RISK FACTORS: Genetic predisposition (risk of prostatic cancer increases if a malignancy has occurred in a first degree relative), Endogenous hormonal influences, Exposure to chemical carcinogens, Sexually transmitted diseases, Male over 60 years
APPROPRIATE HEALTH CARE
. Inpatient for surgery, outpatient for other treatment
. Main options for clinically localized prostate cancer treatment are:
. Radical prostatectomy
- Retropubic
- Perineal
- Laparoscopic
- Robotic (robotic assisted laparoscopic)
. External beam radiation therapy
. Brachytherapy (seed implementation)
GENERAL MEASURES
. Treatment - consider age factor
. T1a - observation may be appropriate
. T1b, T1c - candidate for prostatectomy, external beam radiation, brachytherapy
. T2a, T2b - prostatectomy, external beam radiation, brachytherapy
. T3 - possible prostatectomy, possible radiation
. T4 - hormonal (androgen) ablation, palliative therapy if needed
SURGICAL MEASURES
. Under age 70, aggressive therapy for cure
. Orchiectomy (reduces serum testosterone by 90%)
DRUG(S) OF CHOICE
. In androgen-dependent tumors a reduction in serum testosterone is helpful in reducing tumor size, bone
pain, and for improving survival. Orchiectomy is the simplest androgen ablation method, however, medical
castration can alternatively be utilized.
. CAB or MAB (combined or maximum androgen blockade). Often recommended although some studies have shown no survival advantage over orchiectomy alone. Reduction in pain (54% versus 37% in patients with orchiectomy alone) is signifi cant, although the side effects of the anti-androgens (hot fl ashes, night blindness,
diarrhea, etc.) may be troublesome.
. For androgen ablation (medical castration), in patients without orchiectomy :
. Leuprolide (Lupron) 1 mg subcutaneously daily or 7.5 mg IM depot monthly or 30 mg IM depot-4 months
sustained q 4 months
. Goserelin (Zoladex) 3.6 mg q month
. Nonsteroidal anti-androgens (to block testosterone produced outside the testes, i.e., used with androgen
ablation or orchiectomy)
ALTERNATIVE DRUGS
. Chemotherapy considered experimental. Many combinations of chemotherapeutic agents have been tried
- none have been effective to date.
. Mitoxantrone (Novantrone)12mg/m2 IV q 3 weeks + prednisone 5mg bid po appears to reduce pain and
reduces PSA levels in some patients
. Other nonsteroidal anti-androgens
. Bicalutamide (Casodex) 50 mg qd
. Flutamide (Eulexin) 250 mg tid (no survival advantage over bicalutamide and has increased diarrhea, Antabuse effects, and occasional elevations of liver enzymes)
. Nilutamide (Nilandron) give 50 mg on day of castration and for 30 days, then continue at 150 mg qd
(compared to bicalutamide has more side effects including diarrhea, occasional interstitial pneumonitis, and light-dark adaptation problems)
PATIENT MONITORING
β’ Routine clinical examination every 3 months for 1 year, then every 6 months for a year
β’ Annual examinations indefi nitely
β’ PSA every 3 months for 1 year, every 6 months 1 year, then yearly
β’ Other studies dependent on rising PSA
PREVENTION/AVOIDANCE None
POSSIBLE COMPLICATIONS
β’ Cardiac failure
β’ Phlebitis
β’ Pathologic fracture
EXPECTED COURSE/PROGNOSIS
β’ Early diagnosis and treatment of lesions should be curable
β’ Advanced disease favorable prognosis if endocrine sensitive
β’ Advanced unresponsive disease progresses in 18 months average
Ten year survival for prostate cancer by stage
Stage TNM 10-year Survival
A T1 NC
B T2 75%
C T3 55%
D N1-2 (70% at 7yr)
D M1 15%
----------------------------------------
NC = no change from general population