Impact of radiation on prostate cancer

Impact of Radiation on Prostate Cancer H e r e ' s h o w to h e l p p a t i e n t s c o p e with t h e side effects of t r e a t m e n t for t h e #1 c a n c e r in m e n . BY

LINDA

L.

LILLEY

LINDA L. LILLE'/', RN, MS, is an oncology-certified nurse and associate professor at the School of Nursing, Old Dominion University, Norfolk, VA. The author thanks Joseph J. Konefal, MD, urologist in Norfolk, for his encouragement and her father for his inspiration.

174 GeriatricNursing JulylAugust1991

xternal beam radiation therapy can prevent detectable local recurrence in essentially all early stages and up to 80 to 90 percent of Stage B and C p r o s t a t e c a n c e r s ( l ) . But prostate cancer tends to be the ign o r e d male disease, m u c h as breast cancer once was the ignored female disease. The prostate normally is the size of a chestnut, with the soft consistency of the nose tip. In cancer, however, the prostate either develops one or more discrete nodules or becomes uniformly hard(2). When the tumor extends outside the prostate capsule, the seminal vesicles become firm, enlarged, and rigid. Approximately 60 percent of newly diagnosed cases generally are local adenocarcinomas of the prostate. Most patients either are asymptomatic or have symptoms of bladder-outlet obstruction(3). Early symptoms may include difficulty initiating the urinary stream; change in urinary stream or flow, with possible dribbling; and urinary retention, frequency, and urgency. In later stages, metastasis to the spine, femur, or ribs can produce bone pain due to pathological fractures or spinal cord compression(4). P e r i p h e r a l l y m p h a denopathy and renal failure are other signs of advanced prostate cancer(3). P r o s t a t e cancer progresses along four major clinical stages, each differentiated by the size and the extent to which the cancer has spread (see "Stages of Prostate Cancer," on page 176). The stage determines the degree of radiocurability as well as the mode of treatm e n t . As with most cancers, patients With the least extensive disease and a well-differentiated cell type achieve the best results. Differentiation means the extent to which the cell looks and acts like the tissue of origin. T h a t is, if prostate cancer cells are "well differentiated," their structure and function are similar to those of normal prostate cells. For the most part; the more differentiated the cell, the better the prognosis; the

E

less differentiated, the graver the prognosis(5). In general, the typical treatment for localized prostate cancer is radical prostatectomy, external radiotherapy, or watch-and-see(see "Diagnostic Tools," on the next page). The last may be sufficient for Stage A1, when combined with follow-up examinations every six months. The success rates of surgery and radiotherapy are comparable(6). For patients who are poor surgical risks, have complicating conditions, or who refuse surgery, radiation is a good option. Radiation, however, affects normal as well as malignant cells. Cells that are rapidly proliferating (as cancer cells do) are more sensitive to the effects of r a d i a t i o n t h a n are most healthy cells. But rapidly dividing normal cells (for example, bone marrow, gastrointestinal [GI] epithelium, and hair follicles) that are within the field of radiation can be destroyed. This fact explains many of the side effects that so often develop from radiotherapy, including bone-marrow suppression, stomatitis, and alopecia. What you teach a patient to expect as a result of radiotherapy can make the difference in how comfortable a patient is with this treatment and how well he handles side effects. John Casson, a healthy 68-yearold, went to a urologist's office complaining of "difficulty urinating." He stated that he was unable to empty his bladder well and that his urinary stream was not strong. The urologist found Mr. Casson to be in excellent health except for a suspicious "hard nodule," measuring approximately 2.5cm, on the prostate. Two days later, the urologist performed a transurethral resection of the prostate (TURP) and biopsied the tissue. The test revealed a moderately well differentiated adenocarcinoma of the prostate. The TURP immediately improved the urinary flow and would help prevent possible urinary obstruction, a potential side effect of radiation-induced inflammation. A metastatic work-up following the TURP included a bone scan, computed tomography (CT) scan of the abdomen and pelvis, along with prostatic acid phosphatase tests. All proved negative for metastasis, and

Mr. Casson's prostate cancer was then staged at B2. The urologist told Mr. Casson and his wife what the options were, including radical prostatectomy and ext e r n a l beam radiotherapy (see " T h e r a p y Options," on page 177). Within a few days, Mr. Casson opted for radiotherapy at a local radiation oncology facility. But he had many fears and questions about the radiation therapy. Some questions made very clear his concern about the short- and longterm effects of the radiation: "How long am I going to be debilitated from the treatments? .... Will I be radioactive and for how long?" Easing One Patient's Concerns Hearing his questions, the nurses realized that education was the most significant need for Mr. Casson and his wife. Staff first assessed how much Mr. Casson and his wife knew about the treatment and about Stage B2 prostate cancer. They asked if he had had any previous i n s t r u c t i o n on prostate cancer, its diagnosis, and its t r e a t m e n t with radiation therapy. They explored his feelings and fears about the cancer and radiotherapy. Staff assured him that only implantation of radioactive sources renders one radioactive. They also reassured him that each person reacts individually to radiation but most men tolerate the treatment well and without major complications. The nurses went into great detail explaining to Mr. Casson what he should expect with the external beam radiation. They described how he would first go through a simulation and be taught to maintain a supine position on a treatment table under the simulator (a diagnostic X-ray machine that mimics the treatment capabilities of radiation-therapy machines). He was told he would be asked to lie perfectly still while an oncologist took a series of pelvic measurements and made X-rays. After the oncologist completed the X-rays, the radiation technologist would use a waterproof marker to indicate reference points in the pelvic area. Mr. Casson was reassured that he would not experience any unusual sensations, that a technologist would be available through a

nearby intercom-television system, and that each of the steps would take no more than 10 minutes. Staff also discussed thoroughly with Mr. Casson how long and on what schedule he would undergo treatments. They would occur generally the same time, every day for 34 days. The first 24 treatments would target the pelvic area and "sweep" the pelvis so that the treatment field for the first 24 treatments would cover a large area. In the last 10 treatments, the area would be "coned" down, with treatments targeting the prostate gland. Mr. Casson completed therapy in three months. He received a total of 6200cGys and suffered moderate cystitis and mild diarrhea. Mr. Casson continued to complain of periods of mild cystitis. Five years after treatment, the urologist and radiation oncologist assessed him to be disease free, as reflected by negative digital rectal examination (DRE) and transrectal ultrasound, plus normal levels of prostatic acid phosphatase and prostate-specific antigen. GI and urinary problems are the most frequent side effects of radiation to the pelvic area and occur in approximately one-third of the patients. Radiation-hzduced diarrhea (rapid movement of fecal contents through the intestines, resulting in poor absorption of water, nutrients, and electrolytes) results from the destruction and inflammation of the GI mucosa leading to edema, sloughing, and possible thinning and ulceration. Radiologists c o n s i d e r GI i n j u r y from radiation to be acute or early when it occurs within three to six months after treatment begins,and chronic or late if it persists for more than six months. Diarrhea may range from mild to moderate; with occurrence of four to six stools per day. Severe diarrhea (rarely Occurring with the radiotherapy for prostate cancer) is characterized by the passage of eight stools or greater per day(7). The nurses alerted Mr. Casson that diarrhea can precipitate hemorrhoids. They told him that if he experienced prolonged bouts of diarrhea, his physician might need to prescribe antidiarrheal medications. The staff encouraged Mr. Casson to report to the physician the development of more than four stools per day

GerlatricNursing Jul2dAugttst 1991 175

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176 Geriatric Nursing July/August 1991

and any weakness, fatigue, or loss of appetite. They emphasized the need to begin radiation with a well-balanced diet that includes 90 grams of protein (56 grams is recommended for normal men) and 2900-3000 calories (compared to 2700 for normal men), low-residue, soft, bland, and easily digestible food. Among the foods the nurses listed for him were cooked cereals (e.g., cream of wheat), bananas, peeled apples (pectin being a naturally occurring antidiarrheal agent), carrots, eggs, fish, poultry, and beef that was baked or roasted until tender. They encouraged Mr. Casson to practice good hygiene after each loose stool to prevent anal and perineal excoriation and breakdown. Washing with lukewarm water and a mild soap, patting the area dry, and applying a steroid cream to the anal area (if excoriated) were all recommended. Other recommendations included that he take sitz baths for healing and c o m f o r t , plus drink at least 3000ml/day fluids to prevent dehydration (cardiac, renal, or liver disorders would make this amount of liquid inadvisable). He was advised to drink oral electrolye solutions, such as Gatorade. He was told to avoid milk and milk products because they are often associated with distention and cramping, plus lactose intolerance may promote diarrhea. It was suggested that he avoid very cold or hot foods and liquids to help diminish peristalsis.

Radiation cystitis, or inflammation of the urinary bladder, is another common side effect of pelvic radiation. It generally occurs within six months of treatment and is characterized by cystoscopic findings of marked mucosal edema, diffuse erythema, and prominent submucosal vascularity. Mild mucosal r e a c t i o n s m a y occur with radiation doses of 3000cGy. (Mr. Casson received 6200cGy.) Associated symptoms include urgency, frequency, burning and pain with voiding, possible back pain, mucus or blood in the urine with inflammation and infection. These symptoms may occur up to a few years after treatment. In more chronic cases (longer than six months), the skin shows areas of extreme pallor separating areas of intense erythema, with petechia and occasional ulceration. Symptoms of radiation cystitis may be mild, as they w.ere for Mr. Casson, with dysuria and hematuria developing. In more severe cases, urinary incontinence, bladder ulcers, chronic cystitis, or urethral strictures may develop(8). After the TURP and at the start of his treatments, Mr. Casson was free of symptoms of urinary dysfunction. But two months into the radiation therapy, and up to two years after it, he complained of continued urinary frequency and urgency. He worried whether the symptoms were from the cancer or from the treatments.

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Since his knowledge about the impact of radiation on the bladder was very limited, the nurses explained to him that the epithelial cells in the bladder lining are very sensitive to the effects of radiation. When located within the treatment field, the bladder lining may become thinned, inflamed, and ulcerated. -To minimize the effects of radiation to the bladder, nurses encouraged Mr. Casson to drink at least 3000ml of liquids, such as water and Gatorade, per day at regular intervals and to avoid food, beverages (tea, coffee, chocolate), and medications (such as many over-the-counter analgesics) that contain caffeine, which may irritate the bladder. To prevent the urine from stagnating, which could precipitate a urinary-tract infection, he was advised to void as soon as he had the urge. Since radiation generally inflames the bladder and makes it more susceptible to infection, maintaining the urine at an acidic pH (<7.0) is important to avoid bacterial growth. If diarrhea is not a problem, an acid ash diet--which may precipitate diarr h e a - i s effective in acidifying the urine. The nurses, therefore, encouraged Mr. Casson to eat m e a t s , cheeses, prunes, cranberries, and plums. A l t h o u g h clinicians once t h o u g h t t h a t ingesting ascorbic acid, as in cranberry juice, lowered

urinary pH, current research indicates that it has no major effect. The fears that patients and their families experience may, in some cases, be u n f o u n d e d . But t h e y are n o n e t h e l e s s real. Nurses are in a unique position to provide the information that can alleviate those fears and help patients recognize when they need to consult their physician. REFERENCES 1. Hanks, G. E., and others. A ten year follow-up of 682 patients treated for prostate cancer with radiation therapy in the United States. Intl. Radia~OncoLBioLPhys. 13:499, August 1987. 2. Huben, R. E, and Murphy,G. E Prostate cancer, an update. CA 36:274290, Sept.-Oct. 1986. 3. nadalemant, R. A., and Drago, J. R. Prostate cancer: Promising advances that may alter survival rates. PostgradMed 87:6.5-67, 70-72, Apr. 1990. 4. Gross, J. S. Current management modalities for prostate cancer. Geriatrics 45:60-62, 67-68, Apr. 1990.

5. Johnson, B. L, and Gross,J. S., eds. Handbook of Oncology Nursing, New York, John Wiley and Sons, 1985. 6. Hanks, G. E. Radical prostatectomy or radiation therapy for early prostate cancer. Two roads to the same end. Cancer61:2153-2160,June 1,1988. 7. Dewit, L., and others. Acute side effects and late compficatlons after radiotherapy of localized carcinoma of the prostate. Cancer Treat.Rev. 10:79-89, June 1983. 8. Otto, S. E. Oncology Narsb~g. St. Louis, C. V. Mosby, 1991. 9. Catalona, W. J., and Scott, W. W. Prostate cancer. In Campbell's Urology, 5th edition, edited by E C. Walsh and others. Philadelphia, W. B. Sounders, 1986, pp. 1490-1499. 10.Catalona, W. J., and others. M e a s u r e m e n t of prostate-specific antigen in serum as a screening test for prostate cancer. N. EngL J. Med. 324: 1156--1161, Apr. 25,1991. 1 I. Bagshaw, M. A., and others. Selecting initial therapy for prostatic cancer. Radiation therapy perspective. Cancer 60 (3 Suppl):521-523, Aug. 1,1987.

THERAPY OPTIONS Surgery

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approximately 60%(11 ). This surgery is asso,:~cl ~ up to 95% ~ t ~ y of

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failure ~ ejaculate {allhough new nefveS.l~ring ~ i e s improve nu::~nlion c~ se~.ml 1 ~ in so'no cases}. Pelvic ~¢mphadenectomy to remove pelvic ~,nock~s, r,,aybe done ~ cc,~u~ w,~ o I~~Y. When diagnosis reveals i~e ~

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R~d|C~on ~'emal radiolh~ uses a ~ine i~ p!aced at o Sl~ft~F distance f~m b~ and ~ around it ~rea~'~mte~ I~d~ Fa 4 to 6 w ~ t ~ It is rn~ suoms~ w~ wel~~:l ~o mode~,~:¢~well diffe~m~l ,~ageA (:~d B. For Sa~;ieA or B, a 1..,~ye~survival rate is a p p r ~ motely 60 ~I'I). Polliative wilh ~ag.e ~) and sometimes eur~ve w ~ Stag~ (2. It can cause C~ and ~nary side effe~, ally mild w:) rnod~o~; canie~ 20~ 1o 30% risk d sexual~ . S~le effects sub side u,~ally wi~in 4 weeks, require only lemp~_ary in~em~pl~on~ Ih~'apy in abo~l 5% c~ p~enls, and usuallyare ossocialed v,,,h o dose d 2 C ~ : ~ pe~d~yl9).

Geriatric Nursing July/August 1991 17"/