Prostate: Management Options Flashcards
When is active surveillance used as an option?
- Only in T1 and T2 stage cancers
- Localised
What is active surveillance?
- Monitors disease for low or intermediate risk
- Can only be on active surveillance if they are eligible for radical treatment in the future
- Can avoid or delay the surgery/treatment
- Regular PSA tests, MRI and biopsies
What is watchful waiting?
- Aim is to control rather than to cure
- for patients who are ineligible for radical treatment
- Involves deferred use of hormone therapy
- Less regular monitoring than active surveillance often via a GP
What are the disadvantages of watchful waiting/active surveillance?
- If fast growing, then may not be eligible for radical treatment
- Biopsies can lead to infection and side effects
- General health may deteriorate
- Anxiety
What is a radical prostatectomy?
- Removal of the entire prostate gland
- Laparoscopic surgery, robotic assisted or open surgery
What are the side effects of a radical prostatectomy?
- Urinary leakage/incontinence
- Erectile dysfunction
- <5% of patients will develop acute urinary retention which is a medical emergency
Who is offered a radical prostatectomy?
- Localised prostate cancers (T1 and T2)
- Patients with locally advanced prostate cancer are not usually offered the surgery
How is radiotherapy used to treat prostate cancer?
- Image guided IMRT or Vmat
- Convention = 74-78Gy in approx 39# in 7.5 weeks
- CHHiP trial changed to 60Gy in 20#s in 4 weeks
- High risk localised post-surgery = 66Gy in 33#
- Nodal 55-60Gy in 37#
What pre-treatment radiotherapy preparation might be used?
- Microenema to empty rectum
- Full bladder e.g. 3 cups in 20 minutes
Why are rectal spacers used?
- SpaceOAR to reduce bowel side effects by moving rectum out of the high dose region
- Made witha hydrogel liquid inserted through perineum under anaesthetic
- remains there for three months then is naturally absorbed by the body
What are the acute side effects of radiotherapy?
- Cystitis, nocturia or retention
- Radiation proctitis (diarrhoea, tenesmus, urgency, rectal bleeding)
- Radiaiton enteritis ( abdominal pain, bloating, nausea/vomiting, diarrhoea)
- Fatigue
- Sexual dysfuntion
What are late effects of radiotherapy?
- Urinary symptoms
- Faecal incontinence
- Sexual dysfunction
- Pelvic radiation disease
- Usually said to be 3 months later
When is brachytherapy used to treat prostate cancer?
- Used to achieve dose escalation
- Used for localised prostate cancer, T1 and T2
- Can also be used as a boost in T3 patients
When is hormone therapy used to treat prostate cancer?
- It is not curative
- Used adjuvant or neoadjuvantly
How does hormonal therapy work?
- ADT or androgen deprivation therapy reduces the level of androgens (testosterone) produced
- These are injected or implanted LHRH agonists or LHRH/GnRH antagonists
- Anti-Androgen drugs can block the effects of androgens on prostate cancer cells, these are in tablet form
- Could remove testicles to reduce testosterone too
How long are hormones typically taken?
- 3-6 months before RT, during or after
- Up to three years after treatment
- Can be lifelong in advanced cancers
What are the side effects of hormone therapy?
- Hot flushes
- Fatigue
- Mood Changes
- Alopecia
- Osteoporosis (bisohosphonates can be given)
- Cognitive issues
- Sexual Dysfunction
- Penis shortening
- Weight gain
- Breast swelling/tenderness
- Reduces strength and muscle mass
When is chemotherapy combined with hormone therapy?
- In advanced metastatic prostate cancer
- STAMPEDE Trial
- Chemo within 12 weeks of radiotherapy
- Dependent on patient fitness
What options are there for metastatic prostate cancer?
- Docetaxel chemo + hormone (STAMPEDE)
- Hormone alone
- RT ( no evidence that improved lifespan, but improved length of time without disease) 36Gy in 6 weeks
What is hormone-relapsed/resistant prostate cancer?
- Return of disease after hormone therapy
How does hormone-relapsed/resistant prostate cancer typically get treated?
- Anti-androgen tablets: Bicalutaminde (casodex)
- Sometimes in combi with LHRH agonist injection = combined androgen blockade
- Abiraterone
- Could have docetaxel chemo if they have not had it before
- Radium-223 injections to kill bone mets
- oestrogen tablets, rarer
What is the follow up procedure for prostate cancer?
- Follow up at 6-8 weeks, 12 weeks, six months
- PSA levels should be checked at six weeks then every six months and following that, once a year
- After six months, stable PSA = remote follow up
What is HIFU?
- High-intensity Focused Ultrasound
- New treatment
- Treats whole or local prostate area
- Low or intermediate risk locally advanced cases
- Not suitable for men with a large prostate
- Similar side effects to current treatment options
How does cryotherapy work for prostate cancer?
- Uses extreme cold
- Whole focal or salvage
- Localised low and intermediate cancers
