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Terms in this set (87)
Prostate cancer is the ___ leading cause of cancer related death in men.
Under what age is prostate cancer rare?
Who has the highest risk of prostate cancer in the world?
African American men
What percentage of men with prostate cancer present with localized diseased
Most risk factors for prostate cancer are associated with an increased exposure to what hormone?
What gene mutations occur that lead to prostate cancer?
changes in androgen receptors and increased activity of 5 alpha reductase
What is 5 alpha reductase responsible for?
It converts testosterone to dihydrotestosterone
What are the risk factor for prostate cancer?
Age: average 66 years of age.
Race: african american men
High fat diets
What is the clinical presentation of localized disease for prostate cancer?
It is typically asymptomatic & is diagnosed during routine screening
What is the clinical presentation of locally invasive disease
Ureteral dysfunction, frequency, hesitance, dribbling and impotence.
What is the clinical presentation of advance disease
Back pain related to bone metastasis, core compression, lower extremity edema, pathological fractures, anemia, weight loss
What can be used to treat core compression (abrupt weakness in the legs)
What products may be used for the prevention of BPH, but is not currently approved
Finasteride, Selenium & Vitamin E, Lycopene
Where is prostate specific antigen produced.
In the cytoplasm of benign and malignant prostate cells
What is the PSA test specific for? What is it not specific for?
Specific to the prostate
Non specific for cancer
What is the normal range for PSA level?
A PSA level of _____ requires further evaluation
A PSA over _____ is suspicious for cancer.
Can a man have a PSA level and still have cancer?
What is PSA velocity?
An evaluation of the rate of rise of PSA over serial measurements. A level of > 0.75 ng/ml/year is suspicious for malignancy.
What percent of free PSA is associated with prostate cancer
less than 25%
What are advantages of a digital rectal exam (DRE)
Low cost, safe and ease of performance
What are some disadvantages for the digital rectal exam (DRE)
1. Test is insenstitive to prostate cancer
2. subject to interobserver availabilty
3. poor compliance
4. Little effect on preventing metastatic prostate cancer
When should a PSA test and DRE be offered?
If the PSA and DRE tests results are normal, when should routine screening begin?
African Americans and men who have first degree relatives diagnosed before the age of 60 should start annual screenings at what age?
List the Gleason Scores for prostate cancer
2-4 well differentiated
5-6 moderately differentiated
7-10 poorly differentiated
Poorly differentiated tumors grow ______(poor prognosis), while well differentiated tumors grow ______(better prognosis).
What is the MOA for LHRH agonist?
Decreases the release of LH and FSH which results in decrease level of testosterone
Name the LHRH agonist
What are the brand names and formulations for leuprolide?
Lupron ®(Depot), Eligard®(SQ), Viadur® (Implant)
How do you give Eligard?
How to you give Lupron?
once every 4, 12 , 16 weeks, or 24 weeks
How do you give Viadur?
In the upper arm, delivered over 12 months
What are the monitoring parameters for leuprolide?
Serum testosterone (less 20ng/dl is goal)
PSA every 3 to 6 months
DEXA scans at baseline every one to two years
Common side effect for leuprolide
disease flare during 1st week of tx, because of testosterone surge, hot flashes, gynecomastia, impotence, decreased libido, osteoporosis, bone pain, elevated triglycerides, injections site pain
Supportive care for leuproide
Calcium 1,200 mg in 2 divided doses
Vitamin D 800-1000 IU for prostate cancer (usually 400-800 in normal pts)
Brand name for Goserelin
Zoladex (implant) dosed every 4 or 12 weeks
Name the Antiandrogens
Eulexin (250mg tid)
Casodex (50mg po qd)
Nilandron (300mg po qd 1 month; 150mg qd)
Side effects of antiandrogens
Photosensitivity, hot flashes, impotence, decreased libido, Diarrhea
Which antiandrogen causes the most diarrhea
flutamide & bicalutamide
Which antiandrogen cause a disulfarim reaction?
What is part of the BBW for flutamide?
liver failure over half occurs within the first 3 months
What is the BBW for nilutamide?
Monitoring parameters for antiandrogens
PSA, Testosterone Levels, Liver Function Tests
Drug interactions for antiandrogens
What is combined androgen blockade (CAB)?
combination of an LHRH agonist with an antiandrogen
When is CAB usually used?
patients with gleason greater than 8 and a testosterone level greater than 20 ng/dL
Most patients with advanced prostate cancer will respond to initial hormonal treatment, but almost all will relapse within _______ yrs.
What are second line agents for prostate cancer
Corticosteroids: Prednisone or Dexamethasone
How does Aminoglutethimide work
Inhibition of steroid synthesis in the adrenal gland
Is Amiglutethimide a 3A4 inducer or inhibitor?
How does ketoconazole work? Is it a 3A4 inhibitor or inducer?
Inhibits androgen synthesis in the testes & adrenal gland. Is it a inhibitor
How does megace work?
Inhibits release of LH, blocks androgen receptor and inhibits 5 alpha reductase.
How the drugs that are second line agents more effective depending on the type?
no single agent is more effective than another and the response is short-live lasting only 3-14 months
What drugs are used for hormone refractory prostate cancer?
1. Docetaxel + Prednisone
4. Mitoxantrone + Prednisone
The combination of these 2 drugs doesn't increase survival, but can provide pain control and better QOL for pts with HRPC.
Docetaxel + Prednisone
The combination of these 2 drugs increase overall survival and better pain control for pts with HRPC but cause more side effects
Mitoxantrone + Prednisone
This is a chemotherapeutic agent that is a synthetic fusion of nitrogen mustard to estradiol.
What radionucleotide can you give for the management of bone metastasis?
Strontium 89. It concentrates in the osteoblastic bone lesions and delivers radiation therapy to the site
Which biphosphonate can you give for bone metastasis?
Zometa 4 mg IV every 3-4 weeks in patients with metastatic bone disease prevents disease related skeletal events. Reduced doses should be initiated in men with reduced renal function.
Which monoclonal antibody do we use for the management of bone metastasis?
What should a patient have done before taking Zometa?
A dental exam, biphosphonates are associated with osteonecrosis of the jaw
How do you confirm diagnosis for prostate cancer?
Only by a biopsy taken by removal of part of the prostate
What is stage 1 of prostate cancer?
cancer is found only in the prostate and usually grows slowly
What is stage 2 of prostate cancer?
The cancer has not spread beyond the prostate gland, but involves more than one part of the prostate.
What is stage 3 of prostate cancer?
The cancer has spread beyond the outer layer of the prostate into nearby tissues or to the seminal vesicles.
What is stage 4 of prostate cancer?
The cancer has spread to other areas of the body such as the bladder, rectum, bone, liver, lungs, or lymph nodes.
What is the main area prostate cancer metastasize to?
What are the main types of treatment for prostate cancer?
1. Expected Management
4. hormonal therapy
Describe expected management for prostate cancer.
for men with < 5 year life expectancy and low grade disease The PSA, DRE, and symptoms are monitored on a periodic basis (every 6 months).
What is the advantages and disadvantages of expected management
Advantage: It avoids immediate morbidity associated with treatment and maintains the quality of life
Disadvantage: There is a risk of progression, increased anxiety, frequent medical exams, and subsequent treatment may be more intense.
What are 2 types of radiation for prostate cancer?
external beam radiation or brachytherapy
What are complications of radiation therapy?
2. Rectal Symptoms
3. Bladder Symptoms
What is a radical prostatectomy?
operation to remove the prostate gland and some of the tissue around it. There is a 10 year cure rate of 85% of men with disease confined to the prostate.
Complications of prostatectomy
1. Early mortality
2. Bladder contracture
Advantages and disadvantages of prostatectomy?
Advantage: The cancer is removed from the body
Disadvantages :impotence, incontinence, loss of ejaculation, infertility.
What is androgen ablation therapy?
Treatment designed to suppress the production of male hormones. Involves the administration of a LHRH agonist +/- anti androgen or orchiectomy
The goal of androgen ablation therapy is to reduce serum testosterone to _____ one month after initiation of therapy.
20ng/dl (castration level)
What is an orchioectomy?
removal of the testes. Also a considered androgen ablation therapy
What treatment should you use for stage 3 prostate cancer?
Radiation Therapy +/- Neoadjuvant Hormonal Therapy
Neoadjuvant therapy typically starts 2-3 months before radiation treatment begins and continues for several months to years after.
What treatment should you use for stage 4 metastatic prostate cancer?
Bisphosphonates or denosumab for management of bone metastasis
What are 1st line therapies for hormone sensitive prostate cancer?
1. LHRH Agonist
What should you give for hormone refractory prostate cancer (HRPC)?
1. Docetaxel + Prednisone
2. Cabazitaxel is docetaxel resistance
3. Mitoxantrone + prednisone as palliative care
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