Download Prostate Cancer Udor

Title: Prostate cancer: The assessment needs
Key words: prostate cancer, quality of life, assessment
Author: Michelle Brown
Job specification: Senior Lecturer
Word Count: 3094
Correspondence:
Michelle Brown
University of Derby at Chesterfield
Chamber of Commerce Business Link
Canal Wharf
Chesterfield
Derbyshire
S41 7NA
Tel: 01246 212512
Email: [email protected]
Aim

Establish the consequences of prostate cancer treatments for the patient

Identify how quality of life assessment could aid care management and
delivery

Identify one quality of life tool that may be suitable for assessing this
particular client group.
Abstract
Prostate cancer treatments often affect quality of life and problems may present
themselves at any point both during and post treatment. Measuring and identifying
quality of life issues may create an opportunity for a patient to discuss problems
and induce information transfer from healthcare professional to patient and
conversely, from patient to healthcare professional. Treatment for the disease can
have a dramatic effect on lifestyle. Therefore, I suggest that quality of life should
be assessed to enable the healthcare professional to provide a more holistic
approach to patient care.
Utilising a quality of life assessment tool may promote and enhance the current
service provision and aid identification of bothersome side effects. In addition it
may provide a basis for further research and audit.
With the emphasis on quality of service for cancer patients (National Health
Service Improvement 2009, Department of Health 2000 Department of Health
(DH) 2007a), we should examine our practice and the quality of the service we
deliver. Addressing quality of life issues for the patient with cancer is a priority.
Introduction
Prostate cancer (PC) has been recognised as a debilitating disease. In its advanced stages
it can leave gentlemen with a multitude of problems including severe bone pain and
psychological distress regarding the possibility of a reduced life expectancy with no
possibility of cure (Wu et al 2007).
For men with PC, quality of life often diminishes and this may not be identified in a busy
clinic environment (Kirby 1997). The distress ensued following a diagnosis of PC may
be understated by PC patients whether it be an early or advanced presentation (Hedestig
et al 2005). In a study by Namiki et al (2010) they concluded that men being treated for
PC require a comprehensive assessment and multidisciplinary approach to maximize
health related quality of life (HRQOL). Patients with cancer are two or three times more
likely to suffer depression than a healthy person but early identification can improve
survival time and quality of life (National Institute of Health and Clinical Excellence
2009).
One way of creating a more comprehensive approach to assessment would be by
adopting a quality of life assessment tool. Sufferers could assess their own health
subjectively and issues or concerns may be identified promptly. These may then
be addressed in the clinical situation minimising the fear of embarrassment to the
patient. Depression in patients with cancer is not uncommon (Reyes-Gibby et al
2006, Ritterband & Spielberger 2001) but identifying problematic issues which
may be impinging on a gentleman’s HRQOL may minimise the degree of
depression and potentially reduce the incidence. Choosing an effective,
understandable, user-friendly questionnaire is extremely important for its success
in the clinic environment. Issues raised may be discussed freely facilitating an
open dialogue surrounding their condition, providing much needed information
and improve support available. In the Department of Health’s ‘Cancer Plan’,
deficits were identified in information provision which limited the patient’s ability
to feel empowered and, in addition, service provision varied in areas examined
(Department of Health 2000). More recently, information and knowledge were
still identified as insufficient for patients with PC (United health Europe 2007).
Background
Advanced prostate cancer is a slow growing tumour where the side effects of treatment
may increase the burden of a cancer diagnosis. Bjorck et al’s (1999) study determined
that older men, who make up the majority of those suffering from prostate cancer,
experience more helplessness due to lack of power over their illness e.g. sexual
dysfunction and incontinence. Nimiki (2010) concurs regarding the sexual function
domain of HRQOL, they suggest reasons for not seeking help were because elderly men
believed is was part of the aging process. Paradoxically it has been suggested that men on
androgen deprivation therapy (medical or surgical castration) for their PC are reluctant to discuss
concerns or problems due to humiliation about the treatment features i.e. castration rather than
perceiving it to be part of aging (Oliffe & Thorne, 2007).
PC is now the leading cancer diagnosis in males totalling 29% and the second most
common causes of death in males in the USA at around 9% (America Cancer Society
2007). In the UK during 1999, prostate cancer superseded lung cancer diagnoses and
became the most common cancer in men. In the UK in 2005, of all the new cancer
diagnosis registered 24% of them were prostate cancer. Despite these daunting statistics,
the five-year survival rate has improved from 42.4% between 1986 and 1990, to 68.4%
between 1996 and 1999. Survival is improving, but in the UK new cancer diagnoses are
predicted to rise further with approximately 283,000 new cases by 2016 (Office for
National Statistics 2007, DH 2007b).
There have been radical changes to the treatment and care for those with prostate cancer,
and indeed, many other cancers, e.g. development of the clinical nurse specialist post,
team coordinator roles and fast track referral processes (DH 2007b). In addition the
clinical management of prostate cancer has been developed but it remains that
approximately 50% of those treated for early PC will progress and proceed to androgen
deprivation therapy in an attempt to halt the disease progression (Meng et al. 2002). This
extended survival time has augmented the prospect of requiring further treatment thus
leading to more quality of life related concerns for patients (Walker and Robinson 2010).
Many of the treatments for prostate cancer have a negative impact on quality of
life. Porterfield (1997), carried out a study examining the treatment phase in 1000
men with prostate cancer, 81% felt their quality of life important during the
treatment phase. Herr et al (1993) compared a treatment group with a nontreatment group. The non-treated patients reported a better quality of life.
Even radical, potentially curative treatment may leave men with problems,
Hedestig et al (2005, pg 681) examined patients’ narratives following radical
surgery for their prostate cancer. Patient narratives post treatment described,
“becoming a changed man,” “striving to gain a sense of control in a new life
situation,” and feelings of being “mutilated,” “half human,” and a “weak man.”
Despite having potentially curative treatment, the men still had concerns, anxieties
and distress relating to the cancer and fears of recurrence. They required regular
clinician follow-up to gain reassurances that all was well. The researchers in this
study suggested that the respondents kept their anxieties and fears generally to
themselves but when things became “unbearable,” they would access the
professionals for help (Hedestig et al 2005, pg 684). It appears disappointing that
men have to get to the point of ‘unbearable’ before they seek support from
healthcare providers.
One domain in HRQOL assessment is that of sexuality and sexual dysfunction. It
is well established that intimacy and sexual function is important to men with
prostate cancer but also, their partners. Despite problems encountered in this
domain being common for all the treatment regimes, issues are rarely raised by
healthcare professionals (Oliffe 2005, Walker and Robinson 2010).
Hedestig et al (2003) suggested that men with prostate cancer concealed their
diagnosis from others preferring to try to live a ‘normal life’ in avoidance of their
diagnosis. Approximately 80% of prostate cancers fail to induce any mortality
risks but the remaining 20% are aggressive and harmful, and if left untreated will
induce premature mortality (DH 2004). Although we have established prostate
cancer as a slow growing tumour, it does invade local and distant sites e.g. lymph
nodes, bones and lungs, bone being more common for distant spread). These
presentations are not rare and present a dilemma when considering treatment
options. Treatment at this point becomes palliative with symptom control the
priority.
What’s the problem?
It is documented that ill health has an impact on social and personal life, but it can cause
financial worries and relationship problems, especially in terminal and palliative care
(Wilson-Barnett 1989). This is pertinent to the treatment of prostate cancer as we
immasculinate the male by obliterating his testosterone levels. Obliteration would appear
an appropriate adjective as the impact that this can have on an individual can be
devastating and demoralising. This must be borne in mind when considering how best to
care and treat these men.
The impact cancer has on the sexuality of the female has had a great deal of publicity and
breast care specialist nurses reside in many areas. A great deal has been published
relating to general quality of life and examining QoL tools (Wu et al 2007), but relatively
little has been established regarding cancers impact on male sexuality (Waxman 1993,
Walker and Robinson 2010). With impotence been a possibility with many of the
treatments for prostate cancer and loss of libido particularly with hormonal manipulation
issues may be underestimated and historically treat as a taboo subject (Baider 1996).
Why should we assess quality of life?
Hormonal manipulation is a common treatment for prostate cancer and involves
pharmacologically destroying testosterone production (medical castration), or operating
to remove the source of testosterone production (surgical castration). Both have dramatic
side effects that include, gynaecomastia (swollen breasts), painful breasts, impotence,
loss of libido, weight gain, testicular atrophy, loss of body hair, lethargy, hot flushes
(Newling 1997). These have an impact on the individual's lifestyle and treatment is an
immasculinating method of tumour control
Common complications resulting from prostate cancer treatment are the loss of erections,
reduced sexual desire and some have reported penile shortening. These are individually
extremely important when dealing with the client with prostate cancer and his partner.
The sexual relationship suffers as the man will often not attempt any intimacy rather than
fail to achieve an erection which may lead to withdrawing from the partner and potential
marital disharmony at a time when support is of benefit (Schover 1993, Walker and
Robinson 2010). Courtens et al (1996) carried out a study addressing family support for
patients with cancer. Family support correlated positively with increased quality of life.
It is obviously a priority when initiating treatment that the patient and his partner are
aware of the treatment action and understand that there are ways of regaining potency.
Reassurance regarding treatments may be achieved and a more candid approach may be
facilitated as well as the recognition that intimacy should not be treat as a taboo subject.
The loss of libido is a more problematic area. This is complex and may not be regained,
in addition, psychosexual counselling for the couple may be crucial. Anecdotally,
psychosexual counsellors are not in abundance and so long waiting times for
appointments may be a problem. Comprehensive assessment may highlight presenting
problems in a prompt manner minimising delay in treatment and referral, should it be
deemed necessary.
By using quality of life assessment tools we can identify areas of concern for patients.
This increased knowledge may help when counselling patients with new diagnosis and
initiating treatment. Numerous studies regarding cancer and effects on quality of life have
been undertaken but many of these have concentrated on breast cancer with
proportionately less focused on prostate cancer (Bloom 1996). Numerous quality of life
assessments have not taken the family reaction, coping skills or support for the patient
with cancer into consideration (Bloom 1996).
Various definitions have been used to describe ‘Quality of Life’ in an attempt to measure
it. ‘Quality of Life scales are increasingly a familiar sight in clinical trials but not
routinely used in clinical practice.
Quality of life, the background
Quality of life was a term first adopted shortly after the second world war but it is a term
that is not clearly defined and is overused to emphasise a treatment benefits (Meeberg
1993). Quality of life tools have been designed but are often not specific for prostate
cancer (EuroQoL, QALY’s). Many of these tools are designed for the purpose of clinical
trials (Kirby & Wager 1997). There is a need for quality of life assessments that focus on
the impact of treatments and diagnosis on the individual's lifestyle. At present a great deal
of work has concentrated on cost benefit and treatment comparison. Outcomes have been
in the form of survival (Litwin 1994). Although research must obviously play an
important part in assessing treatment preferences, the therapeutic value of utilising
HRQOL instruments in routine practice has received little attention (Thompson 1994).
Quality is a degree of excellence and if we establish quality of life as a degree of
excellence in life then we come close to a definition for what is often poorly understood.
Measuring quality of life can highlight problems encountered following diagnosis but
also give the client a cue for raising subjects for discussion. Major depression in a cancer
patient is quite rare but problems with adjustment to the diagnosis and lifestyle associated
with depressed mood are quite common (AHRQ Research Activities 2006).
If we measure and assess quality of life
To optimise a patients’ quality of life we must be measuring it from diagnosis and
throughout the duration of treatment (Litwin 1994). By utilising a quality of life tool we
can provide a forum for the discussion of real problems rather than ones we think may be
a problem. The consultation will concentrate on real issues and the patient will hopefully
benefit from his visit. Consultations are rarely long enough without sitting through
irrelevant discussion and coming out after ten minutes failing to feel more optimistic
about life and the quality of it. Being told that your PSA is still down and discussing what
your prostate feels like can reassure that all is well with the disease, but the side effects
and the problems they are causing in your social or personal life are still going to be there
long after the consultation is over.
What tool?
Selecting a tool that is fit for purpose is essential. Fundamentally, one should ensure it is
appropriate for the client group and for the treatments they are having, highlighting issues
surrounding sexuality and urological function, in addition to, psychological, social and
basic physical needs.
The communication between the practitioner and the patient should be in-depth, assessing
the psychosocial factors that are affected by the initiated treatments which can be
facilitated through the issues flagged up on the completed HRQOL tool. This is
particularly essential as treatments for this condition they have such profound
immasculinating effects and these can cause significant distress to the individual and to
his partner. A comprehensive quality of life tool could inform and signal the presence of
distressing symptoms and the Functional Assessment of Cancer Therapy –Prostate
specific (FACT-P) is one tool that has all the prerequisites suggested (Cella et 1993).
Measures of disease status are not sufficient in themselves for a true picture of treatment
outcomes, the burden of treatments on the individual are required, acknowledgement of
this need has influenced the increased use of HRQOL assessment in clinical practice
(Muldoon et al 1998). By using quality of life assessment, we are encompassing all there
is about the individual, acknowledging the psychological, emotional, spiritual, social,
sexual and physical effects the treatment is having. The treatment can become patientcentred and he can assess his side effects and decide on the treatment that would be best
for him and even initiating treatment change if side effects become too distressing or
burdensome.
From the assessments we can also identify coping problems and anxieties and deal with
these issues rather than leave the patient in a distressed state. For patients who find it
difficult to discuss their anxieties or worries about deterioration, the quality of life tool
can provide a prompt or ‘permission’ to discuss what they may feel is not medical so
should not be discussed. As a Specialist Nurse dealing with patients with prostate cancer,
I have known gentlemen request cessation of therapy due to their poor quality of life. The
quality of life problems had not been addressed in clinic or identified until they had
become a problem that was unbearable.
Addressing the impact and the severity of side effects profiled could be easily obtained
by examining the quality of life tools from these clients. Looking at deterioration or
improvement in aspects of quality of life is another area we could investigate by using
quality of life assessment. We should utilise this valuable information because this is real
information as experienced by the client rather than a from drug profile, which could
provide the basis for further comprehensive phenomenological studies.
Conclusion
We have established that prostate cancer treatments induce significant morbidity for
some patients. The opportunity to discuss problems and concerns does not always arise in
the clinical situation. In addition the subject matter may make it inherently difficult to
discuss due to embarrassment and, to some extent, humiliation regarding the treatment
side effects. Providing a comprehensive assessment strategy should be a standard
requirement for patients who will often have diverse ranges of treatment side effects.
Measuring and quality of life using a HRQOL assessment tool will fulfil this
requirement. In addition it may give the patient the prompt they need to discuss how they
really feel about their treatment and the effects it is having on their well-being and
lifestyle. This need is not exclusive to patients with PC, the principle can be true for all
life threatening illnesses.
There is a need to continually examine effects from therapeutic interventions to
understand the burden and emotional load it can have on patient and their family
(Merrick et al 2000) and utilising a HRQOL like this may help us start to realise what we
do not know.
Using assessments like these we can examine isolated aspects of life e.g. the emotional
well-being. Once we know what the issues and problems are, we can address deficiencies
in the service we provide. Further work examining quality of life is needed in the clinical
setting
One should not have to be an expert in other people’s problems but a person that acts
rather as a facilitator (Morrison 1991), the client can work out their own problems and be
reassured that we are there to discuss more than the blood test and the prostate
examination. We can discuss worries and problems using their own values and belief
systems in the freedom of a non-prejudiced and non-judgmental environment.
Although PC is being diagnosed at earlier stages, men continue to be diagnosed with
regional or distant metastases and progressive disease is becoming more evident as
survival times are extended. In these situations hormonal manipulation is a significantly
common form of treatment with significant issues and side effects, furthermore, even
potentially curative treatments take their toll on HRQOL. The incidence of prostate
cancer continues to rise (Office for National Statistics 2009) in this knowledge we must
advance practice and attempt to minimise patient’s suffering.
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Key points

Quality of life is diminished in the majority of patients suffering with prostate
cancer

To improve service provision we need to assess patients comprehensively

Attending to specific worries, concern and problems may allow us to improve
patients quality of life and that of their partners.

Examining quality of life will allow an opportunity to conduct essential quality of
life research and audit our practice