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Case 3: Chuck. Patient History. Chuck is a 66 year old retired chemical compounder He is distressed by the development of urinary symptoms that began about 1 year ago

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Patient history
Patient History

  • Chuck is a 66 year old retired chemical compounder

  • He is distressed by the development of urinary symptoms that began about 1 year ago

  • Chuck complains of reduced force in his urine stream, as well as waking in the middle of the night to urinate and frequently urinating during the day. His wife says he can never sit still for more than 60 minutes!




Chuck s response
Chuck’s response

  • Chuck also says that his father was a pulp mill operator who died in his 70's of prostate cancer and Chuck fears he may face the same fate

  • From further questioning you ascertain that he is experiencing both obstructive and irritative symptoms

  • He has terminal dribbling and straining, his nocturia, and day time voiding are accompanied by extreme urgency



In your practice how would you determine the severity of chuck s symptoms at this stage
In Your Practice, How Would You Determine the Severity of Chuck’s Symptoms at this Stage?


IPSS = International Prostate Symptom ScoreAUA = American Urological Association


Results of chuck s ipss qol question
Results of Chuck’s IPSS & QoL Question

  • To get more information and validate the impact of symptoms on his life, you ask Chuck to complete the IPSS and Quality of Life due to Urinary Symptoms Questionnaires

  • The following are Chuck’s results:

International Prostate Symptom Score (IPSS)

Patient name: Chuck

DOB: 14/08/39

ID: 0019-0023

Date of assessment: 27/05/05

Initial assessment (X)

Monitor: during _X__ therapy after _____therapy/surgery





Interpreting the IPSS and Bother Score Symptoms?

  • Chuck’s IPSS = 17 (moderate symptoms)

  • Chuck’s Bother Score = 5 (unhappy)

IPSS = International Prostate Symptom Score




Physical exam results
Physical Exam Results Symptoms?

DRE = Digital Rectal Examination



Possible diagnoses
Possible Diagnoses Symptoms?

BPH = Benign Prostatic Hyperplasia


Discussion
Discussion Symptoms?

  • Chuck may have BPH, prostate cancer or both conditions simultaneously or bladder cancer to account for his symptoms

BPH = Benign Prostatic Hyperplasia



Lab Results Symptoms?

Lab tests:

Urinalysis: no abnormal findings

Blood Glucose: normal

PSA: 7.5 ng/mL

Urine Cytology: normal – no malignant cells

Biopsy:

Gleason: 7 (indicative of moderate grade

prostate cancer)

PSA = Prostate-Specific Antigen


Discussion of lab results
Discussion of Lab Results Symptoms?

  • Urinalysis, urine cytology and random blood glucose revealed no abnormal findings

  • In men with voiding symptoms, particularly those with a DRE showing asymmetrical enlargement of the prostate, it is important to exclude a diagnosis of prostate cancer

  • Serum prostate specific antigen (PSA) is the best marker for detecting and monitoring the progression of prostate cancer

  • PSA levels for Chuck are elevated (7.5 ng/mL) and require further investigation. However, PSA levels can be elevated for other reasons

  • The increased size of the prostate alone can be associated with increased levels of PSA

DRE = Digital Rectal ExaminationPSA = Prostate-Specific Antigen



Possible diagnosis for chuck
Possible Diagnosis for Chuck Symptoms?

  • On the basis of his elevated PSA levels, suspicious findings on DRE, Gleason of 7 as well as Chuck’s family history, prostate cancer is suspected

PSA = Prostate-Specific AntigenDRE = Digital Rectal Examination


How do you answer if chuck asks if i have cancer what will happen to me
How Do You Answer if Chuck Asks Symptoms? “If I have cancer, what will happen to me?”


Discussion about options and prognosis
Discussion About Options and Prognosis Symptoms?

  • Provide a basic discussion for Chuck to understand the options for management and the prognosis for cancer in an individual with evidence of cancer localized to the prostate



Management Strategy Symptoms?

PSA = Prostate-Specific Antigen


Feedback from urologist
Feedback from Urologist Symptoms?

  • Chuck returns from the urologist to see his family physician

  • His prostate biopsy was positive for cancer

  • He brings a letter from the urologist to summarize his situation and next steps


Chuck s urology consult letter
Chuck’s Urology Consult Letter Symptoms?

Dear Doctor,

Chuck has been evaluated because of urinary problems, mainly weak stream associated with frequency and urgency.

On exam, his abdomen was unremarkable. His prostate was noted enlarged and asymmetrical, the right side larger than the left. His urinalysis is normal, and his PSA elevated at 7.5 ng/mL.

The patient was already on α1-blocker treatment when I saw him, and was much improved. A prostate ultrasound with biopsies was done under local anesthesia at his first visit with me, and I have seen him again 2 weeks later.

PSA = Prostate-Specific Antigen


Chuck s consult letter cont
Chuck’s Consult Letter (Cont.) Symptoms?

The results of his biopsy were positive for a localized prostate cancer (two out of 8 biopsies positives for adenocarcinoma of the prostate, both on the right side, Gleason grade 7).

In summary, 1 - This patient has a localized prostate cancer (stage T1c) 2 - This patient is under medical treatment with α1-blockers for LUTS

LUTS = Lower Urinary Tract Symptoms


Chuck s consult letter continued
Chuck’s Consult Letter, continued: Symptoms?

  • Plan of Treatment:

  • As this patient was consulted initially because of LUTS, we should continue medical treatment with α1-blockers as this treatment has improved his symptoms. However, since a localized prostate cancer has been identified, treatment of this condition should be sought. I have discussed four treatment options for his prostate cancer.

LUTS = Lower Urinary Tract Symptoms


Chuck s consult letter continued1
Chuck’s Consult Letter, continued: Symptoms?

  • Treatment options:

  • One is observation with regular follow-up because his cancer is probably of low volume and will probably have a slow progression. As the patient is relatively young and is healthy, he will probably live long enough to see his cancer progress. I do not recommend this option.

  • The three other options are active treatments. He would be a good candidate for any one of these treatments and I have recommended that he select one of the three.


Chuck s consult letter continued2
Chuck’s Consult Letter, continued: Symptoms?

  • Choice of 3 Active Treatments

    • External beam radiotherapy

      • or

    • Brachytherapy

      • or

    • Radical prostatectomy, either by open surgery or by laparoscopy

      As discussed with him, all these treatments have very good chances of curing his cancer, but they have different side effects. I have discussed the different options with him and he was hesitant to choose one. I have given him brochures and websites about the different treatments and he will come back to see me to discuss the different options and make his decision. He requires follow up.


What are the Symptoms? Pros and Cons for Radical Prostatectomy, External Beam Radiotherapy, and Brachytherapy for this Patient?


  • Chuck is a candidate for radical prostatectomy Symptoms?

  • This is the best way to remove all the cancer, however long term side effects may result:

    • Possibility of erectile dysfunction

    • Incontinence

  • Radiotherapy has almost as good results in terms of long term survival in this age group, and side effects consist of:

    • Inflammation of bladder (cystitis)

    • Inflammation of prostate and rectum (prostatitis and proctititis)

    • Erectile dysfunction

  • Brachytherapy is optimally indicated for men with a PSA < 10 and Gleason score ≤6 (so in this case he is not a good candidate)

PSA = Prostate-Specific Antigen


Depending on the Surgical Option Chuck Selects, What is the Role of the Family Physician in the Follow-up?


  • Family physician will follow: Role of the Family Physician in the Follow-up?

    • Symptoms

    • DRE

    • PSA

  • If there are any changes then a referral back to the urologist is indicated

DRE = Digital Rectal Examination

PSA = Prostate-Specific Antigen


End of Case 3 Role of the Family Physician in the Follow-up?


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