Prostate cancer

Management approaches and impact on urinary incontinence,

By all accounts, the prevalence of prostate cancer is rising. The trend has been attributed to a range of factors, including increased detection of early-stage disease, improvements in survival, and an apparent decline in prostate cancer mortality.

A range of treatment options is available, but studies are still required to adequately compare the survival outcomes of the various options. For men and their physicians, each option must therefore be considered in terms of its effect on survival, morbidity and quality of life.

Choosing the management approach

Patient preference is an important factor in treatment decisions, according to the NHMRC clinical practice guidelines for the management of localised prostate cancer.1 A patient’s values of quality and quantity of life, their acceptance of risk, and fear of complications will all play a part in determining the appropriate management option.

Of all treatment modalities, radical prostatectomy has the most research to support it. The NHMRC guidelines suggest that such surgery is likely to benefit patients who have a relatively long life expectancy (>10 years) and no significant surgical risk factors.

Many men who undergo surgical treatment will need to deal with postprostatectomy urinary incontinence, although nerve-sparing techniques have reduced complication rates. Adequate education and management of urinary incontinence is thus an important aspect to the overall care of men undergoing surgical treatment for prostate cancer. Radiotherapy is generally recommended for patients with no significant risk factors for radiation toxicity and a preference for radiotherapy.

Brachytherapy is not yet widely practised in Australia; it involves insertion of radioactive seeds into the rostate to deliver a calculated dose of radioactive isotope to the cancer. Another option is no treatment at all, whereby symptoms and progression of the disease are managed if and when they arise. Evidence suggests that this ‘watch and wait’ approach (see box) may have comparable outcomes to active treatments, although studies are ongoing to confirm this.

Post prostatectomy urinary incontinence

The incidence of urinary incontinence following prostate cancer treatment ranges from 0.5% in men receiving radiation therapy to 87% in men after surgery. Non nerve-sparing surgical techniques tend to have a higher incidence of incontinence than do nerve-sparing techniques, although men with large, undifferentiated tumours may not be candidates for the latter. Authors of a paper on post prostatectomy incontinence point out that knowledge of the risk of urinary incontinence can help men prepare for such complications.2 They add, “Assurance that effective help is available to contain or improve incontinence may help men cope better with the aftermath of treatment.

Patient education plays a key role in the preoperative and postoperative care of these men.” Main causes of post prostatectomy incontinence have been identified as bladder spasms, damage to the sphincter muscle, or a combination of bladder malfunction and sphincter damage. A recent Cochrane Review concluded that the value of various approaches to conservative management of post prostatectomy incontinence remains
uncertain, although there may be some benefit in offering muscle training with biofeedback early in the postoperative period, immediately following catheter removal.

Did you know:
• The number of men who die of prostate cancer is equivalent to the number of women who die of breast cancer.
• Over 10,000 new cases of prostate cancer are diagnosed each year.
• Reports of prevalence of urinary incontinence after prostate cancer treatment range from 0.5% to 87%, depending on the type of treatment.
• Studies report that more than 90% of men are willing to be impotent or incontinent to have their prostate cancer cured.

Courtesy of Incontinence Advisor - June 2005.

References:
1. National Health and Medical Research Council. ‘Clinical Practice Guidelines: Evidence based information and recommendations for the management of localised prostate cancer’, Canberra: NHMRC, 2002.

2. Palmer H Postprostatectomy incontinence: The magnitude of the problem. J WOCN 2000; 27:129-37.

3. Hunter, K. Conservative management for postprostatectomy urinary incontinence (Cochrane review). The Cochrane Library, Issue 1. 2005. Chichester, UK: John Wiley & Sons, Ltd.

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