Prostate: Management Options

Question 1

When is active surveillance used as an option?

Answer 1

• Only in T1 and T2 stage cancers

- Localised

Question 2

What is active surveillance?

Answer 2

• Monitors disease for low or intermediate risk
• Can only be on active surveillance if they are eligible for radical treatment in the future
• Can avoid or delay the surgery/treatment
• Regular PSA tests, MRI and biopsies

Question 3

What is watchful waiting?

Answer 3

• Aim is to control rather than to cure
• for patients who are ineligible for radical treatment
• Involves deferred use of hormone therapy
• Less regular monitoring than active surveillance often via a GP

Question 4

What are the disadvantages of watchful waiting/active surveillance?

Answer 4

• If fast growing, then may not be eligible for radical treatment
• Biopsies can lead to infection and side effects
• General health may deteriorate
• Anxiety

Question 5

What is a radical prostatectomy?

Answer 5

• Removal of the entire prostate gland

- Laparoscopic surgery, robotic assisted or open surgery

Question 6

What are the side effects of a radical prostatectomy?

Answer 6

• Urinary leakage/incontinence
• Erectile dysfunction
• <5% of patients will develop acute urinary retention which is a medical emergency

Question 7

Who is offered a radical prostatectomy?

Answer 7

• Localised prostate cancers (T1 and T2)

- Patients with locally advanced prostate cancer are not usually offered the surgery

Question 8

How is radiotherapy used to treat prostate cancer?

Answer 8

• Image guided IMRT or Vmat
• Convention = 74-78Gy in approx 39# in 7.5 weeks
• CHHiP trial changed to 60Gy in 20#s in 4 weeks
• High risk localised post-surgery = 66Gy in 33#
• Nodal 55-60Gy in 37#

Question 9

What pre-treatment radiotherapy preparation might be used?

Answer 9

• Microenema to empty rectum

- Full bladder e.g. 3 cups in 20 minutes

Question 10

Why are rectal spacers used?

Answer 10

• SpaceOAR to reduce bowel side effects by moving rectum out of the high dose region
• Made witha hydrogel liquid inserted through perineum under anaesthetic
• remains there for three months then is naturally absorbed by the body

Question 11

What are the acute side effects of radiotherapy?

Answer 11

• Cystitis, nocturia or retention
• Radiation proctitis (diarrhoea, tenesmus, urgency, rectal bleeding)
• Radiaiton enteritis ( abdominal pain, bloating, nausea/vomiting, diarrhoea)
• Fatigue
• Sexual dysfuntion

Question 12

What are late effects of radiotherapy?

Answer 12

• Urinary symptoms
• Faecal incontinence
• Sexual dysfunction
• Pelvic radiation disease
• Usually said to be 3 months later

Question 13

When is brachytherapy used to treat prostate cancer?

Answer 13

• Used to achieve dose escalation
• Used for localised prostate cancer, T1 and T2
• Can also be used as a boost in T3 patients

Question 14

When is hormone therapy used to treat prostate cancer?

Answer 14

• It is not curative

- Used adjuvant or neoadjuvantly

Question 15

How does hormonal therapy work?

Answer 15

• ADT or androgen deprivation therapy reduces the level of androgens (testosterone) produced
• These are injected or implanted LHRH agonists or LHRH/GnRH antagonists
• Anti-Androgen drugs can block the effects of androgens on prostate cancer cells, these are in tablet form
• Could remove testicles to reduce testosterone too

Question 16

How long are hormones typically taken?

Answer 16

• 3-6 months before RT, during or after
• Up to three years after treatment
• Can be lifelong in advanced cancers

Question 17

What are the side effects of hormone therapy?

Answer 17

• Hot flushes
• Fatigue
• Mood Changes
• Alopecia
• Osteoporosis (bisohosphonates can be given)
• Cognitive issues
• Sexual Dysfunction
• Penis shortening
• Weight gain
• Breast swelling/tenderness
• Reduces strength and muscle mass

Question 18

When is chemotherapy combined with hormone therapy?

Answer 18

• In advanced metastatic prostate cancer
• STAMPEDE Trial
• Chemo within 12 weeks of radiotherapy
• Dependent on patient fitness

Question 19

What options are there for metastatic prostate cancer?

Answer 19

• Docetaxel chemo + hormone (STAMPEDE)
• Hormone alone
• RT ( no evidence that improved lifespan, but improved length of time without disease) 36Gy in 6 weeks

Question 20

What is hormone-relapsed/resistant prostate cancer?

Answer 20

• Return of disease after hormone therapy

Question 21

How does hormone-relapsed/resistant prostate cancer typically get treated?

Answer 21

• Anti-androgen tablets: Bicalutaminde (casodex)
• Sometimes in combi with LHRH agonist injection = combined androgen blockade
• Abiraterone
• Could have docetaxel chemo if they have not had it before
• Radium-223 injections to kill bone mets
• oestrogen tablets, rarer

Question 22

What is the follow up procedure for prostate cancer?

Answer 22

• Follow up at 6-8 weeks, 12 weeks, six months
• PSA levels should be checked at six weeks then every six months and following that, once a year
• After six months, stable PSA = remote follow up

Question 23

What is HIFU?

Answer 23

• High-intensity Focused Ultrasound
• New treatment
• Treats whole or local prostate area
• Low or intermediate risk locally advanced cases
• Not suitable for men with a large prostate
• Similar side effects to current treatment options

Question 24

How does cryotherapy work for prostate cancer?

Answer 24

• Uses extreme cold
• Whole focal or salvage
• Localised low and intermediate cancers