Prostate Caner

Question 1

Descrbe the epidemiology of prostate cancer

Answer 1

• Commonest cancer in men • 2nd commonest cause of death from cancer in men • 1 in 8 men will be diagnosed with prostate cancer during their lifetime • Incidence is increasing • Mortality started decreasing in the last decade • It is rare in men aged <50 • Nearly every man in their 80s has prostate cancer
– Most don’t know they have it
– Most don’t need to know they have it
– Most die with it, not from it
The challenge is to identify men who will come to harm from prostate
cancer

Question 2

Describe the correlations with creasing are

Answer 2

Increased urinary symptoms with age. Prostate - benign enlargement with age. More likely to have prostate cancer with ge too. Hence increased urinary symptoms

Question 3

What are the risk factors for prostate

Answer 3

• ↑age
• Family history
– 4x ↑risk
• if one 1st degree relative diagnosed with prostate cancer before age 60 – BRCA2 gene mutation
• Ethnicity
– Black > White >Asian
Black ppl - high risk of having more aggressive CaP but more common in white ppl

Question 4

Describe the nhs official policy for prostate cancer risk management

Answer 4

Prostate Specific Antigen (PSA) blood test
• Does not recommend mass population screening
• Supports opportunistic screening if patients are counselled
• Discussing PSA test
– When they present with associated symptoms
– When they come to discuss about a family member who has prostate
cancer or because they have read about PSA
However, a GP practice should NOT
- be sending invites out to men to have their PSA checked at a certain age

Question 5

What are teh issues for spa screening

Answer 5

• Over-diagnosis 
• Over-treatment 
• QoL
– Co-morbidities of established treatments 
• Cost-effectiveness 
• Other causes of raised PSA
– Infection
– Inflammation
– Large prostate
– Urinary retention

Question 6

Is a spa diagnostic of prostate cancer?

Answer 6

You can’t rely on a PSA within 6 weeks of a urinary infection
Having a normal PSA does not mean you do not have prostate cancer
You can have a normal PSA but an abnormal feeling prostate on DRE

Question 7

Describe the typical presentation of prostate cancer

Answer 7

• Urinary symptoms
• Bone pain (If mets. Prostate cancer mets to bone. Bone mets are sclerotic. )
• Had their PSA checked, then biopsied
• DRE for another reason
– e.g. change in bowel habit
• Incidental finding at transurethral resection of prostate (TURP) for retention/urinary symptoms

Question 8

Desribe the diagnostic pathway for prostate cancer

Answer 8

Digital rectal examination
(DRE)
Serum PSA
(Prostate specific antigen)
->
TRUS (transrectal ultrasound)- guided biopsy of prostate

Lower urinary tract symptoms
(LUTS) ->
Transurethral resection of prostate (TURP)

Question 9

What are the factors influencing treatment decisions

Answer 9

• Age 
• DRE
– Localised (T1/T2)
– Locally-advanced (T3)
– Advanced (T4) 
• PSA level (Higher psa - more advanced, more likely it has speread. But some hve normal psa and bad prostate cancer.neuroendocrine differentiated - not making as. They would have a highly abnormal Dre)
• Biopsies
– Gleason Grade
– Extent 
• MRI scan and bone scan
– Nodal & visceral metastases

Question 10

Describe the natural history of clinically localised prostate cancer

Answer 10

Ss

Question 11

Describe the localised restate cancer stretament

Answer 11

• Established Rxs
– Surveillance
– Robotic radical prostatectomy
– Radiotherapy
• External beam
• Brachytherapy - Brachy - extrenal - less target to other tissues
Over 65 but less than 80, no mets, high risk prostate cancer on Dre - favour radio

Question 12

Describe the treatment for locally advances prostate cancer

Answer 12

• Surveillance Deferred treatment - not neglect - if it increases a lot in a short time - need treatment. But if t deteriorated rapidly - need treatment
• Hormones
• Hormones & radiotherapy

Question 13

Describe the bone mets

Answer 13

• Bone metastases
– Sclerotic (Osteoblastic)
– ‘Hot spots’ on bone scan
– Highly unlikely if PSA <10 ng/ml

Question 14

Describe the treatment for metastatic prostate cancer

Answer 14

• Hormones (+-  chemotherapy)
- Surgical castration 
-  Medical castration
    - LHRH agonists
Want to reduce testosterone levels/ surgical castration?. Very uncommon nor away. Now done with lord agonists 

Pulsation gnrh - lh ascots on leydig cells -produce testosterone . Can give it - continuous release - more lh more testosterone - system gets worn out, less testosterone. Nee to give ablets in first 4 weeks to counteract fear - anti androgen tablet until flair is gone

• Palliation
• Single-dose radiotherapy 
• Bisphosphonates
 – Zoledronic acid 
• Chemotherapy (docetaxel) 
• New treatments (e.g. abiraterone, enzalutamide)