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Prostate Cancer Diagnosis

Case: Your next patient in GP practice is a 56-year-old man who came to you after consultation with a urologist. He
was diagnosed with prostate cancer and has explained this to him already. Further tests were ordered and the
patient has come to you now to discuss the results and find out about the management. The results are PSA 6.0
(N<4.0), biopsy of prostate revealed adenocarcinoma of prostate, Gleason score 5. Bone scan is negative for
metastases and CT scan of pelvis and abdomen is negative for metastases as well.
Task
a. Counsel patient about results and management
Case 2: Your next patient in GP practice is a 68-year-old male who has had recurrent urinary tract infections.
Investigations were done and he was diagnosed with prostate cancer by urologist. Patient came to your clinic for
more explanations Some of the result from the investigation: PSA 6ng/ml, MSU: E.coli, Biopsy: Adenocarcinoma,
Gleason score: 5, Cystoscopy: No outflow obstruction of bladder, Bone scan: No metastasis, CT chest/abdomen:
Normal.
Task
a. Explain the results
b. Discuss further management plan
c. Answer patients questions
Features
- Most common cancer in men
- Very slow growing; Male >80years have 80% chance they have prostate cancer but are slow growing
- The younger a family member is diagnosed the higher the risk for the patient
- Usually asymptomatic or may get symptoms (LUTS, bladder outlet obstruction, back pain, hematuria,
uremia, tiredness, weight loss and perineal pain)
- Slow growing cancer
- Screening: DRE and PSA (sensitive indicator for progress of disease)
- Clinical features:
o Hard
o Asymmetric borders
o Indurated
o Loss of median sulcus
- GLEASON GRADE (histopathological diagnosis)
o 1-5
o How aggressive/undifferentiated the tissues are
- GLEASON SCORE
o 2-10
o 2 different zones of the prostate
o Determines prognosis; the higher the score, the more aggressive disease
Gleason Score
Threat from cancer
2-4

Minimal or low

5-6

Moderate

Moderate to high (intermediate)

8-10

High

TNM Staging
o T1 found only in prostate; cannot be felt on DRE
o T2 tumor located within the prostate but it can be felt on DRE
o T3 tumor has spread from prostate to nearby structures such as seminal vesicles
o T4 tumor has spread to bones or lymph nodes
o N0 no lymph node involvement
o N1-3 cancer has spread to lymph nodes near prostate
o M0 no metastasis
o M1 distant metastases to bone or other organs

Treatment:
- >70 years: wait and watch;
o Follow up every 3 months and do PR and PSA
o PSA: good indicator of progression of disease and response to treatment
<4: normal
>20: advanced disease
>30: distant metastasis (bone, liver, lymph nodes)
- <70 years
o Radiotherapy:
Cystitis, proctitis,
o Brachytherapy: local delivery of radioactive materials
o Radical prostatectomy: (not usually done)
Complications: impotence; urinary incontinence
o Hormone therapy: if with late-stage/active disease
- Metastasis: (+) sclerotic lesions on x-ray
- Diagnostics:
o PSA: specific but not sensitive
o Initial Dx: DRE + PSA
o Transurethral USD-guided biopsy
Counseling
- I understand that you came here for the explanation of your results. I am sorry that you have been
diagnosed. Do you what the prostate is?
- You had some surgery and the surgeon took a part of your prostate and it was analyzed under the
microscope. The analysis shows that you have a cancer of prostate, adenocarcinoma. I understand that it
is not a very good news, but let me reassure you that the cancer is just in the prostate and it has not
spread anywhere else. The gleason score is also not high. The score shows how nasty the tumor is which
is fortunately not very high which means you have a good prognosis. You are in good hands and you are
fortunate that we have picked it up early. Prostate cancer is a common cancer in men. It is a slow-growing
cancer, but it can spread to the lymph nodes, bones, and liver.
- The treatment options available are:
o Surgeon may recommend watchful waiting. It is usually recommended for patient over 70 and
has no symptoms
o Total prostatectomy or radical prostatectomy usually recommended for patients <70 and for
tumors confined to the prostate and if PSA <20
o TURP an instrument with a camera is inserted to the urethra and the tumor will be taken out.
There is no need for cuts in your tummy. You will be asleep under general anesthesia and will
be given proper pain relief after surgery and you will need to stay in the hospital for a few days
while you recover. There might be some bleeding. Side effects: incontinence, retrograde
ejaculation, impotence
o Radiotherapy especially for metastases; SE: impotence and incontinence
o Brachytherapy another form of radiotherapy where tiny radioactive seeds are directly injected
in the tumor; has less side effects; Urinary frequency, urgency, fecal urgency, incontinence,
diarrhea, impotence can happen 2 years after the therapy
o Androgen suppression mainstay for metastatic or locally advanced disease either surgical
(bilateral orchidectomy) or medical (LHRH analogues and anti-androgens), cyproterone acetate
and flutamide Initially: testosterone surge. Later on they cause decrease of testosterone
o Bilateral orchidectoy: S/E: Impotence, osteoporosis, mastalgia, gynecomastia
- We would monitor you regularly with PSA every 3 months and DRE.
- What will happen if I dont undergo the procedure? There will be a tendency for the cancer to spread to
nearby structures or to the bone and elsewhere. It is good that we have picked up at an early stage which
is why I would highly recommend for you to undergo the surgery.
- Reading material. Review.
- Red flags (symptoms gets worse or with bone pain)

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