Clinical Practice Guideline

for

CARCINOMA OF THE PROSTATE

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

 

Overview: Prostate cancer is the most common malignancy in men in the United States and is the third most common cause of cancer death in males.  It is rarely diagnosed before the age of 50 and the incidence increases with age.  Adenocarcinoma accounts for 95% of prostatic cancers.  Tumors are frequently multifocal and have a predilection for the periphery of the gland.  Gleason grading of the dominant and secondary glandular histology, independently assigning numbers 1-5 (from best to least differentiated) to each for a score of 2 to 10 correlates well with course of disease and survival.  Both early and advanced prostate cancer may be asymptomatic at diagnosis.  When symptomatic, presenting complaints include in order of frequency: dysuria, difficulty voiding, frequency, urinary retention, back or hip pain, and hematuria.  Diagnosis is made by transrectal ultrasound-guided (TRUG) biopsy of the prostate.  Complications of such a biopsy are less than 1%.  If the prostatic specific antigen (PSA) test is greater than 10 at time of diagnosis, a bone-imaging scan should be performed.

 

Staging is as follows: T0 - No evidence of primary tumor; T1 - Impalpable tumor, not visualized on TRUG; T1a - Incidental tumor, <5% of tissue resected at prostatectomy; T1b - Incidental tumor, >5% of tissue resected at prostatectomy; T1c -Tumor identified by needle biopsy alone (because of elevated PSA); T2 - Tumor confined within prostate; T3 - Tumor extends through prostatic capsule; T4 - Tumor fixed to adjacent structures; N0 - No regional node metastases; N1-3 - Regional node metastases; MO - No distant metastases; M1 - distant metastases.

 

Management options for patients with clinically organ-confined disease (T1-T2) include observation, radiation therapy, radical prostatectomy, and brachytherapy (interstitial radioactive seeds).  Individuals presenting with Gleason scores < 5 and low-stage tumors (T1a or less) are unlikely to experience tumor related complications for 10 years or more. However, of those treated with observation, 75% will experience local progression and 20% will develop metastatic disease.  Those with Gleason scores > 7 and higher stage tumors are clear candidates for definitive therapy.  Before therapy, PSA is a useful prognostic marker and after treatment, progressive elevation of PSA is an indication of recurrent disease. Radical prostatectomy often results in impotence and occasionally incontinence.  Simple prostatectomy may be adequate in true T1a and some T1c disease.  Radiation therapy consists of 60 to 70 Gy to the prostate over six weeks and is associated with acute and chronic proctitis/urethritis, impotence, occasional rectal stricture, fistula and bleeding.  Serious morbidity is unusual following radiation therapy regardless of delivery.  Advanced prostate cancer is treated with surgical or medical castration and hormone therapy.  Chemotherapy is reserved for hormone-unresponsive tumors.

 

Aeromedical Concerns: Impairment may result from urinary frequency/urgency or urinary tract obstruction.  Metastatic disease can occur at presentation or after initial treatment affecting bony sites, especially spine, with resultant impairment to incapacitation secondary to pain or paraplegia.  Sudden lower extremity weakness is an ominous sign.  Ongoing treatment is generally disqualifying.  In the military services, an individual should be at least two years disease-free off all medications before consideration of waiver.  Aviators with a diagnosis of carcinoma of the prostate are to be initially placed in a non-flying status in each of the military services.

 

For civilian medical certification all classes of medical can be granted.  No airman is granted certification during active therapy.  In general the FAA waits for one year after any form of treatment in all the varying forms of malignancy, however in prostate cancer the airman can regain medical certification as soon as they have completed treatment and there are no evidence of side effects.  In the case of Brachytherapy, as soon as the airman has demonstrated that they are stable and the PSA level has fallen, the airman can gain medical certification.  The FAA has granted medical certification in the case of “watchful waiting” providing there is no evidence of malignancy.  All medications used in treatment are acceptable. 

 

Treatment and Aeromedical Disposition: Aeromedical summary should include: (1) initial presentation, (2) all surgical reports, (3) Armed Forces Institute of Pathology (AFIP) confirmation of histology and Gleason grading in the military or civilian hospital pathology reports, (4) chronology of therapy and results, (5) remarks concerning any medications and whether there have been any side effects, and a discussion of physical limitations, (6) remarks concerning future follow-up including Tumor Board and oncology or urology recommendations.  For the military, upgrading of flying category requires full flying physical, serial PSA determinations, recent renal functions and urinalysis.  A bone scan is required if symptomatic or PSA elevated for age.

 

The FAA will follow airmen with prostate cancer yearly for a minimum of five years.  The airman is required to provide yearly current status reports and PSA level. 

 

Experience: Review of waiver files data in the US Air Force reveals essentially all requests for waivers have been favorably acted upon but all were T1 or less disease without progression. 

As mentioned above all civilian classes of medical certificate are granted provided there are no metastasis.  Follow-up reports are required every year for at least five years along with PSA level.  Airmen who have had radical prostatectomy and brachytherapy have been granted medical certification.   

 

As of November 2005 the FAA has 1,020 first-class, 1,729 second-, and 5,029 third-class airmen who are currently issued with this condition.

 

References:

 

Scher HI, Motzer RJ. Bladder and renal cell cancer. Harrison's Principles of Internal Medicine. 14th ed. McGraw-Hill Companies, Inc.; 1998:592-6.

 

Seigne JD, Grossman HB. Malignant tumors of the urogenital tract. Conn's Current Therapy. W.B. Saunders Company; 1997:712-24.

 

 

December 14, 2005