Prostate cancer

Androgen deprivation therapy

(ADT) Primary therapeutic approach Reduces levels of circulating androgens to reduce tumor growth Can be used before surgery or radiation to reduce tumor size and in advanced disease

Cryosurgery

(cryoablation) Surgical technique that destroys cancer cells by freezing the tissue Initial and second-line treatment after radiation therapy has failed

Prostate cancer stats

1 in 7 men will develop a malignant tumor of prostate gland in their lifetime Most common cancer among men, excluding skin cancer Second leading cause of cancer death in men

Overall Goals

Active participation in treatment plan Satisfactory pain control Follow therapeutic plan Understand effects of treatment on sexual function Satisfactorily manage bladder and bowel function

Outcomes

Actively participate in treatment plan Satisfactorily control plan Follow therapeutic plan Understand effect of treatment on sexual function Satisfactorily manage bladder and bowel function

LH-RH agonists

After an initial ↑ , LH and testosterone levels ↓ with continued administration Produce a chemical castration Available in SQ, IM, or implant Can improve overall survival rates

Known risk factors

Age, ethnicity, and family history Incidence rises markedly after age 50 Median age at diagnosis is 67 years old Highest incidence in Jamaican men of African descent

cultural considerations

Be aware of ethnic and cultural considerations when providing information about disease and screening recommendations Incidence of prostate cancer Health promotion practices Knowledge level Socioeconomic conditions and access to care Varied coping strategies Consider effectiveness of communication strategies

Biopsy

Biopsy of the prostate tissue is usually indicated when -PSA levels are continually elevated -DRE is abnormal Biopsy is necessary to confirm diagnosis of prostate cancer -Transrectal ultrasound procedure -MRI/ultrasound fusion biopsy

Androgen receptor blockers

Compete with circulating androgens at receptor sites Available in oral form Can be combined with LH-RH agonists

Sporadic prostate cancer

Damage to genes occurs by chance after a person is born About 75% of prostate cancers

Possible risk factors

Diet High red and processed meat intake High-fat dairy products Diet low in vegetables and fruits Obesity Environment- possibly smoking or BPH

Health Promotion

Encourage annual DRE and PSA screenings Consult with HCP Follow recommendations according to age and risk factors

Radical prostatectomy

Entire gland, seminal vesicles, and part of bladder neck are removed Retroperineal lymph node dissection is done for men at high risk for metastasis Not indicated for advanced disease stages

Postop radical prostatectomy Major complications

Erectile dysfunction (ED) Incontinence Other complications include hemorrhage, urinary retention, infection, wound dehiscence, DVT, PE

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

Drug Therapy

For treatment of advanced or metastatic prostate cancer Androgen deprivation therapy (ADT) Chemotherapy Combination

HBOC

Hereditary breast and ovarian cancer syndrome (HBOC) Associated with mutations in BRCA1 and BRCA2 genes Associated with an increased risk of breast cancer and prostate cancer Cause only a small percentage of familial prostate cancers

Postop radical prostatectomy care

Indwelling catheter Surgical site drain -careful dressing changes and perineal care after each bowel movement are important for comfort and to prevent infection. Hospital stay for 1 to 3 days

Direct extension

Involves seminal vesicles, urethral mucosa, bladder wall, and external sphincter

brachytherapy side effects

Irritative or obstructive urinary problems are common May experience ED May be offered in combination with external beam radiation treatment for those with more advanced tumors

Androgen synthesis inhibitors

Luteinizing hormone-releasing hormone - (LH-RH) agonists LH-RH antagonist CYP17 enzyme inhibitor

Hereditary prostate cancer

Occurs when gene mutations are passed down through generations Rare (5% to 10%)

osteoporosis effect of ADT

Osteoporosis and fractures may occur in prostate cancer patients receiving ADT. Drugs recommended to reduce bone mineral loss in these patients include zoledronic acid (Reclast) and raloxifene (Evista). Denosumab (Prolia), a drug that slows the breakdown of bone, may also be used to increase bone mass in men with nonmetastatic prostate cancer

PSA levels

PSA is a glycoprotein produced by prostate gland Normal levels are within 0 to 4 ng/mL (0 to 4 mcg/L)

PSA for monitoring tx

PSA levels are used to monitor treatment success and recurrence of prostate cancer Levels should be undetectable

PSA screening guidelines

PSA screening (American Urological Association) Every 2 years Especially for men ages 55-69 When symptoms of prostatic hyperplasia are present, further diagnostic screening may be necessary (Table 54-2)

Symptoms of metastasis

Pain in lumbosacral area that radiates down to hips or legs that is combine with urinary symptoms

PSA screening risks and benefits

Potential risks of PSA screening Unnecessary evaluation and treatment Potential benefits of PSA screening Early detection of prostate cancer Follow-up involves An annual PSA test DRE

Nerve-sparing surgical procedure

Preserves nerves responsible for erection Only for patients with cancer confined to prostate No guarantee that potency will be maintained

Chemotherapy

Primarily limited to treatment for those with hormone-resistant prostate cancer (HRPC) in late stages Goal is mainly palliative

psychosocial support

Provide sensitive, caring support to patient and family to help them cope with cancer diagnosis Encourage joining a support group, seeking information, and participating in their care decisions

Radiotherapy

Radium-223 dichloride (Xofigo) For treatment of patients with Castration-resistant prostate cancer Symptomatic bone metastases No known visceral metastatic disease

Familial prostate cancer

Runs in a family Occurs because of a combination of Shared genes Shared environment Lifestyle factors About 20% of prostate cancers

etiology of prostate cancer

Slow growing androgen-dependent cancer Can spread by 3 routes -Direct extension -Through lymph system -Through bloodstream

Prostate cancer can be classified into 3 categories:

Sporadic Familial Hereditary

Orchiectomy

Surgical removal of testes Produces androgen deprivation No side effects Very low cost Facilitates cancer control and rapid relief of bone pain in advanced stages of the disease Rarely performed today

classification

TNM system (tumor, node, and metastasis) Most common classification system used to determine extent of prostate cancer

Ambulatory Care

Teach catheter care Teach pelvic floor exercises Manage pain

determining extent of metastasis

Tests used to determine location and extent of metastasis Bone scan CT scan MRI using an endorectal probe

Active Surveillance

Watchful waiting when Life expectancy is less than 10 years Presence of low-grade, low-stage tumor Serious coexisting medical conditions

Chemoprevention of prostate cancer

an active area of research Finasteride and dutasteride (used to treat BPH) may reduce the chance of getting cancer Early recognition and treatment are important for treatment and prognosis

Cryosurgery Complications

include Damage to urethra Urethrorectal fistula Urethrocutaneous fistula Tissue sloughing, ED, urinary incontinence, prostatitis, and hemorrhage can also occur

Traditional surgical approaches for a radical prostatectomy

include retropubic and perineal resection. A, Retropubic approach involves a midline abdominal incision. The pelvic lymph nodes can be dissected. B, Perineal approach involves an incision between the scrotum and anus.

cardiovascular side effects of ADT

including elevated serum cholesterol and triglyceride levels and coronary artery disease.

Common side effects of radiation therapy

involve changes to the skin (dryness, redness, irritation, pain), gastrointestinal tract (diarrhea, abdominal cramping, bleeding, radiation proctitis), urinary tract (dysuria, frequency, hesitancy, urgency, nocturia), and sexual functioning.

A robotic-assisted (e.g., da Vinci system) prostatectomy

is a type of surgery in which the surgeon sits at a computer console while controlling high-resolution cameras and microsurgical instruments. Robotics is being used more frequently since it allows for increased precision, visualization, and dexterity by the surgeon when removing the prostate gland. It results in less bleeding, less pain, and a faster recovery compared with other approaches.

A urethrorectal fistula

is an opening between the urethra and rectum.

A urethrocutaneous fistula

is an opening between the urethra and skin.

stages

stage, tumor size, lymph node involvement, metastasis, PSA level I Not felt on DRE. Not seen by visual imaging. No No <10 ≤6 II Felt on DRE. Seen by imaging. Tumor confined to prostate. No No 10-20 II Felt on DRE. Seen by imaging. Tumor confined to prostate. No No 10-20 IV Any size. Any nodal involvement. Yes Any level

NDs

• Decisional conflict related to numerous alternative treatment options • Acute pain related to surgery, prostatic enlargement, bone metastasis, and bladder spasms • Urinary retention and impaired urinary elimination related to obstruction of the urethra by the prostate and loss of bladder tone • Sexual dysfunction related to effects of treatment • Anxiety related to uncertain outcome of disease process on life and lifestyle and effect of treatment on sexual function

Other indicators of prostate cancer

↑ PAP (prostatic acid phosphatase) Especially if cancer has spread

Genetic link

No single gene is known cause No genetic tests are available to determine predisposition to this cancer A family history indicates increased risk Genetic counseling may be indicated

inherited family characteristics

A family with an inherited form of prostate cancer has any of following characteristics -3 or more 1st degree relatives with prostate cancer -Prostate cancer in 3 generations on same side of family -2 or more close relatives on same side of family diagnosed with prostate cancer before age 55 Father, brother, son, grandfather, uncle, nephew

screening

ACS recommends screening should be discussed with men Age 50 if at average risk and expected to live at least 10 more years Age 45 if at high risk Age 40 when more than one first degree relative has had prostate cancer at an early age

Brachytherapy

Implantation of radioactive seed into prostate gland Spares surrounding tissue Placement guided by transrectal ultrasound A, Prostate brachytherapy. Implantation of seeds with a needle guided by TRUS to ensure accurate placement of the seeds. B, Radioactive seeds.

onset

May be no symptoms in early stages Eventually patient may experience LUTS symptoms similar to BPH

population with the greatest potential to benefit from PSA screening

Men aged 55-69 years old African American men Men with a first degree relative with prostate cancer

mild elevations of PSA

Mild elevations may occur with Aging BPH Recent ejaculation Constipation Acute or chronic prostatitis After long bike rides *doesn't necessarily mean cancer

PSA screening

Most men are diagnosed by PSA screening Smaller cancers are being found in older men Most slow-growing cancers probably do not need to be treated Many men live with prostate cancer - most will not die from it

metastasis pain

The tumor can spread to the pelvic lymph nodes, bones, bladder, lungs, and liver. Once the tumor has spread to distant sites, the major problem becomes the management of pain. As the cancer spreads to the bones (common site of metastasis), pain can become severe, especially in the back and legs because of compression of the spinal cord and destruction of bone.

(sipuleucel-T [Provenge]).

The vaccine stimulates the patient's system against the cancer and may prolong survival, although its exact mechanism is unknown. It prolongs survival by about 4 months, but does not reduce tumor burden. It is individually prepared for each man, by a process that combines his own white blood cells with granulocyte macrophage colony stimulating factor (GM-CSF), which then attacks the prostate tumor cell

Through bloodstream

To axial skeleton: pelvic bones, head of femur, lower lumbar spine, liver, and lungs

Through lymph system

To regional lymph nodes

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 Gleason score ranges from 2-10

ADT "Hormone refractory"

Tumors become resistant to therapy within a few years Elevated PSA level is often first sign that therapy is no longer effective

Symptoms similar to BPH

Urgency Hematuria Nocturia Retention Interruption of urinary stream Inability to urinate