Station 2

Question 1

Man. Aged 74. PSA 8.6 mcg/L

History

Answer 1

Dedicated Raised PSA Clinic with CNS present

Focused History
Age/Racial Origin
LUTS
UTI
ED
Relevant Family History
Red Flags - Haematuria, Pain, Nocturnal Enuresis, Recurrent UTI, Back/Bony Pain, Neurological Symptoms, WL, Change in Appetite,

HPC - ?Previous BOO intervention, ?Previous Prostate Ca

PMH - ?Any metalwork, ?MRI safe pacemaker/valves
Performance Status

Question 2

Examine

Answer 2

General - Ethnicity, Age, Frailty, WL, Mobility Issues
Abdomen - Palpable Bladder
Rectal - Size, Consistency, Tenderness
Neurological exam if indicated

Question 3

Investigations

Answer 3

IPSS, Urine Dip, Flow Rate, Bloods ( U+E, INR)
MRI Prostate -> Consideration of transperineal prostate biopsies

IF PSA >20 - Bone Scan

Question 4

Close up initial consultation

Answer 4

Will be seen with results of MRI where we will consider further investigations. Give contact details of prostate cancer CNS team.

Question 5

Consent for prostate biopsy

Answer 5

Bleeding (Urine,Semen,Rectal), Bruising , Infection, Pain

<5% Urinary Retention, Temporary Erectile Dysfunction

<1% Repeat Biopsy, Missed Cancer, Clot Retention, Infection/Sepsis, Anaesthetic Risk,

Question 6

What is CPG?

Answer 6

Cambridge Prognostic Group Risk Stratification

1 - Gleason 6 and PSA <10 and T1-T2
2- Either Gleason 3+4 or [PSA 10 -20 micrograms/L and T1-T2]
3 - Either [3+4 and PSA 10-20 and T1-T2] OR [4+3 and T1-T2]
4 - Either [Gleason 4+4] OR [PSA >20] OR [T3]
5 - Either [ 2 or more of Gleason 8 / PSA>20 / T3] OR [Gleason 9-10] OR T4

Question 7

What is watchful waiting

Answer 7

Deferred palliative treatment - not suitable for men who would be considered for radical treatment

Indications:
<15 years life expectancy
Co- Morbidities
Low grade/stage
Patient choice

Question 8

What is Active Surveillance

Answer 8

Deferred Radical Treatment to preserve QOL

Indications:
Age 50-80
Fit
Life Expectancy >15 years
Low / Intermediate RIsk (PSA < 15, Gleason Score 3+4 or less, <50% Tumour burden)

Monitoring:
Year 1 - PSA 3-4 monthly, DRE 6-12 months, Repeat MRI 12 monhts
Year 2 - PSA 3-6 monthly, DRE 6-12 months
Year 5+ - PSA Every 6 months, DRE 12 months

My Trust:
Year 1 PSA - 6 monthly then MRIP at 12 months
Following on - > PSA 6 monthly -> MRI Q2

Question 9

What is Active Surveillance

Answer 9

Deferred Radical Treatment to preserve QOL

Indications:
Age 50-80
Fit
Life Expectancy >15 years
Low / Intermediate RIsk (PSA < 15, Gleason Score 3+4 or less, <50% Tumour burden)

Monitoring:
Year 1 - PSA 3-4 monthly, DRE 6-12 months, Repeat MRI 12 monhts
Year 2 - PSA 3-6 monthly, DRE 6-12 months
Year 5+ - PSA Every 6 months, DRE 12 months

My Trust:
Year 1 PSA - 6 monthly then MRIP at 12 months
Following on - > PSA 6 monthly -> MRI Q2

Question 10

What are radical treatment options in prostate cancer

Answer 10

Radical Prostatectomy
Radical Radiotherapy
Brachytherapy

Question 11

Treatment Options in prostate cancer (locally advanced)

Answer 11

Palliative
Radical Treatment Options

Question 12

Treatment Options in metastatic prostate cancer

Answer 12

Palliative
Low burden metastatic disease/pelvic LNs - Radical treatment options +* Radiotherapy to nodes* + hormones
Hormones Alone - (Bicalutamide for 7-14 days then LHRH Analogue Or Degaralex then LHRH after 2 months)
Consider adjuvant chemotherapy (as per STAMPEDE)