Once diagnosis and staging of prostate cancer is confirmed, an assessment of treatment determinants should occur, including:39
- life expectancy
- overall health status
- tumour characteristics
- individual preferences.
Many men are diagnosed with prostate cancer, but it contributes to death in only a small proportion of those diagnosed. Newly diagnosed men are faced with a difficult therapeutic dilemma due to a number of factors, including:39, 42, 43
- increasing numbers of men who are asymptomatic at diagnosis
- variability of the course of the disease
- unpredictability of prognosis
- similarity in survival rates associated with different treatments
- new technologies and emerging therapies
- an increasing amount of information available.
The treatments following diagnosis of prostate cancer consist of watchful waiting, active surveillance (monitoring with further biopsies), or active treatment which may include surgical removal of the prostate, external beam radiotherapy, interstitial prostate brachytherapy, antineoplastic agents or hormonal treatments.14, 39, 44, 45 Each approach is associated with significant potential morbidity.
Radical therapy maximises the chance of cure but may involve significant sexual or urinary morbidity, while active surveillance preserves genitourinary function in exchange for psychological effects.46 With careful evaluation of suitability for active surveillance, about 70% of men will avoid treatment for five or more years, although the risk of prostate cancer death may become unacceptable if continued beyond 10-15 years.47, 48 The term ‘watchful waiting’ is not synonymous with active surveillance, and relates to the care of men with comorbidities and an incidental diagnosis unlikely to affect their survival.47
Therapeutic decisions must be weighed up in light of reported risks and benefits of therapies and disease progression and is often based on an individual's circumstances. At this time, men and their partners have many physical, psychological, social, informational and spiritual needs.
In determining treatment plans, NHMRC Clinical Practice Guidelines44 state that:
- A person with clinically localised prostate cancer should be informed about the commonly accepted initial interventions including, at a minimum, radical prostatectomy, radiotherapy and no initial treatment. A discussion of the estimates for benefits and harms of each intervention should be offered to the individual.
- Psychological factors need to be given significant recognition, particularly the need for education with regard to therapeutic choices and which would be optimal for the individual.
Predictive nomograms may be helpful in the complex decision making process by providing an estimation of the probability of recurrence after initial treatment. Concerns have been raised regarding the applicability and accessibility of existing tools and how responsive they are to novel treatment modalities.49
Prostate Cancer Treatment factsheet(PDF, 389KB).50 Andrology Australia, 2014
Ted’s story 3: Treatment decision
Outline how you would determine Ted and June’s information needs at this time.
Consider how Ted’s response to his diagnosis might be similar or different for Ted, aged 60, if he was aged 80.
Access the Memorial Sloan-Kettering Cancer Centre’s Prostate cancer prediction tool. Discuss how, as an SCN, you could advise Ted on the use of this tool. Access evidence based literature to support your response.
- Adamis, S. and I.M. Varkarakis, Defining prostate cancer risk after radical prostatectomy. European Journal of Surgical Oncology (EJSO), 2014. 40(5): p. 496-504.
Access the Guidelines on Prostate Cancer (2014)31 and:
- Discuss the meaning of the term 'active surveillance', including indications, and recommended follow up and actions to be taken following evidence of progression.
- Outline how you would respond to a 75-year-old man with clinically localised disease who asks you how he can find out more about the advantages and disadvantages of active surveillance.
- Explain how an individual's life expectancy and overall health status can impact on treatment determination.
Multidisciplinary care of prostate cancer
Treatment plans should be determined by a multidisciplinary team (MDT). Discussion among MDT members is essential in the absence of clear evidence of the superiority of one treatment over the other.22 MDTs are perceived to improve communication, coordination and decision-making between health care professionals when weighing up treatment options with individuals.51
The MDT generally comprises:22
- medical oncologist
- radiation oncologist
- social worker
The SCN specialising in prostate cancer is involved in the care of men in all treatment streams and is an integral part of the MDT. The Prostate Cancer Specialist Nurse is an evolving specialist nurse role. The Prostate Cancer Foundation of Australia (PCFA) supports a number of positions nationally and is evaluating the impact of the role in cancer control efforts related to prostate cancer. The PCFA Prostate Cancer Specialist Nurse:52
- acts as an expert point of contact for the man and their family
- provides both psychosocial and clinical support using a structured approach
- works alongside existing healthcare providers to contribute to the delivery of effective care
- promotes the optimal use of resources available in their immediate community
- streamlines service delivery when referral to another centre is required
- adopts a strategic function to influence care at a systems level both locally and at State and national level
A practice Framework was developed by PCFA which describes the scope of the Prostate Cancer Specialist Nursing role at both a clinical and strategic level to both inform and influence practice at an advanced level. The Competency Standards for the Prostate Cancer Specialist Nurse are based on the EdCaN competency standards for the SCN and have been adapted for application in the prostate cancer nursing context.52 This Framework may be useful to guide all SCN specialising in prostate cancer.
Practice Framework and Competency Standards for the Prostate Cancer Specialist Nurse.52 Prostate Cancer Foundation of Australia, 2013
Access the Practice Framework and Competency Standards for the Prostate Cancer Specialist Nurse52, and read part one. Familiarise yourself with the role of the Prostate Cancer Specialist Nurse.
Explain how an SCN, as part of an MDT, can facilitate assessment of an individual's preference for information and involvement in decisions.
Ted’s story 4: Multidisciplinary care
Access the treatment recommendations based on risk stratification outlined in Guidelines on Prostate Cancer (2014)31 and identify how treatment recommendations based on risk stratification assist treatment decision making in Ted's situation.
Discuss how you could, as part of an MDT, assist Ted and June to understand the risks and benefits of various treatment options, and make a decision consistent with their values and preferences.