Prostate Cancer Flashcards
what is the most common cause of cancer in men in australia
prostate cancer
prostate cancer is the x most common cause of cancer death in men
2nd
prostate cancer average age of diagnosis
69yo
does prostate cancer have a good prognosis?
what is the 5 year survival rate?
- generally good prognosis
- 5 year survival rate of 96%
types of cancer in prostate cancer
- adenocarcinoma (malignant)
- urothelial cancer
- squamous cell carcinoma (malignant)
pathogenesis of prostate cancer
- acquired genetic mutation (like all cancers)
ie/ rate of cell division exceeds rate of cell death
urothelial cancer arises from
urothelial lining of the prostate urethra
(urothelium = lines inside of urinary tract)
risk factors of prostate cancer (4)
- age (older)
- family history of prostate cancer
- genetic mutations( (BRCA2)
- race (african american>caucasian>asian and hispanic)
presentation of early prostate cancer can be ____, usually detected by ____
- asymptomatic
- screening
(2) symptoms of locally advanced prostate cancer
- obstructive or irritative urinary symptoms (eg/ polyuria, dysuria, feelings of incomplete voiding, nocturia)
- blood in urine (haematuria) or semen
(4) symptoms of metastatic prostate cancer
- back or bone pain
- leg swelling
- weight loss
- fatigue
list 3 presentations of prostate cancer
- early prostate cancer
- locally advanced prostate cancer
- metastatic prostate cancer
(4) investigation options regarding prostate cancer
- prostate specific antigen (PSA) - most common
- free-to-total PSA
- MRI
- prostate biopsy
prostate specific antigen (PSA) is used for what
prostate cancer screening
list a consideration for interpretation of PSA levels
- levels go up as people get older - normal ranges change in age grps
speed of level increase in PSA can also be indicative of
prostate cancer
(level increasing quickly)
high or low PSA level indicates prostate cancer
high level
if patient has been referred to a specialist for high PSA, they may also be looking at doing….
MRI
free to total PSA may be done depending on (2) and will provide ___ ____
- age
- PSA level
- extra information
MRI has _____ amount of prostate biopsy done
but can also help to _____ biopsy
- reduced
- plan
from prostate biopsy, can get ____ ____
Gleason Score
what is Gleason Score
- part of prostate cancer workup
- grading system: measure for how aggressive the prostate cancer is
how is Gleason Score calculated
- by looking at the 2 most common populations of cells for how abnormal they look compared to normal prostate tissue
- then they are each scored & added together
Gleason Score - graded from -
1-5
Gleason Score ranking of 1 is
- lowest score
- represents well differentiated cells
Gleason Score ranking of 5 is
- highest score
- represents poorly differentiated cells
Gleason Score of 5 or less is considered
no longer cancer
Gleason Score of 6 and above is considered
prostate cancer
Gleason Score report provides which numbers and why
components of score (2) & total score
- first number: cell group that is most populous
therefore 3 + 4 is better than 4 + 3
treatment approach to prostate cancer - watchful waiting is a ___-________ approach
non-curative
indications for watchful waiting treatment
- low risk prostate cancer
- life expectancy <7years (generally due to other issues with their health)
low risk prostate cancer is a Gleason Score of
6
process of watchful waiting (monitoring method & frequency)
- progress monitored by PSA
- initially 3-4 monthly for 12 months then 6 monthly
treatment prostate cancer thats non-curative and not watchful waiting
active surveillance
indications for active surveillance
low risk prostate cancer
process of active surveillance (coordinated by whom, how is it monitored)
- coordinated by urologist
- combination of PSA testing, DRE, prostate MRI, prostate biopsy
for watchful waiting, what 2 things can occur indicative of __________ that prompt treatment initiation where they referred back to urologist for review and change treatment path
ie/ indicators for progression of disease
- rapid rise PSA level
- new symptoms
evidence of progression of their prostate cancer
rationale of active surveillance
most men with low risk prostate cancers. won’t die from their prostate cancer
curative treatment comes with side effects
this option for people not wanting curative treatment at this time
can be monitored for progression of their disease
indicators of progression of disease for active surveillance
then can change approach when required
(same as watchful waiting)
- rapid rise PSA levels
- onset symptoms
curative treatment of prostate cancer is
surgery - radical prostatectomy
radiotherapy
surgery (radial prostatectomy) is recommended for which presentations of prostate cancer AND also what
- localised or locally advanced prostate cancer
- AND has life expectancy of at least 10 years
complications of surgery (radical prostatectomy)
- erectile dysfunction (ie/ nerve damage)
- urinary incontinence (ie/ nerve damage)
- urethral stricture (scarring that narrows urethra - tube that passes urine out of body)
- change in ejaculation
- infertility (due to disruption in connection to testicles)
different approaches to surgery possible
- open
- laparoscopic
- robot assisted (depending on specialist)
why change in ejaculation from prostate removal surgery
- prostate makes most of ejaculatory fluid
- that fluid not going to be available
2 types radiotherapy for prostate cancer
- external beam radiotherapy
- brachytherapy
indications for external beam radiotherapy
- localised or locally advanced prostate cancer if patient has life expectancy of at least 10 years
- locally advanced disease which may benefit from multimodal therapy
- rising / persistent PSA or established recurrence without metastasis following prostatectomy
- patients with limited bone metastasis (to improve their survival ie/ palliative method)
indications for brachytherapy
- PSA <10
- Gleason Score 6 or 7
- small to moderate size prostate
- low to intermediate grade prostate cancer
- no previous prostate surgery
- normal urine flow
what is external beam radiotherapy
radiotherapy that is shot into patient externally
what is brachytherapy
implant small radioactive seeds into prostate
brachytherapy is ideal for those who
- don’t want to undergo active surveillance
- doesn’t want or not appropriate to have surgery
why need small to moderate size prostate for brachytherapy
seeds should be placed close together
side effect of brachytherapy
con of brachytherapy
- can cause swelling of prostate -> can cause problems voiding
hence need normal urine flow to begin with
con of brachytherapy
hard to know whether it can cure prostate cancer or not
complications of radiotherapy
- fatigue
- urinary frequency
- urinary strictures
- erectile dysfunction
- changes to bowels
- radiation burns (external beam radiotherapy)
treatments for Advanced and Metastatic Disease (2)
- Androgen Deprivation Therapy
- Other Systemic Therapy (eg/ cytotoxic chemotherapy, biphosphonates)
reason behind Androgen Depravation Therapy
- testosterone = major growth factor for prostate cancer
- androgen depravation therapy aims to restrict access to testosterone hence restrict growth of cancer
side effects of Androgen Depravation Therapy
menopause like symptoms
medication for Androgen Depravation Therapy
GnRH agonists (stimulate release GnRH) of GnRH antagonists (block GnRH -> prevent production FSH, LH hence testosterone)
how are GnRH agonists useful for androgen depravation therapy
- stimulate release of GnRH-> initially cause increase in production and release of gonadotrophins (initial surge)
- overtime they lead to downregulation and desensitisation of GnRH receptors -> decrease in gonadotrophin release
increase testosterone briefly; continuous administration ends up inhibiting FSH, LH -> suppress testosterone production
benefits of androgen depravation therapy
- reduce tumour growth
- symptomatic benefit
who helps decide use of Other Systemic Therapy for treatment of advanced and metastatic disease
multidisciplinary team
2 groups recommending prostate cancer screening
- RACGP
- prostate cancer foundation of australia
old biopsy method for prostate screening diagnostics had issues because
- risk of infection due to site where biopsy was taken
prostate cancer screening has been not recommended since harms of screening outweighed benefits from factors such as
- emotional distress from false positive screening tests or false positive biopsies
- complications with biopsy (infection)
- harms (side effects) related to overtreatment (many prostate cancers won’t go on to cause problems)
do RACGP recommend prostate cancer screening
no
what do RACGP suggest
- discussion between patient and their GP regarding risks and benefits of screening
- if patient still wants screening after discussion, PSA is recommended every 2 years
why are DREs not recommended for prostate cancer screening (by both organisations)
- sensitivity not very high
- DRE can elevate some body’s PSA -> false positive result
- distressing for patient
unlike RACGP, prostate cancer foundation of Australia think that prostate cancer screening
should be more widespread
prostate cancer foundation of australia want screening to be _____ by everybody; only………
- discussed
- only for those who are interested in prostate screening after
age range for screening by prostate cancer foundation of australia is from
- risk stratification based on family history
from prostate cancer foundation of australia, screening is not recommended after age ? since
70yo
- risks outweigh benefits
why is screening becoming less frowned upon
as new technologies come in such as prostate MRI, new biopsy (trans-perineal instead of trans-rectal)
what bodily locations doe prostate cancer usually spread to (2)
- bones
- lymph nodes
prostate zones on MRI
- transition zone (anterior): benign prostatic hypertrophy
- peripheral zone (posterior): most cancers
prostate zones across ages
- young: small transition zone, much larger peripheral zone
- adult: larger transition zone ie/ benign prostatic hypertrophy, peripheral zone gets smaller
- elderly: very large transition zone, peripheral zone can be so small
benign prostatic hypertrophy
- non-cancerous enlargement of prostate gland
- organised chaos
- can push prostate into other structures (eg/ bladder)
- urethra gets squished in transition zone - hence issues voiding
with age often get ____ in peripheral zone which leads to irregular looking areas
this means what for cancers here
- scarring
- difficult to find tumour
in prostate cancer a lot of extension is _____ so sensitivity of MRI is low for staging prostate cancer
- microscopic
MRI for prostate cancer detection (pT2)
useful
MRI for prostate cancer staging (pT3)
not useful
cancer is ____ of cells packed ____ together, and so ___ diffusion is helpful in detecting
- lots
- restricted
do any cancers occur in transition zone
what helped be able to find these
yes
PI-RADS
PSMA PET scan stands for
prostate specific membrane antigen
radioactive tracer gets _____ into patient and it is linked to ____
- injected
- PMSA
radioactive tracer ____ in parts of the body that takes out the ____ & patients emits _____ which is detected by the scanner
- collects
- PSMA
- radiation
PSMA is not that _____ so can have false ____ on PSMA PET
- specific
- positives
do all prostate cancers pick up PSMA, are these likely to be higher or lower grade cancers
no
high
PSMA PET has made a signif difference in being able to detect ____
that may not be picked up on routine __
nodes
CT
what else can PSMA PET be used for
primary staging
localisation of recurrence
treatment planning
assessment of treatment response
restaging
prostate cancer imaging now
- multi parametric MRI - for cancer detection
- MRI - staging (aware can’t be microscopic T3)
- PI-RADS v2.1 - cancer detection and staging
- PSMA PET - identifying nodes and mets
- CT abdo as backup
