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Module 3: Prostate Cancer Required Reading Instructor Joe Veys Unit 3: Major Cancers, Prevention, & Staging Objectives 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 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 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 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 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 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 Hormonal factor have been suggested as an explanation for the differences in incidence and mortality rates Genetic links have been suggested Heredity is estimated to account for only 3% of prostate cancer overall. Detection 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 Screening Pros and Cons Pros Advanced prostate cancer is not curable 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) 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) DRE testing by trained professional can detect: 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 Most prostate cancers arise from the outer peripheral zone of the gland, distant from the urethra Early–stage prostate cancer patients are often symptom free Progression of the disease may cause symptoms from obstruction such as: Decrease urinary stream force Urinary hesitancy Incomplete bladder emptying Increase urinary frequency Diagnosis and Symptoms Progression of disease may also cause: Blood in semen Decrease ejaculatory volume Less commonly impotence Advanced disease: Bone pain Hematuria Anemia Diagnosis 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 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: Elevated temperature Excessive bleeding Difficulty with urination Diagnosis Other diagnostic test Magnetic Resonance Imaging (MRI) Evaluate extracapsular penetration beyond the prostate gland and lymph node metastisis Computed Tomographic Scans Evaluate prostate size and lymph noe status Radionucleotide 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 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 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 Total scores range form 2-10 with higher scores indicating more aggressive disease and subsequently poorer prognosis Treatment Three Main Treatment Options for early stage prostate cancer: Radical Prostatectomy Radiation Therapy ( external beam and/or brachytherapy) Watchful waiting or expectant management approach 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 Stage I disease (T1,N0, M0 , grade1) Close observation, including PSA testing biannually or annually For young patients: aggressive treatment ,generally radical prostatectomy 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 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 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 Multidisciplinary approach is critical The patient The patients partner The health care team Ultimate decision is affected by: Medical considerations Patient unique preferences 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 Key factors in decision enhancement models include: Patient age Projected survival Coexisting medical conditions Stage of disease Gleason score Decision Making 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 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 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 Radiation may be delivered as a single modality of combination with other treatments modalities Radiation Therapy Nursing Considerations: Symptom management Acute- diarrhea, proctitis ,cystitis, fatigue, and local skin reactions. 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 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 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 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 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 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 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 Four major types of hormonal manipulation: Bilateral removal of the testicles (orchiectomy) Luteinizing hormone –releasing hormones (LHRH) Antiandrogens Estrogen therapy Pulse hormonal therapy or intermittent hormonal therapy has been successful in decreasing side effects Rehabilitation Two main long-term issues: Urinary Incontinence management Impotence management Urinary Incontinence 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: Anticholinergic drugs Alpha-sympathomimetic Kegel exercise Artificial sphincter Other- pads ,bladder training, penile clamps and diet restrictions Conclusion 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 As nurses it is our duty and commitment to provide patients and families with the most competent and compassionate care possible!