Prostrate Cancer and Screening / Testicular Cancer

Prostrate Anatomy  Prostrate Cancer Screening Reference: EARLY DETECTION OF PROSTATE CANCER: AUA GUIDELINE The strongest evidence of benefit for PSA screening for early diagnosis of prostate cancer is in the age group 55 to 69 years since this is the group studied in randomized trials. Thus, targeting of men age 55 to 69 years, after a risk benefit discussion, represents one approach to screening that is based on best evidence Strong evidence for a lack of treatment benefit for men in the age group 74+, especially those with a life expectancy below 10-15 years Studies SRSPC PLCO No survival benefit, 25 % of screening patients had LUTS / BPH  PIVOT  New upcoming studies Protect T Study  Diagnosed of Prostrate cancer by screeing in 1999-2001 Usual care: US NHS  CAP study  5 ARIS : No decrease by 50 % then, strongly suspect for prostrate cancer. Do a pretreatment PSA check up in these patients.  Harm associated with PSA screening Bleeding Infection  Incontinence ED Fasle positive rates Over-diagnosis  Death  Various organization recommendation  USPTF: Against screening  They are reevaluating it and results will come back in next 12 months  ACP: 50-69 Discuss the risk and benefits, and documents < 50 : No > 60 NO  < 10 yrs survival : No AUA <40 NO 40-54 : No 55-59: Discuss For those screened every 2 yrs  >70 NO    References Screening for Prostate Cancer NEJM 2011 Early Detection of Prostrate Cancer AUA Guideline 2013 Early Detection of Prostrate Cancer AUA Guideline 2013 Once Diagnosed: Define the Risk and the Life expectancy to decide on the work up and treatment approach Risk Categories Low Risk  Very-low Risk(Gleason score of 6 or less on biopsy and a serum PSA <10 ng/mL; <3 positive cores, no core ≥50 percent involved, serum PSA <10 ng/mL,and PSA density <0.15) Low Risk (limited disease in one lobe of the prostate gland, a serum PSA <10 ng/mL, and the Gleason score ≤6) Intermediate Risk (a serum PSA between 10 and 20 ng/mL or a biopsy Gleason score 7) High Risk (Stage T3 and T4, Gleason score 8-10, or s PSA level > 20 ng/mL) High-risk, clinically localized prostate cancer Very high risk prostate cancer  Lymph node involvement  Disseminated disease  Life Expectancy (that we look for different stage is different) Low Risk: <10 yr, 10-20, >20 yr Intermediate risk: <10 yr, >10 yr High Risk: <5 yr, >5 yr High Risk Disease usually has a lethal course if left untreated (28% 5 yr survival in T4) https://mksap17.acponline.org/app/tables Pre-treatment risk stratification of prostate cancer patients: A critical review Can Uro Ass 4 Stages T1: Clinically Inapparent Tumor T2: Tumor confined to prostrate T3: Tumor extends through prostrate capsule and may invade the seminal vesicles T4: Tumor fixed or invades adjacent structures 81 % patient with T1 or T2 (100% 5 yr survival) 12 % present with T3 and T4 without metastasis (100% 5 yr survival) 5% present with T4 with metastasis (28% 4 yr survival) References: T stages of prostate cancer.http://accessmedicine. Prostate cancer: summary of updated NICE guidance BMJ 2014 Treatment 5 treatment options exists for patients with newly diagnosed prostrate cancer Observation or Active Surveillance Radiation Prostatectomy Androgen deprivation therapy (ADT; hormonal therapy) Usually ADT is done for 8 months followed by Radiation therapy Screen for osteopenia, may need bisphosphonates Ca and Vit D are given Chemotherapy (if metastatic disease or hormone resistance)  docetaxel plus prednisone is usually used Table 42. Initial Treatment of Prostate Cancer MKSAP 16 Testicular Cancer            Testicular Cancer — Discoveries and Updates NEJM 2014