Case 3: Chuck

1. Case 3: Chuck

2. 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!

3. What Questions Do You Have for Chuck?

4. Some Possible Questions for Chuck

5. 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

6. What Other Questions Will You Have for Chuck at this Stage?

7. In Your Practice, How Would You Determine the Severity of Chuck’s Symptoms at this Stage?

8. IPSS = International Prostate Symptom ScoreAUA = American Urological Association

9. 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

11. Total IPSS Score = 17

12. Chuck’s QoL Score = 5 (unhappy)

13. How Do You Interpret the Severity and Bother of Chuck’s Symptoms?

14. Interpreting the IPSS and Bother Score • Chuck’s IPSS = 17 (moderate symptoms) • Chuck’s Bother Score = 5 (unhappy) IPSS = International Prostate Symptom Score

15. What Physical Examinations Would you Include for Chuck?

16. DRE = Digital Rectal Examination

17. Physical Exam Results DRE = Digital Rectal Examination

18. What Are Your Possible Diagnoses for Chuck?

19. Possible Diagnoses BPH = Benign Prostatic Hyperplasia

20. Discussion • Chuck may have BPH, prostate cancer or both conditions simultaneously or bladder cancer to account for his symptoms BPH = Benign Prostatic Hyperplasia

21. What Are Your Next Steps?

22. Lab Results 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

23. Discussion of Lab Results • 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

24. What is the Possible Diagnosis for Chuck?

25. Possible Diagnosis for Chuck • 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

26. How Do You Answer if Chuck Asks “If I have cancer, what will happen to me?”

27. Discussion About Options and Prognosis • 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

28. What Would Be Your Management Strategy for Chuck?

29. Management Strategy PSA = Prostate-Specific Antigen

30. Feedback from Urologist • 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

31. Chuck’s Urology Consult Letter 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

32. Chuck’s Consult Letter (Cont.) 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

33. Chuck’s Consult Letter, continued: • 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

34. Chuck’s Consult Letter, continued: • 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.

35. Chuck’s Consult Letter, continued: • 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.

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

37. Chuck is a candidate for radical prostatectomy • 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

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

39. Family physician will follow: • 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

40. End of Case 3