Prostate cancer

Treatments – Side effects and

management in the community setting

Kristoffer Ohlin – CNS Urology

Janice Minter – Lead Cancer Nurse

St George’s Hospital

Agenda

• Prostate cancer treatments

– Radiotherapy

– Surgery

– Focal therapies

- Who is offered what

• Side effects of treatment

– Management in the community setting

• Breakout session on ED and Continence

• Hands on training – Holistic needs assessments & care plans

Prostate cancer is a very

treatable form of cancer

• Many different treatment

options with similar

outcomes

• Who is offered what and

why?

8Re-referral

3MRI/Biopsy

2Review

1Referral

5Diagnostic

Interventions

Diagnosis and how it impacts treatment- The diagnostic pathway

4MDT

6Treatment

7Follow-up

Staging of the prostate cancer affects

choice of treatment

Staging made simple

Localised prostate cancer

(stage 1 and 2)

Locally advanced prostate

cancer (stage 3)

Advanced prostate cancer

(stage 4)

Focal treatments – Stage 1 and 2a+b

• Cryotherapy

• Hifu

• Nanoknife

• Targeted photodynamic therapy

Focal treatments

• The main cancer lesion(s) within the prostate are targeted with

the treatment – the whole gland is not treated – the patient will

likely require multiple such treatments over his lifetime.

Curative treatments – Prostate cancer

stage 1 – 3

Can be divided into two treatment types

Radical treatment – Treatment aimed at the whole gland

• Surgery

• Radical radiotherapy

• (Permanent seed brachytherapy)

Radical prostatectomy

Radical prostatectomy

• The prostate is removed in its entirety, together with the

seminal vesicles and sometimes with extended lymph node

clearance in order to cure the cancer.

External beam

radiotherapy

Radiotherapy

• The whole prostate is treated with radiation daily over 6 weeks,

destroying the prostate tissue and the prostate cancer – often

combined with hormone treatment

Permanent seed

brachytherapy

Permanent seed brachytherapy

• Seeds of radioactive material are inserted directly into the

prostate through the perineum using a mapping template,

these seeds over time will destroy the prostate tissue and the

prostate cancer. Not suitable for men with BPE.

Androgen deprivation

therapy (hormone

therapy)

Used for Advanced

prostate cancer or in

conjunction with

radiotherapy

Androgen deprivation therapy (Stage 4 or

used in conjunction with radiotherapy)

• Stops the production of the male hormone testosterone that

allows the prostate cancer to grow and spread

• Used as monotherapy for men with cancer that can’t be cured

or with radiotherapy in order to stop the cancer from spreading

while the treatment is ongoing.

Side effects resulting from treatment

• Incontinence

• Erectile dysfunction

• Infertility

• Cystitis

• Bowel irritation

• Urinary retention

• Fatigue

• Mood changes

• Loss of libido

• Depression

• Cardiovascular events

• Osteoporosis

• Hot flushes

• Memory problems

Side effects of surgery

• Side effects are immediate and include

– Fatigue

– Incontinence

– Erectile dysfunction

Side effects likely to improve over time with good

management

Continence Pelvic floor muscle exercises will

strengthen the support for the

bladder and most men will regain

continence within a year

In those men that do not regain

continence, surgical implants can

help

Erectile dysfunction PDE5 inhibitors like Viagra and

Cialis introduced early will improve

local blood flow and nerve

regeneration

Use of a vacuum device helps

preserve erectile tissues

Other medical treatments

Implants if not successful

Management of surgical side effects

Side effects of radiotherapy

• Immediate side effects include

– Fatigue

– Bowel problems – diarrhoea, blood in the stool, abdominal pain

– Irritation of bladder and urinary tract (dysuria, urgency, frequency, retention, leakage)

– Dysorgasmia

• Long term side effects can develop over time, including the above but also include

– Erectile dysfunction

– Incontinence

– Secondary cancers (more than 15 years later).

• Side effects are irreversible but can be managed symptomatically

Side effects of androgen deprivation

therapy

• Weight gain

• Hair loss

• Breast tenderness and enlargement

• Loss of libido

• Erectile dysfunction

• Hot flushes

• Fatigue

• Mood swings

Side effects of androgen deprivation

therapy continued

• Strength and muscle loss

• Osteoporosis

• Memory loss

• Increased risk for cardiovascular disease and events

• Increased risk of developing type 2 diabetes

• Increased risk of stroke

• Side effects last for as long as treatment continues and will

continue until testosterone levels normalise

• Some side effects may never improve

Management of side effectsfrom treatment is tailored based on the patient’s needs and wants.

A useful tool for measuring your patient’s distress levels and concerns is a Holistic Needs Assessment

• A simple questionnaire that

is completed by a person

affected by cancer

• 3 Parts- set of questions,

Discussion, Written Care

Plan

Holistic Needs Assessment

Holistic Needs Assessment

Men with urological cancer

Common concerns

Any Questions?

Hands on training:Holistic needs assessments and care plans

In your groups, consider this scenario, review the holistic needs assessment, and make a care plan.

A 54 year old African Caribbean gentleman comes to see you at work. He had his prostatectomy a year ago and is struggling emotionally and financially and is having regrets about having the operation. His stage of cancer was T3a, which means his cancer was just breaching the capsule of the gland. He does not seem to understand what his stage of cancer means. He had partially nerve sparing surgery, but is yet to have return of erections usable for sexual intercourse. He is still suffering from incontinence and uses two pads per day. He has grown estranged from his life partner and his children, struggling to connect, as he himself feels inadequate as a man. He feels ashamed of himself, and has not talked to anyone else about his issues. He does not feel comfortable around the doctors and nurses in the hospital and is struggling to open up to them. From your conversation it becomes apparent that he has not spoken to anyone in his community about his issues.