Diseases and Disorders

Prostate Cancer

INTRODUCTION

DRG Category: 713

Mean LOS: 4.1 days

Description SURGICAL: Transurethral Prostatectomy with CC or Major CC

DRG Category: 715

Mean LOS: 6.3 days

Description MEDICAL: Other Male Reproductive System Operating Room Procedure for Malignancy with CC or Major CC

classification section:

Prostate cancer is the most common type of cancer in men and the second leading cause of death among men in the United States. The American Cancer Society estimated that, in 2008, there were 200,000 new cases of prostate cancer and approximately 30,000 deaths from the disease. Overall, 1 in 6 men are diagnosed with prostate cancer and 1 in 33 die from this disease. The 5-year survival rate is 99%. Prostate cancer may begin with a condition called prostatic intraepithelial neoplasia (PIN), which can develop in men in their 20s. In this condition, there are microscopic changes in the size and shape of the prostate gland cells. The more abnormal the cells look, the more likely that cancer is present. It has been noted that 50% of men have PIN by the time they are 50 years old.

Adenocarcinomas compose 99% of the prostate cancers. They most frequently begin in the outer portion of the posterior lobe in the glandular cells of the prostate gland. Local spread occurs to the seminal vesicles, bladder, and peritoneum. Prostate cancer metastasizes to other sites via the hematologic and lymphatic systems, following a fairly predictable pattern. The pelvic and perivesicular lymph nodes and bones of the pelvis, sacrum, and lumbar spine are usually the first areas to be affected. Metastasis to other organs usually occurs late in the course of the disease, with the lungs, liver, and kidneys being most frequently involved.

Although the recommendation is controversial, the American Cancer Society now advises screening for prostate cancer in asymptomatic men beginning at age 40. American Cancer Society guidelines include an annual digital rectal examination beginning at age 40 and annual serum prostate-specific antigen (PSA) testing beginning at age 50.

CAUSES

The cause of prostate cancer remains unclear, but age, viruses, family history, diet, and androgens are thought to have contributing roles. Men who have an affected first- and second-degree relative have an eightfold increased risk of developing prostate cancer. A high-fat diet may alter the production of sex hormones and growth factors, increasing the risk of prostate cancer. Environmental exposure to cadmium (an element found in cigarettes and alkaline batteries) is also considered a risk factor.

GENETIC CONSIDERATIONS

Men who have first-degree family members with prostate cancer tend to be diagnosed 6 to 7 years earlier than men without a family history. The risk of developing prostate cancer is approximately 40% higher in men with three or more affected relatives. Several genes/loci (RNASEL, MXI1, KAI1, PCAP, CAPB, HPCX1, HPCX2) have been associated with the origin, progression, or an increased susceptibility to hereditary prostate cancer. Other candidate loci have been described and are being further investigated.

GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS

The peak incidence of prostate cancer is in men between the ages of 60 and 70; 85% of the cases are diagnosed in men over the age of 65. The highest incidence of prostate cancer occurs in African American men, and it is also diagnosed at a later stage. Asians and Native Americans have the lowest rate. Prostate cancer is rare in men under the age of 40, but when the disease occurs in younger men, it is generally more aggressive.

GLOBAL HEALTH CONSIDERATIONS

The global incidence of prostate cancer is 21.7 per 100,000 males per year. The incidence is 10 to 15 times higher in developed than in developing countries.

ASSESSMENT

HISTORY. Ask about family history of prostate cancer, an occupational exposure to cadmium, and the usual urinary pattern. A patient may report symptoms such as urinary urgency, frequency, nocturia, dysuria, slow urinary stream, impotence, or hematuria if the disease has spread beyond the periphery of the prostate gland or if benign prostatic hypertrophy is also present. Presenting symptoms that include weight loss, back pain, anemia, and shortness of breath are often indicative of advanced or metastatic disease.

PHYSICAL EXAM. Most men with early-stage prostate cancer are asymptomatic. The physician palpates the prostate gland via a digital rectal examination. A normal prostate gland feels soft, smooth, and rubbery. Early-stage prostate cancer may present as a nonraised, firm lesion with a sharp edge. An advanced lesion is often hard and stonelike with irregular borders. A suspicious prostatic mass is further evaluated by extending the examination to the groin to look for the presence of enlarged or tender lymph nodes.

PSYCHOSOCIAL. Men have reported not having a rectal examination because of embarrassment. In addition, treatment for prostate cancer can be accompanied by distressful side effects, such as sexual dysfunction and urinary incontinence. Assess the patient's knowledge and feelings related to these issues and the presence of support systems. Note the coping strategies the patient has used in the past to manage stressors. Include the patient's spouse or significant other in conversations.

Diagnostic Highlights
General Comments: Positive findings during the digital rectal examination and an elevated PSA suggest the diagnosis. Other tests may be needed to confirm and determine metastasis.



TestNormal ResultAbnormality with ConditionExplanation
PSA< 4 ng/mLIncreased levels, > 10 ng/mLThe higher the level, the greater the tumor burden; can be used to monitor response to treatment or recurrent cancer (CA)
Transrectal ultrasoundProstate gland is of normal size, contour, and consistencyEnlarged, solid prostate mass is notedCan identify prostatic CA early; very small tumors can be detected
BiopsyBenignMalignantConfirms the diagnosis


Other Tests: Computed tomography scan of the abdomen and pelvis, magnetic resonance imaging, lymphangiogram, intravenous pyelogram, chest x-ray, bone scan, laparoscopic pelvic lymphadenectomy, serum reverse transcriptase–polymerase chain reaction, and acid phosphatase level.

PRIMARY NURSING DIAGNOSIS

DIAGNOSIS. Pain (chronic bone) related to metastatic spread of disease

OUTCOMES. Pain control; Pain: Disruptive effects; Well-being

INTERVENTIONS. Analgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application

PLANNING IMPLEMENTATION

COLLABORATIVE

CONSERVATIVE. Periodic observation, or "watchful waiting," may be proposed to a patient with early-stage, less-aggressive prostate cancer. With this option, no specific treatment is given, but the progression of the disease is monitored via periodic diagnostic tests. Large-scale clinical trials show that men who opt for conservative treatment have a slightly higher risk for death and significantly higher rate of metastasis than those who have a radical prostatectomy. Note that men who ingest diets high in omega-3 fatty acids and low in glycemic index as well as weight loss may have slowed tumor growth and improved prognosis.

SURGICAL. Radical prostatectomy has been the recommended treatment option for men with middle-stage disease because of high cure rates. This procedure removes the entire prostate gland, including the prostatic capsule, the seminal vesicles, and a portion of the bladder neck. Two common side effects of prostatectomy are urinary incontinence and impotence. The urinary incontinence usually resolves with time and after performing Kegel exercises, although 10% to 15% of men continue to experience incontinence 6 months after surgery. Impotence occurs in 85% to 90% of patients. All men who undergo radical prostatectomy lack emission and ejaculation because of the removal of the seminal vesicles and transection of the vas deferens. Newer surgical techniques (nerve-sparing prostatectomy) preserves continence in most men and erectile function in selected cases. Cryosurgery (cryoablation of the prostate) with liquid nitrogen is less invasive and may be associated with fewer long-term consequences (impotence and incontinence). Both techniques are under study for their long-term outcomes.

Transurethral resection of the prostate (TURP) may be recommended for men with more advanced disease, especially if it is accompanied by symptoms of bladder outlet obstruction. This procedure is not a curative surgical technique for prostate cancer but does remove excess prostatic tissue that is obstructing the flow of urine through the urethra. The incidence of impotence following TURP is rare, although retrograde ejaculation (passage of seminal fluid back into the bladder) almost always occurs because of the destruction of the internal bladder sphincter during the procedure. Many men equate ejaculation with normal sexual functioning, and to some the loss of the ejaculatory sensation may be confused with the loss of sexual interest or potency. Also, a bilateral orchiectomy may be done to eliminate the source of the androgens, since 85% of prostatic cancer is related to androgens.

All patients return from surgery with a large-lumen three-way Foley catheter. The large lumen of the catheter and the large volume in the balloon (30 mL) help splint the urethral anastomosis and maintain hemostasis. Blood-tinged urine is common for several days after surgery, but dark red urine may indicate hemorrhage. If continuous urinary drainage is used, maintain the flow rate to keep the urine light pink to yellow in color and free from clots, but avoid overdistention of the bladder.

Antispasmodics may be ordered for bladder spasms. Anticholinergic and antispasmodic drugs may also be prescribed to help relieve urinary incontinence after the Foley catheter is removed. Because of the close proximity of the rectum and the operative site, trauma to the rectum should be avoided as a means of preventing hemorrhage. Stool softeners and a low-residue diet are usually ordered to limit straining with a bowel movement. Rectal tubes, enemas, and rectal thermometers should not be used.

RADIATION. Both external beam radiotherapy and internal implant (brachytherapy) are used in the treatment of prostate cancer. Radiation therapy is also used in areas of bone metastasis. The goal in extensive disease is palliation: Reduce the size of the prostate gland and relieve bone pain. Brachytherapy involving the permanent (iodine-125 or gold-198) or temporary (iridium-192) placement of radioactive isotopes can be used alone or in combination with external radiation therapy.

Patients who receive permanently placed radioisotopes are hospitalized for as long as the radiation source is considered a danger to persons around them. The principles of time, distance, and shielding need to be implemented. Care needs to be exerted so that the radioisotope does not become dislodged. Dressings and bed linens need to be checked by the radiation therapy department before these items are removed from the patient's room.

Pharmacologic Highlights



Medication or Drug ClassDosageDescriptionRationale
Acetaminophen/NSAIDs, opioids, combination opioids/NSAIDsDepends on drugAnalgesicAnalgesic is determined by severity of pain; pain may be postoperative or caused by metastasis
Cyclophosphamide (Cytoxan), fluorouracil, doxorubicin hydrochloride (Adriamycin), paclitaxel (Taxol)Depends on drug; may be given singly or in combinationAntineoplasticUsed to treat or stabilize the disease
Goserelin acetate (Zoladex), leuprolide (Lupron)Depends on stage of CA and treatment combination; given monthly or every 3, 4, 6, or 12 moLuteinizing hormone-releasing hormone (LHRH) analog; antineoplastic hormonal agentBlocks the action/secretion of androgens, that stimulate tumor growth (causes temporary tissue flare)
Flutamide (Eulexin), nilutamide (Nilandron), bicalutamide (Casodex)250 mg tid, q 8 hrAntineoplastic, hormonal agent; antiandrogenBlocks androgens; often given with other similar agents
Ketoconazole, aminoglutethimideDepends on drugAdrenal androgen synthesis inhibitorRapidly decreases testosterone levels, sometimes in 24 hr
Abarelix (Plenaxis)Injection, given dorsal gluteal, every 2 wk for 1 mo, then q 4 wkLHRH antagonistLowers testosterone levels more quickly, and does not cause tumor flare like LHRH agonists do


Other Drugs: Finasteride (Proscar), an androgen hormone inhibitor currently being used to treat benign prostatic hyperplasia, may reduce the risk of developing prostate cancer by 25%.

INDEPENDENT

Dispel misconceptions, and explain all diagnostic procedures. Patients with early-stage disease need support while they make decisions about treatment options. Encourage the patient and his partner to verbalize their feelings and fears. Clarify the differences between the various treatment options and reinforce the treatment goals. Provide written materials, such as Facts on Prostate Cancer published by the American Cancer Society or What You Need to Know about Prostate Cancer published by the National Cancer Institute. Suggest that the patient write down questions that arise so they are not forgotten during visits with the physician.

Ask about pain regularly, and assess pain systematically. Believe the patient and family in their reports of pain. Inform the patient and family of options for pain relief as proposed by the National Cancer Institute (pharmacologic, physical, psychosocial, and cognitive-behavioral interventions), and involve the patient and family in determining pain relief measures.

Implement postoperative strategies to decrease complications. Patients are usually able to ambulate on the first day after surgery. Help the patient to get out of bed and walk in the halls to his tolerance level, usually three or four times a day. Once nausea has passed, bowel sounds are present, and fluids are allowed, encourage a fluid intake of 2,500 to 3,000 mL/day to maintain good urine output. Adequate fluid intake, and thus output, minimizes the formation of blood clots in the urinary bladder that can obstruct the Foley catheter.

Be alert for behavior indicating denial, grief, hostility, or depression. Inform the physician of any ineffective coping behaviors and the patient's need for more information or a referral for counseling. Postoperative incontinence and impotence may be difficult for patients to discuss. Inform patients of exercises, medications, and products that can assist with incontinence. Suggest alternative sexual behaviors, such as touching and caressing. Patients who are undergoing orchiectomy need extensive emotional support. Establish a therapeutic relationship to promote the expression of feelings. Be sensitive to the patient's fear of his loss of masculinity. Reinforce that having the testes removed in adulthood does not affect the ability to have an erection and orgasm.

Stress to patients who are hospitalized for insertion of a radioactive implant that, while the temporary implant is in place, interactions with nurses and other individuals occur only during brief time periods. Attempt to relieve feelings of abandonment and isolation by communicating with the patient via the hospital intercom system. Once the temporary implant has been removed or the permanent radioactive substance has decayed, remind the patient that he is no longer a danger to others.

DOCUMENTATION GUIDELINES

• Description of all dressings, wounds, drainage collection devices, and urinary output; location, color, and amount of drainage; appearance of incision; color and amount of urine; presence of clots in the urine; urinary pattern after catheter removal

• Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, condition of extremities, bowel patterns, presence of complications (hemorrhage, infection, pulmonary congestion, activity intolerance, unrelieved discomfort, blockage of Foley catheter)

• Urinary pattern following removal of Foley catheter

• Response to potential for alteration in sexual function

• Description of the skin in the radiation field or site of insertion of radiation implant

DISCHARGE HOME HEALTHCARE

TEACHING. Provide the following instructions to patients who have undergone a radical prostatectomy:

• Perform Kegel exercises to enhance sphincter control after the Foley catheter is removed. Establish a voiding pattern of every 2 hours during the day and every 4 hours during the night. With each voiding, contract the pelvic muscles to start and stop urinary flow several times. Contract the pelvic floor muscles and the muscle around the anus as though to stop a bowel movement 10 to 20 times, four times each day.

• Maintain an oral fluid intake of 2,000 to 3,000 mL/day. Avoid alcoholic and caffeinated beverages.

• Eat high-fiber foods and take stool softeners to prevent constipation. Avoid straining with bowel movements and do not use suppositories and enemas.

• Avoid strenuous exercise, heavy lifting, and driving an automobile until the physician allows.

• Avoid sitting with the legs in a dependent position for 3 to 4 weeks, and avoid sexual intercourse for 6 weeks.



CARE OF SKIN IN EXTERNAL RADIATION FIELDS. Instruct the patient to do the following:

• Wash the skin gently with mild soap, rinse with warm water, and pat dry daily.

• Leave (not wash off) the dark ink markings that outline the radiation field.

• Avoid applying any lotions, perfumes, deodorants, or powder to the treatment area.

• Wear soft, nonrestrictive cotton clothing directly over the treatment area.

• Protect the skin from sunlight and extreme cold.



CARE AFTER THE INSERTION OF A PERMANENT RADIOISOTOPE. Instruct the patient to observe for lost seeds in bed linens. Teach the patient to use tweezers to place lost seeds in aluminum foil, wrap them tightly, and take them to the radiation oncology department at the hospital. Teach the patient to call the physician if he experiences a temperature over 100°F, burning or difficulty with urination, excessive bleeding or clots in urine, or rectal bleeding.

FOLLOW-UP CARE. Teach the patient when to see the physician for follow-up care and to watch for any sign of recurrent disease.

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