Prostate cancer (module 4) Flashcards
anatomy and size of the prostate gland
sits at the base of the bladder, in front of the rectum
weighs approx 20g, size of a walnut
the prostate gland is responsible for producing
30% of seminal fluid
seminal fluid contains enzymes indluding prostate specificc antigen
incidence of prostate cancer
most common cancer for Australian men
often occurs after the age of 50
more prevalent in African men and less prevalent in Asian men
risks factors for prostate cancer
genetic - family history increases risk
race - more often affects African men
dietary factors - may have a role but are controversial, high dietary fat is a risk factor.
early disease in prostate cancer
early disease is usually asymptomatic
patients who present with LUTS usually have an enlarged prostate secondary to BPH though prostate cancer may coexist
locally advanced disease symptoms
urinary symptoms similar to those in BPH
eg. frequency, nostril, hesitancy, poor stream, dysuria
haematuria may be present
metastatic disease symptoms
bone pain, fractures, cord compression
investigations for diagnosis of prostate cancer
digital rectal examination
- firm nodule is usually T2 disease
- hard, craggy prostate is usually T3 disease
PSA test
trans-rectal ultrasound biopsy (TRUS biopsy)
TRUS biopsy
performed as a day case under local anaesthetic, sedation or general anaesthetic
biopsies taken through the rectum under ultrasound visualisation
usually 12 biopsies taken
potential complications of TRUS biopsy
infection - (all pts get prophylaxis but infections can still occur)
bleeding - all pts may see blood PR, but serious post biopsy bleeding can also occur, all patients should stop anti coagulating drugs before biopsy
urinary retention
how long might normal bleeding be seen after a TRUS biopsy
PR blood, haematuria and haematospermia may last several weeks
anti coagulating drugs must be stopped before a TRUS biopsy
how many biopsies should be taken in a trus biopsy
usually like 12
is PSA prostate specific
yes but it is not cancer specific
what are some conditions that can cause elevated PSA
benign prostatic hyperplasia BPH
urinary tract infections
instrumentation eg. catheter
idiopathic
what is the chances that the patient has cancer if the PSA is elevated but there’s no urinary tract infection?
PSA 4-10ng/ml = 25% chance
PSA >10ng/ml = 50% chance
PSA > 20ng/ml = 90% chance
what should patients with elevated age related PSA have?
a DRE
what percentage of prostate cancer will be missed on DRE alone
45%
what percentage of prostate cancer will be missed on PSA testing alone
18%
what investigations might be used for staging of prostate cancer
DRE (clinically)
CT or MRI pelvis
Isotope bone scan
what do you use to grade prostate cancer
prostate biopsy - Gleason score
what is the Gleason score
used for grading prostate cancer
gives prognostic information and indicator of tumour aggression
histological grading system 1-5
95% of prostate tumours are
adenocarcinoma
indication for radical prostatectomy
localised prostate cancer
has been shown to improve survival in these men
how is a radical prostatectomy performed
can be performed as open retropubic operation or laparoscopically with or without robotic assistance
what length of stay will be needed for radical prostatectomy
approx 5 days or more, less if the operation was laparoscopic
post operative management after radical prostatectomy
catheter left in situ for 10 days post operatively
not to be removed as reinsertion may disrupt urethral anastomosis
complications of radical prostatectomy
impotence
incontinence
recusancy of disease
mortality
two types of radiotherapy for prostate cancer
external beam radiotherapy (EBRT)
brachytherapy
external beam radiotherapy
given in fractions delivered over several weeks
3 dimensional conformational and intensity modulated techniques allow increased dose to be delivered to the prostate whilst minimising dose to rectum and other structures
what is brachytherapy
implanting radioactive material into the prostate
two types of brachytherapy
seed brachytherapy
high dose rate brachytherapy
seed brachytherapy
permanently implanting radioactive seeds (iodine or palladium) into the prostate
high dose rate brachytherapy
temporary insertion of a high dose radioactive source to give a boost of treatment to the prostate
usually combined with EBRT for high risk locally advanced disease
complications of radiotherapy
bladder and bowel irritation e.g. proctitis
impotence
disease recurrence
androgen suppression agents
prostate cancer is a testosterone dependant tumour
androgens may be suppressed by
- surgical castration
- LHRH agonist
- anti-androgens
- oestrogens
LHRH agonist examples
goserelin (zoladex)
leupropelin (lucrin)
anti-androgens examples
cyproterone acetate
biclutamide
when should androgen suppression be prescribed
androgen suppression with an LHRH agonist is usually a palliative treatment but has been shown to improve survival when used in the adjuvant setting with radiotherapy
advanced prostate cancer treatment
40% of patients present with advanced disease
mean survival 3-3.5 years
usually require hormone manipulation
GnRH agonist most frequently used therapy
bone complications from prostate cancer
testosterone is essential in maintaining bone mass in men and androgen suppression causes osteopenia and osteoporosis
bone metastasis are common
bone pain, fracture, spinal cord compression
should prostate cancer be screened for?
prostate cancer screening is controversial and there is little evidence suggesting that it would improve survival rates
at what point does prostate cancer become symptomatic
usually only once it is advanced
is prostate cancer usually curable?
yes
does increased PSA level confirm a prostate cancer diagnosis?
no, you need histological diagnosis via a TRUS biopsy
