Prostate cancer

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Prostate cancer

• Key slides

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Diseases of the prostatewww.cancerscreening.nhs.u
k/prostate

• Prostate cancer
• malignant growth of prostate cells, localised and
  may spread
• nearly all prostate cancers are adenocarcinomas,
  mainly occurring in the peripheral zone of the
  prostate gland
• rare in men under 50, and is more common with
  increasing age
• Benign prostatic hyperplasia
• non-malignant increase in size of the prostate
  with age
• rare in men under 50
• Prostatitis
• inflammation of the prostate
• can occur in men of any age

The early symptoms of prostate diseases are very
similar
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Clinical features of prostate cancerwww.cancerscr
eening.nhs.uk/prostate/prostate-booklet-text.pdf

• Prostate cancers (unlike BPH) tend to develop in
  the outer part of the prostate gland
• Unusual for early cancers to cause any symptoms
• Locally advanced prostate cancers that have
  extended outside the capsule are also frequently
  without symptoms
• If the tumour is large enough, it can cause lower
  urinary tract symptoms (LUTS) eg frequency,
  urgency, hesitancy, leaking, but by the time this
  happens the cancer will usually have reached an
  advanced stage

• LUTS are similar to those of BPH. Most men with
  LUTS will not have prostate cancer
• Often the first sign of prostate cancer is
  evidence of metastases (frequently in bone,
  causing bone pain)
• About 2030 of patients in the UK present with
  metastatic disease

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Overview Initial investigations

• Symptoms may occur only when the cancer is
  advanced and may be similar to BPH
• Offer a DRE and a PSA test after counselling to
  patients with symptoms suggestive of prostate
  cancer before referral to a specialist
• There is no criterion for PSA level below which
  men may be reassured that they do not have
  prostate cancer, nor an agreed level that is
  considered diagnostic
• Transrectal ultrasound biopsy (TRUS) should be
  offered after discussion of the likely risks and
  benefits to the patient

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www.nice.org.uk/CG58
TREATMENTS
Localised Watchful waiting Active
surveillance Radical prostatectomy External beam
radiotherapy Brachytherapy
Metastatic Orchidectomy or continuous
LHRHa Bicalutamide or androgen withdrawal Intermit
tent androgen withdrawal Hormone refractory
Docetaxel Corticosteroids Spinal MRI (spinal
metastases) Decompression of urinary tract
(obstructive uropathy) Palliative care
Managing side effects of treatment Erectile
dysfunction (PDE5 inhibitors first line) Urinary
incontinence refer for possible artificial
sphincter Side effects of hormonal treatments
?Hot flushes progestogens ?Gynaecomastia with
bicalutamide radiotherapy to breast buds (or
tamoxifen if fails) Painful bone metastases
strontium-89 or bisphosphonates
High Intensity Ultrasound or Cryotherapy Only as
part of a clinical trial
Localised advanced Neoadjuvant and concurrent
LHRHa with radiotherapy Adjuvant hormonal
therapy with radiotherapy Pelvic radiotherapy
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Hormone therapy(androgen deprivation
therapy)EAU Guidelines 2005 NICE TA101 2006
Damber JE, Aus G. Lancet 200837117101721

• Prostate cells are physiologically dependent on
  androgens (mainly testosterone) to stimulate
  growth, function and proliferation
• The testes are the source of 9095 of androgens
  (510 from adrenal glands)
• If prostate cells are deprived of androgenic
  stimulation, they undergo apoptosis (programmed
  cell death)
• Any treatment that ultimately results in
  suppression of androgen activity is called
  androgen deprivation therapy (ADT)
• Can be achieved by suppressing secretion of the
  testicular androgens (castration, LHRH agonists),
  by inhibiting the action of circulating androgens
  (anti-androgens), or both (complete androgen
  blockade)

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Methods used for androgen depletionNICE.
Improving outcomes in urological cancers. 2002
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NICE recommendations for managing the
complication of hormonal therapy NICE Clinical
Guideline and Full Guideline 582008

• Offer oral or synthetic progestogens for hot
  flushes. Offer oral therapy for 2 weeks and
  re-start when flushes recur, if effective
• Offer prophylactic radiotherapy to breast buds
  within the first 6 months of long-term (gt6
  months) treatment with bicalutamide
• Consider weekly tamoxifen if radiotherapy does
  not prevent gynaecomastia
• Do not routinely offer bisphosphonates to prevent
  osteoporosis in men receiving androgen withdrawal
• More research is needed into the prevention and
  management of osteoporosis in men receiving
  long-term withdrawal deprivation therapy (NICE)

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Prescribing trends

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Summary

• Prostate cancer is the most common cancer in men,
  and is second only to lung cancer in terms of
  cancer deaths
• Unusual for early cancers to cause any symptoms
• Offer a DRE and a PSA test after counselling to
  patients with symptoms suggestive of prostate
  cancer before referral to a specialist
• NICE guidance makes disease staging-based
  treatment recommendations
• Androgen deprivation therapy recommended for
  locally advanced and metastatic disease