Prostate cancer Flashcards
Localized treatment for early stage
observation
active surveillance
Localized treatment for advanced high risk early stage
radiation and LHRH (leuprolide or goserelin) - option for those who cannot handle surgery
Prostatectomy and lymph node dissection for those with greater than 10 year life expectancy will follow surgery with a Leuprolide or goserelin and possibly anti-androgen treatment if lymph positive or high rate or recurrence
SE with LHRH agonists
these will cause tumor flare because it needs to increase levels of hormones to desensitize the receptors
other side effects include ED, hot flashes, man boobs, edema - makes sense because its messing with the hormone levels in the body and stopping the production of man type hormones
Long term: osteoporosis, fracture, insulin resistance, increased risk in diabetes and cardiovascular events
Relugolix
oral option that is compated to the LHRH agonists and is a good option for those with cardiac history
Anti-androgens
given in combo with the LHRH agonists to prevent the flare up side effect
commonly used option is Bicalutamide
usually given 1 week before starting LHRH and stopped one month into therapy
can cause diarrhea and hematuria
M0HSPC
this is when patient has non-melaginancy but elevated PSA levels (greater than 4)
focus on the doubling time of PSA
If PSA doubles in less than 6 months patient can be treated with ADT
If PSA doubling time is longer than 6 months we will continue to observe the disease and testing levels every 6 months
M0HSPC and PSA doubled in less than 6 months - treatment
orchiectomy (removal of testes)
this causes an immediate drop in testosterone levels
toxicities include impotence (no boner) and hot flashes
intermittent ADT
FOR men with biochemical failure ONLY
Patients start a LHRH agonist with or without a ADT and PSA levels are monitored throughout the duration of therapy
If patients levels return to 4 ng/dl they can discontinue therapy but monitoring of PSA will continue and when patients PSA levels spikes again to 10-20 ng/dl we will restart therapy
this on and off therapy can be beneficial because it decreases the cost and decreases the side effects associated with the therapy regimen
M0CRPC tx
When patients PSA levels are continuing to increase although on proper ADT therapy and no distant metastasis found in scan
Continue on LHRH agonist
Add in ONE of the following: (darolutamide is safe option)
enzalutamide - DO NOT USE IN SEIZURE history, AVOID CYP2C8 inhibitors, decreases serum concentration of wafarin
Enzalutamide can cause seizures, diarrhea, confusion
apalutamide - Non-steroidal androgen receptor inhibitor, use with caution in seizure history, QT prolongation (watch out for heart problems)
apalutamide can cause hypertension, falls, rash, diarrhea, fatigue
darolutamide - NO seizure or falls - great for patients with seizure history or older patients that live alone
side effects in the two other drugs were less in darolutamide
M1HSPC
PSA level increased and metastasis found on scan
Therapy is determined based on volume which can either be low or high
before treating get patient MSI-H or dMMR testing as well as germline mutation testing - these will help us determine the treatment for the patient
Low volume M1HSPC treatment
start patient with leuprolide or any other GnRH agonist
continue ADT listed above and add any of the following
-Abiraterone + prednisone (prednisone must be given with because it is treating the adrenal insufficiency caused by abiraterone)
Causes hypertension, edema, increased triglycerides, liver toxicities, atrial fibrillation
- Enzalutamide - not great for seizure history and causes alot of confusion
- Apalutamide - not great for seizure and causes QT prolongation
High volume M1HSPC treatment
can give any of the following regimens
-Leuprolide and anti-androgen (ADT)
- ADT +/- abiraterone and prednisone
- ADT +/- enzalutamide
-ADT +/- apalutamide
Chemotherapy is now a possible treatment option
First line treatment for M1 disease high volume
Docetaxel + abiraterone + prednisone
M1CRPC
in addition to continuing ADT therapy
patient should add docetaxel + abiraterone + prednisone
if patient progresses on docetaxel regimen start them on cabazitaxel - this will work even with resistant tumors
cabazitaxel side effects include more severe neutropenia, more diarrhea, more febrile neutropenia
Treatment for bone mestastases
radium 223 dichloride
Used for CRPC symptomatic bone metastases
Cannot be given with chemotherapy
side effects include thrombocytopenia, anemia, and neutropenia
