eus` case was discussed at a multi-disciplinary meeting. The team`s decision was:
• To arrange a MRI scan of the pelvis and an isotope bone scan (IBS) to stage his cancer
• If no evidence of metastatic disease is seen, to offer him neo-adjuvant therapy and radical radiotherapy
Part B
Question 10: What is the principle of neo-adjuvant therapy?
Prior to surgical extraction of a tumor neoadjuvant therapy is performed with the aim to reduce the size of the tumor. Reducing the tumor decreases the invasiveness of surgery allowing a clearer distinction between the cancerous and non-cancerous tissue. This not only simplifies the procedure but also potentially aids recovery post operation. (Chemoth.com, 2016)
Question 11: What would be used for neo-adjuvant therapy in this case?
The results from the IBS showed no evidence of metastatic disease. The pelvic MRI indicated tumour invading seminal vesicles (T3B disease) node negative. Perseus stated neo-adjuvant treatment and radical radiotherapy was given as an outpatient over 7 weeks.
Question 12: Comment on which if any are likely side-effects of neo-adjuvant therapy? Affected concentration; affected libido; affected bone marrow activity; resulting in cold sweats?
Neo-adjuvant therapy can potentially cause short term side effects because the procedure may damage surrounding healthy cells in the process of destroying cancerous cells. While some patients only experience mild side effects it is possible for patients to experience more severe side effects, this is dependent on the area of treatment, the dose of radiotherapy and how quickly the healthy cells repair the damage.
• Tiredness and loss of concentration is a likely side effect towards the end of the course of treatment. It is believed that this side effect is caused by the energy required by cells to repair damage caused by the therapy to healthy cells. It is commonly noted that the decreased production of new red blood cells due to the decreased activity of bone marrow is a likely cause of fatigue. (Nhs.uk, 2016)
• In men following pelvic radiotherapy it is common for patients to experience temporary erectile dysfunction and decreased libido this is a likely result of the combination of side effects after treatment such as tiredness. (Nhs.uk, 2016)
• Hormonal therapy to treat prostate cancer may lead to osteoporosis where the bones in the area where treatment is targeted weaken, reducing the uptake of vital minerals and production of new red and white blood cells and platelets. The decreased production of RBC is commonly linked with the feeling of fatigue, the decreased levels of white blood cells increases the risk of infection and the decreased level of platelets increases the risk of bruising and bleeding (Macmillan.org.uk, 2016)
• Cold sweats are likely to be a result of hormone therapy such as anti-androgen therapy, used to reduce the levels of androgens which promote the growth of prostate cancer cells. (sweats, 2016) (Cancer.org, 2016)
Question 13: Comment on Perseus` pelvic MRI result.
The T3B disease shown by the MRI scan indicates that the tumour extends through the prostatic capsule, neck of the bladder and or the seminal capsule. Furthermore, the stage indicates that the tumour is bilateral, extracapsular extension. The staging of the tumour suggests that the tumour has not metastasised. Node negative indicates that the tumour has not begun to affect the surrounding lymph nodes.
At the end of radiotherapy Perseus’ PSA was 0.1ng/ml and he remained on neoadjuvant therapy, seen at three-monthly intervals at an outpatient clinic.
He reported no further symptoms, but at 18 months after completion of radiotherapy his PSA was 10ng/ml. His PSA continued to rise and at 24 months it was 50ng/ml.
Perseus now reported back pain and was prescribed regular analgesics. An isotope bone scan (IBS) is arranged.
Question 14: What is the most likely cause of Perseus’ back pain and raised PSA? What other possible explanations have you discounted?
Hormonal therapies used to treat prostate cancer may cause weakening of the bones, when hormone levels are reduced this has potential to lead to bone loss. Bone health is also a implication of increasing age, especially in people over the age of 50, where bone loss is slowly increasing resulting in the bones becoming weaker. This begins with osteopenia with the potential to worsen and develop into osteoporosis. Osteoporosis can go undetected until a bone fracture actually occurs where in Perseus’ case it is likely the fracture has occurred in the lower spine causing the back pain. (Macmillan.org.uk, 2016) Due to the presence of the ‘hot spots’ on the IBS scan it is likely further tests may need to be done to eliminate the possibility of arthritis. (Macmillan.org.uk, 2016)
Due to the nature of the radiation therapy Perseus received it may be possible that not all the cancerous cells were destroyed during the course of treatment which would explain the consecutively rising PSA levels. If Perseus received brachytherapy as a form of treatment it is possible that the increasing PSA levels may be a PSA bounce, although it is uncertain what causes this, one theory suggests the bounce is a result of late reaction to the radiation treatment such as radiation prostatitis. (Harvard Prostate Knowledge, 2016)
Perseus’ bone pain was resolved with NSAIDs. He was started on oral cyproterone acetate and referred to the community palliative care team for ongoing symptom management.
Question 15: Explain the rationale for Perseus’ management.
NSAIDs provide a symptomatic release from pain and swelling which commonly occurs in arthritis and acute inflammatory conditions such as fractures. The analgesic effect of NSAIDs is effective peripherally, reducing the production of prostaglandins which sensitise nociceptors, therefore effective in arthritis and the pain of cancer metastasis in bone. Due to the uncertainty of the diagnosis the NSAIDs treats both possibilities of what Perseus may be suffering from. (Rang and Dale, 2012)
Cyproterone an anti-androgen used alone or in combination with other agents, is used to treat tumours in the prostate. By depressing the synthesis of gonadotrophins, cyproterone aids the treatment of prostate cancer during the beginning of GnRH treatment. However, the initial stimulation of gonadotrophin secretion upon starting treatment may cause a temporary worsening of pain from bone metastasis in men with prostate cancer therefore treatment is only started prior to receiving an androgen antagonist. (Rang and Dale, 2012)
Twelve months later Perseus’ PSA had risen to 100ng/ml and he described generalised bone pain unresponsive to increased analgesia.
The management team discussed the following treatment options with Perseus – chemotherapy with docetaxel, external beam radiotherapy to sites of pain, bisphosphonate therapy, anti-androgen withdrawal.
Question 16: Discuss the above treatment options
Chemotherapy is systemic so the treatments runs through the bloodstream killing cancerous cells wherever they are. Docetaxel is given alongside chemotherapy drugs, it is given when visiting the day unit or during a sort stay in hospital. Prior to the treatment, a blood test is taken to check the suitability of the patient to receive the treatment. Anti-sickness drugs and the docetaxel are given through the following options: a cannula into the vein in the arm or hand, a fine tube inserted under the skin of the chest to into a vein nearby or a fine tube inserted into the arm going up into a vein in the chest. Docetaxel is given as an infusion into the cannula where it is given as a drip over a set period of time. (Macmillan.org.uk, 2016)
External beam radiotherapy uses high energy beams to destroy cancer cells. There are two types of radiotherapy which may be given; curative radiotherapy used to treat and cure the cancer and palliative radiotherapy which is aimed at relieving the symptoms caused by the cancer. The treatment typically takes a few minutes and is not painful. (Macmillan.org.uk, 2016) Radiotherapy works by causing damage to the DNA I the cancer cells, either directly or through charged particles known as free radicals, this prevents any further growth of the cancer cells and eventually death of the cancer cells. (Cancerresearchuk.org, 2016)
Bisphosphate therapy is used to treat damage to bones as a result of cancer, either slowing down the damage or preventing further damage. Bisphosphate treatment is prescribed for various reasons such as; control osteoporosis, reduce the risk of bones breaking, reduce calcium levels or manage pain. Bisphosphates target the control of cells which break down bones (osteoclast). It is found that cancer cells are attracted to the area in which bone is broken down, therefore controlling the breakdown may potentially slow the growth of the cancer. (Cancerresearchuk.org, 2016)
Anti-androgen withdrawal therapy reduces levels of androgens which stimulate the growth of prostate cancer. Reducing the levels of androgens shrinks or slows the growth of prostate cancer, however this treatment alone will not cure the prostate cancer. (Cancer.org, 2016)
Perseus and his oncologist decided to proceed with chemotherapy using docetaxel with prednisolone and zoledronate.
His chemotherapy was stopped after five cycles because of progressive paraesthesia and dental problems
Question 17: Discuss the treatment regimen and Perseus’ response to treatment.
Both docetaxel and prednisolone are drugs used alongside chemotherapy, which work by stopping the tumour growth either by destroying the cancer cells or by preventing any further division in the cancer cells. Zoledronic acid can be used to relive the symptoms of bone metastasis, all three drugs used in combination may increase the number of cells destroyed. (Clinicaltrials.gov, 2016)
Paraesthesia experienced following the second cycle of treatment is likely to be a result of nerve damage in the body this is called peripheral neuropathy. This is likely to be a side effect of anti-cancer drugs, the tumour may be pressing down on nerves close by, or damage to the nerves from radiotherapy. (Macmillan.org.uk, 2016)
Neutropenic fever developed at cycle 4 is likely to have developed due to an infection. This is particularly because during cancer treatment patients have a weakened immune system with a significantly reduced level of white blood cells to combat the infection. Perseus’ tooth abscess developed at cycle 5 is likely to be a result of an infection which he would be prone to due to his weakened immune system. (Cancer, 2016)
Three months after stopping radiotherapy Perseus’ PSA results began to rise again.
Question 18: Explain the Perseus’ new signs and symptoms, and the treatment options available.
Perseus’ legs and feet appear to be extremely swollen this may be signs of developed lymphedema caused by either damage to the lymph nodes surrounding the prostate or damage to the lymph nodes from the radiation therapy received. (National Cancer Institute, 2016)
Perseus’ testicles appear to be enlarged suggesting the possibility that the cancer may have spread from the prostate into either the surrounding lymph nodes or the testicles.