Prostate Cancer Management

Aka: Prostate Cancer Management

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II. Protocol: Decision making for Prostate Cancer Management based on risk and Life Expectancy

  1. Estimate Life Expectancy
    1. See Charlson Comorbidity Index (Comorbidity-Adjusted Life Expectancy, CALE)
  2. Determine cancer risk based on PSA, Prostate Cancer Staging and Prostate Cancer grading
    1. See Prostate Cancer Composite Risk
  3. Decide on management based on whether expected onset of Prostate Cancer symptoms occurs within Life Expectancy
    1. Very low risk Prostate Cancer
      1. CALE <10 years: Observation
      2. CALE 10-20 years: Active Surveillance of Prostate Cancer
      3. CALE >20 years
        1. Consider Prostatectomy, Radiotherapy or brachytherapy
        2. Consider Active Surveillance of Prostate Cancer
    2. Low risk Prostate Cancer
      1. CALE <10 years: Observation
      2. CALE >10 years: Consider Prostatectomy, Radiotherapy or brachytherapy
        1. Consider Active Surveillance of Prostate Cancer
    3. Intermediate risk Prostate Cancer
      1. CALE <10 years: Consider Prostatectomy or Radiotherapy (or brachytherapy, hormonal therapy)
      2. CALE >10 years: Prostatectomy or Radiotherapy (or brachytherapy, hormonal therapy for 4-6 months)
    4. High risk Prostate Cancer (with any CALE)
      1. Prostatectomy or Radiotherapy (or brachytherapy, hormonal therapy for 2-3 years)

III. Management: Localized Prostate Cancer (Stages A to C)

  1. Surgical Management
    1. Indications
      1. Well-differentiated tumor (Gleason Score 2-4)
      2. Patient under age 65 years
        1. Better outcomes than with conservative therapy
      3. Bill-Axelson (2005) N Engl J Med 352:1977-84 [PubMed]
    2. Procedures
      1. Radical Prostatectomy
      2. Pelvic Lymph Node biopsy (Rule out Stage D)
        1. Indicated for Prostate Cancer Stage C
  2. Prostate Radiotherapy
    1. Procedures
      1. External Beam Prostate Radiotherapy
      2. Prostate Seed Implant Radiotherapy (Brachytherapy)
      3. Consider Transurethral resection of Prostate
    2. Better quality of life than with Prostatectomy
      1. Lower Incidence of Sexual Dysfunction and Urinary Incontinence post-procedure
      2. Potosky (2004) J Natl Cancer Inst 96:1358-67 [PubMed]
  3. Conservative therapy (no curative treatment)
    1. See Active Surveillance of Prostate Cancer
    2. Indications (Curative treatment with risk exceeding benefit)
      1. Well-differentiated tumor (Gleason Score 2-4)
      2. Gleason Score 5-6 if Life Expectancy less than 10 years
        1. Elderly patients with serious comorbities
    3. Contraindications (Curative treatment preferred)
      1. Poorly differentiated tumor (Gleason Score 7-10)
      2. Gleason Score 5-6 if Life Expectancy greater than 10 years
        1. Younger patients who are otherwise healthy
    4. References
      1. Bhatnager (2004) Urology 63:103-9 [PubMed]

IV. Management: Endocrine Therapy for Advanced Prostate Cancer (Stage D)

  1. Background
    1. Endocrine agents primarily lower Testosterone Levels
    2. Adverse effects
      1. Hot Flashes
      2. Erectile Dysfunction
      3. Metabolic Syndrome
      4. Muscle loss
      5. Osteoporosis
  2. Luteinizing or Gonadotropin Releasing Hormone Agonist (LHRH or GNRH)
    1. Mechanism: Suppress Testosterone
    2. Goserelin acetate (Zoladex)
    3. Leuprolide acetate (Lupron)
      1. Risk of Prolonged QT
  3. GnRH Antagonists
    1. Degarelix (Firmagon)
      1. Risk of Prolonged QT
  4. Antiandrogens
    1. Flutamide (Eulexin)
      1. May increase Warfarin activity and raise INR
    2. Enzalutamide (Xtandi)
    3. Bicalutamide (Casodex)
    4. Abiraterone acetate (Zytiga)
      1. Risk of Hypertension, Hypokalemia
    5. Apalutamide (Erleada)
      1. May decrease Warfarin activity and lower INR
  5. Other Testosterone lowering agents and procedures
    1. Bilateral Orchiectomy
    2. Diethylstilbesterol (DES) 1 to 3 mg daily
  6. References
    1. (2022) Presc Lett 29(1): 5

V. Management: Palliative Care for Bone Metastases (Spinal Metastasis)

  1. Adequate Narcotic Analgesics
  2. Bisphosphonates (e.g. Fosamax)
  3. Local radiation
  4. Strontium 89 Chloride local therapy
  5. Endocrine therapy as above
  6. Dexamethasone (Decadron)
    1. Bolus: 16 mg IV
    2. First 3 days: 4 mg IV q6 hours
    3. Taper over 14 days
  7. References
    1. Eisenberger in Walsh (1998) Campbell Urology, p. 2654

VI. Monitoring

  1. See Prostate Cancer Survivor Care

VII. References

  1. Brawley (2018) Am Fam Physician 97(12): 798-805 [PubMed]
  2. Mohan (2011) Am Fam Physician 84(4): 413-20 [PubMed]
  3. Friedman (1996) Postgrad Med 100(3): 125-36 [PubMed]
  4. Middleton (1996) CA Cancer J Clin 46(4):249-53 [PubMed]
  5. Naitoh (1998) Am Fam Physician 57(7):1531-9 [PubMed]
  6. Porter (1995) CA Cancer J Clin 45(3):165-78 [PubMed]
  7. Taub (1996) Postgrad Med 100(3): 139-54 [PubMed]
  8. Williams (1996) Postgrad Med 100(3): 105-20 [PubMed]

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