Prostate cancer COPY

Question 1

What is prostate cancer?

Answer 1

Prostate cancer is a common condition with up to 30,000 men diagnosed each year in the UK, and up to 9,000 dying from it annually.

Question 2

What are the early symptoms of prostate cancer?

Answer 2

Early prostate cancers have few symptoms. Metastatic disease may present as bone pain, while locally advanced disease may present as pelvic pain or urinary symptoms.

Question 3

What tests are used for diagnosing prostate cancer?

Answer 3

Diagnosis includes prostate specific antigen measurement, digital rectal examination, trans rectal ultrasound (+/- biopsy), and MRI/CT and bone scan for staging.

Question 4

What is the normal upper limit for PSA?

Answer 4

The normal upper limit for PSA is 4 ng/ml. However, this group may include patients with benign disease and localized prostate cancer. False positives can occur due to prostatitis, UTI, BPH, or vigorous DRE.

Question 5

How can free:total PSA percentage help in diagnosis?

Answer 5

The percentage of free:total PSA may help distinguish benign disease from cancer. Values of <20% are suggestive of cancer, and biopsy is advised.

Question 6

What is the most common type of prostate cancer?

Answer 6

95% of prostate cancers are adenocarcinomas.

Question 7

What is the Gleason grading system?

Answer 7

The Gleason grading system awards two grades: 1 for the most dominant grade (scale of 1-5) and 2 for the second most dominant grade (scale 1-5). The two grades added together give the Gleason score, where 2 is the best prognosis and 10 is the worst.

Question 8

What are the treatment options for prostate cancer?

Answer 8

Treatment options include watchful waiting, radiotherapy (external and brachytherapy), surgery (radical prostatectomy), and hormonal therapy.

Question 9

What is the preferred option for low-risk men with prostate cancer in the UK?

Answer 9

The National Institute for Clinical Excellence (NICE) suggests that active surveillance is the preferred option for low-risk men.

Question 10

What criteria should candidates for active surveillance meet?

Answer 10

Candidates should have had at least 10 biopsy cores taken and at least one re-biopsy.

Question 11

What should be done if men on active surveillance show evidence of disease progression?

Answer 11

If evidence of disease progression is shown, radical treatment should be offered.

Question 12

What is the most common cancer in adult males in the UK?

Answer 12

Prostate cancer.

Question 13

What is the second most common cause of cancer death in men after lung cancer?

Answer 13

Prostate cancer.

Question 14

What are the risk factors for prostate cancer?

Answer 14

Increasing age, obesity, Afro-Caribbean ethnicity, and family history.

Question 15

What percentage of prostate cancer cases have a strong family history?

Answer 15

Around 5-10%.

Question 16

Is localized prostate cancer often symptomatic?

Answer 16

No, it is often asymptomatic.

Question 17

Why do localized prostate cancers often not cause obstructive symptoms early on?

Answer 17

Cancers tend to develop in the periphery of the prostate.

Question 18

What are possible features of localized prostate cancer?

Answer 18

Bladder outlet obstruction, haematuria, haematospermia, and pain.

Question 19

What symptoms might indicate bladder outlet obstruction?

Answer 19

Hesitancy and urinary retention.

Question 20

What types of pain may be associated with prostate cancer?

Answer 20

Back, perineal, or testicular pain.

Question 21

What findings might be noted during a digital rectal examination for prostate cancer?

Answer 21

Asymmetrical, hard, nodular enlargement with loss of median sulcus.

Question 22

Answer 22

Isotope bone scan (using technetium-99m labelled diphosphonates which accumulate in the bones) from a patient with metastatic prostate cancer. The scan demonstrates multiple, irregular, randomly distributed foci of high grade activity involving the spine, ribs, sternum, pelvic and femoral bones. The findings are in keeping with multiple osteoblastic metastasis.

Question 23

What was the traditional investigation for suspected prostate cancer?

Answer 23

The traditional investigation was a transrectal ultrasound-guided (TRUS) biopsy.

Question 24

What do recent NICE guidelines recommend as a first-line investigation for suspected prostate cancer?

Answer 24

Recent NICE guidelines advocate the increasing use of multiparametric MRI as a first-line investigation.

Question 25

What are the complications of TRUS biopsy?

Answer 25

Complications include: sepsis (1% of cases), pain (lasting >= 2 weeks in 15% and severe in 7%), fever (5%), haematuria, and rectal bleeding.

Question 26

How are the results of multiparametric MRI reported?

Answer 26

The results are reported using a 5-point Likert scale.

Question 27

What is the recommended action if the Likert scale is >=3?

Answer 27

If the Likert scale is >=3, a multiparametric MRI-influenced prostate biopsy is offered.

Question 28

What should be discussed with the patient if the Likert scale is 1-2?

Answer 28

If the Likert scale is 1-2, NICE recommends discussing the pros and cons of having a biopsy.

Question 29

What are the treatment options for localized prostate cancer (T1/T2)?

Answer 29

Treatment depends on life expectancy and patient choice. Options include: conservative (active monitoring & watchful waiting), radical prostatectomy, and radiotherapy (external beam and brachytherapy).

Question 30

What are the treatment options for localized advanced prostate cancer (T3/T4)?

Answer 30

Options include: hormonal therapy, radical prostatectomy (with erectile dysfunction as a common complication), and radiotherapy (external beam and brachytherapy).

Patients may develop proctitis and are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer.

Question 31

What is one of the key aims of treating advanced prostate cancer?

Answer 31

One of the key aims is reducing androgen levels. A combination of approaches is often used.

Question 32

What is anti-androgen therapy?

Answer 32

Anti-androgen therapy includes synthetic GnRH agonists or antagonists, such as Goserelin (Zoladex).

Question 33

What happens to testosterone levels when using GnRH agonists?

Answer 33

Testosterone levels will initially rise for around 2-3 weeks before falling to castration levels due to overstimulation and disruption of endogenous hormonal feedback systems.

Question 34

What is the purpose of covering GnRH agonist therapy with an anti-androgen?

Answer 34

It is to prevent a rise in testosterone, known as ‘tumour flare’, which may result in symptoms like bone pain and bladder obstruction.

Question 35

What are GnRH antagonists being evaluated for?

Answer 35

GnRH antagonists, such as degarelix, are being evaluated to suppress testosterone while avoiding the flare phenomenon.

Question 36

What is bicalutamide?

Answer 36

Bicalutamide is a non-steroidal anti-androgen that blocks the androgen receptor.

Question 37

What is cyproterone acetate?

Answer 37

Cyproterone acetate is a steroidal anti-androgen that prevents DHT binding from intracytoplasmic protein complexes.

It is used less commonly since the introduction of non-steroidal anti-androgens.

Question 38

What is abiraterone used for?

Answer 38

Abiraterone is an androgen synthesis inhibitor used for the treatment of hormone-relapsed metastatic prostate cancer in patients with no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated.

Question 39

What is bilateral orchidectomy?

Answer 39

Bilateral orchidectomy is used to rapidly reduce testosterone levels.

Question 40

What chemotherapy drug is mentioned for prostate cancer treatment?

Answer 40

Chemotherapy with docetaxel.

Question 41

What is prostate specific antigen (PSA)?

Answer 41

PSA is a serine protease enzyme produced by normal and malignant prostate epithelial cells.

Question 42

What is the controversy surrounding PSA testing?

Answer 42

PSA testing has become an important tumour marker, but much controversy exists regarding its usefulness as a screening tool.

Question 43

When should PSA testing be considered?

Answer 43

PSA testing should be considered in men with suspected prostate cancer and offered to men older than 50 years of age who request a PSA test.

Question 44

Answer 44

Question 45

What are the age-specific PSA thresholds for prostate cancer symptoms?

Answer 45

Age-specific PSA thresholds are as follows:
- < 40: Use clinical judgement
- 40–49: > 2.5 ng/ml
- 50–59: > 3.5 ng/ml
- 60–69: > 4.5 ng/ml
- 70–79: > 6.5 ng/ml
- > 79: Use clinical judgement.

Question 46

What should be done if PSA levels are above the age-specific threshold?

Answer 46

Patients with a PSA above the threshold for their age should be referred on the suspected cancer pathway referral for an appointment within 2 weeks.

Question 47

What conditions can raise PSA levels?

Answer 47

PSA levels may be raised by benign prostatic hyperplasia (BPH), prostatitis, urinary tract infection, ejaculation, vigorous exercise, urinary retention, and instrumentation of the urinary tract.

Question 48

What are the limitations of PSA testing?

Answer 48

PSA testing has poor specificity and sensitivity. Around 33% of men with a PSA of 4-10 ng/ml will have prostate cancer, and around 15% with prostate cancer have a normal PSA.

Question 49

What methods are used to add meaning to PSA levels?

Answer 49

Various methods include age-adjusted upper limits and monitoring change in PSA level over time, such as PSA velocity or PSA doubling time.