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Prostate cancer

Prostate cancer. Key slides. Diseases of the prostate www.cancerscreening.nhs.uk/prostate. Prostate cancer malignant growth of prostate cells, localised and may spread nearly all prostate cancers are adenocarcinomas, mainly occurring in the peripheral zone of the prostate gland

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Prostate cancer

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  1. Prostate cancer Key slides

  2. Diseases of the prostatewww.cancerscreening.nhs.uk/prostate • Prostate cancer • malignant growth of prostate cells, localised and may spread • nearly all prostate cancers are adenocarcinomas, mainly occurring in the peripheral zone of the prostate gland • rare in men under 50, and is more common with increasing age • Benign prostatic hyperplasia • non-malignant increase in size of the prostate with age • rare in men under 50 • Prostatitis • inflammation of the prostate • can occur in men of any age The early symptoms of prostate diseases are very similar

  3. Prostate cancers (unlike BPH) tend to develop in the outer part of the prostate gland Unusual for early cancers to cause any symptoms Locally advanced prostate cancers that have extended outside the capsule are also frequently without symptoms If the tumour is large enough, it can cause lower urinary tract symptoms (LUTS) eg frequency, urgency, hesitancy, leaking, but by the time this happens the cancer will usually have reached an advanced stage LUTS are similar to those of BPH. Most men with LUTS will not have prostate cancer Often the first sign of prostate cancer is evidence of metastases (frequently in bone, causing bone pain) About 20–30% of patients in the UK present with metastatic disease Clinical features of prostate cancerwww.cancerscreening.nhs.uk/prostate/prostate-booklet-text.pdf

  4. Overview: Initial investigations • Symptoms may occur only when the cancer is advanced and may be similar to BPH • Offer a DRE and a PSA test after counselling to patients with symptoms suggestive of prostate cancer before referral to a specialist • There is no criterion for PSA level below which men may be reassured that they do not have prostate cancer, nor an agreed level that is considered diagnostic • Transrectal ultrasound biopsy (TRUS) should be offered after discussion of the likely risks and benefits to the patient

  5. www.nice.org.uk/CG58 TREATMENTS Localised Watchful waiting Active surveillance Radical prostatectomy External beam radiotherapy Brachytherapy Metastatic Orchidectomy or continuous LHRHa Bicalutamide or androgen withdrawal Intermittent androgen withdrawal Hormone refractory Docetaxel Corticosteroids Spinal MRI (spinal metastases) Decompression of urinary tract (obstructive uropathy) Palliative care Managing side effects of treatment Erectile dysfunction (PDE5 inhibitors first line) Urinary incontinence – refer for possible artificial sphincter Side effects of hormonal treatments Hot flushes — progestogens Gynaecomastia with bicalutamide — radiotherapy to breast buds (or tamoxifen if fails) Painful bone metastases – strontium-89 or bisphosphonates High Intensity Ultrasound or Cryotherapy Only as part of a clinical trial Localised advanced Neoadjuvant and concurrent LHRHa with radiotherapy Adjuvant hormonal therapy with radiotherapy Pelvic radiotherapy

  6. Hormone therapy(androgen deprivation therapy)EAU Guidelines 2005; NICE TA101 2006; Damber JE, Aus G. Lancet 2008;371:1710–1721 • Prostate cells are physiologically dependent on androgens (mainly testosterone) to stimulate growth, function and proliferation • The testes are the source of 90–95% of androgens (5–10% from adrenal glands) • If prostate cells are deprived of androgenic stimulation, they undergo apoptosis (programmed cell death) • Any treatment that ultimately results in suppression of androgen activity is called androgen deprivation therapy (ADT) • Can be achieved by suppressing secretion of the testicular androgens (castration, LHRH agonists), by inhibiting the action of circulating androgens (anti-androgens), or both (complete androgen blockade)

  7. Methods used for androgen depletionNICE. Improving outcomes in urological cancers. 2002

  8. NICE recommendations for managing the complication of hormonal therapy NICE Clinical Guideline and Full Guideline 58;2008 • Offer oral or synthetic progestogens for hot flushes. Offer oral therapy for 2 weeks and re-start when flushes recur, if effective • Offer prophylactic radiotherapy to breast buds within the first 6 months of long-term (>6 months) treatment with bicalutamide • Consider weekly tamoxifen if radiotherapy does not prevent gynaecomastia • Do not routinely offer bisphosphonates to prevent osteoporosis in men receiving androgen withdrawal • More research is needed into the prevention and management of osteoporosis in men receiving long-term withdrawal deprivation therapy (NICE)

  9. Prescribing trends

  10. Summary • Prostate cancer is the most common cancer in men, and is second only to lung cancer in terms of cancer deaths • Unusual for early cancers to cause any symptoms • Offer a DRE and a PSA test after counselling to patients with symptoms suggestive of prostate cancer before referral to a specialist • NICE guidance makes disease staging-based treatment recommendations • Androgen deprivation therapy recommended for locally advanced and metastatic disease

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