Prostate cancer. Treatments Side effects and management in the community setting

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1 Prostate cancer Treatments Side effects and management in the community setting Kristoffer Ohlin CNS Urology Janice Minter Lead Cancer Nurse St George s Hospital

2 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

3 Prostate cancer is a very treatable form of cancer Many different treatment options with similar outcomes Who is offered what and why?

4 Diagnosis and how it impacts treatment - The diagnostic pathway 1 Referral 2 Review 3 MRI/Biopsy 4 MDT 8 Re-referral 7 Follow-up 6 Treatment 5 Diagnostic Interventions

5 Staging of the prostate cancer affects choice of treatment

6 Staging made simple Localised prostate cancer (stage 1 and 2) Locally advanced prostate cancer (stage 3) Advanced prostate cancer (stage 4)

7 Focal treatments Stage 1 and 2a+b Cryotherapy Hifu Nanoknife Targeted photodynamic therapy

8 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.

9 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)

10 Radical prostatectomy

11 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.

12 External beam radiotherapy

13 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

14 Permanent seed brachytherapy

15 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.

16 Androgen deprivation therapy (hormone therapy) Used for Advanced prostate cancer or in conjunction with radiotherapy

17 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.

18 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

19 Side effects of surgery Side effects are immediate and include Fatigue Incontinence Erectile dysfunction Side effects likely to improve over time with good management

20 Management of surgical side effects Continence Erectile dysfunction 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 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

21 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

22 Side effects of androgen deprivation therapy Weight gain Hair loss Breast tenderness and enlargement Loss of libido Erectile dysfunction Hot flushes Fatigue Mood swings

23 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

24 Management of side effects from 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

25 Holistic Needs Assessment A simple questionnaire that is completed by a person affected by cancer 3 Parts- set of questions, Discussion, Written Care Plan

26 Holistic Needs Assessment

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29 Men with urological cancer Common concerns

30 Any Questions?

31 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.