Prostate Cancer [treatment] Flashcards
3 main factors that determines Prostate Cancer management
Confirmed Prostate Cancer Patients
- Patients Life expectancy
- Staging of Prostate Cancer
- Presence of High-risk features [Gleason grading]
General approach to Prostate Cancer management
Based on Patients Life Expectancy
Estimate Patients Life Expectancy:
- Formulas available online
- Patients with limited Life expectancy (< 5 years): consider Watchful waiting [asymptomatic patients] or palliative ADT [symptomatic patients]
- Patients with > 5 years Life expectancy: manage according to staging
General approach to Prostate Cancer management
Based on Staging of cancer
1.Localized Prostate Cancers: T1–T2 or tumor with extracapsular extension (T3a) and N0, M0
- Very low/Low risk: Active Surveillance
- Internediate/High risk: Radical Prostatectomy OR Radiotherapy + ADT
2.Locally Advanced Prostate cancer: T3b/T4 OR N1 and M0
- ADT + Androgen Synthesis Inhibitor + Radiation therapy
3.Metastatic Prostate Cancer:
- ADT + Androgen Synthesis Inhibitor + Radiation therapy OR Antiandrogens/Chemotherapy instead of Androgen Synthesis Inhibitor
Stage Cancer [TNM] and Grade Cancer [Gleasons]
What is Watchful waiting? And to what kind of patients do we do this to?
It consists of Regular monitoring with scheduled DRE + serum PSA levels
Done to patients who are
- Less than/Equal to 5 years Life Expectancy
- Slow-growing tumour [low risk or intermediate risk LOCALIZED tumours]
- Asymptomatic or Minimal symptoms
Initiate definitve management according to Cancer Stage only when Symptoms occur
What is Active Surveillance? What type of patients undergo this?
It consists of Regular monitoring with scheduled DRE, PSA, Prostate Biopsies and mpMRI
Done to patients who are
- Very Low-risk and Low-risk LOCALIZED cancers with > 5 years Life expectancy
- In favourable Intermediate-risk LOCALIZED cancers
Initiate definitve management according to Cancer Stage if disease progession is demonstrated
Methodology of ADT
Indications, Options, Adverse Effects
Indications:
- Locally Advanced and Metastatic Prostate Cancers: Primary method, in combination with androgen synthesis inhibitors, antiandrogens, and radiation therapy
- High-risk Localized Prostate Cancers: alternative to radical prostatectomy
Options:
- Medical Castration: decrease pituitary stim of testes [GnRH agonists/Gonadotropin-releasing antagonists/GnRH receptor antagonists]
- Surgical Castration: Bilateral Orchiectomy
Adverse Effects:
- Increased Osteoporosis and fractures risk
- Sexual dysfunction
- Gynecomastia
- Increased Cardiovascular and metabolic risks
- Anaemia
Therapy designated to decrease Testosterone production by Testes
Methodology of Radiation Therapy
Indications, Options, Adverse Effects
Indications:
- Localized Prostate Cancer: Primary option
- Metastatic Prostate Cancer/High-risk Localized Prostate Cancer/Local recurrence follwoing Prostatectomy: Radiotherapy + Androgen Deprivation
- After Prostatectomy: adjuvant therapy if invasion of the seminal vesicles, positive margins, and extraprostatic extension detected on histology
Options: Can be used in combination for greater efficacy
- Brachytherapy: implantation of radioactive iodine-125 seeds in the prostate
- EBRT: external beam radiation therapy
Complications:
- Radiation proctits, enteritis
- Cystits, Urethritis, Urinary Incontinence
- Erectile Dysfunction
- Increased Rectal Cancer risk
General idea of Follow-up for patients
1.Serum PSA monitoring:
- Every 6 months for first five years, then annually for definitive local therapy patients
- Every 3-6 months for ADT patients
2.PSA velocity/PSA doubling time
3.Further studies for abnormal PSA levels
- Post radical prostatectomy: any amount
- Post radiation therapy: any rise of PSA above normal levels for age
4.Annual DRE: monitor for recurrence and rectal cancer [for Radiotherapy patients]
PSA levels must be normal or below post therapies
Basic Prognosis for Prostate Cancer
Lowest and Highest, based on Gleasons score
Gleasons ≤ 6: 96% 5 year survival post-radical prostatectomy
Gleasons 9 or 10: 26% 5 year survival post-radical prostatectomy
How is Gleasons scoring done?
Adding of ‘Most spread Gleason grade of tumour’ + ‘2nd most spread Gleason grade of tumour’
Eg. Grade 3 most seen and Grade 4 second most seen. Gleasons Score = 7
