Prostate cancer

Question 1

RF?

Answer 1

Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids

Question 2

Presentation ?

Answer 2

Prostate cancer may be asymptomatic. It may also present with lower urinary tract symptoms (LUTS), similar to benign prostate hyperplasia. These symptoms include hesitancy, frequency, weak flow, terminal dribbling and nocturia.

Other symptoms include:

Haematuria
Erectile dysfunction
Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)

Question 3

Investigation?

Answer 3

Prostate-specific antigen testing may lead to the early detection of prostate cancer, potentially leading to effective treatment and preventing significant problems. However, research has failed to show that the benefits of using PSA for screening outweigh the risks. In the UK, men over 50 can request a PSA test if they would like one.

PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

exam -> A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule. Any of these features can indicate prostate cancer and warrant further investigation. In primary care, these findings require a two week wait urgent cancer referral to urology.

Prostate biopsy is the next step in establishing a diagnosis. The decision to perform a biopsy depends on the MRI findings (e.g., Likert 3 or above) and the clinical suspicion (i.e. examination and PSA level).

An isotope bone scan (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.

Question 4

Gleason Grading System

Answer 4

The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).

The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):

The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy

A Gleason score of:

6 is considered low risk
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
8 or above is deemed to be high risk

Question 5

TNM Staging for Prostate Cancer

Answer 5

T for Tumour:

TX – unable to assess size
T1 – too small to be felt on examination or seen on scans
T2 – contained within the prostate
T3 – extends out of the prostate
T4 – spread to nearby organs

N for Nodes:

NX – unable to assess nodes
N0 – no nodal spread
N1 – spread to lymph nodes

M for Metastasis:

M0 – no metastasis
M1 – metastasis

Question 6

Management

Answer 6

Depending on the grade and stage of prostate cancer, treatment can involve:

Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery

A key complication of external beam radiotherapy is proctitis (inflammation in the rectum) caused by radiation affecting the rectum. Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.

Brachytherapy involves implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

Hormone therapy aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible. The options are:

Androgen-receptor blockers such as bicalutamide
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Bilateral orchidectomy to remove the testicles (rarely used)

Side effects of hormone therapy include:

Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis

Radical prostatectomy involves a surgical operation to remove the entire prostate. The aim is to cure prostate cancer confined to the prostate. Key complications are erectile dysfunction and urinary incontinence.