Prostate Cancer

Question 1

What is active surveillance?

Answer 1

Monitoring prostate cancer with tests (eg. biopsy, DRE, PSA) instead of curing prostate cancer.

Question 2

When is active surveillance recommended?

Answer 2

Men with low risk prostate cancer that is confined to the gland with a long life expectancy (>10 years)

Question 3

What is watchful waiting?

Answer 3

Monitoring prostate cancer for any symptoms that arise instead of curing prostate cancer.

Question 4

When is watchful waiting recommended?

Answer 4

Men with low risk prostate cancer that is confined to the gland with a lower life expectancy, especially those with co-morbidities.

Question 5

Why is watchful waiting preferred in men with comorbidities?

Answer 5

These men will probably die from comorbidities rather than prostate cancer. Watchful waiting helps control symptoms and also prevent men from being subject to the adverse effects of prostate cancer treatment.

Question 6

What is androgen deprivation therapy?

Answer 6

Also known as castration, decreases testosterone production in the body which contributes to prostate cancer growth.

Question 7

What are the two forms of androgen deprivation therapy?

Answer 7

Bilateral orchiectomy (surgical removal of testicles)
Pharmacological hormone therapy

Question 8

Why is pharmacological hormone therapy preferred?

Answer 8

Bilateral orchiectomy associated with worse psychological outcomes
Bilateral orchiectomy permanent, pharmacological is reversible

Question 9

GnRH agonist examples and MOA?

Answer 9

Goserelin, leuproelin
Agonist for the GnRH receptor which blocks the production of LH and FSH which results in inhibition of testosterone production.

Question 10

What is the ‘flare phenomenon’?

Answer 10

GnRH agonists cause initial transient increase in LH and FSH which results in the increased production of testosterone which lasts for ~3 days. This can cause the prostate cancer to increase in size.

Question 11

How is the ‘flare phenomenon’ managed?

Answer 11

Antiandrogen therapy (e.g. bicalutamide)

Question 12

Antiandrogen examples and MOA?

Answer 12

Bicalutamide, flutamide

Binds to androgen receptors on prostate cancer to inhibit androgen-dependent growth.

Question 13

What is the role of second-generation antiandrogens? Examples?

Answer 13

Enzalutamide, abiraterone

Used in prostate cancer that has not responded to initial ADT treatment.

Question 14

Enzalutamide MOA?

Answer 14

Binds to androgen receptors on prostate cancer to inhibit androgen growth, also inhibits nuclear translocation of the androgen receptor.

Question 15

Abiraterone MOA?

Answer 15

Inhibits products of the CYP17 gene in the testes and adrenal glands which inhibits testosterone production.

Question 16

Why is abiraterone usually administered with a corticosteroid (e.g. prednisone)?

Answer 16

Inhibition of CYP17 gene products in adrenal glands causes adrenal gland suppression which decreases cortisol production.

Question 17

What chemotherapy agents are used for prostate cancer?

Answer 17

Taxanes: docetaxel, cabazitaxel

Cabazitaxel not available in NZ thus docetaxel must be used, but has better adverse effect and toxicity profile.

Question 18

Do we prefer abiraterone or enzalutamide for metastatic prostate cancer?

Answer 18

Abiraterone. Enzalutamide is not available in NZ.

However, abiraterone is also very expensive and requires special authority.

Question 19

What is the role of zoledronic acid in prostate cancer?

Answer 19

Prostate cancer most commonly metastasises to the bones, causing bone pain and weakness. Bisphosphonates such as zoledronic acid help prevent this.