Diagnosis and Management of Prostate Adenocarcinoma

Introduction

The adenocarcinoma of the prostate is development of cancerous growth on the mucus-producing glandular cells in the prostate (Berney et al. 2016). In this assignment, diagnosis of adenocarcinoma of the prostate is to be discussed along with the treatment pathway used for its management. The impact of the treatment and the interventions required for urinary incontinence among people with adenocarcinoma of the prostate is to be explained. Moreover, the nursing role executed in caring for adenocarcinoma of the prostate by collaborating with physiotherapy team is to be evaluated.

Cancer Diagnosis

Prostate cancer is one of the common cancers among elderly men in the UK which is evident as in 2017 nearly 48,600 new cases of prostate cancer are reported which accounts for 26% of all the new form of cancer reported in male within the UK in the year (prostatecanceruk.org, 2019). As commented by Mikropoulos et al. (2018), the protein produced from BRCA2 and BRCA1 genes have the function to manage damaged DNA allowing stability of genetic information of the cells to replicate and work normally. Thus, they are considered to be tumour-suppressor genes which act to protect uncontrolled growth and abnormal functioning of cells in the body. As argued by Torjesen (2013), mutation in BRCA1 and BRCA2 genes makes body cell incapable to fix DNA damage, in turn, contributing to trigger abnormal growth of cells in the body. Thus, the inherited mutation present in genes like BRCA1 and BRCA2 contributes towards development of adenocarcinoma of prostate because the DNA damage in the cells are not repaired leading to uncontrolled growth of cell to form tumour.

The HOXB13 has the function to provide instruction in production of protein known as transcription factor which is part of the homeobox protein family. The HOXB13 protein binds to specific regions of the DNA and controls the activity of different genes in the body. The HOXB13 is also considered to be tumour-suppressor gene like the BRCA1 and BRCA2 along with it regulates androgen receptor which functions as transcription factor to regulate growth and development of prostate (Kote-Jarai et al. 2015). As criticised by Pritchard et al. (2016), the inherited mutation in the HOBX13 leads impairment of the proteins that suppress tumour and regulate androgen receptor. This, in turn, leads to promote uncontrolled cell division and growth in the prostate out of the unrepaired damaged DNA contributing to cancer formation. The mutated genes responsible to develop adenocarcinoma of prostate are transferred mainly from the mothers to their offspring leading prostate cancer to present over generations in the family (Benafif and Eeles, 2016). The exact mechanism behind mutation of the BRCA1, BRCA 2 and HOBX13 that causes prostate cancer is still unknown. However, it is considered that combined effect of the genes leads to development of cancer in the prostate (Kote-Jarai et al. 2015).

Pathway

The External Beam Radiation Therapy (EBRT) is used in early stages of prostate cancer in which radiation is focussed on the prostate glands to destroy and control the growth of the cancerous cells specifically in the gland (Graham et al. 2014). This is effective to control further spread of cancer and ensure cure from the condition for the patients. As criticised by Sooriakumaran et al. (2014), side-effects of EBRT include blood in urine, abdominal cramps, frequent urination and others. The side-effects often make the therapy avoided to be availed by individuals suffering from prostate cancer and consider undergoing other interventions. According to NICE Prostrate Pathway, the patients with localised stage 1 and 2 and locally-advanced prostate cancer of stage 3 are to be provided RALP treatment (NICE, 2019). As asserted by Hoyland et al. (2014), Robotic-Assisted Laparoscopic Prostatectomy (RALP) is the surgical treatment used for prostate cancer in which the prostates are removed through minimal-invasive surgery with the assistance of robots managed and controlled by the surgeon.

The benefit of using RALP as surgical treatment for prostate cancer is that it executes small incision on the patients making their hospital stays and healing time to be shortened. Moreover, RALP inflicts less pain and risk of bleeding for the patients as the robot used in the surgery have flexible arms to make accurate and careful incision without causing much damage (Retèl et al. 2014). Thus, the RALP is effective to be used in treatment of prostate cancer in stage 1 and 2 and when locally advanced. As criticised by Kowalewski et al. (2017), RALP leads to cause urinary incontinence among people with prostate cancer. This is because the initial values holding the urine are removed in the surgical process. Thus, undergoing RALP leads people to face hindered social life as a result of urinary incontinence but it is considered to improve over time.

The NICE Prostrate Pathway guides that patients with prostate cancer of stage 4 in which it becomes metastasis meaning spreading to other parts of the body are to be provided SACT intervention (NICE, 2019). The Systematic Anti-Cancer Therapy Dataset (SACT) indicates collective therapies used for treatment of malignancy to achieve palliation among cancer patients. The NHS, UK mentions that they use chemotherapy as one of the systematic anti-cancer therapies for metastases cancer patients to help them get relieved of the pain and manage their health condition (NHS, 2019). The chemotherapy is mentioned to be used in metastasis stage of any cancer because the medicine used in the process destroy the cancer cells growth in all parts of the body avoiding its further spread to other body parts that are not yet affected. It does not provided cure for metastasis prostate cancer but helps to lower the pain and symptoms of cancer to some extent for the patient (Mayor, 2015). As criticised by Watts et al. (2014), chemotherapy treatment for prostate cancer involves side-effects such as burning and numbness in feet and hands, stomach pains and others. The side-effects often leads individual avoid to adopt the intervention.

Impact of Pathway

The patients who have undergone Robotic-Assisted Laparoscopic Prostatectomy (RALP) have increased chances of urinary incontinence. This is because during prostatectomy the internal sphincter muscles that act as valves to avoid leakage of urine are removed present at the bottom of the bladder neck. It makes the patients prone to leak urine during increased pressure in the bladder (Klein et al. 2016). In the study by Mukherjee et al. (2015), it is reported that 30-40% of patients after prostatectomy for prostate cancer report urinary incontinence as the major side-effect being faced by them. As asserted by Downing et al. (2016), social impact of urinary incontinence on people who had undergone RALP includes restricted lifestyle performance and isolation from society. This is because sudden urine leakage by adults in the society out of urinary incontinence is mocked as childish and unsocial act. As criticised by Watson et al. (2014), urinary incontinence in people who had undergone RALP leads them experience negative work-life and struggles to manage work. This is because they people immediately after RALP is unable to execute any hard work making them compromise on managing work. Moreover, urinary incontinence as the side-effect of the surgery often leads individual to face embarrassment and mocking out of inability to control urination from their colleagues at the workplace making it hard for them to continue working.

The psychological impact of urinary incontinence as result of RALP among prostate cancer individuals includes feeling of depression out of lesser perception of their body image. This, in turn, creates negative impact on their life goals, self-efficacy, effort and persistence to lead a normal life (Hanly et al. 2014). This is because depressed state leads people unable to have effective mood and zeal in fulfilling their goals, in turn, deteriorating their personal life. As argued by Gavin et al. (2016), individuals who are involved in chemotherapy for metastasis prostate cancer treatment develops anxiety out of fear of uncontrolled pain, being left alone and death. This is because they feel anxious that use of chemotherapy to destroy the cancerous cells is going to lead them feel increased pain and they become unsure about the ability of the treatment to heal them. The use of radiation therapy in treatment of prostate cancer affects the patient to have lower functioning immune system. This is because during radiation therapy normal cells in the body are also damaged that leads to lower the immunity of the body. It is evident as during radiation therapy in prostate cancer, the bones in the pelvis are affected where the marrow functions to produce blood cells for the body to support effective functioning (Boyd et al. 2015). As criticised by Donovan et al. (2016), radiation therapy in prostate cancer causes irritation over the skin which lead to small breaks. This allows the germs and bacteria to enter the inner parts of the skin and cause infection.

In the study Watts et al. (2015), it is mentioned that men facing prostatectomy to treat prostate cancer are found no longer able to feel ejaculation during orgasm. This is because the seminal vesicles and prostate that are involved in making semen are removed during the operation leading individuals to feel dry orgasm. As argued by Wilt and Ahmed (2013), men with prostatectomy experience erectile dysfunction during sexual intercourse. This is because the muscles, blood vessels and nerve in the area are weakened as result of the surgery making the patients experience hindrance in getting erection. In sexually active adult men, it leads to negatively affect their sex life and self-esteem as they are unable to provide pleasure to their partners during sexual intercourse. Moreover, their inability to ejaculate and hindered masculinity leads the men to face social ridicule which eventually lowers their self-esteem out of feeling of hopeless to impregnate women or their partners (Hagberg et al. 2016).

The hair loss and contributing side-effects of chemotherapy in patients with prostate cancer lead them to develop negative perception regarding their body image as well as develop depression and stress out of hindered health condition. It psychologically affects the patients to withdraw themselves from society and develop hopelessness to lead their life (Mayor, 2015). As commented by Toren et al. (2013), after prostatectomy the individuals are avoided to involve in any strenuous activity immediately. This is because it may lead to bleeding from the surgical area as well as the surgery leads the body to become weakened making the people require some time to regain strength. Thus, prostatectomy in patients with prostate cancer negatively affects their work-life to avoid involving in heavy physical activity. It creates issues for men who work as labour and required to involve in lifting and managing heavy objects at work making them face initial unemployment after the surgery.

Intervention for urinary incontinence

The key issue faced with RALP is urinary incontinence which emotionally, personally and socially hinder life of the individuals but with effective intervention, the issue could be controlled leading the men to lead a better quality life. In the study of Hirschhorn et al. (2013), it is mentioned that preoperative pelvic floor exercise is effective in treatment of urinary incontinence among people who have undergone prostatectomy due to prostate cancer. This is because it allows them to develop control of urine leakage after the surgery. As criticised by Hodges et al. (2019), pelvic floor exercise is effective for short-term after surgery in controlling urinary incontinence. This is evident as it mentions that preoperative pelvic floor exercise was effective to control urinary incontinence in prostatectomy patients for 3 months and not for 6 months. Thus, it suggests that it is effective only for early incontinence rate in surgery and not later condition for men (Hirschhorn et al. 2013). The pelvic floor exercise is to be initiated by emptying the bladder so that no urine leaks during the pressure created in the exercise. At the initial stage, the pelvic muscles are to be contacted for few seconds and release it. The exercise requires to be continued until 10-15 minutes and during the course of the exercise stomach, thighs, bottoms are not to be contracted at the same time (Hodges et al. 2019).

In comparison, the strategy to be used for long-term management of urinary incontinence among people with prostatectomy includes surgical reconstruction of the urinary area that includes implementation of artificial sphincters, bulbourethral sling surgery and others (Harju et al. 2017). In the study by Serag et al. (2018), it is mentioned that implementation of artificial sphincter in case of prostatectomy patients provides 38.5% success rate in controlling urinary incontinence post-operation. The study also mentioned that efficacy of artificial urinary sphincter is found to be more compared to male slings in follow-up periods between 3-7.7 years. The study mentioned that 58-90% of patients mentioned treatment success after receiving artificial urinary sphincters. The artificial urinary sphincter is referred to the device which has presence of cuff that is connected around the urethra with the pump in the scrotum and balloon in the abdomen area. The cuff remains closed so that leakage of urine can be controlled. The patients use the device by pumping the scrotum which leads to opening of the cuff making the person to urinate. After a minute, when the cuff is refilled with fluid, it leads to cause development of continence to prevent incontinence (Serag et al. 2018).

The advantage of using artificial urinary sphincter surgery is that it enhances the social and emotional quality of life of the patients by cutting their stress and embarrassment regarding urinary incontinence in long-term condition. It also facilitates them to lead a better social life and maintain work without fear of mocking due to the condition (Peralta et al. 2013). The importance of artificial urinary sphincter in people with prostatectomy is that it creates low chances of injury to the pelvic area compared to sling surgery where mesh area or pubic bones may be affected leading to bleeding and infection (Serag et al. 2018). As argued by De Marini et al. (2019), in sling surgery, there is risk of recurrent stress urinary incontinence which is quite low in case of artificial urinary sphincter surgery. This indicates artificial sphincters to be effective for urinary control after prostatectomy. However, there are few risk related to use of artificial urinary sphincter surgery in controlling urinary incontinence among people.

The artificial urinary sphincter (AUS) is required to be changed after 10-20 years as they lose their ability to function effectively due to mechanical failure. After their failure, invasive surgery is required to implant them in the body which may lead to urinary tract infection (UTI) (NICE, 2019). As criticised by Wang et al. (2014), risk of using AUS is lack of manual dexterity in people to manage the opening and closing of the AUS. This causes problematic management of urinary incontinence leading to failure of urine control in patients. As argued by Peralta et al. (2013), risk involved with using AUS is erosion in the urethra out of hindered management of the device. Thus, effective training is required to be provided to the patients so that they have effective knowledge regarding the way AUS is to be managed to avoid harm to the internal parts of the body. Further, urinary incontinence may be faced until 4-6 weeks after AUS surgery (Wang et al. 2014). During this tenure, the pelvic floor exercises are to be executed so that for the brief period of time effective management of urinary incontinence can be reached. Therefore, involvement of both pelvic floor exercise and AUS surgery is essential to ensure effective recovery from urinary incontinence after RALP.

Evaluating nursing role

In order to support patients undergoing RALP to perform preoperative pelvic floor exercise, the nurses require working in collaboration with the multi-disciplinary team which include the physiotherapy experts. In pre-surgical situation of RALP, the nurses have the role to mentally and physically prepare the patients in showing compliance during the surgery. During this condition, the nurses are to share information to the patients regarding the way surgery is to be performed, cause of urinary incontinence, use of bladder catheter, the importance of pelvic floor exercises and others (Wade et al. 2015). As argued by Stanciu et al. (2015), avoiding detailed information about surgery to be provided to patients leads them to show non-compliance in care. This is because the patients are unable to ensure whether not care is effective for their health. The nurse's role before RALP for the patient is that they are preparing their skin, take records of vitals to be shared with the health professionals, arrange equipment for the surgeon and assist them during surgery (Harju et al. 2017). As criticised by Emery et al. (2014), in post-surgery of RALP, the nurses have the role to manage urinary catheter and control infection. This is because immediately after the surgery if the urinary catheter is not adequately and hygienically maintained it would lead to raise urinary tract infection in people (Harju et al. 2017). In addition, to care for patients after RALP, the nurses have the role to manage medication, arrange wound care, educate regarding sign and symptoms of postoperative communication, arrange pain control and pelvic-floor exercises (Allchorne et al. 2020).

The physiotherapy is referred to treatment in which massage therapy, heat treatment and others are used for the patient instead of medication or surgery to manage physical condition. Thus, the involvement of physiotherapy experts in supporting patients to perform preoperative pelvic floor exercise is required so that patients have effective knowledge regarding the way to manage urinary incontinence for brief amount of time after the prostatectomy. As criticised by Fox et al. (2018), the nurse’s role includes identifying the needs and demands of the patients to be communicated to the multi-disciplinary team. This is to ensure effective care actions to be taken in collaborative manner for treatment of the patient. Thus, the role of nurse in case of prostate cancer patients is to identify patients those are undergoing RALP as they are going to need performing pelvic floor exercises before he surgery. It is to ensure the specific care is arranged to be provided to the patients in need and not others who have ability to control urine even after surgery.

As a nurse, the role in multi-disciplinary team (MDT) care is to determine who are at risk of certain health condition so that such patients can be identified and effectively treated with collaboration actions of experts from the MDT (Østergren et al. 2016). The elderly patients who undergo RALP are prone to face increased urinary incontinence. This is because with ageing muscle control diminishes and the additional impact of RALP in elderly is seen to make them have weakened muscle control to manage urinary incontinence. The patients after prostate surgery who involves in excessive alcohol intake are prone to experience urinary incontinence. This is the nerves present in the bladder area are irritated leading the patients unable to control urine and face incontinence. As argued by Harju et al. (2017), the role of the nurse is to refer patients who had undergone RALP to adequately trained physiotherapist to help them develop knowledge regarding the way to perform pelvic floor exercises. This is because without adequate training the patients would not have enhanced knowledge regarding the way to exercise to strengthen their urinary control to avoid incontinence after surgery.

Conclusion

The above discussion informs that prostate cancer mainly affects people who are older in age and the causes include mutation in genes, heredity and others. The RALP is used for patients who are in stage 1-3 of prostate cancer where their prostate glands are removed. The preoperative pelvic floor urinary exercise provides short-term control and artificial urinary sphincter surgery provide long-term control for urinary incontinence among people undergoing RALP. The nurse's role is to collaborate with multi-disciplinary team in which physiotherapist is to be used to educate patients regarding pelvic floor exercises.

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