Prostate Cancer Flashcards
What is prostate cancer?
Adenocarcinoma of the Prostate (also transitional cell and rarely small cell or squamous cell) and most common non-cutaneous cancer in men.
How common is prostate cancer?
2nd most common cause of male cancer death. 80% have histological prostate cancer at death if 80+. Cancer totally dependant on Testosterone.
What are the risk factors for prostate cancer?
Age
Some inheritance – HPC1 and BRCA
Obesity
Ethnic origin (afro-Caribbean and African-American)
What are the signs and symptoms of prostate cancer?
Lower urinary tract symptoms although usually a sign of BPH as prostate cancer usually occurs peripherally and BPH centrally. These include: nocturia, hesitancy, poor stream, terminal dribbling or obstruction.
Bone pain, back pain and weight loss in advanced disease
Usually an incidental finding from PSA, DRE or TURP for BPH
What investigations should be done in suspected prostate cancer?
PSA
DRE – showing hard irregular craggy surface
Multiparametric MRI and bone scan for staging
TRUS (transrectal USS) biopsy – more common to do trans perineal, biopsy avoided in 80+
Bone scan using Technetium in high patient risk or those with bone pain
What can cause PSA to be raised other than prostate cancer?
PSA – seminal anticoagulant is increased with prostatic cancer but also in for other reasons so should do at least 2: • Urinary retention • Inflammation e.g. UTI, prostatitis • Instrumentation • BPH • Exercise • Ejaculation
When shouldn’t PSA be done according to NICE?
NICE advise that, as PSA levels may be increased, testing should not be done within at least:
• 6 weeks of a prostate biopsy
• 4 weeks following a proven urinary infection
• 1 week of digital rectal examination
• 48 hours of vigorous exercise
• 48 hours of ejaculation
What does a PSA >100 indicate?
If PSA is >100 you are likely to have mets
How is prostate cancer staged?
Gleason grading – 3-5 based on differentiation. Add the most common with the next most common seen on biopsy. Grade 7 has two variants – 4+3 and 3+4.
What are the TNM staging criteria for prostate cancer?
TNM T1 = clinically unapparent Tumour T2 = clinically apparent, T2a one lobe <50%, T2b one lobe >50%, T2c both lobes T3 = spreading outside the capsule T4 = invading local structures
How is low risk vs high risk decided for prostate cancer?
Gleason plus TNM plus PSA gives you a risk category
Low Risk PSA < 10, Gleason =/< 6 and =/< T2b
High risk PSA > 20, Gleason >/=8 and >/= T2c
How is prostate cancer managed?
Radical Prostatectomy – only really better than radiotherapy in younger patients and not offered to those over 73. Incontinence and impotence important risks.
Radiotherapy external beam or seeds – patient choice
Hormone treatment (this never cures the cancer) responds for limited time until the cancer develops its own testosterone supply. Can be used neo adjuvant or adjuvant. Done using GnRH agonists (goserelin/leuprorelin) with cover from an anti-androgen (bicalutamide) over the initial surge in testosterone which could otherwise lead to cord compression or metastasis.
What is the difference between active surveillance and watchful waiting/deferred hormone treatment/delayed treament?
Active Surveillance (treatable but unlikely to progress) – Monitor PSA/DRE 6 monthly aim to avoid unnecessary treatment but treat radically if needed. PSA every 6 months DRE every 12months
Watchful waiting/Deferred hormone treatment/Delayed treatment – older patients with co-morbidities. Start hormone therapy if development of mets or systemic disease.
What is benign prostatic hyperplasia?
Benign growth of prostate tissue from the inner transitional zone. Very common especially as men get older.
What are the clinical features of BPH?
Lower urinary tract symptoms – nocturia, hesitancy, post micturition dribble, terminal dribbling, incomplete emptying, straining, poor stream, frequency and urgency. Haematuria Stones Overflow incontinence Retention UTI
