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PROSTATE CANCER

  • It is the most common cancer and the second leading cause of cancer in men
  • Age is the most important risk factor. The older you are the higher the chance of developing prostate cancer
  • To date, screening has not proved to reduce the incidence of prostate cancer and the exact cause is not known
  • The prostatic cell proliferation and death is controlled by testosterone, a male hormone
  • Screening modalities include:
       o Digital rectal examination (DRE)
       o Prostatic specific antigen (PSA)
 The following are associated predisposing factors:
  • Age is the most important as explained above
  • More common in black men
  • Increased incidence in people who eat diets high in fat
  • Environmental factors seem to play a role as men in the far East have reduced incidence compared to men in America
  • Prostate cancer could be familial
  • No clear-cut association with vasectomy
  • Most tumors are adenocarcinomas
  • Other forms of histology are: small cell, transitional and sarcomas
  • The higher the Gleason Scoring system, the higher the chance of spread

 SIGNS AND SYMPTOMS

  • May be asymptomatic
  • Dysuria, hesitancy, dribbling of urine
  • Hematuria
  • Bone pains
  • Elevated PSA levels
  • May be confused with Benign Prostatic Hyperplasia (BPH)
  • Urethral dysfunction
  • Urinary tract obstruction


 DIAGNOSIS

  • PSA level, Prostatic Acid Phosphatase, chest x-ray to rule spread to lungs, full blood count, SMA18
  • Digital rectal examination, alone, is not a sensitive test to detect prostate cancer
  • Transrectal ultrasound is not reliable
  • Prostate biopsy
  • MRI of the pelvis
  • Prostatectomy
    o Radical Retropubic prostatectomy (nerve sparing) hypogastric and obturator lymph nodes are removed but the overlying lymphatics are preserved to avoid edema in the legs
    o Radical Perineal prostatectomy


 MANAGEMENT OF PROSTATE CANCER

A. Localized Disease

  • Not all patients need to be treated because prostate cancer has a long natural history
  • If a patient has a life expectancy less than 10 years and a low grade malignancy, observation is the best approach
B. Radical Prostatectomy is the standard treatment for disease localized to the prostate
  • The importance of hormonal therapy in this group is not clear
C. Radiation therapy can be in the form of External Beam or Brachytherapy (implantation of radioactive iodine, etc.)
  • Commonly used in the older age groups and patients who cannot tolerate surgery due to their poor clinical condition
D. Cryosurgery: Long term follow-up results have not clearly shown significant efficacy

E. Adjuvant Hormonal Therapy
  • No study has been carried out in patients after radical prostatectomy
  • Hormonal therapy given in addition to radiation shows a benefit (one study)


 SIDE EFFECTS OF RADICAL PROSTATECTOMY

  • Diarrhea
  • **Urinary frequency /incontinence
  • **Sexual dysfunction - varying grades from loss of erection to inadequate erection


 SIDE EFFECTS OF RADIOTHERAPY

  • Diarrhea
  • Nausea and vomiting
  • Urinary frequency
  • Dysuria
  • Radiation dermatitis
  • Hematuria
  • Generalized weakness
  • Bone marrow suppression - anemia, low platelets, low white count
  • Crampy abdominal pain

 MANAGEMENT OF ADVANCED DISEASE

  • Luteinizing Hormone Release Hormone (LHRH) agonists, e.g. Leuprolide or Zoladex

    1. These agents decrease Luteinizing Hormone and follicle stimulating hormone
    2. Long acting depot injections are available and they are equally as effective as daily injections. Hormone manipulation prolongs life

  • Orchiectomy: Equivalent to Gonadotrophic Release Hormone analog
  • Total Androgen Blockade: addition of Flutamide and Bicalutamide (Casodex)
  • When complete Androgen blockade fails, response may be obtained by discontinuing antiandrogen (Flutamide or Bicalutamide)
  • Other approaches in patients who failed complete androgen blockade include:

    1. Use of another antiandrogen, especially in previously sensitive tumors
    2. Ketoconazole
    3. Steroids
    4. Radiation therapy to control pain and the disease, e.g., Strontium is used in pain palliation
    5. Chemotherapy: for palliation Estramustine based regimens Mitoxantrone + Prednisone Taxanes, e.g. Docetaxel and Paclitaxel
    6. Suramin It is a growth factor inhibitor
    7. Vaccines - PSA vaccines, PAP-loaded Dendritic cells
    8. Pro-apoptotic gene therapy
    9. Antiangiogenesis Thalidomide trials are ongoing
    10. Differentiating agents