Question

C. A., a 63 year old Filipino male with hormone-refractory prostate cancer is your clinic patient. C. A. was diagnosed with benign prostatic hypertrophy (BPH) several years ago and was taking alpha blockers for this condition.

A year ago, his BPH symptoms worsened despite maximal therapy. At that time, his primary physician performed a digital rectal examination and noted that he had a new hard nodule (1cm x 1cm) in the right lobe of his prostate and a PSA of 2.4 (PSA in the year prior to that was 2.2). A prostate biopsy revealed high-grade adenocarcinoma. A bone scan showed a small focal abnormality in the lumbar spine at the level of the L2 vertebra. The prostate cancer was staged as T2b.

1. What are the risk factors of prostate cancer?
2. How is prostate cancer diagnosed?

C. A.’s past medical history includes the following:

• Hormone-refractory metastatic prostate cancer per HPI (history of present illness)
• Severe Gastroesophageal Reflux Disease
• Coronary artery disease status post myocardial infarction two years ago with a history of left circumflex percutaneous transluminal coronary angioplasty
• Pulmonary nodules 2 mm , stable per CT for the last 5 years
• Hypertension
• History of depression
• Current tobacco abuse
• Hyperlipidemia

At the time of diagnosis, the patient was seen by the oncologist and then by radiation oncologist. Their recommendation was for the patient to undergo radiation therapy (external beam Intensity Modulated Radiation Therapy) followed by hormonal therapy and possible Taxotere trial.

1. Based on this information, what aspect of C. A.’s history do you think will have an implication in his nursing care?

Six months post-cancer diagnosis, C. A. was treated with radiation therapy (external beam Intensity Modulated Radiation Therapy) to his prostate and pelvic lymph nodes and placed on hormonal therapy and a Taxotere trial. He complained of increasing low back pain. An MRI scan showed bony metastasis to the L2 and L3 spine. The PSA was increasing at 18.6. He received radiation therapy to the spine.

1. What will be your priority concern at this time?
2. What changes in the plan of care will you recommend?

Eleven months post-cancer diagnosis, C. A. is here with his wife to see this physician for routine follow-up. He reports moderate pain control on his current pain regimen. He also states that his appetite is poor and that he tires easily. He is independent in his ADLs and IADLs, and even working occasionally on his good days. You note that he has lost 2 pounds since his last clinic visit 2 months ago. (BMI= 25.6).He is alert and oriented. His recent labs show a PSA = 70.7

1. You assisted C. A. for an interval history (wt loss, fatigue, Taxotere, etc). He lies down on the examination table for the physician to do a routine examination. What questions will you ask C. A.?
2. C. A. is looking anxious and asks: “How much time do I have?” What will be your response?

The physician’s progress notes read: C. A. is a 63 year old male with hormone refractory prostate cancer, KPS = 70%, anorexia, weight loss, increasing pain and fatigue. His PSA is increasing despite multi-modal therapy. He is alert and oriented. He has no other reported symptoms.

1. Which of these findings is your priority concern at this time? Why?

You researched that patients with hormone refractory prostate cancer who have indices similar to C. A. (age 63, PSA 70.8, Albumin 2.6, Alkaline Phosphatase 219, Hgb 11.5, LDH 680), who are tracked through the database at Memorial Sloan Kettering Cancer Center. They show a median survival of 3 months at a Karnofsky Performance Scale (KPS) of 70 (which is C. A.’s KPS score at the present time) and a 1yr survival probability of 2% with 2-yr survival probability of < 1%. (These estimates don’t directly consider presence or extent of metastases, PSA doubling time or patient ethnicity).

As for the patient’s health care goals, his primary objective is to remain pain free. He realizes that despite his young age, metastatic prostate cancer is an uncurable disease with treatments being primarily palliative with rather modest survival benefit at the current stage.

1. With this new development, what changes will you expect in C. A.’s plan of care?
2. What recommendations will you include for C. A.’s benefit?

Though his wishes are to continue considering available chemotherapy/radiation, C. A.’s primary goal is to be pain free, and to be able to spend quality time with his family, and to stay active. Though he would prefer to have CPR and intubation as treatments for acute issues, he would not like prolonged life support and would wish to have them withdrawn if they only served to prolong his life artificially.

1. What are the available resources that you can recommend for C. A. so he can achieve these goals?

Answer 1

What are the risk factors of prostate cancer?

Prostate cancer is the leading cancer among mens causing severe illness and death among men. The major risk factors of prostate cancer are

• Advanced age( Age above 40 years)
• Family history
• Male sex
• Any metastatic tumour in body
• Alcoholism
• Exposure to radiation and chemicals
• Consuming smoked food
• Heavy red meat consumption
• Diet less in fiber
• Patient with any history of colorectal cancer
• Obesity
• Inflammation of prostate gland
• High intake of processed meat and fatty food
• Increased inatake of diary products
• Physical inactivity
• Role of Genetics

How is prostate cancer diagnosed?

Intially the prostate cancer is diagnosed by a detailed history collection from the patient. Where various details are collected about his clinical manifestations. family history of diseases. role of genetics, habbits, exposure to chemicals, radiation, type of occupatio, life style etc are collected by the physician. Followed by which a detailed physical examination is carried out.During physical examination,the clinical symptoms of the patient is carried out.Digital rectal examination is carried out to identify the Development of prostate cancer.During which, the physician will insert his fingers to identify any hard area, growth, enlargement etc, This will provide information about any extra growth or enlargement.Prostate specific antigen is another blood test used to detect prostate cancer. Its a protein secreted by the prostate gland. SO usually in patients with prostste cancer may have elevated PSA level which may suggest that any infection, inflammation or cancer of the prostste gland. A part from that image studies like CT, MRI scan also carried out to identify the disease.Trans rectal ultra sound are also beneficial. Inorder to identify the metastasis of the disease, PET scan ,bone scan etc can also carried out.

Six months post-cancer diagnosis,What will be your priority concern at this time?

Following, 6 months of radiation therapy and hormonal therapy, Patient is having complaints of increasing low back pain. And MRI scan shows bony metastasis to the L2 and L3 spine. The PSA also increasing at 18.6. He received radiation therapy to the spine.

All these indicating that the cancer started to spread to his bone also.In this situation major priority concern is about treating the pain and providing palliative care to the patient.the nursing acre must be focused up on releving the lower back pain,mainatin the spinal function, maintain normal bone integrity and to establich the activity level of the patient.Analgesics can be included in the treatment plan of the patient. A part from that, non pharmacological measures of pain management also included in the tretament plan of the patient.protect the patient from all kind of injuries, bone fracture etc.Maintain adequate calcium intake and mineralization of the bone.

He lies down on the examination table for the physician to do a routine examination. What questions will you ask C. A.?

• Hi, how you feeling now?
• WHat about your complaints of pain, its reduced? Can you rate me your pain on a scale of 1-10?
• Do you feel pain anywhere else in the body?
• Are you able to move freely?
• Do you still have complaints of pain while urinating, burning micturation etc?
• Do you have any chest pain or associated breathing difficulties?
• What about the intake of food? Are you eating adequately or having any difficulty with swallowing?
• Are you still having the habbit of smoking?
• Do you feel any difficulty for urination and defication?
• Hows the fecal elimination pattern?

“How much time do I have?” What will be your response?

"We all are working for you Mr. CA. Lets see, if some mirackles happen or not. You dont worry about your physical status now, rather follow your medications, do light exercise and eat a well balanced food. You are a good warrior. There are many people who survived cancer. Let thnk you also do the same."

Which of these findings is your priority concern at this time? Why?

The patient is having the complaints of increased pain and anorexia.the major concern is regarding pain management. Effectiv pain management will improve the quality of life of cancer patients.For that usually palliative care is provided.This will provide high satisfaction to them. usually they are in their end stage of life.Pain management and proper palliative care make the individual happy about their life and that feeling amke them to live their life happily till death.It heps to reduce the depresiive mood of the patient as well as his family members also.