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Module 3: Prostate Cancer
Required Reading
Instructor
Joe Veys
Unit 3: Major Cancers, Prevention, & Staging
Objectives
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The participant will be able to discuss incidence,
and risk factors for prostate cancer
The participant will be able to describe American
Cancer Society Prostate Cancer Screening
Guidelines
The participant will be able to explain prostate
cancer diagnosis and staging
The participant will be able to design and
incorporate the role of the nurse in treatment and
care of the patient.
Objectives
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The participant will be able to assess prostate cancer
patients needs, and formulate educational plan based on
individuals patients treatment plan
The participant will be able to compare and contrast
treatment options for the patient and his family
The participant will be able to describe and discuss the two
main rehabilitation issues related to prostate cancer.
Unit 3: Major Cancers, Prevention, & Staging
Prostate Cancer
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Definition of prostate cancer: Cancer that forms in tissues
of the prostate (a gland in the male reproductive system
found below the bladder and in front of the rectum).
Prostate cancer usually occurs in older men.
Prostate cancer is the most commonly diagnosed cancer in
men, and second only to lung cancer in the number of cancer
deaths. In 2005 (the most recent year for which statistics are
available), 185,895 men were diagnosed with prostate
cancer, and 28,905 men died from it (CDC)
Incidence
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Estimated new cases and deaths from prostate
cancer in the United States in 2009:
New cases: 192,280
Deaths: 27,360
Five –year survival rate for all races within the USA
is 97%-98% for whites and 93% for African
Americans
Fast Facts
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Not counting some forms of skin cancer, prostate cancer in the United
States is—
 The most common cancer in men, no matter race or ethnicity.
 The second most common cause of death from cancer among white,
African American, American Indian/Alaska Native, and Hispanic men.
 The third most common cause of death from cancer among Asian/Pacific
Islander men.
 More common in African-American men compared to white men.
 Less common in American Indian/Alaska Native and Asian/Pacific
Islander men compared to white men.
 More common in Hispanic men compared to non-Hispanic men.

U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2005 Incidence and Mortality Web-based Report.
Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer
Institute; 2009. Available at: http://www.cdc.gov/uscs.
Risk Factors
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80% of al prostate cancer are diagnosed in men
=>65yrs of age
Ethnicity
No conclusive evidence exists linking prostate cancer
with diet and lifestyle some experts suggest:
 Diet
high in fat with decrease fiber associated with double
risk
 Diet high in vitamins E and D, selenium, and lycopene
suggested to be protective.
 Occupational chemical exposure
 Job related physical activity not conclusive
Risk Factors
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Hormonal factor have been suggested as an
explanation for the differences in incidence and
mortality rates
Genetic links have been suggested
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Heredity is estimated to account for only 3% of prostate
cancer overall.
Detection
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Controversy exist at the national and international level
regarding cancer screening.
American Cancer Society guidelines:
PSA Test and DRE offered annually, beginning at age 50,to men
who have a life expectancy of at least 10years
 Men at high risk (African American men and men with a strong
family history of one or more first-degree relatives diagnosed with
prostate cancer at an early age) should begin testing at age
45years
 Men at average risk and high risk should be provided with
information about what is known and what is uncertain about
benefits and limitations of early detection and treatment of
prostate cancer so that they can make an informed decision about
testing
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Screening Pros and Cons
Pros
Advanced prostate cancer is not curable
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Men who are screened have a greater likelihood of
being diagnosed at an earlier stage that is more
conductive to cure
Screening Pros and Cons
Cons
 The
fact that many men die with the disease and not of the
disease.
 The
lack of clear scientific evidence to conclude that
screening does in fact decrease a man’s risk of dying from
prostate cancer
Prostate Specific Antigen (PSA)
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Normal- less than or equal to 4.0 ng/ml
PSA is prostate specific not cancer specific
Elevation may be related to benign prostatic
hypertrophy or prostatitis.
PSA increases with age and prostatic volume
Digital Rectal Examination (DRE)
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DRE testing by trained professional can detect:
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Nodules
Asymmetry
Swelling
Changes in texture
One in four prostate cancers is detected in men with
normal PSA’s and abnormal DRE’s
Diagnosis and Symptoms
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Most prostate cancers arise from the outer
peripheral zone of the gland, distant from the
urethra
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Early–stage prostate cancer patients are often symptom free
Progression of the disease may cause symptoms
from obstruction such as:
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Decrease urinary stream force
Urinary hesitancy
Incomplete bladder emptying
Increase urinary frequency
Diagnosis and Symptoms
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Progression of disease may also cause:
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Blood in semen
Decrease ejaculatory volume
Less commonly impotence
Advanced disease:
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Bone pain
Hematuria
Anemia
Diagnosis
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Diagnosis is established by biopsy only
Transrectally under transrectal ultrasound to
facilitate visualization of the gland
Spring loaded biopsy gun is used to obtain multiple
samples ( generally 6-13)
Diagnosis
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Biopsy procedure is performed on an outpatient
basis.
Patient education for this procedure include:
 Instructions
that hematuria and hematospermia may occur
for several days to weeks after procedure
 Instructions should be given to contact urologist if any of the
following occur:
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Elevated temperature
Excessive bleeding
Difficulty with urination
Diagnosis
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Other diagnostic test
 Magnetic
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Resonance Imaging (MRI)
Evaluate extracapsular penetration beyond the prostate gland
and lymph node metastisis
 Computed
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Tomographic Scans
Evaluate prostate size and lymph noe status
 Radionucleotide
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Bone Scans
Generally performed only if PSA levels are >10ng/ml
Performed to assess possible bone metastasis
Interpreted with caution- may yield false-positive results
Staging
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Cancer is staged as a means of describing the
extent of the disease and determination of
appropriate treatment.
The American Joint Committee on Cancer staging
system:
T
refers to the primary tumor
 N is the level of lymph node involvement
 M refers to the metastatic status
Staging- Gleason Score
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Gleason Scores
The Gleason grading system assigns a grade to each of the
two largest areas of cancer in the tissue samples. Grades
range from 1 to 5, with 1 being the least aggressive and 5
the most aggressive. Grade 3 tumors, for example, seldom
have metastases, but metastases are common with grade 4
or grade 5.
The two grades are then added together to produce a
Gleason score. A score of 2 to 4 is considered low grade; 5
through 7, intermediate grade; and 8 through 10, high
grade.
Gleason Score
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Total scores range form 2-10 with higher scores
indicating more aggressive disease and subsequently
poorer prognosis
Treatment
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Three Main Treatment Options for early stage
prostate cancer:
 Radical
Prostatectomy
 Radiation Therapy ( external beam and/or brachytherapy)
 Watchful waiting or expectant management approach
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Cryotherapy is becoming more available although it
remains investigational as a first line therapy
without long-term outcome data.
Neoadjuvant hormonal therapy may be offered
before surgical or radiation therapy treatment
Treatment
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Stage I disease (T1,N0, M0 , grade1)
 Close
observation, including PSA testing biannually or annually
 For young patients: aggressive treatment ,generally radical
prostatectomy
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Stage II disease (T1a,b, c, N0, M0, grade 2,3,4)
 Radical
prostatectomy
 External beam radiation therapy or interstitial radioisotope
implants
 Watchful waiting or expectant management
 Cryosurgery ( under investigation)
Treatment
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Stage III disease (T3, N0, M0.any grade)
 External
beam radiation therapy (with or without hormonal
therapy)
 Asymptomatic patients with comorbid conditions: Watchful
waiting
 Hormonal therapy
Treatment
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Stage IV disease ( T4,N0, M0 , any grade; any T,
N1, M0; any N,M1
 Hormonal
therapy/orchiectomy
 Chemotherapy for hormone-resistant disease
 External-beam radiation therapy for selected patients
with M0 disease
 Watchful waiting for selected asymptomatic patients
 Palliative radiation therapy for bone metastasis
 Systemic radioisotope for generalized bone pain
Decision Making
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Multidisciplinary approach is critical
 The
patient
 The patients partner
 The health care team
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Ultimate decision is affected by:
 Medical
considerations
 Patient unique preferences
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Personal preference
Biases against particular treatment options
Personal and vicarious experience with cancer and treatments
Potential side effects, quality of life, cost, loss work time and
tolerance of uncertainty
Decision Making
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Key factors in decision enhancement models include:
 Patient
age
 Projected survival
 Coexisting medical conditions
 Stage of disease
 Gleason score
Decision Making
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Racial disparities are of particular concerns and
signal an area where nurses can effectively
intervene in the public education arena.
Comprehensive ,accurate information from credible
sources is the critical factor in decision making
Radical Prostatectomy
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Mainstay of treatment in the USA
 Includes
complete removal of the prostate gland with
lymph node sampling
 Nerve- sparing approach involves isolation of the
neurovascular bundles needed for innervations of the
corpus cavernosa of the penis necessary for erection.
 Nursing priorities
 Post-op
prevention of complications
 Post –op interventions
 Patient and family education
Radiation Therapy
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Viable potentially curative option for men with :
 Early-stage
prostate cancer
 Management of advanced disease for palliation of
painful bone metastasis, urethral or rectal obstruction,
lymphatic blockage and spinal cord compression
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Radiation may be delivered as a single modality of
combination with other treatments modalities
Radiation Therapy
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Nursing Considerations:
 Symptom
management
 Acute-
diarrhea, proctitis ,cystitis, fatigue, and local skin
reactions.
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Brachytherapy-radiation in the form of implantation
seeds directly into the prostate gland.
 May
be used as a solo treatment or in combination with
XRT and or hormonal therapy
 Usually a same day surgery procedure
Radiation Therapy
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Brachytherapy nursing considerations:
 Similar
to XRT
 Additional considerations include-assessment and
teaching regarding potential pain, ecchymosis, and
scrotal edema
 Radiation safety
Watchful Waiting or Expectant Management
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Defined as initial surveillance followed by active
treatment in the presence of bothersome symptoms
 Option
for early-stage cancer rationale:
 Prostate
cancer incidence rates far exceed prostate cancer
death rates
 More men die with the disease than of the disease
 Aggressive
 Significant
treatment is associated with:
negative effects on patient quality of life
 Studies fail to demonstrate conclusively that screening and
early detection lead to improved survival
Watchful Waiting or Expectant Management
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General consensus as to which men are
appropriate candidates for watchful waiting:
 Life
expectancy of 10 years or less
 Gleason scores (<7)
 Cancer involving less than three biopsy specimens
 PSA levels of <10ng/ml
 Absence of palpable disease on DRE
Watchful Waiting or Expectant Management
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Nursing considerations
 Continuous
assessment of quality of life (physiologic
and psychosocial)
 Patient and family teaching and guidance in reporting
symptoms and reporting
 Support groups and spiritual support access
 Reassure that treatment may be started at any time
Hormonal Therapy
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Treatment of choice for the management of
metastatic prostate cancer and, for management of
recurrent disease
The goal of treatment is paaliation and prolonged
survival.
Neoadjuvant hormonal therapy used in some cases
to shrink tumor prior to surgery or radiation
Hormonal Therapy
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Adjuvant hormonal therapy an option for men who
have had prostatectomy or radiation therapy with
unfavorable prognosis of recurrence
Hormonal therapy based on rational that
androgens regulate tissue growth
Hormonal Therapy
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Four major types of hormonal manipulation:
 Bilateral
removal of the testicles (orchiectomy)
 Luteinizing hormone –releasing hormones (LHRH)
 Antiandrogens
 Estrogen therapy
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Pulse hormonal therapy or intermittent hormonal
therapy has been successful in decreasing side
effects
Rehabilitation
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Two main long-term issues:
 Urinary
Incontinence management
 Impotence management
Urinary Incontinence
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Dysfunction in either the storage or emptying of urine
Most common cause after prostatectomy is sphincter
insufficience
Incidence in literatur vary from 2%-87%
Medical Interventions:
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Anticholinergic drugs
Alpha-sympathomimetic
Kegel exercise
Artificial sphincter
Other- pads ,bladder training, penile clamps and diet restrictions
Conclusion
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Prostate cancer is a model of uncertainty in terms of
prevention, screening, and treatment.
Nurses are in an important position to be leaders in
public education.
Care of the patient undergoing treatment for
prostate cancer must be:
 Family
focused
 Requires expertise in symptom management
 Psychological support
Final Thoughts
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As nurses it is our duty and commitment to provide
patients and families with the most competent and
compassionate care possible!