The treatment of Ca P depends upon the patient's age, the stage and grade of the cancer, severity of co-morbid conditions, and the patient's preference. It is important for the patient to realize that all treatment options for prostate cancer have side effects. Table 4 lists treatment options available for the patient with Ca P.
For localized Ca P (cancer that is contained within the prostate), the treatment options include observation ("watchful waiting"), surgery (radical retropubic, perineal, laparoscopic, or da Vinci robotic-assisted prostatectomy), radiation therapy (brachytherapy or external beam radiation therapy [EBRT]), and cryosurgery. Brachytherapy and EBRT may be done singly or in combination, and may also include hormone therapy.
Locally advanced Ca P is not likely to be cured by a single treatment modality alone (for example, surgery or radiation therapy). Multimodality treatments are currently being studied as a part of clinical trials, and these options may include chemotherapy followed by surgery, surgery followed by external beam radiation therapy or chemotherapy, or hormone therapy and radiation therapy (Zippe & Kedia, 2000).
For advanced Ca P (cancer that has spread beyond the prostate), the treatment involves decreasing or stopping the production of testosterone, the "fuel" that can cause the cancer to spread. Testosterone is a product of the testicles (primary source) and the adrenal glands. Medical or surgical castration is an option available to the patient.
Surgical castration (bilateral orchiectomy) involves the surgical removal of the testicles, the primary source of testosterone. While this may not be the preference of men in the United States currently, it is the most cost-effective method of stopping the production of testosterone and slowing the spread of Ca P.
Medical castration involves the use of medications to prevent the production of testosterone by the testicles. Luteinizing hormone releasing hormone (LHRH) agonists are injections of medications that the patient receives at intervals (monthly, every 3 or 4 months, or yearly) to block testosterone production. Anti-androgen medication blocks the use of testosterone produced by the adrenal glands. In addition, there are clinical trials involving the use of hormonal or nonhormonal medications to decrease testosterone production.
Following definitive treatment for Ca P by surgery or radiation therapy, each physician has a protocol to evaluate the patient. If the PSA begins to rise, this indicates that the cancer has recurred, and the next step in treating the patient depends upon the primary treatment that the patient received. For the patient who has had surgery, treatment options might include observation, radiation therapy (the patient with a positive margin), or hormone therapy (the patient with metastatic disease). For the patient who has undergone radiation therapy, the treatment options might include observation, surgery (salvage prostatectomy), cryotherapy, or hormone therapy. Enrollment in a clinical trial may be an option if the patient meets the eligibility requirements.
Hormone-refractory Ca P occurs when hormone therapy has failed and the PSA values continue to rise indicating cancer progression. Checking the testosterone level to verify that the patient is at castrate level (less than 50 ng/ml) is important. If the patient's testosterone is not at castrate level, the patient should begin LHRH agonist therapy. If the patient's testosterone is at castrate level, the patient should consider enrolling in a clinical trial. The current methods to manage the patient with hormone-refractory disease have met with limited success (Smith, Dawson, & Trump, 2000).
All treatments for prostate cancer have side effects. It is important for the patient to be aware of these effects because the side-effect profile may help the patient decide which is the best treatment option for him. Observation or "watchful waiting" (monitoring the patient by a PSA blood test and a DRE at a predetermined time period) may have a psychological effect for the patient. It is often difficult for him to know that he has cancer and is "doing nothing." The man may be comfortable with this option, but his family and/or friends may not be. They may encourage the patient to "do something" to treat the cancer causing the man to suffer from additional psychological stress.
Surgical removal of the prostate is a major procedure with the potential and side effects of any major surgical procedure such as the potential for infection, pneumonia, blood clots, etc. Additional side effects of radical prostatectomy may include postoperative incontinence and impotence. Postoperative incontinence is usually temporary but stress incontinence (such as leaking a few drops of urine when coughing, laughing, lifting heavy objects) may persist indefinitely. Potency rates vary postoperatively, even if a bilateral nerve-sparing procedure was completed. For men between ages 60 to 69, potency rates with a bilateral nerve-sparing procedure can range from 25% to 75% (Presti, 2004). For men in that age range who have undergone a unilateral nerve-sparing procedure, the potency rates can range from 10% to 50% (Presti, 2004). Recovery of spontaneous erections can take a year or longer (Presti, 2004).
Brachytherapy (implantation of radioactive "seeds" into the prostate gland) is a procedure that is done in the operating room with general anesthesia. The side effects may include the risks of general anesthesia, as well as specific side effects from the radiation. Irritative voiding symptoms (urgency, frequency, dysuria) are common. These symptoms can be treated with medications. The use of tamsulosin HCl (Flomax®), doxazosin (Cardura®), or terazosin (Hytrin®) may help relieve the symptoms. Phenazopyridine (Pyridium®) may be useful to alleviate the burning feeling that the patient may also experience. A small percentage of patients (usually less than 10%) will experience urinary retention due to swelling of the prostate from the radiation (Speight & Roach, 2004). This will usually resolve in time and is treated in the short term with intermittent self-catheterization (ISC) (Jhaveri & Klein, 2001).
External beam radiation therapy (EBRT) can be done by the conventional 3-D conformal method. This uses imaging and computerized treatment planning software that allows a high-dose radiation to conform to the prostate with greater sparing of the surrounding normal tissue. The radiation is usually fractionated over 35 to 37 treatments. This same technology allows the delivery of a higher dosage of radiation without unacceptable toxicity, providing better local control of prostate cancer in select patients; this technique is known as intensity-modulated radiation therapy (IMRT) (Speight & Roach, 2004).
Common side effects related to either EBRT or IMRT include the irritative urinary symptoms of urgency, frequency, and dysuria. These may be treated with medications described earlier and usually subside with time. Urethral strictures and radiation cystitis (in less than 10% of patients) can occur (Speight & Roach, 2004). In addition, there may be rectal discomfort (the prostate sits in front of the rectum and radiation can affect the rectum) and/or rectal urgency. Treatment with Anusol® (hydrocortisone) suppositories or Sitz baths provides relief for these symptoms, which usually diminish over time. Anal stricture and radiation proctitis are rare complications (Speight & Roach, 2004).
Side effects of a combination of brachytherapy and EBRT are the same as described previously, but the effects may be intensified due to the combined effect of the treatments (Speight & Roach, 2004). Cryosurgery or freezing of prostate tissue is also a treatment option for Ca P. This is done in the operating room under general anesthesia. The ice destroys the Ca P tissue and prostate tissue. Side effects may include impotence and urinary tract obstruction (due to necrotic prostate tissue).
The main side effect of hormone therapy with the LHRH agonist medication is hot flashes. Vitamin E or Megace® may help to alleviate this symptom, but if the hormone therapy is being done in conjunction with radiation therapy, the use of vitamin E is not recommended. Vitamin E is an antioxidant and radiation therapy works through oxygen radicals. There could potentially be some scavenging of this which would negate the effectiveness of the radiation therapy. It is commonly thought that this effect decreases over time (Speight & Roach, 2004).
Other side effects may include erectile dysfunction, loss of libido, increased appetite, weight gain (especially in the waist area), decreased energy, muscle wasting, anemia, and mood changes. One of the long-term sequelae of the LHRH agonists is osteoporosis. Diet and exercise (especially weight-bearing exercises) are interventions that may lessen the effects of LHRH therapy.
Anti-androgen therapy side effects vary according to the medication, but all can result in some degree of feminization or regression of secondary sexual characteristics, loss of libido, and erectile dysfunction. Nilutamide (Nilandron®) can cause nausea, hot flashes, and affect night vision. Flutamide (Eulexin®) can cause nausea, diarrhea, hot flashes, and breast tenderness. Bicalutamide (Casodex®) can cause gynecomastia. Rare cases of hepatotoxicity with flutamide have been reported (Daw & Peereboom, 2001).
Older men diagnosed with Ca P can vary in age (from 65 years to more than 85 years). Each man may experience a wide variation in co-morbid conditions which requires that each man be individually assessed based his overall health prior to any discussion regarding the best treatment for Ca P. Health care practitioners must be aware of two situations that may be more prevalent in older men. Some men may believe that "whatever the doctor decides" is the thing that they will do because "the doctor knows best." These men should be encouraged to ask pertinent questions that will help them to understand what they will experience when they agree to a specific treatment.
The patient and his spouse may be so overwhelmed by the diagnosis of cancer that they hear nothing after hearing the word "cancer." For many of these men the word "cancer" has a very negative connotation of great suffering and death, and it is one of the most feared medical diagnoses (Balducci, 2003). For this patient and spouse, there is no one way that will guarantee that the patient makes an educated treatment decision. Written material as well as a verbal discussion of treatment options may be helpful. In addition, an identified resource person who can answer questions as they arise can also help. As Ca P is typically a slow-growing cancer, the patient and his family have time to consider the treatment that will best suit the patient and his lifestyle.
Health care workers dealing with the older man and his partner need to realize that the patient may experience difficulty in seeing and hearing. Men may seem to agree to everything that is discussed, when in reality, they have not heard and therefore have not understood what has been presented. Assessing the patient for a hearing or sight problem during the initial history and physical examination will help identify men who have special needs. For the patient with limited sight, information should be given verbally, and written information should be in a larger-than-normal font. For the patient who has difficulty with hearing, speaking slowly and distinctly will help and should be supplemented with written information.
Many men between the ages of 65 and 74 years have the potential for a long life, especially if they do not have multiple medical problems. For those men, surgery or radiation therapy is a viable option that can potentially cure their prostate cancer. Each man needs to identify what is important to him and what side effects he is willing to endure to meet those ends. Knowing the side effects may help the man decide which option will be the best option for him.
The surgical treatment option for a man older than age 70 years without significant medical problems becomes slightly less clear cut. This patient may have unknown underlying medical problems that could affect the surgical experience. Older men may take longer to recover from surgery and may also experience a slower recovery of continence. In addition, potency is less likely to be recovered in this population (Presti, 2004). Whether this is due to the surgery or the likely co-morbid conditions is unknown. If the patient understands the risks and wishes to pursue surgery as his preferred treatment option, the urologist is likely to recommend additional testing to rule out co-morbid conditions and ensure that the patient is in optimal condition to undergo a major surgical procedure.
For the 65 to 70-year-old man with multiple medical problems and/or and an expected lifespan of less than 10 years, a form of radiation therapy may be the recommended treatment option. This is especially true for the patient with a high-grade prostate cancer. While radiation can have side effects, a higher-grade cancer can potentially be cured with radiation therapy, and prevent the significant effects that metastatic cancer involves.
Older men have a great fear of cancer and the pain and suffering that may occur with the diagnosis. For men with a low-grade cancer (Gleason six and below), observation may be a very reasonable option. Many men (or their partners) may not be comfortable psychologically with this option, since they do not feel that they are actively treating the cancer. Continued support and encouragement may help the man and his partner understand that this cancer is not likely to be life threatening. The man and his partner must be told that if there is a need to institute treatment, the treatment will be started. The treatment can be either radiation therapy or hormone therapy depending upon the particular patient situation. For example, if the patient's cancer spreads, hormone therapy would be appropriate. Likewise, if the patient becomes psychologically uncomfortable due to a rising PSA, radiation therapy might be the best treatment. Individual situations will dictate the best treatment for this patient population.
For the patient over 75 years of age with an aggressive prostate cancer (a Gleason score of seven or above), there needs to be a discussion of treatment options because these men may die of their prostate cancer (and not with the prostate cancer). Radiation therapy and/or hormone therapy will be the treatment(s) of choice. Helping the man and family understand what to expect, how to deal with side effects, and who to call with questions or concerns will help these patients and families through the difficult time.
Often the caregiver of this patient population is overlooked. An elderly spouse may need to take care of matters that she never had to do before such as assistance with ADL or managing the family finances. Helping the patient deal with side effects of treatment, as well as dealing with the suffering of the loved one can be very stressful. If the patient has no spouse, these duties will fall to another family member such as a child or grandchild who has responsibilities of his or her own. These issues should be addressed when providing information regarding treatment options and side effects (Haley, 2003).
Urol Nurs. 2004;24(4) © 2004 Society of Urologic Nurses and Associates
Cite this: Prostate Cancer in Older Men - Medscape - Aug 01, 2004.