Hello, this is a voice, annotated presentation on prostate cancer. My name is abasing and I'm a urology resident at Duke. On our second side, we can see an outline of what we will cover in the next ten minutes. It'S very important to note that prostate cancer is a very, very large topic. We makes it impossible to discuss all of it.
There are also a lot of controversial aspects of prostate cancer, so even what I will talk about may seem confusing at times, but I will try to make things as clear as possible. The goal of this lecture is to give you a basic understanding of what the disease is, how we will diagnose it, our different options to treat localized disease and some of the well-known side effects that these treatments can cause.
We will then finish up by discussing the options for treating advanced, prostate cancer. The prostate gland is an extra kind grant in the male genital urinary system that produces prostatic fluid. This fluid is alkaline in nature and makes up about a quarter of semen and helps sperm survive in the acidic vagina.
Moving on to prostate cancer, though prostate cancers are most common cancer in men, aside from skin cancer, 95 % of prostate cancers are adenocarcinoma, the prostate. Rarely the cancer may be transitional cell.
Remember that the prostatic urethra is composed of transitional cells and even more rare is squamous or neuroendocrine cancers. Most men will not die from their prostate cancer. This means, despite having prostate cancer, they are far more likely to die from some other reason, because prostate cancer is usually not aggressive.
However, it is still the second most common cause of cancer death in men after lung cancer. This is a function of how common prostate cancer is multiplied by the small but real chance of the disease being aggressive, and this brings us to the big problem with prostate cancer right now.
We are simply not good at telling which cancers will probably never hurt a man versus determining which are the more aggressive diseases that will very likely kill him. Just a few years ago, almost everyone agreed. It was best to be screened for prostate cancer.
The point of screening was to catch the cancer, since it's very rare to have symptoms of prostate cancer unless the disease is very advanced. The official recommendations or any man over 50 should be screened annually.
But if a man had risk factors such as being african-american or having a family history of prostate cancer, then they should be screened at an earlier age, such as 40. You should know now that there are many people who say we shouldn't screen for prostate cancer at all, since this leads to over treatment by over treatment, I mean, even though we may be able to treat a man's prostate cancer and get rid of it. He may not prolong his life, since he probably wouldn't have died of the disease anyway.
The discussion whether the screen is long and very controversial - you won't spend more time on it, just know that it's controversial, let's get back to how we screen. So screening is done with an exam and a blood test called a PSA which checks the level of prostate, specific antigen in the blood in general.
Higher levels of PSA are worrisome for prostate cancer, but PSA is a poor predictor for disease and there a lot of reasons men can have an elevated PSA, including normal aging. Also many prostate cancers have been found in men wouldn't low or so-called normal PSA. Therefore, there's no good cutoff value to call a PSA normal pros abnormal, but most providers will use the value of 4 nanograms per milliliter.
The exam portion of screening is a digital, rectal, exam abbreviated to D re, and it's a test where a doctor puts a gloved finger into man's rectum to feel the back of the prostate. You can see a cartoon depiction of it in this slide. A normal, prostate should feel smooth and feeling a nodule is concerning for cancer, since nod32 tests are very good, doctors have looked for other ways to also diagnose, prostate cancer, imaging is gaining use and the most common imaging modalities are ultrasound and MRI in this ultrasound image. You can see a hypoechoic area near the bottom of the slide demarcated by an arrow which is concerning for prostate cancer.
In this next image, which is an MRI, you can see an area of low signal demarcated by a white arrow on the right base of this prostate, which is also concerning for prostate cancer. Use of the imaging of prostate cancer is still on a national and global scale. Uncommon because in general, it's hard to see prostate cancer in imaging is also worth mentioning.
There are a blood and urine tests, but other than free PSA, which is somewhat helpful. None of that pass muster, therefore, for most men it still comes down to the PSA and directly exam, and if one or both unwrapped normal, it raises concern for cancer, and the man is recommended to get a prostate biopsy.
A biopsy is done in an outpatient setting and almost always with the use of an ultrasound to help the doctor see the prostate and biopsy different parts of it. This ultrasound is called trusts for transrectal ultrasound. The transrectal means we put the ultrasound probe inside the man's rectum. As seen in this picture. We then use the image provided as a guide to get small pieces of tissue using a biopsy gun.
We usually try and get six samples from each side of the prostate. As well as any additional samples from any part of the prostate that felt that normal on the digital, rectal exam or looked abnormal on the ultrasound, these samples are then reviewed by pathologists.
Who'Ll look for cancer and if it is there, he will grade it on a Gleason score where higher numbers indicate more aggressive cancer. The biopsy Gleason score has been associated with worse, prostate cancer outcomes. A point to keep in mind regarding the biopsy is it's a random sampling of the prostatic gland, so it's possible to miss a large or aggressive tumor.
You should also know the risks of a biopsy, the biggest of which is infections, since the biopsy needle goes through the rectum, which has plenty of stool and bacteria and then into the prostate Brutis reason. Antibiotics are given before and after biopsies. The other risks are hematuria and perennial pain which are usually temporary. So if the box, we know the man has prostate cancer. Next question is: what are we going to do about it?
The first question is: do we think this patients cancer may hurt or kill him? Remember most cases of prostate cancer will not kill a man, and if we can be relatively sure of this, if, for example, the biopsy found a very small amount of unaggressive disease and or the man was very sick with heart disease etc, it may not make sense To do anything, we think that cancer may kill him.
The next question is: is the cancer confined to the prostate and the vast majority it is. If it is compacted to prostate, then we can offer to man definitive treatment for his disease, either through surgery or radiation. If we think the cancer spread out of the prostate, then this type of local therapy will not help the other option for a man is something called active surveillance.
This means not treating the cancer right away, but instead keeping close eye on it through frequent PSA tests and annual biopsies and then treating the cancer only if it appears to be aggressive. This has meant for cancers, we think probably will not kill a man, even if his health is just that he will live for a long time. It may seem crazy to not treat a cancer in an otherwise fairly healthy man immediately and to instead just watch it, but please remember that most men, even otherwise healthy men, will not die the prostate cancer. So by not doing surgery or radiation. You spared the patient.
Two negative side effects that come with these treatments, which we will talk about. As you can imagine, active surveillance is a very controversial topic and still emerging as a field of research. The majority of men definitely get a treatment, either surgical or radiation. The surgical ways to take out a prostate are open and laparoscopic. If there's unlock birth topically, it's usually done with the aid of a robot, specifically the da Vinci robot in the USA.
Radiation is the other way to treat the prostate, and this is done in an external beam radiation. A doctor can also put a radioactive seeds into the prostate, which is called brachytherapy, but this is not as common as other forms of radiation for high-risk, prostate cancer. Some men will get both surgery and radiation at this point. Surgery, radiation both treat cancer really well, and the research shows there's no significant difference in one over the other in terms of better cancer control. There are other ways to treat prostate cancer in a more focal manner, meaning we're only going to treat the part of the gland which we think has cancer.
Two of these modalities are high foo, which stands for high intensity, focused, ultrasound and cryoablation, which uses an ice ball to freeze parts of prostate. These two Matz's are not as good for cancer control and reserved for patients when we think the cancers dangerous, but the men are not good candidates for surgery or radiation.
Finally, another option treat prostate cancers through medications and the most important of these are anti androgens. The most widely used work by blocking the release of luteinizing hormone, releasing hormone which results in no luteinizing hormone, which in turn stops testicular testosterone production. Other drugs work by blocking androgen receptors, prostate cancer needs androgens to live, and by blocking it, you can treat a man's prostate cancer.
Often hormones are used in conjunction with surgery or radiation. There are side effects from treatment. Surgery and radiation can both cause some important and debilitating side effects, primarily issues with urinary, continence and erectile function.
It takes about a year to after surgery for these symptoms to level out and when they do about, 10 percent of men will continue having continents and the majority of men will require medications such as viagra to gain erectile function sufficient enough for sexual relations. The reason for incontinence is, as you know, the prostate makes up the most proximal part of the urethra and is therefore attached to the bladder.
Therefore, both Surgeon radiation can damage the bladder and external urethral sphincter the nerves for erections run along the prostate, which is a reason for reckless function in surgery. The surgeon can try to spare the nerves which helps some, but not entirely. There are treatments for both of these problems for incontinence.
Men can wear pads or are undergo another procedure, such as artificial urethral, sphincter placement for rectal dysfunction. We already mentioned the first line of therapy, which is oral medications such as viagra, and if these does not work, then a man can use a vacuum pump and there's also surgical options to implant a prosthesis.
We also talked about the other option for treating prostate cancer, which is anti androgens. The side effects from anti androgens is a side effects from becoming castrate, which means the man can feel fatigued. Poor bone health have decreased sexual drive and possibly have negative cardiovascular implications want to talk about is advanced prostate cancer by advanced disease, referring to prostate cancer that is outside of the prostate elsewhere in the body.
The good news about advanced disease is that we've gone pretty good at treating it, and while we cannot really cure advanced, prostate cancer, we can usually prolong men's lives by years with our current treatment modalities. If a patient presents with advanced disease, there is usually no reason to surgically remove or radiate the prostate, since the cancer is already spread, most cancers go to the lymph nodes first or the bone, so we can look for these cancers through bone scans and CTS.
Processing is another option, since prostate cancer cells to make PSA - and this is an imaging test that is able to look for PSA in the body. It'S also an important point to bring up that bought. Psa is not a great task for diagnosing prostate cancer, which we mentioned earlier. It is a good test to follow the cancer once you know, a man has it followed. New PSA level is a good way to follow the effectiveness of treatment for prostate cancer commands, prostate, has been surgically removed or radiated.
There should be no profit to make PSA, so any PSA measure in the blood suggests prostate cancer cells are present too. Psa goes higher suggest to cancer is growing and/or spreading the first-line treatment against advanced disease is hormonal therapy, as we mentioned earlier.
prostate cancer symptoms prostate cancer treatment prostate cancer causes prostate cancer uk prostate cancer nhs how to avoid prostate cancer types of prostate cancer Prostate Cancer, prostate cancer treatment, prostate cancer causes, prostate cancer stages, prostate cancer signs, prostate cancer prevention, prostate cancer definition, prostate cancer age, prostate cancer symptoms and treatmentThe goal of this medication is to remove testosterone from the body, in other words, to make demand medically castrate as opposed to surgical castration, which is done through the removal of a man's testicles. And indeed, was the treatment used for advanced disease before the current medications were available. These medications almost always will work for men in for a certain period of time.
The cancer then appears to have the ability to not need testosterone or seems to make its own. At this point, the cancer is called castrate-resistant, prostate cancer, when this happens, chemo therapies, next line of treatment, usually with docs taxol or karbas attacks.
All these drugs are taken with prednisone and generally, it helped add on a few months of life, once they stopped working, men can be put on other drugs. There are a number of options, the first of which I want discuss, is sickle cell. This is the so called prostate cancer vaccine.
Another exciting treatment is abiraterone which blocks an enzyme called 17a, which is part of the dasta's front production pathway. Both of these drugs have been shown to prolong men's lives and they're in place in the prostate cancer. Armamentarium is still being worked out. Thank you for taking the time to listen to presentation, let's review briefly some to take home messages. First, prostate cancer is very common and normally not aggressive.
Based on research. Most men with prostate cancer will not be hurt or died their disease, but a small percentage can and will die of it. Second, we use PSA and digital rectal exam to look for prostate cancer. Imaging is being used more often. Third, when we think a man may have cancer, we do a prostate biopsy to check forth.
The man has localized prostate cancer. Are options treat him our surgery, radiation and active surveillance, which means not treating the cancer right away, but following him closely, surgery and radiation are both equally effective at treating. The cancer medications can also be used, usually as adjunct of treatment. Fifth, our major treatment options which are surgery radiation, can cause significant morbidities with urination and erectile dysfunction.
Finally, if a man has advanced disease, which means the disease is outside of the prostate, the first line of therapy is anti-androgen medications and when the cancer becomes resistant, chemotherapy here are some suggested further readings if you're interested in learning more about prostate cancer.
I hope you found this session helpful.
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