Marianne Mathewson-Chapman, PhD, ARNP
Incidence
The American Cancer Society predicted that 334,500 new
cases of prostate cancer would be diagnosed in 1997, but the prediction
was revised to 209,000 cases to reflect the 24% decline between the years
of 1992 and 1994.
1,2 Between 1976 and 1994, prostate cancer
rates doubled. The rise in new cancer cases may be explained by many factors,
including an increase in longevity for men, an increase in disease prevalence
due to environmental carcinogens, an acceptance of the prostate-specific
antigen (PSA) blood test, and improvements in techniques such as transrectal
ultrasonography and prostate biopsy. Although the cancer rates have risen
at all age levels, of particular note is the percentage of men under 70
years of age, with increases from 38% to 47% from 1986 to 1993.
3
With the advancing age of the population, prostate cancer will remain a
significant worldwide health care issue into the 21st century.
Incidence of prostate cancer is low in Asian men
and highest in black American men and Scandinavian men.1 In
Japan, the number of new cancer cases is expected to double by the year
2000 and quadruple by the year 2010. In contrast to white American and
Japanese men, black American men have a 47% higher incidence and a 128%
higher mortality rate than white men who live in the same geographic area.4
Men around the world are concerned with being diagnosed with prostate cancer,
with the treatment decisions, and most importantly, with the impact of
prostate cancer and its treatment on their quality of life. They have been
called the "walking worried": anxious about slow-rising PSA test results,
the recurrence of cancer, and the need for education about the disease.
Education/Prevention
Nurses as educators must be aware of the following issues
concerning prostate cancer. (1) Age: Prostate cancer is known as the disease
of the elderly, and it increases faster with age than any other malignancy.
(2) Family history: Prostate cancer has a heredity correlation. Male relatives
of prostate cancer and breast cancer patients have an increased risk of
developing prostate cancer.
5 (3) Race: Black American men develop
the disease more frequently and have a worse prognosis. Decision-making
to respond to the disease, to seek medical attention, and to choose and
comply to medical treatment programs may be a complex multidimensional
process and may explain certain racial differences in outcome.
6
(4) Socioeconomic status: Socioeconomic factors may not explain major differences
among racial groups, while economic factors may explain access to care,
type of care, and attitudes about personal health beliefs. (5) Occupation:
Studies focus on men’s exposure to occupational hazards that may impact
the biology of the disease. (6) Cigarette smoking: Data are not convincing
to link smoking with the disease. (7) Heavy metal exposure: Cadmium exposure
(batteries/ paint exposure) may contribute to prostate cancer directly,
or the risk may result from the availability of zinc and cadmium. (8) Sexually
transmitted infections: Data implicating sexual activity, the number of
sexual partners, or the presence of gonorrhea, human papillomavirus, cytomegalovirus,
and herpes viruses have shown an association but not causation. (9) Vasectomy:
Data are conflicting regarding vasectomy as a cause of the disease. (10)
Benign prostatic hyperplasia: Studies are inconclusive to prove that BPH
is a precursor. (11) Hormones: Testosterone, estrogen, and prolactin may
influence the growth of the prostate gland, but their roles in developing
the disease are conflicting. (12) Diet: Circulating androgen levels are
influenced by diet, and an association exists between high-fat diets and
an increased risk in developing prostate cancer.
Although there is no definitive cause of prostate
cancer, researchers have found that on autopsies from around the world,
prostate cancer becomes histologically detectable at age 30 in a few instances,
and by age 80 to 90 years, almost 70% to 90% of men will have evidence
of histologic tumors on autopsy regardless of national origin.7
Dietary factors, environmental hazards, and hormone influence are currently
under investigation.8 The nurse’s role in education is vital.
Prostate Cancer Screening Guidelines
In 1997, the American Cancer Society updated their guidelines
to recommend that digital examination and the PSA test be offered annually
beginning at age 50 years to men with a life expectancy of 10 years and
beginning at 45 years of age for those at high risk. Nurses must educate
men as to the benefits and risks of cancer screening. An abnormal PSA test
has been defined as a value more than 4.0 ng/mL, although PSA elevations
may be caused by benign conditions. Digital rectal examination should be
performed by a trained professional, but this examination is less effective
than the PSA test in detecting cancer. More education is needed regarding
the risks and benefits of screening and guidance about the PSA test results
for men of all ages. Men with positive screening results are faced with
difficult decisions regarding treatment options and the impact of such
treatment to their quality of life. Further research is needed to evaluate
the psychosocial impact and cost effectiveness of screening, enhancements
of PSA testing, new screening tests to predict the aggressiveness of the
disease, imaging and biopsy techniques, and impact of early detection on
patient outcomes. Nurses can make a vital contribution to prevention efforts
through cancer risk assessment, patient education, and promotion of alterations
in lifestyle and diet, all of which may lower the incidence, mortality,
and impact on quality of life for men with prostate cancer.
Treatment Decision Making
Men may present to their physicians with signs of urinary
obstruction including frequency, dysuria, slow stream or hematuria, and
increasing symptoms as the tumor increases in size. Following the prostate
cancer diagnosis, diagnostic tests are used to stage the disease. Treatment
is based on the TNM staging system: stage A (well-differentiated) through
stage D (distant metastasis).
The treatment options offered to men include periodic
observation, radical prostatectomy, radiation therapy, hormonal therapy,
and combination therapy.9 Each option offers challenges for
the nurses who care for patients. Nurses must address issues with patients
that impact quality of life and physical functioning (eg, sexual dysfunction,
incontinence, problems associated with radiation and surgery, recurrence
of disease, and living with advanced metastatic disease). Nursing care
is critical in the management of prostate cancer patients throughout the
disease continuum. Patient education, as well as emotional support to the
patient and spouse, is vital from screening to diagnosis, from treatment
to cure, or from palliative care to hospice care. The challenge to oncology
nursing is to assist men in making appropriate decisions regarding treatment
options.
Research and Rehabilitation
Three areas that seriously impact decisions regarding
treatment are sexual dysfunction, urinary/bowel incontinence, and impaired
quality of life.
10 The CARES (Cancer Rehabilitation Evaluation
System) tool is a quality-of-life measurement designed to identify rehabilitation
needs in physical, psychosocial, marital, sexual, and medical interaction
domains and to track needs over time.
11,12 Further research
in instrument development specific for prostate cancer is needed to determine
needs early after diagnosis and to target interventions that will enhance
optimal outcomes and improve quality of life for prostate cancer survivors.
References
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