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02.06 Prostate Cancer

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Overview

  1. 2nd most common cancer in males
    1. Behind only skin cancer
    2. 1 in 9 men
  2. Treatment modalities
    1. Surgery
    2. Chemotherapy/Immunotherapy
    3. Radiation
    4. Hormonal

Nursing Points

General

  1. Treatment dependent on tumor stage and grade
    1. Stage = amount of disease spread; grade = speed of disease growth
    2. Distant metastases will require chemo for cure
    3. Radiation often recommended in multi-modal approaches
    4. Surgery common in lower stages
      1. Can affect sexuality/reproduction
      2. Onco-fertility is up and coming
    5. Hormonal therapy can be prescribed long-term
  2. Risk factors
    1. Age > 50
    2. African-American descent
    3. Family history
      1. BRCA-1, BRCA-2
    4. Diet
      1. Link unclear
      2. We know North Americans are at higher risk than their peers in Asia
  3. Prevention
    1. Biggest risk factors not modifiable
      1. Age
      2. Race
      3. Genetics
    2. Modifiable
      1. Weight
      2. Physical activity
      3. Diet high in vegetables
  4. Life expectancy
    1. Dependent on staging at diagnosis
      1. Local/regional mets: 99% at 5 years
      2. Distant: 30% at 5 years
    2. Lower grades in older men may not be treated aggressively
      1. Manage symptoms in cancers we do not treat for cure
      2. Urinary symptoms
      3. Pain
    3. Metastisis – each changes life expectancy in its own way
      1. Bone
      2. Lungs
      3. Lymph nodes
      4. Brain
      5. Liver

Assessment

  1. Screening
    1. Done on patient-specific basis
      1. Symptoms
      2. Genetic hitsory
      3. Age
      4. Provider discretion
    2. PSA level
      1. Suggested to start between ages 50-60
      2. Blood test for prostate-specific antigen
      3. Also used post-treatment to monitor for recurrence
    3. Patient history
      1. Difficulty urinating
      2. Frequent urination
      3. Blood in urine/ejaculate
      4. Erectile dysfunction
      5. Hip and/or lower back pain
  2. Side effects
    1. Dependent on treatment modality
      1. Changes in fertility
      2. Weight loss
    2. Disease process
      1. Impotence
      2. Change in sex drive
      3. Pain with urination
  3. Sexuality
    1. Often guides decision making process for patient
    2. Decreases with disease process and treatment
    3. Younger patients should be referred to fertility

Therapeutic Management

  1. Hormonal – 1st line for metastatic
    1. Suppresses androgens (testosterone)
      1. Surgical: orchiectomy
      2. Pharmacological
    2. Impotence
    3. Absent sex drive
    4. Fatigue
  2. Chemotherapy
    1. Hair loss
    2. Nausea
    3. Weight loss
    4. Fatigue
    5. Infection
  3. Radiation
    1. Skin rash
    2. Blood in urine
    3. Pain
  4. Surgery
    1. Can be nerve-sparing
    2. Impotence
    3. Many require urinary catheters post-surgery
    4. May require hospital say

Nursing Concepts

  1. Coping
    1. Cancer diagnosis
    2. Stress survivorship
  2. Sexuality
    1. Can cause ED
    2. Can alter sex drive
    3. Refer to onco-fertility
  3. Elimination
    1. Symptoms can prompt diagnosis
    2. Needs may change over time

Patient Education

  1. Dependent on treatment
    1. Surgery: signs of infection, difficulty urinating
    2. Radiation: skin rash, hematuria
    3. Chemotherapy: weight loss, infection prevention
    4. Hormonal: sexual changes
  2. Fertility
    1. Sexual dysfunction
    2. Sperm banking
  3. Treatment modalities
    1. Aggressive care may not be best choice
    2. Long-term monitoring is common

Reference Links

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Video Transcript

Hey there. You’ve gotten Meg again. Today we’re going to talk about prostate cancer, which is one of the most common cancers and adult males in the U S so let’s go ahead and get started behind skin cancer. Prostate cancer is the second most common cancer in males. What that means is that one in nine males is going to get prostate cancer sometime in their lifetime. That’s almost 10% the important thing to know is that while it’s common, the treatment depends very much on the patient’s entire picture. We want to know their age as well as the grade of their tumor and that helps us to more accurately pinpoint their life expectancy and then we have fertility and sexuality. Now, this is a growing field in oncology right now. We call it oncofertility and I only expect this to get more and more popular and more used by our patients in the coming years.

The reason that fertility and sexuality are important in prostate cancer is if we look at our patient’s anatomy over here, this is the prostate. And you can see that it’s intricately involved, not only with the patient’s bladder, which is where we get a lot of symptoms but also with seminal vesicles and the male reproductive system in general. So a lot of the treatments that we’re gonna talk about are going to someway potentially alter the patient’s fertility or their sexuality. And so that’s something that we want to have in the back of our minds every time we’re having a conversation with one of these patients.

So let’s first talk about, uh, the risk factors for prostate cancer and how we can prevent it. Now, unfortunately, most of their risk factors for prostate cancer, like other cancers are non-modifiable. That means there’s not a whole lot that the patient can really handle or do about it. So when we talk about the patient’s age, their descent, or their family history, these are all non-modifiable. The one risk factor that we do know the patient can change is their diet. So when we talk about a, a preventative diet for a patient at high risk of prostate cancer, we’re talking about one that’s high in vegetables and therefore low in red meats and those sorts of things. And then also, um, when we’re trying to prevent any disease, we want our patients to be at a healthy weight. So we know sort of what causes prostate cancer, how we can prevent it.

Let’s talk about the way that patients are actually gonna look. So, um, unlike some other cancers, there’s really no hard and fast rule for how um, a provider should screen a patient for prostate cancer when they should do it. But the two things that we do know that are common risk factors are going to be age greater than 50 and family history. So those were the two things that we’re going to take into consideration. The main symptom in early-stage prostate cancer is going to be urinary changes. These are for the most part related to an enlarged prostate. So having an enlarged prostate in and of itself does not mean that the patient has cancer, can be indicative of benign prostate. Hypertrophy or BPH. Um, but those symptoms of an enlarged prostate are going to be hematuria. So blood in the urine can have dis urea, which is painful urination and knocked urea which is having to get up and urinate at night.

Those symptoms let us know this patient has an enlarged prostate. We need to look into this further. When we have a patient that presents with late-stage prostate cancer at, that’s when we’re going to have hip and back pain and this is typically related to one of three things. So we have a hip and back pain in a patient. It can be from a tumor burden, which is to say that the tumor is compressing somewhere in those areas. It can be from the swelling of lymph nodes. Those can get very, very swollen down in that pelvic region and cause a lot of tenderness and discomfort. And then we also have bone Mets. So having metastasis to the pelvis, the spine, any of the bony structures near the patient’s pelvis is very common and that is going to be indicative of late stage disease. When we talk about the way that we’re going to assess and screen for prostate cancer, we’ve got two steps here.

It’s important that we first do the PSA or the prostate-specific antigen, so you can consider this my PSA, PSA. So PSA, prostate-specific antigen. What that means is it’s an antigen that we can measure that we know is specific to the prostate gland. So say for example, that we remove our patient’s prostate surgically. It’s called a Terp, transurethral resection of the prostate. If we’ve taken the patient’s prostate out and then we measure their PSA, that means that somewhere in that patient’s body we have residual prostate cells or prostate cancer cells. So think of it that way. Theoretically, if we removed a patient’s prostate, they shouldn’t have PSA levels, right? So if they do, we know there’s a residual disease that can be either myths or that can be that a couple of cancer cells got left behind during that surgery. The second way that we’re going to assess for prostate cancer is going to be a digital rectal exam.

This is one of those things when we talk about not having a hard and fast rule, there is no hard and fast rule on when providers should be performing digital rectal exams or D R ease on male patients. There’s just not, the important thing to remember is if we have a patient that we’re worried about having prostate cancer, we absolutely must do the PSA level first because once we do a digital rectal exam and manually assess the prostate, that releases PSIS into the bloodstream and can give us a false positive. So it’s important that we do the PSA level first followed beat by the DRG, D R. E excuse me. So the other thing to remember is that we need that baseline PSA because that is what we are going to judge all future PSA levels, um, as the patient goes through their care continuum. So it’s very common that a patient has a PSA drawn.

Um, sometimes before every chemo infusion, before or after surgery, every couple of appointments if they’re getting radiation, that sort of thing. So we need a baseline PSA and ongoing and that’s going to let us know how the treatment is working for that patient. So let’s talk about life expectancy because this is a question that comes up whenever a cancer diagnosis is introduced to a patient. The thing to know about life expectancy, in this case, is that it is highly, highly patient-specific. So it’s dependent on the patient’s age at the time of diagnosis, the staging, which has it spread and the grade, which is how fast the cancer cells are growing. The reason this is important is that say we have a 90-year-old patient with a low-grade tumor, which means this 90 year old man has uh, prostate cancer cells that aren’t growing that fast.

What that means when we do our risk-benefit analysis for that patient is that putting the patient through the uncomfortable therapies that we do for patients with cancer could actually cause more harm than good for him. He’s 90 years old. Um, some patients will live, um, with prostate cancer for years if it’s low grade. So we always need to consider that in general though, our five year life expectancy for a patient with either um, local Mets or a low grade tumor, so slow growing tumor is 100% or almost a hundred percent, I should say. However, when we talk about distant Mets or a high grade tumor, the life expectancy drops to 30%. And this is why when a patient is asking about life expectancy with any cancer, but especially with prostate cancer, it’s important that we let the patient know it’s difficult to pinpoint and until we have more information, um, the physician is not going to be able to make that determination. And then finally on the location of where those Mets are also helps to guide the care. So we’ve talked a little bit about local Mets, um, but then also distant Mets like long brain and liver. So let’s write those down. Lung, brain, liver, um, that, that could drastically change that patient’s care plan. So we need to take all of those things that can take into consideration when we’re thinking about life expectancy and the care plan in general.

Let’s touch on treatment modalities. Um, so most of us know by now that a common treatment for any side of sort of cancer could be chemotherapy. It could be radiation, it could be surgery. And then in this case, because we’re dealing with something that is often fed by Tosca, testosterone or androgens, we might also talk about hormone therapy. So let’s talk about the benefits of targeted versus systemic therapy. Systemic therapy is going to go into the patient’s bloodstream and circulate through their entire body. So systemic is a necessity for metastatic disease. And then, um, targeted therapy or sometimes called regional localized, that sort of thing. Um, targeted therapies like radiation and surgery, those are great for the local cancers. Now, if we have a patient with prostate cancer that has ms task decides to the lungs, we might still take out their prostate. So we might do a combination of targeted therapy and a systemic therapy. So all of this, again, it’s gonna depend on the patient’s age, what we know about the tumor and what the patient’s goals are for their, their plan of care. We take all of those things into consideration.

And then finally we have fertility and sexuality. Um, this is what we call collectively oncofertility. This is a huge area of growth in oncology right now, both for men and women undergoing treatment for cancers in general, but especially those related to the reproductive organs. The reason this is important is that we talked about male anatomy. So first of all, the prostate is very close to not only the male urinary tract but also the male reproductive organs. So not only can the tumor itself affects the males, fertility, and sexuality, but a lot of the treatments can also impact that as well. We also need to talk about the patient’s sexuality. So, um, because prostate cancer is more common in males over the age of 50, um, not all of them are as concerned about fertility because they’re past the typical childbearing age.

However, when we talk about treating the whole patient, um, and really holistic patient centered care, sexuality is something that is very important for a lot of adult relationships. So making sure that we’re meeting our patients’ needs, they’re answering their questions and helping them understand the impact that it could have. It’s incredibly important. The other reason that prostate cancer is important to loop in oncofertility is going to be the hormone therapy. When we talk about hormone therapy, we’re typically suppressing testosterone. So this can greatly, greatly alter the male sex drive and can be something that at the very least we need to make the patient aware of, but can also impact the patient’s decision to go through with that sort of therapy. And then finally, when we’re talking about sexuality or any difficult patient, um, conversation to have, it’s underreported and it’s under assessed because not only are patients uncomfortable bringing it up, so we’re health care providers, we’re human. So we need to be aware of the things that concern us so that we are aware of the way that we will react to these conversations. And so that we can prepare ourselves to have them with our patients.

Okay. So let’s do our nursing concepts for a patient with prostate cancer. First we have coping. This is because prostate cancer is an oncology diagnosis. So not only are we dealing with the fact that the patient has cancer, but with the fact that it can impact their fertility and their sexuality. So then we have sexuality, we can have changes in sex drive, we can have difficulty achieving an erection, and it can just, in general, impair that patient’s relationship with their partner. And then finally we have an elimination because not only is difficulty urinating a sign of prostate cancer, but treatment can also impact the patient’s ability to eliminate urine. This is incredibly disruptive to daily life. And so it’s very important that we’re assessing that on a regular basis with our patients.

Okay. And then finally, our key points, life expectancy. I have that first because remember, it varies widely and we need to make sure that our patients’ expectations are realistic. Next, we have treatment modalities because no two patients are the same and no two cancers are the same. So having a really good understanding of the treatment modalities is important. We have sexuality and fertility. We can’t be shy when we discuss these topics with our patients. And then finally we have symptom management. This is always important with any diagnosis, but especially in oncology patients because we want to cure or treat our patient’s cancer, but we cannot do so at the expense of their quality of life.

Okay. So that is all for our lesson on prostate cancer. So go out, be your best selves today, and as always, happy nursing.

 

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