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PROSTATE CANCER

Key Clinical Questions

  • image What is the current landscape of treatment for advanced prostate cancer?

  • image Which treatments for advanced prostate cancer are more likely to result in hospital admission?

  • image What is the current landscape of treatment for advanced testicular cancer?

  • image What treatments for advanced testicular cancer are more likely to result in hospital admission?

  • image What are some commonly used strategies to mitigate the risk of hospital admission in the context of therapy for advanced prostate cancer and advanced testicular cancer?

  • image What are some of the disease-related sequelae of prostate and testicular cancer that can result in inpatient admission?

DISEASE OVERVIEW

Prostate cancer is the most common cancer in men, with an estimated 233,000 cases diagnosed in 2014. Due to the therapeutic advances outlined herein, the death rate for prostate cancer has been declining over the past decade—nonetheless, approximately 29,480 deaths were still attributable to the disease in 2014. Screening for prostate cancer is controversial and largely beyond the scope of the current chapter. Briefly, widespread screening in the mid-1990s led to a dramatic rise in the incidence of prostate cancer. Given that many of the detected prostate cancers might be indolent and not result in prostate-cancer-related mortality, the utility of screening has been called into question. Current recommendations suggest individual counseling of patients, with consideration of risk factors (eg, family history) and consideration of risks associated with screening (eg, infection and pain secondary to prostatic biopsies performed in response to an elevated prostrate-specific antigen [PSA]).

For the vast majority of patients (>90%), prostate cancer is diagnosed when still localized to the pelvis. For these individuals, a risk-adapted approach is often employed. This approach entails utilizing clinical factors (including clinical stage, Gleason grade, and baseline PSA) to determine the potential risk of metastatic recurrence. Similar emphasis is also placed on ascertaining the patients’ projected life expectancy, utilizing Social Security Life Indices and other tools. Patients with low-risk disease who have a shorter anticipated life expectancy may be considered for conservative measures, such as active surveillance (repeat assessment of the PSA and intermittent prostatic biopsies), while younger individuals with higher-risk disease might be considered for more definitive strategies such as surgery or radiation. Typically, radiation therapy to the prostate is conducted in the outpatient setting in multiple daily fractions over several weeks. Surgery for prostate cancer typically entails removal of the prostate and adjacent lymph nodes. Prostatectomy is typically followed by a 1- to 2-day postoperative stay prior to discharge.

TREATMENT OF METASTATIC PROSTATE CANCER

In the management of prostate cancer, the hospitalist will more likely be called upon to care for the patient with metastatic disease. The treatment of metastatic disease has evolved markedly over the past decade, and some familiarity with the wide range of agents used in this setting may be helpful. In the ensuing section, these treatments will be described.

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