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Prostate cancer update

VOL: 98, ISSUE: 28, PAGE NO: 56

Jayne Lewey, RGN, BSc, DNert, Cert Ed, is MacMillan urology nurse specialist, Lister Hospital, Stevenage, Hertfordshire

Every year around 20,000 men are diagnosed with prostate cancer in the UK (Department of Health, 2000). This is predicted to triple by the year 2018. Prostate cancer is now second only to lung cancer as the most common cause of cancer death in men (Kirby et al, 2001). Over 10,000 men die from prostate cancer annually in the UK (Prostate Cancer Charity, 1999).

Every year around 20,000 men are diagnosed with prostate cancer in the UK (Department of Health, 2000). This is predicted to triple by the year 2018. Prostate cancer is now second only to lung cancer as the most common cause of cancer death in men (Kirby et al, 2001). Over 10,000 men die from prostate cancer annually in the UK (Prostate Cancer Charity, 1999).


When we consider that the incidence of prostate cancer increases with age and that life expectancy among most populations is increasing, prostate cancer presents a major challenge to health care services.


Risk factors
Although the incidence of prostate cancer appears to be rising, the cause of the disease is not fully understood. Currently no proven preventative measures have been identified. However, a number of risk factors have been established (Mettlin, 1997):


Ageing - carcinoma of the prostate is predominantly a tumour of older men. Prostate cancer risk rises very steeply with age. Clinical disease is rare in men under the age of 50 (Alexander, 1999), with the incidence increasing markedly in men over 60 (Kirby et al, 2001);


Family history - there is very strong evidence that men who have close relatives who have, or have had, cancer of the prostate are more likely to develop the disease (Eeles, 1997);


Ethnic origin and county of residence - there are major variations in incidence rates between countries and between ethnic groups. The groups with the highest recorded incidence rate are black Americans and Afro-Caribbeans. The populations with the highest risk are northern America and northern European countries, and the risk is lowest in the Far East (Parker et al, 1996). However, when Japanese men migrate to northern America their incidence of prostate cancer rises with one generation. Most attention has focused on the possible association between dietary factors and prostate cancer. Specific attention has been paid to the correlation between prostate cancer and unsaturated fat or red meat consumption, vitamins (A, C, E) and other carotenes and phyto-oestrogens (Alexander, 1999).


Diagnosis
Prostate cancer can grow slowly for several years before it shows any signs and symptoms. Many older men with prostate cancer live to their normal life expectancy without it causing them any problems. The disease is now being diagnosed earlier in asymptomatic younger men. Traditionally, most men presented with clinically significant disease with a variety of symptoms related to bladder outflow obstruction (Table 1), local extension of the tumour (Table 2) or distant metastatic spread (Table 3).


Investigations
Recommended diagnostic staging investigations may include a digital rectal examination, serum prostate specific antigen (PSA), transrectal ultrasound scan and guided biopsy, CT scan, bone scan and chest X-ray.


Controversy still exists in regard to the value of screening for prostate cancer using the tumour marker PSA (Neal and Donovan, 2000). Unfortunately PSA is not cancer-specific and PSA levels are also elevated in benign prostatic hyperplasia (BPH), with infection of the prostate or urine and with increasing age. Additionally, a low PSA test result does not exclude prostate cancer. The National Screening Committees' policy on PSA testing is published on the internet (www.nelh.nhs.uk/psatesting).


All men requesting a PSA blood test should be given information about the sensitivity and specificity of the test, on the nature and complications of prostatic biopsy and on the management of prostate cancer, including advanced disease (Dearnaley et al, 1999).


Treatment options
Deciding on the best treatment is not straightforward, and a number of important factors have to be considered:


  • The stage of the disease - for instance, its extent and spread;
  • The grade of the prostate cancer cells - for instance, their aggressiveness;
  • Age of the patient;
  • General state of health of the patient;
  • Side-effects of treatment on the patient's quality of life. Alterations in bladder, bowel and sexual function can be a major deterrent to treatment (Table 4).
Radical prostatectomy


This involves surgical removal of the entire prostate, the seminal vesicles and adjacent tissue. It is reserved for patients with tumours believed to be confined to the prostate gland who are in good health, with a life expectancy of at least 10 years, who select surgical intervention.


Radical external beam radiotherapy


This is an alternative treatment for patients with early prostate cancer, particularly those who are unsuitable candidates for surgery or as treatment for patients who have evidence of local spread of the tumour to surrounding tissue. The treatment generally involves a five to six-week course of radiotherapy with or without neoadjuvant and adjuvant hormone therapy. Recent technological advances include conformal external beam radiotherapy, which focuses the radiation beam more precisely, enhancing treatment outcomes and reducing side-effects (Dearnaley et al, 1999).


Brachytherapy


This is a treatment option generally for patients with organ-confined disease of a low grade and with a low PSA level. The technique involves inserting radioactive seeds into the prostate gland which deliver a high dose of radiation to surrounding tissue over the following months.


Watchful waiting


In asymptomatic patients of advanced age or with concomitant illness it may be appropriate to consider a policy of careful observation, especially older patients with low volume, low grade, localised disease (Albertsen et al, 1998).


Hormone therapy


The majority of prostate cancer tumours are dependent on the male sex hormone testosterone for their growth and development.


Several different hormonal approaches can benefit men with various stages of prostate cancer. These may include bilateral orchidectomy (surgical removal of testicles) or luteinising hormone-releasing hormone (LHRH) analogues, antiandrogens and sometimes oestrogen therapy. Conventional hormone therapy used in locally advanced disease usually involves the use of an LHRH analogue, given as a monthly or three-monthly injection and often preceded and accompanied by an antiandrogen tablet for at least two to six weeks to prevent tumour 'flare'. Such treatment significantly reduces the amount of testosterone in the body and as such reduces tumour volume and delays disease progression for a period of time in up to 80% of patients with locally advanced prostate cancer (Kirby et al, 2001). In advanced metastatic disease the use of antiandrogens is often continued long-term with the LHRH analogue (Soloway 1998). Additional hormone deprivation therapy may be used in conjunction with radical radiotherapy in patients with localised prostate cancer. Data suggests that the effect of radiotherapy is enhanced by neoadjuvant and adjuvant hormone therapy using an LHRH analogue (Bolla et al, 1997).


Palliative care


In almost all cases advanced prostate cancer treated with hormone therapy will begin to grow again. Despite a number of second-line treatments the prognosis is poor.


Pain, fatigue, anorexia and anaemia are all common symptoms of the later stages of the disease. Painful bone metastases can be a major problem in prostate cancer and are often difficult to relieve with analgesia alone. External beam radiation therapy for palliation of bone pain can be useful. Additionally, the use of radio-isotopes, such as strontium-89, may significantly reduce the need for other analgesic agents. Urethral and ureteric obstruction, spinal cord compression and pathological fractures are potential complications requiring immediate medical treatment.



TABLE 1.SYMPTOMS OF BLADDER OUTFLOW OBSTRUCTION (Kirby et al, 2001)


  • Weak stream;
  • Hesitancy;
  • Sensation of incomplete emptying;
  • Frequency;
  • Urgency;
  • Urge incontinence;
  • Urinary tract infection.


TABLE 2.SYMPTOMS OF LOCAL EXTENSION OF THE TUMOUR (Kirby et al, 2001)


  • Haematuria;
  • Dysuria;
  • Perineal and suprapubic pain;
  • Impotence;
  • Incontinence;
  • Loin pain (obstructed ureters);
  • Renal failure;
  • Haemospermia;
  • Rectal discomfort/symptoms.


TABLE 3.SYMPTOMS OF METASTATIC PROSTATE CANCER (Kirby et al, 2001)


  • Bone pain;
  • Sciatica;
  • Paraplegia secondary to cord compression;
  • Lymph node enlargement;
  • Loin pain and/or anuria (obstructed ureters);
  • Lethargy;
  • Weight loss and cachexia;
  • Rectal bleeding.

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