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 <20 years: Observation
      2. 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
    3. Intermediate risk Prostate Cancer
      1. CALE <10 years: Consider Prostatectomy or radiotherapy and also consider brachytherapy, hormonal therapy
      2. CALE =10 years: Prostatectomy or radiotherapy and also consider brachytherapy, hormonal therapy (for 4-6 months)
    4. High risk Prostate Cancer
      1. CALE <5 years: Observation
      2. CALE =5 years: Prostatectomy or radiotherapy and also consider 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. 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
    2. 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
    3. References
      1. Bhatnager (2004) Urology 63:103-9 [PubMed]

IV. Management: 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

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

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