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ONCOLOGY AND PALLIATIVE CARE > PROSTATE CANCER > Flashcards

PROSTATE CANCER Flashcards

1
Q

What is the incidence of prostate cancer in the UK per year?

A

36 000 men per year

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2
Q

If a patient has a first degree relative diagnosed with prostate cancer, what is his relative risk of developing the disease?

A

Two fold increase

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3
Q

If a patient has two or more first degree relatives diagnosed with prostate cancer, what is his relative risk of developing the disease?

A

5 to 11 fold increase

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4
Q

What are the risk factors for developing prostate cancer?

A

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

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5
Q

What factors might be protective for prostate cancer?

A

Lycopenes (cooked tomatoes)

Green tea

Aspirin 75 mg

Physical activity

Ejaculation

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6
Q

What do most people eventually diagnosed with prostate cancer present with?

A

It is usually asymptomatic at presentation and is diagnosed by PSA screening.

Urinary symptoms are actually rare unless there is extensive disease.

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7
Q

What are the symptoms of metastatic prostate cancer?

A

Bone pain

Spinal cord compression

Malaise

Weight loss

Anaemia

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8
Q

What should do before testing someone’s PSA levels?

A

Make the patient aware of the advantages and disadvantages of the test and the possible treatment options.

DRE

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9
Q

What is the normal upper limit of PSA for someone in their 40s above which we would worry about prostate cancer? 50s? 60s? 70s?

A

40s: Less than 2.5
50s: Less than 3.5
60s: Less than 4.5
70s: Less than 6.5

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10
Q

Where in the prostate are most prostate cancers found?

A

Peripheral zone - adjacent to the rectum

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11
Q

What should prompt prostate biopsy?

A

Abnormality on DRE

Elevated age-specific PSA

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12
Q

From a PR, how might you work out if there is cancer vs benign prostate hyperplasia?

A

BPH - symmetrical enlargement

Cancer - enlargement on one side

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13
Q

How do we perform prostate biopsies?

A

Local anaesthesia

Antibiotic prophylaxis

Transrectal ultrasound probe

8-12 biopsies directed at areas most likely to contain cancer

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14
Q

What are the risk of prostate biopsy?

A

RIsk of prostatitis

Risk of sepsis

Risk of bleeding

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15
Q

What percentage of prostate cancers are missed by transrectal ultrasound directed biopsy?

A

10-20%

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16
Q

What method of investigation might we offer men in whom prostate cancer is suspected but who come up negative on transrectal ultrasound assisted biopsy?

A

Transperineal template biopsy technique - will diagnose another 40% of those missed by transrectal biopsy

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17
Q

What is the problem with PSA screening all men over a certain age?

A

Not a very specific test and therefore as much as it reduces mortality, it leads to huge amounts of over-diagnosis and over-treatment.

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18
Q

Having found prostate cancer through biopsy, what other investigations should be offered?

A

Imaging for staging purposes

MRI (or CT)

Bone scan (99 Tech)

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19
Q

What is the classification system used for staging prostate cancer?

A

TNM classification

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20
Q

What are the different staging levels of T (primary tumour) in the staging classification of prostate cancer?

A

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

21
Q

What are the staging levels of N (regional lymph nodes) in the staging classification of prostate cancer?

A

N0 - No nodal metastases

N1 - Regional lymph node metastases

22
Q

What are the staging levels of M (distant metastases) in the staging classification of prostate cancer?

A

M0 - No distant metastases

M1a - Non regional lymph nodes

M1b - Bone metastases

M1c - Other sites

23
Q

What three factors do we use to risk stratify men with localised prostate cancer?

A

PSA
T stage
Gleason score

24
Q

What is the Gleason score?

A

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.

25
Q

What is the higher Gleason score?

A

5/5

26
Q

In terms of PSA, T stage and Gleason score, what would be the parameters of a low risk prostate cancer?

A

PSA less than 10 ng/ml

T1 - T2a

Gleason 3/3 or less

27
Q

In terms of PSA, T stage and Gleason score, what would be the parameters of a moderate risk prostate cancer?

A

PSA between 10 - 20 ng/ml

T2b - T2c

Gleason 3/4 or 4/3

28
Q

In terms of PSA, T stage and Gleason score, what would be the parameters of a high risk prostate cancer?

A

PSA above 20 ng/ml

T3 - T4

Gleason 4/4 or above

29
Q

What are the management options for localised prostate cancer (T1 - T2)?

A

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

30
Q

What do we mean by active surveillance in the context of prostate cancer?

A

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.

31
Q

What are the three ways of doing a radical prostatectomy?

A

Open

Laparoscopically

Robotic

32
Q

How do we measure the success of a radical prostatectomy?

A

The PSA should fall to unrecordable levels

33
Q

How do we follow-up someone who has a radical prostatectomy following a diagnosis of localised prostate cancer?

A

PSA monitoring for at least 5 years

34
Q

If post-radical prostatectomy the grading of the cancer is found to be higher than expected what adjuvant therapy is normally done?

A

Radiotherapy

35
Q

What are the complications of radical prostatectomy?

A

Incontinence

Impotence

Haemorrhage

Infection

36
Q

What are the complications of external beam radiotherapy in the treatment of prostate cancer?

A

Proctitis

Bowel and bladder cancer

Urinary frequency and urgency

37
Q

What is the type of brachytherapy used in the treatment of localised prostate cancer?

A

Iodine 125

38
Q

What are the main complications of brachytherapy used in the treatment of localised prostate cancer?

A

Urinary retention

Frequency and urgency

39
Q

What are the complications of high intensity focused ultrasound used in the treatment of localised prostate cancer?

A

Impotence

Stress incontinence

UTI

Fistula

40
Q

What are the complications of cryotherapy used in the treatment of localised prostate cancer?

A

Impotence

Stress incontinence

UTI

Fistula

41
Q

What are the management options for locally advanced prostate cancer (T3 - T4 with no metastases)?

A

Radical prostatectomy with extended pelvic lymphadenectomy

External beam radiation with neoadjuvant and adjuvant androgen deprivation therapy (ADT) using LHRH agonists

High dose brachytherapy

42
Q

What is the brachytherapy used in locally advanced prostate cancer?

A

Iridium 192 used in conjunction with external beam radiotherapy

43
Q

How do we manage metastatic prostate cancer?

A

Castration and oestrogen therapy

44
Q

What are the two methods of castration in the treatment of prostate cancer?

A

Surgically

Medical - LHRH agonists or antagonist

45
Q

Name some LHRH agonists used in medical castration as treatment for prostate cancer.

A

Goserelin

Leuprorelin

Triptorelin

46
Q

How do LHRH agonists work?

A

Act on the pituitary gland to stop the release of LH and FSH

47
Q

What must be prescribed along with medical castration using LHRH agonists? Why?

A

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.

48
Q

What are the side effects of medical castration?

A

Impotence

Loss of libido

Gynaecomastia

ONCOLOGY AND PALLIATIVE CARE (14 decks)

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