Prostate Cancer

Question 1

What is PSA? When (3) is it elevaed?

Answer 1

Protein produced within prostate.

2/3 of elevated PSA are not prostate cancer

DDx of elevated PSA:

• Prostate cancer
• prostatitis
• benign prostatic hyperplasia (BPH)
• urinary infection
• inflammation of prostate due to instrumentation

Question 2

What is the most common cancer in men?

Answer 2

prostate cancer

Question 3

What information does Free:Total ratio PSA provide?

Answer 3

More bound property in cancer

Hence Low ratio = more likely to be prostate cancer
High ratio = less likely to be prostate cancer

Question 4

SE of perineal prostate biopsy

Answer 4

urinary retention

but less infection compared to transrectal biopsy

Question 5

Pros and cons to Prostate screening tests

Answer 5

(-): can over investigate & over diagnose (high NNT)
(-): risks for prostate biopsy to be followed
(+): increased PSA screening leads to increased survival rates

Question 6

Difference between active surveillance and watchful waiting

Answer 6

Active surveillance:

• intent to cure in active surveillance c.f. watchful waiting (palliative)
• regular checks of PSA, DRE (3 monthly and 6 monthly after), biopsy (6 month)
• avoid overtreatment
• tight criteria; low volume cancers (Gleeson 6)
• MRI before biopsy to hit the target

C.f. Watchful waiting: non-curative treatment (palliative for those who are elderly with multiple comorbidities)

Question 7

What range of Gleason scores do you usually see for prostate cancer?

Answer 7

Gleason 6-10 (as pathologists do not report grade 1 or 2; remember Gleason score is sum of 2 patterns scores)

Question 8

What are the positive PSA test implications?

• Ix
• (3) Rx
• Engagement with other professionals

Answer 8

Ix further consider: MRI, CT, bonescan particularly for Gleason 7 or above.

Mx:

• Brachytherapy (internal irradiation with wires inside) vs. external beam therapy
• surgery (open, laparoscopic, robotic)
• active surveillance for Gleason score 6 cancers

Engagement

• GP
• urologist
• oncologist
• radiation oncologists
• MDMs

Question 9

(4) Mx options for concurrent/end stage prostate cancer

Answer 9

1. ADT: androgen deprivation therapy
   - commenced post intervention e.g. RRx, surgery
   - PSA monitoring
2. LHRH (LH release hormone) agonists: Goserelin (Zoladex); minimal testosterone activity on prostate. Good for elderly (who don’t care about fertility)
3. Anti-andorgens: blocks testosterone from reaching prostate cancer cells e.g. bicalutamide (Casodex): used with LHRH agonists or before introduction of LHRH. Good for young
4. Surgery; orchidectomy

Question 10

Androgen deprivation therapy (5) SEs

Answer 10

• CNS: cognitive change, low mood
• CVS: hypercholesterolaemia, IHD risks
• obesity
• osteoporosis (recommend Bone density scan biannually). encourage exercise
• General: lethargy, reduction in libido, hot flushes (like male menopause)

Question 11

Mx of metastatic prostate cancer

Answer 11

ADT + Chemotherapy = much better than ADT alone before chemotherapy once resistant

Question 12

Who gets screening test for the prostate cancer? Who decides?

Answer 12

There is no strict guideline by the Government; the GPs are encouraged to give the facts to the patients and let the PATIENTS decide.

Recommended for 50-70yo + negative FMHx and perhaps younger from 40yo for positive FMHx.

Question 13

Risk factors for prostate cancer

Answer 13

• age
• Afro-American men
• FMHx