Prostate Cancer Survivor Care

Aka: Prostate Cancer Survivor Care

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II. Epidemiology

  1. Prevalence prostate Cancer Survivors in U.S.: 3 Million (2014)
  2. Incidence new Prostate Cancers per year: 233,000 (2014)
    1. Most Prostate Cancers are diagnosed as local or regional disease
    2. Most patients with newly diagnosed Prostate Cancer will survivor decades

III. Complications

  1. General concerns
    1. See Cancer Survivor Care
    2. Address Major Depression or Anxiety Disorder (including Adjustment Disorder)
    3. Address concerns of family members supporting the patient
    4. Encourage healthy lifestyle (Tobacco Cessation, weight management, nutrition, aerobic activity)
  2. Prostate Cancer recurrence
    1. Treated initially with androgen suppression (resistance inevitably develops)
    2. Later treatment with Radiotherapy or Chemotherapy
  3. Androgen suppression adverse effects
    1. Osteopenia or Osteoporosis
      1. See Osteoporosis Prevention
      2. Obtain Bone Mineral Density (DEXA Scan) and calculate FRAX Score before initiating
    2. Hot Flashes (40% of patients)
      1. Symptoms may persist for years after completion of androgen suppression
      2. See Hot Flashes for management strategies
      3. Consider low dose Paroxetine, Venlafaxine, Gabapentin
    3. Normochromic Normocytic Anemia
    4. Erectile Dysfunction
    5. Fatigue
    6. Gynecomastia
    7. Weight gain (with risk of Metabolic Syndrome)
    8. Loss of body hair
    9. Dry Eyes
    10. Venous Thromboembolism
  4. Radiotherapy adverse effects
    1. Radiation Proctitis
      1. Inital symptoms of Diarrhea, Rectal Bleeding, Flatulence
      2. Later findings include Rectal Fistulas or ulceration, fecal urgency, frequency, Stool Incontinence
      3. Start with hydration and Stool Softeners
      4. Consider rectal steroids (e.g. Hydrocortisone) or antiinflammatories (e.g. Mesalamine)
    2. Urinary Dysfunction
      1. Urinary Incontinence (Stress Incontinence, Urge Incontinence)
      2. Urethral Stricture
      3. Urinary tract fistulas
      4. Urinary obstructive symptoms similar to BPH
      5. Other urinary symptoms (urinary urgency or frequency, dribbling, Nocturia)
        1. May present in similar fashion to Urinary Tract Infection
        2. See management strategies below under Prostatectomy adverse effects
    3. Erectile Dysfunction (72% at five years)
      1. Erectile Dysfunction onset may be delayed 6 to 36 months from treatment
      2. May respond to standard Erectile Dysfunction methods (e.g. PDE5 Inhibitors such as Viagra)
    4. Secondary cancer (Rectal cancer, Bladder Cancer)
      1. Occurs in 1 in 220-290
      2. Refer for Hematuria (routine Urinalysis screening not recommended)
  5. Prostatectomy adverse effects
    1. Erectile Dysfunction (76% at five years)
      1. May respond to standard Erectile Dysfunction methods (e.g. PDE5 Inhibitors such as Viagra)
    2. Urinary Dysfunction
      1. Urethral Stricture
      2. Other urinary symptoms (urinary urgency or frequency, dribbling, Nocturia)
      3. Urinary Incontinence (esp. Stress Incontinence)
        1. Stress Incontinence improves over first year, and typically resolves
        2. Urge Incontinence responds to standard treatments
          1. Consider Pelvic Floor Exercises, timed voiding at regular intervals
          2. Consider Anticholinergic Medications (e.g. Oxybutynin)
          3. Invasive methods are available (e.g. Collagen, slings)

IV. Monitoring: General Protocol after Prostate Cancer Diagnosis

  1. See Active Surveillance of Prostate Cancer (non-treatment approach)
  2. Prostate Specific Antigen (PSA) as below
  3. Digital Rectal Exam yearly (may be omitted if PSA remains undetectable)
  4. Clinical examination every 6 months for 5 years
  5. Focus area on exam
    1. Bladder Cancer (new second tumor)
    2. Erectile Dysfunction
    3. Stool or Urinary Incontinence
    4. Radiation Proctitis
    5. Major Depression
  6. Quality of life assessment tool
    1. Expanded Prostate Cancer index composite for clinical practice (EPIC-CP)
      1. https://medicine.umich.edu/dept/urology/research/epic

V. Monitoring: Prostate Specific Antigen (PSA) after Prostate Cancer Diagnosis

  1. Frequency of PSA Testing
    1. Initial: PSA every 6 months (to 12 months) for 5 years
    2. After fifth year: PSA every year
  2. PSA Levels after Radical Prostatectomy
    1. PSA <0.03 ng/ml within 2 months of Prostatectomy
    2. Refer if PSA becomes detectable again
    3. PSA rise >2 ng/ml/year suggests high grade lesion
      1. D'Amico (2004) N Engl J Med 351:125-35 [PubMed]
  3. PSA Levels after Radiotherapy
    1. PSA falls gradually to under 1 ng/ml by 1 year
    2. PSA remains under 1 ng/ml unless cancer recurrence
    3. Repeat PSA in 3 months if PSA increased from previous level (Refer if trending upwards)
  4. PSA after Androgen Suppression
    1. PSA falls to <0.05 to 0.1 ng/ml within 8 weeks of starting suppressive therapy
    2. Co-manage PSA results with oncology or urology

VI. Resources

  1. NCCN Clinical Practice Guidelines in Oncology
    1. https://www.nccn.org/professionals/physician_gls/f_guidelines.asp

VII. References

  1. Mohan (2011) Am Fam Physician 84(4): 413-20 [PubMed]
  2. Friedman (1996) Postgrad Med 100(3): 125-36 [PubMed]
  3. Middleton (1996) CA Cancer J Clin 46(4):249-53 [PubMed]
  4. Naitoh (1998) Am Fam Physician 57(7):1531-9 [PubMed]
  5. Noonan (2016) Am Fam Physician 93(9): 764-70 [PubMed]
  6. Porter (1995) CA Cancer J Clin 45(3):165-78 [PubMed]
  7. Skolarus (2014) CA Cancer J Clin 64(4): 225-49 [PubMed]
  8. Taub (1996) Postgrad Med 100(3): 139-54 [PubMed]
  9. Wilbur (2014) Am Fam Physician 91(1):29-36 [PubMed]
  10. Williams (1996) Postgrad Med 100(3): 105-20 [PubMed]

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