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17th European Urology Residents Education Programme > Prostate cancer > Flashcards

Prostate cancer Flashcards

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1
Q

What share of male cancer consists of prostate cancer?

A

20%

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2
Q

What is the estimated mortality of prostate cancer out of all male cancers?

A

10%

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3
Q

In autopsy studies, what race had the highest prevalence of prostate cancer?

A 
US Black 
followed by 
US white and european
followed by
Asian
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4
Q

What kind of molecule is Prostate Specific Antigen (PSA)?

A

Serine Protease

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5
Q

When was PSA first used clinically?

and for what?

A

1986

post-treatment follow-up

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6
Q

What is the risk of prostate cancer at PSA 4?

What is the risk of Gleason >7 at PSA 4?

A

26,9%

6,7%

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7
Q

What was the conclusion of the PLCO Trial?

A

There is no evidence of mortality benefit for organized annual screening compared with opportunistic screening

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8
Q

What was did the Göteborg Randomized Population-Based Screening Trial find?

A

42% lower PCa mortality in the organized screening vs the opportunistic testing arm

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9
Q

To avoid 1 PCa death:

How many men have to be screened?
How many PCa’s have to be diagnosed?

A

139 screened

13 PCa found

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10
Q

When does the USPTF (US Preventive Services Task Force) recommend individual (a man can choose for himself after information) screening of prostate cancer?

A

Men aged 55-69

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11
Q

When does the EAU recommend PSA-testing?

A

After counselling the patient on potential risks and benefits

AND

good performance status and a life expectancy of >10-15 years

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12
Q

How should an inital PSA-test be followed?

A

Offer an risk-adapted strategy (based on initial PSA level), with follow-up intervals of 2 years for those initially at risk:

  • PSA >1 at 40 years of age
  • PSA >2 at 60 years of age

Postpone follow-up to 8 years in those not at risk

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13
Q

How does the EAU recommend that you avoid unnecessary biopisies for men with PSA 2-10 and normal digital rectal examination (DRE)?

A

use one of the following tools:

risk-calculator
imaging
additional serum or urine-based test

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14
Q

Which risk calculator is superior when predicting clinicallly significant prostate cancer?

A

ERSPC-RC

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15
Q

What is the risk of prostate cancer if PSA is < 2 but there is a suspect DRE (digital rectal examination)?

A

5-30%

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16
Q

How reliable is TRUS (transrectal ultrasound) for detecting prostate cancer?

A

TRUS in not reliable in detecting prostate cancer.

Thus, there is no evidence that US-targeted biopises can replace systematic biopsies.

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17
Q

How many biopsies should you take in a 30 cc prostate?

A

At least 8 systematic

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18
Q

How many biopsies should you take in a prostate >30cc?

A

10-12

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19
Q

What type of painrelief should be used when performing prostate biopsies?

A

a periprostatic block

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20
Q

What are the top 4 complications of prostate biopsies?

A

Haematospermia 37,4%
Haematuria >1 day 14,5%
Rectal bleeding >2 days 2,2 %
Prostatitis 1%

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21
Q

How common is fewer > 38,5 after prostate biopsies?

A

0,8%

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22
Q

ISUP 1

A

Gleason 2-6

Low risk

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23
Q

ISUP 2

A

Gleason (3+4) =7

Intermediate risk favourable

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24
Q

ISUP 3

A

Gleason (4+3) =7

Intermediate risk unfavourable

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25
ISUP 4
Gleason 8 | High risk
26
ISUP 5
Gleason 9 | High risk
27
What did the PROMIS trial find?
Sensivity of mpMRI for clinically significant PCa is almost double compared to TRUS-biopsy 27% of primary biopsy procedures could be avoided if mpMRI was used as a triage test
28
What did the PRECISION trial show?
That when using MRI-targeted biopsies you can find a greater share of clinically significant PCa
29
If an MRI is performed that show PI-RADS 3 or more, how should you aim the prostate biopsies?
Combine targeted and systematic biopsies
30
Risk stratification of PCa: | what are the criterias for low risk?
PSA <10 Gleason <7 / ISUP1 cT1a-2a
31
Risk stratification of PCa: | what are the criterias for intermediate risk?
PSA 10-20 Gleason 7 / ISUP2-3 cT2b
32
Risk stratification of PCa: | what are the criterias for high risk?
PSA >20 Gleason >7 / ISUP4-5 cT2c
33
When should you perform a Bone Scan for patients with PCa?
Symptomatic patients regardless of PSA Intermediate unfavourable risk cancer (Gleason 4+3) High risk cancer (PSA >20) Locally advanced cancer (T3 or worse)
34
When should you perform a mpMRI for patients with PCa?
Intermediate unfavourable risk cancer High risk cancer Locally advanced cancer
35
Risk stratification of PCa: | what are the criterias for locally advanced PCa?
Any PSA Any Gleason cT3-4 or N+
36
When should you perform an abdominal CT for patients with PCa?
Intermediate unfavourable risk cancer and worse for N-staging
37
What is the sensisivity of an abdominal CT for detecting nodal invasion of PCa?
<40% | MRI performance is similar
38
What is the sensivity and specificity for prostate cancer when using PSMA PET/CT?
sensitivity 50% | specificity >90%
39
What is the gold standard for N-staging in prostate cancer?
surgery -lymph node dissection
40
When is surgery the best option for a patient with prostate cancer?
<65 years | intermediate risk disease
41
How likely is it that a patient in monitoring will recieve active treatment within 10 years?
54,8%
42
Number needed to treat with radiotherapy to avoid: clinical progression? metastatic disease?
9 | 33
43
Number needed to treat with surgery to avoid: clinical progression? metastatic disease?
9 | 27
44
What is vital to inform patients of before chosing course of action after a prostate cancer diagnosis?
"No active treatment has shown superiority over any other active management options in terms of survival" "all active treatments have side-effects"
45
Which side effect(s) is worse with surgery compared to radiation or active-monitoring?
Incontinence | Impotence
46
How many men used incontinence protection after surgery for prostate cancer 6 years postop?
17%
47
How many men had erections firm enough for intercourse at the time of diagnosis of Prostate Cancer?
67%
48
How many men had erections firm enough for intercourse after prostatectomy vs radiotherapy for prostate cancer?
12% vs 22%
49
Number needed to harm with surgery vs radotherapy rather than active monitoring when it comes to urinary incontinence at 2 years:
Surgery 5 | Radiotherapy 143
50
When it comes to quality of life how does surgery, radiotherapy and active monitoring compare?
No significant differences
51
Should PLND (Pelvic lymph node dissection) be performed on patients with localized PCa?
No (strong recommendation)
52
Should PLND (Pelvic lymph node dissection) be performed on patients with intermediate risk PCa?
No (strong recommendation)
53
Should PLND (Pelvic lymph node dissection) be performed on patients with high risk PCa?
Yes (strong recommendation)
54
What is the difference between open, laprascopic or robot assisted radical prostatectomy in terms of functional and oncological results?
NONE
55
What is the difference between active surveillance and watchful waiting?
Active surveillance focuses on delaying therapy until the tumour becomes progressive and curative treatment can be offered Watchful waiting focuses on minimising treatment-related toxicity and i palliative
56
What follow up should Active surveillance include?
Digital rectal examination PSA Repeated biopsies
57
What should the neoadjuvant ADT-duration be after radiotherapy? (ADT = androgen deprivation therapy)
intermediate risk 6 months | high risk 3 years
58
When is brachytherapy as monotherapy recommended?
``` Stage cT1b-T2a Gleason 6 <50% of biopsy cores with cancer / Gleason 7 <33% of biopsy cores with cancer PSA <10 <50cc prostate IPSS< 12 Urinary flow >15mL/min ```
59
What anatomical sites should be included in extended pelvic lymph node dissection (ePLND)?
external iliac axis obturator fossa around the internal iliac artery
60
What is standard recommended radiotherapy dose in most European Centers for prostate cancer?
≥ 76-78 Gy in 37 fractions
61
What is the benefit of ADT (androgen deprivation therapy) in addition to radiotherapy?
20% added 10-year survival 20% added disease specific survival No difference in cardiovascular mortality
62
When should you wait with ADT for patients with high risk prostate cancer that is unable to recieve local treatment?
PSA doubling time >12 months and | PSA < 50
63
What are the possible different courses of action after surgery of a high risk N+ prostate cancer?
Offer adjuvant ADT Offer adjuvant ADT + additional radiotherapy Offer observation for patients efter eLND and < 2 nodes with microscopic involvement and PSA <0,1
64
What treatment should be offered for a geriatric patient who presents with metastasised prostatecancer and symptoms?
Castration: 1. bilateral orchiectomy 2. GnRH agonist with flare protection Bicalutamide 3. GnRH antagonist For fit patients castration can be combined with docetaxel or abiraterone acetate plus prednisolone or prostate radiotherapy
65
How quickly do you reach castration levels with antiandrogen (degarelix)?
By day 3
66
When should you treat prostate cancer patients with intermittent ADT?
Highly motivated asymptomatic patients who have a major PSA response after the induction period
67
What are the side effects of hormone therapy? | 9
Loss of libido and sexual interest , erectile dysfunction, impotence Fatigue Hot flushes Decline in intellectual capacity, emotional liability, depression Decrease in muscular strength Increase in (abdominal)fat apposition, diabetes, risk of CV events Osteoporosis Anaemia
68
How low is castrations lewel testosteron?
<50 ng/dl
69
When should bone health agents (bisphosponates/denosumab) be used?
For men with risk of osteoporotic fractures
70
What are valid (cytostatic) options for treatment of HSMPC (hormone sensitive metastatic prostate cancer)?
Early Docetaxel Enzalutamid Abiraterone
71
What is the current wiev of prostatectomy and radiation for low volume disease?
Radiation is proven beneficial | Surgery is not yet proven
72
What are two ways a prostate cancer cell can become castration resistant?
1. mutation of the androgen receptor so they get a higher affinity and can be activated by non-steroidal ligands 2. by-pass pathways independent of the androgen receptor
73
Definition of castration-resistant PCa:
``` Testosteron <50 ng/dL or 1,7 nmol/L and biochemical progression or radiological progression ```
74
What kind of drug is Docetaxel?
Mitosis inhibitor
75
What is the second line treatment after Docetaxel?
Cabacitaxel
76
Where does Docetaxel have its effect?
In the cell membrane
77
What kind of drug is Enzelutamid?
It binds androgen within the cell and prohibits it to enter the cell nucleus
78
According to EAU what is the "correct" order to use antiprostate cancer drugs?
ADT (androgen deprivation therapy) (Zoledronic acid or Denosumab to prevent SRE) Abirateron or Enzelutamid Docetaxel Cabacitaxel Radium-223
79
When is it wrong to use bone protective agents in prostate cancer?
In hormone sensitive bone metastatic PCa
80
What is importen to remember when prescribing Zoledronic acid or Denosumab?
Also offer calcium and vitamin-D
81
How should you act with a patient who has a spinal cord compression from metastasised PCa?
start immediate high-dose corticosteroids and assess for spinal surgery followed by irradiation Offer radiation therapy alone if surgery is not appropriate

17th European Urology Residents Education Programme (17 decks)

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