Flashcards in BPH and Prostate Cancer, PSA Screening Deck (40)
A 51 y/o caucasian male is at his PCP for his annual physical. He has a family hx of prostate cancer (father, diagnosed at age 74). Would you order a PSA screening for this patient?
A 57 y/o healthy caucasian male with no hx of prostate cancer. Should you order a PSA?
Should you order a PSA on a 55 y/o African American male with no family history of prostate cancer?
What is PSA?
- serine protease of the kallikrein family primarily produced by prostatic luminal epithelial cells. It cleaves seminogelin (semen liquefaction).
- found within serum as bound and unbound forms.
What conditions can elevate PSA?
- prostate CA
- infections (prostatitis, cystitis)
- manipulation or trauma
What factors can reduce PSA?
- 5-alpha reductase inhibitors
- low serum testosterone
- prostatic surgery
- radiation therapy
Is PSA screening recommended in men over age 70?
NO, bc most would die without symptoms due to prostate cancer found at this time.
What are the benefits of PSA screening?
- early detection
- may prolong survival
What are the disadvantages of PSA screening?
- over-detection of indolent disease
- false positives
- testing associated with morbidity
What did the PLCO trial find?
- no survival benefit for PSA based screening
*flaws however due to pre-screening and contamination in control arm (75% were screened at least once).
What did the ERSPC trial in Europe show?
- 21% reduction in death in screened group
*flaws due to contamination issue
Is there a universal consensus for threshold for "elevated" PSA?
NO bc there is a trade off between sensitivity and specificity.
*must be adjusted to age and ethnicity.
How can we better diagnose the high risk cancers without over treating the low risk cancers?
- blood tests
*aka there are other modalities available.
What is the prostate health index (PHI)?
- mathematical formula that combines total, free, and proPSA to help in your decision making process.
What is the 4K score?
- panel of 4 serum kallikrein markers (tPSA, fPSA, single chain iPSA, and hK2) that can be found in your blood.
*good test but expensive.
What is ConfirmMDX?
- epigenetic assay of tissue biopsy looking for methylation changes associated with cancer.
*96% negative predictive value
What is PCA3?
- urine test that looks at non-coding, large chain RNA that is highly over-expressed in prostate cancer compared with noncancerous prostate tissue.
- independent of age, prostate volume, and PSA.
**** What would we expect to see now that the the newest USPSTF guidelines recommend against PSA testing? (TEST QUESTION)
- higher risk of finding patients with advanced stage prostate cancer
**** What race has the highest risk for prostate cancer? (TEST QUESTION)
- African Americans
**** To where does most prostate cancer metastasize? (TEST QUESTION)
- bone (osteoblastic)
**** How do you treat localized vs metastatic prostate cancer? (TEST QUESTION)
- localized= localized treatment (active surveillance, surgery, or radiation)
- metastatic= systemic treatment (chemotherapy)
How would you pick up prostate cancer?
- rectal exam (DRE) and abnormal PSA
What do symptoms such as bleeding, flank pain, or back pain usually indicate in relation to prostate cancer?
- late stage disease :(
What is the trifecta goal of treatment?
- oncologic control
- maintenance of erectile function
What are some newer treatment options for metastatic prostate cancer?
- immunotherapy= sipuleucel
- radium 223
- abiraterone= CYP17 lyase inhibitor (must be taken with prednisone)
- enzalutamide= ARB with high affinity for androgen receptor
Is surgical therapy generally preferred for older or younger patients with localized cancer?
Is radiation therapy generally preferred for older or younger patients for localized cancer?
- OLDER (70 and up)
What is Benign Prostatic Hyperplasia (BPH)?
- a PHYSIOLOGIC increase in the number of prostatic STROMAL and EPITHELIAL cells that commonly contribute to lower urinary tract symptoms (LUTS) in aging men.
What are LUTS?
- symptoms that include poor stream, intermittent stream or hesitancy, terminal dribbling, straining, urgency, nocturia, and sensation of incomplete bladder emptying.
Does the size of the prostate always correlate with the degree of symptoms?
**** Where in the prostate does BPH typically occur? (TEST QUESTION)
- the TRANSITIONAL ZONE
*contrast this to prostate cancer which occurs in the peripheral zone.
**** Will alpha blockers (nonselective= terazosin, doxazosin, alfuzosin; or selective= tamsulosin and silodosin) or tadalafil (PDE5 inhibitor; cialis) affect your PSA? (TEST QUESTION)
**** Will 5-alpha reductase inhibitors (finasteride or dutasteride) affect your PSA? (TEST QUESTION)
**** What are the indications for surgical treatment for patients with BPH?
- urinary retention
- gross hematuria
- bladder or renal calculi stones
- renal insufficiency or hydronephrosis
- failed medical management
What is the function of the prostate?
- to secrete certain enzymes into semen to facilitate sperm survival in the female reproductive tract.
*prostatic secretions have a large concentration of ZINC compared to blood.
-also aids in emission of semen during ejaculation by contracting around the urethra.
What are the main receptors found in the prostatic stroma?
- alpha-1A receptors= contraction of smooth muscle and leads to restriction of urine flow
What medications can exacerbate urinary retention?
- anticholinergics (atropine, oxybutynin, dicycloamine, glycopyrrolate...)
- antihistamines (diphenhydramine, hydroxyzine, chlopheniramine...)
- antidepressants (TCAs)
- sympathomimetics (alpha-adrenergic agonists; ephedrine, phenylephrine)
What should be on your DDx for a patient that comes in with lower urinary tract symptoms (LUTS)?
- bladder stones
- neurogenic bladder
- urethral stricture (scar tissue)
- bladder cancer
What is a complication associated with the use of selective alpha blockers like Tamsulosin (Flowmax) or nonselective alpha blockers?
- intraoperative floppy iris syndrome (IFIS).
*basically not a problem, but if going to the eye doctor, let them know before any eye surgery.