Prostate cancer

Question 1

Aetiology of prostate cancer

Answer 1

Malignant tumour of glandular origin - ADENOCARCINOMA

Question 2

How does prostate cancer evolve/develop

Answer 2

1. Localized prostate cancer: confined within the capsule and seldom causes symptoms.
2. Locally advanced prostate cancer extends beyond the capsule of the prostate and is often asymptomatic when diagnosed.
3. Metastatic prostate cancer most frequently affects the bones, where it causes pain and fragility fractures.

Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease.

Question 3

Risk factors for prostate cancer

Answer 3

Age >50
Afro-Caribbean/black ethnicity
Family history of prostate (greatest risk >2 first degree relatives)
BRCA2 gene
High fat diet

Question 4

epidemiology of prostate cancer

Answer 4

Most common cancer in males
Second most common cause of cancer mortality among men
Median age of diagnosis 66

Question 5

What is PSA

Answer 5

Prostate specific antigen
Protein secreted by epithelial cells of the prostate into the lumen of the duct -> joins seminal fluid -> discharged
Prevented from entering blood via the basement membrane but damage to the gland -> PSA leaks

Concentration > 4 ng/mL indicates possible prostate disease

Question 6

What can PSA be elevated in

Answer 6

Prostate cancer
BPH
Urinary retention
UTI
Catheterisation/instrumentation of urethra
(Post-biopsy
Post-DRE)

Question 7

Symptoms of prostate cancer

Answer 7

Asymptomatic in most/early stages

LUTS
- Storage: Frequency, urgency, nocturia,
- Voiding: hesitancy, dribbling, straining, intermittency, dysuria
Pain (lower back)
Erectile dysfunction
Bone pain, weight loss, lethargy, spinal cord compression (mets)
Urinary retention/renal failure
Visible Haematuria

Question 8

Signs of prostate cancer on examination

Answer 8

Digital rectal examination
Palpable prostate
Cancer - a hard gland, sometimes with palpable nodules
Benign enlargement - smooth, firm, enlarged gland

+/- lymphadenopathy

Question 9

Investigations for prostate cancer

Answer 9

PSA >4 micrograms/L (do not offer if asymptomatic)
Testosterone (when considering androgen deprivation)
LFTs (when considering androgen deprivation)
FBC (when considering androgen deprivation)
Renal screen (when considering androgen deprivation)

First line: multiparametric MRI
- Report using Likert scale
- Not routinely offered to those who will not be able to have radical treatment

Likert 3 or more -> biopsy
Lower -> consider biopsy

TRUST prostate biopsy
Isotope bone scan: ?mets
Plain x-rays: ?bone mets
Pelvic CT/MRI: lymph nodes, staging

Question 10

What are the cautions to PSA testing

Answer 10

Should NOT be done within:
6 weeks of a prostate biopsy
4 weeks following a proven urinary infection
1 week of digital rectal examination
48 hours of vigorous exercise
48 hours of ejaculation

Question 11

How is prostate cancer graded and staged

Answer 11

Staging: TNM
Grading: Gleason score (find 2 largest areas and score with 5 being most aggressive -> quote both scores and the sum)

Question 12

Management for prostate cancer

Answer 12

Prostate feels like cancer on DRE → Refer for 2ww pathway
MRI/biopsy negative → discuss at MDT meeting

Options:
Active surveillance
Watchful waiting
HIFU
Hormones
Chemotherapy
Radical prostatectomy
Radical radiotherapy

Question 13

Describe the active surveillance option for prostate cancer

Answer 13

Only tumours showing signs of progressing will be considered for radical treatment
Check the PSA every 3 months, annual DRE and multiparametric MRI
Re-biopsy years 1, 3, 7

Question 14

Describe the watchful waiting option for prostate cancer

Answer 14

Measure PSA levels at least once a year
Review by urological cancer specialist

Does NOT have repeat biopsies (differentiates from active surveillance)

Question 15

Describe the surgical options for prostate cancer

Answer 15

Open or laparoscopic radical prostatectomy
Measures PSA 6 weeks prior to treatment and every 6 months for 2 years

Question 16

Describe hormone therapy for prostate cancer

Answer 16

Prostate is androgen-dependent → i.e. requires testosterone for growth – produced by Testes (& adrenal gland)

Leuprolide - GnRH receptor agonist (synthetic agonist)
very high affinity for this receptor → initial large surge of LH → initial surge effect on testes -> desensitises the system

Flutamide - androgen receptor antagonist
Completely reduces the remaining androgen effect to almost zero

Question 17

Advantages and disadvantages of PSA testing

Answer 17

Early detection - PSA testing may lead to prostate cancer and detection means treatment before symptoms of progression
Early treatment - May extend life or facilitate a complete cure

15% of people have a normal PSA level but have underlying prostate cancer (False negative)
75% of people with raised PSA level have a negative biopsy (false positive) -> invasive investigations

Question 18

Complications of prostate cancer treatment

Answer 18

LHRH agonists -> tumour flares: temporary increase in testosterone-> spinal mets to flare → spinal cord compression. Therefore anti-androgens are given to cover for this, then removed when possible

TRUS biopsy
Sepsis (1 in 100)
Acute urinary retention
Severe haematuria
Severe rectal bleeding
Sexual dysfunction
Urinary incontinent
Androgen withdrawal: change in body shape, weight gain, tiredness, hot flushes, loss of libido, erectile dysfunction, gynaecomastia, loss of bone density

Question 19

Complications of prostate cancer

Answer 19

Local invasion:seminal vesicles, base of the bladder, urethral sphincter, or side wall of the pelvis.

Distant metastases:spreads to the bones, where it can cause pain, pathological fractures, or spinal cord compression.

Lower urinary tract symptoms (LUTS): By the time prostate cancer causes LUTS, it may be advanced and incurable.

Question 20

Prognosis for prostate cancer

Answer 20

Curable cancer, prognosis depends on stage at diagnosis

Stage 1-3: 5 year survival rate 96-100%

Mets (Stage 4): survival around 18 months