After effects: Tackling the morbidity of prostate cancer treatment

“.” .1.. .I, ’4:. L.y .,./

COMMENTARY After Effects: Tackling the Morbidity Prostate Cancer Treatment Katherine

N. Moore,

PhD

A

t the conclusion of research articles, authors inevitably pose questions for future research. The future is now upon us. The treatment-related bowel and bladder toxicities and associated psychosocial sequelae presented in this issue of ]WOCr\r underscore the need to systematically evaluate the nursing care provided to men after they receive treatment for prostate cancer. Yet how can we as researchers and practitioners make a difference? Where should we begin? Perhaps this is a time for taking stock of what we know to set an agenda for the future.

WHAT WE KNOWURINARY INCbNTlNENCE AS A TEMPLATE

Katherine N. Moore. PhD. is Assistant Professor. Faculty of Nursing. and Adjunct Professor, Faculfy of Medlclne, University of Alberta, Edmonton. Alberfa, Canada. Repflnf requests: Katherine N. Moore. PhD, 3-C%. UnlversMy of Alberta, Edmonton, Alberta, Canada T6G 20. J WOCN 2000:27: 18590. Copyrlghf 8 2000 by the Wound, Osfomy and Confinence Nurses Soctety 1071-.5754/2000/$‘12.00 21/9/106813 do/: 10.1067/m~w.2000.1068

of

+ 0 13

Recognizing the significance of providing evidence-based care, we know that research is critical in building the foundation for contemporary WOC nursing care. Yet, in the absence of empirical evidence, the first line of the clinical management of urinary symptoms has been based on expert opinion. Behavioral management of urinary symptoms has included strategies addressing fluid adjustment, caffeine and alcohol reduction, smoking cessation, exercise, weight loss, and bowel regularity. These strategies have also been combined with pelvic muscle exercises and/or bladder retraining. During the past decade we have seen research related to urinary incontinence (UI) increase dramatically. The following research findings are related to what we have learned about the behavioral strategies commonly used in the management of UI. Fluid adjustment. Evening fluid restriction and nighttime toileting may slightly improve symptoms in the very elderly’; however, in younger women, changes in fluid intake do not significantly improve incontinence.2

Caffeine reduction. No studies have assessed the relationship between reduced caffeine intake and LJI in men. Some authors have reported an improvement in women,-? but others have been unable to establish a relationship between caffeine reduction and continence.4 Smoking. Men who smoke put themselves at a higher risk of lower urinary tract symptoms.5 For smokers and former smokers, the odds ratios are 1.47 and 1.38, respectively, compared with men who have never smoked. Physical activity is also associated with fewer lower urinary tract symptoms. Men who walk 2 to 3 hours per week have a 25% lower risk of total benign prostatic hyperplasia.6 Weight loss. No published studies exist on weight loss and incontinence in men. In obese women, reduction in body weight of more than 50 kg significantly improved bladder control,7 but more modest weight loss has no clear relationship to continence. Constipation. No studies have directly assessed the relationship between constipation and urinary incontinence. In people with multiple sclerosis, bowel dysfunction has not been directly associated with bladder dysfuncti0n.s However, it is known that chronic constipation can result in the symptoms of outlet obstruction.9 Bladder retraining. Bladder training is intended to reduce the symptoms of urgency and frequency associated with an overactive bladder. At present, only 7 randomized controlled trials on bladder retraining have been published. The existing research provides only modest evidence as a therapy for women and little evidence as a therapy for men.10 Pelvic floor muscle exercises. Pelvic floor muscle exercises with or without biofeedback remain the mainstay of therapy for incontinence after a radical prostatectomy, yet no compelling evidence supports the therapy. Of 5 randomized controlled trials published to date, only onerr has shown

JWOCN Volume

27, Number

3

a difference in men who practice a combination of pelvic floor muscle exercises, bladder retraining, electrical stimulation, and behavioral strategies. As noted, most of the existing research on incontinence has been primarily conducted on women. Although these findings are important, they limit the conclusions that can be drawn about the best interventions for managing Ul after prostatectomy. Even as they provide a backdrop to the management of UI, studies in men are needed to assess a cumulative treatment effect as well as the single therapeutic effect. Treatments focused on postprostatectomy UI, as outlined in Dr Robinson’s paper, include bladder retraining, pelvic muscle exercises, and electrical stimulation. However, evidence to support these strategies for Ihe management of incontinence after a radical prostatectomy remains modest at best. Several studies have examined postprostatectomy UI and are consistent in showing improvement over time without therapy. However, the range in the reported incidence of this problem raises concern about study design, instrumentation, and sample size. Based on previous incontinence research, questions related to postprostatectomy UI also arise. For example, can we prevent the onset of incontinence? Would men who start a physical exercise regimen be less likely to develop problems than those who are sedentary? Would combining bladder retraining and electrical stimulation enhance the continence outcomes after radical prostatectomy? If pelvic floor muscle exercises were introduced prior to radical prostatectomy, would men experience less postoperative incontinence? Using this template for review of the literature, we need to consider the evidence for symptom management of other treatment modalities used in the treahnent of prostate cancer. What is the best way to manage erectile dysfunction resulting from prostate cancer therapy? What do we know about managing the symptoms of external beam therapy or brachytherapy? How can we best manage radiation proctitis? Other research questions also beg to be asked. For example, although long-term follow up by physicians indicates a low percentage of men experiencing postradiotherapy symptoms, no qualitative researchers have followed men’s recovery after brachytherapy. Would the qualitative

Moore

approach identify problems men may not be willing to discuss with their physician? What are the social and personal consequences of living with a chronic syndrome like UI? Do the symptoms of radiation proctitis affect quality of life to an even greater degree than urinary symptoms? Case-matched controlled studies comparing the short-term and long-term influence of surgery and radiation therapy would assist in pretreatment and posttreatment counseling. The contributors to this outstanding issue of ]WOCN have clearly identified the shortcomings in our knowledge base about the short-term and long-term outcomes of prostate cancer treatment. Researchers and clinical practice nurses alike have a responsibility to provide effective, economically sound care that is evidence based. Collaboration, multiple sites, and networking during protocol development may go far to correct some of the issues which, to date, have interfered with obtaining meaningful outcomes in nursing research. The WOCN has shown itself a leader in nursing practice by creating a Center for Clinical Investigation. Such a strategic move will surely ensure that future practice will be based on sound evidence rather than expert opinion. REFERENCES 1. Grifffths DJ. McCracken PN, Harrison GM, Moore KN. Urge incontinence in elderly people: factors predicting the severity of urine loss before and after pharmacological treatment. Neurourol Urodyn 1W6;15:53-7. 2. Dowd ll, Campbell JM, Jones JA. Fluid intake and urinary Incontlnence in older communitydwelling women. J Community Health Nurs 1996 13: 179-86. 3. Tomlinson BU. Dougherty MC, Pendergast JF, Boyington AR, Coffman MA, Pickens SM. Dietary caffeine, fluid intake and urinary Incontinence In older rural women. Int Urogynecol J Pelvic Floor Dysfunct 1999:10:22-B. 4. Burgio Kl, Matthews KA, Engel BT. Prevalence, Incidence and correlates of urinary incontinence In women. J Urol 1991:146:1255-9. 5. Koskimakl J. Hakama M, Huhtala H. Tammela TL. Association of smoking with lower urinary tract symptoms. J Urol 1W&159:15&Z-2. 6. Plak EA, Kawachl I, Rimm EB. Coldlk GA, Stampfer JF, Wlllett WC, et al. Physical activity and benign prostatlc hyperplasla. Arch Intern Med 1W&l 58:2349-56. 7. Bump RC, Sugerman HJ. Fantl JA. McClish DK. Obesity and lower urinary tract function in women: effect of surgically induced welght loss. Am J Obstet Gynecol 1992:167:392-9. 8. Chla YW, Fowler CJ, Kamm MA, Henry MM.

189

190

JWOCN May 2000

Moore

Lemieux MC, Swosh M. Prevalence of bowel dysfunction In patients with multiple sclerosis and bladder dysfunction. J Neural 1995:242:1058. 9. MacDonald A, Shearer M. Poterson PJ. Finlay IG. Relationship between outlet obstructlon constipotlon and obstructed urinary flow. Br J Surg 1991;70:693-5. 10. Roe B. Williams K, Palmer M. Bladder training

for urlnory incontinence In adults (Cochrone Review). In: The Cochrane Library, Issue 4, 1999. Oxford: Update Software. 1 I. VanKampen M. De Weerdt W, Van Poppel H. De Rldder D. Feys H. Baert L. The effect of physiotherapy on the duration and the degree of incontinence after rodlcol prostatectomy: o randomized controlled study. Loncet 2000;355:9&102.

Don’t miss a single issue of the journal! To ensure prompt service when you change your address, please photocopy and complete the form below. Pleasesend your change of address notification at least six weeks before your move to enszzrecontinued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL

TITLE:

Fill in the title of the journal

OLD Affix

here.

ADDRESS: the address

label from

a recent

issue of the journal

here.

NEW

ADDRESS:

Clearly

print

your

new address

here.

Name Address City/State/ZIP

COPY

AND

MAIL

THIS

FORM

Mosbv Subsckption Customer Service 6277 Sea Harbor Dr Orlando, FL 32887

TO:

OR FAX TO:

OR PHONE:

407-363-9661

800-654-2452 Outside the U.S., call 407-345-4000

h’il Mosby