Prostate Cancer

Question 1

RFs for prostate cancer

Answer 1

65+ yrs old
BRCA-1/2
Scandanavian/US
Father/Brother
High Fat Diet
Smoking increases mortality
 -not incidence

Question 2

95% of prostate cancers are

Answer 2

Adenocarcinomas

Question 3

Survival of prostate cancer

Answer 3

100% if local

30% if distant dz

Question 4

Prevalence of prostate cancer

Answer 4

median 68 yrs old

up to 50% of men over 50

Question 5

Tx goal for early stage prostate cancer

Answer 5

Block androgens
-tumor regression
In adv stage, becomes hormone refractory/castration resistant/androgen independent

Question 6

When should you start screening for prostate cancer?

Answer 6

If over 50 or 
 over 45 if
   -AA
   -1st degree relative w/PC under 65
PSA +/- DRE

Question 7

PSA level to start discussing therapy

Answer 7

If PSA is 3 or greater,
 discuss chemo prevention
  -dutasteride/finasteride
     -if dev cancer, more aggressive
     -25% less incidence, more aggressive

Question 8

Gleason Score

Answer 8

Two specimens (1-5) added.
4 or less = well diff (slow)
5-6 = mod diff
7+ = poor diff (rapid)

Question 9

DRE

Answer 9

Specific
Safe
Insensitive
Inter-observer variability

Question 10

PSA

Answer 10

Simple, but not specific
Goal is less than 4
Can not tell BPH from PC if 4-10
Also look at velocity

Question 11

Clinical presentation of Localized PC

Answer 11

Asymptomatic

Question 12

Clinical presentation of Locally Invasive PC

Answer 12

Urinary dysfx
impotence
painful ejaculation

Question 13

Clinical presentation of Advanced PC

Answer 13

*BONE PAIN
BACK PAIN
Cord compression
Edema in lower extremities
Anemia
Wt loss
pathologic fractures

Question 14

Common mets for PC

Answer 14

skeletal

-Lumbar spine is most common distant spread

Question 15

Dgx of PC

Answer 15

DRE
PSA (TRUS of elevated)
Biopsy - Staging

Question 16

Stages of PC that req pharm tx

Answer 16

Only in meta or locally advanced dz

Question 17

After discussing screening, those who choose to screen who have a PSA above ___ should:

Answer 17

Above 2.5
should be tested annually
with PSA +/- DRE

Question 18

Prognosis depends on

Answer 18

Gleason Score (best)
Tumor Size
Local Extent of dx

Question 19

Tx options for PC

Answer 19

1 Expectant mgmt
   -PSA +/- DRE q 6mo
2 Surgery
   -Orchiectomy or radical prostatectomy
3 Radiation Tx
   -EBRT
   -Brachytherapy (implant)
4 Pharm Tx
   -Andro Dep Tx (ADT)
   -Chemo
   -Immunosuppression

Question 20

Tx Options for Castration Resistant PC

Answer 20

Chemotherapy

Immunotherapy

Question 21

ADT

Answer 21

Androgen Deprivation Therapy
 -used for locally advanced / meta PC
LHRH
GnRH
Antiandrogens
Androgen Synthesis Inhibitors
 -newer agents used for cast. resist. PC

Question 22

Initial Tx options for localized PC

Answer 22

Active surveillance
EBRT or Brachytherapy
RP (+/- PLND)
Observation

Question 23

Initial Tx for Locally Advanced PC

Answer 23

EBRT + ADT for 2-3 yrs

Question 24

Initial Tx for Meta PC

Answer 24

If not M1, EBRT + ADT

Once M1, only ADT

Question 25

___ is the gold standard for men with metastatic PC

Answer 25

ADT

Question 26

ADT options for Advanced PC

Answer 26

Orchiectomy
LHRH agonists 
   \+/- antiandrogen 7+ days
    to prevent testosterone flare
LHRH agonists alone
Continuous ADT and Docetaxel

Question 27

LHRH agonists

Answer 27

Leuprolide, goserelin, triptoelin

• lower LH/FSH which lowers T
• *ADE = TUMOR FLARE, bone density
• **(give antiandrogens x2 wks)
• *Supp w/ 500 Ca and 400 Vit D

Question 28

GnRH Antagonists

Answer 28

Degarelix
-lower LH/FSH which lowers T
ADE - bone mineral density
Supp w/500 Ca and 400 Vit D
Due to ALL, restricted access

Question 29

Antiandrogens

Answer 29

Flutamide, bicalutamide, nilutamide
Ind in META-PC W/ LHRH agonists
-prevent TUMOR FLARE from LHRH

Question 30

CRPC

Answer 30

Cast Resist PC
Dz progresses during ADT
AND
at least 4 wks after withdrawal of ADT

Question 31

Tx for CRPC with NO visceral mets

Answer 31

Abiraterone + Pred
Enzalutamide
Docetaxel + Pred
Radium-223

Question 32

Tx for CRPC with Visceral Mets

Answer 32

Enzalutamide

Docetaxel + Pred

Question 33

Sipuleucel-T

Answer 33

Immunotherapy for mCRPC
Must have:
  -ECOG score 2 or less
  -Est. life expectancy over 6 mo
  -No visceral dz (no organ involvement)
  -Minimal symptoms
B/C very expensive process
Uses pts own immune sys to fight

Question 34

Abiraterone

Answer 34

ADT
Inhibits T synthesis
 -inhibits CYP17
ADEs:
   -mineral cort excess
    (hypoK, HTN, fluid retention)
   -adrenal cort insufficiency
PC
  -EMPTY STOMACH
  -Take w/prednisone 5 BID 
     to reduce MCE and ADI

Question 35

Enzalutamide

Answer 35

ADT
Pure Androgen Receptor Antagonist
-can be used alone

Question 36

PC for Abiraterone

Answer 36

EMPTY STOMACH
Take with Prednisone
-to prevent MCE and ADI

Question 37

Use of chemo in PC

Answer 37

Reserved for mCRPC
Docetacel q3wks +/- Pred
Cabazitaxel is 2nd line

Question 38

Docetaxel

Answer 38

Preferred 1st line chemo for mCRPC

Cabazitaxel is 2nd line

Question 39

Supportive therapy for mCRPC

Answer 39

Prevent Skeletal Related Events
 (SREs)
Bisphosphonates
 -zolidronic acid or pamidronate
Denosumab

Question 40

Zolidronic acid vs denosumab

Answer 40

Both used for supportive tx in mCRPC
-to prevent Skeletal Related Events (SRE)

***ZA must be renally adjusted

***Both have ADE of osteonecrosis of jaw