Prostate Cancer

Question 1

What is the lifetime risk of being diagnosed withh prostate cancer?

Answer 1

1 in 8

Question 2

What is the survival rate of prostate cancer?

Answer 2

5 year: > 8 / 10
10 year: 7/10

Strongly related to disease: organ-confined: 90% (5 yr)
metastatic disease: 30% (5 yr)

Question 3

What are the risk factors for developing prostate cancer?

Answer 3

Definitive = Age, Race, Family history

Probable = dietary fat intake, hormones

Potential = vasectomy, environmental, dietary

Question 4

What is the peak age for developing prostate cancer?

Answer 4

60 - 70 y/o

Question 5

Which ethnicities are at higher risk of getting prostate Ca?

Answer 5

Black ? white > asian > chinese/japanes

Question 6

How does family Hx affect risk of prostate Ca?

Answer 6

Affected father => about 100% increase
Affected brother => about 200% increase
Mother with breast Ca => about 20% increase

BRCA2 gene associated

Question 7

Symptoms of prostate cancer?

Answer 7

Very little in early disease. symptoms may indicate advanced disease

Local symptoms: obstructive voiding, irritative, blocked ejaculatory ducts (haemospermia), impotence

Metastatic symptoms: bone pain, anaemia, lympoedema, renal failure

Question 8

What is PSA?

Answer 8

PSA = Prostate specific antigen

Serine protease coded for by a gene on choromosome 19

Expression is hormone dependent

Question 9

Indications of PSA?

Answer 9

LUTS suggestive of benign prostatic hyperplasia (BPH)
Prostate feels abnormal on DRE
Patient concerned about prostate cancer

Don’t perform if:

• presence of retention or infection
• < 10 year life expectancy
• after use of instrumentation on LUT

Question 10

How is PSA measured and what is it’s half life?

Answer 10

Measured by immuno-assay

Half life of 2-3 days

Small amount absorbed into bloodstream

Question 11

What factors affect the PSA level?

Answer 11

Bed rest => decrease

Ejaculation => increase
Cycling => increase
BPH => increase
Prostatic biopsy => increase
Prostatitis => increase
Prostatic massage/cytoscopy/TRUSS => increase
UTI => increase
Urinary retention => increase

Question 12

How is PSA utilised in clinical medicine?

Answer 12

Can’t always reliably predict which tumours are aggressive and those which require no treatment

Low specificity
Low sensitivity

Question 13

Normal size of a prostate?

Answer 13

Ping pong ball

Question 14

What must be done before referring to urologist for suspected prostate Ca or abnormal DRE?

Answer 14

Perform urine test to rule out infection

Question 15

What is the three step method for diagnosing prostate cancer?

Answer 15

DRE
PSA test
Trans Rectal Ultrasound biopsy

Question 16

What staging system is used for prostate cancer?

Answer 16

TNM system (T=Tumour, N=Lymph Nodes, M=metastases)

• clinical stage
• radiological stage

Question 17

What are the factors that determine whether radical treatment is possible?

Answer 17

Tumour factors

• gleason grade (how aggressive cancer cells are)
• stage
• PSA

Patient factors

• concurrent medical problems
• age

Local service provision

Question 18

How to treat localised cancer in a patient with life expectancy > 10 years?

Answer 18

Active surveillance

Radical prostatectomy +/- hormone ablative therapy

Radical radiotherapy +/- hormone ablative therapy

Brachytherapy (radioactive implants)

Alternative treatments currently undergoing research

• cryotherapy
• thermotherapy
• HIFU

Question 19

What are the options available for men presenting with metastatic disease?

Answer 19

Most men respond to hormone deprivation

• surgical castration
• anti-androgens
• GnRH analogues

Hormone ablative therapy may be delivered in various ways: single agent, maximal androgen blockade, intermittent hormone therapy

Abiraterone - new hormone therappy

Chemotherapy

Radium-233

Enzalutamide = androgen receptor antagonist

Palliation

Question 20

Give examples of chemotherapy drugs used in prostate cancer?

Answer 20

Docetaxel

Cabazitaxel

Question 21

How are skeletal complications managed in hormone refractory prostate cancer?

Answer 21

Bisphosphonates

Question 22

What are the treatment options for complications of advanced prostatic cancer/metastases?

Answer 22

Pain control

• analgesic ladder
• palliative external beam radiotherapy
• strontium 90
• radium 233

Obstructive symptoms => Channel TURP

Obstructive uropathy => nephrostomy and antegrade stents for UUT obstruction

Palliative care service in general

Question 23

How do biphosphonates work?

Answer 23

Inhibit osteoclast formation, migration, and osteolytic activity, promotes apoptosis

Modulates signalling from osteoblasts to osteoclasts