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Prostate Disorders

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Prostate Cancer Management

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  1. See Also
    1. Prostate Cancer Staging
  2. Localized Prostate Cancer (Stages A to C) Management
    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
      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. Potosky (2004) J Natl Cancer Inst 96:1358
    3. Conservative therapy (no curative treatment)
      1. Indications (Curative treatment with risk > benefit)
        1. Well-differentiated tumor (Gleason Score 2-4)
        2. Gleason Score 5-6 if life expectancy <10 years
          1. Elderly patients with serious comorbities
      2. Contraindications (Curative treatment preferred)
        1. Poorly differentiated tumor (Gleason Score 7-10)
        2. Gleason Score 5-6 if life expectancy >10 years
          1. Younger patients who are otherwise healthy
      3. References
        1. Bhatnager (2004) Urology 63:103
  3. Endocrine Therapy for Advanced Prostate Cancer (Stage D)
    1. Bilateral Orchiectomy
    2. Diethylstilbesterol (DES) 1 to 3 mg qd
    3. Leutonizing Hormone Releasing Hormone Agonist (LHRH)
      1. Goserelin acetate (Zoladex)
      2. Leuprolide acetate (Lupron)
    4. Antiandrogens
      1. Flutamide
      2. Bicalutamide
  4. 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
  5. Follow-up Protocol: General
    1. Prostate Specific Antigen (PSA) as below
    2. Digital Rectal Exam yearly
    3. Clinical examination every 6 months for 5 years
    4. Focus area on exam
      1. Bladder Cancer (new second tumor)
      2. Erectile Dysfunction
      3. Stool or Urinary Incontinence
      4. Radiation proctitis
      5. Major Depression
  6. Follow-up Protocol: Prostate Specific Antigen (PSA)
    1. Frequency of PSA Testing
      1. First year: PSA every 6 months for 5 years
      2. After fifth year: PSA every year
    2. PSA Levels after Radical Prostatectomy
      1. PSA 0 within 3 months of Prostatectomy
      2. PSA rise >2 mg/ml/year suggests high grade lesion
        1. D'Amico (2004) N Engl J Med 351:125
    3. PSA Levels after Radiotherapy
      1. PSA falls gradually to under 1 ng/ml by 1 year
      2. PSA remains under 1 ng/ml unless cancer recurrence
  7. References
    1. Friedman (1996) Postgrad Med 100(3):125
    2. Middleton (1996) CA Cancer J Clin 46(4):249
    3. Naitoh (1998) Am Fam Physician 57(7):1531
    4. Narayan (April, 1996) Hospital Physician, p.37-50
    5. Porter (1995) CA Cancer J Clin 45(3):165
    6. Taub (1996) Postgrad Med 100(3):139
    7. Williams (1996) Postgrad Med 100(3):105

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