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17th European Urology Residents Education Programme > Prostate cancer > Flashcards

Prostate cancer Flashcards

1
Q

What share of male cancer consists of prostate cancer?

A

20%

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2
Q

What is the estimated mortality of prostate cancer out of all male cancers?

A

10%

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3
Q

In autopsy studies, what race had the highest prevalence of prostate cancer?

A 
US Black 
followed by 
US white and european
followed by
Asian
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4
Q

What kind of molecule is Prostate Specific Antigen (PSA)?

A

Serine Protease

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5
Q

When was PSA first used clinically?

and for what?

A

1986

post-treatment follow-up

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6
Q

What is the risk of prostate cancer at PSA 4?

What is the risk of Gleason >7 at PSA 4?

A

26,9%

6,7%

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7
Q

What was the conclusion of the PLCO Trial?

A

There is no evidence of mortality benefit for organized annual screening compared with opportunistic screening

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8
Q

What was did the Göteborg Randomized Population-Based Screening Trial find?

A

42% lower PCa mortality in the organized screening vs the opportunistic testing arm

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9
Q

To avoid 1 PCa death:

How many men have to be screened?
How many PCa’s have to be diagnosed?

A

139 screened

13 PCa found

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10
Q

When does the USPTF (US Preventive Services Task Force) recommend individual (a man can choose for himself after information) screening of prostate cancer?

A

Men aged 55-69

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11
Q

When does the EAU recommend PSA-testing?

A

After counselling the patient on potential risks and benefits

AND

good performance status and a life expectancy of >10-15 years

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12
Q

How should an inital PSA-test be followed?

A

Offer an risk-adapted strategy (based on initial PSA level), with follow-up intervals of 2 years for those initially at risk:

  • PSA >1 at 40 years of age
  • PSA >2 at 60 years of age

Postpone follow-up to 8 years in those not at risk

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13
Q

How does the EAU recommend that you avoid unnecessary biopisies for men with PSA 2-10 and normal digital rectal examination (DRE)?

A

use one of the following tools:

risk-calculator
imaging
additional serum or urine-based test

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14
Q

Which risk calculator is superior when predicting clinicallly significant prostate cancer?

A

ERSPC-RC

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15
Q

What is the risk of prostate cancer if PSA is < 2 but there is a suspect DRE (digital rectal examination)?

A

5-30%

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16
Q

How reliable is TRUS (transrectal ultrasound) for detecting prostate cancer?

A

TRUS in not reliable in detecting prostate cancer.

Thus, there is no evidence that US-targeted biopises can replace systematic biopsies.

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17
Q

How many biopsies should you take in a 30 cc prostate?

A

At least 8 systematic

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18
Q

How many biopsies should you take in a prostate >30cc?

A

10-12

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19
Q

What type of painrelief should be used when performing prostate biopsies?

A

a periprostatic block

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20
Q

What are the top 4 complications of prostate biopsies?

A

Haematospermia 37,4%
Haematuria >1 day 14,5%
Rectal bleeding >2 days 2,2 %
Prostatitis 1%

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21
Q

How common is fewer > 38,5 after prostate biopsies?

A

0,8%

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22
Q

ISUP 1

A

Gleason 2-6

Low risk

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23
Q

ISUP 2

A

Gleason (3+4) =7

Intermediate risk favourable

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24
Q

ISUP 3

A

Gleason (4+3) =7

Intermediate risk unfavourable

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25
Q

ISUP 4

A

Gleason 8

High risk

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26
Q

ISUP 5

A

Gleason 9

High risk

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27
Q

What did the PROMIS trial find?

A

Sensivity of mpMRI for clinically significant PCa is almost double compared to TRUS-biopsy

27% of primary biopsy procedures could be avoided if mpMRI was used as a triage test

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28
Q

What did the PRECISION trial show?

A

That when using MRI-targeted biopsies you can find a greater share of clinically significant PCa

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29
Q

If an MRI is performed that show PI-RADS 3 or more, how should you aim the prostate biopsies?

A

Combine targeted and systematic biopsies

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30
Q

Risk stratification of PCa:

what are the criterias for low risk?

A

PSA <10
Gleason <7 / ISUP1
cT1a-2a

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31
Q

Risk stratification of PCa:

what are the criterias for intermediate risk?

A

PSA 10-20
Gleason 7 / ISUP2-3
cT2b

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32
Q

Risk stratification of PCa:

what are the criterias for high risk?

A

PSA >20
Gleason >7 / ISUP4-5
cT2c

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33
Q

When should you perform a Bone Scan for patients with PCa?

A

Symptomatic patients regardless of PSA

Intermediate unfavourable risk cancer (Gleason 4+3)
High risk cancer (PSA >20)
Locally advanced cancer (T3 or worse)

34
Q

When should you perform a mpMRI for patients with PCa?

A

Intermediate unfavourable risk cancer
High risk cancer
Locally advanced cancer

35
Q

Risk stratification of PCa:

what are the criterias for locally advanced PCa?

A

Any PSA
Any Gleason
cT3-4 or N+

36
Q

When should you perform an abdominal CT for patients with PCa?

A

Intermediate unfavourable risk cancer and worse for N-staging

37
Q

What is the sensisivity of an abdominal CT for detecting nodal invasion of PCa?

A

<40%

MRI performance is similar

38
Q

What is the sensivity and specificity for prostate cancer when using PSMA PET/CT?

A

sensitivity 50%

specificity >90%

39
Q

What is the gold standard for N-staging in prostate cancer?

A

surgery -lymph node dissection

40
Q

When is surgery the best option for a patient with prostate cancer?

A

<65 years

intermediate risk disease

41
Q

How likely is it that a patient in monitoring will recieve active treatment within 10 years?

A

54,8%

42
Q

Number needed to treat with radiotherapy to avoid:
clinical progression?
metastatic disease?

A

9

33

43
Q

Number needed to treat with surgery to avoid:
clinical progression?
metastatic disease?

A

9

27

44
Q

What is vital to inform patients of before chosing course of action after a prostate cancer diagnosis?

A

“No active treatment has shown superiority over any other active management options in terms of survival”

“all active treatments have side-effects”

45
Q

Which side effect(s) is worse with surgery compared to radiation or active-monitoring?

A

Incontinence

Impotence

46
Q

How many men used incontinence protection after surgery for prostate cancer 6 years postop?

A

17%

47
Q

How many men had erections firm enough for intercourse at the time of diagnosis of Prostate Cancer?

A

67%

48
Q

How many men had erections firm enough for intercourse after prostatectomy vs radiotherapy for prostate cancer?

A

12% vs 22%

49
Q

Number needed to harm with surgery vs radotherapy rather than active monitoring when it comes to urinary incontinence at 2 years:

A

Surgery 5

Radiotherapy 143

50
Q

When it comes to quality of life how does surgery, radiotherapy and active monitoring compare?

A

No significant differences

51
Q

Should PLND (Pelvic lymph node dissection) be performed on patients with localized PCa?

A

No (strong recommendation)

52
Q

Should PLND (Pelvic lymph node dissection) be performed on patients with intermediate risk PCa?

A

No (strong recommendation)

53
Q

Should PLND (Pelvic lymph node dissection) be performed on patients with high risk PCa?

A

Yes (strong recommendation)

54
Q

What is the difference between open, laprascopic or robot assisted radical prostatectomy in terms of functional and oncological results?

A

NONE

55
Q

What is the difference between active surveillance and watchful waiting?

A

Active surveillance focuses on delaying therapy until the tumour becomes progressive and curative treatment can be offered

Watchful waiting focuses on minimising treatment-related toxicity and i palliative

56
Q

What follow up should Active surveillance include?

A

Digital rectal examination
PSA
Repeated biopsies

57
Q

What should the neoadjuvant ADT-duration be after radiotherapy?
(ADT = androgen deprivation therapy)

A

intermediate risk 6 months

high risk 3 years

58
Q

When is brachytherapy as monotherapy recommended?

A 
Stage cT1b-T2a
Gleason 6 <50% of biopsy cores with cancer / Gleason 7 <33% of biopsy cores with cancer
PSA <10
<50cc prostate
IPSS< 12
Urinary flow >15mL/min
59
Q

What anatomical sites should be included in extended pelvic lymph node dissection (ePLND)?

A

external iliac axis
obturator fossa
around the internal iliac artery

60
Q

What is standard recommended radiotherapy dose in most European Centers for prostate cancer?

A

≥ 76-78 Gy in 37 fractions

61
Q

What is the benefit of ADT (androgen deprivation therapy) in addition to radiotherapy?

A

20% added 10-year survival
20% added disease specific survival
No difference in cardiovascular mortality

62
Q

When should you wait with ADT for patients with high risk prostate cancer that is unable to recieve local treatment?

A

PSA doubling time >12 months and

PSA < 50

63
Q

What are the possible different courses of action after surgery of a high risk N+ prostate cancer?

A

Offer adjuvant ADT

Offer adjuvant ADT + additional radiotherapy

Offer observation for patients efter eLND and < 2 nodes with microscopic involvement and PSA <0,1

64
Q

What treatment should be offered for a geriatric patient who presents with metastasised prostatecancer and symptoms?

A

Castration:

  1. bilateral orchiectomy
  2. GnRH agonist with flare protection Bicalutamide
  3. GnRH antagonist

For fit patients castration can be combined with docetaxel or abiraterone acetate
plus prednisolone or prostate radiotherapy

65
Q

How quickly do you reach castration levels with antiandrogen (degarelix)?

A

By day 3

66
Q

When should you treat prostate cancer patients with intermittent ADT?

A

Highly motivated asymptomatic patients who have a major PSA response after the induction period

67
Q

What are the side effects of hormone therapy?

9

A

Loss of libido and sexual interest , erectile dysfunction, impotence
Fatigue
Hot flushes
Decline in intellectual capacity, emotional liability, depression
Decrease in muscular strength
Increase in (abdominal)fat apposition, diabetes, risk of CV events
Osteoporosis
Anaemia

68
Q

How low is castrations lewel testosteron?

A

<50 ng/dl

69
Q

When should bone health agents (bisphosponates/denosumab) be used?

A

For men with risk of osteoporotic fractures

70
Q

What are valid (cytostatic) options for treatment of HSMPC (hormone sensitive metastatic prostate cancer)?

A

Early
Docetaxel
Enzalutamid
Abiraterone

71
Q

What is the current wiev of prostatectomy and radiation for low volume disease?

A

Radiation is proven beneficial

Surgery is not yet proven

72
Q

What are two ways a prostate cancer cell can become castration resistant?

A
  1. mutation of the androgen receptor so they get a higher affinity and can be activated by non-steroidal ligands
  2. by-pass pathways independent of the androgen receptor
73
Q

Definition of castration-resistant PCa:

A 
Testosteron <50 ng/dL or 1,7 nmol/L  
and 
biochemical progression
or 
radiological progression
74
Q

What kind of drug is Docetaxel?

A

Mitosis inhibitor

75
Q

What is the second line treatment after Docetaxel?

A

Cabacitaxel

76
Q

Where does Docetaxel have its effect?

A

In the cell membrane

77
Q

What kind of drug is Enzelutamid?

A

It binds androgen within the cell and prohibits it to enter the cell nucleus

78
Q

According to EAU what is the “correct” order to use antiprostate cancer drugs?

A

ADT (androgen deprivation therapy)

(Zoledronic acid or Denosumab to prevent SRE)

Abirateron or Enzelutamid

Docetaxel

Cabacitaxel

Radium-223

79
Q

When is it wrong to use bone protective agents in prostate cancer?

A

In hormone sensitive bone metastatic PCa

80
Q

What is importen to remember when prescribing Zoledronic acid or Denosumab?

A

Also offer calcium and vitamin-D

81
Q

How should you act with a patient who has a spinal cord compression from metastasised PCa?

A

start immediate high-dose corticosteroids and assess for spinal surgery followed by irradiation

Offer radiation therapy alone if surgery is not appropriate

17th European Urology Residents Education Programme (17 decks)

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