Prostate Cancer

Question 1

What is the most common cancer in men?

Answer 1

Prostate cancer

Question 2

How is prostate cancer usually diagnosed?

Answer 2

Usually diagnosed after a PSA test coming back as elevated. MAny men with prostate cancer die due to other causes, the cancer does not cause their death. Most prostate cancers are either localised or locally advanced when diagnosed.

Question 3

What is the main type of prostate cancer?

Answer 3

Adenocarcinoma

Others include transitional cell carcinoma (transitional cell carcinoma) or small cell prostate cancer (arises from neuroendocrine cells)

Question 4

What zone of the prostate do prostate cancers generally arise from?

Answer 4

Posterior peripheral zone

Question 5

What are risks factors for prostate cancer?

Answer 5

Increasing age
Afro-caribbean ethnicity (associated with earlier development)
Family history of prostate cancer
Obesity
BRCA1 and BRCA2

Question 6

What are some symptoms of prostate cancer?

Answer 6

Early on causes minimal symptoms
LUTS- Urgency, poor stream, hesitancy, inability to completely empty bladder (retention), most micturition dribble, painful urination, nocturia
Painful ejaculation
Haematuria- visible or invisible
If mets to bone- lower back/pelvic pain

Question 7

What investigations would you do if you suspect a patient has prostate cancer?

Answer 7

Digital rectal examination
PSA level
Secondary care- Transrectal US guided biopsy, MRI
ALP- If suspicion bone mets, Bone Isotope scanning should be done to investigate for bony metastases.

Question 8

What system is used to grade prostate cancers?

Answer 8

Gleason Score- scored out of 10 based on how poorly differentiated cells are. This requires a tissue biopsy which is obtained via tran-rectal USS.

Question 9

How are prostate cancers staged?

Answer 9

Using the TNM system- Imaging is required to investigate for metastases or nodal involvement. CT or MRI.

Question 10

What factors do NICE recommend are used to score the risk of prostate cancer?

Answer 10

Prostate cancers are defined as high, medium or low risk using PSA levels, Gleason Score and Staging using TNM system (uses the T stage)

Question 11

Who should be referred urgently using a 2 week wait for suspected prostate cancer according to NICE guidance?

Answer 11

Anyone with a malignant feeling prostate on DRE
PSA levels above age specific range

Consider a PSA test and DRE for anyone with LUTS (nocturia, urgency, hesitancy, poor stream, post-micturition dribble, increased frequency or urination), Erectile dysfunction or haematuria

Question 12

What are the age specific ranges for PSA?

Answer 12

40-49- Less than 2
50-59- Less than 3
60-69- Less than 4
70 or older- Less than 5

Question 13

What else can cause PSA levels to be raised?

Answer 13

Acute urinary retention
Prostatitis
Recent catheterisation
TURP
BPH
Increases anyway with age
UTI

Question 14

What should happen for patients with a raised PSA?

Answer 14

They should be offered a biopsy. This is transrectal ultrasound guided biopsy

Question 15

Does a normal or low PSA rule out prostate cancer?

Answer 15

No it doesn’t- around 15% of men with prostate cancer do not have a raised PSA

Question 16

A patient has recently been diagnosed with prostate cancer, what are the treatment options?

Answer 16

Active surveillance- regular PSA and DRE. Repeat biopsy at 12 months. Many men with prostate cancer do not die from it. Consider for men who do not want surgery or radiotherapy

Surgery- Radical prostatectomy with curative intent. Can be done laparoscopically or using da-vinci robot.

Radiotherapy

Hormone Therapy

Note currently recommended by NICE- High Intensity Focussed Ultrasound, Cryotherapy

Question 17

What radiotherapy options are used in the treatment of prostate cancer?

Answer 17

External beam radiotherapy- directs high energy X-rays at the tumour to induce DNA damage and kill the cancerous cells. Often combined with hormone therapy.

High Dose-Rate Brachytherapy- Source of radiation delivered into the tumour to cause local DNA damage, may be combined with external beam

Note- Radiotherapy can also be used palliatively to reduce symptoms

Question 18

Outline the hormone treatments that may be used in the treatment of prostate cancer?

Answer 18

Testosterone drives the growth of prostate cancer- not curative (may be combined with other treatments) but does reduce the rate of prostate cancer growth

LHRH Agonists e.g. Goserelin, Triptorelin - Reduce the production of testosterone. Initially they cause an increase in testosterone production so anti-androgens are given (this is called a flare)

Antiandrogens e.g. Flutamide, Bicalutamide- Block the effects of testosterone

Orchiectomy also reduces testosterone production but not commonly done.

Question 19

How does Goserelin work?

Answer 19

This is a Luteinizing Hormone Releasing Hormone Agonist or Gonadotropin releasing hormone agonist. Initially it causes a surge of testosterone (called a flare, give anti-androgen such as Flutamide) but then there is down regulation of the LHRH receptors and reduced testosterone stimulation.