Prostate Cancer- Heemer

What are probable risk factors for prostate cancer?

• age (most >65)

• genetics

• various germline mutations

• environmental

• occupational (ex: cadmium exposure)

• diet

Are there any current drugs on the market for the prevention of prostate cancer? List the drugs that were also studied, but not recommend for prevention.

• no current drugs available for prevention

• drugs that were studied for possible prevention, but still not recommended:

  • Finasteride

  • Dutasteride

  • selenium and Vitamin E

Is prostate screening routinely recommended?

no—> recommended based on risk/benefit with doctor

What is the screening for prostate cancer called? What are the risks/benefits to it?

• screening is called “Prostate Specific Antigen” Screening

  • problem: this marker can be elevated in others things not just prostate cancer

• risks: false-positive, biopsy comp (sexual/urinary issues), and over-diagnosis

• benefits: early detection= early tx = lower mortality risk

What is the major pathologic cell type in prostate cancer? (this accounts for >95% of all prostate cancers)

adenocarcinoma

Prostate cancer is graded based on histology on a scale of ___ - ___.

• how many specimens are examined

• how are the scores given?

• scale of 1-5

• 2 specimens examined and scored and then added together

• scored between 1-well differentiated and 5-poorly differentiated

Normal growth/differentiation in the prostate depends on the presence of androgens like DHT. What is the major androgen hormone? What’s the primary source?

testosterone- testes

Fill in the missing parts of the feedback mechanism of androgen synthesis:

Hypothalamus—> _________—> ____________—> testes

Hypothalamus—> Pituitary Gland—> Adrenal Glands—> testes

Early stage prostate cancers can be treated by blocking androgens, or removing the organs responsible for hormone production.

What classes of drugs can be used in this process?

• androgen synthesis inhibitors

• LNRH agonists

• LNRH/GnRH antagonists

• 1st gen antiandrogens

• 2nd gen antiandrogens

Early stage prostate cancers can be treated by blocking androgens, or removing the organs responsible for hormone production.

What organs can be removed? (this is referred to as “androgen source ablation”)

• adrenal glands- adrenalectomy

• testicle- orchiectomy

• pituitary gland- hypophysectomy

What drugs are androgen synthesis inhibitors?

• abiraterone

• ketoconazole

What drugs are LNRH agonists?

(we know them as GnRH agonists from Kearns)

• goserelin

• leuprolide

• triptorelin

What drugs are LNRH/GnRH antagonists?

• degarelix

• relugolix

What drugs are 1st gen anti-androgens?

• bicalutamide

• flutamide

• nilutamide

What drugs are 2nd gen anti-androgens?

• apalutamide

• darolutamide

• enzalutamide

What are the localized disease, locally invasive disease, and advanced disease signs and symptoms of prostate cancer?

( i don’t think that imp)

• localized disease—> asymptomatic

• locally invasive disease—> peeing problems (dribble, impotence, ureteral dysfunction)

• advanced disease—> back pain, spinal cord comp, edema, fractures, anemia, weight loss

How is prostate cancer staged and diagnosed?

• staging—> TNM

• diagnostic test—> rectal exam, PSA levels, biopsy

What is the initial tx for each of the following prostate cancer:

• very low recurrence risk and expected survival <10 years

• very low recurrence risk and expected survival 10-20 years

• very low recurrence risk and expected survival >20 years+

(KNOW TX OPTIONS, DO NOT MEMORIZE EACH!!!)

• observation

• active surveillance

• active surveillance or radical prostatectomy or radiation therapy

What is the initial tx for each of the following prostate cancer:

• low recurrence risk and expected survival <10 years

• low recurrence risk and expected survival >10 years +

(KNOW TX OPTIONS, DO NOT MEMORIZE EACH!!!)

• observation

• active surveillance or radical prostatectomy or radiation therapy

What is the initial tx for the following prostate cancer:

• favorable intermediate recurrence risk and expected survival <10 yrs

• favorable intermediate recurrence risk and expected survival >10 yrs +

(KNOW TX OPTIONS, DO NOT MEMORIZE EACH!!!)

• <10 year

  • observation

  • radiation therapy

  • brachytherapy

• >10 years+

  • active surveillance

  • radical prostatectomy (± pelvic lymph node dissection)

  • radiation therapy

What is the initial tx for the following prostate cancer:

• unfavorable intermediate recurrence risk and expected survival <10 yrs

• unfavorable intermediate recurrence risk and expected survival >10 yrs +

(KNOW TX OPTIONS, DO NOT MEMORIZE EACH!!!)

• <10 years

  • observation

  • radiation therapy+ ADT

  • radiation + brachytherapy ± ADT

• >10 years

  • radical prostatectomy (± pelvic lymph node dissection)

  • radiation therapy + ADT

  • radiation + brachytherapy ± ADT

What is the initial tx for the following prostate cancer:

• high or very high recurrence risk, expected survival 5 yrs+

(KNOW TX OPTIONS, DO NOT MEMORIZE EACH!!!)

• radiation + ADT ± docetaxel

• radiation + ADT + brachytherapy

• radical prostatectomy and pelvic lymph node dissection

What is the initial tx for the following prostate cancer:

• locally advanced/metastatic disease and expected survival 5 yrs+ with any T, N1

• locally advanced/metastatic disease and expected survival 5 yrs+ with any T, any N, M1

(KNOW TX OPTIONS, DO NOT MEMORIZE EACH!!!)

• any T, N1

  • ADT± abirtaterone + prednisone

  • radiation therapy + ADT ± abiraterone + prednisone

• any T, any N, M1

  • ADT alone

  • ADT +

    • Apalutamide

    • Abiraterone + prednisone

    • docetaxel

    • enzalutamide

What’s the difference between castration naive and castration resistant?

• castration naive- ADT initiated to achieve testosterone <50ng/mL

• castration-resistant- ADT continued to maintain testosterone <50 ng/mL

How is castration-resistant prostate cancer tx?

• locally advanced

• metastatic

• locally advanced- 2nd gen antiandrogen (apalutamide, darolutamide, enzalutamide)

• metastatic

  • abiraterone+ steroids

  • enzalutamide

  • docetaxel+ prednisone

  • radium-223

  • Sipuleucel-T

How is castration-naive prostate cancer tx?

• locally advanced

• metastatic

• locally advanced

  • ADT

  • ADT+ abiraterone + corticosteroid

• metastatic

  • ADT

  • ADT+ abiraterone + corticosteroid

  • ADT + docetaxel

  • ADT+ enzalutamide

If you have castration-resistant prostate cancer you should perform genetic testing on the following genes. If you are positive for the gene what drug should be given?

• MSI-H or dMMR or TMB >10 mut/Mb

• HR gene mutation

• BRCa 1/2

• MSI-H or dMMR or TMB- pembrolizumab

• HR gene mutation- olaparib

• BRCa 1/2- rucaparib

If you have castration resistant prostate cancer what can you use if the following treatments fail?

• Docetaxel fails

• if a patient can’t tolerate other therapies or has visceral metastases

• If Docetaxel fails—> use Cabazitaxel

• if a patient can’t tolerate other therapies or has visceral metastases—> use Mitoxantrone

What 2 drugs used in the tx of prostate cancer are antimicrotubule agents?

• cabazitaxel

• docetaxel

What 2 drugs used in the tx of prostate cancer are immunotherapy agents?

• Pembrolizumab

• Sipuleucel-T

What 2 drugs used in the tx of prostate cancer are targeted therapy agents?

• Olaparib

• Rucaparib

What drug used in the tx of prostate cancer is a part of nuclear medicine?

radium-223