Prostate Cancer

Question 1

What is the referral criteria for prostate cancer?

Answer 1

Refer men on 2ww if their prostate feels malignant on examination

Consider a PSA in men with LUTS, erectile dysfunction or visible haematuria.
If aged 50-69 refer on 2ww if PSA is 3 or higher.

Question 2

What are the risk factors for prostate cancer?

Answer 2

Increased age
+ve family history
Genetic factors- BRCA mutation, HPC
Ethnicity- black/african>white>asian

Question 3

How do we diagnose prostate cancer?

Answer 3

DRE- feels malignant- hard and craggy
Clinical features- lower urinary tract sx, ejaculatory symptoms, bone pain, raised PSA on opportunistic screening

Patients will then go on to have an MRI and then biopsy
This can be either TRUS or template depending on where the abnormality is

Bloods- PSA, FBC, calcium, U&E

May require uroflow measurement, cystoscopy and imaging of upper urinary tract

Question 4

What are the issues with PSA screening?

Answer 4

Poorly cost-effective
Overdiagnosis
Over treatment

• low PSA does not exclude cancer, high does not confirm.
• biopsy is not perfect- sepsis, if negative does not exclude
• many people often die with prostate cancer, not from it.

Question 5

What is the histology of prostate cancer?

Answer 5

Adenocarcinoma

Question 6

What is gleason grading?

Answer 6

Describes the histologic appearance of the cancer under low magnification. Scored from 1-5. Mutliple biopsies are taken. The two worst scores are added up to give a grade

6 or under- low grade
7-intermediate
8 or over- high grade

Question 7

What determines a high risk prostate cancer?

Answer 7

TNM> 2c, gleason grade 8-10, serum PSA> 26

Question 8

How is low risk Prostate Ca managed?

Answer 8

Active surveillance- we dont biopsy if catching it early wont affect the management. I.e if they are very elderly.
Watchful waiting is another strategy- treat metastases, less intense.

If younger:
Radical prostatectomy
Cryotherapy
Chemotherapy
Radiotherapy

Question 9

How do we treat intermediate prostate cancer?

Answer 9

Radical prostatectomy

Combined androgen deprivation treatment and radical radiotherapy

Question 10

What are the complications of prostatectomy?

Answer 10

Incontinence and impotence

Question 11

How do we treat metastatic prostate cancer?

Answer 11

Anti-androgen therapy.

Acts by inhibiting signalling through androgen receptor which leads to apoptosis and inhibition of growth

Can be LHRH agonist or antagonist.

If using agonist will get initial flare which should be covered by bicalutamide

Question 12

Where does prostate cancer commonly metastasise?

Answer 12

Pelvic lymph nodes, bones and lungs

Bony metastases are osteoblastic