PROSTATE CANCER Flashcards
What is the incidence of prostate cancer in the UK per year?
36 000 men per year
If a patient has a first degree relative diagnosed with prostate cancer, what is his relative risk of developing the disease?
Two fold increase
If a patient has two or more first degree relatives diagnosed with prostate cancer, what is his relative risk of developing the disease?
5 to 11 fold increase
What are the risk factors for developing prostate cancer?
Increasing age
Relatives with prostate cancer
BRCA2 gene
Lynch syndrome
Black more than Caucasian
Caucasian more than Chinese
Calcium in diet
High BMI
Diabetes
?HPV
What factors might be protective for prostate cancer?
Lycopenes (cooked tomatoes)
Green tea
Aspirin 75 mg
Physical activity
Ejaculation
What do most people eventually diagnosed with prostate cancer present with?
It is usually asymptomatic at presentation and is diagnosed by PSA screening.
Urinary symptoms are actually rare unless there is extensive disease.
What are the symptoms of metastatic prostate cancer?
Bone pain
Spinal cord compression
Malaise
Weight loss
Anaemia
What should do before testing someone’s PSA levels?
Make the patient aware of the advantages and disadvantages of the test and the possible treatment options.
DRE
What is the normal upper limit of PSA for someone in their 40s above which we would worry about prostate cancer? 50s? 60s? 70s?
40s: Less than 2.5
50s: Less than 3.5
60s: Less than 4.5
70s: Less than 6.5
Where in the prostate are most prostate cancers found?
Peripheral zone - adjacent to the rectum
What should prompt prostate biopsy?
Abnormality on DRE
Elevated age-specific PSA
From a PR, how might you work out if there is cancer vs benign prostate hyperplasia?
BPH - symmetrical enlargement
Cancer - enlargement on one side
How do we perform prostate biopsies?
Local anaesthesia
Antibiotic prophylaxis
Transrectal ultrasound probe
8-12 biopsies directed at areas most likely to contain cancer
What are the risk of prostate biopsy?
RIsk of prostatitis
Risk of sepsis
Risk of bleeding
What percentage of prostate cancers are missed by transrectal ultrasound directed biopsy?
10-20%
What method of investigation might we offer men in whom prostate cancer is suspected but who come up negative on transrectal ultrasound assisted biopsy?
Transperineal template biopsy technique - will diagnose another 40% of those missed by transrectal biopsy
What is the problem with PSA screening all men over a certain age?
Not a very specific test and therefore as much as it reduces mortality, it leads to huge amounts of over-diagnosis and over-treatment.
Having found prostate cancer through biopsy, what other investigations should be offered?
Imaging for staging purposes
MRI (or CT)
Bone scan (99 Tech)
What is the classification system used for staging prostate cancer?
TNM classification
What are the different staging levels of T (primary tumour) in the staging classification of prostate cancer?
T1 - Clinically inapparent tumour, not palpable or visible on imaging. Either found incidentally in TURP chips or by needle biopsy.
T2 - Tumour confined to prostate:
a) One half of one lobe
b) More than half of one lobe
c) Both lobes
T3 - Tumour extends beyond confines of prostate
T4 - Tumour invades local structures
What are the staging levels of N (regional lymph nodes) in the staging classification of prostate cancer?
N0 - No nodal metastases
N1 - Regional lymph node metastases
What are the staging levels of M (distant metastases) in the staging classification of prostate cancer?
M0 - No distant metastases
M1a - Non regional lymph nodes
M1b - Bone metastases
M1c - Other sites
What three factors do we use to risk stratify men with localised prostate cancer?
PSA
T stage
Gleason score
What is the Gleason score?
Grading system of differentiation of cancer cells seen under a microscope. The score gives the differentiation grading of the two most abundant types of cell. The first number is the most abundant. So 4/3 is worse or less well differentiated than 3/4. The total may also be given.
What is the higher Gleason score?
5/5
In terms of PSA, T stage and Gleason score, what would be the parameters of a low risk prostate cancer?
PSA less than 10 ng/ml
T1 - T2a
Gleason 3/3 or less
In terms of PSA, T stage and Gleason score, what would be the parameters of a moderate risk prostate cancer?
PSA between 10 - 20 ng/ml
T2b - T2c
Gleason 3/4 or 4/3
In terms of PSA, T stage and Gleason score, what would be the parameters of a high risk prostate cancer?
PSA above 20 ng/ml
T3 - T4
Gleason 4/4 or above
What are the management options for localised prostate cancer (T1 - T2)?
Active surveillance
Radical prostatectomy
External beam radiotherapy (EBRT)
Brachytherapy
High intensity focused ultrasound (HIFU) - only as part of a clinical trial
Cryotherapy - only as part of a clinical trial
Hormone manipulation
What do we mean by active surveillance in the context of prostate cancer?
As prostate cancer is normally a slow growing cancer, it may not be appropriate to active treat a man who may have less than 10 years life expectancy. In these cases, PSA levels are closely monitored and in some repeat TRUS or template biopsies will be done. The aim is to reduced treatment related morbidity, whilst keeping an eye on things whilst they are still curable.
What are the three ways of doing a radical prostatectomy?
Open
Laparoscopically
Robotic
How do we measure the success of a radical prostatectomy?
The PSA should fall to unrecordable levels
How do we follow-up someone who has a radical prostatectomy following a diagnosis of localised prostate cancer?
PSA monitoring for at least 5 years
If post-radical prostatectomy the grading of the cancer is found to be higher than expected what adjuvant therapy is normally done?
Radiotherapy
What are the complications of radical prostatectomy?
Incontinence
Impotence
Haemorrhage
Infection
What are the complications of external beam radiotherapy in the treatment of prostate cancer?
Proctitis
Bowel and bladder cancer
Urinary frequency and urgency
What is the type of brachytherapy used in the treatment of localised prostate cancer?
Iodine 125
What are the main complications of brachytherapy used in the treatment of localised prostate cancer?
Urinary retention
Frequency and urgency
What are the complications of high intensity focused ultrasound used in the treatment of localised prostate cancer?
Impotence
Stress incontinence
UTI
Fistula
What are the complications of cryotherapy used in the treatment of localised prostate cancer?
Impotence
Stress incontinence
UTI
Fistula
What are the management options for locally advanced prostate cancer (T3 - T4 with no metastases)?
Radical prostatectomy with extended pelvic lymphadenectomy
External beam radiation with neoadjuvant and adjuvant androgen deprivation therapy (ADT) using LHRH agonists
High dose brachytherapy
What is the brachytherapy used in locally advanced prostate cancer?
Iridium 192 used in conjunction with external beam radiotherapy
How do we manage metastatic prostate cancer?
Castration and oestrogen therapy
What are the two methods of castration in the treatment of prostate cancer?
Surgically
Medical - LHRH agonists or antagonist
Name some LHRH agonists used in medical castration as treatment for prostate cancer.
Goserelin
Leuprorelin
Triptorelin
How do LHRH agonists work?
Act on the pituitary gland to stop the release of LH and FSH
What must be prescribed along with medical castration using LHRH agonists? Why?
Testosterone antagonists. This is because of ‘tumour flare’ where initially LHRH agonists causes a rise in LH and FSH leading to rapid progression of the tumour.
What are the side effects of medical castration?
Impotence
Loss of libido
Gynaecomastia
