Lucinda Poulton, Lead Uro-oncology Clinical Nurse Specialist, GHT PROSTATE CANCER Diagnosis, treatment and side effects. Living with and beyond Prostate Cancer Lucinda Poulton, Lead Uro-oncology Clinical Nurse Specialist, GHT & Amanda Morss, Gloucestershire Community Prostate Cancer Nurse Specialist

Facts and Figures Prostate cancer is the most common cancer in men Over 47,000 men are diagnosed with Prostate cancer every year- 129 men per day 11,000 men die from prostate cancer every year

Facts and Figures 1 in 8 men will get prostate cancer in their lifetime Over 333,000 men are living with and after prostate cancer 3x higher risk in Afro-Caribbean men vs Caucasian in UK

Local Data NHS Gloucestershire- Incidence of newly diagnosed Prostate cancer 2011-2013 was 636 per year NHS Gloucestershire mortality 2011-2013 was on average 200 per year

Gleason Grade

Gleason Score There may be more than one grade of cancer in the biopsy samples. An overall Gleason score is worked out by adding together two Gleason grades. The first is the most common grade in all the samples.(eg 3 out of 5) The second is the highest grade of what’s left.(e.g 4 out of 5) When these two grades are added together, the total is called the Gleason score.eg 3+4=7

Gleason Score Grade 6 low risk Grade 7 moderate risk Grade 8-10 high risk

STAGING Most common method is TNM (Tumour-nodes-Metastases) T: Stage measures the tumour N:Stage measures whether cancer has spread to lymph glands M: Stage measures whether the cancer has spread to other parts of the body

T stage T stage shows how far the cancer has spread in and around the prostate T1- The cancer cannot be felt or seen on scans (Localised)

T stage T2 -The cancer can be felt but is contained within the prostate gland T2a -The cancer can be felt in half of one side(lobe) (Localised)

T stage T2b- The cancer can be felt in in more than half of one of the lobes, but not in both lobes of the prostate gland T2c -The cancer can be felt in both lobes but is still inside the prostate gland These are all stages of localised disease

Localised Prostate Cancer It may never cause a health problem or affect the individuals life physically It may never require active/radical treatment but will require active monitoring- ie Active Surveillance or Watchful Waiting

Active Surveillance A way of systematically monitoring localised prostate cancer within secondary care It is to avoid treatment unless there are signs the cancer is growing The patient can opt for treatment at any time

Advantages Avoids side effects of treatment. It won’t impact on physical aspects of quality of life/everyday life as much. Treatment can be offered should the cancer show signs of growing or the patient decides treatment is preferred.

Disadvantages Further biopsies required as part of the monitoring programme- side effects of biopsies, discomfort, risk of infection If general health changes then some treatments may no longer be suitable Some men worry that ‘nothing’ is being done with the cancer

Localised Prostate Cancer Some men may have a cancer that grows more quickly and has an increased risk of spreading. These will require active treatment

Treatment Options Men may be faced with several options of radical treatment for localised disease. Support from the clinical team is vital to allow the individual to make an informed decision about the treatment that is best suited for them and their cancer These may include- Surgery External Beam Radiotherapy Brachytherapy

Treatment Options Other treatment such as HIFU- High Intensity Focused Ultrasound and Cryotherapy are offered in certain centres but are not widely available and may be accessed/offered as part of a clinical trial Evidence and evaluation of outcomes for these treatments is still being gathered.

Surgery Types:- Open Radical Prostatectomy Laparoscopic Prostatectomy Robotically assisted Laparoscopic Prostatectomy

Advantages If the cancer is completely contained within the prostate, surgery will remove the cancer. Histology is gained on the entire gland, giving a clear picture of the aggressiveness of the disease and whether further treatment is required. Psychological benefits for patients knowing that the gland and the cancer is removed.

Disadvantages Major operation Hospital stay -2-5 days dependant on type of surgery/ recovery time Urinary leakage/ urethral strictures Risk of bowel injury Erectile Dysfunction Quality of life changes/impact on work Unable to produce semen- affects on fertility

Post –operative 1-2 days in hospital- local data for RALP Indwelling catheter for 10-14 days Clips removed 7-10 days OPA 6-8 weeks post surgery to discuss histology and post op PSA result( should be <0.1/un-recordable) Commence PDE5 Inhibitor – Cialis/Viagra Pelvic Floor Exercises/Physio review

Follow up 3 monthly PSA tests with Outpatient review for first 12 months 3 monthly PSA test with 6 month Outpatient review for second year A recordable PSA post surgery may indicate disease recurrence therefore referral back to secondary care for review and assessment will be required PSA Tracker- remote monitoring

Staging T3 and T4

Treatment Options for T3 Hormones Hormones and External Radiotherapy T3a disease may still be appropriate for radical surgery

Treatment Options for T4 Hormones Hormones and Chemotherapy Second line Hormones Radium

Hormone Therapy Works by stopping testosterone reaching the prostate cancer cells Testosterone can make the prostate cancer cells grow faster If testosterone is taken away, the prostate cancer cells begin to shrink wherever they are

When is Hormone therapy used? Hormone therapy on its own is not a cure for prostate cancer Used in different ways depending on the stage of the cancer Used alone, it can keep the cancer under control for many months or years before requiring further treatment

When is Hormone Therapy used? Localised disease -used alongside External beam radiotherapy- neo-adjuvant. Generally 3-6 months before and during radiotherapy T3 disease(locally advanced) hormone therapy can be used up to 2-3 years after completing radiotherapy

Hormone Therapy and Advanced Prostate Cancer Can be a life long treatment for men with advanced/metastatic prostate cancer Although not curative, it can keep the disease under control for many months and even years. It can also help manage symptoms of advanced prostate cancer such as bone pain

Types of Hormone Therapy Tablets- to block the effects of testosterone- Bicalutamide/ Cyproterone Acetate Surgery- Orchidectomy- surgical removal of testicles Injections/Implants- used to stop the testicles making testosterone. LHRH injections (agonists) are most common type of injections used- monthly, 3 monthly, six monthly preparations

Types of Hormone Therapy GnRH antagonists- not used as commonly as LHRH. Degarelix (Firmagon) is the only antagonist available in the UK. It can be used as first line treatment for advanced prostate cancer that has already spread to the bones. May help to prevent Metastatic Spinal Cord Compression(MSCC) Unlike LHRH agonists, Degarleix does not cause temporary rise in testosterone

Side Effects Hot flushes Changes to sex life- libido getting/maintaining erection changes to ejaculation/less semen/less intense orgasm Can make the penis testicles shorter and smaller

Side Effects Weight gain Gynaecomastia Fatigue Strength and muscle loss Mood changes Risk of osteoporosis Cardiovascular risks

Tips to help with side effects Hot Flushes- healthy diet good fluid intake reduce caffeine reduce spicy foods keep rooms cool light/ cotton clothing/sheets lukewarm showers/baths

Tips to help with side effects Hot Flushes cont: Medicines: anti- androgens may be used to counteract the effects of the flushes. Gabapentin may offer some improvement Complimentary therapies- acupuncture and hypnotherapy may offer an alternative solution

General Tips Physical activity/exercise Resistance exercise may help reduce muscle loss. Swimming, fast walking/ small weights Healthy diet Keeping motivated/lifestyle adjustments/ personal expectations Addressing sleep issues/patterns

The Future Holistic support for men with prostate cancer throughout the journey Promoting Self management following cancer treatment and its side effects Patient focused treatment workshops Macmillan Next Steps – living with and beyond cancer programme Treatment Summaries/PSA Tracker

The Uro-oncology Clinical Nurse Specialist Team Lucinda Poulton- Lead Uro-oncology Clinical Nurse Specialist- 0300 422 6913 Lucinda.Poulton1@nhs.net Zoe Eastman- Uro-oncology CNS- 0300 422 4334 Zoe.Eastman@nhs.net Karen Edwards- Uro-oncology CNS- 0300 422 6672 Karen.Edwards6@nhs.net

The Uro-oncology Clinical Nurse Specialist Team Hannah Hamblin- Uro-oncology CNS Hannah.Hamblin@nhs.net Joanne Shaw- Uro-oncology CNS Joanne.Shaw8@nhs.net Sophie Davies- Uro-oncology CNS Sophiee.Davies@nhs.net

The Uro-oncology Clinical Nurse Specialist Nurse Team Amanda Morss- Gloucestershire Community Prostate Cancer Specialist Nurse 0300 422 2950 Amanda.Morss@nhs.net Karen Collyer- Macmillan Cancer Support Worker. Karenl.Collyer@nhs.net