Focus on Prostate Cancer (Relates to Chapter 55, “Nursing Management: Male Reproductive...

Focus onProstate Cancer

(Relates to Chapter 55, “Nursing Management:

Male Reproductive Problems,” in the textbook)

Significance

Malignant tumor of the prostate

Estimated 192,280 new cases diagnosed and 27,360 deaths annually

1 in every 5 men will develop it in their lifetime.

Etiology and Pathophysiology

Androgen-dependent adenocarcinoma

Majority of tumors occur in outer aspect of the gland.

Usually slow growing

Spreads by three routesDirect extensionThrough lymph systemThrough bloodstream

Direct extension involves seminal vesicles, urethral mucosa, bladder wall, and external sphincter.

Cancer later spreads through lymphatic system to the regional lymph nodes.

Veins from the prostate seem to be mode of spread toPelvic bonesHead of femurLower lumbar spineLiverLungs

Age, ethnicity, and family history are nonmodifiable risk factors.

Incidence rises markedly after age 50.

African Americans have highest incidence.

Having a first-degree relative with prostate cancer increases risk.

High-fat diet is associated with increased risk.

Exposure to certain chemicals may be associated with higher risk.

History of BPH is NOT a risk factor.

Clinical Manifestations

Usually asymptomatic in early stages

Eventually may experience symptoms similar to BPHDysuriaHesitancyDribblingFrequency

Clinical Manifestations

Symptoms similar to BPHUrgency HematuriaNocturiaRetention Interruption of urinary

streamInability to urinate

Clinical ManifestationsPain in lumbosacral area that

radiates to hips or legs, when coupled with urinary symptoms, could indicate metastasis.

Once cancer has spread to distant sites, pain management becomes major problem.

Metastasis of Prostate Cancer to the Pelvis and Lumbar Spine

Fig. 55-4. Metastasis of prostate cancer to the pelvis and lumbar spine.

Diagnostic Studies

Two primary screening toolsPSA (prostate-specific antigen)

blood test•Elevated levels indicate prostatic pathology—not necessarily cancer.•Marker of tumor volume when cancer exists•Also used to monitor success of treatment

Diagnostic Studies

Two primary screening toolsDRE (digital rectal

examination)•Abnormal prostate findings include hardness, nodular and asymmetric.

Diagnostic Studies

Elevated levels of PAP (prostatic acid phosphatase) also indicate prostate cancer.

Diagnostic Studies

Neither a PSA nor DRE is a definitive diagnostic test.

Biopsy of prostate tissue is necessary to confirm diagnosis.Done using TRUS to allow

physician to visualize and pinpoint abnormalities

Diagnostic Studies

Bone scan, CT, MRI with endorectal probe, and TRUS are used to determine location and spread.

Collaborative Care

Whitmore-Jewett and tumor, node, metastasis (TNM) system used to stage prostate cancerBased on size (volume) and

spread

Collaborative Care

Grading of tumor is done using 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.

Collaborative Care

Conservative therapyWatchful waiting when•Life expectancy is less than 10 years•Presence of low-grade, low-stage tumor

Collaborative Care

Surgical therapyRadical prostatectomy•Entire gland, seminal vesicles, and part of bladder neck are moved.•Retroperineal lymph node dissection usually is done.•Considered most effective for long-term survival

Prostatectomy

Fig. 55-5. Common approaches used to perform a prostatectomy. A, Retropubic approach involves a midlineabdominal incision. B, Perineal approach involves an incision between the scrotum and anus.

Collaborative Care

Radical prostatectomy •Patient catheterized for a couple of days•Stay in hospital for 1 to 3 days•Major complications are erectile dysfunction and incontinence.

Collaborative Care

Other complications of radical prostatectomyHemorrhageUrinary retentionInfectionWound dehiscenceDVTPulmonary emboli

Collaborative Care

Nerve-sparing surgical procedureSpares nerves responsible

for erectionOnly for cancer confined to

prostateNo guarantee that potency

will be maintained

Collaborative Care

CryosurgerySurgical technique that

destroys cancer cells by freezing the tissue

Initial and second-line treatment after radiation fails

Collaborative Care

CryosurgeryComplications include damage

to urethra, urethrorectal fistula, and urethrocutaneous fistula.

Tissue sloughing, ED, urinary incontinence, prostatitis, and hemorrhage have also been reported.

Collaborative Care

Radiation therapyExternal 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.

Collaborative Care

Radiation therapyBrachytherapy •Implantation of radioactive seed into prostate gland•Spares surrounding tissue•Placement guided by transrectal ultrasound

Brachytherapy

Fig. 55-6. A, Prostate brachytherapy. Implantation of seeds with a needle guided by ultrasound and atemplate grid. B, Radioactive seeds.

Collaborative Care

Brachytherapy (cont’d)•Best suited for stage A or B•Irritative or obstructive urinary problems are common side effects.

Collaborative Care

Drug therapyHormonal therapy•Androgen deprivation is primary therapeutic approach.•Focused on reducing levels of androgens to reduce tumor growth•Can be used before surgery or radiation to reduce tumor size and in advanced disease

Collaborative Care

Hormone therapy“Hormone refractory”•Tumors become resistant to therapy within a few years.•Elevated PSA level is often first sign that therapy is no longer effective.

Collaborative Care

Types of hormonal therapyLuteinizing hormone–

releasing hormone agonists Androgen receptor blockersEstrogen

Collaborative CareLuteinizing hormone–releasing

hormone agonists With continued administration, LH

and testosterone levels decrease.Produces a chemical castration

similar to orchiectomySide effects include hot flashes,

gynecomastia, loss of libido, and ED.

Collaborative Care

Androgen receptor blockersCompete with circulating

androgens at receptor sitesCan be combined with LH-RH

agonistsSide effects include loss of

libido, ED, hot flashes, breast pain, and gynecomastia.

Collaborative Care

EstrogenUsed as a form of androgen

deprivation therapyDeclining because of

cardiovascular complications (MI, DVT, cerebrovascular disease) and new therapies

Collaborative Care

OrchiectomySurgical removal of testes

for advanced stages of prostate cancer

May be done alone or with prostatectomy

Collaborative Care

OrchiectomyReduces circulating

testosterone by 90%Side effects include hot

flashes, ED, loss of libido, irritability, weight gain, loss of muscle mass, and osteoporosis.

Collaborative Care

ChemotherapyPrimarily limited to

treatment for those with hormone-resistant prostate cancer (HRPC) in late stages

Goal is palliation, as prostate cancer has responded poorly to chemotherapy.

Nursing AssessmentHealth history

Medications, especially testosterone supplements, morphine, anticholinergics, monoamine oxidase inhibitors and tricyclic antidepressants

Family historyHigh-fat diet, anorexia, weight

Nursing Assessment

Health historyUrinary urgency, frequency,

retention with dribbling, hematuria, nocturia

Dysuria, low back pain radiating to legs or pelvis, bone pain

Nursing AssessmentObjective data

Anxiety Distended bladder on palpation;

unilaterally hard, enlarged fixed prostate on rectal examination

High PSA, PAP nodular irregularities on ultrasonography, positive biopsy results, anemia

Nursing Diagnoses

Decisional conflictAcute pain Urinary retentionImpaired urinary

elimination

Nursing Diagnoses

ConstipationDiarrheaSexual dysfunctionAnxiety

Planning

Will be active participant in therapeutic plan

Will have satisfactory pain control

Will follow therapeutic plan on sexual dysfunction

Planning

Understand the effect of treatment on sexual function.

Find a satisfactory way to manage impact on bladder or bowel function.

Nursing Implementation

Encourage DRE and PSA screenings.

Provide sensitive, caring support to patient and family.

Encourage joining a support group and seeking information.

Nursing Implementation

Teach catheter care.Teach pelvic floor

exercises.Administer pain

medication.

Evaluation

Actively participate in treatment plan

Have satisfactory pain control

Follow therapeutic plan

Evaluation

Accept effect of treatment on sexual function

Find satisfactory way to manage impact on bladder or bowel function

After radical perineal prostatectomy for advanced cancer of the prostate, the priority nursing diagnosis for the patient is:

1. Risk for infection.2. Risk for situational low self-esteem.3. Sexual dysfunction.4. Total urinary incontinence.

Audience Response Question

Case Study

70-year-old man presents to clinic with urinary urgency, difficulty initiating stream, and urinary retention.

Case Study

Symptoms began 6 months ago.

His last PSA with digital rectal examination was 10 years ago.Results were normal.

Case Study

Current digital rectal examination finds the prostate hard and nodular.

His current PSA is 12 ng/mL.

Case Study

A biopsy is performed and indicates cancer.

He decides to undergo radical prostatectomy.

Discussion Questions

1. What should you tell him about the surgical procedure?

2. What side effects of the treatment should he be aware of?

Discussion Questions

3. You notice that he is embarrassed to discuss sexual dysfunction. What approach should you take?

Focus on Prostate Cancer (Relates to Chapter 55, “Nursing Management: Male Reproductive...

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