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
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.
Seigne
JD, Grossman HB. Malignant tumors of the urogenital tract.
December
14, 2005