is proven beneficial

Surgery is not yet proven

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72
Q

What are two ways a prostate cancer cell can become castration resistant?

A
  1. mutation of the androgen receptor so they get a higher affinity and can be activated by non-steroidal ligands
  2. by-pass pathways independent of the androgen receptor
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73
Q

Definition of castration-resistant PCa:

A 
Testosteron <50 ng/dL or 1,7 nmol/L  
and 
biochemical progression
or 
radiological progression
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74
Q

What kind of drug is Docetaxel?

A

Mitosis inhibitor

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75
Q

What is the second line treatment after Docetaxel?

A

Cabacitaxel

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76
Q

Where does Docetaxel have its effect?

A

In the cell membrane

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77
Q

What kind of drug is Enzelutamid?

A

It binds androgen within the cell and prohibits it to enter the cell nucleus

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78
Q

According to EAU what is the “correct” order to use antiprostate cancer drugs?

A

ADT (androgen deprivation therapy)

(Zoledronic acid or Denosumab to prevent SRE)

Abirateron or Enzelutamid

Docetaxel

Cabacitaxel

Radium-223

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79
Q

When is it wrong to use bone protective agents in prostate cancer?

A

In hormone sensitive bone metastatic PCa

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80
Q

What is importen to remember when prescribing Zoledronic acid or Denosumab?

A

Also offer calcium and vitamin-D

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81
Q

How should you act with a patient who has a spinal cord compression from metastasised PCa?

A

start immediate high-dose corticosteroids and assess for spinal surgery followed by irradiation

Offer radiation therapy alone if surgery is not appropriate

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82
Q

MOA:
Leuprolide
Goserelin

A

GnRH agonist

Increase LH release

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83
Q

MOA:
Degarelix
Abarelix

A

GnRH Antagonist

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84
Q

MOA:
Abiraterone
Ketoconazole

A

Androgen Synthesis Inhibitors (Adrenal)

Ketoconazole: CYP 17, 11B hydroxylase
Abiraterone: CYP 17

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85
Q

MOA:
Bicalutamide
Flutamide
Nilutamide

A

1st Gen Anti-Androgen

decreases binding at AR

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86
Q

MOA:
Enzalutamide
Apalutamide
Darolutamide

A

2nd Gen Anti-Androgen

decreases binding at AR, decreases nuclear translocation and transcription

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87
Q

MOA:
Docetaxel
Cabazitaxel

A

Chemotherapy

microtubule disruption

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88
Q

MOA:

Mitoxantrone

A

Chemotherapy

Topoisomerase II inhibition

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89
Q

MOA:
Olaparib
Rucaparib

A

PARP inhibitor

BRCA 1/2 mutations, other HRR mutations

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90
Q

MOA:

Sipuleucel-T

A

Immunotherapy

Target cells displaying PAP-GMCSF

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91
Q

MOA:

Pembrolizumab

A

Immunotherapy

Anti-PD1

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92
Q

PLCO Trial

A
  • RCT - Screening trial
  • Prostate, lung, colorectal, ovarian screening = PLCO
  • No difference in prostate cancer specific mortality with yearly PSA screening vs. no screening
  • Criticism = contamination (there was a LOT of screening and even previous biopsy in the control arm as well)
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93
Q

MOA:
Denosumab
Zoledronic acid

A

Bone Protecting Agents

Decrease osteoclast activity

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94
Q

MOA:

Radium-223

A

Alpha particle creating double strand breaks in DNA

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95
Q

Treatment options:

Low Risk Prostate Cancer

A 
AS
Cryo
(HIFU)
RP (no LND)
XRT (prostate +/- SV)
Brachy monotherapy
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96
Q

Treatment options:

Favorable Intermediate Risk Prostate Cancer

A 
AS
Cryo
(HIFU)
RP (no LND)
XRT (prostate +/- SV +/- LN) +/- 4-6 months ADT
Brachy +/- XRT
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97
Q

Treatment options:

Unfavorable Intermediate Risk Prostate Cancer

A

(AS)
RP + LND
XRT (prostate + SV + LN) + 4-6m ADT
Brachy + XRT +/- 4-6m ADT

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98
Q

Treatment options:

High Risk Prostate Cancer

A

RP + LND
XRT (prostate + SV + LN) + 2-3y ADT
Brachy + XRT + 1-3y ADT

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99
Q

Treatment Options:

N1M0 Prostate Cancer

A 
WW
ADT immediately (alone; intermittent or continuous)
RP + LND + XRT + long term ADT
XRT (prostate + SV+ LN) + long term ADT
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100
Q

Definition:

Low Volume Metastatic Burden in Prostate Cancer

A

No visceral mets
Any # nodal mets
Bone mets confined to vertebral bodies/pelvis

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101
Q

Definition:

High Volume Metastatic Burden in Prostate Cancer

A

At least 1 visceral (non-nodal) met

>= 4 bone mets with at least one bone met outside of vertebral column/pelvis

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102
Q

ERSPC Trial

A

ERSPC = European Randomized Study for the Screening of Prostate Cancer

  • RCT, 162k men age 55-69, PSA checked every 4 years
  • Primary outcome = prostate cancer specific mortality (1 death fewer per every 1,000 men screened)
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103
Q

Urine Biomarkers

A

PCA3
Select MDx
MiPS

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104
Q

Tissue Biomarkers

A

OncotypeDx
ConfirmMDx
Prolaris
Decipher

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105
Q

Serum Biomarkers

A

PHI

4K score

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106
Q

CAP/ProtecT trial

A
  • 415k men randomized to one single PSA vs no PSA at 50-69 years
  • 10 years follow up
    1. More cancer in intervention arm
    2. No difference in cancer mortality
    3. No difference in survival
  • -> Single PSA test not recommended for population screening
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107
Q

Important AEs

Abiraterone

A

Glucocorticoid deficiency, increased mineralocorticoid production
Give with steroids

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108
Q

Important AEs:

Enzalutamide

A

Seizures, falls, HTN, hallucination, CV, mental

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109
Q

AUA Guideline Statement for screening in men >70 in excellent health

A
  • Higher threshold for biopsy (>10 ng/mL)

- Stop screening if PSA <3ng/mL

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110
Q

Important AEs:

Apalutamide

A

rash, hypothryoidism, falls/fractures, seizures, CV

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111
Q

Important AEs:

Ketoconazole

A

Decreased androgen, glucocorticoid and mineralocorticoid synthesis
Hepatotoxicity, N/V

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112
Q

Important AEs:

Docetaxel, Cabazitaxel

A

BM suppression, neutropenia

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113
Q

How do tumor look on multiparametric MRI?
T1/T2?
DWI?
DCE?

A
  • T1 + T2: Water content – tumors are water poor/dark on T2
  • Diffusion‐weighted images (DWI): Water diffusion – tumors are dense/dark
  • Dynamic contrast enhanced images (DCE): Contrast flow – vascularity, tumors are bright
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114
Q

Important AEs:

Zoledronic Acid, Denosumab

A

Osteonecrosis of the jaw

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115
Q

PROMIS Trial

A
  • 576 Men
    • MRI, TRUS‐bx and Saturation transperineal bx
    • Avoid 27% of the biopsies if negative MRI
    • MRI guidance ‐ found 18% more cases of significant cancers
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116
Q

Important AEs:

Olaparib

A

Anemia, fatigue, anorexia, diarrhea, cough, dyspnea, thrombocytopenia, AKI

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117
Q

Definition:

Castration

A

Bilateral Orchiectomy
LHRH Agonist
GnRH Antagonist

Goal Testosterone <50 ng/dL

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118
Q

Definition:

Biochemical Recurrence after RP

A

Undetectable PSA after surgery –> 2+ increases above threshold 0.2 ng/dL

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119
Q

PRECISION trial

A
  • 500 men randomized to MRI vs. standard biopsy

Clinically Significant Cancer (GS ≥ 3+4): More found in MRI targeted group

Clinically Indolent Cancer: More found in standard biopsy group

28% in MRI group could avoid a biopsy

120
Q

Definition:

Biochemical Recurrence after RT

A

PSA increase by >= 2ng/mL above nadir

121
Q

Treatment Options:

M1 CSPC

A 
ADT + 
Abiraterone/prednisone
Docetaxel (high volume)
Apalutamide
Enzalutamide
EBRT (low volume)
122
Q

Treatment Options:

M1 CRPC

A 
ADT+
Abiraterone/prednisone
Docetaxel
Enzalutamide
Radium 223
Mitoxantrone
Sipuleucel T
Pembrolizumab
123
Q

Treatment Options:

M0 CRPC

A

Ensure castrate levels of testosterone
If PSADT >10m (long): may be able to monitor
If PSADT <10m (short): Enzalutamide, apalutamide, darolutamide

124
Q

AUA vs. NCCN Risk Stratification Table

A
125
Q

Prostate Cancer Staging

A
126
Q

SPCG-4 Trial

A
  • Swedish trial, mostly healthy younger patients with intermediate or higher risk disease, followed for 23 years
  • Surgery (RP) vs. watchful waiting
  • Improved overall and disease specific survival in RP group compared to observation
127
Q

PIVOT Trial

A
  • Mixed risk disease, older sicker VA patients
  • Underpowered*
  • Surgery (RP) vs. watchful waiting
  • No survival advantage in surgery group
  • BUT surgery reduced the risk of metastases (p=0.0001) among men with Gleason score ≥ 7 tumors
128
Q

CHAARTED Trial

A

M1 CSPC

ADT + Docetaxel

  • 790 men with mHSPC randomized to ADT +/‐ docetaxel
  • Improved OS (57.6 mo vs 44 mo)
  • Improved PFS and rate of PSA <0.2
  • Significant improvement in high‐volume disease
  • At long term follow up, even greater OS benefit, especially in high volume disease
129
Q

STAMPEDE Trial

A

M1 CSPC

ADT + Docetaxel

  • Long term follow up
  • Improved OS (43.1 mo vs 59.1 mo)
  • No difference in low vs high volume disease

ADT + Abiraterone
-37% relative improvement in survival (HR 0.63) at 40 month follow up

ADT + Prostate EBRT

  • 2061 men randomized to ADT v ADT plus EBRT to primary tumor
  • Median OS 48m (EBRT) vs 46m (control)
  • In all pts: HR 0.92, p 0.266
  • In low met burden: HR 0.68, p 0.007
130
Q

PROTECT Trial

A
  • Mostly low risk disease
  • Surgery (RP) vs. Radiation (RT) vs. Active Surveillance (AS)
  • No differences in overall or disease specific survival between groups
    ‐ RP and RT were better than AS for Clinical progression (p<0.001) and Metastatic disease (p=0.004)
131
Q

LATITUDE Trial

A

M1 CSPC

  • 1199 patients receive ADT +/‐ abiraterone acetate + prednisone
    • 50% symptomatic at baseline
  • Needed 2of 3 high risk features (Gleason >=8, >=3 bone lesions, visceral mets)
  • Improved OS and radiographic PFS
132
Q

ENZAMET Trial

A

M1 CSPC

ADT + Enzalutamide

  • Compared ADT + enzalutamide with standard of care (ADT+ bicalutamide, nilutamide, flutamide, docetaxel)
  • Improved OS (HR 0.67)
  • More AEs in enzalutamide group
133
Q

TITAN Trial

A

M1 CSPC

ADT + Apalutamide
-HR 0.67

134
Q

Adjuvant vs. salvage XRT after RP

A 
Adjuvant
• pT3 pathology
• Positive margin
• No BCR
• Consider genomic testing

Salvage
• PSA recurrence
• Low pretreatment PSA and long PSADT better
• Give with ADT

135
Q

Trials: Salvage RT + ADT

A 
GETUG 16
• 743 Patients with PSA failure after RP
– PSA between 0.2 and 2 ng/mL
• RT vs RT plus 6 months ADT 
• Improved progression free survival

RTOG 9601
• 760 Men with PSA failure after RP
• RT vs RT plus bicalutamide
• Improved overall survival

136
Q

Biochemical Recurrence after Prostatectomy

A
  • Undetectable PSA after surgery with a subsequent increases on
    2 or more determinations above threshold of 0.2 ng/mL
137
Q

Biochemical Recurrence after RT Treatment

A

– RTOG‐ASTRO Phoenix Consensus: PSA increase by > 2 ng/mL
above the nadir
– Consider earlier evaluation in candidates for salvage local
therapy (young, healthy)

138
Q

Definition: CRPC

A

Testosterone <50 ng/dL AND

New radiographic or clinical mets on ADT OR
PSA greater than 2ng/mL and rising

139
Q

SPARTAN Trial

A

M0 CRPC
PSADT <= 10m

ADT + Apalutamide (vs. ADT + placebo)
-Improved MFS (40.5 mo vs 16.2 mo)

140
Q

PROSPER Trial

A

M0 CRPC
PSADT <= 10 mo

ADT + Enzalutamide (vs ADT + placebo)
-Improved MFS (36.6 mo vs 14.7 mo)

141
Q

M1 CRPC ADT + Abiraterone Trials

A

• COU‐AA‐301 – ADT + Abiraterone
– Prior docetaxel

• COU‐AA‐302 – ADT + Abiraterone
– No prior docetaxel/chemotherapy naive

Addition of abiraterone: time to PSA progression and progression free survival both better in Abiraterone groups

142
Q

M1 CRPC ADT + Enzalutamide Trials

A

AFFIRM – ADT + Enzalutamide
– Prior docetaxel

• PREVAIL – ADT + Enzalutamide
– No prior docetaxel/chemotherapy naive

Addition of enzalutamide better for overall survival

143
Q

Chemotherapy Drugs for M1 CRPC

A
  • Docetaxel (TAX 327, SWOG 9916): OS improved
  • Cabazitaxel (TROPIC, FIRSTANA) - FDA approved after Docetaxel, OS improved

• Mitoxantrone (CALGB 9182)
– Currently limited role in mCRPC

144
Q

ARAMIS Trial

A

M0 CRPC
PSADT <= 10 mo

ADT + Darolutamide (vs ADT + placebo)
-Improved MFS (40.4 mo vs 18.4 mo)

145
Q

IMPACT Trial

A

M1 CRPC Immunotherapy with Sipuleucel-T

  • Improved OS
  • No difference in PFS
  • No PSA decline
146
Q

PROFOUND Trial

A

PARP Inhibitor: Olaparib
mCRPC
– Patient who progressed on enzalutamide or abiraterone
– >/= 1 homologous recomb. repair gene mutated

Improved PFS and OS

SE: anemia, fatigue, anorexia, diarrhea, cough, dyspnea, thrombocytopenia, AKI

147
Q

TRITON2 Trial

A

PARP Inhibitor: Rucaparib

Phase 2 trial, mCRPC
>/=1 somatic or germline mutation
– Progressed on prior AR‐therapy and taxane

Most notable response rates (ORR/PSA) for BRCA1/BRCA2 mutations
• Accelerated FDA approval

148
Q

What the RECOMMENDATION for PSA screening < 40 yo?

A

GUIDELINE STATEMENT 1

Do NOT
Low prevalence of CaP, no evidence of screening benefit

149
Q

For ages 40-54 what RECOMMENDATIONS for PSA for CaP screening?

A

GUIDELINE STATEMENT 2

Do NOT perform

*not studied sufficiently in PLCO and ERSPC trials

UNLESS shared decision making d/ higher risk:

  1. AA race
  2. Family hx of metastatic/lethal adenocarcinoma(prostate, male/female beast cancer, ovarian, pancreatic) spanning multiple generations, multiple first degree relatives at young ages
150
Q

What does the panel RECOMMENDED for PSA screening for ages 55-69?

A

GUIDELINE STATEMENT 3

Shared decision making to proceed

Multiple approaches subsequent to PSA to determine need for second biopsy (no proof of utility as primary screening tests)

**urine, serum biomarkers, imaging, risk calculators to help detect men harboring CaP

151
Q

What does the panel offer and OPTION for PSA screening frequency?

A

GUIDELINE STATMENT 4

To reduce harms, interval q 2 years or more may be preferred over annually (can be individualized by baseline PSA)

Goteborg data→rescreening every 4 years not likely to miss curable CaP among men PSA < 1.0

152
Q

What are the risks of prostate cancer screening?

A
  1. Psychological
  2. Hematuria
  3. Hematochezia
  4. Hematospermia
  5. Dysuria
  6. Retention
  7. Pain
  8. Infection
  9. Over-diagnosis
  10. Over treatment
  11. Transient ED
153
Q

Describe some elements included in SDM for PSA screening for CaP?

A
  1. Putative mortality benefit of screening (overall 3% risk of dying)
  2. Description of options after abnormal PSA
  3. Likelihood of FP and FN (no screening test perfect, can be elevated for many reasons, PLCO trial annual screening no advantage over biannual in regards to mortality)
  4. Description of subsequent tests needed
  5. Harms of screening (additional procedures, hospitalizations, sepsis)
  6. Information about prostate gland anatomy an function
  7. CaP incident and mortality
  8. Treatment options for early and late CaP
  9. Complications of treatment options
154
Q

Current AUA guidelines recommend which abx for prostate biopsy?

A

1 dose of either FQ OR 1st/2nd Gen Cephalosporin +/- Aminoglycoside OR 3rd Gen Cephalosporin

Aztreonam (if resistance)

Local antibiogram

Rectal swab can be considered (hx of resistance, travel, FQ in past 6 mo, healthcare worker)

155
Q

List the grade groups for CaP:

A
  1. Grade Group 1: Gleason 3+3
  2. Grade Group 2: Gleason 3+4
  3. Grade Group 3: Gleason 4+3
  4. Grade Group 4: Gleason 8 (4+4, 3+5, 5+3)
  5. Grade Group 5: Gleason 9-10 (4+5, 5+4, 5+5)
156
Q

Prostate cancer T1 staging

A

T1a → <5% of tissue removed, incidental during unrelated sx

T1b → >5% of tissue removed, incidental during unrelated sx

T1c → cancer found on biopsy, usually related to elevated PSA

157
Q

Prostate cancer T2 staging

A

T2 → prostate cancer completely inside gland

T2a → in only < 50% of one lobe

T2b → in > 50% of one lobe

T2c → cancer in both lobes

158
Q

Prostate cancer T3 staging

A

T3 → cancer broken through capsule

T3a → broken through capsule

T3b → spread to SV

159
Q

Prostate cancer T4 staging

A

T4 → spread to other organs nearby (rectum, bladder, levator muscles, pelvic wall)

160
Q

CaP Risk Stratification → Low Risk

A
161
Q

CaP Risk Stratification → Intermediate Risk

A
162
Q

CaP Risk Stratification → High Risk

A
163
Q

At CaP diagnosis, it is a STRONG RECOMMENDATION to utilize SDM, incorporating these key elements:

A

GUIDELINE STATEMENT 1 (CLINICALLY LOCALIZED CAP)

  1. Risk category
  2. Patient values and preferences
  3. Life expectancy
  4. Pre-treatment General functional and GU sxs
  5. Expected post-treatment functional status
  6. Potential for salvage tx
164
Q

EXPERTS suggest importance of counseling in regards to what factors at the time of CL CaP Dx?

A

GUIDELINE STATEMENT 2

Modifiable Health-Related Risk Factors

Smoking

Obesity

(Also consider frailty)

165
Q

Clinicians are RECOMMENDED to encourage patients to meet with whom at time of dx of CaP?

A

GUIDELINE STATEMENT 3

Different prostate cancer specialists

Urology

Radiation Oncology

Med Oncology

166
Q

Effective SDM at time of CaP dx requires clinicians to inform patients of what to make proper treatment decisions?

A

GUIDELINE STATEMENT 4

Immediate and LT morbidity or side effects of proposed treatment decisions

Active surveillance: preserves QOL until Surgery/XRT necessary, declines in urinary, bowel, sexual function over time with age, anxiety

Sx: (immediate) bleeding, infection, pain, (longer term) ED, UI, stricture, bowel problems, death (<0.1%)

XRT: (immediate) urinary irritation, bowel irrigation, GI effects (longer term) UI, ED, secondary cancer, radiation cystitis

167
Q

Experts suggest clinicians SHOULD inform patients to participate in what additional measure at time of CaP?

A

GUIDELINE STATEMENT 5

Clinical trials (based on eligibility and access)

168
Q

At time of dx for low risk or very low risk CL CAP, what imaging is RECOMMENDED?

A

GUIDELINE STATEMENT 6

Clinician should NOT perform CT A/P or Bone scans

(no evidence to support need for staging)

169
Q

Clinicians should RECOMMEND which initial tx for very-low risk CL CaP?

A

GUIDELINE STATEMENT 7

Active Surveillance

(limited or no metastatic potential, major risk serial bx → at 3-5 year intervals after confirmatory bx)

Reminder:

  1. PSA <10
  2. GG1 (Gl 6)
  3. T1-T2a
  4. <34% biopsy cores positive
  5. no core >50% involved
  6. PSA density <0.15
170
Q

Clinicians should RECOMMEND which initial tx for low risk CL CaP?

A

GUIDELINE STATEMENT 8

Active surveillance as preferable care option

(regardless of life expectancy)

**Higher volume disease >50% of cores positive or larger lesions on MRI, while still low risk, may benefit from tx

Reminder:

  1. PSA < 10
  2. Grade Group 1
  3. T1-T2a
171
Q

Clinicians should RECOMMEND which initial tx for select low risk CL CaP?

A

GUIDELINE STATEMENT 9

Definitive tx RP or XRT

High probability of progression on AS (PIVOT, ProtecT→small reduction in progression)

Clinical Predictors:

PSA denisty >0.15 (2x risk)

Obesity (3 x risk)

AA race

extensive Gl 6 on systematic cores

FHx of aggressive CaP or early mets

172
Q

If a patient chooses RT for low-risk CL CAP, what is RECOMMENDATION regarding ADT?

A

GUIDELINE STATEMENT 10

NO ADT with RT

**Exception → reducing size prostate for brachytherapy

173
Q

If a patient is considering whole gland cryotherapy for low-risk CL CAP, what is RECOMMENDED counseling?

A

GUIDELINE STATEMENT 11

A/E are considerable: ED, UI, LUTs, bowel sxs, AUR, urethral sloughing

Survival benefit not shown when compared to AS

174
Q

If a patient is considering focal therapy of HIFU for low-risk CL CAP, what is RECOMMENDED counseling?

A

GUIDELINE STATMENT 12

These intervention are NOT the standard of care

*Fails to improve survival outcomes or provide comparable QOL, insufficient data to support

175
Q

Clinicians should RECOMMEND which initial tx for low risk CL CaP with life expectancy < 5 years?

A

GUIDELINE STATEMENT 13

Watchful waiting/observation

Palliative, non-aggressive intent→no bx

176
Q

What is EXPERT consensus for patients with low risk CL CaP considering AS in regards to tissue based genomic biomarkers ?

A

GUIDELINE STATEMENT 14

Have not shown a clear role in selection of candidates for AS

3 approved by FDA:

  1. Genomic Classifier (GC)–22 marker based on RNA → high score on bx associated with increased risk of mets
  2. Genomic Prostate Score (GPS)–12 cancer genes, 20 point increase associated with SS increase HG or non-organ confined dz
  3. Cell Cycle Progression (CCP)–31 cell cycle genes–increased denotes HR disease
177
Q

At time of dx for UNFAVORABLE intermediate risk CL CAP, what imaging is should be considered by EXPERT OPINION?

A

GUIDELINE STATMENT 15

CT A/P or MRI prostate or pelvis and Bone Scan (18F NaFl PET/CT or PMSA considered but not standard in US)

Baseline staging if 2 or more: palpable nodule on DRE (stage T2b/c), Gl 7, or PSA >10

Reminder:

  1. PSA 10-20 OR
  2. GG 2-3 OR
  3. T2b-c
    1. Favorable GG1 (with PSA 10 - <20) or GG2 (with PSA <10)
    2. Unfavorable: GG2 (either PSA 10 - <20) or T2b-c OR GG3 (PSA < 20)
178
Q

At time of dx for intermediate risk CL CAP, what tx is RECOMMENDED?

A

GUIDELINE STATEMENT 16

RP or XRT+ADT

179
Q

Patient with FAVORABLE intermediate risk CL CAP, what counseling is RECOMMENDED regarding RT and ADT?

A

GUIDELINE 17

Can be tx with RT alone, but less evidence than in combination with ADT

Unfavorable should especially be considered for ADT

Reminder:

  1. PSA 10-20 OR
  2. GG 2-3 OR
  3. T2b-c
    1. Favorable GG1 (with PSA 10 - <20) or GG2 (with PSA <10)
    2. Unfavorable: GG2 (either PSA 10 - <20) or T2b-c OR GG3 (PSA < 20)
180
Q

Patients with intermediate risk CL CAP, what other tx options can be considered besides RP or RT?

A

GUIDELINE 18, 19, 20, 21

MAY consider Cryosurgery (limited to 1 RCT) → whole gland may be appropriate if contraindications to RP or RT

MAY offer AS → favorable int risk CL→ inform higher risk mets compared to definitive tx (benefit MRI + target bx)

Watchful waiting < 5 years life expectancy (no AS, no overall improvement in life expectancy with intervention)

HIFU → not the standard options because comparative evidence lacking

181
Q

At time of dx for high risk CL CAP, what imaging is A CLINICAL PRINCIPAL?

A

GUIDELINE STATEMENT 22

CT/MRI and Bone Scan

Reminder:

  1. PSA >20 OR
  2. GG 4-5 OR
  3. _>_T3
182
Q

Clinicians should RECOMMEND which initial tx options for high risk CL CaP?

A

GUIDELINE STATEMENT 23

RP or RT + ADT

GUIDELINE STATMENT 24, 25, 26

should NOT recommend AS

Watchful waiting only if asx < 5 life expectancy

NO cryotherapy or HIFU (outside clinical trial)

NO primary ADT (unless limited life expectancy and local sxs)

183
Q

In addition to treatment, what do EXPERTS suggest for high-risk CL CaP at time of dx?

A

GUIDELINE STATEMENT 27

consider referral for genetic counseling for patient and families

when high risk and strong fhx of specific cancers (breast, ovarian, pancreatic, GI tumors, lymphoma)

*Germline DNA repair mutations

184
Q

Describe AS CLINICAL PRICIPALS AND RECOMMENDATIONS:

A

GUIDELINE STATEMENT 28

CL CaP pts who elect AS should have accurate disease staging including systematic bx with US or MRI

(10-12 core with some targeted per DRE or MRI)

GUIDELINE STATEMENT 29

Routine PSA and DRE

optimal schedule not est, but ProtecT suggests q 3 mo x year 1, q3-6 subsequently

GUIDELINE STATEMENT 30

Confirmatory bx within initial 2 years and surveillance bx thereafter (some protocols recommend repeat bx before committing to AS or w/in 6 mo)

GUIDELINE STATEMENT 31

Consider MP Prostate MRI as part of AS (improve retention by reducing need for bx)

GUIDELINE STATEMENT 32

Tissue based genomic markers have NOT shown clear role in AS and are not necessary for f/up

*(ex. Prolaris, Oncotype Dx, Decipher Score)

GUIDELINE STATEMENT 33

Offer definitive tx when develop adverse reclassification (growth, rises in psa, changes in density, upstaging)

*PIVOT and ProtecT, 20% and 50% pts on AS received definitive tx by 10 years

185
Q

What is RECOMMENDED that clinicians inform patient’s about outcomes, preparation, and types of RP for CL CaP?

A

GUIDELINE STATEMENT 34

Younger or healthier men are more likely to experience cancer control from RP than older men

*<65 yo or >10 year life expectancy

GUIDELINE STATEMENT 35

Open and RALP offer similar cancer control, continence, and sexual recovery

GUIDELINE STATEMENT 36

RALP or perineal techniques are associated with less blood loss than RRP

GUIDELINE STATEMENT 37

Nerve-spring is associated with better EF (50-95% erections)

GUIDELINE STATEMENT 38

NOT tx with neoadjuvant ADT or other systemic tx (outside clinical trial)

GUIDELINE STATEMENT 39

Older men experience higher rates of permanent ED and PPI compared to younger men

186
Q

What do EXPERTS suggest for CL CaP undergoing RP in regards to PLND?

A

GUIDELINE STATEMENT 40

Consider for any

RECOMMENDED for unfavorable intermediate and high risk

Counsel for complications (i.e. lymphocele→ 0.4-16 % incidence, drain +/- sclerosis, occasional MIS marsupialization)

187
Q

What is RECOMMENDED for adjuvant ADT after RP?

A

GUIDELINE STATEMENT 41

unfavorable intermediate and high risk advised of r/b/a of adjuvant ADT when locally extensive CaP found during sx

188
Q

What types of RT are RECOMMENDED for low risk CL CAP?

A

GUIDELINE STATEMENT 42

EBRT OR brachytherapy

189
Q

What types of RT are RECOMMENDED for favorable intermediate risk CL CAP?

A

GUIDELINE STATEMENT 43

EBRT or brachytherapy ALONE or in combination +/- ADT

Reminder:

  1. PSA 10-20 OR
  2. GG 2-3 OR
  3. T2b-c
    1. Favorable GG1 (with PSA 10 - <20) or GG2 (with PSA <10)
    2. Unfavorable: GG2 (either PSA 10 - <20) or T2b-c OR GG3 (PSA < 20)
190
Q

What protocol of RT and tx are RECOMMENDED for high risk CL CAP? What are a/e?

A

GUIDELINE STATEMENT 44

24-36 mo of ADT in adjunct to EBRT alone or EBRT + brachytherapy

GUIDELINE STATEMENT 45

use of ADT with RT increases a/e on EF and systemic a/e (hot flashes, dec bone mineral density, gynecomastia, depression, fatigue, and weight gain)

191
Q

What type of EBRT is RECOMMENDED for any risk category of CL CaP?

A

GUIDELINE STATEMENT 46

consider moderate hypofractionation (without nodal therapy)

GUIDELINE STATEMENT 48

Proton beam therapy offers no clinical advantage over other forms of therapy

192
Q

For CL CaP patient with obstructive LUTS which is RECOMMENDED in regards to treatment?

A

GUIDELINE STATEMENT 47

Surgical approaches

Discourage with volume >60 g

If RT for these patient or they have had previous large TURP, low dose brachytherapy should be discouraged

GUIDELINE 49

Brachytherapy has similar effects as EBRT with regard to EF and proctitis, BUT can exacerbate obstructive sxs

193
Q

When is whole gland cryosurgery a possibility for treatment per EXPERT opinion? What should patients be informed in regards to this treatment and a/e?

A

GUIDELINE STATEMENT 50

Low- and intermediate risk CL CaP when RP or RT d/ comorbidities is not possible but > 10 years life expectancy

(max recommended 60 g)

GUIDELINE STATEMENT 51

Cryosurgery has similar PFS as non-dose escalated EBRT + ADTin low- and intermediate-risk dz

Conclusive comparison of mortality lacking

GUIDELINE STATEMENT 52

TURP defects are relative contraindication d/t increased risk of urethral sloughing

GUIDELINE STATEMENT 53

Utilize a 3rd or higher generation, argon-based system (double freeze-thaw cycle)

GUIDELINE STATEMENT 54

Unclear +/- ADT improves cancer control, can reduce prostate size to facilitate tx

(>40g, consider 3-6 mo of ADT)

GUIDELINE 55

ED is expected

GUIDELINE 56

A/E include UI, irritative, and obstructive urinary sxs (sloughing, fistula, bowel effects)

194
Q

What should clinician inform patient with CL CaP considering focal therapy or HIFU?

A

GUIDELINE STATEMENT 57

these tx options lack evidence of efficacy

GUIDELINE STATEMENT 58

approved by FDA for destruction of prostate tissue, not explicitly for CaP

GUIDELINE STATEMENT 59

tumor location may influence oncologic outcome (apex avoided for morbidity risks cancer persistence)

GUIDELINE STATEMENT 60

CaP is often multifocal, focal therapy may not be curative and further tx needed

195
Q

What should clinicians inform patients regarding long term secondary effects of RP, cryotherapy, and RT?

A

GUIDELINE STATEMENT 61

ED occurs, lacking ejaculate, preserved orgasm (no sexual dysfunction with observation)

GUIDELINE STATEMENT 62

Long term obstructive or irritative sxs for AS, RT whereas RP can relieve LUTs

GUIDELINE STATEMENT 63

Whole gland cryotherapy associated with worse sexual side effects and similar urinary/bowel a/e as RT

GUIDELINE STATEMENT 64

PPI occurs in most patients and persists long-term in small but significant subset (more than AS or RT)

GUIDELINE STATEMENT 65

Temporary proctitis s/p RT persists in some patient in LT (rare in AS or RP)

196
Q

What is RECOMMENDED for follow up for CL CaP?

A

GUIDELINE STATEMENT 66

PSA (even though all PSA recurrences are not associated with mets or mortality)

RP < 0.02

RT + ADT nadir PSA < 2 with T recovered (if ADT)

recommended for at least 10 years

197
Q

What can be used to inform patients of individualized post-treatment prostate cancer recurrence?

A

GUIDELINE STATEMENT 67

Nomograms taking in to consideration:

tumor grade and stage

race

fhx

age

pathologic stage

etc

+/- genomic testing

198
Q

What would you tell a patient are the benefits of PSA screening as expressed in the number of deaths averted per 1000 men from a key RCT? What study is this? What study refutes this?

A

ERSPC (European Randomized Study of Screening for Prostate Cancer): 1 death fewer per 1000

**RRR of CSM 21% at median f/up of 11 years

PLCO (Prostate, Lung, Colorectal, and Ovarian): NO benefit

199
Q

What are FP and FN in regards to CaP screening?

A

FP (false positive): elevated PSA with neg bx

FN (false neg): cancer present without elevation in PSA

200
Q

Potential harms associated with PSA screening?

A
  1. Over Diagnosis: ERSPC 66%, SEER 23-43%
  2. Hematuria/hematospermia: ERSPC 20-50%
  3. Fever: ERSPC 3.5-4.2%
  4. Psychological
  5. Sepsis: 4%
  6. Pain (pain, fever, bleeding, infection, problems urinating 30%)
201
Q

Discuss possible patient factors that may trigger prostate biopsy being performed?

A
  1. PSA > 3, ERSPC
  2. Prostate volume
  3. Inflammation (no benefit of abx in asx man)
  4. Age (55-69)
202
Q

What does the panel RECOMMEND for PSA screening > 70 years old or any man with < 10-15 year life expectancy?

A

GUIDELINE STATEMENT 5

NO screening

If so, increase threshold to PSA > 10 (PIVOT study)

Discontinue if PSA < 3

203
Q

DDX of elevated PSA (asx)

A

BPH

UTI

Prostatits

Prostate cancer

204
Q

Describe some key features of mpMRI prostate?

A

Key Points

Optimal scanning technique should utilize 3.0T surface coil; an endorectal coil may be necessary for older 1.5T scanners

T2→dark lesion concerning for cancer

DWI (diffusion weighted)→bright lesion corresponding T2 lesion

DCE (dynamic contrast enhanced imaging)→early enhancement with early washout corresponding to T2 lesion

ADC (apparent diffusion coefficient)→dark corresponding to T2 lesion

Identification and reporting of putative tumors uses anatomic and functional images.

The radiographic report should identify up to 4 suspicious lesions with each individual lesion reported and characterized using PI-RAD v2 criteria.

205
Q

Stratified by PiRADS score, what is correlation to all tumor and Gl_>_7 detection?

A

All tumor detection:

PI-RADSv2: 2→0-22%, 3→10-16%, 4→30-77% and 5→78-89%

Gleason _>_7

PI-RADSv2: 2→5-6%, 3→0-14%, 4→21-78% and 5→75-100%

206
Q

Can you use mp MRI in biopsy naïve patients?

A

Two randomized clinical trials (PROMIS, PIVOT, MRI-FIRST)have provided level 1 data to support use mpMRI prior to biopsy for ALL men

mpMRI-targeted prostate bx in naive patients detects more clinically significant CaP when combined with systematic biopsy (less clinically insignificant CaP, than systematic biopsy alone), but must combine systematic due to risk of missing some clinically significant cancer with targeted alone

207
Q

How do FQ work? What are a/e?

A

Inhibit DNA gyrase

A/E include allergic reaction, tendonitis, and tendon rupture, exacerbation of muscle weakness in pts with MG

208
Q

What is important for template of systematic biopsy?

A

Incorporation of templates that adequately sample apex, anterior apex, far-lateral region, including base and midgland (little benefit of TZ)

Size important

209
Q

Describe risks of RP?

A

invasive, anesthesia, recovery and time off, limitation of activity post-op, risk death (<0.1%), hemorrhage (<5%), infection, positioning injury (fibular and ulnar nerves), injury to rectum (1%), bladder/bladder neck contracture (<5%), damage to obturator nerves and iliac vessels

Risks of positive margins (up to 20%), need for adjuvant tx (RT +/- ADT)

210
Q

What are risks of RT for CaP?

A

higher risk of bladder/bowel dysfunction→acutely (50%) → LT (5%) (brachy>EBRT), no pathologic specimen, PSA is not a great marker, fatigue, impotence, incontinence (longer term)

211
Q

Key element to account for when describing the start RP?

A
  1. Pre-operative abx
    1. (Ancef, Gent + Flagyl, Aztreonam +Flagyl, Gent+ Clinda, Aztreonam + Clinda)
  2. Mechanical and Chemical DVT ppx
  3. Positioning to pad pressure points (ulnar/fibular nerves)
  4. RALP→supine arm tucking
  5. Access Veress or Hasson (drop test, check opening pressure with gas, use visual obturator)
212
Q

Describe standard steps of RALP?

A
  1. After positioning and access
  2. Enter space of Retzius (drop bladder)
  3. Isolate and ligate the DVC
  4. Separate bladder and prostate
  5. Athermal dissection of SV and Vas
  6. Blunt and athermal dissection of posterior plane between rectum
  7. Antegrade nerve sparing
  8. Preservation of urethral length
  9. Vesico-urethral anastomosis (test anastomosis)
  10. PLND
213
Q

Describe PLND with RALP?

A
  • A standard PLND from the external iliac vein down to the internal iliac artery (including tissue within the obturator fossa), pelvic sidewall laterally, proximally up to the bifurcation of the common iliac artery, and distally to Cooper’s ligament.
  • Definitions of extended and super extended lymph node dissection have been introduced. Their role is currently under investigation.
    • Extended LND: External iliac, obturator fossa, hypogastric/internal iliacs, common iliac below the point where the ureter crosses.
    • Super extended LND: Above, plus pre-sacral lymph nodes and entire common iliac below the aortic bifurcation.
214
Q

Ddx of bradycardia and hypotension during RALP? Next steps?

A
  1. Cardiac events
  2. Air embolus
  3. Vagal response to pneumo

*Check for injury if port in place

*Desufflate to release intra-abdominal pressure

*Auscultate for cogwheel murmur (air embolus)

215
Q

What do you do if you lose control of DVC during RALP?

A
  1. suction judiciously to keep up pneumo
  2. turn pneumo to 20 mmHg (if pt can tolerate)
  3. pack with sponge/raytec, lap → needle drivers → ligate, stitch
216
Q

Describe intraoperative iatrogenic injuries during RALP and mgmt.?

A
  1. Rectal injury
    1. Sharp < 1.5 cm → close primarily, leave drain, advance diet slowly
    2. If RT/salvage → colorectal consult (diversion with colostomy)
    3. Thermal injury → debride injury prior to closing
    4. Large size → consider colostomy
  2. Nerve transection
    1. Intraoperative repair of obturator nerve (can ask for NSG-prob unavailable)
    2. Robotic magnification or loupes, close perineural tissue in one later interrupted 6-0 Prolene non-absorbable monofilament (tension free)
  3. Secondary hole (button hole) bladder
    1. When dissecting posterior BN off prostate
    2. Inspect BN for damage to UOs (can insert 5 Fr caths)
    3. Leave drain, cystogram before foley removal
217
Q

Post RALP patient severe pain and decreased UOP, next steps? DDx?

A
  1. Examine patient, vitals, abdomen, JP output
  2. Labs (CBC, BMP, Trop/CKMB, EKG, JP Cr)
  3. Irrigate foley gently for clot

DDX:

  1. Cardiac event
  2. PE
  3. Hemorrhage
  4. Unrecognized bowel injury
  5. Clogged Foley
218
Q

Post RALP f/up ?

A

Removal of foley/staples

Kegels (help recovery continence)

+/-PDE5I (penile rehab)

Repeat PSA 1 mo

219
Q

What are a/e for PDE5I?

A

All→ flushing, nasal congestion, priapism (theoretical)

Viagra→blue/green visual changes

Cialis→muscle aches

220
Q

What are options for post RALP ED?

A
  1. PDE5I
  2. ICI (a/e priapism, pain, curvature/scarring)
  3. VED (floppy, ecchymosis, pain)
  4. IPP (if failure non-invasive)
221
Q

If 39 yo M comes in for PSA due to fear, no FHX? What do you do?

A

Examine patient, VS

Review prostate screening guidelines (low prevalence, no benefit of screening)

222
Q

Age adjusted PSA trends:

A

40-49 (don’t screen): 0-2.5

50-59: 0-3.5

60-69: 0-4.5

70-79: 0-6.5

Not exhaustive, somewhat from old doctrine, but as a reference

223
Q

Patient with cT2b CaP, PSA 7.8, and lower back pain, what should be considered as part of workup?

A

Bone Scan

224
Q

What are treatment options for favorable intermediate risk CaP?

A
  1. RP + PLND
  2. EBRT + 4-6 mo ADT
  3. EBRT + Brachy with 4-6 mo ADT
  4. Brachy
225
Q

What are potential problems when considering RP as tx option?

A
  1. Advanced age
  2. Previous intra-abdominal or pelvic surgery (trauma-i.e. GSW)
  3. Post-prostatectomy sepsis (impact tissue planes)
226
Q

What are definitions for BCR after RT?

A

ASTRO: 3 consecutive rises in PSA

Pheonix: Nadir + 2

227
Q

A/E of ADT:

A
  1. Body habitus changes→gynecomastia, testicular atrophy, loss of muscle mass, increase in fat
  2. Elevation of lipids and cholesterol
  3. Diabetes
  4. CVD (+/-)
  5. Anemia
  6. Fatigue (common)
  7. Osteoporosis
  8. Sexual dysfunction→decreased libido, ED
  9. Infertility
  10. Hot flashes (common)
228
Q

Define types of Biochemical recurrence (BCR)

A

rising PSA without metastatic disease

After initial therapy OR after exhaustion of local treatment (i.e. salvage RT or salvage RALP/local ablative therapy)

RP: PSA 0.2 and confirmatory 0.2

RT: Pheonix → nadir + 2; Astro → 3 consecutive rises

229
Q

Define metastatic hormone-sensitive prostate cancer

A

not yet treated with ADT or still responsive

absence of clinical progression, radiographic progression or rising PSA of _>_2 above nadir

can occur as recurrence after initial local therapy or de novo mets→at time of initial dx

(distinction important when deciding systemic tx)

Also volume and site important

230
Q

Define castrate resistant prostate cancer:

A

either metastatic→

non-metastatic→PET-CT (small volume better than CT/MRI/bone scans used in past)

patient on ADT

despite castrate levels of androgens (T<50, <20→post orchiectomy), the androgen receptors (AR) remain active and continues to drive CaP progression

PSADT at least 3 values measured > 4 weeks apart or continuous rising PSA (minimal value 2), or new radiographic or clinical progression

231
Q

High volume metastatic CaP vs. low volume

A

CHAARTED study

visceral or bone mets > 4 mets

At least one outside vertebral column and pelvis

low volume is anything less

232
Q

High risk metastatic CaP

A

LATITUDE study

poorer prognosis

Gl_>_8, _>_3 bone lesions, measurable visceral mets

233
Q

In patients with suspicion of advanced prostate cancer and no histologic diagnosis, what is the next step based on CLINICAL PRINCIPLE?

A

GUIDELINE STATEMENT 1

Obtain tissue diagnosis from primary tumor or metastatic site (when feasible)

234
Q

CLINICAL PRINCIPLE would dictate that clinicians discuss treatment options for advanced CaP based on:

A

GUIDELINE STATEMENT 2

life expectancy, comorbidities, preferences, tumor characteristics, and multidisciplinary approach (uro, med onc, palliative, RT)

235
Q

When diagnosing advanced prostate cancer CLINICAL PRINCIPAL states clinicians should encourage what QOL and support measures?

A

GUIDELINE 3

  1. Pain control, manage urinary sxs, a/e, and sexual sxs
  2. Engagement in professional and community based advocacy groups
236
Q

What SHOULD clinicians advise patients with BCR about risks and follow up studies?

A

GUIDELINE STATEMENT 4

risks of metastatic disease

serial PSA and clinical evaluation

consider radiographic assessment based on overall PSA and PSA kinetics

High risk s/p RP: GG4/5 (Gl > 8) or PSADT < 1 year

High risk s/p RT: GG4/5 (Gl > 8) or PSADT < 18 months

*Pts that don’t meet these criteria considered low risk

237
Q

Clinicians SHOULD perform what in patients with BCR who are considered high risk for clinical metastasis?

A

GUIDELINE STATEMENT 5

Perform periodic staging imaging: cross sectional (CT/MRI) and bone scan

GUIDELINE STATEMENT 6

Conventional studies rarely detect mets PSA _<_5

May utilize novel PET-CT (fluciclovine, choline, PMSA) as alternative (greater sensitivity)

Reminder:

High risk s/p RP: GG4/5 (Gl > 8) or PSADT < 1 year

High risk s/p RT: GG4/5 (Gl > 8) or PSADT < 18 months

*Pts that don’t meet these criteria considered low risk

238
Q

In patients with BCR (after failure of local therapy) and no evidence of mets by conventional imaging, clinicians SHOULD offer:

A

GUIDELINE STATEMENT 7

Observation vs. clinical trial

*Jump to systemic therapy does not always yield better outcomes (balance with a/e and QOL)

GUIDELINE 8

ADT should not routinely be initiated

IF it is, intermittent (studies 8 mo treatment cycle) in lieu of continuous

239
Q

In patients with mHSPC, clinicians SHOULD assess the extent of mets where and how?

A

GUIDELINE STATEMENT 9

bone, LN, visceral

Conventional imaging

Aggressive Cancer → D’Amico risk factors

cT3a or greater, GG 4/5, PSA >20

CT/MRI (with consideration of chest) and bone scan

Rapid progression to met dz → high path or bx Gl score, short interval to BCR, short PSADT

PET holds great promise [PSMA, fluciclovine (PSA >1)]

240
Q

In newly dx mHSPC what stratification SHOULD clinicians perform? What also SHOULD be assessed to guide discussions of prognosis and further dz mgmt.?

A

GUIDELINE STATEMENT 10

High volume vs. Low volume

High volume → > 4 bone mets with at least one met outside spine/pelvis and/or presence of visceral mets

*CHAARTED study shows OS benefit for high volume dz of chemohormonal tx

GUIDELINE STATEMENT 11

Assess for symptoms

*bone pain with poorer 10-year survival

241
Q

When initiating ADT in mHSPC, how SHOULD clinicians utilize PSA and imaging?

A

GUIDELINE STATEMENT 12

Baseline PSA, serial PSA at q3-6 mo. intervals after initiation of ADT

consider periodic conventional imaging

*PSA nadir (~6 -7 mo.) important in prognosis and risk stratification (PSA < 4 and < 0.2, important cutoffs regarding OS)

Imaging: esp. for poorly differentiated, ductal, neuroendocrine (often no PSA rise) → sxs → periodic imaging

242
Q

In mHSPC, regardless of FHx or age, clinicians SHOULD offer the following:

A

GUIDELINE STATEMENT 13

genetic counseling and germline testing

GUIDELINE STATEMENT 14

ADT with either LHRH agonists or [antagonists or surgical castration]→avoid “testosterone flare”

GUIDELINE STATEMENT 15

Continued ADT in combo with androgen pathway directed tx (abiraterone + prednisone, apalutamide, enzalutamide) or chemotherapy

GUIDELINE STATEMENT 18

Do NOT offer androgen receptor pathway tx w/out ADT

243
Q

What chemotherapy for mHSPC? What is pharmacologic MOA?

A

Docetaxel → potent inhibitor of microtubule assembly and disassembly

CHAARTED AND STAMPEDE TRIALS

Greater OS and longer median time to progression

*A/E febrile neutropenia, lethargy, asthenia, GI effects

244
Q

What androgen pathway agents are used for mHSPC? What is pharmacologic MOA?

A
  1. Abiraterone Acetate (Zytiga)

→ non-steroidal irreversible inhibitor of CYP17A1 (which catalyzes conversion of C21 progesterone precursors to C19 adrenal androgens, DHEA and androstenedione)

ESSENTIALLY potent inhibition of gonadal and extragonadal androgen synthesis

1000 mg daily (250 mg x 4 at once)

Significantly longer OS and median length of radiographic PFS

A/E → elevate liver enzymes (caution liver failure), mineralocorticoid-related HTN (20%) and hypokalemia (10%)

  1. Apalutamide (Erleada)

→ non-steroidal anti androgen, acts as AR inhibitor that binds directly to t he ligand binding domain of AR (inhibits DNA binding)

240 mg daily

A/E: rash, seizure, GI, weight loss, arthralgia, fatigue, falls

  1. Enzalutamide (Xtandi)

→ novel AR signaling inhibitor, competitive for androgen binding and inhibits translocation of AR, DNA binding, and co-activator recruitment

*PFS significantly reduced + ADT (HR = 0.39)

160 mg daily

A/E: fatigue, seizures

245
Q

In patients with mHSPC, low-volume mets clinicians MAY offer:

A

GUIDELINE STATEMENT 16

primary radiotherapy to prostate + ADT

246
Q

When SHOULD clinicians offer first generation anti-androgens? What are they? What is pharmacologic MOA?

A

GUIDELINE STATEMENT 17

ONLY for blockage of testosterone flare

bicalutamide, flutamide, nilutamide

in combo with ADT for 2-4 weeks

MOA: competes with androgen for AR, blocking the action of androgens of adrenal and testicular origin

247
Q

At what intervals should PSA and conventional imaging be used for nmCRPC?

A

GUIDELINE STATEMENT 19

PSA q3-6 mo. interval, and calculate PSADT at time of development of castrate resistance (PSADT < 10 mo. used to ID highest risk)

GUIDELINE STATEMENT 20

Assess for mets q6-12 mo.

*Exact interval determined by PSADT, sxs, patient/MD preference (< 10 mo.), once on ART could extend intervals to 12 mo.

248
Q

In patients with nmCRPC what denotes high risk of developing mets? What SHOULD patients be offered for tx?

A

GUIDELINE STATEMENT 21

Apalutamide, darolutamide, enzalutamide with continued ADT

high risk patients PSADT < 10 mo

(**Lack of FDA approval of abiraterone + prednisone in men with nmCRPC–some data to support OS and PFS, but insufficient for approval)

249
Q

In patients with nmCRPC AND low risk of developing mets? What SHOULD patients be offered for tx?

A

GUIDELINE STATEMENT 22

observation with continued ADT (PSADT > 10 mo)

GUIDELINE STATEMENT 23

Do NOT offer systemic chemotherapy or immunotherapy (only clinical trial)

250
Q

In patient with newly diagnosed mCRPC, what labs, imaging, and patient specific factors should be done/reviewed? What interval of imaging ongoing?

A

GUIDELINE STATEMENT 24

Baseline labs → PSA, testosterone, LDH, Hgb, ALP

Review CT/MRI and bone scan → location of mets (visceral highest risk)

Disease related sxs and performance status

*Risk factors increased with elevated LDH, T <20-50, higher PSA, shorter PSADT

GUIDELINE STATEMENT 25

Conventional (CT/MRI, bone scan) at least annually or interval determined by lack of response (BCR, sxs)

251
Q

In pts with mCRPC what SHOULD be done to inform prognosis and counsel regarding familial risk and targeted tx?

A

GUIDELINE STATEMENT 26

Germline and somatic tumor genetic testing

→ ID DNA repair deficiency mutation and microsatellite instability status

252
Q

In newly dx mCRPC clinician SHOULD offer the following tx and MAY offer which tx:

A

GUIDELINE STATEMENT 27

continued ADT + abiraterone+ pred, docetaxel, OR enzalutamide

GUIDELINE STATEMENT 28

MAY offer sipuleucel-T in asx or minimally sxs

→ immunotherapy (IMPACT trial RRR death 22%)

→ often does not show reduction PSA or radiologic dz

GUIDELINE STATEMENT 30

In sequencing agents, consider prior tx and new tx with alternate MOA

*possibly abiraterone followed by enzalutamide (suggested in study)

253
Q

What SHOULD clinicians offer to patients with sxs of bony mets from mCRPC AND without known visceral dz or LAN >3 cm?

A

GUIDELINE STATEMENT 29

Radium-223

→ alpha emitting radiopharm capable of inducing ds DNA breakage in cancer cells with little damage to surrounding tissues

→ not usually associated with PSA decline, must assess for occult visceral dz (CT + CXR prior to cycle 4/6 months)

254
Q

In mCRPC pts who received prior docetaxel +/- abiraterone + pred OR enzalutamide, clinician MAY offer:

A

GUIDELINE STATEMENT 31

Cabazitaxel

3 chemotherapies FDA approved:

docetaxel, mitoxantrone (no surv. benefit), and cabazitaxel

GUIDELINE STATEMENT 32

Cabazitaxel OVER other alternative androgen pathway directed tx as third line

255
Q

In patients with deleterious or suspected deleterious germ-line or somatic homologous recombination repair gene-mutated mCRPC AND prior tx with enzalutamide OR abiraterone + pred and/or taxane chemotherapy, clinician SHOULD offer:

A

GUIDELINE STATEMENT 33

PARP inhibitor (Lynparza)

→ leverage defects in DNA repair → cell death

OR

Platinum base chemotherapy (Carboplatin) → (if cannot use/obtain PARP inhib.)

256
Q

In patients with mismatch repair deficient or microsatellite instability high mCRPC, clinicians SHOULD offer:

A

GUIDELINE STATEMENT 34

Pembrolizumab (anti PD-1 → Ketruda)

257
Q

In regards to bone health in advanced CaP, what SHOULD physicians discuss and recommend?

A

GUIDELINE STATEMENT 35

Discuss risk of osteoporosis associated with ADT, assess risk of fx

GUIDELINE STATEMENT 36

Preventative tx for fx: supplemental Ca, Vit D, smoking cessation, weight bearing exercise

GUIDELINE STATEMENT 37

High risk of fx → bisphosphonates or denosumab (Prolia) (dentist-jaw)AND referral to MD who manages osteoporosis (endo, ortho, PCP)

GUIDELINE STATEMENT 38

Should rx bone-protective (denosumab-Prolia or zolendronic acid-Reclast/Zometa) agent for mCRPC with bony mets to prevent SRE

258
Q

Define adjuvant RT:

A

ART (adjuvant) is post RP with higher risk of recurrence because of adverse pathologic features prior to recurrence (i.e. undetectable PSA)

First PSA 2-3 mo

ART usually starts 4-6 mo (after return of acceptable urinary control)

259
Q

Define salvage RT:

A

RT to prostatic bed and surrounding tissues, including LN, in patient with PSA recurrence after sx but no evidence of mets

260
Q

Some outcomes to support ART:

A

SWOG, EORTC, ARO

Reduction in BCR

Locoregional recurrence

Hormone tx free survival

Clinical progression

Metastatic recurrence and OS (unclear benefit–1 of 3 studies suggest yes)

261
Q

What are key NNT for the SWOG, EORTC, and ARO studies in relation to ART?

A

BCR 4.2 (combine SWOG and EORTC)

Local recurrence 9.8

Clinical Progression 13.8

**based on NNT should be offered to all patient at high risk of recurrence

262
Q

Doses of RT for SRT and ART?

A

65 Gy in post RP setting

263
Q

RT toxicity is measured how?

A

Rating system 0 - 5

0 → no change in function

3 → outpt tx

4 → inpt tx

5 → death

Common Toxicity Criteria Adverse Event

264
Q

When counseling a patient for RP, what SHOULD they be counseled regarding the pathologic features and additional tx?

A

GUIDELINE STATEMENT 1

Adverse pathologic features: + margins, SVI, EPE (recurrence >60% @ 5 y)

Advised adjuvant therapy such as RT +/- ADT may be beneficial

265
Q

Adverse pathologic findings on RP, patients SHOULD be advised that RT compared to RP alone reduces what?

A

GUIDELINE STATEMENT 2 and 3

should inform and offer due to reduction in:

BCR, local recurrence, and clinical progression

ART on subsequent mets and OS is less clear (⅓ RCT addressed this, ⅔ did not–were not designed for that)

reduction in salvage tx and associated toxicities

266
Q

PSA recurrence after RP carries what risks? What SHOULD clinicians do to monitor?

A

GUIDELINE STATEMENT 4

higher risk of mets or death

regular PSA monitoring

early admit of salvage tx

[early rise of PSA → more rapid dev of mets < 2 years, PSADT <10 mo, mets w/in 5 years and died approx. 5 years (2-12)]

267
Q

Definition of BCR after RP:

A

GUIDELINE STATEMENT 5

BCR → detectable or rising PSA after sx > 0.2 with second confirmatory > 0.2

Ultrasensitive assays ( > 0.07) → lack of data (but clinician knowledge and patient specific factors)

268
Q

At PSA recurrence, what MAY be considered before tx:

A

GUIDELINE STATEMENT 6

A re-staging evaluation

(low yield bone scan PSA <10)

MRI w/contrast (DCE) → highest and most consistent sens (>70-80%) and spec for detection of local recurrence

LN recurrence → insufficient data, possibly PET

Bones → SPECT, DWE MRI, PET???

269
Q

Pts with PSA or local recurrence after RP with no evidence of distant mets SHOULD be offered which txs and counseling:

A

GUIDELINE STATEMENT 7

SRT

(significant reduction in local recurrent and systemic progression)

GUIDELINE STATEMENT 8

effectiveness for SRT (for PSA recurrence) is greater when given at lower levels of PSA

→ ideally < 1

GUIDELINE STATEMENT 9

+ offer ADT

→ pts s/p RP PSA > 0.2 with no distant mets

270
Q

Patients should be informed of what A/E and clinical benefits for RT:

A

GUIDELINE STATEMENT 10

Short and Long Term urinary, bowel, and sexual

Benefits of controlling dz recurrence

Urinary incontinence (mild worsening after ART/RP or new onset)

ED (few studies, likely worsened, additional salvage tx with ADT increase osteoporosis, CVD, other issues)

Secondary malignancy (little date, confounding i.e. smoking, real risk not known)

271
Q

For EBRT what is moderate and conventional fractionation:

A

Moderate hypofractionation: 240-340 cGy per fraction

Conventionally fractionated 180-200 cGy per fraction

Ultrahypofactionated > 500 cGy per fraction

272
Q

In men with low risk prostate cancer who decline AS, which RT SHOULD be offered?

A

GUIDELINES STATEMENT 1A

EBRT to prosate w/ or w/o SV

Offer moderate hypofractionation

273
Q

In men with intermediate risk prostate cancer RT SHOULD be offered?

A

GUIDELINE STATEMENT 1B

EBRT to prosate w/ or w/o SV

Offer moderate hypofractionation

274
Q

In men with high risk prostate cancer RT SHOULD be offered?

A

GUIDELINE STATEMENT 1C

Prostate, not PLN

Offer moderate hypofractionation

275
Q

Moderate hypofractionation should be offered to whom? What about f/up of studies?

A

GUIDELINE STATEMENT 1D

Offer regardless of patient age, comorbidity, anatomy, and urinary function

→ limited f/up beyond 5 years for most RCTs

276
Q

What should men be counseled about regarding toxicities with moderate hypofractionation?

A

GUIDELINE STATEMENT 1E

small increased risk of acute GI toxicity

similar risk of acute and late GU and GI toxicity compared to conventional

277
Q

What regimen of hypofractionated EBRT SHOULD be delivered? Is one recommended over another based on cancer or patient features?

A

GUIDELINE STATMENT 2A

6000 cGy delivered in 20 fractions of 300 cGy (4 weeks)

7000 cGy delivered in 28 fractions of 250 cGy

GUIDELINE STATEMENT 2B

One moderate hypofractionated regimen is not suggested over another for specific risk group

Efficacy of regimens does not appear to be impacted by age, comorbidity, anatomy, or urinary function

278
Q

In men with CaP describe which men you can consider ultrahypofractionated RT?

A

GUIDELINE STATMENT 3A

Low-risk men who decline AS

GUIDELINE STATEMENT 3B

Intermediate-risk men (strong encouragement to participate in clinical trial or multi-institutional registry)

GUIDELINE STATEMENT 3C

High-risk men NO ultrahypofractionation outside of clinical trial or multi-institutional registry

279
Q

What is ultrahypofractionated RT doses targeted to low and intermediate risk patients? What prostate size?

A

GUIDELINE STATEMENT 4A

3500 - 3625 cGy in 5 fractions of 700 - 725 cGy

Prostate volume < 100 cc

GUIDELINE STATMENT 4B

5 fractions at doses of 3625 c Gy and above is not suggest outside trial or registry due to late toxicity

GUIDELINE STATEMET 4C

5 fraction using consecutive daily treatments is not suggested (late urinary and rectal toxicity)

280
Q

For moderately- or ultra- hypofractionated tissue constraints used in clinical trials for RT compare in terms of toxicity and QOL?

A

GUIDELINE STATEMENT 5A

At least 2 low-dose volume constraint points for rectum and bladder should be used, one at high-dose end (near the total dose prescribed) and one in the mid-dose range (near the midpoint of the total dose)

GUIDELINE STATEMENT 5B

Use of normal tissue constraints differing from published studies is NOT recommended

281
Q

What are other key features of RT with moderate hypofractionation or ultrahypofractionation?

A

GUIDELINE STATEMENT 6A

Not recommended for volume and margin definitions other than those published

GUIDELINE STATEMENT 7A

IGFR is universally recommended

GUIDELINE STATEMENT 8A

Non-modulated 3-D CRT techniques are not recommended

282
Q

What are some worrisome features when considering RALP?

A

Advanced age

Hx of intra-abdominal and pelvic sx (collateral damage for adhesions etc.)

Post biopsy prostatitis/sepsis (impact tissue planes)

283
Q

What should you do for a patient with hx of CaP, severe low back pain, weakness in LE, decreased rectal tone on DRE?

A

Concern mets and cauda equina syndrome

NSG consult

MRI

Possible urgent surgical decompression

284
Q

What is the quickest way to medically castrate a CaP patient?

A

Ketoconazole and Prednisone → inhibits multiple cytochrome p450 enzymes, inhibits production of glucocorticoids and mineralocorticoids, castrate in 8 h

GnRH antagonists → block pituitary receptors, no flares, castrate in days (follow LFTs)

285
Q

What are AUA recs for Abx ppx in patients with previous joint replacement? What is recommended?

A

Must meet both criteria below:

  1. Increased risk of hematogenous total joint infections: 2 years after replacement, immunocompromised (inflammatory arteriopathies, drug induced, radiation), comorbidities (previous joint infections, malnourishment, hemophilia, HIV, DMII, cancer)
  2. Increased risk of bacteremia associated with urologic procedures: stone manipulation, transmural incision into urinary tract, endoscopic procedure of upper tract, including bowel segments, prostate biopsy, high risk of colonization (indwelling or CIC, stent, retention, hx of recurrent UTI, diversion)

Tx:

single Quinolone dose, amp (2 g) + gent (1.5 mg/kg)

286
Q

How does Bactrim (TMP/SMX) work?

A

inhibiting folate in bacterial cells → death

a/e nausea, vomiting, rash, diarrhea, Steven’s Johnson, c. diff

287
Q

How many men avoid treatment because of AS?

A

67%

288
Q

What are predictors of positive response to SRT?

A

Radiation dose and modality

Slow PSADT (< 10 mo)

Low pre-radiation PSA (optimally <0.5)

Low Gleason score

289
Q

Compare SRT to ART?

A

RFS → SRT: 47% ART: 52%

MFS → SRT: 69% ART: 70%

OS → SRT: 72% ART: 73%

*Insufficient data, little long term difference

290
Q

What are the theoretical mechanisms of RT + ADT synergistically?

A
  1. Alter PSA kinetics in patients who eventually relapse
  2. Systemic disease control (micromets might retain sensitivity to ADT)
291
Q

Why can’t you compare observational studies for ART and SRT?

A
  1. Differences in failure definition, follow up duration, RT technique, use of ADT
  2. SRT usually higher dose than ART
  3. ART with more adverse pathology
  4. ART studies include low risk patients w/ or /wo RT, so skews results
292
Q

Patient presents with PSA 20, up from 2.3, 1 mo ago, with hx of RALP, pT3bN1M0? Labs? Imaging?

A

PSA, testosterone, LDH, Hgb, ALP

CT A/P, Bone Scan, F18 PET +/-

293
Q

A/E of Abiraterone

A

Fluid retention

HTN

Hypokalemia

Liver dysfunction

(Monitor: PE (edema) BP, K+, LFTs → AST, ALT, bili q 2 weeks x 3 mo, then monthly)

294
Q

The most common a/e of docetaxel?

A

infections, neutropenia, anemia, febrile neutropenia, hypersensitivity, thrombocytopenia, neuropathy, dysgeusia (taste), dyspnea, constipation, anorexia, nail disorders, fluid retention, asthenia, pain, nausea, diarrhea, vomiting, mucositis, alopecia, fingernail changes

295
Q

.

A

01. Prostate Cancer (1883) (15 decks)

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