HOMEPAGE Resources for SBM

1999 Spring Year2 Case1- Prostate Cancer

Case History
Learning Objectives
Web References
Literature References


CASE HISTORY

January 7, 1999
The patient is a 50 year old white male. He lives with his wife and son and feels good today.

He dates the history of his illness back about 4 years when he suddenly developed an episode of back pain and inability to move his bowels. After taking a large amount of milk of magnesia, his symptoms cleared. However, about 6 months later, the symptoms returned. This time the pain in his back was more along his lower back ribs. He was unable to move his bowels at all. He went to the VA because of this. He was given large amounts of milk of magnesia without much affect and returned to the VA several times because of this. Eventually he moved his bowels and felt better but still had some residual pain in his back ribs. He had another episode where he could not move his bowels and was seen again at the VA. He was given Demerol for the pain and given multiple tests, including x-rays, digital rectal exam and blood tests. With milk of magnesia he eventually got relief and was able to move his bowels. However, the pain in the rib area seemed to persist. Over the next several months he was seen at the VA multiple times and had multiple studies done to try to detect the cause of his discomfort. He had blood tests, x-rays and a colonoscopy. There was no evidence of abnormalities in his colon. Other tests showed no evidence of kidney stones or gallstones. About this time, he also noted a decrease in his urine volume and slow passage of his urine. Eventually his primary care physician noted some nodularity to his prostate. A PSA antigen test was done which was markedly elevated at 56. Following this he had more x-rays, bone scans and MRIís. Abnormal areas were found on his 9th, 10th and 11th thoracic spine. He stated that the spine looked transparent. A prostate biopsy was performed which revealed cancer of the prostate. He was then referred to an oncologist, . She reviewed the findings with him and told him he had stage D prostate cancer which was metastatic to the thoracic spine.

He also saw a neurosurgeon who suggested operating on his spine because of possible nerve involvement. However, he decided not to do this. He was started on therapy with flutamide as well as doxazosin. He was told that the flutamide was a type of female hormone which would reduce the growth of his prostate cancer. The doxazosin was given to reduce swelling of the prostate. Following institution of the flutamide, a repeat PSA level was 0.001. However, because he was losing weight and his testosterone level was elevated he was also started on Zoladex. This is an injection which also has a hormone effect on the prostate. He also received a pain medication in the form of oxycodone and was also given ibuprofen. He is able to control his pain symptoms with these medications.

On this regime, his prostate cancer has remained stable for the last 29 months. His PSA test remains at 0.001. He was told that as long as this test remains at this level, no additional therapy is needed. However he is concerned that the prostate cancer is still present and wonders if he should not receive other treatment. He has sought other opinions at in-state and out-of-state institutions, but feels comfortable with the care and opinions he has received at the VA.

He has read a great deal about prostate cancer. He says that it is very unusual for somebody his age to have such extensive disease and then to have done so well for the past 2 Ĺ years. He has talked to other people with prostate cancer as well. He knows 2 people who had cancer detected at a very early stage. One decided to have his prostate removed; the other had radiation therapy with pellets implanted in his prostate.

Because of the nerve involvement from his prostate cancer, he occasionally has bowel incontinence. When he has to be out of the house for a long period of time he uses Fleetís enemas to clean out his intestine before going out. He stated that he got up at 6:00 this morning to use the enemas so that he would not have any problems while talking to the class.

He has had significant side effects from his therapy. He used to be very physically active and physically fit with low body fat. On his medication, he states that he has developed breast enlargement, fat in his abdomen and thighs as well as his arms. He also had hot flashes. He says that sometimes he feels more like 50 year old woman rather than a 50 year old man. In fact at one time he was given Premarin to try to control the hot flashes but this did not help very much. He has lost all sexual desire with the hormonal therapy for his cancer.

He is not sure why he developed prostate cancer. He was always very careful about what he ate and for a long time was on a vegetarian diet. However, he was stationed in Viet Nam, was exposed to Agent Orange, and thinks his prostate cancer may be related to that.

He tried taking herbal tea for awhile to see if that would help his prostate disease. He does not take any other herbal medications. He eats great quantities of vegetables such as broccoli and carrots, which are supposed to have anti cancer effects. He also has started smoking because he feels this helps relax him and reduce his need for pain medication.

He knows his cancer is incurable but feels he has done well because it has not advanced. He feels that his positive attitude has a lot to do with him doing well. He tries to be as active as possible but does get fatigue and back pain.


LEARNING OBJECTIVES

Anatomy of prostate, including histology
Relationship to surrounding structures
Clinical features of prostate cancer
Incidence
Symptoms
Prognosis and course
Mortality
Epidemiological factors related to the development of prostate cancer
Race
Relation to benign prostatic hypertrophy (BPH)
Screening for prostate cancer
Diagnosis of prostate cancer
Role of PSA in prostate cancer
Biochemistry
Screening
Diagnosis
Needle biopsy, ultrasound, CT/MRI
Treatment decisions
Pathologic features of prostate cancer
Gross/microscopic
Concept of prostatic intraepithelial neoplasia (PIN)
Staging of prostate cancer
Treatment option related to stage of prostate cancer
Surgery Ė type
Radiation therapy
Hormonal therapy
Chemotherapy


WEB REFERENCES

Making sense of PSA and ejaculation
DESCRIPTION:Effect of ejaculation on the PSA assay.
URL: HTTP://www.jr2.ox.ac.uk/bandolier/index.html

PSA Page
DESCRIPTION:List of links for PSA in particular and urology in general.
URL: http://www.a-urology.com/PSA.htm

Prostate Cancer - Sloan Kettering
DESCRIPTION: none
URL: HTTP://www.mskcc.org/document/WICPROS1.htm

Prostate Cancer : Detection and Symptoms
DESCRIPTION:Good discussion of PSA
URL: HTTP://www3.cancer.org/cancerinfo/main_cont.asp?st=ds&ct=36

Prostate Cancer Detection - an editorial
DESCRIPTION:Has an interesting diagram illustrating levels of detection.
URL: HTTP://www.infobiogen.fr/agora/journals/cancer/articles/10-2/zaji.htm

Prostate Cancer Detection and Treatment
DESCRIPTION:Large discussion of whether or not to screen
URL: http://rattler.cameron.edu/ww/

Prostate Cancer InfoLink
DESCRIPTION:Lots of information.
URL: HTTP://www.comed.com/Prostate/

Prostate Dictionary
DESCRIPTION:Lots of terms defined.
URL: HTTP://www.comed.com/Prostate/Glossary.html#P

Prostate-Specific Antigen
DESCRIPTION:Details about PSA by its discoverer.
URL: HTTP://oncolink.upenn.edu/disease/prostate/screening/Ablin.html

Screening for Prostate Cancer
DESCRIPTION:Good article on screening including the PSA test. They do not recommend routine screening.
URL: HTTP://cpmcnet.columbia.edu/texts/gcps/gcps0020.html

Screening for prostate cancer
DESCRIPTION: none
URL: HTTP://cancernet.nci.nih.gov/clinpdq/screening/Screening_for_prostate_cancer_Physician.html

The PSA Page
DESCRIPTION: none
URL: HTTP://www.prostatelab.com/psapage.htm

Univ of Michigan Prostate Cancer Page
DESCRIPTION:Good articles
URL: HTTP://www.cancer.med.umich.edu/prostcan/prostcan.html


LITERATURE REFERENCES

Steinberg, G. D. et al.
An Analysis of Watchful Waiting for Cliniclly Localized Prostate Cancer
J. of Urology 159, 1431 (1998)

Loivosto, P., et al.
Androgen Receptor Gene and Hormonal Therapy Failure of Prostate Cancer
Am. J. Pathology, 152, 1 (1998)

W. K. Oh
Management of Hormone Refractory Prostate Cancer: Current Standards and Future Prospects
J. of Urology, 160: 1220 (1998)

M. J. Haggman et al.
the Relationship Between Prostatic Intraepithelial Neoplasia and Prostate Cancer: Critical Issues
J. of Urology, 158: 12 (1997

G. J. O'Dowd et al
Update on the Appropriate Staging Evaluation For Newly Diagnosed Prostate Cancer
J. of Urology, 158: 687 (1997)

C. M. Coley et al
Screening for Prostate Cancer
Ann. Int. Med, 126: 480 (1997)

M. B. Garnick et al
Prostate Cancer: Emerging Concepts - Part I
Ann. Int. Med, 125: 118 (1996)

M. B. Garnick et al
Prostate Cancer: Emerging Concepts - Part I
Ann. Int. Med, 125: 205 (1996)

R. G. Aarnink
Transrectal Ultrasound of the Prostate: Innovations and Future Applications
??? 159: 1568(1998)