1. MODULE 5 1/40 Case 3: Chuck

2. MODULE 5 Case 3: Chuck 2/40 Patient History  Chuck is a 66 year old retired chemical compounder  He is distressed by the development of urinary symptoms that began about 1 year ago  Chuck complains of reduced force in his urine stream, as well as waking in the middle of the night to urinate and frequently urinating during the day. His wife says he can never sit still for more than 60 minutes!

3. MODULE 5 Case 3: Chuck 3/40 What Questions Do You Have for Chuck?

4. MODULE 5 Case 3: Chuck 4/40 Some Possible Questions for Chuck 1.Has your urine stream changed? 2.How many times do you have to get up at night to urinate? 3.Does it burn when you urinate? 4.Have you had a fever? 5.Has there been any blood in your urine? 6.Questions around irritative and obstructive symptoms 7.Have you ever had a catheter, or trauma or surgery to your penis or urethra?

5. MODULE 5 Case 3: Chuck 5/40  Chuck also says that his father was a pulp mill operator who died in his 70's of prostate cancer and Chuck fears he may face the same fate  From further questioning you ascertain that he is experiencing both obstructive and irritative symptoms  He has terminal dribbling and straining, his nocturia, and day time voiding are accompanied by extreme urgency Chuck’s response

6. MODULE 5 Case 3: Chuck 6/40 What Other Questions Will You Have for Chuck at this Stage?

7. MODULE 5 Case 3: Chuck 7/40 In Your Practice, How Would You Determine the Severity of Chuck’s Symptoms at this Stage?

8. MODULE 5 Case 3: Chuck 8/40 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association

9. MODULE 5 Case 3: Chuck 9/40 Results of Chuck’s IPSS & QoL Question  To get more information and validate the impact of symptoms on his life, you ask Chuck to complete the IPSS and Quality of Life due to Urinary Symptoms Questionnaires  The following are Chuck’s results: International Prostate Symptom Score (IPSS) Patient name: Chuck DOB: 14/08/39 ID: 0019-0023 Date of assessment: 27/05/05 Initial assessment (X) Monitor: during _X__ therapyafter _____therapy/surgery

10. MODULE 5 Case 3: Chuck 10/40 International Prostate Symptom Score Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Chuck’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0123453 2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0123453 3. Over the past month, how often have you found you stopped and started again several times when you urinated? 0123452 4. Over the past month, how often have you found it difficult to postpone urinating? 0123452

11. MODULE 5 Case 3: Chuck 11/40 Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Chuck’s Results 5. Over the past month, how often have you had a weak urinary stream? 0123452 6. Over the past month, how often have you had to push or strain to begin urinating? 0123452 None1 time2 times3 times4 times 5 or more times Chuck’s Results 7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? 0123453 Total IPSS Score = 17

12. MODULE 5 Case 3: Chuck 12/40 Chuck’s QoL Score = 5 (unhappy) Quality of Life Due to Urinary Symptoms DelightedPleased Mostly Satisfied Mixed about equally satisfied and dissatisfied Mostly dissatis- fied UnhappyTerrible 1. If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 0123456

13. MODULE 5 Case 3: Chuck 13/40 How Do You Interpret the Severity and Bother of Chuck’s Symptoms?

14. MODULE 5 Case 3: Chuck 14/40 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 Chuck’s IPSS = 17 (moderate symptoms) Chuck’s Bother Score = 5 (unhappy) IPSS = International Prostate Symptom Score

15. MODULE 5 Case 3: Chuck 15/40 What Physical Examinations Would you Include for Chuck?

16. MODULE 5 Case 3: Chuck 16/40 Necessary Examinations: 1.Abdominal exam 2.Genital exam 3.DRE DRE = Digital Rectal Examination

17. MODULE 5 Case 3: Chuck 17/40 Physical Exam Results Height6 ft 3" Weight77 kg (170 lb) Abdominal examNormal Genital examNormal DRE: -Anus and rectal ampulla -Prostate - Normal - Asymmetrically enlarged with no areas of hardness DRE = Digital Rectal Examination

18. MODULE 5 Case 3: Chuck 18/40 What Are Your Possible Diagnoses for Chuck?

19. MODULE 5 Case 3: Chuck 19/40 Possible Diagnoses 1.BPH 2.Prostate cancer 3.Bladder cancer 4.Co-existing conditions BPH = Benign Prostatic Hyperplasia

20. MODULE 5 Case 3: Chuck 20/40 Discussion  Chuck may have BPH, prostate cancer or both conditions simultaneously or bladder cancer to account for his symptoms BPH = Benign Prostatic Hyperplasia

21. MODULE 5 Case 3: Chuck 21/40 What Are Your Next Steps?

22. MODULE 5 Case 3: Chuck 22/40 PSA: 7.5 ng/mL Blood Glucose: normal Urinalysis: no abnormal findingsLab tests: Lab Results Urine Cytology: normal – no malignant cells PSA = Prostate-Specific Antigen Biopsy: Gleason: 7 (indicative of moderate grade prostate cancer)

23. MODULE 5 Case 3: Chuck 23/40 Discussion of Lab Results  Urinalysis, urine cytology and random blood glucose revealed no abnormal findings  In men with voiding symptoms, particularly those with a DRE showing asymmetrical enlargement of the prostate, it is important to exclude a diagnosis of prostate cancer  Serum prostate specific antigen (PSA) is the best marker for detecting and monitoring the progression of prostate cancer  PSA levels for Chuck are elevated (7.5 ng/mL) and require further investigation. However, PSA levels can be elevated for other reasons  The increased size of the prostate alone can be associated with increased levels of PSA DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen

24. MODULE 5 Case 3: Chuck 24/40 What is the Possible Diagnosis for Chuck?

25. MODULE 5 Case 3: Chuck 25/40 Possible Diagnosis for Chuck  On the basis of his elevated PSA levels, suspicious findings on DRE, Gleason of 7 as well as Chuck’s family history, prostate cancer is suspected PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination

26. MODULE 5 Case 3: Chuck 26/40 How Do You Answer if Chuck Asks “If I have cancer, what will happen to me?”

27. MODULE 5 Case 3: Chuck 27/40 Discussion About Options and Prognosis  Provide a basic discussion for Chuck to understand the options for management and the prognosis for cancer in an individual with evidence of cancer localized to the prostate

28. MODULE 5 Case 3: Chuck 28/40 What Would Be Your Management Strategy for Chuck?

29. MODULE 5 Case 3: Chuck 29/40 1)At this point you refer Chuck to his urologist, and counsel him on the issues he will face if prostate cancer is in fact diagnosed 2)Prescribe an α 1 -blocker, rather than a 5 α -reductase inhibitor so that his PSA levels are not altered before his examination with the urologist 3)If the patient is severely symptomatic consider prescribing a 5 α -reductase inhibitor in situations with a 3 or more month waiting period before they are able to see the urologist However, in a case of elevated PSA, the patient should be seen by a urologist In cases of shortage of specialists, some urologists request their referring GPs to have their patients scheduled for a transrectal ultrasound (TRUS) and prostate biopsies before referring the patient Management Strategy PSA = Prostate-Specific Antigen

30. MODULE 5 Case 3: Chuck 30/40 Feedback from Urologist  Chuck returns from the urologist to see his family physician  His prostate biopsy was positive for cancer  He brings a letter from the urologist to summarize his situation and next steps

31. MODULE 5 Case 3: Chuck 31/40 Chuck’s Urology Consult Letter Dear Doctor, Chuck has been evaluated because of urinary problems, mainly weak stream associated with frequency and urgency. On exam, his abdomen was unremarkable. His prostate was noted enlarged and asymmetrical, the right side larger than the left. His urinalysis is normal, and his PSA elevated at 7.5 ng/mL. The patient was already on α 1 -blocker treatment when I saw him, and was much improved. A prostate ultrasound with biopsies was done under local anesthesia at his first visit with me, and I have seen him again 2 weeks later. PSA = Prostate-Specific Antigen

32. MODULE 5 Case 3: Chuck 32/40 Chuck’s Consult Letter (Cont.) The results of his biopsy were positive for a localized prostate cancer (two out of 8 biopsies positives for adenocarcinoma of the prostate, both on the right side, Gleason grade 7). In summary, 1 - This patient has a localized prostate cancer (stage T1c) 2 - This patient is under medical treatment with α 1 -blockers for LUTS LUTS = Lower Urinary Tract Symptoms

33. MODULE 5 Case 3: Chuck 33/40  Plan of Treatment: As this patient was consulted initially because of LUTS, we should continue medical treatment with α 1 -blockers as this treatment has improved his symptoms. However, since a localized prostate cancer has been identified, treatment of this condition should be sought. I have discussed four treatment options for his prostate cancer. Chuck’s Consult Letter, continued: LUTS = Lower Urinary Tract Symptoms

34. MODULE 5 Case 3: Chuck 34/40 Chuck’s Consult Letter, continued:  Treatment options:  One is observation with regular follow-up because his cancer is probably of low volume and will probably have a slow progression. As the patient is relatively young and is healthy, he will probably live long enough to see his cancer progress. I do not recommend this option.  The three other options are active treatments. He would be a good candidate for any one of these treatments and I have recommended that he select one of the three.

35. MODULE 5 Case 3: Chuck 35/40 Chuck’s Consult Letter, continued:  Choice of 3 Active Treatments  External beam radiotherapy or  Brachytherapy or  Radical prostatectomy, either by open surgery or by laparoscopy As discussed with him, all these treatments have very good chances of curing his cancer, but they have different side effects. I have discussed the different options with him and he was hesitant to choose one. I have given him brochures and websites about the different treatments and he will come back to see me to discuss the different options and make his decision. He requires follow up.

36. MODULE 5 Case 3: Chuck 36/40 What are the Pros and Cons for Radical Prostatectomy, External Beam Radiotherapy, and Brachytherapy for this Patient?

37. MODULE 5 Case 3: Chuck 37/40  Chuck is a candidate for radical prostatectomy  This is the best way to remove all the cancer, however long term side effects may result:  Possibility of erectile dysfunction  Incontinence  Radiotherapy has almost as good results in terms of long term survival in this age group, and side effects consist of:  Inflammation of bladder (cystitis)  Inflammation of prostate and rectum (prostatitis and proctititis)  Erectile dysfunction  Brachytherapy is optimally indicated for men with a PSA < 10 and Gleason score ≤6 (so in this case he is not a good candidate) PSA = Prostate-Specific Antigen

38. MODULE 5 Case 3: Chuck 38/40 Depending on the Surgical Option Chuck Selects, What is the Role of the Family Physician in the Follow-up?

39. MODULE 5 Case 3: Chuck 39/40  Family physician will follow:  Symptoms  DRE  PSA  If there are any changes then a referral back to the urologist is indicated PSA = Prostate-Specific Antigen DRE = Digital Rectal Examination

40. MODULE 5 Case 3: Chuck 40/40 End of Case 3