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Prostate cancer: spotting the warning signs

Georgia Diebel
RGN HPCert
Support and Information Specialist Nurse and Specialist Nurse Programme Coordinator
Prostate Cancer Charity
London

With over 31,000 men diagnosed each year, prostate cancer is now the most common form of cancer among men in the UK. In 2003 there were 10,164 deaths as a result of prostate cancer in the UK, and over 92% of these occurred in men over 65.(1)
 
Epidemiology
Prostate cancer mainly affects men over the age of 60. Less than 1% are diagnosed under the age of 50, and 9% under 60.(2) The risk of developing prostate cancer increases with age, with the majority diagnosed in their 70s. Once in their 80s, about 80% of men will have prostate cancer, but most will be unaware and will die from other causes.(3)
Men are at an increased risk if there is a history of prostate cancer in their immediate family (father or brother),(4) or if they are of African-Caribbean ethnicity.(5) There is an increased incidence in men who habitually eat a western diet, high in saturated fat.(6) Overall, men have a one in 11 lifetime risk of developing prostate cancer.(7,8)
 
Where is the prostate?
Prepubescent boys have a prostate about the size of a pea and with puberty it grows to the size of a walnut. It starts to grow again once men reach their 50s and beyond, often causing lower urinary tract symptoms (LUTS). It sits just under the bladder, in front of the rectum.
The urethra passes from the bladder down through the middle of the prostate, draining urine from the bladder and out through the penis. The gland is complex, made up of an internal (transitional) zone and external or peripheral zones of fibrous tissue. Prostate cancer usually develops on the outer part of the gland and away from the urethra, which is possibly why not all men experience urinary symptoms even when they have cancer.(9)
 
Functions of the prostate
As well as playing a part in urinary function, the prostate is key to sexual and reproductive function. Not all of its functions are yet known. It produces about 30% of seminal fluid necessary for ejaculation. The seminal vesicles are joined to the prostate gland where they store sperm, protected in seminal fluid. During sexual activity the muscles around the seminal vesicles contract, expelling seminal fluid out via the ejaculatory ducts in the prostate, and along the urethra for ejaculation.

Signs and symptoms
There are three prostate conditions:

  • Prostate cancer.
  • Benign prostatic hyperplasia (BPH).
  • Prostatitis.

          All three cause LUTS, including:
Voiding

  • Hesitancy.
  • Postmicturition dribbling.
  • Weak stream.
  • Prolonged micturition.
  • Retention.
  • Incomplete emptying.
  • Intermittency of flow.
  • Straining to void.                                               

Storage

  • Frequency.
  • Urgency.
  • Nocturia.
  • Urge incontinence.

Additional symptoms of prostate cancer
These can include:

  • Lower back pain.
  • Problems getting or keeping an erection.
  • Pain in the hips or pelvis.
  • Blood in the urine - but this is rare.

It is important to note that men can have prostate cancer with no symptoms at all. Men may experience a variety of urinary symptoms as their prostate gland begins to enlarge, though they generally seek treatment only when their symptoms become sufficiently bothersome or quality of life becomes impaired.(10,11)

Stages of prostate cancer
The multidisciplinary team, including the uro-oncology specialist nurse, meet to evaluate all the tests and investigations, including:

  • Prostate-specific antigen (PSA) blood test.
  • Digital rectal examination (DRE).
  • Biopsy and Gleason grade.
  • Bone scan.
  • MRI and/or CT scan.
  • Chest X-ray (optional).

They will then categorise each case into one of the following stages:

  • Localised - contained within the prostate gland.
  • Locally advanced - the cancer has breeched the capsule of the gland and spread just outside the gland.
  • Advanced - the cancer has spread, typically to bone or the lymph system.

Approximately 50% of cases in the UK are classified as localised disease and can be offered curative treatment.
The majority of the remaining 50% receive hormone therapy alone (some may be offered additional radiotherapy) to suppress cancer activity for as long as possible.

Treating prostate cancer
Treatments are planned according to the stage of the disease, but can commonly include:

  • Radical surgery to remove the prostate.
  • External beam radiotherapy.
  • Brachytherapy (implanting radioactive seeds into the prostate).
  • Hormone therapy.
  • Active monitoring (no medical intervention, but close monitoring).      

Later in advanced disease, treatments can include:

  • Chemotherapy.
  • Steroids.
  • Bisphosphonates (in cases of hypercalcaemia).
  • Analgesia.

Side-effects of treatment
All treatment options, apart from active monitoring, carry the risk of side-effects, which can have a profound effect on quality of life. The most significant of these are:

  • Erectile dysfunction (impotence).
  • Incontinence.
  • Hormonal changes, including hot flushes, weight gain, mood changes.

Implications for services in primary care
We do not have a national screening programme in the UK using the PSA test because there is no evidence yet that it saves lives. Some practitioners suggest that a nationwide screening programme would lead to a large number of false-positive results, increasing costs and anxiety in patients. No other country appears to have a screening programme, although it is increasingly popular in many developed countries despite the lack of clarity surrounding its effectiveness. The NHS Prostate Cancer Risk Management Programme was launched in primary care on 23 September 2002 in order to address this issue.
Prostate cancer incidence is rising, due in part to the advent of PSA testing and the increasing ageing population. With it, the demand for services to support the care needs of men and their families will increase too. Primary care services will need to support men through a variety of treatment options and care pathways:

  • The undiagnosed man undergoing investigations.
  • The newly diagnosed man.
  • Those considering radical treatment options.
  • Those suffering side-effects of treatment.
  • Those on long-term hormone therapy.
  • Those requiring palliative care.

In order to achieve optimal care, prostate education in primary care will need to be widespread and comprehensive so that primary care teams are engaged and prepared to meet the needs of the prostate cancer community.
Primary care nurses are ideally placed to enquire about urinary symptoms and raise awareness. They can encourage men to seek assessment of their symptoms in order to determine a cause, minimise future complications and improve their quality of life. Health promotion environments, such as waiting rooms, provide the ideal environment for posters and literature about prostate conditions.
Working collaboratively with secondary care partners and the voluntary sector, primary care workers are ideally positioned to capture the key audience for important health messages.

Conclusion
The political and campaigning climate will increase pressure on prostate cancer as a key topical issue for the men's health agenda. The inevitable increase in incidence created through raising awareness and due to the ageing population will see an ever-increasing demand on primary care services to meet the needs of each individual man.
Primary care nurses are well placed to address the initial assessment needs and ongoing care of many men living with prostate cancer and the side -effects that can impact on quality of life for many years. Responsibility lies with the government to make sufficient provision for the education and resources to equip primary care providers to deliver this care.
The additional benefits of the voluntary sector commitment to the provision and delivery of this care will only serve to enhance the outcomes for the patient and their family.

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References

  1. Cancer Research UK. Cancer facts and figures. Available from http://www.cancerresearchuk.org.uk/statistics
  2. Office for National Statistics. Cancer statistics registrations: Registrations of cancer diagnosed in 2003, England. London: Office for National Statistics; 2005. Available from: http://www.statistics.gov.uk/downloads/theme_health/MB1_34/MB1_34.pdf
  3. Office for National Statistics. Cancer statistics registrations: Registrations of cancer diagnosed in 2002, England. Series MB1 no 33. London: Office for National Statistics; 2005. Available from: http://www.statistics.gov.uk/downloads/theme_health/MB1_33/MB1_33.pdf
  4. Bandolier. Familial prostate cancer risk. Available from http://www.jr2.ox.ac.uk/bandolier/booth/Cancer/fampca.html
  5. Chinegwundoh F, Enver MK, Lee A, Ben-Shlomo Y, et al. Increased risk of prostate cancer in UK Afro-Caribbean immigrants. BJU Int 2003;91(S2):16.
  6. Pandian S, Heys S, Wahle K, McClinton S. Dietary fats and prostate cancer: a review. Prostate 2000:2(3):123-9.
  7. Office for National Statistics. 2004. (Personal correspondence - please contact ONS for details)
  8. Hsing A, Tsao L, Devesa S. International trends and patterns of prostate cancer incidence and mortality. Int J Cancer 2000;85:60-7.
  9. Kirby RS. The prostate: small gland, big problem. Oxford: Health Press; 2002.
  10. Medina J, et al. Benign prostatic hyperplasia (the ageing prostate). Med Clin North Am 1999;83:1213-29.
  11. Spickett I. Benign prostatic hyperplasia: clinical top 50. Independent Nurse 2005;10 Oct:23-4.

Resources
The Prostate Cancer Charity The Prostate Cancer Charity is the largest and most comprehensive charity working specifically in the field of prostate cancer. We aim to provide hope through research and practical support.
To receive free patient literature and further information about Prostate Cancer Awareness Week 2006, please contact The Prostate Cancer Charity.
T:0845 300 8383
confidential helpline, which is staffed by
specialist nurses and is open from 10am-4pm Monday to Friday and Wednesdays from 7-9pm
W:www.prostate-cancer.org.uk

Cancer Research UK
W:http://info.cancerresearchuk.org/cancerstats/types/prostate/

Office for National Statistics
W:www.statistics.gov.uk

NHS Cancer Screening Programmes
W:www.cancer screening.nhs.uk/

UK Prostate Link
W:www.prostate-link.org.uk