Prostate on the CCFP exam

Approach

• Know both Canadian positions (table below). Marks go to the approach, not a yes or no.
• Ask what raises his risk: a father or brother with prostate cancer, or Black ancestry.
• A known gene change, such as BRCA2, needs a testing plan made with genetics.
• Ask what changes the benefit: past PSA results, illness that shortens his life, what he would do with a high result.
• If he chooses testing: start at 50, or 45 if his risk is higher.
• Stop at 70 for most men, or at any age if he is not expected to live 10 more years. Think about stopping at 60 if his PSA is below 1 µg/L.

Approach

• Do a rectal exam at the same interval as the PSA. A gland that feels very suspicious needs referral, even with a normal PSA.
• Repeat a high PSA before anything else. In one Canadian study, a quarter fell back to normal.
• No PSA during an infection. It can take up to 2 months to settle.
• On finasteride or dutasteride, double the PSA before you read it.
• A confirmed rise goes to urology. The CUA backs MRI before a first biopsy where good MRI is available.

Approach

• Ask about mood, worry and fear of the cancer and of dying, at diagnosis and through treatment. Many men with prostate cancer live with anxiety and distress.
• Ask about sex drive, erections and body image. Androgen deprivation can change all three.
• Ask how it is affecting closeness with his partner.
• Warn that androgen deprivation can bring low mood, tiredness and memory change. Watch for depression for as long as he takes it.

Approach

• Low risk means PSA under 10, Gleason 6 or less, and cancer confined to the prostate. Discuss active surveillance before any treatment.
• Active surveillance means PSA tests, rectal exams and biopsies when needed. Treatment can start at any time if the cancer grows.
• Low-risk cancer needs no routine bone scan and no pelvic CT.
• Androgen deprivation needs a plan for bone, blood sugar, lipids and blood pressure from day one.
• At the start, check blood pressure, weight and waist, fasting glucose or A1c, lipids, calcium and vitamin D. Get a bone density scan and his 10-year fracture risk.
• After that, repeat the metabolic checks every 6 to 12 months. He needs 1,200 mg of calcium a day in total, 800 to 2,000 IU of vitamin D, and regular exercise.
• Start a bisphosphonate or denosumab for osteoporosis, a hip or spine fragility fracture, or moderate to high fracture risk.

Approach

• Treat new back pain in a man with prostate cancer as a red flag. A red flag is a reason to image, not to wait.
• Weakness or numbness that is severe or getting worse is a red flag too. So is cauda equina syndrome.
• Androgen deprivation thins bone, so a compression fracture is on the list as well.
• After radiotherapy, a PSA 2 µg/L or more above its lowest value means the cancer is back.

Approach

• Every man: history, rectal exam, urinalysis. Score symptoms and bother with the IPSS.
• Look for drugs that make it worse: diuretics, decongestants, antihistamines, antidepressants.
• Offer PSA if he is expected to live 10 more years and finding cancer would change the plan.
• Only if unsure: creatinine, leftover urine after voiding, flow rate, a voiding diary, sleep apnea screening.
• Not routine: cystoscopy or urine cytology.
• Refer for surgery with retention, repeat infections, stones, repeat bleeding, kidney damage or failed medicines.

Approach

• Suspect it with pain between the legs or low in the pelvis, burning, urgency or trouble passing urine. Fever points to the acute form.
• Send a midstream urine culture to confirm it and guide the antibiotic. Add a first-void urine test if an STI is possible.
• Examine gently: a tender, swollen, boggy prostate fits. A firm press can push bacteria into the blood.
• Treat for at least 2 weeks, guided by the culture. Send him to hospital if he looks septic or cannot pass urine.
• Same germ again: chronic bacterial prostatitis, treated for at least 4 weeks. Pelvic pain for 3 of the last 6 months with no infection is chronic pelvic pain syndrome.