Prostate cancer Flashcards
What is prostate cancer?
Prostate cancer is a common condition with up to 30,000 men diagnosed each year in the UK, and up to 9,000 men die from it annually.
What are the symptoms of early prostate cancer?
Early prostate cancers have few symptoms.
What symptoms may indicate metastatic disease?
Metastatic disease may present as bone pain.
What symptoms may indicate locally advanced prostate cancer?
Locally advanced disease may present as pelvic pain or with urinary symptoms.
What tests are used for diagnosing prostate cancer?
Diagnosis includes PSA measurement, digital rectal examination, transrectal ultrasound (with or without biopsy), and MRI/CT and bone scan for staging.
What is the normal upper limit for PSA?
The normal upper limit for PSA is 4 ng/ml.
False positives may occur due to prostatitis, UTI, BPH, or vigorous DRE.
What PSA percentage suggests cancer?
Values of <20% for the percentage of free to total PSA are suggestive of cancer, and a biopsy is advised.
What is the most common type of prostate cancer?
95% of prostate cancers are adenocarcinomas.
What is the Gleason grading system?
The Gleason grading system awards two grades (1-5) to the most dominant and second most dominant cancer grades, with the sum giving the Gleason score.
What is the significance of the Gleason score?
A Gleason score of 2 indicates the best prognosis, while a score of 10 indicates the worst.
How does prostate cancer typically spread?
Lymphatic spread occurs first to the obturator nodes, and local extra prostatic spread to the seminal vesicles is associated with distant disease.
What are the treatment options for prostate cancer?
Treatment options include watchful waiting, radiotherapy, surgery (radical prostatectomy), and hormonal therapy.
What is the purpose of watchful waiting?
Watchful waiting is suitable for elderly patients with multiple co-morbidities and a low Gleason score.
What are the potential side effects of surgery for prostate cancer?
Erectile dysfunction is a common side effect of radical prostatectomy.
What does hormonal therapy for prostate cancer involve?
Hormonal therapy may involve bilateral orchidectomy or pharmacological alternatives like LHRH analogues and anti-androgens.
What does NICE recommend for low-risk prostate cancer patients?
NICE suggests active surveillance for low-risk men, particularly those with specific clinical and biopsy criteria.
What criteria must candidates for active surveillance meet?
Candidates should have had at least 10 biopsy cores taken and at least one re-biopsy.
What should be done if disease progression is observed in active surveillance?
If disease progression is observed, radical treatment should be offered.
What is the most common cancer in adult males in the UK?
Prostate cancer is now the most common cancer in adult males in the UK.
What is the second most common cause of cancer death in men after lung cancer?
Prostate cancer is the second most common cause of death due to cancer in men after lung cancer.
What are the risk factors for prostate cancer?
Risk factors include increasing age, obesity, Afro-Caribbean ethnicity, and family history.
What percentage of prostate cancer cases have a strong family history?
Around 5-10% of cases have a strong family history.
Is localized prostate cancer often symptomatic?
Localized prostate cancer is often asymptomatic.
Why are localized prostate cancers often asymptomatic?
Cancers tend to develop in the periphery of the prostate and hence don’t cause obstructive symptoms early on.
What are possible features of localized prostate cancer?
Possible features include bladder outlet obstruction, haematuria, haematospermia, and pain in the back, perineal, or testicular areas.
What symptoms may indicate bladder outlet obstruction?
Symptoms may include hesitancy and urinary retention.
What findings might be observed during a digital rectal examination for prostate cancer?
Asymmetrical, hard, nodular enlargement with loss of median sulcus.
What was the traditional investigation for suspected prostate cancer?
The traditional investigation was a transrectal ultrasound-guided (TRUS) biopsy.
What do recent NICE guidelines recommend for suspected prostate cancer?
Recent NICE guidelines advocate the increasing use of multiparametric MRI as a first-line investigation.
What are the complications of TRUS biopsy?
Complications include:
- Sepsis: 1% of cases
- Pain: lasting >= 2 weeks in 15% and severe in 7%
- Fever: 5%
- Haematuria and rectal bleeding.
What is the first-line investigation for clinically localised prostate cancer?
Multiparametric MRI is now the first-line investigation.
How are the results of multiparametric MRI reported?
The results are reported using a 5-point Likert scale.
What is the recommendation if the Likert scale is >=3?
If the Likert scale is >=3, a multiparametric MRI-influenced prostate biopsy is offered.
What should be discussed if the Likert scale is 1-2?
If the Likert scale is 1-2, NICE recommends discussing with the patient the pros and cons of having a biopsy.
What was the traditional investigation for suspected prostate cancer?
The traditional investigation was a transrectal ultrasound-guided (TRUS) biopsy.
What do recent NICE guidelines recommend for suspected prostate cancer?
Recent NICE guidelines advocate the increasing use of multiparametric MRI as a first-line investigation.
What are the complications of TRUS biopsy?
Complications include:
- Sepsis: 1% of cases
- Pain: lasting >= 2 weeks in 15% and severe in 7%
- Fever: 5%
- Haematuria and rectal bleeding.
What is the first-line investigation for clinically localised prostate cancer?
Multiparametric MRI is now the first-line investigation.
How are the results of multiparametric MRI reported?
The results are reported using a 5-point Likert scale.
What is the recommendation if the Likert scale is >=3?
If the Likert scale is >=3, a multiparametric MRI-influenced prostate biopsy is offered.
What should be discussed if the Likert scale is 1-2?
If the Likert scale is 1-2, NICE recommends discussing with the patient the pros and cons of having a biopsy.
What are the treatment options for localized prostate cancer (T1/T2)?
Treatment depends on life expectancy and patient choice. Options include: conservative: active monitoring & watchful waiting, radical prostatectomy, radiotherapy: external beam and brachytherapy.
What are the treatment options for localized advanced prostate cancer (T3/T4)?
Options include: hormonal therapy, radical prostatectomy (with erectile dysfunction as a common complication), radiotherapy (external beam and brachytherapy).
Patients may develop proctitis and are also at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer.
What is one of the key aims of treating advanced prostate cancer?
One of the key aims is reducing androgen levels. A combination of approaches is often used.
What is GnRH agonist therapy?
GnRH agonists, such as Goserelin (Zoladex), initially cause a rise in testosterone levels for 2-3 weeks before falling to castration levels due to overstimulation and disruption of hormonal feedback systems.
Initial therapy is often covered with an anti-androgen to prevent a rise in testosterone - ‘tumour flare’.
What are some examples of anti-androgen therapies?
Examples include bicalutamide (non-steroidal anti-androgen) and cyproterone acetate (steroidal anti-androgen).
Cyproterone acetate is used less commonly since the introduction of non-steroidal anti-androgens.
What is abiraterone used for?
Abiraterone is an androgen synthesis inhibitor used for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated.
What is bilateral orchidectomy?
Bilateral orchidectomy is used to rapidly reduce testosterone levels.
What is PSA?
Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and malignant prostate epithelial cells.
What is the controversy surrounding PSA testing?
PSA testing has become an important tumour marker, but much controversy still exists regarding its usefulness as a screening tool.
When should PSA testing be considered?
PSA testing should be considered in men with suspected prostate cancer and offered to men older than 50 years of age who request a PSA test.
What are the age-specific PSA thresholds for referral?
Age-specific PSA thresholds are as follows:
- < 40: Use clinical judgement
- 40–49: > 2.5 ng/ml
- 50–59: > 3.5 ng/ml
- 60–69: > 4.5 ng/ml
- 70–79: > 6.5 ng/ml
- > 79: Use clinical judgement.
What should be done if a patient’s PSA level is above the threshold for their age?
Patients with a PSA above the threshold should be referred on the suspected cancer pathway referral for an appointment within 2 weeks.
What can raise PSA levels?
PSA levels may be raised by benign prostatic hyperplasia (BPH), prostatitis, urinary tract infection, ejaculation, vigorous exercise, urinary retention, and instrumentation of the urinary tract.
What is the recommendation regarding PSA testing after treatment for prostatitis or urinary tract infection?
NICE recommends postponing the PSA test for at least 6 weeks after treatment.
What are the limitations of PSA testing?
PSA testing has poor specificity and sensitivity; around 33% of men with a PSA of 4-10 ng/ml will have prostate cancer, and around 15% with prostate cancer have a normal PSA.
What methods are used to add meaning to PSA levels?
Various methods include age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time).
