Advances in Prostate Cancer Treatment: how do providers help patients choose appropriate treatments?

Although the prostate cancer mortality rate has been decreasing steadily over the past 20 years because of improvements in detection, early diagnosis, and treatment (Strief, 2007), it is still the most commonly diagnosed cancer and the second-leading cause of cancer-related death in men in the United States. In the United States in 2008, approximately 186,320 new cases of prostate cancer will be diagnosed and 28,660 men will die from the disease (American Cancer Society, 2008). Nurses caring for patients with prostate cancer need to be aware of the variety of treatment options available and able to answer patients' questions about the treatments as they decide what's right for them. Sometimes the best treatment is no treatment at all.

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Treatments such as watchful waiting, radical prostatectomy, da Vinci[R] robotic-assisted prostatectomy (Intuitive Surgical Inc.) (see "One Nurse's Perspective," p. 13), external-beam radiation therapy, intensity-modulated radiation therapy, and brachytherapy all may be used in patients with prostate cancer. Each has an impact on patients' quality of life, but can one treatment be considered the best? Healthcare providers must consider a number of factors when recommending treatment for prostate cancer.

Proton-beam radiotherapy has few Side Effects

ONS member Tai Ly, RN, MSN, ANP-C, is a registered nurse in the Genitourinary Proton Therapy Center at the University of Texas M.D. Anderson Cancer Center in Houston. Although proton therapy has been used for years to treat prostate cancer, M.D. Anderson only recently began offering the treatment. Ly says she sees patients who are interested in receiving proton therapy because it has minimal side effects.

Proton-beam radiotherapy (PBRT) uses a beam of protons to irradiate the DNA of cancer cells while reducing the dose delivered to the surrounding healthy tissues. The result is an effective treatment for prostate cancer. However, only five proton facilities currently exist in the United States, so PBRT may not be routinely available as a treatment option for many patients.

"The advantage of proton therapy is its ability to deposit a high dose of radiation to the desired target, with little to no radiation deposited beyond the target," Ly says.

Selecting potential patients for proton therapy is a comprehensive process to ensure that they are suitable candidates who will receive maximum benefits, Ly says. Typically, patients will submit medical information pertaining to their cancer diagnosis, and the healthcare team reviews all of the necessary information. A full patient history is needed because certain conditions may preclude treatment with proton therapy (e.g., metallic hip prosthesis, weight restriction, metastatic disease).

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Proton therapy is a desirable treatment option for men with prostate cancer because it has few side effects and patients can be functional during and after treatment. Minor side effects include increased urinary frequency or urgency. However, virtually all men are physically able to work full-time and carry out their normal activities of daily living (e.g., driving, social events, exercise).

Ly says that one drawback for patients receiving proton therapy is that they may have to make adjustments to their normal schedules or make living arrangements in Houston if they are from out of town because the treatment course may be as long as eight weeks.

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Nomograms assist in Decision making

ONS member Mary A. Schoen, MSN, MPH, NP-C, a nurse practitioner in the Urology Cancer Survivorship Program at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, NY, says that many services and treatments are available for patients with prostate cancer.

"Patients at MSKCC have the options of surgery, brachytherapy, and external-beam radiation available to them, and the treatments are appropriate for a majority of patients," Schoen says.

Patients are encouraged to meet with surgeons and radiation oncologists to discuss the options. At these initial consultation visits, healthcare practitioners often will review a prostate cancer nomogram with patients.

Nomograms are widely used in urology. They are used as clinical prediction tools to assess a patient's level of risk before making important decisions about treatment modalities. Nomogram algorithms incorporate multiple independent prognostic factors into a mathematical model to predict outcomes for individual patients.

At MSKCC, physicians rely on the Kattan nomogram to help assist patients with treatment decision making. Schoen says that the nomogram helps patients in deciding which of the three major treatment options will result in the greatest benefit and the probability of remaining cancer free.

The prediction tool looks at a combination of factors, including cancer stage, prostate-specific antigen (PSA) level, biopsy pathology, use of hormone therapy, and radiation dosage. In addition, for men who have already had a prostatectomy, the tool predicts the probability of cancer-free survival. The postoperative nomogram looks at the Gleason score, prostate capsule invasion, surgical margins, seminal vesicle involvement, and lymph node involvement to predict the progression-free probability over time.

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Schoen cautions that "the Kattan nomogram is only a tool, and it is essential for patients to work closely with physicians and other health professionals in deciding on treatment."

Patients and healthcare providers outside of MSKCC can access the Kattan nomogram at www.nomograms.org.

Schoen and her colleagues in the Urology Cancer Survivorship Program try to meet the needs of a growing volume of patients with prostate cancer by providing direct patient care to men who have completed treatment for their cancer and are disease free. Schoen's caseload includes patients who are at least 6-12 months postprostatectomy, and her colleague, Robin Rawlins-Duell, MSN, NP-C, provides care to patients who have had radiation therapy.

The nurses' survivorship visits include a review of patients' medical history, a physical assessment, management of treatment side effects, and surveillance for cancer recurrence, with a strong emphasis on the promotion of healthy behaviors such as diet, exercise, and smoking cessation.

Schoen says that her patients often suffer from anxiety about their PSA scores, so she likes to review their postoperative Kattan nomogram during their visit in the survivorship program to help them understand their risk for cancer recurrence. According to Schoen, the patients usually feel reassured that their prognosis is not as bleak as they thought. She also says that the nomogram can help to start mentally preparing patients for additional treatment if the chance of recurrence is high.

Patients with prostate cancer may be overwhelmed with the various treatment options available to them. With assistance from healthcare providers, including oncology nurses, they can make the best choices to treat their disease.

American Cancer Society. (2008). What are the key statistics about prostate cancer? Retrieved June 4, 2008, from http://www.cancer.org/ docroot/CRI/content/CRI_2_4_1X_What_are_ the_key_statistics_for_prostate_cancer_36 .asp?sitearea=

Strief, D. (2007). An overview of prostate cancer: Diagnosis and treatment. Urology Nursing, 27(6), 475-479.

Hanan Saca-Hazboun, RN, MSN, Contributing Editor

RELATED ARTICLE: African American Men Have Higher Prostate Cancer Death Rates

In the mid-1970s, the annual death rate from prostate cancer in the United States was approximately 29 per 100,000 white males, with African American men having a higher rate of approximately 55 per 100,000.

In 2004, the overall death rate from prostate cancer among American men was 25 per 100,000. Since 1994, the rate has decreased by 4% each year, and, in 2004, an estimated 2 million prostate cancer survivors were living in the United States. However, African American men still have mortality rates that are more than twice the rates observed in other racial and ethnic groups in the United States.

National Cancer Institute. (n.d.). Cancer advances in focus: Prostate cancer. Retrieved July 21, 2008, from http://www.cancer.gov/cancertopics/cancer-advances-in-focus/prostate

RELATED ARTICLE: What Is Prostate-Specific Antigen?

Prostate-specific antigen (PSA) is a substance produced by healthy and cancerous prostate cells. Adult men usually have a PSA level lower than 4 ng/ml, but the level can vary with age and may rise with infection, prostate manipulation, and benign prostatic hypertrophy. Some medications, such as finasteride or dutasteride, or herbal preparations may falsely lower the PSA level.

PSA may be measured in several ways.

* Total PSA measures all PSA in blood.

* Free PSA measures PSA that is not bound to protein (a lower free PSA indicates greater likelihood of prostate cancer).

* Complexed PSA measures PSA that is bound to other proteins.

* PSA velocity or slope measures how fast PSA values rise over a period of time.

American Cancer Society. (2007). Can prostate cancer be detected early? Retrieved July 21, 2008, from http://www.cancer.org/docroot/cri/content/ cri_2_4_3x_can_prostate_cancer_be_found_early_36.asp

RELATED ARTICLE: Program Encourages Men to Take Control of Prostate Health

Stay on Track for Better Prostate Health, a new program sponsored by the Prostate Cancer Education Council and sanofi-aventis, encourages men to take control of their own prostate health. Spokesperson Kyle Petty, a third-generation NASCAR driver, challenges men to take a pledge to undergo routine prostate cancer screening and to evaluate all treatment options if diagnosed with the disease. Patients can take the pledge or request a free prostate health educational brochure at www.pcaw.com/stayontrack.asp.

Contributing Editor Hanan Saca-Hazboun, RN, MSN, is a lecturer in the Faculty of Nursing and Health Science at Bethlehem University in West Bank, Palestinian Authority.