Prostate Cancer Flashcards
What are factors that impact the risk of Prostate cancer?
#1 factor: age, esp after 40y testosterone status- significant family history- significant diet/lifestyle race/nationality: more likely to present with aggressive dz and more likely to die from dz. weight /hormonal factors
What is the increase in risk with an effected 1st degree relative v. a first and second degree relative?
affected 1st degree relative 2.8x
1st and 2nd degree 6x
(6 familial loci have been found)
What features of a diet lend more risk for prostate cancer?
obesity
high saturated fats, red meats, low fruits, low vegetables, low tomato products (lycopene), low fish (observational studies)
What are hormonal risk factors that can put someone at higher risk for prostate cancer?
greater action of 5a-reductase to convert androgen to DHT within prostate cells can increase risk, chemoprevention to decrease 5a-reductase leads to reduced prevalence overall but those who do get PCa have higher grade cancers
What are the most common symptoms at presentation?
symptoms are rarely present at the time of dx.
most common symptoms result from bladder outlet obstruction: hesitancy, nocturne, incomplete emptying and diminished urine stream
What is the efficacy of the DRE?
PPV of 51%; most cancers 65% arise in the peripheral zone, often posteriorly (these can be palpated
How does PSA help to detect cancer?
PSA is a glycoprotein produced by epithelium of the prostate and PSA levels in the blood an be detected if it leaks from the prostate (due to trauma or architectural distortion)- **it cannot be used to distinguish between benign conditions, indolent and lethal prostate cancers
elevation seen with: prostatitis, trauma, ejaculation, BPH, cancer, medications
Does PSA screening save lives?
generally thought to reduce death rates (high NNTT) due to prostate cancer but is not thought to reduce overall mortality; may be most effective in high risk groups
complicated by morbidity of testing and treatment of indolent cancers (fear of over treatment)
USPSTF recommends shared decision making regarding informed choice to screen by patient
When receiving lab values of elevated PSA, what is the next appropriate follow up step?
repeat PSA in 3-12mo
Consistently hight PSA or alarming doubling rate in PSA levels can prompt which next dx test?
core biopsy
What type of histology (tissue type) is most like the source of prostate cancer?
nearly all prostate cancer is derived from glandular epithelium of the prostate (prostatic adenocarinoma)
other types such as sarcoma or lymphoma are rare
What are the features of a prostatic intraepithlial neoplasia?
large nuclei, prominent nucleoli, still contained within the basal cells and basement membrane (ID’d by karatin immunization)
general loss of normal gland structure but not yet invasive
What are the features of prostatic adenocarcinoma?
loss of basal cell layer
small, round crowded glands
enlargement of cells
prominent nucleoli
What does a Gleason system tell you about a tumor and how is it determined?
determined by examining the tissue and assigning a number grade to the dominant and subdominant aptters
scoring is one of the number factors used to determine prognosis and treatment
What are the 4 treatments available for localized disease?
active surveillance, radical prostatectomy, radiation and androgen deprivation therapy
How is active surveillance carried out?
follow patient with semiannual PSA, free PSA and DRE, early prostate biopsy
any Gleason 4 or 5, >2 cores involved or >50% involvement of a single core are indications for definitive treatment
watch and weight method has a failure rate of only 3%
What are the two approaches for radical prostatectomy? List possible complications.
open (suprapubic) prefered for high grade of involved tumors
minimally invasive (laparoscopic, robot-assisted $$)
can lead to complications of urinary incontinence, urinary distress, ED and surgical complications
What are the indications for radiation therapy ?
- -can be a definitive therapy for localized disease
- -after surgery if positive margins or at time of relapse
- painful or morbid metastases
What are options for different radiation modalities? List possible complications.
intensity modified radiation therapy (computer assisted)
proton therapy
brachytherapy (radioactive ‘seeds’)
urinary incontinence, ED, bowel urgency, rectal bleeding, secondary malignancies (sarcomas and leukemias)`
Contrast the pros of surgery v. radiation
both are effective for ⅔ patients
surgery: less time, visualization of tumor, pathologic stain possible, minimal rectal toxicity, reserves radiation for future relapses and no risk of secondary malignancy
radiation: more effective if used in combo with ADT, no surgical complications, able to treat pelvic lymph nodes, less urinary incontinence
What factors are considered when deciding between radiation and surgery?
age of patient and patient comorbidities
risk of tumor (PSA, stage, Gleason)
institutional and physician bias
patient convenience
What are different options for androgen deprivation therapy?
medical castration with LHRH agonists or antagonists (expensive) surgical castration (bilateral orchiectomy)
alternatives: anti-androgens that block receptor, estrogens (suppress production) and 17,20 lyase inhibitors to stop synthesis
When would you advise ADT as a primary treatment ?
NOT A CURATIVE TREATMENT
elderly or patients with multiple co-morbidities
those cancers where there is a high probability that the disease is not curable: high PSA or high Gleason
What imaging is useful for screening for bone metastases?
bone scan and CT A/P
What is the front line treatment of metastatic prostate cancer?
androgen deprivation therapy : can result in symptomatic improvement in 80-90% and can modestly improve survival (1.5-3y)
associated with significant side effects, all cancers eventually become resistant to castration
What systemic treatments are available for metastatic disease?
androgen deprivation therapy- GnRH agonist/antagonist
immune therapy
cytotoxic therapy
radiation/palliative radiation
secondary hormonal manipulations: ketoconazole, abiraterone acetate, enzalutamide
Why is bone health a problem in prostate cancer?
ADT-associated bone mineral density loss (2-4%/y) precipitating life-limiting hip fracture
treat with calcium and vitamin D when ADT is begun or with evidence of osteopenia; anti-reprotive agents (zoledronic acid/year)
75% of advanced PCa develop bone metastasis leading to osteoclast mediated bone destruction- IV zoledronic acid is a bisphophonate approved to delay or prevent SREs in castration-resistant prostate cancers
