Transcript PPT

Cancer Survivorship
Prostate Cancer Risks and Treatments
Photo collection is courtesy of PEIR - University of Alabama at Birmingham
Department of Pathology via the HEAL (Health Education Asset Library) database
© 2005 University of California Regents
Cancer Survivorship Grant
Start
Case
Goal of this Module
This is an interactive and self-directed learning module
intended to build a foundation of knowledge around the
epidemiology and late effects of cancer survival. This is
one of several educational modules you will complete
during your core clinical clerkships. Themes
emphasized in this, and other modules, are:

Epidemiology of survival

Late effects

Psychosocial concerns

Secondary prevention

Strategies for behavior change
Meet
your
patient
Paul R. State III is a 55-year old African-American
male who presents to a family practice clinic because
his wife insists he have a prostate evaluation. He is in
good health and has no active medical issues or
symptoms. He has not seen a doctor in over 5 years,
but his 51-year old brother was recently diagnosed
with prostate cancer and Mr. State’s wife insisted that
he be evaluated for prostate cancer, as well. He had a
prostate-specific antigen (PSA) test done a few weeks
ago, and Mrs. State says you should have the results in
the computer. He reports no obstructive symptoms of
hesitancy, incomplete emptying, double voiding, or
dribbling. He has no irritative symptoms of urgency,
frequency, or nocturia.
Case continued
Case continued
Family history is significant only for his brother who was
recently diagnosed with prostate cancer. He has smoked
2 packs of cigarettes a day since he was 20 years old,
drinks 1-2 beers per day, and denies using drugs. He
works as a manager at a local car garage. He eats fast
food daily because he can’t resist double doubles from
In-N-Out next to his shop.
His wife leaves the room for the physical exam. As soon
as she leaves, he says “I’m not really at risk for prostate
cancer, right doc? I just want my wife to get off my
back.”
Go to
Question #1
Question #1: Which of Mr. State’s risk
factors poses the largest relative risk for
prostate cancer?
A.
B.
C.
D.
E.
Ethnicity
Age
Family History
Diet
Environmental Exposure
Question #1: Incorrect Answer
A. Ethnicity: African-Americans are at higher risk
for prostate cancer than matched Caucasians. On
average, they present with more advanced
disease at initial diagnosis. The potential
increased mortality for African-Americans
compared to Caucasians is controversial.
Prostate cancer screening should begin at 40
years of age for African-Americans. Ethnicity
does not pose the largest relative risk in this
patient.
Ethnicity article (Kang, BJU 2004)
Return to
Question #1
Question #1: Correct Answer
B. Age: The incidence of prostate cancer
increases with age. Clinically significant
prostate cancer develops in 0.01% of
men<40 years old, 1% of men 40-59 years
old, and 13% of men over the age of 60.
Age article (Thompson, NEJM 2004)
Continue
case
Question #1: Incorrect Answer
C. Family History: The age at which the disease
was diagnosed in a first-degree family member
is vital to determining the relative risk for Mr.
State. The relative risk for prostate cancer is 47x if the age of onset was 50 years old, 3-5x if
the age of onset was 60 years old, and 2-4x if the
age of onset was 70 years old. Prostate cancer
screening should begin at 40 years of age for
patients with a family history of prostate cancer.
Family history article (Thompson, NEJM 2004)
Return to
Question #1
Question #1: Incorrect Answer
D. Diet: Although high fat intake doubles
Mr. States risk of prostate cancer, diet
does not pose the largest relative risk.
Diet article (Mazhar: BJU 2004)
Return to
Question #1
Question #1: Incorrect Answer
E. Environmental exposure: His risk of
prostate cancer increases with exposure to
alkaline batteries, welding chemicals, and,
possibly, tobacco (all contain cadmium,
which is carcinogenic in the prostate.)
However, these exposures do not pose the
largest relative risk.
Environmental exposure article (Deutsch: Lancet
Oncol 2004)
Return to
Question #1
Case Continued
On physical exam, Mr. State is obese and in
no apparent distress. HEENT,
cardiovascular, pulmonary, and abdominal
exams are within normal limits.
Continue
case
Case Continued
On rectal exam, sphincter tone is normal. The
prostate margins are distinct and it appears to
be normal in size, but a firm, 0.5 cm x 0.5 cm
nodule is palpated along the right lateral
sulcus.
After the exam, you remember to check Mr.
State’s labs on the computer. CBC and
Chem-7 are within normal limits. PSA is 4.8.
Go to
Question #2
Question #2: Which of the following factors
will allow you to decide definitively
whether Mr. State has prostate cancer?
A.
B.
C.
D.
E.
PSA velocity
Age-adjusted PSA
PSA density
Ratio of free PSA to bound PSA
None of the above
Question #2: Incorrect Answer
A. PSA velocity: A change in PSA (PSA
velocity) of >1.5 ng/mL over 2 years may
be associated with prostate cancer.
However, the same laboratory should be
used, and even then PSA velocity has a low
sensitivity and specificity for prostate
cancer.
PSA velocity article (D’ Amico: NEJM 2004)
Return to
Question #2
Question #2: Incorrect Answer
B. Age-adjusted PSA: Adjusting PSA for age
increases the sensitivity for younger men
and specificity for older men. The normal
range, in ng/mL, is 0-2.5 for 40-49 year
olds, 0-3.5 for 50-59 year olds, 0-4.5 for
60-69 year olds, and 0-6.5 for 70-79 year
olds. However, PSA is useful only as a
screening tool, not for definitive
diagnosis.
Age-adjusted PSA article (Chu, Cancer 2002)
Return to
Question #2
Question #2: Incorrect Answer
C. PSA density: The PSA density adjusts for
benign prostatic hyperplasia (BPH), since
1 gram of BPH tissue elevates PSA by
approximately 0.12 ng/mL. While a PSA
density >0.15 is more likely to warrant a
biopsy, it only raises the positive
predictive value to 30-40%.
PSA density (D’Amico: NEJM 2004)
Return to
Question #2
Question #2: Incorrect Answer
D. Ratio of free PSA to bound PSA:
Normally, approximately 90% of PSA is
bound to alpha-1-antichymotrypsin. Free
PSA levels below 21% tend to correlate
with prostate cancer, while levels above
21% are often seen in older men whose
disease is slowly progressing. These ratios,
however, must be correlated with other
studies.
Ratio of free PSA to bound PSA article
(Uemura: Int J Urol 2004)
Return to
Question #2
Question #2: Correct Answer
E. None of the above: PSA>4ng/mL has a positive
predictive value of 20-30% for carcinoma of the
prostate. While each of the above adjustments is
useful in improving the sensitivity and specificity
of the test to some extent, PSA should still be used
to guide a further work-up and should be
considered in the context of the patient’s other
personal risk factors, history, physical exam, and
other findings. PSA may be elevated secondary to
BPH, urethral instrumentation, infection, prostatic
infarction, or prostatic massage. The only way to
definitively diagnose prostate cancer is with
biopsy.
Continue
case
Case Continued
You tell Mr. State that you would like to perform a
trans-rectal ultrasound (TRUS)-guided biopsy. He
argues that it is an uncomfortable procedure and says
he doesn’t see the point, but Mrs. State chides him
that “the doctor knows best”. He agrees to the
procedure.
Before performing the TRUS, you try to predict
where a potential cancer might be found.
Go to
Question #3
TRUS-Guided Bx
The most common adverse event of
prostate biopsy is rectal bleeding, which
occurs in up to 50% of patients but rarely
needs to be packed for tamponade. The
most common minor complication is
prostatitis, which occurs in approximately
2.5% of patients. Infectious
complications requiring hospitalization
are seen in <1% of patients who are
properly medicated with antibiotics
before biopsy.
Back to
case
Question #3: In which zone of the prostate
will carcinoma most likely arise?
A.
B.
C.
D.
Transition zone
Peripheral zone
Central zone
Anterior
fibromuscular area
Question #3: Incorrect Answer
A.
Transition zone: 10-20% of prostatic
carcinoma arises in the transition zone.
Benign prostatic hyperplasia almost always
occurs in the transition zone.
Return to
Question #3
Question #3: Correct Answer
B. Peripheral zone: 65-70% of prostatic
carcinoma arises in the peripheral zone. The
peripheral zone can be palpated on digital
rectal exam (DRE), making DRE a useful
screening tool for prostate cancer.
Continue
case
Question #3: Incorrect Answer
C. Central zone: About 5% of prostate cancer
arises in the central zone.
Return to
Question #3
Question #3: Incorrect Answer
D. Anterior fibromuscular area: Prostatic cancer
rarely arises in the anterior fibromuscular
area.
Return to
Question #3
Case Continued
After pre-medication with broad-spectrum
antibiotics, TRUS is performed and shows a
hypoechoic pattern in the peripheral zone and the left
base. Core biopsies of the hypoechoic area are taken
and random sampling is done by dodecad biopsies.
You go to the pathology lab to review the findings so
you can sound smart if your attending questions you.
To your dismay, the pathologist asks you a series of
questions before reviewing the slides with you.
Go to
Question #4
Question #4: If Mr. State has cancer of the
prostate, which is the most likely histology?
A.
B.
C.
D.
Small cell carcinoma
Sarcoma
Adenocarcinoma
Transitional cell carcinoma
Question #4: Incorrect Answer
A.
Small cell carcinoma: Small cell
carcinomas account for less than 1% of
prostate cancer.
Return to
Question #4
Question #4: Incorrect Answer
B. Sarcoma: Sarcomas account for less than
1% of prostate cancer.
Return to
Question #4
Question #4: Correct Answer
C.
Adenocarcinoma: Adenocarcinomas account for over
95% of prostate cancers. The distinguishing histologic
characteristic of prostate cancer is the absence of basal
cells, which can be seen with high-molecular-weight
keratin staining (which stains basal cells). Absence of
staining is consistent with carcinoma of the prostate.
Continue
case
Question #4: Incorrect Answer
D. Transitional cell carcinoma: Transitional
cell carcinomas account for approximately
4% of prostate cancer. They do account
for over 90% of bladder cancer.
Return to
Question #4
Case Continued
Upon viewing the slides with the pathologist, you
note a basophilic cytoplasm with enlarged,
hyperchromatic nuclei with enlarged nucleoli. You
ask the pathologist if she has stained the cells with
high-molecular-weight keratin and, impressed by
your knowledge, she says she has and points out the
absence of staining where the basal cell layer is
normally found.
The pathologist asks how prostatic cancer is graded.
After you correctly identify the Gleason grading
system, she asks about the significance of different
Gleason scores.
Go to
Question #5
Gleason Score
The Gleason grading system is based on the glandular
architecture of prostatic samples under low power:
▪ Grade 1 or 2: samples are closely packed, have little
stroma, and are small and uniform.
▪ Grade 3: samples have variable-sized glands between
normal stroma.
▪ Grade 4: samples have incomplete gland formation.
▪ Grade 5: samples have no gland formation or lumen
appearance, or they may (rarely) be comedocarcinoma.
The Gleason score is the sum of the most commonly found
pattern and the second most commonly found pattern. The
primary Gleason grade is more important than the second
one, so Gleason 6 (4+2) is more poorly differentiated than
Gleason 6 (3+3).
Return to
Question #5
Question #5: What Gleason score would
suggest that Mr. State’s cancer is poorly
differentiated?
A.
B.
C.
D.
Gleason 2 (1+1)
Gleason 4 (2+2)
Gleason 6 (3+3)
Gleason 10 (5+5)
Question #5: Incorrect Answer
A.
Gleason 2 (1+1): Gleason 2 (1+1) is
considered very well-differentiated.
Normal
Gleason 1
Return to
Question #5
Question #5: Incorrect Answer
B. Gleason 4 (2+2): Gleason 4 (2+2) is
considered well-differentiated.
Normal
Gleason 2
Return to
Question #5
Question #5: Incorrect Answer
C. Gleason 6 (3+3): Gleason 5-6 is considered
moderately differentiated. The primary Gleason
grade is more important than the second one, so
Gleason 6 (4+2) is more poorly differentiated
than Gleason 6 (3+3).
Normal
Gleason 3
Return to
Question #5
Question #5: Correct Answer
D. Gleason 10 (5+5): Gleason 8-10 is considered
poorly differentiated.
Normal
Gleason 5
Continue
Case
Case Continued
Mr. State’s Gleason score is 7 (4+3).
Gleason 4
Normal
Gleason 3
Continue
Case
Case Continued
Mr. State now inquires about the clinical
stage of his prostate cancer.
Go to
Question #6
Question #6: Evidence supports the
usefulness of which of the following
possible staging modalities for localized
prostate cancer?
A.
B.
C.
D.
E.
Pelvic CT
PSA
Digital Rectal Exam (DRE)
Trans-rectal ultrasound
Radionuclide bone scan
Question #6: Incorrect Answer
A.
Pelvic CT: Pelvic CT is rarely used to
assess whether pelvic lymph nodes are
enlarged, a finding that would suggest
possible nodal metastasis. Because lymph
node metastasis is exceedingly rare with
Gleason score ≤ 7 and PSA < 10, pelvic
CT is not routinely done with these values
unless clinically indicated.
Return to
Question #6
Question #6: Incorrect Answer
B. PSA: Serum PSA correlates very roughly
with tumor extent.
Return to
Question #6
Question #6: Correct Answer
C. DRE: Since prostatic carcinoma is staged
by the TNM system, DRE is used to
assess the primary tumor (T stage).
Because lymph node or other metastasis is
exceedingly rare with Gleason score ≤ 7
and PSA < 10, no nodal involvement (N0)
or metastasis (M0) is assumed for clinical
staging purposes.
Go to
Question #7
Question #6: Incorrect Answer
D. Trans-rectal ultrasound (TRUS): TRUS is
typically used to direct biopsy, not for
staging.
Return to
Question #6
Question #6: Incorrect Answer
E. Radionuclide bone scan: Bony metastases
are rare with a PSA < 20 ng/mL.
Although radionuclide bone scanning is
very sensitive to detect bony metastasis, it
is not routinely done with a PSA < 10 if
the Gleason score is ≤ 7.
Return to
Question #6
Question #7: What is the CLINICAL
STAGE of Mr. State’s carcinoma?
A.
B.
C.
D.
E.
T1N0M0
T2N0M0
T3N1M0
T4N1M0
T4N1M1
Click here
to see
the stages
STAGE
SUBSTAGE
T1
DEFINITION
Clinically unapparent tumor, not detected by DRE nor visible by imaging
T1a
Incidental histologic finding; <5% of tissue resected during TURP
T1b
Incidental histologic finding; >5% of tissue resected during TURP
T1c
Tumor identified by needle biopsy due to elevated PSA
T2
Confined within the prostate (detectable by DRE, not visible on TRUS)
T2a
Tumor involves half of the lobe or less
T2b
Tumor involves more than one half of one lobe but not both lobes
T2c
Tumor involves both lobes
T3
Most common
clinical stage
since
screening
with PSA was
instituted.
Tumor extends through the prostate capsule but has not spread to other organs
T3a
Unilateral extracapsular extension
T3b
Bilateral extracapsular extension
T3c
Tumor invades seminal vesicle(s)
T4
Tumor is fixed or invades adjacent structures other than seminal vesicles
T4a
Tumor invades bladder neck and/or external sphincter and/or rectum
T4b
Tumor invades levator muscles and/or is fixed to pelvic wall
Go to
N Stage
STAGE
SUBSTAGE
Node (N)
DEFINITION
Regional lymph nodes
N0
No lymph nodes metastasis
N1
Metastasis in single lymph node <2 cm in greatest
dimension
N2
Metastasis in single lymph node >2cm but <5 cm in
greatest dimension, or multiple lymph nodes, none
>5 cm
N3
Metastasis in lymph node >5 cm in greatest
dimension
Go to
M Stage
STAGE
SUB-STAGE DEFINITION
Metastasis
Systemic spread
M0
No distant metastasis
M1a
Non-regional lymph node metastasis
M1b
Bone metastasis
a) Axial skeleton only
b) Extending to peripheral skeleton also
M1c
Metastasis at other sites
Return to
Question #7
Question #7: Incorrect Answer
A.
T1N0M0: T1 tumors have a normal digital
rectal exam (DRE). These are the most
common tumors diagnosed and are
detected by biopsy following an abnormal
PSA. Since routine PSA screening was
instituted, this has been by far the most
common clinical stage of prostate cancer.
Return to
Question #7
Question #7: Correct Answer
B. T2N0M0: T2 tumors are either palpable by DRE
or visible by trans-rectal ultrasound (TRUS), but
are confined to the prostate. T2a tumors involve
less than half of one lobe, T2b involve more than
half of one lobe but not both lobes, and T2c
tumors are bilateral. With Mr. State’s PSA of 4.8,
no nodal metastasis is assumed for the clinical
staging, as lymph node metastases are
exceedingly rare with Gleason <7 and PSA <10
Continue
Case
Question #7: Incorrect Answer
C. T3N1M0: T3 tumors have extracapsular
extension. T3b involves the seminal
vesicles. N1 indicates nodal involvement.
Return to
Question #7
Question #7: Incorrect Answer
D. T4N1M0: T4 tumors extend into the bladder neck,
sphincter, levator muscles, pelvic sidewall, or
rectum (involvement of the rectum is rare because
of the strength of Denonvillier’s fascia separating
the prostate from the rectum). N1 indicates nodal
involvement. M1 indicates metastases: M1a to
nonregional lymph, M1b to bone (typically
osteoblastic lesions), and M1c to other sites.
Return to
Question #7
Question #7: Incorrect Answer
E. T4N1M1: T4 tumors extend into the bladder
neck, sphincter, rectum, levator muscles, or
pelvic sidewall. N1 indicates nodal
involvement.
Return to
Question #7
Case Continued
Mr. State inquires about his different
treatment options. You explain that the major
categorical options include watchful waiting,
radiation therapy, and radical prostatectomy.
You recommend the National Cancer Institute
(NCI) website discussion on treatment
options.
http://www.nci.nih.gov/cancertopics/understanding-prostate-cancertreatment/page5
Continue
Case
Case Continued
At this time, he has normal erections
sufficient for penetration and no urinary
incontinence. Despite his high-fat diet, his
lipid panel is within normal limits and he has
no other cardiovascular risk factors other than
smoking and obesity (BMI 32). On review of
systems, he appears to be in good health.
Continue
Case
Case Continued
Mr. State is not enthusiastic about surgery or
radiation and says “Doc, if I just wait and
don’t do anything else, won’t I die of
something else before the prostate cancer
gets me?”
Go to
Question #8
Question #8: What is the likelihood that Mr.
State will die of prostate cancer within 10
years if he chooses watchful waiting?
A.
B.
C.
D.
1%
15%
50%
95%
Question #8: Incorrect Answer
A.
1%: Very few prostate cancers are
indolent enough to have a 10 year diseasespecific mortality of ≤ 1%
Return to
Question #8
Question #8: Correct Answer
B.
15%: Results of most watchful waiting studies
suggest a 10-year disease-specific mortality of
approximately 10-15%, although there is a wide
variability based on patient population (4-45%).
Watchful waiting may be an appropriate option
for an older patient with many co-morbidities,
because non-prostate cancer-related mortality is
high and the patient is likely to die of another
disease before he dies of prostate cancer.
Watchful waiting article #1 (Johansson: JAMA 2004)
Watchful waiting article #2 (Bil-Axelson: NEJM 2005)
Continue
case
Question #8: Incorrect Answer
C. 50%: While some prostate cancers are
aggressive enough to result in diseasespecific death within 10 years, most are
less aggressive.
Return to
Question #8
Question #8: Incorrect Answer
D. 95%: Very few prostate cancers are
aggressive enough to have a 10 year
disease-specific mortality of ≥ 95%
Return to
Question #8
Case Continued
After hearing your discussion of the watchful
waiting option, Mr. State wants to know more
about radiation therapy. A family friend who
had prostate cancer 10 years ago and was
treated with external beam therapy had terrible
side-effects and discontinued treatment before
completing the entire course. His cancer
recurred within 5 years and he passed away.
Mr. State is concerned about the side-effects
of radiation therapy.
Radiation therapy article (Nilsson, Acta Oncol,
2004)
Go to
Question #9
Question #9: Which of the following are
potential complications of radiation
treatment?
A.
B.
C.
D.
E.
Frequency
Fatigue
Impotence
Bowel bother
All of the above
Question #9: Incorrect Answer
A.
Frequency: Most patients experience
urinary frequency and dysuria. Over 90%
of these cases, however, resolve within
one year.
Back to
Question #9
Question #9: Incorrect Answer
B. Fatigue: The degree of fatigue is variable,
but significant in up to 75% of patients
during radiation treatment. Within 2-3
months of treatment completion, most
patients return to baseline energy levels.
Back to
Question #9
Question #9: Incorrect Answer
C. Impotence: Impotence has been reported
in up to 35-40% of patients.
Back to
Question #9
Question #9: Incorrect Answer
D. Bowel bother: Mild, self-limited rectal
bleeding is present in approximately 10%
of patients.
Back to
Question #9
Question #9: Correct Answer
E. All of the above. Frequency, fatigue,
impotence, and bowel bother are all
potential side-effects of radiation therapy.
Continue
Case
Case Continued
Mr. State now inquires about survival rates
after radiation therapy.
Go to
Question # 10
Question #10: What are overall and
disease-specific 10-year survival after
radiation therapy?
A.
B.
C.
80% and 90%, respectively
60% and 70%, respectively
40% and 50%, respectively
Question #10: Correct Answer
A. 80% & 90%: Overall 10-year survival after
radiation therapy is approximately 80%.
Disease-specific survival is approximately
90%. These results indicate that
approximately 20% of patients with
prostate cancer treated with radiation
therapy die within 10 years, with half
(10%) dying of prostate cancer. Continue
Case
Question #10: Incorrect Answer
B. 60% & 70%: Both overall and diseasespecific 10-year survival are significantly
better than 60% and 70%, respectively.
Return to
Question #10
Question #10: Incorrect Answer
C. 40% & 50%: Both overall and diseasespecific 10-year survival are significantly
better than 40% and 50%, respectively.
.
Return to
Question #10
Case Continued
Mr. State now wants to know more about
radical prostatectomy. You explain that the
procedure entails a 2-3 hour operation that
generally requires a 2-3 day hospital stay. He
will be able to donate autologous units of
blood to minimize the likelihood of
transfusion reaction if transfusion becomes
necessary. He will have a catheter to drain his
bladder for the first 7-10 days after surgery.
Continue
Case
Case Continued
You discuss potential complications of radical
prostatectomy, including blood loss, incontinence,
and impotence. You explain that reports of postoperative potency after radical prostatectomy vary
widely based on surgical techniques, patient
population, and method of data collection. If potency
does return, it will typically return within 6-12
months post-operatively, with significant variability.
Go to
Question #11
Question #11: If he chooses surgery, Mr.
State’s post-operative potency will be most
strongly influenced by which of the
following?
A.
B.
C.
D.
Tumor size
Pre-operative PSA
Age
Surgical technique
Baseline potency article (Hu, J Urol 2004)
Question #11: Incorrect Answer
A.
Tumor size: Tumor size correlates very
roughly with post-operative potency.
Extremely large tumors, however, are
associated with a higher likelihood of
capsular penetration, often precluding
nerve-sparing operative techniques.
Return to
Question #11
Question #11: Incorrect Answer
B. Pre-operative PSA: Pre-operative PSA
correlates very roughly with post-operative
potency. PSA>10, however, is associated
with a higher likelihood of capsular
penetration, often precluding nerve-sparing
operative techniques.
Return to
Question #11
Question #11: Correct Answer
C. Age: Patient age is the strongest predictive
factor for post-operative potency.
Increasing age is inversely proportional to
post-operative potency. Reports of potency
rates for men under 60 range from 20-80%,
for men 60-79 from 10-70%, and for men
>80 years of age from 5-70%. Although
surgical technique and other factors also
influence post-operative potency, age is the
most important factor.
Go to
Question #12
Question #11: Incorrect Answer
D. Surgical technique: Reports of potency
rates for men under 60 after bilateral
nerve-sparing operations range from 4080%, but drop to 20-60% after unilateral
nerve-sparing operations. The respective
rates are 25-75% and 10-50% in men over
the age of 60. Surgical technique is not the
strongest predictor of post-operative
potency.
Return to
Question #11
Question #12: If he chooses surgery, what
is the likelihood he will be continent of
urine within 1 year?
A.
B.
C.
D.
10%
35%
60%
85%
Continent article (Hu, J Urol 2004)
Question #12: Incorrect Answer
A. 10%: Most patients are continent of urine
within 1 year.
Return to
Question #12
Question #12: Incorrect Answer
B. 35%: Most patients are continent of urine
within 1 year.
Return to
Question #12
Question #12: Incorrect Answer
C. 60%: >60% of patients are continent of
urine within 1 year.
Return to
Question #12
Question #12: Correct Answer
D. 85%: The rate of complete post-operative urinary
incontinence is approximately 3%, but the rate of
mild stress urinary incontinence may be as high
as 20%. Return to continence is gradual, with
50% of patients continent 3 months postoperatively and approximately 75% continent at
6 months. Although most patients report no
significant incontinence after one year, only 6065% report restoration of baseline continence
(i.e. they have minor episodes of incontinence
that they do not deem significant).
Continue
Case
Case Continued
Based on Mr. States clinical exam, PSA and
biopsy results you use a Partin table to
determine there is a 67% likelihood his
prostate cancer is confined to the prostate.
Continue
Case
Case Continued
Mr. State chooses to undergo radical
prostatectomy. His final surgical pathology is
Gleason (4+3=7) confined to the prostate.
Go to
Question #13
Question #13: In this patient, what is the
likelihood of disease-free 10 year survival?
A.
B.
C.
D.
40%
60%
80%
95%
Disease-free 10 year survival article (Roehl, J Urol 2004)
Question #13: Incorrect Answer
A. 40%: Patients with extensive extracapsular
extension have 70% 5-year disease-free
survival rates and 40% 10-year survival
rates.
Return to
Question #13
Question #13: Incorrect Answer
B. 60%: Because he does not have
extracapsular extension, the probability of
disease-free 10 year survival is better than
60%.
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Question #13
Question #13: Correct Answer
C. 80%: Patients with organ-confined
prostate cancer have approximately 80%
10-year disease-free survival rates.
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Case
Question #13: Incorrect Answer
D. 95%: Even if he had extracapsular
extension there would be a >5% possibility
of disease-specific 10 year mortality.
Return to
Question #13
Case Continued
Mr. State does well after surgery. His catheter
is removed 10 days post-operatively and his
wounds are well-healed. You schedule a
follow-up appointment for 3 months.
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Case
Case Continued
Mr. State comes for a 3 month follow-up. He
has occasional loss of urine when he plays
tennis, but is otherwise fully continent. He has
begun having satisfactory erections again. You
discuss cancer surveillance.
Go to
Question #14
Question #14: What is the best way to test
for recurrence of Mr. State’s prostate
cancer?
A.
B.
C.
D.
Bone scan
PSA
Chest X-ray
Physical exam
Question #14: Incorrect Answer
A.
Bone scan: Unnecessary due to the low
likelihood of bone metastasis.
Return to
Question #14
Question #14: Correct Answer
B. PSA: PSA levels should be undetectable
following radical prostatectomy. This test
is typically ordered at the 3 month followup visit. Rising PSA levels suggest
biochemical disease recurrence.
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case
Question #14: Incorrect Answer
C. Chest X-ray: Unnecessary due to the low
likelihood of bone metastasis.
Return to
Question #14
Question #14: Incorrect Answer
D. Physical exam: Should be performed, but
will only identify gross disease, which is
highly unlikely in this patient.
Return to
Question #14
Case Continued
Mr. State’s PSA is undetectable.
He returns 9 months later (1 year post-operatively) to
recheck his PSA, which is <0.1. He has returned to
full continence and is having satisfactory erections.
He passes away 10 years later of unrelated
cardiovascular disease.
End
case
Thank you.
You have successfully completed this
cancer survivorship case.
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This case was developed by Steve Lerman, MD and
Jonathan Bergman, MD, Department of Urology
This module was designed by
Tatum Langford Korin and Sarah Afrand,
Instructional Design & Technology Unit
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Photo collection is courtesy of PEIR - University of Alabama
at Birmingham Department of Pathology via the HEAL
(Health Education Asset Library) database
Cancer Survivorship Grant Project #
© 2005, University of California Regents
Start of
case
Glossary
Dodecad Biopsy: During prostate biopsy, 12 or more
samples are taken to increase the likelihood of
detecting cancer if it is present.
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case
Glossary
Hypoechoic: A region through which ultrasonography
cannot penetrate; this region usually represents a
prostatic nodule (red arrows).
Prostate
transverse
section
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case
Glossary
Autologous: One’s own blood. By donating blood to
themselves pre-operatively, patients can decrease the
risk of transfusion reaction if they require an
intraoperative or postoperative blood transfusion.
Donation is done a few months prior to the procedure
so the patient’s red blood cell count can re-stabilize.
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case
Partin Tables
1)
2)
3)
4)
Partin coefficient tables estimate prognosis by
determining four probabilities:
The probability that the patient has completely organconfined disease
The probability that the patient has “established
capsular penetration”
The probability that the patient has extension of his
prostate cancer into his seminal vesicles
The probability that the patient has prostate cancer
which has spread into his lymph nodes
Partin Table (word document)
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case
Gleason Score
The Gleason grading system is based on the
glandular architecture of prostatic cells under low
power. Grade 1 or 2 cells are closely packed, have
little stroma, and are small and uniform. Grade 3
cells have variable-sized glands between normal
stroma. Grade 4 cells have incomplete gland
formation. Grade 5 cells have no gland formation or
lumen appearance, or they may (rarely) be
comedocarcinoma. The Gleason score is the sum of
the most commonly found cell and the second most
commonly found cell. The primary Gleason grade
is more important than the second one, so Gleason 6
(4+2) is more poorly differentiated than Gleason 6
(3+3).
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Case
Clinical versus Pathological
Staging
Clinical staging of prostate cancer involves
estimation of disease extent based on physical
examination, laboratory studies, and imaging
studies. Pathological staging involves
analysis of the removed specimen, as well.
The pathologic stage of prostate cancer is as
advanced as the clinical stage in 30% of
cases, more advanced in 70% of cases, and
rarely less advanced.
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Case
Clinical versus Pathological
Staging
Clinical staging of prostate cancer involves
estimation of disease extent based on physical
examination, laboratory studies, and imaging
studies. Pathological staging involves
analysis of the removed specimen, as well.
The pathologic stage of prostate cancer is as
advanced as the clinical stage in 30% of
cases, more advanced in 70% of cases, and
rarely less advanced.
Return to
Question #7
Denonvillier’s fascia
Denonvillier’s
fascia
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Previous slide
Disease-Free Survival
Disease-free survival is the length of time a
patient lives with no evidence of the disease
in question. If a prostate cancer patient were
alive 10 years after radical prostatectomy, but
with a rising PSA, the patient would be
categorized as a cancer survivor, but not a
disease-free survivor.
Return to
Question #13
Obesity
Obesity is currently defined by body mass
index (BMI). A BMI of 25-29 kg/m2 is
overweight, 30-39 kg/m2 is obese, and >40
kg/m2 is morbidly obese.
Return to
Text
Disease-Free Survival
Disease-free survival is the length of time a
patient lives with no evidence of the disease
in question. If a prostate cancer patient were
alive 10 years after radical prostatectomy, but
with a rising PSA, the patient would be
categorized as a cancer survivor, but not a
disease-free survivor.
Return to
Question #10