Treatment and pre-meds

Question 1

Treatment decision

Answer 1

Based on stage, gleason score, life expectancy, and patient preference

Question 2

Observation

Answer 2

Elderly of frail men with comorbidities likely out-competing prostate cancer
Monitor w/ expectation to deliver palliative therapy for symptoms

Question 3

Active surveillance

Answer 3

Actively monitor with expectation to intervene if cancer progresses
Men with >10 yrs life expectancy

Question 4

EBRT

Answer 4

External beam radiation therapy

Question 5

Brachytherapy

Answer 5

You’re inserting a needle into the prostate that seeds it with radioactive seeds- avoids side effects from ebrt

Question 6

RP

Answer 6

Radical prostatectomy
Curative therapy for tumors confined to prostate and life expectancy 10+ years
Urinary incontinence, impotence SIGNIFICANTLY reduced w/ robotic surgery
Don’t do open surgery.

Question 7

ADT

Answer 7

Androgen deprivation therapy

Goal: testosterone <50 ng/ml

Question 8

ADT: LHRH agonists

Answer 8

Goserelin
Leuprolide
Triptorelin
Equivalent efficacy and toxicity.
Precede with anti-androgen or continue in combo X 7 days to prevent tumor flare.
Acute: gynecomastia, hot flashes, ED, edema, injection site reactions
Long-term: osteoporosis, obesity, insulin resistance, lipid alterations, increased CV events

Question 9

ADT: LHRH antagonist

Answer 9

Degarelix
Faster at achieving castrate levels (7d vs 28d) compared to LHRH agonist, no tumor flare
Injection site reactions

Question 10

Anti-androgens

Answer 10

ONLY used in combo with LHRH agonist to reduce tumor flare
Flutamide, bicalutimide, nilutamide
All cause diarrhea

Question 11

Recurrence

Answer 11

Treat with surgery or radiation if you haven’t done that before. Treat with hormonal therapy.
If you started with hormonal therapy- anti-androgen withdrawal followed by hormonal therapy.

Question 12

Castration resistant

Answer 12

Testosterone <20 ng/mL and still progressing.
Docetaxel + prednisone

Abiraterone + prednisone, hyperkalemia, HTN, fluid overload, renin suppression; may be used for docetaxel-refractory CRPC too.

Enzalutamide- first line and docetaxel-refractory CRPC.

Sipuleucel-T $$$$$$$$$$

Cabazitaxel + prednisone is second line, febrile neutropenia risk.

Question 13

Stage I/II

Answer 13

Observation/AS
RP
RT (EBRT or brachytherapy)

Question 14

Stage III

Answer 14

Observation/AS
RP + adjuvant RT
EBRT +/- ADT
ADT

Question 15

Stage IV

Answer 15

*ADT

RT in highly selected patients
Chemotherapy
Immunotherapy
Palliative RT/surgery