Prostate Cancer

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Clinical Description

  • Cancer that occurs in Prostrate. One of the most common Cancer in Men
  • Many prostrate cancers grow slowly and are confined to the prostrate gland, where they may not cause serious harm. However, while some types of prostrate cancer grow slowly and may need minimal or even no treatment, other types are aggressive and can spread quickly.
  • Prostrate cancers that’s detected earlier, when its still confined to the prostrate gland has the best chance for successful treatment.

 

Clinical Features

SIGNS AND SYMPTOMS

  • Prostate Cancer may cause no signs and symptoms in its early stages.
  • Prostate cancer that is more advanced may cause signs and symptoms such as
    • Trouble Urinating
    • Decreased force in the stream of urine
    • Blood in the urine
    • Blood in semen
    • Bone pain
    • Weight loss
    • Erectile dysfunction

INVESTIGATIONS

  • Transrectal ultrasound guided prostate biopsy (12 core biopsy is the standard; 6 from each lobe) and PSA.
  • Fusion biopsies are not routinely done in the country now.
  • Patients presenting with ‘BPH’ should have a routine prostate biopsy to rule out coexisting malignancy

 

Treatment

PHARMACOLOGICAL

Treatment Options

Localized prostate cancer:

Low risk

  • PSA <10, GS 6, cT1c, Life expectancy > 10yrs
  • Active surveillance: 6 monthly PSA, DRE every 6 to 12 months, Prostate biopsy every 1 to 3 years
  • Radical prostatectomy
  • External beam radiation therapy (EBRT)
  • Brachytherapy

Intermediate risk

  • PSA 10 - 20, GS 7, cT2a/T2c, Life expectancy > 10yrs
  • Active surveillance (low-tier IR GS 3+4)
  • Radical prostatectomy
  • External beam radiation therapy + Androgen deprivation therapy (ADT) 4-6 months
  • Brachytherapy

High risk

  • PSA >20, GS 8-10, cT3/T4
  • Neoadjuvant ADT + EBRT + Adjuvant ADT
  • Radical prostatectomy + pelvic lymph nodes dissection

Metastatic Disease

  • Castrate – naïve
    • First treatment is castration:
    • bilateral orchidectomy or Goserelin
    • Docetaxel + Prednisolone +/- Abiraterone for high volume disease
    • Abiraterone 
    • Enzalutamide
    • Ketoconazole
    • Bicalutamide
  • Castrate Resistant
    • Abiraterone
    • Docetaxel
    • Enzalutamide
    • Cabazitaxel

Bone disease: Palliative radiotherapy, Zoledronic acid, Denosumab, Analgesia. Pathological fractures should be jointly assessed and managed with Orthopaedic team for possible stabilization.