Case Study: Expectant Management as a Treatment for Early-Stage Prostate Cancer

The patient is a 74-year-old male in generally good health. He reported having several episodes of prostatitis over the past 5–10 years. His prostate-specific antigen (PSA) levels rose to 5 ng/mL from an initial value of 2.6 ng/mL. Biopsies at this time were positive for malignancy in both lobes, clinical stage T2. His Gleason score was 6, suggesting that he had a favorable prognosis with a low risk of recurrence.^[1] The patient and his wife met with the urologist, who discussed treatment options: radiation therapy (RT), radical prostatectomy (RP), or expectant management (EM). Other treatment options such as cryotherapy were not discussed.

Both the patient and his spouse shared their concerns about potential treatment-related side effects and how these might have a negative impact on their active lifestyle. After an exhaustive online search, a second opinion that yielded no new information, and serious consideration of each option, the patient elected to forego active treatment in favor of the EM approach. He was followed by the urologist for the next 4 years and was diligent in his compliance with PSA testing and digital rectal examination. In the fourth year however, his PSA rose to 9 ng/mL, although he remained essentially asymptomatic. Following a lengthy discussion with his urologist, primary care provider, and spouse, he decided to pursue active treatment with brachytherapy.

Over the 4-year course of his EM follow-up, both the patient and his wife voiced their concerns about dealing with constant uncertainty. Any slight change in urinary or sexual functioning, as well as any new aches or pains seemed to trigger anxiety that these changes could be cancer-related. He reported that this anxiety was a new feeling and considered himself otherwise to be an "easy-going kind of guy." Despite these concerns, he was pleased to have been spared potential incontinence and impotence, and had continued enjoying activities such as golf and tennis, as well as considerable travel.

TREATMENT SUMMARY

The National Comprehensive Cancer Network (NCCN) treatment guidelines recommend that for men with a life expectancy of >10 years who choose EM, surveillance should consist of PSA testing as often as every 3 months, along with digital rectal exam as often as every 6 months. Biopsies are recommended as often as annually. In the case of progressive disease such as in the patient detailed in this report, the NCCN recommends that men with localized T1–T2a disease who are asymptomatic, with Gleason scores of 2–6 and PSA values < 10 and life expectancy of < 10 years, treatment with RT (3D conformal or brachytherapy) should be initiated.^[1] This patient was 78 years of age when treatment was initiated, and his life expectancy was less than 10 years. EM is a conservative treatment strategy and involves active disease monitoring with the expectation of treatment if the cancer progresses or the patient becomes symptomatic. The rationale for EM is based on the observation that prostate cancer incidence rates far exceed mortality rates. Early retrospective Scandinavian studies reported low death rates among men electing the EM approach. Two early randomized clinical trials compared this approach with RP and found no statistically significant differences in survival.^[2,3]

In 2002, however, Holmberg and colleagues reported the results of a large randomized clinical trial comparing EM with RP, indicating that at the 8-year follow-up point, RP patients had a 50% reduction in disease-specifi c mortality and distant metastasis. No overall survival benefi t was noted, however.^[4] Despite the lack of evident overall survival benefi t, local progression and distant metastasis can have signifi cant negative effects on quality of life, including pain, urinary diffi culties, and interference with sexual performance. Additionally, such symptoms may lead to declining quality of life in terms of social functioning as well.

NURSING MANAGEMENT AND DISCUSSION

Nursing considerations for men who choose the EM approach consist of continuous assessment of quality of life (QoL), including both the physiologic and psychosocial dimensions. Proponents of the EM option highlight the potential for better QoL based on the absence of treatment-related side effects; this has not been substantiated by research, however. Steineck and colleagues examined QoL among patients having RP versus EM.^[5] While overall QoL, anxiety, depression, well-being, and bowel function were similar across groups, erectile dysfunction and urinary leakage were more common among men having RP.

Galbraith and colleagues examined health-related QoL and prostate-specific symptoms among 185 men with localized prostate cancer who were enrolled in fi ve treatment groups: RP, EM, RT, proton-beam radiation, or a combination RT protocol.^[6] While no signifi cant differences in overall health-related QoL were observed, post hoc analyses revealed more gastrointestinal symptoms among radiation patients and more sexual dysfunction among surgical patients. Men in the EM group had poorer general health overall. Wallace reported that the QoL of 21 men surveyed who had elected EM was negatively affected by anxiety, uncertainty, and a perception of danger.^[7] According to Wallace,^[7] O'Rourke,^[8] and Bailey et al,^[9] men and their spouses use a variety of cognitive schemas to cope with uncertainty and persistent worry, one of which is reframing treatment as negative while focusing on the potential adverse side effects. Additionally, some men viewed the EM choice as an opportunity to buy themselves time as they awaited more positive treatment alternatives in the future.

Other strategies include upward social comparisons, wherein men focus on how much better off they are than others who chose different treatments. Patients also may couple this strategy with attempts to minimize the signifi cance of the cancer threat by focusing on the small size of the tumor, their own low PSA levels, and/or low Gleason scores.^[8] The use of prayer, refl ection, spending more time with family, and working harder physically have also been reported with varying levels of efficacy.^[10] Men choosing EM, and their partners, need reassurance that although no active treatment is being employed, they are being closely monitored. Both patients and their partners also need reassurance that no decision is irrevocable and that treatment can be initiated if and when their needs change. Nurses should encourage the use of active problem solving and cognitive strategies such as positive social comparison and reframing to deal with uncertainty. Participation in support groups, either as a couple or as an individual, may be benefi cial and lead to the exploration and development of new coping strategies.

When viewed cumulatively, the research indicates that for many men the goal of EM is to maintain or maximize QoL. This being the case, there is a critical need to develop and test nursing interventions to attenuate the negative aspects of uncertainty surrounding this option.

OUTCOME

Following 4 years of expectant management, the patient elected a course of brachytherapy when disease progression was noted. Initially he reported expected side effects including mild pain, dysuria, and increased urinary frequency. He was instructed to maintain a high level of fl uid intake and completed a 7-day course of antibiotic therapy. Hematuria resolved within 96 hours. Nine months following treatment he reports that he is continent and able sustain an erection sufficient for sexual intercourse. His PSA level is 2 ng/mL and he expresses no regret over his treatment choices.

Disclosures:

The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1.

National Comprehensive Cancer Network: Clinical Practice Guidelines in Oncology, v.2.2007: Prostate Cancer. Available at

http://www.nccn.org/professionals/physician_gls/PDF/prostate.pdf

. Accessed November 20, 2007.

2.

Graversen PH, Nielsen KT, Corle DK, et al: Radical prostatectomy versus expectant treatment in stages I or II prostate cancer. A fi fteen-year follow-up. Urology 36:493–498, 1990.

3.

Iversen P, Madsen PO, Corle DK: Radical prostatectomy versus expectant treatment for early carcinoma of the prostate. Twenty-three-year follow-up of a prospective randomized study. Scand J Urol Nephrol Suppl 172:65–72, 1995.

4.

Holmberg L, Bill-Alexson A, Helegessen F: A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 347:781–786, 2002.

5.

Steineck G, Helgesen F, Adolfsson J, et al: Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 347:790–796, 2002.

6.

Galbraith ME, Ramirez JM, Pedro LW: Quality of life, health outcomes, and identity for patients with prostate cancer in fi ve different treatment groups. Oncol Nurs Forum 28:55–60, 2001.

7.

Wallace M: Uncertainty and quality of life of older men who undergo watchful waiting for prostate cancer. Oncol Nurs Forum 30:303–309, 2003.

8.

O'Rourke ME: Prostate cancer treatment selection: The family decision process. Doctoral dissertation, University of North Carolina, Chapel Hill, 1997.

9.

Bailey DE, Wallace M, Mishel M: Watching, waiting and uncertainty in prostate cancer. J Clin Nurs 16:734–741, 2007.

10.

Hedestig O, Sandman PO, Widmark A: Living with untreated localized prostate cancer: A qualitative analysis of patient narratives. Cancer Nurs 26: 55–60, 2003.