Shared Flashcard Set


Prostate Cancer

Additional Pharmacology Flashcards




What are the risk factors for developing prostate cancer?

- Age --> >70% of cases happen in those ages 65 and older

- African American or Jamaican descent

- Family history in 5-10% of cases

- Genetics play a role through BRCA 1 and BRCA 2 expression

- Diet high in saturated fat

- Risk of dying increases with body weight

- Prostate cancer is the most common cancer in men, but NOT the most deadly


What is significant regarding Prostate Specific Antigen (PSA?)



- Protein made by the prostate gland

- Elevated in BPH, infection, prostatitis, cancer, post-ejaculation

- Controversy over normal value and use as a screening tool

- Value of <4ng/ml is normal, but cancer can be seen at this level also

- Some studies recommend using 2.5 or 3ng/ml as a cut-off

- > 20ng/ml is significantly elevated

- Useful for monitoring response to tx

What are the signs and symptoms of prostate cancer?

- Usually none

- If symptomatic, problems with urination (starting/stopping/urgency), and ED

- Metastatic disease present with pain in lower back, pelvis, and upper thighs

What do we use to diagnose prostate cancer?

DRE - MD feels for lumps or rough areas

PSA - controversial > 20ng/ml suspicious

TRUS - trans-rectal ultrasound, probe inserted through rectum to take sonogram

Biopsy - 2 biopsies from separate areas of prostate

Bone scan, CT, and MRI - To check for metastases

What is a gleason score?

- Sum of the scores (1-5) assigned by pathologist to each sample from biopsy

- Max score = 10

- Prognostic indicator

- Gleason of 8-10 shows highest risk of death from prostate cancer

- Gleason 2-4 lowest risk of death

What do the different stages of prostate cancer represent?

Stage I - Localized to prostate, caught by chance, not seen or felt

Stage II - Localized to prostate, may be seen or felt

Stage III - Spreads just outside of prostate, not found in lymph nodes

Stage IV - Cancer in lymph nodes or bones


Using the diagnostic principles of prostate cancer, what kind of work-up would be needed if......


A.  A patient had a life expectancy of < 5 years AND is ASYMPTOMATIC

B.  A patient had a life expectancy of > 5 years OR is SYMPTOMATIC


A.  No additional work-up beyond DRE, PSA, biopsy for gleason score unless Gleason score is 8+ or "bulky" disease

B.  Deserves further work-up such as....
- Bone scan

- Pelvic CT scan or MRI

What does the gleason score give you an indication of?
The number of cancer cells in the biopsy (I believe)
What is the general treatment approach to prostate cancer therapy? (Stages I-IV)

Stage I or II (Localized)- Active surveillance OR radiation OR surgery (radical prostatectomy)

Stage III (Locally Advanced) - Radiation with 4-6 months ADT

Stage IV (Metastatic) - Radiation + 4-6 months ADT if only lymph nodes; long-term ADT if distant metastases

What is active surveillance and who is a candidate for it?  What are its advantages and disadvantages?

- Active monitoring of disease with expectation to intervene if cancer progress

- DRE and PSA q6-12 months, and needle biopsy every 6-18 months as indicated


Appropriate Candidates: 

- Low risk cancer

- Gleason of <8, and <50% of prostate biopsies have cancer + PSA < 10-15 ng/ml

- Short life expectancy (<10 years)



- Retain QOL

- Equal in life expectancy to other more drastic measures

- No SE's b/c of treatment


- Missed opportunity of care, risk of progression, frequent follow-up visits, subsequent treatment may be more intense, uncertain of natural history of prostate cancer

What are the first 6 lines of treatment in the general treatment algorithm for prostate cancer?

- LHRH or GnRH analog

- Add anti-androgen

- Withdraw anti-androgen

- Ketoconazole

- Docetaxel/prednisone

- Mitoxantrone/prednisone


*This is if we even decide to treat the cancer*

How does ADT therapy work with chemotherapy in the treatment of prostate cancer?

- ADT is use of hormonal therapies to block synthesis of dihydrotestosterone

- First line for symptomatic advanced disease or metastatic disease

- Continued indefinitely

- Start chemo after ADT failure

- When EXACTLY to start is controversial

- Doxetaxel regimens preferred (with prednisone x 3 weeks or with estramustine x 3 weeks)

- Mitoxantrone used for pain but doesn't help survival in patients

- Docetaxel continued until disease progression

- Mitoxantrone continued until lifetime max dose

What do LHRH analogs do, and what are some examples?  What if the patient isn't a candidate for LHRH therapy?

- Suppress negative feedback release of FSH and LH, reducing testosterone production in testes

- Can be considered "medical castration"

- Equal in efficacy to orchiectomy

- Leuprolide 7.5mg IM monthly, Eligard is same but SQ

- Goserelin --> basically same as Leuprolide but 3.6mg SQ qmonth


If patient can't take LHRH:

- Go with GnRH analog

- Degarelix.....must have.....

- Risk of neurological compromise due to metastasis

- Uretral or bladder outlet obstruction from CA

- Severe bone pain from mets in spite of narcotics

- 240mg injection SQ (separate) during first month, then 80mg SQ q28 days

What is an anti-androgen, and when would we use one?

- Used to block conversion of testosterone to dihydrotestosterone

- Used after progression on LHRH analog or orchiectomy alone


- Used for 7 days when starting LHRH in patient w/metastatic disease to prevent tumor "flare"

SE:  soft stools, hormonal effects

- Bicalutamide (Casodex) --> 50mg daily

- Also causes HTN, disulfiram-like rxn

- Technically approved for only post-orchiectomy


**Finasteride can make cancer more aggressive in those who actually have it**

What is the purpose of ketoconazole in prostate cancer therapy?

- Blocks production of multiple hormones, like testosterone, in the adrenal cortex

- 400mg PO TID +/- hydrocortisone to prevent adrenal gland suppression

- Best absorbed emtpy stomach but likely take with food to reduce upset GI

- Used to postpone chemo

What is significant regarding Docetaxel as it relates to prostate cancer?

- In combo with prednisone 5mg BID, this is gold standard for metastatic prostate cancer

- 75mg/m2 IV q 3 weeks

- Edema/fluid retention, premedicate with dexamethasone

- SE:  Mucositis, myelosuppression, alopecia, hepatic issues --> do not administer if AST/ALT < 1.5x ULN, or ALP > 2.5x ULN

What is significant regarding Estramustine as it relates to prostate cancer?

Dose:  280mg TID days 1-5 q21 days with Docetaxel

- Not commonly used, keep in refridgerator

- Calcium reduces absorption

- Causes edema, gynecomastia, leukopenia, THROMBOEMBOLISM

What is significant regarding Mitoxantrone as it relates to prostate cancer?

- Anthracyclinone = cardiotoxic

- Second line after docetaxel

- 12mg/m2 IV q21 days

- Dark blue, shows up green in bodily fluids

- Myelosuppression

- N/V is mild

- Mucositis

- Alopecia

- Adjust for bili, not for renal

- Max lifetime dose 140mg/m2

What do we need to give for supportive care in ADT therapy, while treating prostate cancer?

Bone mets - prostate cancer metastasizes to bone, can be mild pain in lower back, hip, or spine, can cause spinal cord compression!

- Must treat aggressively

- Risk increases with ADT

- Dexamethasone and radiation can be used to treat the pain, opioids also used

- Zoledronic acid 4mg over 15 minutes qmonth

- Prevents bone loss but not mets

- bone pain and flu-like sx are adverse effects

- CI if Scr > 3, > 1 in normal renal function, > 0.5 g/dl in CKD

- Calcium and Vitamin D is a must, could give Alendronate also

- Need to be screened for diabetes and other cardiovascular issues

- Must get PSA and DRE starting at age 50, age 45 if African American or high risk, or 1st degree relative of someone who has prostate issues

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