Men s Health Topics Jerome Baca, MS, PA-C Albuquerque Urology Associates January 6 th, 2018 1
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Prostate Cancer (pca) Most common type of cancer in men 45-75yo > 95% is adenocarcinoma: CA arising from a gland/glandular like structure Screening serum tests: Prostate Specific Antigen (PSA) Test (+/- Free/Total), 4k score (newer & not covered by ins.), Genetic testing (trials) Physical Examination: Digital Rectal Examination annually for those at high risk or 50 or older Risk factors: Age, race, family Hx, diet & lifestyle 3
Elevated PSA and/or Suspicious DRE..Biopsy Prostate Biopsy: Urology office procedure, local anesthetic, US guided needle biopsy gun used, results in 5-7 days Some Urology centers are using MRI guided biopsy 12 cores are standard (more if suspicious area identified) Risks: Bleeding, infxn, hematochezia, hematuria, hematospermia, retention, false negatives, danger of treating low risk/low grade disease, pain in the 4
pca pca is Dx with positive biopsy Graded according to Gleason system with higher number more indicative of aggressive tumor behavior Aggressive pca will spread most commonly to bone but also to seminal vesicles, lung, brain, liver, rectum & retroperitoneal soft tissue Bone Scan & CT Abd/Pelvis w/contrast w/psa > 10/Gleason 7 or > 5
Gleason Grading System 6
Gleason Pattern Scale 7
pca 8
pca Staging: TNM 9
pca Treatment Controversial management (every Urologist has their own expert opinion) Men with <14yr life expectancy Trxt may be unnecessary Men with >10yr life expectancy and low grade tumors (Gleason </= 6 total) may elect Active Surveillance Gleason =/> 7 total usually require curative therapy 10
pca Treatment Active Surveillance for low grade tumors Radical Prostatectomy (open or robotic) Radiation Therapy (external or proton-beam) Brachytherapy (Iodine-125 seeds) Cryotherapy (freezing) & High Intensity Focused Ultrasound (HIFU) Not as common a Trxt in U.S. Vascular-Targeted Photodynamic Therapy (VTP) Hormonal Therapy Castrate Resistant Prostate Cancer (Boney METS) 11
pca Trxt: Active Surveillance Active Surveillance: annual biopsy and q3-6mon PSA and DRE to monitor possible disease progression Usually Gleason 6 not always.. Typically for PSA <10ng/dL and fewer than 3positive cores with small % pca on core sample Thought is that Trxt can be delayed until evidence of pca progression Risks: Disease may spread rapidly leading to worse outcomes 12
pca Trxt: Active Surveillance Active Surveillance: annual/bi-annual biopsy and q3-6mon PSA and DRE to monitor possible disease progression Typically for PSA <10ng/dL and fewer than 3positive cores Thought is that Trxt can be delayed until evidence of pca progression Risks: Disease may spread rapidly leading to worse outcomes 13
pca Trxt: Radiation (XRT) Radiation Therapy: Intensity Modulated Radiation Treatment (IMRT) or Proton Beam Both are externally performed either at Oncology clinics or some imaging centers 6-8wk time frame, sometimes more/less PSA labs do not initially decline and risk of pca progression Radiation Therapies: The gift that keeps on giving Risks: Initially pain (think internal sunburn), then progressive fibrotic tissue proliferation & sphincter dysfunction (i.e., incontinence), ED, recurrence 14
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pca Trxt: Brachytherapy Brachytherapy: Radiation Seeds Iodine-125 or Palladium-103 are the isotopes used Implanted thru perineum w/rectal US guidance PSA labs may not achieve nadir for up to 24mons Risks: Pain, pellet expulsion in ejaculate/urination, limit contact w/children & others (i.e., toddler lap sitting) initially, incontinence, ED, recurrence, same progressive Sx as other radiation Trxt 16
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pca Trxt: Cryotherapy & HIFU Cryotherapy: Freezing of pca cells HIFU: Heating of pca cells Both are newer therapies and there is not much data regarding long-term outcomes as compared to other Trxt Risks: Recurrence, incontinence, ED, increased risk vesicorectal fistula w/hifu NOT widely accepted/performed 18
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Vascular-Targeted Photodynamic Therapy (VTP) MOA: injecting a light-sensitive drug into the bloodstream and then activating it with a laser to destroy tumor tissue in the prostate Use limited to low risk (Gleason 6) with core samples <5mm (currently) Not widely available in U.S. New trial underway at Memorial Sloan Kettering Cancer Center in NY for higher risk pca Risks: Dysuria, Hematuria, ED & concern for undertreatment 20
pca Trxt: Hormonal Therapy Endocrine Manipulation: Reserved for advanced &/or metastatic pca Goal is to reduce serum androgen to castrate levels Surgical orchiectomy or Luteinizing Hormone- Releasing Hormone analogues (LHRH) injections q3/6/12mon which paradoxically decrease pituitary gland Luteinizing Hormone (LH) production +/- antiandrogen Rx Once pca demonstrates progression prognosis is poor Risks: Osteoporosis, fatigue, decreased libido, hot flashes, etc. (HINT) 21
Castrate Resistant pca Boney METS The body constantly rebuilds bones to keep them strong. In a person with bone metastases, the cells that break down bone may become overactive 2 As a result, the cells that normally rebuild the bones do not work properly, leading to weakened bones and serious bone problems 2 * XGEVA stops cells from becoming overactive and may interrupt the process of bone destruction Side effects: fatigue/asthenia, hypophosphatemia and nausea. Additionally there is a risk for hypocalcemia. A need to monitor calcium levels and administer, calcium, magnesium and Vitamin D as necessary. Lastly, there is a risk of Osteonecrosis of the Jaw which can manifest as jaw pain, osteomyelitis, osteitis, bone erosion, tooth or periodontal infection, toothache, gingival ulceration, or gingival erosion.
Erectile Dysfunction & Incontinence Diet and lifestyle Pre-existing medical conditions PDE5I Rx Prostaglandins Vacuum Erection Devices (VED) Intrapenile Implants Absorbent pads Timed Voiding Cunningham Clamps Condom Catheters Chronic Indwelling Foley or Suprapubic Tube Artificial Urinary Sphincter 23
ED: Post Prostatectomy Rehab (pca) ED in varying degrees is a common problem after pca surgery D/T nerve & vessel trauma, traction, cautery, radiation tissue changes (even in nerve sparing & robotic surgeries) Latest studies indicate a 3-prong staged approach for maintaining potency after pca surgery shows promising results Daily pde5i with weekly challenge doses VED use prior to and 4-6weeks after surgery Initiate prostaglandin Trxt 8-12weeks after surgery 24
VED
Prostaglandin Trxt (Trimix/Quadmix)
Intrapenile Prosthesis
Cunningham Clamps & Condom Catheters
Foley & Suprapubic Catheters
Artificial Urinary Sphincter
Thanks for your attention Questions/Comments