Prostate Cancer - Early Detection

Question 1

Screening process

Answer 1

Shared decision making PSA
REPEAT if high
+/- validated risk calculators
+/- MRI
+/- adjunct urine/serum markers

Question 2

What age can PSA screening start?

Answer 2

Age 45-50 normally
Age 40-45 if increased risk (black, germline mutations like BRCA, strong FMHx)

Question 3

PSA screening interval

Answer 3

every 2-4 years for people age 50-69

Question 4

Clinicians ___ use DRE along PSA

Answer 4

MAY

Question 5

Should PSA velocity trigger more workup?

Answer 5

Not alone

Question 6

Does a template biopsy need to be performed at the time of a targeted biopsy?

Answer 6

Optional

Question 7

High risk for cancer and neg MRI management?

Answer 7

systematic biopsy

Question 8

When can biopsy be skipped?

Answer 8

PSA >50, no clinical concerns for infection, “significant risk” or need for prostate cancer treatment is urgent

Question 9

What should trigger repeat biopsy?

Answer 9

Risk assessment tool
do NOT use PSA threshold alone
Consider biomarkers
NOT one core HGPIN
ASAP/AIP```````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````

Question 10

How many needle passes per target lesion on MRI?

Answer 10

At least two per lesion

Question 11

How many people with elevated PSA will have a normal level with a retest?

Answer 11

25-40%

Question 12

What increases PSA?

Answer 12

NOT bike
NOT DRE
10% change with ejaculation
infection
instrumentation

Question 13

PSA half life

Answer 13

3 days

Question 14

Age thresholds for PSA

Answer 14

2.5 for men in 40s
3.5 for men in 50s
4.5 for men in 60s
6.5 for men in 70s

Question 15

Definition for strong family history

Answer 15

brother or father or two other male relatives with:
-diagnosis <60
-lethal prostate cancer
-metastatic prostate cancer
OR
FMHx for Lynch cancers

Question 16

General steps for transrectal prostate biopsy

Answer 16

Discuss risks and benefits
Obtain informed consent
Consider checking for FQR
Stop anticoagulation
Antibiotics - fluoroquinolone, FQ + 1/2/3cephalosporin, aminoglycoside, amikacin, fosfomycin
Prep/drape
Register MRI if appropriate
Assess prostate volume
Prostatic block
Biopsy with 2 cores per container/per target
Avoid TZ

Question 17

Risks of prostate biopsy

Answer 17

UTI
Sepsis
Hematuria
Hematochezia
Hematospermia
Transient ED

Question 18

Prostate cancer clinical T staging

Answer 18

T1 - nonpalpable
-T1a incidental finding in <5% of tissue resected
-T1b incidental finding in >5% of tissue
-T1c identified on needle biopsy
T2 - palpable within prostate
-T2a half of one side or less
-T2b one whole side
-T2c both sides
T3 - extraprostatic tumor that is not fixed
-T3a extraprostatic extension
-T3b invades seminal vesicles
T4 Fixed or invades rectum or bladder or pelvic wall

Question 19

Prostate cancer pathological T staging

Answer 19

NO pT1!
T2 organ confied
T3 extraprostatic extension
-T3a EPE or microscopic bladder neck involvement
-T3b invades SVs
T4 fixed, invades sphincter, rectum
Add R1 if margin

Question 20

Prostate cancer N staging

Answer 20

N0 none
N1 regional nodes

Question 21

Prostate cancer M staging

Answer 21

M0 none
M1 distant
-M1a nonregional LNs
-M1b Bone
M1c Other sites with or without bone disease

Question 22

GGG system

Answer 22

1 = 6 = 3+3
2 = 7 = 3+4
3 = 7 = 4+3
4 = 8 = 4+4, 3+5, 5+3
5 = 9/10

Question 23

Very low risk CaP requirements

Answer 23

cT1c
GGG1
PSA <10
<3 cores positive with <50% each
PSAD <0.15

Question 24

Low risk CaP requirements

Answer 24

cT1c-cT2a (on biopsy or DRE)
GGG1
PSA <10

Question 25

Can a palpable nodule on DRE be very low risk CaP?

Answer 25

No

Question 26

Intermediate prostate cancer

Answer 26

No high or very high risk features
1 or more: cT2b-cT2c (very palpable), GG2-3, PSA 10-20

Question 27

Favorable intermediate risk prostate cancer

Answer 27

No high risk or very high risk features
GG1 or 2
1+ of these: cT2b-cTc, <50% cores positive

Question 28

Unfavorable intermediate risk prostate cancer

Answer 28

No high risk or very high risk features
GGG3 OR >50% of cores with cancer OR (PSA 10-20 and cT2b-cT2c)

Question 29

High risk prostate cancer

Answer 29

No very high risk features
cT3 OR GGG4/5 OR PSA >20

Question 30

Very high risk prostate cancer

Answer 30

cT3b-cT4 OR
GG5 OR
2+ high risk features OR
>4 cores with GG4/5

Question 31

Risk of prostate cancer with PIRADs4

Answer 31

58% any cancer
37% clinically significant prostate cancer

Question 32

Risk of prostate cancer with PIRADs5

Answer 32

85% any prostate cancer
70% clinically significant prostate cancer

Question 33

Optional biomarkers for prostate cancer

Answer 33

Free PSA
4K score
PHI
isoPSA

Question 34

Management of focal HGPIN

Answer 34

Surveillance - do not rush to repeat biopsy

Question 35

Management of ASAP/AIP

Answer 35

Further workup (MRI, repeat biopsy, biomarkers)

Question 36

What should be done before repeat biopsy?

Answer 36

MRI if not already done

Question 37

SHARE framework

Answer 37

Seek participation
Help explore options
Assess values
Reach decision
Evaluate decision

Question 38

Risks of TRUSBx and frequency

Answer 38

Infection 5%
Hospitalization 1-3%
Hematuria 50%
BRBPR 30%
Hematospermia 50%
LUTS 6-25%
ED <1%

Question 39

Most common organism causing infection after PNBx

Answer 39

FQR E. coli

Question 40

Fluoroquinolone mechanism

Answer 40

Targets gyrase - reduces DNA replication

Question 41

How common is FQR?

Answer 41

10-20%

Question 42

Risk factors for PNBx infection

Answer 42

DM2
Significant comorbidities
Immunosuppression
Prior sepsis
More biopsy cores?
Recent travel or antibiotics
Known FQR

Question 43

Treatment of copious BRBPR after TRUSBx

Answer 43

Tampon or Foley in the rectum
Bedrest, admission
Endoscopic epinephrine
Hemostatic agents
Gensurg/IR consult