Common Treatment Related Sideeffects. Radical Prostatectomy Urinary Effects. Survivorship what is the unmet need?

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1 Side Effects of Prostate Cancer Treatment Christian Smith Clinician Nurse, Velindre Cancer Centre Common Treatment Related Sideeffects Urinary RP, EBRT, Brachy Bowel EBRT & Brachy Sexual All treatment Hormone related Androgen Deprivation Therapy Survivorship what is the unmet need? 85% reported that they had experienced side effects from treatment 31% said they received too little aftercare for the treatment of side effects 19% said the care and support they received for the side effects they experienced were bad or very bad after treatment completion Radical Prostatectomy Urinary Effects Urinary incontinence temporary or permanent Varies enormously About 17 in 100 men have incontinence two years after surgery (The NHS shared decision-making website Rightcare ) Stricture PCUK 2012 Radical Prostatectomy - Urinary Effects Incontinence commonly stress incontinence Use of appropriate products Pelvic floor exercises Referral to continence service Bladder retraining Referral to specialist surgeon Internal male slings Artificial sphincters Radiotherapy _ Urinary Effects Radiation cystitis Greater risk of incontinence in men who have also had trans urethral resection of the prostate Lack of stats on incontinence Reduced bladder capacity Urethral stricture Haematuria 1

2 Brachytherapy Urinary Effects Difficulty passing urine Frequency and Urgency Nocturia Retention 5 in 100 men have incontinence after three years (NHS Rightcare) Urethral stricture RT & Brachy Urinary Effects Urinary frequency, urgency, urge incontinence, nocturia. Pelvic floor exercises Fluid management Bladder retraining Medication Use of appropriate products Referral to continence service RT & Brachy Urinary Effects Poor urinary stream Assessment of urinary symptoms Medication Cystoscopy Haematuria Cystoscopy Frequency volume chart Fluid assessment Number of pads per day IPSS Bladder scan (flow rate) Expectations and support Bowel Side Effects Good understanding of pelvic floor exercises Incontinence can range from a few drops to no control Continence can take anything from day-weeks-months to return Close fitting underpants for pads, dark coloured trousers Support and supplies varies enormously across the country When to ask for support or referral 2

3 Radiotherapy and Brachytherapy Bowel Side Effects Most commonly rectal problems following EBRT or Brachytherapy Men receiving RT to lymph nodes may experience small bowel problems Early bowel toxicity Dietary changes: Low fibre diet Fybogel Diarrhoea/constipation Faecal urgency/incontinence Tenesmus Bleeding Rectal pain Anti-diarrhoeal drugs Pads Late Bowel Effects Do not assume it is radiotherapy effect (1-2% risk of RT induced cancer over years) Refer Gastroenterologist Investigate PR bleed or sudden bowel habit change Flexible sigmoidoscopy Continence team referral Side Effects of Hormone therapy Side effects of Hormone Therapy Hot flushes tiredness and fatigue loss of sex drive (libido) and impotence mood swings and depression breast swelling & nipple tenderness weight gain around the middle loss of muscle mass increased risk of cardiovascular disease and diabetes osteoporosis. Hot Flushes- self management 80% of men 27% - most troublesome side effect Stop smoking Drink plenty of fluid, cut down alcohol and caffeine Reduce amount of spicy food Keep room temperature cool and use a fan Wear cotton clothes, especially at night Use cotton bed sheets Use a cotton towel on top of sheets that you can change easily Have lukewarm baths and showers 3

4 Complementary Therapies Acupuncture Hypnotherapy Herbal remedies Red clover Evening Primrose Sage Hot Flushes Medical Management Medroxyprogesterone Low dose Anti-androgen cyproterone acetate SSRI s Consider intermittent hormone therapy Gynacomastia and breast pain Occurs in around 50% of patients on antiandrogen Breast bud radiotherapy Tamoxifen Surgery Weight gain and muscle loss Regular resistance exercise such as swimming Diet dietician Reduced muscle and increase in body fat can affect body image of the patient. National exercise referral scheme Exercise advice Remember a little exercise is better than no exercise Start with small changes Set yourself realistic goals Keep a diary to monitor your progress Don t be too hard on yourself if you have an off day Listen to your body Involve your friends and family Acceptance of a new norm Lethargy, cognitive decline, mood changes Exclude other causes eg anaemia May improve with time Some exercise can increase energy levels Counselling Refer to National Exercise referral scheme Bone Health in Prostate cancer Androgen deprivation (ADT) is associated with Osteoporosis and Bone fragility. DEXA scans at diagnosis and 2 yearly thereafter if found to have osteoporosis (EAU guidelines). 4

5 Yearly bone loss, % 16/12/2014 Bone Loss Is Accelerated With ADT Normal men Postmenopausal women ADT 13 How to improve Bone Health with Regular exercise Resistance training improves Muscle strength, functional performance and balance. Gentle regular exercise reduces cancer related fatigue especially when delivered as a formal programme Payne H etal 2011 How to improve Bone Health Metastatic spinal cord compression Smoking Cessation Reduce alcohol intake Healthy BMI Diet sufficient in Vit D and Calcium. If not supplement Bisphosphantes Useful for pain relief from bone deposits Reduce and delay skeletal complications No survival benefit MSCC General Incidence 5 10 % of patients with cancer will develop MSCC (Smith et al 1993, Doyle 1998) 3-7.4% of all patients with Ca lung, breast and prostate will develop MSCC Also lymphoma, melanoma, sarcoma, myeloma, thyroid and renal cell carcinoma Epidemiology 4000 cases of MSCC per year Ref: NICE 50% present off their legs 20% of these walk after treatment and rehab 50% present on their legs 80% of these walk after treatment and rehab 5

6 GP s perspective 30% of population have back pain 20% of these visit their GP = 4 million people <1/1000 GP cases of spinal pain have spinal mets 23% of patients with MSCC have no prior cancer diagnosis MSCC - Distribution Cervical Vertebrae - 10% Thoracic Vertebrae 70% Lumbar Vertebrae 20% Ref: NICE MSCC an oncological emergency Why? 1. Devastating effects 2. Irreversible damage Signs and Symptoms Pain Muscle weakness Sensory disturbance Bladder/bowel dysfunction 3. Potentially life threatening Early Warning Signs of Metastatic Spinal Cord Compression Referred pain that is segmental or band-like Escalating pain which is poorly responsive to treatment (including medication) Different character or site to previous symptoms Funny feelings, odd sensations or heavy legs (multi-segmental) Lying flat increases pain Agonising pain causing anguish & despair Gait disturbance, unsteadiness, especially on stairs (not just a limp) Sleep grossly disturbed due to pain being worse at night Greenhalgh & Selfe 2009 Diagnosis and treatment Investigation of choice: MRI Medical treatment High dose steroids dexamethasone 8mg bd Radiotherapy Surgery 6