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Crit Care, Oncology & Hematology > Prostate Cancer > Flashcards

Prostate Cancer Flashcards

1
Q

What are risk factors for prostate cancer?

A

Race (Black)
Ethnicity (US, Scandinavia)
Age (>65)
Family Hx (first degree relative)

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2
Q

Why is prostate screening controversial?

A

There are benefits to screening but also the harm of overdiagnosis
Screening via PSA blood test w digital rectal exam
DO NOT screen past 70 yo! Not necessary!

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3
Q

What is the clinical presentation of locally invasive prostate cancer?

A

Ureteral dysfunction
Increased urinary frequency
Urinary hesitancy
Dribbling
Incomplete bladder emptying

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4
Q

What is the clinical presentation of advanced prostate cancer?

A

Back pain
Spinal cord compression
Leg edema
Pathologic fractures
Anemia
Weight loss

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5
Q

What are prognosis factors in prostate cancer?

A

Prostate-Specific Antigen (PSA)
Tumor SIZE + EXTENT
Histologic grade (Gleason score)

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6
Q

What kind of marker is PSA (prostate-specific antigen)?

A

Specific to the prostate but not for prostate CANCER
- Finasteride/dutasteride may decrease
- BPH may increase
Even WNL PSA people still get cancer
PSA > 10 ng/mL = higher risk of prostate cancer

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7
Q

How is prostate cancer staged?

A

Tumor: based on imaging and digital rectal exam
Node: are regional lymph nodes affected? [NX = not assessed, N1 = yes N0 = no]
Metastasis: M0 = no metastasis, M1 = yes metastasis

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8
Q

How does the Gleason Score work in prostate cancer? What score is “low risk” and what is “high risk”?

A

Defined by how prostate cells look under a microscope
Observes first + second most predominant pattern (sum)
Score 1-5 each, lower is better

LOW risk ≤ 6
HIGH risk ≥8

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9
Q

If a prostate cancer patient has VERY LOW recurrence risk with < 10 years expected survival, what treatment should be initiated?

A

Observation

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10
Q

If a prostate cancer patient has VERY LOW recurrence risk with 10-20 years expected survival, what treatment should be initiated?

A

Active surveillance

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11
Q

If a prostate cancer patient has VERY LOW recurrence risk with ≥20 years expected survival, what treatment should be initiated?

A

Active surveillance (preferred)
RT/brachytherapy
Prostatectomy

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12
Q

If a prostate cancer patient has LOW recurrence risk with < 10 years expected survival, what treatment should be initiated?

A

Observation

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13
Q

If a prostate cancer patient has LOW recurrence risk with ≥10 years expected survival, what treatment should be initiated?

A

Active surveillance (preferred)
RT/brachytherapy
Prostatectomy

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14
Q

If a prostate cancer patient has FAVORABLE INTERMEDIATE recurrence risk with 5-10 years expected survival, what treatment should be initiated?

A

Observation (preferred)
RT/brachytherapy

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15
Q

If a prostate cancer patient has FAVORABLE INTERMEDIATE recurrence risk with ≥10 years expected survival, what treatment should be initiated?

A

Active surveillance
RT/brachytherapy
Protectomy +/- pelvic lymph node dissection

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16
Q

If a prostate cancer patient has UNFAVORABLE INTERMEDIATE recurrence risk with 5-10 years expected survival, what treatment should be initiated?

A

Observation
RT + androgen deprivation therapy
RT + brachytherapy +/- androgen deprivation therapy

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17
Q

If a prostate cancer patient has UNFAVORABLE INTERMEDIATE recurrence risk with ≥10 years expected survival, what treatment should be initiated?

A

Protectomy + pelvic lymph node dissection
RT + androgen deprivation therapy
RT + brachytherapy +/- androgen deprivation therapy

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18
Q

If a prostate cancer patient has HIGH or VERY HIGH recurrence risk with ≤ 5 years expected survival AND asymptomatic, what treatment should be initiated?

A

Observation
Androgen deprivation therapy
RT

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19
Q

If a prostate cancer patient has HIGH or VERY HIGH recurrence risk with >5 years expected survival OR symptomatic, what treatment should be initiated?

A

RT + androgen deprivation therapy
RT + brachytherapy + 1-3 yrs androgen deprivation therapy
RT + androgen deprivation therapy + ABIRATERONE
Prostectomy + pelvic lymph node dissection

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20
Q

If a patient has LOCALLY INVASIVE prostate cancer with ≤ 5 years expected survival AND asymptomatic, what treatment should be initiated?

A

Observation
Androgen deprivation therapy

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21
Q

If a patient has LOCALLY INVASIVE prostate cancer with > 5 years expected survival OR symptomatic, what treatment should be initiated?

A

RT + androgen deprivation therapy + abiraterone
RT + androgen deprivation therapy
Androgen deprivation therapy +/- abiraterone
Prostectomy + pelvic lymph node dissection

22
Q

If a patient has ADVANCED prostate cancer, is CASTRATE NAÏVE with NO METASTASIS, what treatment should be initiated?

A

Monitoring
ADT

23
Q

If a patient has ADVANCED prostate cancer, is CASTRATE NAÏVE with METASTASIS, what treatment should be initiated?

A

ADT:
+ Abiraterone OR Enzalutamide OR Apalutamide
+ Docetaxel x 6 cycles + [Abiraterone or Darolutamide]

24
Q

If a patient has ADVANCED prostate cancer, is CASTRATE RESISTANT with NO METASTASIS, what treatment should be initiated?

A

ADT plus:
- PSA doubling time > 10 months = MONITOR
- PSA doubling time ≤ 10 months = Apalutamide/Darolutamide/Enzalutamide

25
Q

If a patient has ADVANCED ADENOCARCINOMA prostate cancer, is CASTRATE RESISTANT with METASTASIS, what treatment should be initiated? [WORST]

A

Adenocarcinoma
ADT plus:
- Abiraterone
- Enzalutamide
- Docetaxel x 6 cycle
- Sipuleucel-T
- Radium 223

26
Q

If a patient has ADVANCED SMALL CELL prostate cancer, is CASTRATE RESISTANT with METASTASIS, what treatment should be initiated? [WORST]

A

Chemotherapy
- Cisplatin/etoposide
- Carboplatin/etoposide
- Docetaxel/carboplatin
- Cabazitaxel/carboplatin

27
Q

What is the GOLD STANDARD treatment for prostate cancer?

A

Androgen Deprivation Therapy
Surgical (bilateral orchiectomy)
OR
Medical (LH releasing hormone agonist +/- antiandrogen)

28
Q

What is the goal serum testosterone after one month of ADT in prostate cancer?

A

Goal: testosterone < 50 ng/dL after one month

29
Q

Name the FOUR LHRH agonists

A

Goserelin
Leuprolide
Triptorelin
Histrelin (implant)
[monthly/multimonthly injections]

30
Q

What are some ACUTE AEs of LHRH agonists?

A

Tumor flare, hot flashes, erectile dysfunction, edema, gynecomastia, injection site reaction (like menopause for men)

31
Q

What are some LONG-TERM AEs of LHRH agonists?

A

Osteoporosis, clinical fracture, obesity, insulin resistance, increased risk of diabetes, CV events, hyperlipidemia

32
Q

Why do LHRH agonists have tumor flares when it should be decreasing the tumor?

A

Initial tumor flare caused by a surge in LH/FSH release

33
Q

What kind of test should be done before starting long-term ADT in prostate cancer?

A

Baseline bone mineral density test before starting longterm ADT
Vitamin D + calcium supplementation

34
Q

Name the 2 LHRH ANTagonists used in prostate cancer. What is the MoA?

A

Degarelix
Relugolix
MOA: binds reversibly to receptors in pituitary gland, dramatically reducing LH/FSH

35
Q

What are the three FIRST GEN ANTIANDROGENS? What are some AEs of these drugs? What is monitored?

A

Bicalutamide
Flutamide
Nilutamide

ADEs = diarrhea, gynecomastia, increased LFTs, hot flashes
Monitoring = LFTs monthly, serum testosterone, PSA, pulmonary function (nilutamide)

36
Q

What are the three SECOND GEN antiandrigens? Can these be used in metastasis or not?

A

Apalutamide (non-metastatic)
Enzalutamide (non-metastatic AND metastatic)
Darolutamide (non-metastatic)

37
Q

What is the MOA and some AEs of antiandrogen APALUTAMIDE for advanced prostate cancer? What did the SPARTAN trial find about this drug?

A

MOA: Nonsteroidal androgen receptor inhibitor
AEs: Fatigue, HTN, rash, diarrhea, nausea, arthralgias, fracture risk, peripheral edema

SPARTAN trial = increased falls and fractures, with a small number of people developing seizures!

38
Q

What is the MOA of antiandrogen DAROLUTAMIDE for advanced prostate cancer? What are some AEs? Should it be taken with or without food? Do any dose adjustments need to be made? What did the ARAMIS trials find?

A

MOA: Competitive androgen receptor inhibitor
AEs: fatigue, HTN, rash
WITH FOOD
Dose adjust for renal impairment
ARAMIS trial = NO increase in seizures!

39
Q

What is the MOA of antiandrogen ENZALUTAMIDE for advanced prostate cancer? What are some AEs? Do any dose adjustments need to be made? What did the AFFIRM trial find?

A

MOA: pure androgen receptor signaling inhibitor
AEs: diarrhea, fatigue, headache, myalgias, edema
Dose adjustment for CYP2C8 inhibitors/CYP3A4 inducers
AFFIRM trial showed increase risk of seizures!

40
Q

If a patient with metastatic prostate cancer has NOT had prior docetaxel and NO prior hormone therapy, what treatments are preferred?

A

Abiraterone
Docetaxel
Enzalutamide
(Consider: radium-223, olaparib/niraparib, Sipuleucel-T)

41
Q

If a patient with metastatic prostate cancer has NOT had prior docetaxel and HAS prior hormone therapy, what treatments are preferred?

A

Docetaxel
Olaparib/Rucaparib

42
Q

If a patient with metastatic prostate cancer has HAD prior docetaxel and NO prior hormone therapy, what treatments are preferred?

A

Abiraterone
Cabazitaxel (docetaxel alternative)
Enzalutamide

43
Q

If a patient with metastatic prostate cancer has HAD prior docetaxel and HAD prior hormone therapy, what treatments are preferred?

A

Cabazitaxel (docetaxel alternative)
Docetaxel rechallenge

44
Q

In what cases may RADIUM-223 be considered in prostate cancer?

A

Symptomatic bone metastasis from prostate cancer

45
Q

In what cases may SIPULEUCEL-T be considered in prostate cancer?

A

Asymptomatic but METASTATIC (not to liver) with life expectancy > 6 months and good performance status

46
Q

What drug must be taken adjunctively with docetaxel? What are some AEs of docetaxel? in what organ dysfunction should we use caution?

A

Adjunctive PREDNISONE
AEs: myelosuppression, alopecia, edema, peripheral neuropathy
Caution in hepatic impairment

47
Q

What is the MOA of abiraterone?

A

Irreversibly inhibits CYP17 (enzyme for androgen synthesis)
Inhibits formation of testosterone precursors

48
Q

What are some AEs of abiraterone? What drug should be used adjunctively? What should we monitor?

A

AEs: diarrhea, edema, increase K+, HTN, hepatotoxicity, increased triglycerides
Adjunctive STEROIDS (prednisone or MPS)
Monitor: LFTs, K+ & phosphate, BP monthly

49
Q

What is olaparib in prostate cancer?

A

Selectively inhibits poly (ADP-ribose) polymerase (PARP) enzymes, which aid in DNA repair
[by stopping DNA repair, allows other agents to effectively destroy cells]

50
Q

Why is cabazitaxel second line to docetaxel in prostate cancer treatment?

A

Cabazitaxel has poor afinity for multidrug resistant proteins and therefore does not work in all tumor types
Also has severe ADEs (febrile neutropenia, mucositis)

51
Q

In what VERY specific type of prostate cancer could we use Lu-177–PSMA-617 (Pluvicto)?

A

PSMA-positive metastatic castration-resistant prostate cancer

52
Q

Bone metastasis is fairly common in prostate cancer. How would you supportively treat this?

A

Zoledronic acid
Denosumab

Crit Care, Oncology & Hematology (18 decks)

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