Prostate cancer

Guidance for medical examiners when assessing a patient for either a general topic or condition - Prostate cancer.

Aeromedical implications

Effect of aviation on condition

• Fatigue and jet lag will tend to aggravate any adverse effects of radiotherapy and chemotherapeutic agents
• Hypoxia - lowers seizure threshold and thus risk from cerebral secondaries

Effect of condition on aviation

• Overt incapacitation
  • pain from bony metastasis
  • pain from acute bladder obstruction
  • neurologic deficits from spinal cord compression
  • lower extremity pain and oedema due to obstruction of venous and lymphatic tributaries by nodal metastasis
• Subtle incapacitation
  • depression and affective disorders.

Effect of treatment on aviation

• Medication side-effects
• Distraction due to treatment and symptoms eg pain and nausea:
  • distraction due to urinary incontinence secondary to prostate surgery
  • distraction due to rectal irritation secondary to radiotherapy.

Approach to medical certification

Based on the condition

• Absence of symptoms / complications
• In remission / acceptable staging
• Acceptable biochemical and haematological parameters

Based on treatment

• Absence of significant side-effects
  • rectal irritation
  • adverse effects of androgen suppression.

Demonstrated stability

• Stability of treatment and condition confirmed for the period of certification
• May include interim surveillance eg review of PSAs by DAME

Risk assessment protocol - information required

New cases

• Confirmed diagnosis
• Clinical status
  • presenting symptoms/signs
  • progress
• Investigations conducted (if performed)
  • results of staging investigations/histology:
    • collated PSA
    • biopsy results
    • percentage of biopsy cores positive for cancer
    • gleason score
  • surgical report
    • clinical tumour stage
    • involved margins/ Extra-prostatic involvement
    • gleason score
  • imaging for metastasis
    • bone scan
    • CT scan of the abdomen and pelvis
  • follow-up investigations
• Management
  • treatment and response (if performed)
    • Radical prostatectomy
    • Radiation therapy
    • Active surveillance
    • Androgen deprivation therapy (ADT)
  • side-effects
    • Current state of continence
    • Rectal complications
    • Adverse effects of androgen suppression
  • monitoring
    • Serial PSA
• Prognosis
  • risk of possible future recurrence
  • what are the likely clinical presentations of recurrence?
  • could this be accompanied by incapacitating symptoms?
  • could a recurrence be detected before symptoms occur by increasing the frequency of radiological, haematological or other surveillance?
• Follow-up plan. 

Renewal

• Clinical status
  • any symptoms/signs
  • progress (as indicated by serial PSA’s).

Additional information as required:

• Investigations conducted (if performed)
• Management
  • treatment and response (if performed)
  • side-effects
    • current state of continence
    • rectal complications
    • adverse effects of androgen suppression (e.g. mood, glucose intolerance)
  • monitoring
• Prognosis
• Risk of possible future recurrence
  • what are the likely clinical presentations of recurrence?
  • could this be accompanied by incapacitating symptoms?
  • could a recurrence be detected before symptoms occur by increasing the frequency of radiological, haematological or other surveillance?
• Follow up plan.

Indicative outcomes

• Audit requirements will apply as follows
  • successful and definitive prostate cancer treatment - 5 years
  • people who are being monitored without treatment - ongoing
  • metastatic prostate cancer in remission - ongoing
• Hormonal treatment has multiple side-effects and may require additional reports and testing.

Favourable

• Prostate cancer - successfully treated or localised and stable PSA
• No significant consequences of treatment

Unfavourable

• Metastatic cancers
• Unstable cancers requiring radiotherapy or chemotherapy
• Adverse effects of androgen suppression

Pilot information

• Any relapse mandates grounding and must be reported to the DAME or CASA
• Any change of treatment mandates grounding and must be reported to the DAME
• Side effects of erectile dysfunction medications can be aero-medically significant
• Prostate biopsy may be complicated by bleeding, infection and urinary obstruction:
  • most obstructions occur in the first few hours after the procedure, however there are instances where it has occurred up to 5 days later
  • grounding for 5 days post procedure is required to reduce the risk of in-flight incapacitation.