What your patient needs to know about prostate cancer
December 2002
Volume 32 Number 12
Page 36

What your patient needs to know about prostate cancer
This disease can range from indolent to aggressive. Find out about testing, treatment, and patient teaching.

ISAIAH HARVEY, a 45-year-old African-American man, has scheduled a checkup with a urologist. His brother was recently diagnosed with prostate cancer, and he wants to learn more about his own risk for this disease and its treatment options. If he asked for your advice about screening, what would you tell him?

Because more men are living longer and the incidence of prostate cancer increases with age, prostate cancer is becoming a significant health issue. The most common cancer diagnosed in men, prostate cancer is the second leading cause of cancer-related deaths in the United States. The American Cancer Society estimates that 189,000 new prostate cancers will be diagnosed and 30,200 men will die of the disease in 2002.

The prostate is located in the pelvis, in front of the rectum and under the bladder. It's broader at the base than at the apex. The urethra passes through the gland. The prostatic capsule surrounding the gland is weakest at the base and apex and absent at the bladder.

A man like Mr. Harvey who has a family history of the disease is wise to initiate screening at a relatively young age. In this article, I'll review other risk factors, treatment options, and nursing interventions that will help you teach and care for an adult patient with an actual or potential prostate cancer diagnosis.

The prostate is composed of three zones. The transitional zone surrounds the prostatic urethra, and the cone-shaped central zone sits behind it. The transitional zone is a common site for benign prostatic hyperplasia (BPH).

The peripheral zone , which surrounds the other zones, is the largest portion of the gland and the most common site for cancer development. The blood supply and nerves run posterior and lateral to the gland. Lymph nodes that drain the prostate include the obturator, internal iliac, and presacral and external iliac nodes. Most early tumors produce no symptoms because the urethra isn't in the peripheral zone. But as the tumor grows, it may produce symptoms of bladder outlet obstruction, which are often also seen in BPH. Tumors originating in the transitional zone, which houses the urethra, may cause these symptoms sooner.

As the tumor continues to grow, cancer extends into the seminal vesicles, bladder, rectum, and lymph nodes. Seminal vesicle involvement often predicts lymph node spread. As the tumor spreads to the nerves, impotence may occur. Metastasis to the bones causes bone pain. With spinal involvement comes the risk of spinal cord compression and paralysis. Other symptoms of metastatic disease include anemia, weight loss, and lymphedema of the lower extremities and scrotum.

Finding cancer faster
In the past, prostate cancer was typically diagnosed after the disease had advanced and was causing symptoms such as bone pain or the inability to urinate. But since the advent of prostate-specific antigen (PSA) testing, men are being diagnosed with prostate cancer when the disease is less advanced and more curable, giving them more treatment options.

Not all prostate cancers are fast-growing and life-threatening. An elderly man with a slow-growing prostate cancer may eventually die naturally from another medical problem. For health care providers, the challenge is to determine which patients would benefit from aggressive treatment and which patients would suffer a loss in the quality of life with no extension of their life span.

Who's at risk?
Mr. Harvey has two risk factors for prostate cancer: He's African-American and has a first-degree relative (father, brother, son) with the disease. African-Americans have the highest incidence of prostate cancer in the world, followed by whites. And the more first-degree family members affected, the greater the patient's risk of prostate cancer. Researchers believe that about 9% of prostate cancers have a genetic cause.

The incidence of prostate cancer increases in men over age 50 and is most common in men over age 60. Other risk factors include hormones, a high-fat diet, low socioeconomic status, low levels of vitamins or selenium, multiple sexual partners, viruses, and occupations with exposure to chemicals, cadmium, and other metals.

Screening for problems
The American Cancer Society, American Urological Association, and American College of Radiology recommend that men age 50 and older with a life expectancy of more than 10 years have a yearly PSA level and digital rectal exam (DRE) to screen for prostate cancer. Younger men should be screened annually if they're at an increased risk for prostate cancer.

The screening process for all patients starts with a thorough history. After recording your patient's age and race, ask about:

• any first-degree family members with prostate cancer

• prior personal history of prostate problems, benign or malignant

• current use of drugs, including prescribed medications, street drugs, over-the-counter products, herbs, vitamins, and diet supplements. Some drugs affect PSA levels, which can make test results misleading or inaccurate. Others interfere with blood coagulation and must be stopped weeks prior to any procedures being performed. Anticholinergics and alpha-sympathomimetics affect bladder function and can produce symptoms such as urinary hesitancy and urine retention.

• voiding symptoms, such as dysuria, nocturia, frequency, dribbling, incontinence, hematuria, difficulty starting or stopping urine stream, and incomplete bladder emptying

• changes in erectile function

• weight loss

• bone pain, back pain, hip pain

• leg swelling

• hemospermia

• fatigue

• other urologic problems, such as infections

• prior urologic surgery.

Next, examine or assist with examining the patient for manifestations of prostate cancer, such as weight loss, lymph node enlargement, leg edema, and any physical abnormalities in the genitalia and abdomen.

The most important part of the clinical exam, the DRE involves assessing the external rectal area, checking sphincter tone, evaluating for rectal masses or abnormalities, and checking the prostate gland for symmetry, texture, size, and abnormalities. The DRE may be performed with the patient bending over an exam table or lying on his side in the knee-chest position. Abnormal findings include hardness, irregularities in symmetry, enlargement, loss of margins, and nodules. If cancer is present, DRE findings help stage the disease.

Assessing PSA levels
Prostate-specific antigen, a protein made and normally contained within the prostate gland, is responsible for liquefying semen. When the prostate's integrity is disrupted by disease or instrumentation, however, PSA escapes into the bloodstream. Usually PSA is protein-bound, but some circulates unbound. Normal PSA levels are 0 to 4 ng/ml, but values can vary based on age and race (see Looking at Typical PSA Ranges ). Conditions other than cancer can raise PSA, such as benign prostatic hyperplasia, infection, or injury from instrumentation of the prostate (for example, a needle biopsy). Because results differ from lab to lab, each patient's specimen should always be processed by the same lab. If a patient's PSA level is moderately elevated (4.1 to 10 ng/ml), he should be tested for free PSA levels.

As part of the diagnostic workup for prostate cancer, the provider may order other diagnostic tests, such as a complete blood cell (CBC) count, a free PSA level, blood urea nitrogen and creatinine levels, prostate acid phosphatase (a marker that rises with advanced disease), chest X-ray, magnetic resonance imaging, computed tomography, bone scan, or transrectal ultrasound.

A recent study found that testing blood proteins may be more specific for prostate cancer, possibly reducing unnecessary biopsies.

Following up suspicious results
Transrectal ultrasound with biopsy is indicated if DRE and PSA results suggest prostate cancer. After undergoing preprocedure bowel cleaning and receiving a dose of an antibiotic, the patient is placed in the lithotomy or side-lying position and the physician places a transrectal ultrasound probe. This lets him determine the gland's size and examine the gland for abnormal areas.

To obtain a biopsy specimen, he'll use a biopsy gun that makes a noise as it takes the specimens. The patient may experience discomfort and pain during this part of the procedure. Afterward, a urine specimen may be sent to the lab to assess for hematuria.

Teach the patient what to expect before, during, and after the procedure. He'll finish a course of antibiotics at home, so stress the importance of taking them as directed. Also teach him about possible complications. Biopsy-related adverse reactions include hematuria with clots during the first 24 hours postprocedure, bleeding or ecchymosis at the biopsy area, hemospermia, prostatitis, fever, and delayed perineal pain. Instruct him to report fever, chills, or bloody urine after the first 24 hours postprocedure and problems voiding to the physician. Finally, tell him to avoid strenuous physical activity for the first 24 hours after the procedure and to drink plenty of fluids unless contraindicated.

Looking at typical PSA ranges
The figures below are the upper limit of normal for each group in ng/ml. Because prostate-specific antigen (PSA) values vary from lab to lab, the patient's specimens should be processed by the same lab each time a test is done.

African-American Asian White
Ages 40-49 2.0 2.0 2.5
Ages 50-59 4.0 3.0 3.5
Ages 60-69 4.5 4.0 4.5
Ages 70-79 5.5 5.0 6.5

Source: "Percent Free Prostate-Specific Antigen: Entering a New Era in the Detection of Prostate Cancer," Mayo Clinic Proceedings, A. Vashi and J. Oesterling, April 1997.

Grading and staging
After the diagnosis, grading and staging identify the extent of prostate cancer and help guide treatment. The Gleason Grading System, designed to help clinicians evaluate the structure of the gland, is the most commonly used grading system. The structure of the gland is evaluated under microscope, and the two most common structural patterns are each given a grade ranging from 1 (most structurally organized and well differentiated) to 5 (poorly organized and poorly differentiated). The sum of the two grades is the score; higher scores mean greater likelihood of metastases.

The most commonly used staging system is the TNM (tumor, nodes, metastases), which describes disease extent based on tumor involvement, node size, and presence or absence of distant metastases.

Treatment options
Prostate cancer treatments range from watchful waiting to radiation, hormonal therapy, and surgery. When choosing treatment, the patient and health care provider will consider the patient's age, expected life span, comorbidities, quality of life issues such as impotence and incontinence, personal preference, Gleason score, PSA level, and clinical stage.

Patients with locally advanced disease may benefit from combined therapy; for example, hormonal and radiation therapy. Men with metastatic disease or disease relapse after therapy for localized disease may benefit from hormonal therapy or chemotherapy or be candidates for clinical trials involving new treatments.

Let's look at the various options and patient teaching for each.

Watchful waiting means periodically monitoring the patient and not starting treatment until the disease or symptoms progress. This option is suitable for men in poor health and those with multiple medical problems, short life expectancies, or clinically insignificant disease. The major risks are disease and symptom progression. The patient must maintain the schedule of follow-up visits and be taught which symptoms require prompt medical intervention.

External beam radiation therapy can be used to treat localized, locally advanced, and nodal disease, as well as metastatic lesions. With this treatment, the patient avoids surgery, but some disease may remain. Radiation may also be used after prostatectomy in locally advanced disease. Adverse reactions to radiation therapy include incontinence, impotence, diarrhea, acute cystitis, proctitis, skin changes, chronic radiation changes to bowel or bladder, fatigue, and myelosuppression.

Teach the patient the following points.

• Show him how to care for his skin, including perianal skin, and to monitor skin integrity. Explain how to use skin moisturizers and protectants. Suggest that he wear loose cotton undergarments and nonirritating outer clothing.

• Encourage a low-residue diet to help manage diarrhea. He can also use prescribed or over-the-counter antidiarrheal medication. Remind him to drink plenty of fluids and to replace lost electrolytes.

• Advise him to avoid alcohol, caffeine, spices, and tobacco, which irritate the bladder mucosa and can aggravate urinary tract symptoms.

• Teach him to recognize signs and symptoms of infection and ways to prevent infection.

• Assess him for other social issues, such as sexual dysfunction (he may need treatment for erectile dysfunction or a referral for counseling), fatigue (teach energy conservation techniques), and bone marrow depression (he'll have a CBC count weekly and as needed).

Brachytherapy involves implanting radioactive seeds in the prostate, either as monotherapy or after external beam radiation therapy. The seeds, which may be permanent or temporary, are placed while the patient receives general anesthesia. This option is suitable for older patients, those with localized disease, patients who aren't candidates for other approaches, and patients who refuse other treatments. Adverse reactions, which may be minimal when brachytherapy is used alone, include cystitis, proctitis, problems voiding, hematuria, clot retention, urine retention, and scrotal bleeding. The patient must adhere to radiation precautions, which include following the approved method of lost seed disposal and restrictions on sexual activity for 2 weeks, followed by condom use to catch seeds lost during sexual activity.

Teach the patient that hematuria typically lasts up to 3 days after seed placement. He also may notice that his semen is discolored red, brown, or black from blood.

The patient should wash his perineum daily with soap and water and use cold packs, sitz baths, and mild oral analgesics for perineal discomfort for the first day postprocedure. Tell him to call his health care provider immediately if he can't void and to report rectal bleeding, rectal irritation, gassy bowel movements, or diarrhea.

Hormonal therapies include luteinizing hormone-releasing hormone agonists (given alone or with an antiandrogen) and orchiectomy. These therapies are designed to reduce testosterone levels to castrate levels by eliminating or interfering with testosterone release or eliminating its effect on prostate cancer cells. They can be used in combination with radiation therapy for locally advanced, advanced, or metastatic disease. However, using these therapies raises psychosocial issues because they can cause gynecomastia, breast tenderness, impotence, and other adverse sexual effects. Other possible problems include osteoporosis, hot flashes, and fatigue. Increased liver function values and hepatic dysfunction may occur with antiandrogens. Anemia may occur when luteinizing hormone-releasing hormone agonists are given with radiation therapy.

Monitor the patient for symptoms of disease flare at the start of hormonal therapy. An antiandrogen administered before luteinizing hormone-releasing hormone agonist therapy can help reduce the risk of disease flare. Monitor bone mineral density at baseline and yearly (because of the risk of osteoporosis). Monitor liver function tests and assess for jaundice and signs and symptoms of hepatotoxicity. Teach the patient to stay on schedule for drug administration because complications are associated with loss of effective drug level.

Chemotherapy with antineoplastic drugs is used to treat metastatic hormone-refractory disease. Each drug causes specific adverse reactions, but bone marrow depression, fatigue, nausea and vomiting, and hair loss are common with most.

If you're caring for a patient who's undergoing chemotherapy, these nursing considerations apply:

• Monitor the patient for renal toxicity, liver toxicity, allergic reactions, hyperglycemia, appetite loss, taste changes, cardiac toxicity, constipation, diarrhea, arthralgia, and myalgia. If he has advanced or metastatic disease, also monitor him for these potential complications: bone metastases, spinal cord compression, bladder outlet obstruction, deep vein thrombosis (DVT), hydronephrosis, leg edema, and disseminated intravascular coagulation.

• Teach the patient to use antiemetics, antidiarrheals, and laxatives as indicated and to report signs and symptoms of dehydration to his health care provider.

• Assess the patient for leg edema and advise him to elevate his legs while sitting, wear support or compression stockings, and avoid standing for prolonged periods. Teach him the signs and symptoms of DVT and tell him to report redness, pain, or swelling of the legs to his health care provider.

• Monitor him for mouth sores and teach him proper oral care with soft toothbrushes and saline rinses. Advise him to avoid foods that are spicy or difficult to chew or digest.

Radical prostatectomy is the surgical removal of the prostate and surrounding tissue, usually through a retropubic or perineal approach. Candidates for this procedure should be age 70 or younger, in good health, with 10 to 20 years of life expectancy. The cancer should be localized, not metastatic. This surgery offers the patient the potential for cure, but can also result in long-term problems such as incontinence, impotence, urethral strictures, and bladder neck contractures. Possible postoperative complications include DVT, pulmonary embolism, infection, bleeding, urinary tract infection, and paralytic ileus.

Before surgery, the patient will undergo a bowel cleaning preparation, plus measures to prevent DVT (such as compression stockings). Tell him that he'll have an indwelling urinary catheter, which will remain in place when he goes home.

Teach the patient how to manage his indwelling urinary catheter, and tell him to call his health care provider if he notices signs and symptoms of infection, bleeding, fever, or clot retention with urine leakage around the catheter or if he has any problems with his indwelling urinary catheter. Tell him to avoid heavy lifting and other strenuous activity for 4 to 8 weeks. After the urinary catheter is removed, he may need products for incontinence management.

Cryosurgery freezes the tumor via probes placed in the prostate. This treatment is suitable for localized disease, locally advanced disease, or localized disease relapses. Cryosurgery requires general anesthesia and carries the risk of impotence, incontinence, proctitis, urethral sloughing, penile numbness, urine retention, fistulas, and urinary tract obstruction.

Laparoscopic prostatectomy, or laparoscopic removal of the prostate, is suitable for localized disease. Although recovery is faster than for radical prostatectomy, surgery time typically is longer, so monitor for DVT and other problems related to immobility. Complications of this surgery include impotence, incontinence, rectal injury, paralytic ileus, thrombotic events, urinary tract infections, and urethrovesical anastomotic leakage.

The patient will have an indwelling urinary catheter after this surgery, but the catheter may be removed sooner than after radical prostatectomy.

Heat ablative therapy uses microwaves, radiofrequency, high-intensity focused ultrasound, or other technologies to apply heat to the prostate and kill cancer cells. This treatment is suitable for localized disease and requires general or spinal anesthesia. Complications include impotence, fistulas, and burns. Cryosurgery, laparoscopic prostatectomy, and heat ablative therapy all are investigational.

Can anything prevent prostate cancer?
Finasteride, selenium, vitamin E, and dietary measures are a few of the potential prostate cancer preventatives being studied.

Finasteride is a 5-alpha-reductase inhibitor that interferes with the conversion of testosterone to dihydrotestosterone, the active form of testosterone that acts on prostate cells. The Prostate Cancer Chemoprevention Trial, which started in 1993, randomized patients to placebo or 5 mg of finasteride daily for 7 years. Many study participants have completed their drug therapy and have undergone prostate biopsies; results of the study are pending.

Selenium, a trace mineral with antioxidant properties, may reduce the risk of prostate cancer. A study on skin cancer prevention using selenium supplements of 200 mcg/day also found a reduced incidence of prostate cancer in study participants.

Vitamin E, another antioxidant, has been combined with selenium in the Selenium and Vitamin E Cancer Prevention Trial (SELECT), which is now recruiting patients.

Lycopenes are a carotenoid substance found in tomatoes and tomato products and sold as supplements in health food stores. Lycopenes have antioxidant activity and have been studied in relation to cancer risk for different solid tumors. Evidence regarding the ability of high lycopene consumption to reduce prostate cancer risk was found in several studies and research is ongoing.

Meeting the challenge
Caring for a patient being screened or treated for prostate cancer requires frequent nursing assessment, ongoing monitoring, comprehensive and ongoing education, and attention to long-term complications. By helping patients like Mr. Harvey understand their risks and options, you can help them preserve their health for years to come.

Abel, L., et al.: "Nursing Management of Patients Receiving Brachytherapy for Early Stage Prostate Cancer," Clinical Journal of Oncology Nursing. 3(1):7-15, January 1999.

DeKoning, H., et al.: "Large-Scale Randomized Prostate Cancer Screening Trials: Program Performances in the European Randomized Screening for Prostate Cancer Trial and the Prostate, Lung, Colorectal and Ovary Cancer Trial," International Journal of Cancer. 97(2):237-244, January 10, 2002.

Held-Warmkessel, J. (ed): Contemporary Issues in Prostate Cancer: A Nursing Perspective. Sudbury, Mass., Jones and Bartlett, 2000.

Isola, J., et al.: "Predictors of Biological Aggressiveness of Prostate Specific Antigen Screening Detected Prostate Cancer," Journal of Urology. 165(5):1569-1574, May 2001.

Kirby, R., et al.: Prostate Cancer, 2nd edition. St. Louis, Mo., Mosby (Elsevier Science Health Science Division), 2000.

Partin, A., et al.: "Contemporary Update of Prostate Cancer Staging Nomograms (Partin Tables) for the New Millennium," Urology. 58(60):843-848, December 2001.

Smith, R., et al.: "American Cancer Society Guidelines for the Early Detection of Cancer," CA-A Cancer Journal for Clinicians. 52(1):8-22, January-February 2002.

Jeanne Held-Warmkessel is a clinical nurse specialist at Fox Chase Cancer Center in Philadelphia, Pa.

American Cancer Society

American Family Physician: Use of Percent Free PSA in the Detection of Prostate Cancer

Cancer Information Network

Marin Urology: Prostate Specific Antigen

Last accessed on November 4, 2002.