Onc - Prostate Flashcards
What are key risk and age groups relevant to making an initial recommendation for PSA screening?
Family history, brother, uncle.
African American race
Age 55-69 (AUA), 45-75 (NCCN)
How often should PSA screening be repeated?
Every 2 years, depending on baseline PSA
Which low risk groups may not benefit from PSA screening?
<10-15 years life expectancy
Age <40
Age >75 years
What are the benefits of PSA screening expressed as number of deaths averted per 1000 men from a key RCT? What RCT refutes this?
ERSPC - 1 death fewer per 1000 men screened
PLCO - showed no benefit in screening (however >90% of “control” patients had at least one PSA
How do you improve the specificity of the PSA test?
Combining with secondary biomarkers:
4K, PHI, Exosome, Select MDX
What are the potential harms (and approximate percentage of each) for screening patients for prostate cancer?
Over diagnosis: 66% (ERSPC), 23-43% (SEER)
Hematuria/hematospermia: 20-50%
Fever, pain, bleeding, urinating problems: 33%
Sepsis: 3-4%
Psychological impact
What factors may trigger a prostate biopsy?
PSA >3 (ERSPC)
Age (55-69)
Abnormal DRE
Is there any evidence in favor of trying to lower PSA with antibiotics in an asymptomatic patient?
No
Why is PSA not recommended for men between 40-54 years old?
ERSPC and PLCO trials did not study this age group sufficiently
For a motivated man >70 years old who wants to be screened, what may be additional guidance on triggers?
Increase threshold to PSA >10 (PIVOT study).
Stop screening if PSA <3.
Describes steps to prepare for a biopsy and biopsy scheme.
Informed consent: include risk of bleeding, hematuria, hematospermia, infection, sepsis and discomfort.
Blood thinners: discuss which should be held
Antibiotic prophylaxis for all patients: Single dose fluoroquinolone is effective as 3d dosing or Bactrim
12-13 core bx: sextant including lateral biopsies
Use lidocaine for local anesthesia
When is MRI fusion biopsy indicated?
Indicated after a negative biopsy but persistently elevated PSA.
May consider at first biopsy.
If MRI visible lesions are present, MRI targeted bx may be performed.
What is the associated prostate cancer risk with positive mpMRI lesion?
34-68%
What are the two RCT that looked at MRI guided biopsy in detecting prostate cancer?
PROMIS
PRECISION
What did PROMIS and PRECISION (RCTs) show in terms of detecting significant cancer with mpMRI as compared with standard TRUS bx?
mpMRI had a higher sensitivity and was more effective in detecting high risk disease than standard TRUS bx. mpMRI bx detected fewer indolent cancers
What did the PROMIS RCT show?
mpMRI may allow 27% of men to avoid primary bx and diagnose 5% fewer clinically insignificant cancers. mpMRI was more sensitive (93%) and less specific (41%) at detecting clinically significant G4+3 cancer
What did PRECISION RCT show?
Clinically significant cancer was detected in 38% of men in the MRI targeted bx group as compared with 26% in the standard biopsy group.
How would you manage a patient who is at high risk for sepsis (on chronic antibiotics)
Consider preprocedure rectal swab culture and tailor ppx abx.
Describe management considerations for an orthopedic joint prosthesis:
Abx: single dose fluoroquinolone +am/gent
- use in first 2 years of joint replacement
- use in immunocompromised patient with prosthetic joint
- use if prosthetic joint and comorbidities ie HIV, DM
Describe risks/recommendation for a fluoroquinolone
- associated with increased risk of tendinitis and tendon rupture
- higher risk in patients over 60, or transplant patient on steroids
- stope med at first sign of tendon pain/swelling/inflammation
How would you manage post prostate biopsy patient with gross hematuria, lower abdominal pain and fever >101.5, chills and rigors?
Send to ED
Empiric broad spectrum abx, assuming fluoroquinolone-resistant sepsis
Admission with 1-2 weeks abx per cultures
Rule out clot retention
