Cancer of the prostate is the second-leading cause of cancer death among American men and is the most common

carcinoma in men over age 65.

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incidence of prostate cancer is 30% higher in black men. The majority of prostate cancers arise from the peripheral zone of the gland; therefore, most prostatic cancers are palpable on rectal examination.

 Prostate

cancer can spread by local extension, by lymphatics, or by way of the bloodstream. The etiology of prostate cancer is unknown; there is an increased risk for persons with a family history of the disease.

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influences of dietary fat intake, serum testosterone levels, vasectomy, and industrial exposure to carcinogens are under investigation.

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early-stage prostate cancers are asymptomatic. Symptoms due to obstruction of urinary flow: Hesitancy and straining on voiding, frequency, nocturia Diminution in size and force of urinary stream

Symptoms due to metastasis: Pain in lumbosacral area radiating to hips and down legs (from bone metastases) Perineal and rectal discomfort Anemia, weight loss, weakness, nausea, oliguria (from uremia) Hematuria (from urethral or bladder invasion, or both) Lower extremity edema occurs when pelvic node metastases compromise venous return

 Digital

rectal examination prostate can be felt through the wall of the rectum; hard nodule may be felt . Needle biopsy (through anterior rectal wall or through perineum) for histologic study for biopsied tissue, includes Gleason tumor grade if carcinoma present. Transrectal ultrasonography a sonar probe placed in rectum.

PSA serologic marker of prostate cancer. Suspicion of prostate cancer if it measures between 4.0 and 10 ng/mL; however, prostate cancer may also occur at levels under 4.0. Most PSA measurements over 10 ng/mL indicate prostate cancer. A free PSA level can be used to help stratify the risk of an elevated PSA.

 Staging

evaluation skeletal X-rays, CT scan, MRI, bone scan, analysis of pelvic lymph nodes provide accurate staging information.

Newer imaging study called the prostascint scan uses an I.V. infusion of monoclonal antibody to prostatespecific membrane antigen. Immediate and delayed images at 48 and 72 hours may identify soft tissue and bone metastasis for staging. Radiation is excreted through urine and feces and body fluids but is very low and not a risk to others. Patient is monitored for signs of allergic reactions following test.

 Research

is being conducted on a gene (known as AMACR) that triggers production of a specific protein found only in cancer cells. Overexpression of the AMACR gene was found in 90% of prostate cancer patients. Testing for this gene could result in identifying prostate cancer earlier.

No treatment may be indicated in men over age 70 because prostate cancer may be slow growing and it is expected that many men will die from other causes. It is commonly recommended that these patients be followed closely with periodic PSA determinations and examination for evidence of metastases. Symptom control for advanced prostatic cancer in which treatment is not effective:
Analgesics and opioids to relieve pain. Short course of radiotherapy for specific sites of bone pain. I.V. administration of beta-emitter agent (strontium chloride 89) delivers radiotherapy directly to sites of metastasis. TURP to remove obstructing tissue if bladder outlet obstruction occurs. Suprapubic catheter placement.

Surgical Interventions (Curative)

Radical prostatectomy removal of entire prostate gland, prostatic capsule, and seminal vesicles; may include pelvic lymphadenectomy.
Procedure is used to treat stage A and B prostate cancers. Complications include urinary incontinence and impotence, possible rectal injury. Newer nerve-sparing techniques may preserve sexual potency and continence.

Cryosurgery of the prostate freezes prostate tissue, killing tumor cells without removing the gland.

Radiation (Curative) External beam radiation (using linear accelerator) focused on the prostate to deliver maximum radiation dose to tumor and minimal dose to surrounding tissues. Interstitial radiation interstitial implantation of radioactive substances (brachytherapy) into prostate, which delivers doses of radiation directly to tumor while sparing uninvolved tissue. Used to treat stages A, B, and C, especially if patient is not good surgical candidate. Both forms of radiation are used in some patients; external beam followed by brachytherapy. Complications include radiation cystitis (urinary frequency, urgency, nocturia), urethral injury (stricture), radiation enteritis (diarrhea, anorexia, nausea), radiation proctitis (diarrhea, rectal bleeding), impotence, skin reaction, and fatigue.

Hormone Manipulation (Palliative) Prostate cancer is a hormone-sensitive cancer. The aim of hormonal treatment is to deprive tumor cells of androgens or their by-products and thereby alleviate symptoms and retard progress of disease. Bilateral orchiectomy (removal of testes) results in reduction of the major circulating androgen, testosterone. A small amount of androgen is still produced by adrenal glands.

Pharmacologic methods of achieving androgen deprivation also used to reduce tumor volume before surgery or radiation therapy.

Luteinizing hormone-releasing hormone (LHRH) analogues (leuprolide [Lupron], goserelin acetate [Zoladex]) reduce testosterone levels as effectively as orchiectomy. Antiandrogen drugs (flutamide [Eulexin], bicalutamide [Casodex], nilutamide [Nilandron]) block androgen action directly at the target tissues (testes and adrenals) and block androgen synthesis within the prostate gland. Combination therapy with LHRH analogues and an anti-androgen blocks the action of all circulating androgen.

 Complications

of hormonal manipulation include hot flashes, nausea and vomiting, gynecomastia, sexual dysfunction, and osteoporosis.

 Bone

metastasis vertebral collapse and spinal cord compression, pathologic fractures Complications of treatment

Obtain history of current symptoms; assess for family history of prostate cancer. Palpate lymph nodes, especially in supraclavicular and inguinal regions (may be first sign of metastatic spread); assess for flank pain and distended bladder. Assess comorbidities, nutritional status, and coping before treatment.