Clinical Slide Set. Prostate Cancer
Download
Report
Transcript Clinical Slide Set. Prostate Cancer
In the Clinic
Prostate Cancer
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
How can prostate cancer be prevented?
Dietary changes and supplements not proven in
prevention
Lowering intake of animal fat
Antioxidants or lycopene
Selenium and vitamin E
Don’t prescribe 5α-reductase inhibitors for most men
Don’t prolong life
Increase sexual dysfunction
Reduce incidence of low-grade prostate cancer
Increase incidence of high-grade prostate cancer
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Prevention...
Trials don’t support altering diet or taking supplements to
prevent prostate cancer
5α-reductase inhibitors are not recommended for most men
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
Who should clinicians screen for prostate
cancer?
Screening for prostate cancer is controversial
Most men with prostate cancer die of another cause
Curative treatment often causes significant side effects
Moderate evidence that harms outweigh benefits in 50- to
69-year-olds
Data inadequate to make recommendations to patients
with significant risk factors:
African American or first degree family history of prostate
cancer
Don’t screen men <50 with no risk factors
Screening unlikely to benefit men >69 or with <10 to 15
years of life expectancy
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What tests should clinicians use for
screening?
PSA testing is the most useful for screening
But produces false-positives, false-negatives
Serum PSA may be elevated due to prostatitis, prostate
biopsies, UTI, prostate massage, or ejaculation
Sampling error in biopsy process adds uncertainty to the
interpretation of negative results
Digital rectal exam and imaging methods are less
sensitive and not shown to be effective
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Screening...
Screening and treatment may prevent prostate cancer deaths
Screening also produces false-negatives and false-positives
Harm from treatments is more likely than benefit
Treatments commonly cause sexual dysfunction and
distinct patterns of urinary and bowel symptoms
Shared decision-making that reviews benefits and harms is
essential to any informed decision to screen
Screening not recommended for men <50 with no risk factors,
most men >69, and men with life expectancy <10 years
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What should you consider when workingup a patient for prostate cancer?
Awareness that the diagnosis can be harmful
Potential for overdiagnosis of harmless prostate cancer
is substantial
Cancer “label” can have negative social, economic and
psychological consequences
Anxiety can occur when choosing a treatment
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What are the signs and symptoms of prostate
cancer?
Bone pain (most common symptom)
Weight loss
Normocytic anemia
Cachexia
Neurologic dysfunction related to spinal cord
compression
Lower urinary tract obstructive symptoms have low
positive predictive value
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
How should clinicians diagnose prostate
cancer?
Use serum PSA levels and digital rectal exam in men with:
Hematospermia
Pelvic pain
Symptoms of metastatic prostate cancer
Rapidly progressing lower urinary tract obstructive
symptoms or erectile dysfunction
Confirm any elevations in serum PSA
Alternative PSA measures have no proven benefit in
diagnosis
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
When should patients be referred to a
specialist for consultation?
Refer patients to a urologist for transrectal ultrasoundguided biopsy for:
Confirmed elevations >4.0 ng/mL for serum PSA
Prostate nodule or suspicious induration on DRE
Systematic biopsies are subject to sampling error
Repeat biopsy in men with previously negative results
Repeat biopsy at 6-12 months for patients with sustained
PSA elevations
No proven benefit of strategies to enhance yield from
biopsy including imaging, direct sampling of suspicious
areas
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
How is prostate cancer staged?
“Early” or clinically localized prostate cancer
Confined within prostate capsule
Local treatments are potentially curative
Locally advanced cancer
Extends beyond prostate capsule, including seminal vesicles
Curative methods often involve radiation and ADT
Advanced prostate cancer
Spread to retroperitoneal lymph nodes or to bone
Treated palliatively
Use CT and bone scans to stage those at high risk for
advanced and intermediate risk
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Diagnosis
and Staging...
Signs of prostate cancer:
Rapidly worsening LUTS and impotence
Hematospermia
Pelvic pain
Bone pain
Refer to urologist when patient has symptoms, abnormal
results on DRE, and confirmed PSA elevations
Order bone scan and abdominal-pelvic CT if PSA
concentrations ≥20 ng/mL, Gleason score >7, or T3 cancer
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What is the role of shared decision making
and consultation in clinically localized
prostate cancer?
Patients should solicit input from diagnosing urologist
as well as radiation and medical oncologists
Choice: to defer or have curative treatment
Curative treatment may avoid later metastases and death
but often causes significant side effects
Specific treatments have no proven differences in efficacy
but vary in side effects
Decision aids present issues and evidence in a balanced,
clear fashion
Treatment outcomes are better at high-volume
institutions and from high-volume providers
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Shared
Decision Making...
Men with clinically localized prostate cancer should choose
treatment based on how they value potential benefits, harms
They should make shared treatment decisions with surgical,
radiation, and medical oncologists
Essential information for informed decision making includes:
Reason for intervention
Benefits and harms
Alternative approaches
Clear statement that the patient has a choice
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
How is risk defined in prostate cancer?
Low-risk cancer
PSA <10 ng/dL, Gleason score ≤6, clinical tumor
stage ≤T2a
Intermediate-risk cancer
PSA 10 to 20 ng/dL, Gleason score 6, clinical tumor
stage T2b or T2c
High-risk cancer
PSA ≥20 ng/dL, Gleason score 8 to 10, clinical tumor
stage T3
Higher PSA or Gleason score increases likelihood
untreated cancer will metastasize and recur after local
treatment
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What options should be considered for
clinically localized prostate cancer?
Watchful waiting (deferred treatment)
Active surveillance (monitoring for signs of progression
that trigger curative treatment)
Radical prostatectomy (RP)
External-beam radiation therapy (EBRT)
Brachytherapy
High-risk cancer: androgen deprivation therapy (AD)
plus radiation
All active treatments cause side effects
Deferring until metastases or evidence of more aggressive
cancer increases mortality risk by only a small amount continued
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What is the role of radical prostatectomy
in treatment of prostate cancer?
Removes the prostate and seminal vesicles
An effective option in clinically localized prostate cancer
Results in erectile dysfunction in most men
Results in urinary incontinence for many men
Use of nerve-sparing surgery may reduce erectile
dysfunction
Minimally invasive surgery including robotic surgery
decreases hospital stay and may reduce recovery time
but does not improve outcomes
May result in small decreases in mortality
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What is the role of external beam
radiotherapy in the treatment of prostate
cancer?
An effective option in clinically localized or locally
advanced prostate cancer
Patients with high risk prostate cancer should be treated
with EBRT plus ADT
Adjuvant ADT may result in improved cancer-specific
survival and in most cases overall survival
Combined radiation therapy and ADT may be considered
for patients with intermediate risk prostate cancer based
on expert opinion
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What is the role of brachytherapy in the
treatment of prostate cancer?
Appropriate for men with low risk cancer, especially
non-palpable T1C tumors and minimal or no urinary
obstruction
EBRT sometimes added to brachytherapy for patients
with palpable nodules and intermediate-risk features
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What are options when PSA level increases
after treatment for localized prostate
cancer or for those who are at high risk
after prostatectomy?
Monitor serum PSA level regularly after local treatment
Increase from post-treatment nadir indicates persistent
cancer and high risk for metastasis
Prostatectomy: aims to remove all tissue
High-risk findings after prostatectomy:
radiation therapy or ADT
Radiation: may leave benign prostate tissue
“PSA bounce” may occur after radiation treatments end
ADT may be beneficial
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What are options for patients with newly
diagnosed metastatic prostate cancer?
Androgen deprivation therapy (ADT)
GnRH agonists (goserelin, leuprolide): start course of
nonsteroidal antiandrogen 1-2 wks prior to first injection
GnRH antagonists (degarelix)
Bilateral orchiectomy
For extensive metastases:
Add docetaxel to initial ADT
If patient progresses on ADT and does not achieve
testosterone < 50 ng/dL offer bilateral orchiectomy
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
What options should be considered for
patients with castrate-resistant metastatic
prostate cancer?
Docetaxel: first-line systemic treatment
Diethylstilbestrol or nonsteroidal antiandrogen (add to
GnRH agonist)
Agents that target testosterone production (antiandrogen
enzalutamide, abiraterone acetate)
Sipuleucel-T
Radium-223
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
Spinal cord compression in prostate
cancer
A medical emergency!
Can result in:
back pain, vertebral tenderness
perineal numbness
urinary retention, urinary incontinence
constipation, fecal incontinence
Requires spinal magnetic resonance imaging, high-dose
corticosteroids and either radiation therapy or surgery
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Treatment…
Options for low-risk prostate cancer
Watchful waiting (deferred treatment)
Active surveillance (monitoring for signs of progression
that trigger treatment)
RP, EBRT, brachytherapy, ADT in conjunction with EBRT
Options for metastatic prostate cancer
Surgical castration (bilateral orchiectomy)
GnRH agonist with nonsteroidal anti-androgen
GnRH antagonist
Docetaxel + ADT: for men with extensive bone metastases
Options for castrate-resistant prostate cancer
Several treatments briefly prolong survival
© Copyright Annals of Internal Medicine, 2009
Ann Int Med. 164 (1): ITC1-1.