Prostate Cancer Updates

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Introduction   

Nurses should be knowledgeable on the anatomy of the prostate, the devastating consequences of prostate cancer, and the implications for care from a nursing perspective. The prostate gland is a small, walnut-shaped gland located below the bladder and in front of the rectum. The prostate surrounds the urethra and is part of the male reproductive system, playing a key role in seminal fluids and reproduction, which nourishes and protects sperm cells. The prostate also helps to neutralize the acidic environment of the vagina, which can kill sperm cells (7). Androgens, such as testosterone and dihydrotestosterone (DHT), are male sex hormones that are essential for the normal function of the prostate. The prostate also converts dehydroepiandrosterone (DHEA) into testosterone, and then later into DHT.  

This design was created on Canva.com on December 13, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

Statistical Evidence/Epidemiology 

Prostate cancer is the second leading cause of cancer death among men in the United States, after lung cancer, and the most common cancer among men, after skin cancer (1). Research estimates that one in eight men will develop prostate cancer during their lifetime (1). In 2023, there will be over 288,000 new cases of prostate cancer diagnosed in the United States, and over 34,700 men will die from the disease (1). Worldwide, an estimated 1.5 million people received a diagnosed of prostate cancer in 2020, the 4th most diagnosed cancer in the world and the 5th leading cause of death worldwide (4).  

The risk of prostate cancer increases with age, and most men receive a diagnosis over the age of 65 (2). family history of prostate cancer (first-degree relative), positive germline testing for BRCA1, BRCA2, Lynch Syndrome, changes in estrogen receptor α and β levels, androgen receptor signaling, as well as diets high in calories, fats, red meats, and dairy products can all contribute to prostate cancer (2, 27, 28). 

The incidence of prostate cancer varies with the highest rates found in North America and Europe, while the lowest rates are found in Asia and Africa (5). The risk of prostate cancer is more common in non-Hispanic Black men and those of Caribbean descent (1). The reasons for these differences are due to a combination of genetic and environmental factors.  

Since 1993, the prostate cancer death rate has declined by about 50% due to earlier detection and advances in treatment (1). The five-year survival rate for prostate cancer is over 99% when diagnosed at an early stage (3). However, the prognosis for metastatic prostate cancer is poor. 

Etiology/Pathophysiology 

Androgens are male sex hormones that play a key role in the development and growth of the prostate gland and are essential for its normal development and function. The most significant androgen is testosterone, which is converted to dihydrotestosterone (DHT) in the prostate. DHT binds androgen receptors in prostate cells, which triggers a series of events that lead to both normal and cancerous prostate cells growth. Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that is common in older men (25). 

Prostate cancer is often an adenocarcinoma, which is a cancer that develops from glandular cells. The most common location of prostate cancer is in the posterior lobe of the prostate (6). Prostate cancer is a multi-focal disease, meaning that it can develop in multiple areas of the prostate gland at the same time.  

The prostate cancer grading system is based on a Gleason score. A Gleason score is based on how much cancer cells appear like healthy tissue when viewed under a microscope by a pathologist (8). Less aggressive tumors that appear more like healthy tissue receive a Gleason score of 6 or well differentiated. Tumors that are more aggressive appear less like healthy tissue receive a Gleason of 7 or moderately differentiated, medium-grade cancer. A score of 8, 9, or 10 is a high-grade cancer, poorly differentiated, or undifferentiated (8).  

The staging of prostate cancer includes a PSA level and Gleason score.  

Stage I: Cancer in this early stage and slow growing (8).  

Stage II: A confined prostate tumor. PSA levels are medium or low (8). Stage II prostate cancer is small but may have an increasing risk of growing and spreading (8). 

Stage IIA: The tumor is not palpable, and PSA levels are medium with well differentiated cancer cells (8).  

Stage IIB: A confined prostate tumor that may be large enough to appreciate during a digital rectal exam (DRE) (8). The PSA level is medium and there is a moderate differentiation of the cancer cells.  

Stage IIC: A confined prostate tumor that may be large enough to appreciate during a digital rectal exam (DRE) (8). The PSA level is medium and there is moderate or poor differentiation in the cancer cells.  

Stage III: PSA levels are high, the tumor is growing, or the cancer is high grade (8).  

Stage IIIA: The cancer has spread beyond the outer layer of the prostate into nearby tissues (8). It may also have spread to the seminal vesicles. The PSA level is high.  

Stage IIIB: The tumor has grown outside of the prostate gland and may have invaded nearby structures, such as the bladder or rectum (8).  

Stage IIIC: The cancer cells across the tumor are poorly differentiated (8).  

Stage IV: The cancer has spread beyond the prostate (8).  

Stage IVA: The cancer has spread to the regional lymph nodes (8).  

Stage IVB: The cancer has spread to distant lymph nodes, other parts of the body, or to the bones (8). Recurrent prostate cancer is cancer that has returned after treatment.  

Diagnostic and Screening tools 

There are several tests used to diagnose prostate cancer. The most common tests are the digital rectal exam (DRE) and the prostate-specific antigen (PSA) blood test measured in nanograms per milliliter (ng/mL) (9).  

The role of PSA levels in prostate cancer is complex and not appropriate to solely use to diagnosis the disease. The PSA is a blood test that measures the level of PSA in the blood. Men greater than age 50 have a 20-30% risk of having prostate cancer if their PSA level is higher than 4.0 ng/mL. A PSA level between 2.5 and 4.0 ng/mL may require a biopsy to detect cancer in 27% of men (26).  

Prostate-specific antigen (PSA) is a protein made by cells in the prostate gland (both normal cells and cancer cells). A high PSA level can be a sign of prostate cancer or other conditions, such as an enlarged prostate gland or prostatitis (10).  

The DRE is a simple exam that involves the doctor inserting a gloved finger into the rectum to feel for any abnormalities in the prostate gland. A patient with an abnormal DRE or a high PSA level may require additional testing, such as a biopsy of the prostate gland. A biopsy involves removing a small sample of tissue from the prostate gland and examining it under a microscope for cancer cells. Providers can identify many prostate cancers with a medical history and physical exam.  

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Medication Management 

Medications play a vital role in the management of prostate cancer. They can decrease tumors, slow tumor growth, and prevent metastases. Hormone therapy is a common treatment for prostate cancer and works by blocking the production of testosterone, the male hormone that fuels the growth of prostate cancer cells. LHRH (luteinizing hormone-releasing hormone) agonists prevent the testicles from receiving messages sent by the body to make testosterone (11).  

GnRH antagonist (gonadotropin-releasing hormone) stops the testicles from producing testosterone (12). The U.S. Food and Drug Administration (FDA) has approved degarelix (Firmagon) to treat advanced prostate cancer and an oral GnRH antagonist, relugolix (Orgovyx), for the treatment of advanced prostate cancer (12).  

Androgen receptor (AR) inhibitors block testosterone from binding to androgen receptors, which are chemical structures in cancer cells that allow testosterone and other male hormones to enter the cells (14). Newer AR inhibitors include apalutamide (Erleada), enzalutamide (Xtandi), and darolutamide (Nubeqa) which can extend survival for some individuals with metastatic prostate cancer (13). Older AR inhibitors include bicalutamide (Casodex), flutamide (available as a generic drug), and nilutamide (Nilandron) taken orally.  

The FDA approved Apalutamide for the treatment of non-metastatic castration-resistant prostate cancer and for metastatic castration-sensitive prostate cancer (15). Darolutamide can be a treatment option for non-metastatic castration-resistant prostate cancer (16). Darolutamide can be a combination therapy with docetaxel chemotherapy to treat metastatic castration-sensitive prostate cancer. Enzalutamide is a nonsteroidal AR inhibitor approved to treat metastatic and non-metastatic castration-resistant prostate cancer as well as metastatic castration-sensitive prostate cancer (17).  

Although the testicles produce most of the body’s testosterone, other cells in the body can still make lesser amounts of the hormone that may drive cancer growth. These include the adrenal glands and some prostate cancer cells. Androgen synthesis inhibitors that target an enzyme called CYP17 and stop cells from making testosterone (11). Androgen synthesis inhibitors include acetate (Zytiga) and Ketoconazole (Nizoral), an androgen synthesis inhibitor (11).  

Chemotherapy is another common treatment for prostate cancer. In general, standard chemotherapy begins with docetaxel (Taxotere) combined with prednisone (11). 

New Procedures and Interventions 

There are several new procedures and interventions, either used or in development, to treat prostate cancer. Some of these new treatments include: 

• High-intensity focused ultrasound (HIFU): HIFU uses sound waves to heat and destroy prostate cancer cells. 
• Cryotherapy: Cryotherapy uses extreme cold to kill prostate cancer cells. 
• Immunotherapy uses the body’s natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells. Vaccination with sipuleucel-T (Provenge) may be an option. Sipuleucel-T is adapted for each patient (19).  
• Precision medicine is an emerging approach to cancer treatment that uses genetics and other information to tailor treatments to the individual patient.  
• Targeted therapy drugs are designed to attack specific molecules that are involved in the growth and survival of cancer cells with a PARP inhibitor (poly (ADP-ribose) polymerase) a protein that blocks an enzyme in cells and help repair DNA repair itself wen damaged (18).  
  • Targeted therapy for prostate cancer includes Olaparib (Lynparza), Rucaparib (Rubraca) Talazoparib (Talzenna) and Niraparib plus abiraterone (Akeega) (18).  
  • A clinical trial is underway to evaluate the safety and efficacy of a new targeted therapy drug called olaparib (Lynparza) in men with prostate cancer caused by specific genetic mutations (23).  
• Checkpoint inhibitors block proteins on immune cells, making the immune system more effective at killing cancer cells (21).  
  • Two checkpoint inhibitors, pembrolizumab (Keytruda) and dostarlimab (Jemperli), have been approved for the treatment of tumors, including prostate cancers that have specific genetic features (21).  
  • Pembrolizumab has also been approved for any tumor that has metastasized and has a high number of genetic mutations (21). 

Common Misconceptions 

There are several common misconceptions about prostate cancer. These misconceptions include: 

Misconception: Prostate cancer is only a serious disease for older men. While it is true that the risk of prostate cancer increases with age, prostate cancer can also develop in younger men. In fact, about 1 in 8 men will receive a diagnosis of prostate cancer in their lifetime (1).  

Misconception: Prostate cancer is always fatal. The five-year survival rate for prostate cancer is over 99% when diagnosed at an early stage (3).  

Misconception: Masturbation or sex is a cause of prostate cancer. There is no evidence to support this claim. Prostate cancer is a combination of genetic and environmental factors, not by sexual activity.  

Misconception: Prostate cancer is only a problem for men of African American descent. While it is true that African American men are more likely to develop prostate cancer than men of other races, prostate cancer can affect men of all races.  

Misconception: Prostate cancer is only a problem for men with a family history of the disease. While a family history of prostate cancer can increase a man’s risk of developing the disease, most men with prostate cancer do not have a family history of the disease (4).  

Misconception: There are no symptoms of prostate cancer. While early-stage prostate cancer often does not cause any symptoms, more advanced prostate cancer can cause symptoms such as difficulty urinating, frequent urination, and blood in the urine. 

Upcoming Research 

The National Cancer Institute supported researchers who are developing new imaging techniques to improve the diagnosis of recurrent prostate cancer. A protein called prostate-specific membrane antigen (PSMA) is found in large amounts on prostate cells (20). By fusing a molecule that binds to PSMA to a compound used in PET imaging, scientists have been able to see tiny deposits of prostate cancer that are too small to be detected by regular imaging (20).  

The Research on Prostate Cancer in Men with African Ancestry (RESPOND) study is the largest-ever coordinated research effort to study biological and non-biological factors associated with aggressive prostate cancer in African American men (22). The (RESPOND) study, launched by NCI and the National Institute on Minority Health and Health Disparities in partnership with the Prostate Cancer Foundation, is looking at the environmental and genetic factors related to the aggressiveness of prostate cancer in African American (22).  

Researchers are developing a new blood test that can detect prostate cancer with high accuracy, even in men with early-stage disease (24). These tests are still in trials, but early results are promising. Their development is a significant step forward in the fight against prostate cancer. If the tests prove to be effective, they could revolutionize the diagnosis and treatment of prostate cancer.  

Conclusion

Prostate cancer is a serious, but treatable disease. There are many different treatment options available, and the best treatment for a particular patient will depend on the stage and grade of the cancer, as well as the patient’s overall health. Early detection is key to successful prostate cancer treatment. Patients should talk to their doctor about the risks and benefits of prostate cancer and receive regular screenings.  

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