1. 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

2. 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

3. 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

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

5. Gleason Grade

6. 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

7. Gleason Score Grade 6 low risk Grade 7 moderate risk
Grade high risk

8. 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

9. 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)

10. 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)

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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.

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

20. 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.

21. 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

22. Post –operative 1-2 days in hospital- local data for RALP
Indwelling catheter for 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

23. 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

24. Staging T3 and T4

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

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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

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

35. 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

36. 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

37. 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

38. 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

39. The Uro-oncology Clinical Nurse Specialist Team
Lucinda Poulton- Lead Uro-oncology Clinical Nurse Specialist
Zoe Eastman- Uro-oncology CNS
Karen Edwards- Uro-oncology CNS

40. The Uro-oncology Clinical Nurse Specialist Team
Hannah Hamblin- Uro-oncology CNS
Joanne Shaw- Uro-oncology CNS
Sophie Davies- Uro-oncology CNS

41. The Uro-oncology Clinical Nurse Specialist Nurse Team
Amanda Morss- Gloucestershire Community Prostate Cancer Specialist Nurse
Karen Collyer- Macmillan Cancer Support Worker.