Prostate Cancer

Question 1

risk factors

Answer 1

race/ethnicity, age, family history

Question 2

clinical presentation of localized disease

Answer 2

asymptomatic

Question 3

clinical presentation of locally invasive disease

Answer 3

-ureteral dysfunction
-urinary frequency
-urinary hesitancy
-dribbling or decreased stream
-incomplete bladder emptying

Question 4

clinical presentation of advanced disease

Answer 4

-back pain
-cord compression
-lower extremity edema
-pathologic factures
-anemia
-weight loss

Question 5

prognostic factors

Answer 5

-prostate specific antigen (PSA)
-tumor size and extent of primary tumor
-histologic grade (Gleason score)

Question 6

goals of therapy

Answer 6

localized: control disease and symptoms, decrease morbidity and mortality
advanced: palliation, improve qol, prolong survival

Question 7

local disease treatment for very low recurrence risk based on expected survival

Answer 7

<10y: observation
10-20y: active surveillance
>/20y: AS*, EBRT or brachytherapy or prostatectomy

Question 8

local disease treatment for low recurrence risk based on expected survival

Answer 8

<10y: observation
>/10y: AS*, EBRT or brachytherapy, prostatectomy

Question 9

local disease treatment for favorable intermediate recurrence risk based on expected survival

Answer 9

5-10y: obs*, EBRT or brachytherapy
>10y: AS, EBRT or brachytherapy alone, prostatectomy

Question 10

local disease treatment for unfavorable intermediate recurrence risk based on expected survival

Answer 10

5-10y: obs or EBRT + ADT or EBRT + brachytherapy
>10y: RP +/- PLND or EBRT + ADT or EBRT + brachytherapy

Question 11

local disease treatment for high or very high recurrence risk based on expected survival

Answer 11

</5y + asymptomatic: obs or ADT or EBRT
>5y or symptomatic:
-EBRT + ADT
-EBRT + brachytherapy + ADT
-EBRT + ADT + abiraterone
-RP + PLND

Question 12

regional disease treatment based on expected survival

Answer 12

</5y or asymptomatic: obs or ADT
>5y or symptomatic:
-EBRT + ADT + abiraterone
-EBRT + ADT
-ADT +/- abiraterone
-RP + PLND +/- EBRT +/-ADT

Question 13

advanced disease treatment for castrate naive (sensitive)

Answer 13

non-metastatic: monitoring or ADT
metastatic: ADT + (x6c)
-abiraterone
-enzalutamide
-apalutamide
-docetaxel

Question 14

advanced disease treatment for castrate resistant (testosterone <50)

Answer 14

recurrent: ADT +
-psadt >10mo: monitoring
-psadt </10mo: apalutamide, darolutamide, or enzalutamide

metastatic adenocarcinoma: ADT +
-abiraterone
-docetaxel
-sipuleucel
-radium

metastatic small cell/neuroendocrine: chemo

Question 15

androgen deprivation therapy (ADT)

Answer 15

-gold standard for advanced
-surgical castration
-medical castration (LHRH +/- antiandrogen)

Question 16

LHRH agonists

Answer 16

-reversible method of androgen ablation
-as effective as surgical castration
-goal testosterone <50 1mo after starting therapy

Question 17

LHRH agonist options

Answer 17

goserelin, leuprolide, triptorelin, histrelin

Question 18

LHRH acute AE

Answer 18

tumor flare, hot flashes, ed, edema, gynecomastia, inj site reaction

Question 19

LHRH long term AE

Answer 19

osteoporosis, clinical fracture, obesity, insulin resistance, increase risk of diabetes, CV events, hyperlipidemia

Question 20

LHRH antagonists

Answer 20

-more rapid decline in testosterone levels
-less flexibility in dosing schedule
-high cost

Question 21

LHRH antagonist options

Answer 21

degarelix and relugolix

Question 22

anti androgen agents

Answer 22

-bicalutamide, flutamide, nilutamide (monitor LFTs monthly)
-apalutamide, enzalutamide, daroluatmide

Question 23

castration sensitive treatment

Answer 23

-ADT + abiraterone or apalutamide or enzalutamide
-ADT w docetaxel x6c + abiraterone or darolutamide

Question 24

castration resistant (CRPC)

Answer 24

-testosterone <50 and disease progression
-continue ADT and maintain castrate levels while adding other therapies

Question 25

treatment for nonmetastatic CRPC with PSADT >10mo

Answer 25

-monitor (preferred) -secondary hormone therapy

Question 26

treatment for nonmetastatic CRPC with PSADT

Answer 26

1. apalutamide 2. enzalutamide 3. darolutamide 4. secondary hormone therapy

Question 27

secondary hormone therapies

Answer 27

continue ADT and add: -2nd gen antiandrogen (apalutamide- M0, darolutamide- M0, enzalutamide- M1) -androgen metabolism inhibitor (abiraterone with prednisone or methylprednisolone)- M1

Question 28

apalutamide (2nd gen antiandrogen) pearl

Answer 28

permanently d/c in patients who develop seizures during treatment

Question 29

metastatic CRPC treatment options for no prior docetaxel/novel hormone therapy

Answer 29

abiraterone, docetaxel, enzalutamide

Question 30

metastatic CRPC treatment options for prior novel hormone therapy/no prior docetaxel

Answer 30

docetaxel, olaparib or rucaparib for BRCA mutation

Question 31

metastatic CRPC treatment options for prior docetaxel/no prior novel hormone therapy

Answer 31

abiraterone, cabazitaxel, enzalutamide

Question 32

metastatic CRPC treatment options for prior docetaxel and prior novel hormone therapy

Answer 32

cabazitaxel, docetaxel rechallenge

Question 33

metastatic CRPC 1st line treatment options for visceral metastases

Answer 33

docetaxel

Question 34

metastatic CRPC 1st line treatment options with no visceral metastases

Answer 34

treat based on prior therapy

Question 35

metastatic CRPC 1st line treatment options for symptomatic bone metastases only

Answer 35

Radium-223

Question 36

metastatic CRPC 1st line treatment options for asymptomatic or minimally symptomatic, no liver metastases, life expectancy >6mo, and ECOG performance status

Answer 36

sipuleucel-T

Question 37

docetaxel pearl

Answer 37

caution in hepatic impairment

Question 38

abiraterone pearl

Answer 38

given with steroids to minimize mineralacorticoid excess

Question 39

Radium-223 pearl

Answer 39

-not used in combo with chemo -used for symptomatic bone metastases and no visceral metastasis prior to and after docetaxel