Prostate – CTF 2014

1 Appropriately identify patients requiring prostate cancer screening.

Canadian Task force 2014: (Endorsed by CCFP)

1. <55yo or >70yo, no screening for prostate ca with PSA (strong recommendation, low-quality)
2. 55-69 yo – no screening for prostate ca with PSA (weak recommendation, moderate-quality evidence)

Canadian Cancer Society 2014:

• Discuss with asymptomatic men >50yo with an estimated life expectancy >10yr,
  • Screen if pt are well informed about the risks of over-dx, over-Tx, consider PSA for early dx of prostate ca, and wished to be screened

Canadian urology Association 2011

• Average risk: Offer PSA at age 50 with life expectancy ≥ 10yr
• Increased risk: Offer at age 40
• Offer to age 40-49 for baseline PSA

Risks of PSA testing:

1. False negative & positive results
2. Biopsy: pain & rare infection, bleeding
3. Distress & anxiety
4. Overdiagnosis (dx not otherwise have become clincially apparent) & Tx (radiation, Sx, urinary problems & incontinence, sexual dysfunction, bowel problems)

Benefits of PSA testing:

1. Early detection can save lives – screen 293, dx 12 w/ prostate ca to prevent 1 death over 14yr period
2. Early detection & Tx can avert future prostate ca – related problems

Causes of ↑ PSA:

• BPH, prostatitis, prostatic ischemia/infarction, prostate bx/sx, prostatic massage, XRT
• acute urinary retention, AKI, urethral catheterization, cystoscopy, TRUS
• Strenuous exercise, perineal trauma, ejaculation, coronary bypass graft

2 In a patient suitable for prostate cancer screening, use and interpret tests (e.g., prostate-specific antigen testing, digital rectal examination [DRE], ultrasonography) in an individualized/sequential manner to identify potential cases.

1. DRE:
   • Included as part of initial screening
   • Suspicious findings: Abnormal feeling, irregular nodularity, focal lesion, discrete change in texture/fullness/symmetry, diffuse dense induration
   • Ref to urologist if abn regardless of the PSA value
2. PSA (glycogen produced by epithelial cells; <4 = normal)
   • Serum PSA = free (15%) and bound (85%) PSA
   • PSA velocity / density / free:total PSA ratio – increase sensitivity and specificity

3 In patients with prostate cancer, actively search out the psychological impact of the diagnosis and treatment modality.

Ix:

• DRE, PSA
• TRUS-guided needle biopsy
• bone scan – may be omitted in untreated CaP with PSA <10
• CT to assess metastases

Dx:

• TNM staging
• Low risk – PSA <10, Gleason score <7, stage T1-2
• Moderate Risk – PSA 10-20, gleason 7, T2
• High Risk – PSA >20, gleason 8-10, T3/4

4 In patients with prostate cancer, considering a specific treatment option (e.g., surgery, radiotherapy, chemotherapy, hormonal treatment, no treatment):
a) Advise about the risks and benefits of treatment.
b) Monitor patients for complications following treatment.

Tx:

1. T1/T2 (localized, low risk): \
   • consider active surveillance vs definitive Tx (RP,l brachytherapy, EBRT – no difference in cure rate)
   • watchful waiting + palliative Tx if older pt
2. T1/T2 (intermediate / high-risk)
   • Definitive Tx over active surveillance
3. T3/T4
   • EBRT + androgen deprivation therapy or RP + adjuvant EBRT
4. N / M >0
   • Req hormonal Tx – consider combined androgen blockade  / palliative RXT for mets
   • bilateral orchiectomy – remove 90% of Testosterone
   • GnRH agonists: Leuprolide, goserelin
   • Estrogen: DES
   • Antiandrogens – bicalutamide
   • Local irradiation of painful secondaries vs half-body irradiation
   • Hormone-refractory prostate ca:
   • Chemo – docetaxel etc

Modality	Pt considered	Limitations
Watchful waiting	Short life expectancy <5-10yr – receive non-curative hormonal Tx if dz preogresses	Dz progression
Active SurveillanceSerial PSA /DRE/biopsies	Low grade dz, good f/u, still considering more curative Tx if dz progresses	Dz progression; decrease in QOL with serial testings; risks associated with Bx; no optimal monitoring schedule defined
Brachytherapy	Low volume, low PSA <10, low grade	ED (50%), long term effectiveness not well-established
EBRT	Locally advanced dz, older pt	Radiation proctitis, ED, rectal cancer risk
RP	Young pt (<75), high-risk dz	Incontinence, ED

5 In patients with prostate cancer, actively ask about symptoms of local recurrence or distant spread.

Prostate Ca

• Asymptomatic usually, commonly detected by DRE, elevated PSA, incidental finding on TURP
  • DRE: hard irregular noduole / diffuse dense induration involving one or both lobes
  • PSA
• Locally advanced dz: storage / voiding symptoms, ED
• Metastatic dz: bony mets to axial skeleton > visceral mets (liver, lung, adrenal), leg pain & edema with nodal mets obstructing lymphatic and venous drainage

Method of spread

• local invasion
• lymphatic spread to regional nodes: obturator > iliac > presacral/para-aortic
• Hematogenous dissemination occurs early

6 Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations.

BPH

• periurethral hyperplasia of stroma & epithelium in prostatic transition zone
• Unknown etiology:
• DHT required (from Testosterone by 5-a reductase); ?impaired apoptosis, estrogen, Growth factors?
• age-related, common(50% of 50yo & 80% of 80yo) – 25% men require Tx

Hx: Assess LUTS & QOL

• (outlet obstruction & compensatory changes)
• voiding symptoms: hesitancy, straining, weak/interrupted stream, incomplete bladder emptying
• Storage symptoms: urgency, frequency, nocturia, urgency incontinence
• due to detrusor overactivity / decreased compliance
• AUA prostate symptom Score <8 mild, 8-19 moderate, 20-35 severe – FUNWISE – each ./5
• Frequency, Urgency, Nocturia, Weak stream, Intermittency, Straining, Emptying – incomplete feeling

O/E:

• DRE – smooth, rubery, symmetrically enlarged prostate

C/I:

• Retention, hydronephrosis, overflow incontinence
• infection, bladder stones, gross hematuria

Ix:

• U/A – r/o UTI
• Cr / renal U/S to assess for hydronephrosis
• PSA to r/o malignancy
• cystoscopy prior to Sx Tx, Biopsy if suspicious for malignancy
• Optional – uroflowmetry to measure flow rate, PVR (post-void residual)

Tx:

1. Lifestyle modification – evening fluid restriction, planned voiding
2. Med:
   • a-adrenergic antagonists (reduce stromal smooth mm)
   • 5-a reductase inhibitor (block T –> DHT, reduce prostate size)
   • Combination is synergistic
   • Anti-cholinergic ( for storage LUTS w/o elevated PVR)
3. Sx:
   • TURP, Laser ablation, TUIP, open prostatectomy
   • If pt can’t tolerate Sx or wish to avoid Sx – Prostatic stent, TUNA, Microwave therapy

7 In patients presenting with specific or non-specific urinary symptoms:
a) Identify the possibility of prostatitis.
b) Interpret investigations (e.g., urinalysis, urine culture-and-sensitivity testing, Digital Rectal Exam, swab testing, reverse transcription-polymerase chain reaction assay) appropriately.

Prostatitis / prostatodynia

• Most common urologic dx in men <50yo; 2-12%

3 types of prostatitis

1) Acute bacterial prostatitis

• Ascending urethral infection with KEEPS – 80% E Coli, Most occur in the peripheral zone
• Assoicated with outlet obstruction, recent cystoscopy, prostatic biopsy
• Hx: Acute onset f/c, malaise, rectal, lower back, perineal pain, LUTS
• PEx: abd, external genitalia, perineum, prostate
• Ix: U/A, CBC, C&S, transrectal u/s if not resolving (?abscess)
• Tx: Supportive, po/IV abx
  • Ciprofloxacin 500mg po bid x 2-4 weeks
  • 3rd gen cephalosporin IV x 4 weeks
  • Consider catheter if severe obstructive LUTS / retention
  • I&D of bascess if present

2) Chronic bacterial Prostatitis

• Recurent exacerbations of acute prostatitis-like S/Sx; recurrent UTI with same organism
• Hx: pelvic pain, storage LUTS, ejaculatory pain, post-ejaculatory pain
• PEx: As per acute prostatitis + pelvic floor; urine C&S: 4-glass test
  • VB1 (voided bladder): initial (urethra); VB2: midstream (bladder); VB3: post-massage/DR
  • EPS (expressed prostatic secretions) – not usually done
• Tx: Abx, consider addition of an a-blocker
  • Ciprofloxacin 500mg po bid 4-6 week

3) Chronic pelvic pain syndrome (CPPS)

• Inflammatory (3a) vs non-inflammatory (3b)
• intraprostatic reflux of urine ± urethral hypertonia
• multifactorial: immunological, neuropathic, neuroendocrine, psychosocial
• Hx: pelvic pain, storage LUTS, ejaculatory pain, post-ejaculatory pain
• PEx: As per chronic prostatitis; consider psychological assessment
• Tx: Supportive measure,
  • Trial of Abx therapy if newly dx;
  • multi-modal Tx strategy: a-blocker, anti-inflammatories, phytotherapy

KEEPs: Klebsiella, E. Coli, Enterococci, Proteus / Pseudomonas, S. saprophyticus

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References:

• TN 2014
• Candian Task force 2014