Prostate Cancer

Question 1

What is the pathophysiology of prostate cancer?

Answer 1

Testosterone and dihydrotestosterone (DHT) are the major androgens (male hormones) in the adult male. Testosterone is produced by the testis and circulates in the blood. DHT is a testosterone derivative in the prostate gland. In some patients, the prostate grows very rapidly, leading to noncancerous high-grade prostatic intraepithelial neoplasia (PIN). This impairment of cellular regulation causes men to be at a higher risk for developing prostate cancer than men who do not have that growth pattern.
Many prostate tumors are androgen-sensitive. Most are adenocarcinomas and arise from epithelial cells located in the posterior lobe or outer portion of the gland. Of all malignancies, prostate cancer is one of the slowest growing, and it metastasizes in a predictable pattern. Common sites of metastasis are the nearby lymph nodes, and bones, although it can also metastasize to the lungs or liver. The bones of the pelvis, sacrum, and lumbar spine are most often affected.

Question 2

What risk factors are associated with prostate cancer?

Answer 2

• Advanced age is the leading risk factor
• First-degree relative with the disease
• African American men
• Diet high in animal fat and dairy

Question 3

What needs to be taught to the patient regarding prevention?

Answer 3

Teach men to eat a healthy, balanced diet, including decreasing animal fat (e.g., red meat) and the intake of dairy products. Also reinforce the need to increase fruits and vegetables—especially tomatoes, which are high in lycopene. Soy contains phytoestrogens that are thought to be helpful in reducing the risk for prostate cancer

Question 4

What information should the nurse gather when obtaining history from the patient?

Answer 4

• Assess the patient’s age, race/ethnicity, and family history of prostate cancer.
• Ask about his nutritional habits, especially focusing on the intake of red meat and dairy products as a source of concern.
• Recognize that in early prostate cancer, there are often no signs or symptoms experienced by the patient.
• Assess whether the patient has existing or new problems with urinary elimination.
• Take a drug history to determine if he is taking any medication that could affect voiding.
• The first symptoms that the man may notice and report are related to bladder outlet obstruction (BOO), such as difficulty in starting urination, frequent bladder infections, and urinary retention.
• Ask about urinary frequency, hematuria (blood in the urine), and nocturia.
• Ask if he has had any pain during intercourse, especially when ejaculating.
• Inquire if he has had or currently has any other pain (particularly bone pain in the hips and legs), a symptom associated with advanced prostate cancer.
• Ask him if he has had any recent unexpected weight loss.
• Take a sexual history for recent changes in sexuality, including libido or function.
• Ask about current or previous sexually transmitted infections, penile discharge, or scrotal pain or swelling.

Question 5

What is a part of the physical assessment and what are the signs and symptoms are associated with prostate cancer?

Answer 5

• Most early cancers are diagnosed while the patient is having a routine physical examination or is being treated for benign prostatic hyperplasia (BPH).
• Gross blood in the urine (hematuria) is a common sign of late prostate cancer.
• Pain in the pelvis, hips, spine, or ribs, and swollen nodes indicate advanced disease that has spread.
• Take and record the patient’s weight because unexpected weight loss is also common when the disease is advanced.
• Prepare the patient for a digital rectal examination (DRE) by the health care provider.
• A prostate that is stony hard and with palpable irregularities or indurations is suspected to be malignant.

Question 6

What is included in the psychosocial assessment?

Answer 6

• A diagnosis of any type of cancer causes fear and anxiety for most people.
• Some men, particularly African Americans, develop the disease in their 40s and 50s when they are putting their children through college, looking toward retirement in the coming years, and/or enjoying their middle years.
• Assess the reaction of the patient and family to the diagnosis.
• Men may describe their feelings as shock, fear, or anger, or a combination of these. Expect that patients usually go through the grieving process and may be in denial or depressed. Determine what support systems they have, such as family, friends, spiritual leaders, or community group support, to help them through diagnosis, treatment, and recovery.
• One of the biggest concerns the patient may have is his ability for sexual function after cancer treatment. Tell him that function will depend on the type of treatment he has. Common surgical techniques used today do not involve cutting the perineal nerves that are needed for an erection. – A dry climax may occur if the prostate is removed because it produces most of the fluid in the ejaculate.
• Refer the patient to his surgeon (urologist), sex therapist, or intimacy counselor if available.

Question 7

What labs can be done?

Answer 7

• Prostate-specific antigen (PSA) is a glycoprotein produced by the prostate. If the patient and health care provider have agreed to screening, PSA analysis can be used as a screening test for prostate cancer. Because other prostate problems also increase the PSA level, it is not specifically diagnostic for cancer. However, it is commonly used in an effort to detect cancer early. If the test is performed, the specimen should be drawn before the DRE because the examination can cause an increase in PSA as a result of prostate irritation.
• Most authoritative sources agree that the normal blood level of PSA in men younger than 50 years is less than 2.5 ng/mL. PSA levels increase to as high as 6.5 ng/mL when men reach their 70s. African-American men between the ages of 50 and 59 have a slighter higher normal value than men who are Caucasian or Asian, but the reason for this difference is not known. However, levels greater than 4 ng/mL have been noted in more than 80% of men with prostate cancer.
• An elevated PSA level should decrease a few days after a prostatectomy for cancer. An increase in the PSA level several weeks after surgery may indicate that the disease has recurred.
• Because PSA is not absolutely specific to prostate cancer, another blood test, early prostate cancer antigen (EPCA-2), may be a serum marker for prostate cancer. It can reveal changes in the prostate gland early and is a very sensitive test.

Question 8

What diagnostics are associated with prostate cancer?

Answer 8

• After assessments by DRE and PSA, most patients have a transrectal ultrasound (TRUS) of the prostate in an ambulatory care or imaging setting. Before the procedure, the health care provider uses lidocaine jelly on the ultrasound probe and/or injects lidocaine into the prostate gland to promote patient comfort. The provider inserts a small probe into the rectum and obtains a view of the prostate using sound waves. If prostate cancer is suspected, a biopsy is usually performed at that time to obtain an accurate diagnosis.
• After prostate cancer is diagnosed, the patient has additional imaging and blood studies to determine the extent of the disease. Common tests include lymph node biopsy, CT of the pelvis and abdomen, and MRI to assess the status of the pelvic and para-aortic lymph nodes. A radionuclide bone scan may be performed to detect metastatic bone disease. An enlarged liver or abnormal liver function study results indicate possible liver metastasis.
• Patients with advanced prostate cancer often have elevated levels of serum acid phosphatase. Most men with bone metastasis have elevated serum alkaline phosphatase levels and severe pain.
• As with any cancer, accurate staging and grading of prostate tumors guide monitoring and treatment planning during the course of the disease. Based on diagnostic assessment results, the cancer is staged, which can help to guide treatment choices. Table 67.2 shows how prostate cancer is staged.

Question 9

What is the priority collaborative problem?

Answer 9

Potential for cancer metastasis due to lack of, or inadequate, treatment.

Question 10

What is active surveillance and why is it done?

Answer 10

• Because prostate cancer is slow growing with late metastasis, older men who are asymptomatic and have other illnesses may choose observation without immediate active treatment, especially if the cancer is at an early stage. This option is known as active surveillance (AS). This form of treatment involves initial surveillance with active treatment only if the symptoms become bothersome. The average time from diagnosis to start of treatment is up to 10 years. During the AS period, men are monitored at regular intervals through DRE and PSA testing. Factors that are considered in choosing AS include potential side effects of treatment (e.g., urinary incontinence, erectile dysfunction), estimated life expectancy, the presence of comorbid medical conditions, and the risk for increased morbidity and mortality from not seeking active treatment.
• Patients who have very early–stage cancer of the prostate who choose AS require close follow-up by their primary health care provider. If obstruction occurs, a transurethral resection of the prostate (TURP) may be done.
• Specific management is based on the extent of the disease and the patient’s physical condition. The patient may undergo surgery for a biopsy (if not previously done), staging and removal of the tumor, or palliation to control the spread of disease or relieve distressing symptoms. As with AS, the health care provider and patient must weigh the benefits of treatment against potential adverse effects such as incontinence and erectile dysfunction (ED).

Question 11

What are some nonsurgical management options?

Answer 11

• Radiation therapy. External or internal radiation therapy may be used in the treatment of prostate cancer or as salvage treatments when cancer recurs. It may also be done for palliation of the patient’s symptoms.
• External beam radiation therapy (EBRT) comes from a source outside the body. Patients are usually treated 5 days a week for a minimum of several weeks. EBRT can also be used to relieve pain from bone metastasis. Three-dimensional conformal radiation therapy (3D-CRT) can more accurately target prostate tissue and reduce damage to nearby organs and tissue. An advanced type of 3D-CRT radiation is intensity-modulated radiation therapy, which provides very high doses to the prostate. It is the most commonly used type of external beam radiation therapy for prostate cancer.
• Radiation proctitis may also develop but is less likely with 3D-CRT. Radiation that has irritated the rectum can cause urgency and cramping, which leads to rectal leakage. Teach him to report these symptoms to the health care provider. Like cystitis, this problem usually resolves 4 to 6 weeks after the treatment stops, although in rare cases it is permanent. If proctitis occurs, teach patients to limit spicy or fatty foods, caffeine, and dairy products.
• Low-dose brachytherapy is a type of internal radiation that is delivered by implanting low-dose radiation “seeds” (the size of a grain of rice) directly into the prostate gland. This treatment involves transrectal ultrasound, CT scans, or MRI, which are used to guide implantation of the seeds. These procedures are usually done on an ambulatory care basis under spinal or general anesthesia, and are the most cost-effective treatment for early-stage prostate cancer.
• Reassure the patient that the dose of radiation is low and that the radiation will not pose a hazard to him or others. Teach him that ED, urinary incontinence, and rectal problems do occur in a small percentage of cases. Fatigue is also common and may last for several months after the treatment stops.
• Drug therapy. Drug therapy may consist of either hormone therapy (androgen deprivation therapy [ADT]) or chemotherapy. Because most prostate tumors are hormone dependent, patients with extensive tumors or those with metastatic disease may be managed by androgen deprivation. Luteinizing hormone–releasing hormone (LHRH) agonists or antiandrogens can be used.
• LHRH agonists available in the United States include leuprolide, goserelin, histrelin, and triptorelin. These drugs first stimulate the pituitary gland to release luteinizing hormone (LH). After about 3 weeks, the pituitary gland is depleted of LH, which reduces testosterone production by the testes. Leuprolide is used most commonly for advanced prostate cancer with the goal of palliation

Question 12

What should the nurse teach the patient regarding external beam radiation?

Answer 12

Teach patients that external beam radiation causes ED in many men well after the treatment is completed. Remind the patient that other complications from EBRT include urinary frequency, diarrhea, and acute radiation cystitis, which causes persistent pain and hematuria. Symptoms are usually mild to moderate and subside 6 weeks after treatment, although there is a rare chance that this will not go away. Teach the patient to avoid caffeine and continue drinking plenty of water and other fluids.

Question 13

What are other nonsurgical management interventions?

Answer 13

• Antiandrogen drugs, also known as androgen deprivation therapy (ADT), work differently in that they block the body’s ability to use the available androgens. These drugs are the major treatment for metastatic disease. Examples include flutamide, bicalutamide, and nilutamide. They inhibit tumor progression by blocking the uptake of testicular and adrenal androgens at the prostate tumor site. Patients should be taught to follow closely with their health care provider and to undergo all laboratory testing as prescribed. These medications increase the risk for liver toxicity. Regular liver functions tests will be ordered at baseline, monthly during the first 4 months, and periodically thereafter.
• Antiandrogens may be used alone or in combination with LHRH agonists for total or maximal androgen blockade (hormone ablation).
  Systemic chemotherapy may be an option for patients whose cancer has spread and for whom other therapies have not worked. For example, small cell prostate cancer is rare and is more responsive to chemotherapy than to hormone therapy. The goal of therapy is not curative; it is to slow the cancer’s growth so that the patient experiences a better quality of life.

Question 14

What surgical interventions are associated with ;prostate cancer?

Answer 14

• For the LRP procedure, the patient is placed in lithotomy positioning with steep Trendelenburg. The urologist makes one or more small punctures or incisions into the abdomen. A laparoscope with a camera on the end is inserted through one of the incisions while other instruments are inserted into the other incisions. The robotic system may be used to control the movement of the instruments by a remote device. The prostate is removed along with nearby lymph nodes, but perineal nerves are not affected.
• The open radical prostatectomy can be performed via several surgical approaches, depending on the patient’s desired outcomes and the staging of the disease. The perineal and retropubic (nerve-sparing) approaches are most commonly used. The surgeon removes the entire prostate gland along with the prostatic capsule, the cuff at the bladder neck, the seminal vesicles, and the regional lymph nodes. The remaining urethra is connected to the bladder neck. The removal of tissue at the bladder neck allows the seminal fluid to travel upward into the bladder rather than down the urethral tract, resulting in retrograde ejaculation.

Question 15

What preoperative care should be done?

Answer 15

Preoperative care depends on the type of surgery that will be done. Minimally invasive surgery (MIS) is most appropriate for localized prostate cancer and is used as a curative intervention. The most common procedure is the laparoscopic radical prostatectomy (LRP), often done with robotic assistance. Other procedures include transrectal high-intensity focused ultrasound (HIFU) and cryotherapy.

Patients who qualify for LRP must have a PSA less than 10 ng/mL and have had no previous hormone therapy or abdominal surgeries. Remind the patient that the advantages of this procedure over open surgery include:

• Decreased hospital stay (1 to 2 days)
• Minimal bleeding
• Smaller or no incisions and less scarring
• Less postoperative discomfort
• Decreased time for urinary catheter placement (usually removed on third postoperative day)
• Fewer complications
• Faster recovery and return to usual activities
• Nerve-sparing advantages

Question 16

What postoperative care should be done?

Answer 16

• Providing postoperative care of the patient after an open radical prostatectomy includes maintaining hydration, caring for wound drains (open procedure), managing pain, and preventing pulmonary complications are important aspects of nursing care.
• Assess the patient’s pain level and monitor the effectiveness of pain management with opioids given as patient-controlled analgesia (PCA), a common method of delivery during the first 24 hours after surgery. Administer a stool softener if needed to prevent possible constipation from the drugs.
• The patient has an indwelling urinary catheter to straight drainage to promote urinary elimination. Monitor intake and output every shift and record or delegate this activity to assistive personnel (AP), as this is a task that is within an AP’s scope that can effectively and quickly be reported back to the nurse. An antispasmodic may be prescribed to decrease bladder spasm induced by the indwelling urinary catheter. The time for catheter removal depends on the type of procedure that is performed and overall patient condition. Those who undergo the laparoscopic prostatectomy usually have the catheter in place until the third postoperative day. Those who had open surgical procedures use the catheter for 7 to 10 days or longer.
• Ambulation should begin no later than the day after surgery. Provide assistance in walking the patient when he first gets out of bed. Assess for scrotal or penile swelling from the disrupted pelvic lymph flow. If this occurs, elevate the scrotum and penis and apply ice to the area intermittently for the first 24 to 48 hours.
• Many patients who have the minimally invasive techniques are discharged 1 to 2 days after surgery and can resume usual activities in about a week or two. Those who have open procedures are discharged in 2 to 3 days or longer, depending on their progress.
• Remind patients that common potential long-term complications of open radical prostatectomy are erectile dysfunction (ED) and urinary incontinence. For ED, drugs such as sildenafil may be effective. Urge incontinence may occur because the internal and external sphincters of the bladder lie close to the prostate gland and are often damaged during the surgery. Kegel perineal exercises may reduce the severity of urinary incontinence after radical prostatectomy.
• Teach the patient to contract and relax the perineal and gluteal muscles in several ways. For one of the exercises, teach him to:
  1. Tighten the perineal muscles for 3 to 5 seconds as if to prevent voiding, and then relax
  2. Bear down (but not to strain) as if having a bowel movement
  3. Relax and repeat the exercise
• Show him how to inhale through pursed lips while tightening the perineal muscles and how to exhale when he relaxes. He may also sit on the toilet with the knees apart while voiding and start and stop the stream several times.

Question 17

What are some points of care for the patient after an open radical prostatectomy?

Answer 17

• Encourage the patient to use patient-controlled analgesia (PCA) as needed.
• Help the patient get out of bed into a chair on the night of surgery and ambulate by the next day.
• Maintain the sequential compression device until the patient begins to ambulate.
• Monitor the patient for venous thromboembolism and pulmonary embolus.
• Keep an accurate record of intake and output, including drainage from a Jackson-Pratt or other drainage device.
• Keep the urinary meatus clean using soap and water.
• Avoid rectal procedures or treatments.
• Teach the patient how to care for the urinary catheter because he may be discharged with the catheter in place.
• Teach the patient how to use a leg bag.
• Emphasize the importance of not straining during a bowel movement yet to avoid suppositories or enemas.
• Remind the patient about the importance of follow-up appointments with the surgeon and oncologist to monitor progress.

Question 18

What are some home care management tips that the patient should be educated about?

Answer 18

Discharge planning and health teaching start early, even before surgery. A patient can better plan home care management when he knows what to expect. Collaborate with the case manager to coordinate the efforts of various health care providers, surgical unit nursing staff, and possibly a home nurse. As specified by The Joint Commission and other accrediting agencies, continuity of care is essential when caring for this patient because he may need weeks or months of therapies.

Question 19

What is included in self-management education?

Answer 19

• An important area of teaching for the patient going home is urinary catheter care. An indwelling urinary catheter may be in place for 3 days for the patient who had an LRP, or up to several weeks for the patient who underwent an open radical prostatectomy. Teach him and his partner how to care for the catheter, use a leg bag, and identify signs and symptoms of infection and other complications.
• Encourage the patient to walk short distances. Lifting may be restricted to no more than a milk jug for up to 6 weeks if an open procedure was done. Remind him to maintain an upright position and not to walk bent or flexed. Vigorous exercise such as running or jumping should be avoided for at least 6 weeks and then gradually introduced. By contrast, patients having the minimally invasive laparoscopic surgery can usually return to work or usual activities in about a week.
• Teach the patient not to strain to defecate. A stool softener may be prescribed to reduce the need for straining. If an opioid is prescribed for pain management, encourage the patient to drink adequate water to prevent constipation.
• If the patient had an open radical prostatectomy, teach him to adhere to the surgeon’s recommendation for when he can first shower and to continue showering for the first 2 to 3 weeks rather than soak in a bathtub. Patients who had a laparoscopic procedure can usually shower in 1 to 2 days. Teach them to remove the small bandage but leave the wound closure tape in place and allow it to fall off naturally in about a week. Show patients how to inspect the incision or puncture site(s) daily for signs of infection. Remind them to keep all follow-up appointments. PSA blood tests are performed 6 weeks after surgery and then every 4 to 6 months to monitor progress.

Question 20

What should the nurse educate the patient on regarding urinary catheter care at home?

Answer 20

Once a day, gently wash the first few inches of the catheter, starting at the penis and washing outward with mild soap and water.

Rinse and dry the catheter well.

If you have not been circumcised, push the foreskin back to clean the catheter site; when finished, push the foreskin forward.

Change the drainage bag at least once a week as needed:
- Hold the catheter with one hand and the tubing with the other hand and twist in opposite directions to disconnect.
- Place the end of the catheter in a clean container to catch leakage of urine.
- Remove the rubber cap from the tubing of the leg bag or clean drainage bag.
- Clean the end of the new tubing with alcohol swabs.
- Insert the end of the new tubing into the catheter and twist to connect securely.
- Clean the drainage bag just removed by pouring a solution of one part vinegar to two parts water through the tubing and bag. Rinse well with water and allow the bag to dry.

Question 21

How is prostate cancer staged? What does each stage mean?

Answer 21

Stage 0
- Description: No evidence of a primary tumor
- Metastasis: N/A

Stage 1
- Description: Tumor not detectable by digital rectal examination (DRE) cannot be seen on imaging studies.
- Metastasis: No

Stage 2
- Description: Tumor detected by DRE; present only in prostate.
- Metastasis: No

Stage 3
- Description: Tumor extends outside of prostate and possibly to seminal vesicles.
- Metastasis: No

Stage 4
- Description: Tumor has spread to tissues near the prostate and beyond seminal vesicles, such as bladder or pelvis wall.
- Metastasis: Yes