Posted in Med Surg

Prostate cancer is a condition in which a tumor develops in the prostate. In some cases, the cancer metastasizes to other areas of the body. When this occurs, it most commonly metastasizes to the lymph nodes or bones. It is a leading cause of cancer among men in the United States, though the good news is that it is a slow-growing cancer and treatment options are available. 

Who is at risk for prostate cancer?

Individuals most at risk for prostate cancer are males between the ages of 65 and 74, though it can develop in younger individuals. Unfortunately, prostate cancer is not uncommon, with 1 in 8 men in the United States being diagnosed with the condition at some point in their lifetime. In addition to having a family history of prostate cancer, other risk factors for prostate cancer include:

  • Presence of BRCA1 or BRCA2 genetic mutation
  • African American ethnicity
  • A diet high in animal fats and/or low in vegetables
  • Exposure to chemicals and pesticides
  • Exposure to Agent Orange, a chemical herbicide used in the Vietnam War

Now that you’ve got some background information on prostate cancer, let’s learn how to care for these patients using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

In many cases, a patient with prostate cancer can be asymptomatic, especially in the early stages of the disease. When early symptoms do occur, they are similar to the symptoms of benign prostatic hyperplasia (BPH). This includes nocturia, frequent or urgent urination, slow urinary stream, intermittent urinary stream, splitting of the stream of urine, and dribbling of urine. Other signs and symptoms include: 

  • Enlarged prostate
  • Hematuria (blood in the urine)
  • Incontinence
  • Erectile dysfunction
  • Weight loss
  • Weakness
  • Hematospermia (blood in the semen)
  • Bone pain (in cases of metastasis)

A: How do you ASSESS a patient with prostate cancer?

Priority assessments for a patient with prostate cancer involve assessing bladder habits and for the presence of urinary retention, which can lead to urinary tract infections and renal damage. Urinary retention or “post void residual” (PVR) can be assessed via a straight cath procedure after voiding or with a bladder scanner:

  • Have the patient lie in a supine position
  • Place ultrasound gel on the suprapubic area
  • Place the ultrasound probe on the gel and aim it toward the bladder
  • Press the button on the ultrasound probe and the volume will show on the visual display 
  • A normal PVR is less than 12 ml, and volumes over 250 ml are concerning for significant urinary retention

Of course, if the patient is going through chemotherapy, radiation therapy, or immunotherapy, specific assessments will be conducted based on which treatment modality is used. For example, a patient going through chemotherapy can have significant side effects such as nausea, weight loss, and oral mucositis. 

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T: What TESTS are utilized for a patient with prostate cancer?

PSA – The main test for prostate cancer screening is prostate specific antigen (PSA), which is elevated in prostate cancer and some benign conditions such as BPH or an infection. In fact, studies show that approximately 75% of men with an elevated PSA do not have prostate cancer. If an abnormal level is obtained, the PSA is repeated a few weeks later to confirm persistent elevation. It’s important to note that PSA levels increase normally with age. For example, the normal PSA for a man aged 75 is up to 5 ng/ml, while a 50 year old man’s normal range is up to 3 ng/ml. 

Free-PSA – The free-PSA test compares the amount of unbound PSA in the blood to the total PSA level. This test can be helpful to further evaluate men with a PSA level between 4 and 10 ng/ml without always having to advance to a biopsy, which is a more invasive procedure. If the test shows the amount of free or unbound PSA to be below 10%, the individual would then be a candidate for a biopsy. Higher levels of free PSA (above 25%) generally means the individual is likely to have a benign condition.

PSA Density – This test compares the PSA level to total prostate volume and is conducted via a transrectal ultrasound. Higher density is more concerning for prostate cancer (for example, a smaller prostate with a higher  PSA).

Digital rectal exam – A digital rectal examination of the prostate can help the MD detect abnormalities such as asymmetry, firmness, induration or nodules. Since this examination is only applicable to a portion of the prostate, it is not always going to detect prostate cancer.

Prostate biopsy – A biopsy is indicated when the PSA level and/or digital rectal exam indicate cancer is likely. The test may be performed in one of two ways. The transrectal approach involves a needle being passed through the rectum and into the prostate. One drawback of this procedure is the risk of introducing fecal matter into the prostate. The transperineal route is becoming more common due to lower infection risk and greater accuracy. In this procedure, the needle passes through sterilized skin of the perineum and into the prostate, avoiding the rectum altogether. Both techniques are performed as outpatient procedures, and in many cases, use local anesthesia.

T: How is prostate cancer TREATED?

The good news is, there are several treatment options available for prostate cancer. Treatment will be based on the stage of the cancer and whether or not it has metastasized. In some cases, very low risk prostate cancer will just be closely monitored for signs of progression. Treatment options include radiation, androgen deprivation therapy, chemotherapy, immunotherapy, ablation therapy and prostatectomy.

Radiation – Two types of radiation are utilized for prostate cancer: external beam radiation and brachytherapy. 

External beam radiation is generally conducted five days per week for up to eight weeks. Side effects include urinary frequency and urgency, painful urination (dysuria), erectile dysfunction, hematuria, abdominal pain or cramping, and increased frequency in bowel movements.

Brachytherapy involves delivering radiation directly into the prostate. High-dose rate (HDR) brachytherapy involves the placement of thin radioactive tubes into the prostate while under anesthesia. Doses are delivered for a short period of time (a few minutes) and in most cases the tubes are removed. If multiple HDR sessions are needed in a short period of time, the tubes may stay in place. Otherwise, they are reinserted with subsequent treatments. Because the radioactive source is removed, the patient is not radioactive after the procedure. 

Low-dose rate (LDR) brachytherapy involves the implantation of radioactive “seeds” directly into the prostate. The seeds are left in place and slowly emit low doses of radiation over a period of months. During this time the patient emits low doses of radiation, so precautions may need to be followed such as limiting contact with children and pregnant individuals.

Androgen deprivation therapy (ADT) – This treatment option involves lowering blood testosterone through surgery or pharmacology. The surgical procedure is called a surgical orchiectomy, which is removal of one or both testicles. Medical orchiectomy is achieved with administration of a few different medications and you may hear this called “medical castration therapy.”

  • Luteinizing hormone-releasing hormone (LHRH) agonists lower the amount of testosterone produced in the testicles. You may also see these called gonadotropin releasing hormone agonists. Depending on which drug is utilized, they may be administered once a month or once every six months via injections or small implants placed under the skin. Medications of this type include leuprolide (Lupron) and goserelin (Zoladex). When first initiated, these medications cause a “tumor flare” where testosterone levels increase for a short period of time. This may cause men who still have a prostate to have difficulty urinating. If bone metastasis is present, they may experience bone pain. If the cancer has spread to the spine, paralysis and pain can result.
  • LHRH antagonists tend to work faster than agonists to decrease the production of testosterone with the added benefit of not causing the “tumor flare” or surge of testosterone. They work by binding to GnRH receptors in the pituitary gland which causes a decrease in the release of luteinizing hormone, which in turn, decreases the production of testosterone. Relugolix (Orgovyx) is an oral medication taken once per day and degarelix (Firmagon) is administered via subcutaneous injection every 28 days following an initial loading dose. These medications are reserved for treating advanced prostate cancer. A key safety consideration with relugolix (Orgovxs) is they it can prolong the QT interval, so patients should have an EKG conducted prior to initiating therapy and periodically throughout treatment.

Other medications utilized in the treatment of prostate cancer include; 

  • Abiraterone (Zytiga) blocks testosterone synthesis and is utilized in men with metastatic prostate cancer that is not responding to other types of hormone therapy. You may hear this called “castration-resistant” prostate cancer.
  • Enzalutamide (Xtandi) is indicated in patients who have castration-resistant prostate cancer, metastatic prostate cancer, or are at high risk for metastasis.
  • Docetaxel (Docivyx) is an antineoplastic utilized along with prednisone for metastatic castration-resistant prostate cancer. In 2024, the FDA approved the combination of docetaxel and cisplatin as first-line treatments in prostate cancer.

In general, side effects of these medications include weight loss, sexual dysfunction, osteoporosis, bone fractures, hot flashes, decreased size in sexual organs, lack of energy, and increased risk for diabetes.

Chemotherapy – Chemotherapy is utilized to stop or slow the growth of cancer cells and is often used when ADT is not effective or when the cancer metastasizes. The most common chemotherapeutic agent used for prostate cancer is docetaxel, which is administered via IV infusion. Side effects include weight loss, nausea/vomiting, hair loss, and increased risk for infection.

Immunotherapy – A newer approach to prostate cancer treatment is immunotherapy. These therapies use the patient’s own immune system to slow or stop the growth of cancer. Two general approaches are a cancer vaccine and immune checkpoint inhibitors.

  • Cancer vaccine – Provenge is a cancer vaccine that boosts the immune system so it can attack prostate cancer cells. It is generally used to treat advanced prostate cancer that is resistant to hormone therapy. Each vaccine is made specifically for each individual by taking WBCs from the patient and mixing them with prostatic acid phosphatase (PAP), a protein in prostate cancer cells. The mixture is then administered to the patient via an IV infusion for a total of three doses. Note that this therapy does not cure the cancer or completely stop the cells from growing, but it can prolong life. Side effects of the cancer vaccine include fever, chills, fatigue, nausea, headache and joint pain.
  • Immune checkpoint inhibitors – The immune system uses “checkpoint” proteins to keep itself from attacking the body. Cancer cells also use these checkpoints to prevent the immune system from attacking them. Medications that target checkpoints inhibit them so that cancer cells can be susceptible to attack by the immune system. Patients receive these medications via IV infusion about every three to six weeks. Side effects can include fatigue, nausea, diarrhea and decreased appetite.

Ablation therapy – Ablation therapy selectively targets specific areas of prostate tissue using various modalities to destroy cancer cells. These procedures are done under anesthesia or a spinal block and most men go home the same day.

  • Cryotherapy uses very cold temperatures to freeze prostate cancer cells. One drawback of this procedure is the risk for damage to nearby nerves leading to erectile dysfunction.  
  • Focal laser ablation (FLA) involves using MRI guidance to insert a thin laser fiber into the prostate. Once in place near the tumor, the laser is activated to heat and destroy the target tissue.
  • High-intensity focused ultrasound (HIFU) uses ultrasound beams to heat and destroy the tissue. In this procedure a probe is inserted into the body via the rectum and high-intensity ultrasound beams heat and destroy the target tissue.
  • Transurethral ultrasound ablation (TULSA) is similar to HIFU except in TULSA the probe is inserted through the urethra into the prostate.
  • Photodynamic therapy (PDT) involves the IV infusion of a light-activated drug. Once the drug is administered, a light source is inserted into the prostate and directed at the tumor. This light activates the medication which causes the blood vessels around the tumor to be destroyed. Note this procedure is not yet available in the United States for the treatment of prostate cancer, but it’s possibly something you will see in the near future.

Prostatectomy – Patients whose cancer shows signs of progressing or spreading to other parts of the body may have the prostate removed in a surgical procedure called a radical prostatectomy. In this procedure, the entire prostate is removed through several small incisions in the abdomen (a laparoscopic procedure) or one larger incision between the umbilicus and pubic bone (an open procedure). Since this procedure does involve reattaching the urethra to the bladder, most patients will have a urinary catheter in place for several days until the urologist is confident the bladder has healed. Complications of prostatectomy include incontinence and erectile dysfunction, though the risk is less with a “nerve sparing” approach. Other complications include infection and urethral strictures which can impede the flow of urine.

E: How do you EDUCATE a patient about prostate cancer?

Education is going to vary widely depending on what treatment options are being utilized. As for prostate screening, teach your patients that screenings are recommended starting at age 50, though men who are higher risk may have screenings begin at age 40 to 45.

Other things to teach patients include: 

  • Pelvic floor exercises can help with urinary incontinence or “dribbling” which can occur prior to treatment or after.
  • Patients receiving chemotherapy should be taught infection prevention measures such as handwashing, avoiding crowds, and receiving all recommended immunizations.
  • Patients receiving chemotherapy should also be taught to double flush with the lid closed to avoid splashing and to use a separate toilet from the rest of the family if possible.
  • Caregivers of patients receiving chemotherapy should double-glove when coming into contact with body fluids and to wash hands immediately after. In addition, all clothes and bedding should be washed separately from other laundry in warm water. Disposable items such as incontinence pads should be sealed in two plastic bags and thrown away.
  • For patients receiving surgery or invasive procedures, reinforce the discharge teaching provided by the surgeon. This can include lifting restrictions and medications.
  • Patients with implanted seeds for brachytherapy need to understand that the seeds will cause them to emit radiation for a period of time and that it can take up to ten months for the radiation to fully dissipate.They should follow their physician’s recommendations for avoiding close contact with children and pregnant individuals during this time.
  • Implanted brachytherapy seeds may set off airport security systems so instruct the patient to ask their physician for a letter they can show to airport security personnel.
  • Patients receiving external beam radiation may have irritated skin at the site. They should use mild soap and warm water to clean the skin and avoid rubbing with towels. Moisturizers can be used to help soften the skin and keep it intact. Patients should also avoid chlorine pools as well as extremes in heat or cold such as saunas, ice packs, and hot tubs.

Want to learn more about caring for patients with cancer? Check out these posts!

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The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.

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Last Updated on November 21, 2024 by Maureen Osuna, MSN, RN