Prostate Cancer Flashcards
Risk Factors for Prostate Cancer
- Ancestry ?
- Family hx?
- Genetic mutations?
- Age?
Possible other risk factors? (3)
- Sub saharan ancestry such as african american men
- Having a father or brother w/prostate cancer > 2x a man’s risk –> risk higher if you have a BROTHER with the disease than if u have father w/disease
- BRCA 1 or 2, lynch syndrome
- older age! rises rapidly after age 50
- Environmental (incr risk with cadmium exposure)
- Diet (decr intake of vitamin D, lycopene, and beta carotene incr risk)
- Hormonal –> doesnt affect castrated men
What can you use as prevention ? (5)
State why these preventative measures arent necesarily the best
- 5 Alpha reductase inhibs –> incr risk of high grade prostate cancer + AE’s (Gynecomastia, ED) , no survival benefit
- Statins –> no evidence , good for lipids
- Metformin –> no evidence
- Selenium
- Vitamin E –> can actually incr incidence of prostate cancer
State the 2 screening modalities u can use for prostate cancer and why they may be controversial
What’s the process of deciding whether or not a patient should be screened?
- PROSTATE specific antigen (PSA)
-False positives
-Altered by meds (5AlphaRI’s, saw palmetto, androgen blockers) - DRE (digital rectal exam)
-High variable, most guidelines dont recc - Shared decision making involving patient ed and pros and cons –>screening can reduce incidence or mortality but risks of overdiagnosis and tx make long term survival outcomes questionable
When you have prostate cancer, what happens to the PSA levels?
Even if PSA is specific to prostate tissue it is not specific to ___?
WHat’s the normal PSA range?
What are the age specific reference ranges ?
40-49
50-59
60-69
70-79
Incr
cancer
<= 4 ng/mL
0-2.5
0-3.5
0-4.5
0-6.5
What are some clinical sx’s and presentation :
Localized Disease
Locally advanced disease
Advanced/Metastatic Disease
- asymptomatic
- hematuria, frequency, hesitancy, dribbling, incontinence
- back pain, fractures, anemia, weight loss
Principles of Therapy
1. Depends on ?
2. Risk incr with ? (3)
3. Tx options include ? (5)
- Risk of disease and expected survival time
- tumor size, PSA level , Primary gleason pattern and core # w/higher gleason pattern
- Active surveillance, observation, radical prostatectomy, radiation therapy , androgen depprivation therapy
With the goal of castrate levels of Testosterone at < 50 ng/mL in 1 month , what are the 4 options for androgen deprivation therapy ?
- Surgical castration = bilateral orchiectomy
- LHRH agonists
- LHRH antags
- Combined androgen blockade = LHRH agonist + anti-androgen
Between LHRH agonist Vs GnRH (LHRH) antagonist, which one rapidly decreases testosterone production ?
gnRH antag
LHRH AGONISTS
- Goserelin (Zoladex)
- Leuprolide (Lupron)
- Triptorelin (Trelstar)
WHat are the acute adverse events? T, G, H, E,E,I
Long term? O, C, O, I, A, I
How do u choose an agent?
For patients with overt metastasis, what should precede LHRH agonists and be continued in combo for at least 7 days to attenuate tumor flare?
Whats recc for all men over age of 50 yrs?
Acute : Tumor flare, gynecomastia, hot flashes, ED, edema, injection site rxns
Long : Osteoporosis, clinical fracture, obesity, insulin resistance, alt in lipids, incr risk of diabetes and CV events
Choice based on cost and pt /physician preference
Antiandrogen therapy
Calcium 1200 mg daily and vitamin d3 800-1000 IU daily
GnRH ANTAGS
- Degarelix (Firmagon) SQ
- Relugolix (orgovyx) PO
Acute AE’s?
Long Term?
Castrate levels are achieved in how long with Degarelix as compared to Leuprolide?
No ___ seen and no need for ___
gynecomastia, hot flashes, ED, edema, injection site rxns
Osteoporosis, clinical fracture, obesity, insulin resistance, alt in lipids, incr risk of diabetes and CV events , LFT abnormalities
7 days vs 28 days w/leuprolide
Tumor flare, antiandrogens
Anti-Androgens
- Monotherapy with antiandrogens is how effective in comparison to LHRH agonist therapy?
- not currently recc to be used alone unless?
- Flutamide AE’s?
- Bicalutamide 50 mg daily AE’s?
- Nilutamide AE’s ?
- less effective
- patient had a bilateral orchiectomy
- Diarrhea, and hematuria
- Diarrhea and hematuria (preferred due to side effect profile)
- diarrhea, disulfiram like rxn, decr visual accom (night vision) , Interstitial pneumonia
Adverse Effects of Androgen Deprivation Therapy
A, C,L,E,C,F,O,S,M,A
Arterial stiffness
cognitive decline
loss of libido
ED
Cardiovascular morbidity
Fatigue
Osteoporosis
Skeletal fractures
metab syndrome
alt body composition
CArdio-Metabolic Health
- Metabolic risk assessment prior to ADT initiation including the following?
- HOw often is the metabolic assessment during first 24 months ?
- Lifestyle interventions and or dietician to prevent ?
- Stop ___
- BP goals?
- Maintain ___
- BMI, waist circumf, BP, fasting BG, oral glucose tolerance test, fasting lipid profile
- 6 month to yearly
- prevent weight gain or worsening of insulin resistance
- smoking
- < 130/80 mm Hg
- lipid targets
Skeletal Health
- How often for DEXA scan?
- Regular ___
- Stop ___
- ALcohol consumption limited to ?
- total daily calcium intake of ?
- Vit D supp as necessary to achieve a target serum 25-hydroxyl vit D level of?
- TX with a BIPHOSPHONATE IN MEN WITH?
- yearly, during first 24 months of ADT
- physcial exercise
- smoking
- <= 2 standard drinks per day
- 1200-1500 mg thru diet, supps or both
- > = 30 ng/mL
- Minimal trauma fracture OR a BMD T score of <= -2.5 OR 10 yr absolute risk of a major osteoporotic fracture is > 20%
How much exercise should men get ?
Resistance training and weight bearing impact exercises
For those w/low muscle strength and or poor muscle function prior to commencing impact activities?
- resistance training at least 2 times per week
- Weight bearing impact exercises (jumping, hopping, skipping) at least 4 days per week , 2-4 impact exercises
- Aerobic exercises 5-7 days per week (30 mins)
