Focus on Prostate Cancer

Focus on Prostate Cancer
(Relates to Chapter 55, “Nursing Management: Male Reproductive Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Significance Malignant tumor of the prostate Estimated 192,280 new cases diagnosed and 27,360 deaths annually 1 in every 5 men will develop it in their lifetime. Prostate cancer is the most common cancer among men, excluding skin cancer. It is the second leading cause of cancer death in men (exceeded only by lung cancer). A majority (more than 75%) of cases occur in men over age 65. Rates of prostate cancer since 2001 have been decreasing by approximately 4% per year in large part because of increased screening with the prostate-specific antigen (PSA) blood test. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Etiology and Pathophysiology
Androgen-dependent adenocarcinoma Majority of tumors occur in outer aspect of the gland. Usually slow growing Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Direct extension involves seminal vesicles, urethral mucosa, bladder wall, and external sphincter. Cancer later spreads through lymphatic system to the regional lymph nodes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

Age, ethnicity, and family history are nonmodifiable risk factors. Incidence rises markedly after age 50. Additional information on ethnicity is presented in the Cultural and Ethnic Health Disparities box in Chapter 55. More than 66% of men diagnosed are older than 65. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

African Americans have highest incidence. Having a first-degree relative with prostate cancer increases risk. The reason for the higher rate among African Americans is unknown. In addition, African American men are likely to have more aggressive tumors at diagnosis and to have higher mortality rates from prostate cancer. In spite of a poorer prognostic profile, Asian Americans have better survival rates than whites. Differences in survival may be due to body composition, dietary factors, and endogenous hormones. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

High-fat diet is associated with increased risk. Exposure to certain chemicals may be associated with higher risk. History of BPH is NOT a risk factor. A diet high in red meat and high-fat dairy products along with a low intake of vegetables and fruits may increase the risk of prostate cancer. Studies are examining the role of dietary carotenoids (e.g., lycopene) and antioxidants (e.g., vitamins E and D and selenium) in reducing prostate cancer risk. Chemoprevention of prostate cancer is an active area of research. Recent findings of a large trial of more than 18, 000 men indicate that finasteride (Proscar) reduced the chance of getting prostate cancer by up to 25%. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Clinical Manifestations
Usually asymptomatic in early stages Eventually may experience symptoms similar to BPH Dysuria Hesitancy Dribbling Frequency Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Pain in lumbosacral area that radiates to hips or legs, when coupled with urinary symptoms, could indicate metastasis. Once cancer has spread to distant sites, pain management becomes major problem. Early recognition and treatment is important to control tumor growth, prevent metastasis, and preserve quality of life. The tumor can spread to the pelvic lymph nodes, bones, bladder, lungs, and liver. As cancer spreads to the bones (a common site of metastasis), pain can become severe, especially in the back and the legs, because of compression of the spinal cord and destruction of bone. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Metastasis of Prostate Cancer to the Pelvis and Lumbar Spine
Fig Metastasis of prostate cancer to the pelvis and lumbar spine. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Diagnostic Studies Two primary screening tools PSA (prostate-specific antigen) blood test Elevated levels indicate prostatic pathology—not necessarily cancer. Marker of tumor volume when cancer exists Also used to monitor success of treatment Men should discuss with their health care provider the benefits and limitations of early detection testing for prostate cancer. Evidence currently does not exist as to whether routine screening for prostate cancer reduces mortality in men younger than age 75. Normal PSA level, 0 to 4 ng/mL (0 to 4 mcg/L). Mild elevations in PSA may occur with aging, BPH, recent ejaculation, or acute or chronic prostatitis, or after long bike rides. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Diagnostic Studies Two primary screening tools DRE (digital rectal examination) Abnormal prostate findings include hardness, nodular and asymmetric. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Diagnostic Studies Elevated levels of PAP (prostatic acid phosphatase) also indicate prostate cancer. An elevated PAP is an indicator of prostate cancer, especially if there is extracapsular spread. With advanced prostate cancer, serum alkaline phosphatase is increased as a result of bone metastasis. Investigation is now under way to locate a serum biomarker for prostate cancer similar to CA-125, which is a useful marker in ovarian cancer. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Diagnostic Studies Neither a PSA nor DRE is a definitive diagnostic test. Biopsy of prostate tissue is necessary to confirm diagnosis. Done using TRUS to allow physician to visualize and pinpoint abnormalities If PSA levels are continually elevated, or if the DRE is abnormal, a biopsy of the prostate tissue is usually indicated. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Collaborative Care Whitmore-Jewett and tumor, node, metastasis (TNM) system used to stage prostate cancer Based on size (volume) and spread See Table 55-5 for more information. A majority of patients with prostate cancer are initially diagnosed when the cancer is in a local or regional stage. The 5-year survival rate with an initial diagnosis at this stage is 100%. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Collaborative Care Grading of tumor is done using Gleason scale. Tumors are graded from 1 (well differentiated) to 5 (undifferentiated). Grades are given to the two most common patterns of cells and are added together. The Gleason score is a number from 2 to 10. This scale is used to predict how quickly the cancer will progress. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Collaborative Care Conservative therapy Watchful waiting when Life expectancy is less than 10 years Presence of low-grade, low-stage tumor Table 55-6 summarizes the various treatment options available. These patients are typically followed with frequent PSA measurements, along with DRE, to monitor the progress of the disease. Significant changes in PSA level, in DRE, or in the development of symptoms warrant a reevaluation of treatment options. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Collaborative Care Surgical therapy Radical prostatectomy Entire gland, seminal vesicles, and part of bladder neck are moved. Retroperineal lymph node dissection usually is done. Considered most effective for long-term survival The entire prostate is removed because cancer tends to be in many different locations within the gland. {See next slide for figure.} A robotic-assisted (e.g., da Vinci system) prostatectomy is a newer type of laparoscopy in which the surgeon sits at a computer console while controlling high-resolution cameras and microsurgical instruments. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Prostatectomy A, Retropubic approach involves a midline abdominal incision. B, Perineal approach involves an incision between the scrotum and anus. Fig Common approaches used to perform a prostatectomy. A, Retropubic approach involves a midline abdominal incision. B, Perineal approach involves an incision between the scrotum and anus. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Collaborative Care Radical prostatectomy Patient catheterized for a couple of days Stay in hospital for 1 to 3 days Major complications are erectile dysfunction and incontinence. Because the perineal approach has a higher risk of postoperative infection (because of the location of the incision relative to the anus), careful dressing changes and perineal care after each bowel movement are important for comfort and to prevent infection. The incidence of erectile dysfunction is dependent on the patient’s age and preoperative sexual functioning, whether nerve-sparing surgery was performed, and the expertise of the surgeon. Kegel exercises strengthen the urinary sphincter and may help improve continence. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

Collaborative Care Other complications of radical prostatectomy Hemorrhage Urinary retention Infection Wound dehiscence DVT Pulmonary emboli Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Collaborative Care Nerve-sparing surgical procedure Spares nerves responsible for erection Only for cancer confined to prostate No guarantee that potency will be maintained Most young men (<50 years of age) with good preoperative erectile function and low-stage prostate cancer can expect a return of potency after nerve-sparing prostatectomy. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Collaborative Care Cryosurgery Surgical technique that destroys cancer cells by freezing the tissue Initial and second-line treatment after radiation fails A transrectal ultrasound probe is inserted to visualize the prostate gland. Probes containing liquid nitrogen are then inserted into the prostate. Liquid nitrogen delivers freezing temperatures, destroying the tissue. Treatment takes about 2 hours under general or spinal anesthesia and does not involve an abdominal incision. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Collaborative Care Cryosurgery Complications include damage to urethra, urethrorectal fistula, and urethrocutaneous fistula. Tissue sloughing, ED, urinary incontinence, prostatitis, and hemorrhage have also been reported. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Collaborative Care Radiation therapy External beam radiation Most widely used method of radiation for prostate cancer Used to treat cancer confined to prostate and/or surrounding tissue Side effects can be acute or delayed. Patients are usually treated on an outpatient basis 5 days a week for 4 to 8 weeks. Each treatment lasts only a few minutes. Common side effects involve normal tissues, including the skin (dryness, redness, irritation, pain), gastrointestinal tract (diarrhea, abdominal cramping, bleeding), urinary tract (dysuria, frequency, hesitancy, urgency, nocturia), sexual functioning (erectile dysfunction), fatigue, and bone marrow suppression. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Collaborative Care Radiation therapy Brachytherapy Implantation of radioactive seed into prostate gland Spares surrounding tissue Placement guided by transrectal ultrasound {See next slide for figure.} Because brachytherapy is a one-time outpatient procedure, many patients find this more convenient than external beam radiation treatment. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Brachytherapy A, Prostate brachytherapy. Implantation of seeds with a needle guided by ultrasound and a template grid. B, Radioactive seeds. Fig A, Prostate brachytherapy. Implantation of seeds with a needle guided by ultrasound and a template grid. B, Radioactive seeds. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Collaborative Care Brachytherapy (cont’d) Best suited for stage A or B Irritative or obstructive urinary problems are common side effects. Some men may also experience erectile dysfunction. The AUA symptom index (see Table 55-1) can be used to measure urinary function for patients undergoing brachytherapy and can be incorporated into postoperative nursing management. For those with more advanced tumors, brachytherapy may be offered in combination with external beam radiation treatment. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Collaborative Care Drug therapy Hormonal therapy Androgen deprivation is primary therapeutic approach. Focused on reducing levels of androgens to reduce tumor growth Can be used before surgery or radiation to reduce tumor size and in advanced disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Collaborative Care Hormone therapy “Hormone refractory” Tumors become resistant to therapy within a few years. Elevated PSA level is often first sign that therapy is no longer effective. Androgen ablation can be produced by interference with androgen production (e.g., luteinizing hormone–releasing hormone [LH-RH] agonists, orchiectomy) or androgen receptor blockers. Osteoporosis and fractures may occur in prostate cancer patients receiving ADT. Bisphosphonate drugs (e.g., zoledronic acid [Reclast]) are the currently recommended treatment to reduce bone mineral loss in these patients. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

Collaborative Care Types of hormonal therapy Luteinizing hormone–releasing hormone agonists Androgen receptor blockers Estrogen Each type is discussed in the following slides. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

Collaborative Care Luteinizing hormone–releasing hormone agonists With continued administration, LH and testosterone levels decrease. Produces a chemical castration similar to orchiectomy Side effects include hot flashes, gynecomastia, loss of libido, and ED. These drugs cause an initial transient increase in LH and testosterone called a flare. Worsening of symptoms may occur during this time. Current antiandrogen therapy includes leuprolide (Lupron, Eligard, Viadur), goserelin (Zoladex), triptorelin (Trelstar), and buserelin (Suprefact). Antiandrogen medications are given by subcutaneous or intramuscular injection on a regular basis; they must be taken indefinitely. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

Collaborative Care Androgen receptor blockers Compete with circulating androgens at receptor sites Can be combined with LH-RH agonists Side effects include loss of libido, ED, hot flashes, breast pain, and gynecomastia. Flutamide (Eulexin), nilutamide (Nilandron), and bicalutamide (Casodex) are nonsteroidal androgen receptor blockers. The combination of an androgen receptor blocker with an LH-RH agonist is an often used treatment, which results in combined androgen blockade. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

Collaborative Care Estrogen Used as a form of androgen deprivation therapy Declining because of cardiovascular complications (MI, DVT, cerebrovascular disease) and new therapies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

Collaborative Care Orchiectomy Surgical removal of testes for advanced stages of prostate cancer May be done alone or with prostatectomy Another possible benefit of this procedure is the rapid relief of bone pain associated with advanced tumors. Orchiectomy may also induce sufficient shrinkage of the prostate to relieve urinary obstruction in later stages of disease, when surgery is not an option. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

Collaborative Care Orchiectomy Reduces circulating testosterone by 90% Side effects include hot flashes, ED, loss of libido, irritability, weight gain, loss of muscle mass, and osteoporosis. Physical changes can affect self-esteem, leading to grief and depression. Although this procedure is cost-effective (compared with chemical hormone manipulation using LH-RH agonists), it is also permanent. Thus many men indicate a preference for drug therapy over an orchiectomy. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

Collaborative Care Chemotherapy Primarily limited to treatment for those with hormone-resistant prostate cancer (HRPC) in late stages Goal is palliation, as prostate cancer has responded poorly to chemotherapy. In HRPC, the cancer is progressing despite treatment. This occurs in patients who have taken an antiandrogen for a certain period of time. Some of the more commonly used chemotherapy drugs include paclitaxel (Abraxane), mitoxantrone (Novantrone), vinblastine (Velbane), cyclophosphamide (Cytoxan), and estramustine (Emcyt). Recently the drug docetaxel (Taxotere) was shown to improve survival rates in men with advanced metastatic HRPC. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

Nursing Assessment Health history Medications, especially testosterone supplements, morphine, anticholinergics, monoamine oxidase inhibitors and tricyclic antidepressants Family history High-fat diet, anorexia, weight loss Subjective and objective data that should be obtained from a patient with prostate cancer are presented in Table 55-8. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

Nursing Assessment Health history Urinary urgency, frequency, retention with dribbling, hematuria, nocturia Dysuria, low back pain radiating to legs or pelvis, bone pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

Nursing Assessment Objective data Anxiety Distended bladder on palpation; unilaterally hard, enlarged fixed prostate on rectal examination High PSA, PAP nodular irregularities on ultrasonography, positive biopsy results, anemia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

Planning Will be active participant in therapeutic plan Will have satisfactory pain control Will follow therapeutic plan on sexual dysfunction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

Planning Understand the effect of treatment on sexual function. Find a satisfactory way to manage impact on bladder or bowel function. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

Nursing Implementation
Encourage DRE and PSA screenings. Provide sensitive, caring support to patient and family. Encourage joining a support group and seeking information. Because of their increased risk of prostate cancer, African American men and other men with a family history of prostate cancer should have an annual PSA and DRE beginning at age 45. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

Nursing Implementation
Teach catheter care. Teach pelvic floor exercises. Administer pain medication. Instruct the patient to clean the urethral meatus with soap and water once a day, maintain a high fluid intake, keep the collecting bag lower than the bladder at all times, keep the catheter securely anchored to the inner thigh or abdomen, and report any signs of bladder infection, such as bladder spasms, fever, or hematuria. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

Audience Response Question After radical perineal prostatectomy for advanced cancer of the prostate, the priority nursing diagnosis for the patient is: 1. Risk for infection. 2. Risk for situational low self-esteem. 3. Sexual dysfunction. 4. Total urinary incontinence. Answer: 1 Rationale: The perineal approach has a higher risk of postoperative infection (because of the location of the incision in relation to the anus). Careful dressing changes and perineal care are important after each bowel movement to prevent infection. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53

Discussion Questions What should you tell him about the surgical procedure? What side effects of the treatment should he be aware of? The entire prostate will be removed. If possible, the surgeon will perform a nerve-sparing procedure. Erectile dysfunction and urinary incontinence. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 59

Discussion Questions You notice that he is embarrassed to discuss sexual dysfunction. What approach should you take? 3. If available, you can offer him written material that he can read in private whenever he wants, or you can tell him that in the situation, sexual dysfunction is not something to cause embarrassment. It can be a side effect. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 60

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