PSA / Prostate Cancer

Question 1

Where is the prostate located?

Answer 1

Just below the bladder, in front of the rectum and surrounds the urethra.

Question 2

Prostate cancer is the most common cancer in men - true or false?

Answer 2

True

Question 3

How many men are affected by prostate cancer at some point in their life?

Answer 3

1 in 8

Question 4

Prostate cancer is the 3rd most common cause of cancer death - true or false?

Answer 4

True

Question 5

What is the mean age of diagnosis for prostate cancer?

Answer 5

72y

Question 6

What percentage of men in their 80s have prostate cancer on routine post mortem?

Answer 6

67%

Question 7

What percentage of men due due to prostate cancer?

Answer 7

3%

Question 8

Name the top 4 most common cancers (in order)

Answer 8

breast
lung
prostate
bowel

Question 9

Name the top 5 causes of cancer death (in order)

Answer 9

lung 
bowel
breast
prostate
pancreas

Question 10

When did PSA testing get introduced? How has this impacted mortality?

Answer 10

1986 - became popular in 1990’s so we can see a decrease in prostate cancer mortality from the 90s

Question 11

What type of tumour is prostate cancer? Where in the prostate does it occur?

Answer 11

adenocarcinoma and occurs in the peripheral zone of the prostate

Question 12

Where can prostate cancer metastasise to?

Answer 12

lymph nodes and bone - sclerotic metastases

occasionally to lung, liver and brain.

Question 13

Who is at risk of prostate cancer? (3)

Answer 13

• men over 50, risk increases as age increases
• black men
• those with positive family hx are 2.5x more likely

Question 14

Symptoms of prostate cancer? (6)

Answer 14

• asymptomatic
• difficulty urinating / hesitancy
• nocturia
• frequent urination and poor stream
• post-micturition dribbling
• new pain in back, hips or pelvis.

Question 15

Does prostate cancer always need to be treated?

Answer 15

• Prostate cancer often grows slowly and has a low risk of spreading and therefore, the decision might be made by patient and doctor to monitor the cancer instead with regular check ups. This is particularly because the side effects associated with treatment can have significant impact on patient’s lives such as difficulty getting an erection, urinary and bowel problems.
• The PSA test is not good at differentiating slow or fast growing cancers so usually investigations are needed to determine if treatment should be started or if watchful monitoring is better

Question 16

What is the PSA test? What is it measuring?

Answer 16

Blood test which measures the amount of prostate specific antigen (PSA) in the blood.

Question 17

What is prostate specific antigen? Where is it produced?

Answer 17

Serine protein responsible for the liquefaction of semen.
It is produced by normal cells in the prostate but also by prostate cancer cells.

It is normal to have small amounts of PSA and the amount normally rises with age as the prostate naturally enlarges slightly.

Question 18

Why is PSA not cancer specific?

Answer 18

It is produced by the prostate normally too so an enlarged prostate will also have increased levels of PSA

Question 19

What percentage of men with elevated PSA will not have prostate cancer?

Answer 19

70%

Question 20

What percentage of men with a NORMAL PSA WILL have prostate cancer?

Answer 20

6%

Question 21

Does the prevalence of prostate cancer increase as the level of PSA increases?

Answer 21

Yes - when PSA <1ng the prevalence of cancer is only 6% whereas if PSA level is >100 there is a 99% chance there is prostate cancer.

Question 22

Who is eligible for PSA testing?

Answer 22

• Any male patient over 50 and thought about the advantages and disadvantages
• Men over 45 with higher risk of prostate cancer (black or family hx)

Question 23

What problems can the PSA test indicate?

Answer 23

Enlarged prostate
Prostatitis
Prostate cancer

Question 24

What other things can raise PSA levels - what can we do to minimise the chances of these things interfering with the results?

Answer 24

• Urine infection - treat infection and repeat 6weeks later
• Vigorous exercise (especially cycling avoid for 48hr)
• Ejaculation (avoid sexual activity 48hr before test)
• Anal sex and prostate stimulation (avoid for a week before PSA test)
• DRE may stimulate prostate
• Prostate biopsy - up to 6 weeks before PSA test
• Medication - finasteride or dutasteride which is used to treat enlarged prostate may give a falsely low PSA level.

Question 25

Name some advantages and disadvantages of PSA testing

Answer 25

• *Advantages**
• Commonest cancer in men with about 15% life time risk
• 3rd most common cause of cancer death, 10,000 deaths per year in UK
• Helps to pick up prostate cancer before symptoms
• May help pick up a fast growing cancer at an early stage when treatment can stop cancer spreading
• Regular PSA tests can be helpful for those more at risk of prostate cancer
• *Disadvantages**
• Raised PSA can occur even without prostate cancer
• 6% of men with prostate cancer will have a normal PSA
• 70% of men with a raised PSA will not have cancer
• Following on from the PSA test can involve biopsies which can be painful & cause infection
• Might be diagnosed with slow-growing prostate cancer which would have never caused any problems or shortened their life and cause unnecessary worry and unnecessary treatment
• Treatments have side effects (urinary, bowel and erection problems)

Question 26

What is the risk/benefit analysis of PSA testing?

Answer 26

Every 1000 men screened by PSA - 100 men proceed to biopsy - 1 hospitalised with sepsis.
30 men treated for prostate cancer - 3 develop incontinence and 15 will have sexual dysfunction.
1 life saved.

Conclusions: harms from prostate cancer screening using PSA are currently likely to outweigh the benefits.

Question 27

What does a Gleason score between 2-6 mean?

Answer 27

Low grade and likely slow growing

Question 28

What does a Gleason score of 7 mean?

Answer 28

Intermediate grade and moderate growth

Question 29

What does a Gleason score between 8-10 mean?

Answer 29

High grade and likely to grow quickly

Question 30

Treatment options for prostate cancer

Answer 30

Depends on individual and a lot of time, treatment is not needed.

1. Watchful waiting - no treatment and follow up if symptoms occur for very slow growing tumours which are asymptomatic
2. Active surveillance - regular check up’s to track the progression and stepping in if there is any further progress to avoid treatment until necessary.
3. Radiotherapy (slows progression of prostate cancer that’s spread and relieves symptoms - side effects include hair loss, diarrhoea, tiredness, discomfort, cystitis. Brachytherapy is a form of radiotherapy which is directed to the prostate itself)
4. Surgery (radical prostatectomy - side effects include erection problems and incontinence)
5. Hormone therapy - often used in combination with radiotherapy (goserelin implant injected under the skin and stops pituitary making LH which stops the testes making testosterone). Anti-androgen medicines (flutamide and cyproterone)
6. Chemotherapy is rarely used for prostate cancer but is used for prostate cancer which has spread and is used palliatively.

Question 31

Treatment of localised prostate cancer?

Answer 31

Can either cure or observe - up to patient and clinician to discuss
- treatment options: surgery (radical prostatectomy, laptroscopic), radiotherapy, observation.

Question 32

Arguments for and against radical treatment for localised prostate cancer.

Answer 32

For

• curative treatment
• high mortality in prostate cancer
• reduced patient anxiety
• reduces metastases and disease progression by half

Against

• disease of the elderly
• competing causes of death
• 30% men with prostate cancer die of prostate cancer
• adverse effects of treatment