Use normograms to convey: biopsy result prediction, pathological stage, risk of treatment failure
Investigation
Biopsy: Use PSA result together with DRE (digital rectal exam), co-morbidity and risk factors (Age and Afro- Caribbean) to decide on need, not PSA alone, and not if
evidence of bone metastasis
Core Biopsy by trans-rectal ultrasound guided technique
If negative core biopsy (10-12) then offer multi-parametric MRI to guide another biopsy, if negative then do not repeat biopsy
Staging, only if candidate to radical treatment
Isotope bone scans: if hormonal treatment being deferred and risk of bone complications, but not if low risk localised cancer
Multi-parameter MRI or CT (MRI contra-indicated): if knowledge of T or N stage could affect management
Level of Risk
PSA
Gleason Score
Clinical Stage
Low
<10ng/ml
and
<6
and
T1–T2
Intermediate
10–20
or
7
or
T2b
High
>20ng/ml
or
8–10
or
T2c or more
Management
Hormone Therapy
Zoladex (LHRH agonist) reduced testosterone, note GnRH antagonists not widely available. Consider intermittent therapy for long-term androgen deprivation therapy
(not adjuvant setting), check PSA every 3 mths, restart if > 10 ng/ml
Will reduce libido & sexual function (ejaculation and fertility): see managing adverse effects below
Offer medroxyprogesterone (20 mg per day), initially 10 weeks, to manage troublesome hot flushes
Low Risk Localised Prostate Cancer
Offer active surveillance for whom radical therapy an option: Initial MRI, then regular PSA and PSA kinetics, DRE, re-biopsy at 12 mths and continuation to 5 yrs or
beyond until active surveillance end
Offer radical treatment if chosen surveillance and evidence of progression
Before radical therapy: discuss loss of sexual experience, ejaculation, fertility, and urinary function
Intermediate & High Risk Localised Prostate Cancer
Radical prostatectomy or radical radiotherapy, active surveillance requested, intermediate risk only
Radical radiotherapy: offer in combination with 6 mths androgen deprivation therapy (before, during and after), with minimum dose of 74 Gy to the prostate at no
more than 2 Gy per fraction
Consider continuing androgen deprivation therapy for 3 yrs post intervention
Consider high-dose rate brachytherapy in combination with external beam radiotherapy
Surgery: robotic systems cost effective
Locally Advanced Prostate Cancer
Clinical oncologists should consider pelvic radiotherapy in men with locally advanced prostate cancer who have a higher than 15% risk of pelvic lymph node
involvement
Managing Adverse Effects
Sexual dysfunction: access top ED specialists and PDE-5 inhibitors, or vacuum devices, intraurethral inserts or penile injections, or penile prostheses
Urinary incontinence: access to specialist, coping strategies, along with pelvic floor muscle re-education, bladder retraining and pharmacotherapy, as well as
surgery (artificial urinary sphincter)
Investigation radiation induced enteropathy
Osteoporosis: only give Bisphosphonates (Denosumab if contra-indicated) if pre-existing
Gynacomastia: breast bud radiotherapy or wkly Tamoxifen if long-term bicalutamide monotherapy
Follow up
Watchful waiting regimen, no curative intent should be followed up in primary care
Check PSA levels for all men with prostate cancer who are having radical treatment at the earliest 6 weeks following treatment, at least every 6 months for the
first 2 year
Relapse
Biochemical relapse (a rising PSA) alone should not prompt an immediate change in treatment
Do not offer biopsy of the prostatic bed if had a radical prostatectomy
Offer radical radiotherapy to the prostatic bed If no known metastases
