Prostate Cancer - Block 4 Flashcards
What are the risk factors of prostate cancer?
- ≥65YO
- African AMerican
- Family hx and mutations
- BPH can delay diagnosis
- Smoking doesn’t increases mortality
How do you screen for prostate cancer?
PSA is preferred methd
What is the general rec for screening?
Betwen 55-69, discuss with provider
What drugs can decrease PSA levels?
5-a reductase inhibitors, herbal supplements
What is the normal range of PSA?
≤4.0 ng/mL
Chances of acquiring prostate cancer from elevated PSA levels?
Borderline range: 4.1-10 ng/mL (25% chance)
Elevated range: >10 ng/mL (50% chance)
What are the presentations of localized prostate cancer?
Asymptomatic
What are the presentations of locally invasive prostate cancer?
- Ureteral dysfunction, frequency, hesitancy, dribbling
- Impotence
What are the presentations of advanced prostate cancer?
- Back pain
- Cord compression
- Lower extremity edema
- Pathologic fractures
- Anemia
- Weight loss
How do you diagnose prostate cancer?
- Diagnosed by PSA or DRE
- Followed by transrectal ultrasound (TRUS)
- Confirmed by biopsy
- Gleason score assigned
Characteristics of Stage I?
Small tumor load, not palpable nor visible by imaging
Characteristics of Stage II?
Tumor confined within prostate
Characteristics of Stage III?
Tumor extends through the prostate capsule
Characteristics of Stage IV?
Metastatic dx
What is used to deteremine the aggressiveness of prostate cancer?
Gleason Score
How do you interpret the Gleason score?
2 separate specimens:
* Scale of 1 (well differentiated) to 5 (poorly differentiated)
* Total: 2-4 (well), 5 or 6 (moderately), 7-10 (poorly)
- Poorly differentiated grow faster (poor prognosis)
- Well differentiated grow slower (better prognosis)
Initial prostate tx is based on what factors?
- Stage/size
- Gleason’s score
- PSA levels
- Presence of sx
- Life expectanct
- Co-morbitiies
- ADRs and pts preference
- Race
What are the types of initial tx?
- Active surveillance/observation
- Prostatectomy
- Radiation therapy +/- androgen deprivation therapy (ADT)
What are the characterisitcs of active surveillance?
- Monitoring cancer more closely
- Life expectancy ≥10 yrs
- PPSA q6 monthly
- DRE and biopsy yearly
- Progression -> curative tx
What are the characterisitcs of observation?
- Less intensive than follow up
- Life expectancy <10 yrs
- No biopsies, moniotring Q6-12 months
- Progression (sx) -> palliative tx
Indication for radical prostatectomy?
Reserved for patient with >10Y life expectancy and localized dx
What are the complications of radical prostatectomy?
- Blood loss
- Incontinence
- Anesthesia risk
- ED
What are the types of radiation therapy for prostate?
- External beam
- Brachytherapy
What is external beam radiation therapy?
- Aims radiation at the tumor
- Based on availabiloity and duration
What is bracytherapy?
Reserved for low risk -> places radiative seeds in or nearby tumor -> stays in body for months
ADRs of radiation therapy?
- Cystitis
- Proctitis
- Hematuria
- Urinary retention
- Penoscrotal edema
- Impotence
How long are ADT tx for high risk patients?
Long term: 2-3 yrs
How long are ADT tx for intermediate risk patients?
Short term: 4-6 months
What is the goal of ADT?
Lower testosterone level <50 ng/dL -> castration
What is reversible method of androgen ablation?
LH-RH agonsist
* As effective as orchiectomy
What are the LH-RH agonsits?
- Goserelin (Zoladex)
- Leuprolide (Leuprolide)
- Triptorelin (Trelstar LA)
ADRs of LH-RH agonsits? How do you manage them?
Hot flashes, HA, Decreased libido, HA, osteoporosis, increased diabetes and CV, MI, weight gain
Tumor flares that can be controlled with antiandrogens
* Long term use -> Calcium and vit D supplementation
Examples of GnRH antagonsit?
Degarelix (Firmagon)
Benefits of using degarelix over LHRH agonsits?
Castrate levels achieved in 7 days instead of 28
* No tumor flares
ADR of degarelix?
- Inj site rx
- Increased LFTs
- Osteoporosis requires calcium/vit D supplementation
What are the antiandrogens agents?
- Flutamide
- Bicalutamide
- Nilutamide
- Enzalutamide
ADRs of antiandrogens?
diarrhea, gynecomastia, hot flashes, LFT abnormalities
Monitoring schedule for prostate cancer?
PSA: checked every 6-12 months for 5 years, annual after
DRE: Q12 monthsalso performed due to risk of recurrence with no rise in PSA levels seen
Txs for prostate cancer?
Tx for metastatic cancer?
- ADT
- Bilateral Orchiectomy
- LH-RH agonist/antagonist +/- Antiandrogen
- LH-HR agonist/antagonist + docetaxel
What is bilateral orchiectomy?
Inexpensive procedural removal of testes
Other than ADRs what are disadvantages of bilateral orchiectomy?
- May not be a surgical candidate
- Psychologically unaceptable
ADRs of bilateral orchiectomy?
Immediate drop in testosterone within 12 hrs
ADR: impotence (less than with LHRH agonsits), hot flashes
ADT therapies for metastatic prostate cancer?
LH-RH agonists:
Goserelin
Leuprolide
Triptorelin
GnRH antagonist:
Degaralix
What is the difference between continuous and intermittenet ADT?
Due to side effects of ADT may consider intermittent ADT
Continuous tx for 1 year then stopped
Resumes when certain PSA level reached or symptoms appear again
What is castrate naïve prostate cancer?
Cancer has progressed or metastasized but pt has not been treated with ADT therapy
* Advanced prostate cancer
Systemic tx for castrate naive M0?
Systemic tx for castrate naive M1?
What is CRPC?
Cancer doesn’t respond to ADT:
* Progresses despite testosterone castrate level of < 50 ng/dL
* Add on secondary hormone therapy
Drugs used for CRPC or metastatic?
Enzalutamide
Darolutamide
Apalutamide
Abiraterone
MOA fo abiraterone?
Blocks the cortisol production from adrenal glands
How should abiraterone be dosed?
Given with prednisone: formulations are not interchangeable
* Zytiga: must be given on empty stomach, at least 2 hrs before eating and no food for minimum of 1 hr after
* Yonsa: – micronized formulation – can be given without regard to food
Tx for CRPC with PSADT more than 10 months?
Tx for CRPC with PSADT less than 10 months?
Tx for Small cell and neuroendocrine prostate cancer?
First line tx for M1 CRPC?
