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Epidemiology:
Median age at diagnosis is [blank_start]66[blank_end] years.
[blank_start]100%[blank_end] 5 year survival rate with local or regional disease
[blank_start]28.7%[blank_end] 5 year survival rate with distant disease
95% are [blank_start]adenocarcinoma[blank_end](cancer that starts in the mucous glands in epithelial tissue).
In New Zealand…
[blank_start]Most common[blank_end] cancer in men (3000 new cases/year, 600 deaths/year).
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66
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100%
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28.7%
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adenocarcinoma
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Most common
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Which of these is NOT a risk factor for prostate cancer?
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Male
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Age >40
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Black (race)
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Family history
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Alcohol consumption
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There is controversy with screening for prostate cancer as there is no clear evidence of mortality benefit with screening.
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Screening methods:
- Digital rectal exam (circa 1900s).
[blank_start]Cheap, safe, easy[blank_end] BUT not [blank_start]sensitive[blank_end], poor interobserver reliability, poor [blank_start]compliance[blank_end]
- PSA blood test (prostate specific antigen)
Low [blank_start]specificity[blank_end]. Many other causes (BPH, acute [blank_start]prostatitis[blank_end], urinary [blank_start]retention[blank_end],benign prostatic [blank_start]hypertrophy[blank_end]).
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Cheap, safe, easy
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sensitive
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compliance
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specificity
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prostatitis
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retention
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hypertrophy
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Select ALL the symptoms of prostate cancer which indicate advanced disease.
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Painful urination
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Erectile dysfunction
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Urinary hesitance
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Urinary retention
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Hematuria
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Weight loss
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Back pain
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Lower extremity oedema
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Anemia
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Diagnosis
History and physical exam.
DRE and PSA.
TRUS - [blank_start]transrectal ultrasound[blank_end] - if one of above positive).
[blank_start]Biopsy[blank_end] (confirmative)
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transrectal ultrasound
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Biopsy
Frage 7
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Staging:
Stage A - [blank_start]Occult or palpable[blank_end]
Stage B -[blank_start]Confined to the prostate[blank_end]
Stage C - [blank_start]Localised to periprostatic area[blank_end]
Stage D - Metastatic disease
[blank_start]T0N0M0[blank_end] (non-palpable)
[blank_start]T1[blank_end] - Not palpable or visible by imaging
[blank_start]T2[blank_end] - Confined within prostate
[blank_start]T3[blank_end] - Extends through capsule
[blank_start]T4[blank_end] - Fixed or invades adjacent structures (other than seminal vesicles)
Frage 8
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Gleason Score:
Histologic grade of tumor. Calculated based on dominant [blank_start]histological[blank_end] grades. Scores range from 1 = well [blank_start]differentiated[blank_end] healthy tissue, to 5 = very [blank_start]poorly[blank_end] differentiated abnormal tissue. Gleason score = sum of [blank_start]two most common[blank_end] pattern grades ([blank_start]2 to 10[blank_end]). Higher is worse.
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histological
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differentiated
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poorly
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two most common
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2 to 10
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Factors influencing prognosis:
Extent of [blank_start]tumor[blank_end]
Histological [blank_start]grade[blank_end] of tumor
Patient’s [blank_start]age and health[blank_end]
[blank_start]Molecular markers[blank_end] (Bcl-2, Bax, Ki67, p53, p27, E-cadherin, Microvessel density, DNA ploidy, p16)
PSA level?
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tumor
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grade
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age and health
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Molecular markers
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Initial treatment depends on the stage, Gleason score, presence of symptoms, and life expectancy.
Low risk patients (T1 or T2, GS of [blank_start]2-6[blank_end], PSA<10ng/ml) – excellent survival (10yr):
[blank_start]ObservationRadiation[blank_end]
Radical [blank_start]prostatectomy [blank_end]
Life expectancy <10 years?
Observation
Radiation therapy
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2-6
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prostatectomy
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Observation, radiation
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Nonpharmacological Treatments:
Observation - DRE and PSA performed every [blank_start]6[blank_end] months and biopsy if signs of [blank_start]progression[blank_end]
Radiation - Effective yet complications ([blank_start]hematuria, impotence, diarrhea, cystitis[blank_end])
Radical prostatectom y - Complications: [blank_start]blood loss[blank_end], impotence, [blank_start]incontinence[blank_end], fistula
Bilateral orchiectomy (removal of testes). Need [blank_start]androgen deprivation therapy[blank_end].
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6
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progression
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hematuria, impotence, diarrhea, cystitis
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blood loss
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incontinence
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androgen deprivation therapy
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Hormonal Treatment:
Rationale - Androgens stimulate prostate cancer cells to [blank_start]grow[blank_end]. Main androgens are [blank_start]testosterone[blank_end] and dihydrotestosterone (DHT). Most androgens made by [blank_start]testicles[blank_end] but also by adrenal glands. Lowering androgen levels makes prostate cancer cells shrink or grow more [blank_start]slowly[blank_end] but does not cure prostate cancer.
Indication - If cancer cannot be cured by surgery or radiation or [blank_start]remains/relapses[blank_end]... In combination with radiation therapy if high [blank_start]risk of recurrence[blank_end] (high Gleason)... OR before radiation to shrink cancer and make radiation more [blank_start]effective[blank_end] .
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grow
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testosterone
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testicles
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slowly
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remains/relapses
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risk of recurrence
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effective
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Pharmacological (hormone) Treatment:
1. LHRH [blank_start]agonists[blank_end] - Reversible method of androgen ablation as effective as orchiectomy. Puts patient at risk for [blank_start]osteoporosis[blank_end]. Drugs: [blank_start]Leuprolide, Goserelin,[blank_end] Triptorelin, Histrelin.
2. GnRH [blank_start]antagonists[blank_end] - Works directly in [blank_start]pituitary[blank_end] to reduce testosterone
3. Antiandrogens - Bind to [blank_start]androgen[blank_end] receptors so androgens cannot. Not used alone, typically with LHRH agonists/removal of testicles. Drugs: [blank_start]Flutamide, Bicalutamide, Nilutamide[blank_end]
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Which of these is not an ADR of androgen lowering therapies?