Prostate Cancer

Question 1

What are factors that impact the risk of Prostate cancer?

Answer 1

#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

Question 2

What is the increase in risk with an effected 1st degree relative v. a first and second degree relative?

Answer 2

affected 1st degree relative 2.8x
1st and 2nd degree 6x

(6 familial loci have been found)

Question 3

What features of a diet lend more risk for prostate cancer?

Answer 3

obesity
high saturated fats, red meats, low fruits, low vegetables, low tomato products (lycopene), low fish (observational studies)

Question 4

What are hormonal risk factors that can put someone at higher risk for prostate cancer?

Answer 4

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

Question 5

What are the most common symptoms at presentation?

Answer 5

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

Question 6

What is the efficacy of the DRE?

Answer 6

PPV of 51%; most cancers 65% arise in the peripheral zone, often posteriorly (these can be palpated

Question 7

How does PSA help to detect cancer?

Answer 7

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

Question 8

Does PSA screening save lives?

Answer 8

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

Question 9

When receiving lab values of elevated PSA, what is the next appropriate follow up step?

Answer 9

repeat PSA in 3-12mo

Question 10

Consistently hight PSA or alarming doubling rate in PSA levels can prompt which next dx test?

Answer 10

core biopsy

Question 11

What type of histology (tissue type) is most like the source of prostate cancer?

Answer 11

nearly all prostate cancer is derived from glandular epithelium of the prostate (prostatic adenocarinoma)

other types such as sarcoma or lymphoma are rare

Question 12

What are the features of a prostatic intraepithlial neoplasia?

Answer 12

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

Question 13

What are the features of prostatic adenocarcinoma?

Answer 13

loss of basal cell layer
small, round crowded glands
enlargement of cells
prominent nucleoli

Question 14

What does a Gleason system tell you about a tumor and how is it determined?

Answer 14

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

Question 15

What are the 4 treatments available for localized disease?

Answer 15

active surveillance, radical prostatectomy, radiation and androgen deprivation therapy

Question 16

How is active surveillance carried out?

Answer 16

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%

Question 17

What are the two approaches for radical prostatectomy? List possible complications.

Answer 17

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

Question 18

What are the indications for radiation therapy ?

Answer 18

• -can be a definitive therapy for localized disease
• -after surgery if positive margins or at time of relapse
• • painful or morbid metastases

Question 19

What are options for different radiation modalities? List possible complications.

Answer 19

intensity modified radiation therapy (computer assisted)
proton therapy
brachytherapy (radioactive ‘seeds’)

urinary incontinence, ED, bowel urgency, rectal bleeding, secondary malignancies (sarcomas and leukemias)`

Question 20

Contrast the pros of surgery v. radiation

Answer 20

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

Question 21

What factors are considered when deciding between radiation and surgery?

Answer 21

age of patient and patient comorbidities
risk of tumor (PSA, stage, Gleason)
institutional and physician bias
patient convenience

Question 22

What are different options for androgen deprivation therapy?

Answer 22

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

Question 23

When would you advise ADT as a primary treatment ?

Answer 23

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

Question 24

What imaging is useful for screening for bone metastases?

Answer 24

bone scan and CT A/P

Question 25

What is the front line treatment of metastatic prostate cancer?

Answer 25

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

Question 26

What systemic treatments are available for metastatic disease?

Answer 26

androgen deprivation therapy- GnRH agonist/antagonist
immune therapy
cytotoxic therapy
radiation/palliative radiation
secondary hormonal manipulations: ketoconazole, abiraterone acetate, enzalutamide

Question 27

Why is bone health a problem in prostate cancer?

Answer 27

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