Suggest possible risk factors for the development of prostate cancer.
- age >60yrs
- FHx
- Afro-Caribbean > Caucasian > Asian
Is there a prostate cancer screening programme in the UK?
No, there is an informed choice programme where men 50+ can choose to have their PSA tested after discussion with GP.
A 65yo man presents to the GP with obstructive LUTS. On DRE the GP detects a hard craggy asymmetric prostate gland.
What primary care + secondary care investigations are necessary?
Bedside tests
1. urine dipstick + MC+S
Bloods
- PSA: >4ug/L
- U+Es + creatinine: abdnormal if localised advanced disease causing obstruction
- LFTs + calcium
- testosterone: for baseline if androgen deprivation considered
Imaging
- MRI abdo/pelvis: in all men with raised PSA to avoid unnecessary biopsy
- bone scan + X-rays: if PSA >20ug/L, gleason score 8+ or symptomatic
Histology
- TRUS biopsy: under LA
- transperineal biopsy: usually requires GA
What is your differential for a raised PSA?
- prostate cancer
- UTI
- prostatitis
- BPH
- acute urinary retention
- post-ejaculation, DRE, cycling, post-biopsy
Suggest possible complications of a prostate biopsy.
- UTI
- prostatitis
- haematuria or haematospermia
- acute urinary retention
How is severity of pCa classified?
- Gleason grade: histological features
2. TNM staging
What are the management options for localised (PSA <20) pCa?
Curative intent:
- active surveillance: 1st choice for low risk pCa
- radical prostatectomy: if younger men (<70yrs) with intermediate-high risk pCa
- RT
Palliative intent:
4. watchful waiting with deferred hormones
What are the Mx options for localised advanced pCa?
Curative intent:
1. radical RT + adjuvant hormones
Palliative intent:
2. discuss early vs deferred hormones only
What are the Mx options for metastatic pCa?
Curative intent:
1. medical castration with continuous LHRH agonists e.g. GOSERELIN OR orchidectomy
+/- adjuvant hormones e.g. BICALUTAMIDE anti-androgen
2. chemo: DOCETAXEL + PREDNISOLONE
if chemo-resistant: ENZALUTAMIDE anti-androgen (more potent) OR ABIRATERONE (testosterone production inhibitor) + PREDNISOLONE
Palliative intent:
3. single dose RT
+ bisphosphonates e.g. ZOLENDRONIC ACID
What is the MOA and the possible s/e of LHRH agonists e.g. goserelin?
MOA: initial phase of stimulation followed by down-regulation of GnRH Rs… decreased FSH + LH production… decreased androgen production.
S/e
- ‘flare’: temp. increase in testosterone causing Sx worsening (requires short-course of anti-androgens)
- ED and loss of libido
- hot flushes
- osteoporosis
- fatigue
What is the MOA and possible s/e of bicalutamide and enzalutamide?
MOA: block androgen Rs.
S/e
- gynaecomastia + breast tenderness
- hot flushes
- increased weight
- adverse impact on overall survival (but greater chance of retained sexual function)
