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An Overview of Prostate Cancer - Diagnosis and Treatment

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					                   CNE Objectives and Evaluation Form appear on page 264.
                                                                                                        SERIES

      An Overview of Prostate Cancer:
         Diagnosis and Treatment
                                                    Dawn Mielke Strief

                                                                                           Stages of Prostate Cancer
   This review of the state of
 the science for prostate can-
                                             P   rostate cancer is the most
                                                 commonly diagnosed cancer
                                             and the second leading cause of
                                                                                                Localized prostate cancer has
                                                                                           been defined as a cancer confined
 cer includes a description of               cancer-related death among Amer-              to the prostate (Bott, Birtle,
 current screening, diagnosis,               ican males (Terris & Rhee, 2006).             Taylor, & Kirby, 2003). Research to
                                             The incidence of this disease is              date has failed to link prostate
 and treatment options for                   highest among Caucasian and                   cancer to any specific modifiable
 localized prostate cancer.                  African-American males, with re-              lifestyle choices, but it has identi-
 Educational resources ap-                   ported incidences of 161/100,000              fied non-modifiable risk factors.
 propriate for at-risk patients              and 256/100,000, respectively. The            These include increasing age, a
                                             estimated overall incidence of                family history of the disease, and
 are outlined.                               prostate cancer in the United                 ethnicity. Higher incidences of
   — Linda H. Yoder, PhD,                    States for 2008 is 186,320, with              localized prostate cancer are
       MBA, RN, AOCN®, FAAN                  projected mortality of 28,660                 reported among men over age 60,
                                             (Jemal et al., 2008). Despite the             especially in African Americans.
                                             high incidence of the disease, pos-           Caucasian men have the second
                                             itive outcomes can be achieved                highest incidence of prostate can-
                                             through early, effective, and ap-             cer, and rates of the disease are
                                             propriate treatment. Many health              lowest among men of Asian-
                                             professionals will care for individ-          American and Hispanic-American
                                             uals with prostate cancer, or know            decent (U.S. Department of Health
                                             individuals at risk for developing            and Human Services, 2006). The
                                             the disease. All nurses should be             American Cancer Society (ACS)
                                             familiar with the guidelines for              (2007) estimates that one in six
                                             screening, treating, and managing             men will be diagnosed with
                                             early or localized prostate cancer.           prostate cancer during their life-


Dawn Mielke Strief, MS, RN, ANP, GNP, is a Nurse C-Change is a not-for-profit
Practitioner, VA Medical Center, Minneapolis, MN.                 organization whose mission is to
                                                                  eliminate cancer as a public
Editor’s Note: This article is reprinted with permission from health problem, at the earliest possible time, by leveraging
Urologic Nursing, 27(6), 475-479. Certain facts and figures have the expertise and resources of our members. C-Change is the
been updated and modified for MEDSURG Nursing readers by only organization that assembles cancer leaders from the
“Cancer: Caring and Conquering” Column Editor Linda H. three sectors – private, public, and not-for-profit – from across
Yoder, PhD, MBA, RN, AOCN®, FAAN.                                 the cancer continuum – prevention, early detection, treat-
                                                                  ment, and quality of life. C-Change invests in the resolution of
Notes: This column is made possible through an educational problems that cannot be solved by one organization or one
grant from C-Change, a 501(3)c (not-for-profit) organization. sector alone. For more information about C-Change, visit
The purpose of the “Cancer: Caring and Conquering” column is www.c-changetogether.org.
to strengthen the cancer knowledge, skills, and confidence of
                                                                  The author and all MEDSURG Nursing Editorial Board mem-
medical-surgical nurses who care for patients at risk for or liv-
                                                                  bers reported no actual or potential conflict of interest in rela-
ing with cancer.
                                                                  tion to this continuing nursing education article.


258                                                                                       MEDSURG Nursing—August 2008—Vol. 17/No. 4
                                                 An Overview of Prostate Cancer: Diagnosis and Treatment
                                                                                                           SERIES

time, but only 1 in 35 will die of          has been speculation that the            it may be localized and treatment
this disease.                               virus interacts with the prostate        may cure or control.
     The identification of family           and the tissue surrounding it to
history as a major risk factor for          cause prostate cancer. Further           Diagnostic Work-Up
prostate cancer has resulted in a           research in this area is targeting            Screening. PSA is an enzyme
great deal of research to isolate a         development of a vaccine to pre-         created only by prostate cells
genetic component (Lessick &                vent prostate cancer (Simard et          (Stutzman, 2003); it is a normal
Katz, 2006). The first prostate can-        al., 2003).                              product of the prostate gland and
cer susceptibility gene, HPC1                    Prostate cancer frequently          normal component of the seminal
(Hereditary prostate cancer 1),             offers no specific clinical symp-        fluid. Minute amounts of this pro-
was discovered in 1996 (Smith et            toms. Lower urinary tract symp-          tein leach into the blood and are
al., 1996) and mapped to the long           toms may be present, but these are       detectable quantitatively by sev-
arm of chromosome 1. Since then,            neither specific nor sensitive           eral chemical assays (Linn, Ball, &
several other prostate cancer sus-          enough to diagnose prostate can-         Maradiegue, 2007). Catalona and
ceptibility genes have been linked          cer. Lower urinary tract symptoms        colleagues (1991) first reported
to various regions on other chro-           are more specific to another condi-      the use of PSA serum levels as a
mosomes (Ostrander, Markianos,              tion known as benign prostatic           first-line screening tool to detect
& Stanford, 2004; Verhage &                 hyperplasia (BPH) and should not         prostate cancer. They found that a
Kiemeney, 2003).                            be correlated directly to the pres-      single PSA determination was
     In addition to the discovery of        ence of prostate cancer. However, if     more accurate than a DRE, previ-
the HPC1 gene, several other theo-          prostate cancer is present, lower        ously the standard and only
ries have been developed in an              urinary tract symptoms also may          method available to detect
attempt to explain the genetic              be present, especially if the            prostate cancer and to identify
basis of prostate cancer. The               prostate enlarges or intrudes into       early prostate cancer. Elevated
Mendelian autosomal dominant                the urethral space. These symp-          levels of PSA have been correlated
inheritance theory is thought to            toms may include urgency, hesitan-       positively with prostate cancer,
best explain familial clustering of         cy, frequency, dysuria, weak             but are not specific for prostate
prostate cancer among men with              stream, and urine leakage. In a          cancer. Elevated levels of PSA also
early-onset disease. Approximate-           review article, Hamilton and Sharp       are seen in the presence of BPH,
ly 43%-65% of prostate cancer               (2004) determined that lower uri-        prostatitis, prostate abscess, man-
cases diagnosed in patients before          nary tract symptoms are more             ipulation of the prostate, prostatic
age 56 have been linked to the              prevalent in the presence of pro-        infarction, and ejaculation within
presence of a rare autosomal dom-           state cancer, yet the high preva-        the previous 48 hours (Stutzman,
inant, high-risk susceptibility gene        lence of these symptoms among            2003). Thus, screening only by
(Verhage & Kiemeney, 2003). A               the general population decreases         PSA results has been met with
multifactorial model has been               their predictive value. No evidence      some controversy.
developed which describes how               thus suggests that lower urinary              The variability of PSA results
prostate cancer may occur when              tract symptoms are associated            within an individual further com-
several susceptible genes interact          with localized prostate cancer, and      plicates testing and contributes to
with environmental factors (Gong            their presence is not sensitive or       the continuing controversial na-
et al., 2002).                              specific enough to aid in the diag-      ture of the test. Soletormos and
     A virus was identified recently        nosis of prostate cancer.                associates (2005) determined that
which may be an environmental                    At present, no symptoms are         biological variations of total
influence on the development of             specific to the diagnosis of             prostate-specific antigen (tPSA)
prostate cancer. The HPC1 gene              prostate cancer. Rather than rely        exist. These researchers deter-
has been implicated in viral                on symptoms, patients should             mined that while tPSA is increas-
defense, and scientists have found          have routine prostate cancer             ingly used for screening, diagno-
that men with mutations in their            screening, which includes a digital      sis, and monitoring of prostate
HPC1 gene harbor this virus 30              rectal examination (DRE) and             cancer, serial measurements of
times more than men without the             obtaining a blood sample to deter-       individual tPSA levels varied by
genetic mutation. The HPC1 gene             mine the presence of the prostate-       more amplitude than could be
encodes an antiviral protein which          specific antigen (PSA). If one or        accounted for by the analytical
is activated by viral infection. Any        both of these screening examina-         variation of the test. This variation
impairment in this gene has been            tions are abnormal, further inves-       was believed to be caused by
proposed as a susceptibility factor         tigation should occur. Interven-         intra-individual variation. Further
in the development of prostate              tion at this stage allows prostate       research must be performed to
cancer (Hampton, 2006). There               cancer to be detected early, when        determine if the variation of tPSA


MEDSURG Nursing—August 2008—Vol. 17/No. 4                                                                             259
                  An Overview of Prostate Cancer: Diagnosis and Treatment
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is greater in men with known                                             Table 1.
prostate cancer when compared                         Age-Specific Reference Ranges for Serum PSA
to those who do not have the dis-
ease. It appears that the biological        Age Range          Asians           African Americans             Whites
variation of tPSA is 20% and is             40-49 years      0-2.0 ng/mL           0-2.0 ng/mL              0-2.5 ng/mL
influenced by age. Thus, using this
                                            50-59 years      0-3.0 ng/mL           0-4.0 ng/mL              0-3.5 ng/mL
laboratory value to screen or fol-
low treatment is not a certainty.           60-69 years      0-4.0 ng/mL           0-4.5 ng/mL              0-4.5 ng/mL
See Table 1 for age-specific refer-         70-79 years      0-5.0 ng/mL           0-5.5 ng/mL              0-6.5 ng/mL
ence ranges for serum PSA.
     In addition to the biological       Source: Richardson & Oesterling, 1997.
variation associated with tPSA lev-
els, the accuracy of the PSA test
should be explored. The Physi-
cians’ Health Study, performed by        response that can lead to unneces-        ated with and specific for the diag-
Gann and colleagues in 1995              sary and invasive testing. The net        nosis of localized prostate cancer
(Harris & Lohr, 2002), used longi-       benefit of prostate screening activ-      (Berger et al., 2007). If the patient
tudinal follow-up data rather than       ities thus remains controversial.         is asymptomatic, an elevated PSA
biopsy to determine the sensitivi-       However, even in light of these           should be correlated with a DRE. If
ty and specificity of the PSA test.      facts, the American Urological            these results create a suspicion
Analysis of these data determined        Association and ACS recommend             for prostate cancer, a referral and
that the sensitivity for PSA in          offering a screening PSA along            prostate biopsy should follow. If
detecting prostate cancer within 2       with a DRE for men age 50 and             results are positive, the cancer
years was 73.2%. The specificity of      above who are expected to live            should be staged using the
the PSA test was 85.4% among             longer than 10 years. Men at high-        Gleason Scoring System, the
men who did receive a diagnosis          er risk, such as African Americans        Tumor, Nodes, Metastasis (TNM)
of prostate cancer within 2 years.       and men with a family history of          classification, or the Whitmore-
     These data also determined          PCA, should begin testing at age          Jewett staging system (Stutzman,
that the specificity of the PSA level    40-45, or 5 years before the age of       2003).
is lower among men with large            onset of disease of the affected              Gleason Scoring System. The
prostate glands, a population            family member. The DRE is consid-         Gleason Scoring System separates
which includes men with BPH. The         ered an integral part of the screen-      the cancer diagnosis into five dif-
researchers concluded that pro-          ing protocol and is used in con-          ferent histologic grades. Grade 1
state cancer screening using the         junction with the PSA. The sensi-         tissue is well-differentiated and
PSA test is not appropriate among        tivity of diagnosing tumors is            provides the best prognosis.
men with BPH because the PSA             improved markedly with the use            Treatment for individuals with a
level would be decreased falsely.        of both modalities (Coley, Barry,         Grade 1 tumor may result in a
The results of this study have led       Fleming, & Mulley, 1997). See             cure. Poorly differentiated cancers
experts to suggest that PSA levels       Table 2 for a variety of current          are classified as Grade 5 and carry
be adjusted for age, with the            screening recommendations for             a poor prognosis. Affected individ-
abnormal PSA level decreased             prostate cancer. Clearly, further         uals require extensive treatment
from 4.0 ng/mL to 2.6 ng/mL              research needs to occur with              with an appropriate goal being
(Gretzer & Partin, 2003).                respect to appropriate screening          tumor control. Tissue samples are
     Digital rectal examinations also    activities, the meaning of the            obtained from two different sites,
are used as a screening mechanism        results, and necessity and timing         with the grade for each tissue
for prostate cancer. In a metaanaly-     of further diagnostics and treat-         sample defined separately and the
sis, Harris and Lohr (2002) deter-       ment.                                     two scores added. The highest
mined that the sensitivity of this            Diagnostic examinations. Men         Gleason score possible is 10, if
test was 59% and its specificity was     with prostate cancer usually have         each site obtains a grade of 5.
undeterminable. Thus, while this         a PSA result higher than 10 ng/mL,        Prostatic intraepithelial neoplasia
procedure may be useful in detect-       while men with BPH rarely have            (PIN) also may be identified in the
ing prostate cancer among those          such an elevation. Men who have           biopsy tissue. PIN is known to be a
with a low PSA, the limited repro-       a PSA serial increase in 1 year of        premalignant lesion for prostate
ducibility of the examination limits     0.75 ng or more over baseline PSA         cancer and these individuals have
its clinical significance.               should undergo further screening.         an increased risk for prostate
     Prostate cancer screening           This rate of change is known as           cancer in subsequent biopsies
may result in a false-positive           PSA velocity, and has been associ-        (Stutzman, 2003).


260                                                                                MEDSURG Nursing—August 2008—Vol. 17/No. 4
                                                   An Overview of Prostate Cancer: Diagnosis and Treatment
                                                                                                                 SERIES

                                                      Table 2.
                                             Recommendations for Screening
       Organization                                    Published Recommendations for Screening
 American Urologic           The prostate-specific antigen (PSA) test and the digital rectal examination (DRE) should be offered
 Association                 annually, beginning at age 50, to men who have a life expectancy of at least
                             10 years. Men at high risk should begin testing at age 45.

 American Cancer             Annual screening: The American Cancer Society believes that doctors should offer the PSA blood
 Society                     test and DRE (digital rectal exam) yearly, beginning at age 50 to men who do not have any major
                             medical problems and can be expected to live at least 10 more years. Men at high risk should
                             begin testing at age 45. Men at high risk include African Americans and men who have a close rel-
                             ative (father, brother, or son) who had prostate cancer before age 65. Men at even higher risk
                             (because they have several close relatives with prostate cancer at an early age) could begin test-
                             ing at age 40. Depending on the results of the first tests, they might not need more testing until
                             age 45.

 United States               There is insufficient evidence to support prostate cancer screening.
 Preventative Services
 Task Force
 National Cancer Institute   No published standards or guidelines. The National Cancer Institute posts information: “What is
                             PSA?” “Why is PSA performed?” “For whom is it recommended?” http://www.cancer.gov/cancer-
                             topics/factsheet/Detection/PSA
 American College of         There is insufficient evidence to support prostate cancer screening.
 Physicians
 American College of         No published standards or guidelines.
 Family Physicians
 Centers for Disease         Although there is good evidence that PSA screening can detect early-stage prostate cancer, evi-
 Control                     dence is mixed and inconclusive about whether early detection improves health outcomes.
                             Additionally, prostate cancer screening is associated with important harms, which include anxiety
                             and followup procedures based on test results that sometimes are false positive, as well as the
                             complications that may result from treating prostate cancers that, if left untreated, might not have
                             affected the man’s health.
 U.S. Department of          There is insufficient evidence to support prostate cancer screening.
 Veterans Affairs
 National Comprehensive      Practice Guidelines in Oncology suggest “talking points” to discuss with patients. The pros and
 Cancer Network              cons of screening are listed within this guideline. Men should make an informed decision about
                             having a PSA screening test.



     Tumor staging classifications.               Stage B (T2, N0, M0) is limited          of a palpable node and unilateral
Stage A (T1, N0, M0) prostate can-           to the prostate gland and usually             capsular penetration. Stage T3b
cer is disease that cannot be pal-           is found by DRE in which a nodule             describes the presence of a palpa-
pated during DRE of the prostate.            or hardness may be palpated.                  ble node which has bilaterally
This stage is further divided into           Stage T2a is defined as the pres-             extracapsular extension. Stage
T1a and T1b. T1a is well-differenti-         ence of a palpable node which                 T3c involves a palpable node
ated and involves less than 5% of            involves up to one-half of one                which has invaded the seminal
the prostate gland. T1b also is well         lobe. Stage T2b is defined as a pal-          vesicles (Stutzman, 2003).
differentiated, yet involves more            pable lesion which involves more                  Stage D (T4, M+) is a cancer
than 5% of the prostate gland. This          than half of one lobe, but not both           which has invaded adjacent struc-
determination often is made dur-             lobes. Stage T2c describes a pal-             tures, such as the bladder neck,
ing a surgical procedure for symp-           pable node, present in both lobes             sphincter, rectum, or pelvic wall.
toms of BPH. Stage T1c indicates             (Stutzman, 2003).                             The inclusion of N or M in the stag-
that the prostate gland was biop-                 Stage C (T3 and T4, N0, M0) is           ing describes a cancer that has
sied as a result of an elevated PSA          local-extensive prostate cancer.              metastasized to the lymph nodes
level (Stutzman, 2003).                      This stage is marked by presence              or has distant metastases (such as


MEDSURG Nursing—August 2008—Vol. 17/No. 4                                                                                      261
                  An Overview of Prostate Cancer: Diagnosis and Treatment
SERIES

bone), respectively (Stutzman,           comes, but the transperineal           efficacy and clinical outcomes (El-
2003).                                   approach may be accomplished           Hakim & Tewari, 2004).
     Whitmore-Jewett Staging. The        with less blood loss, no abdominal          Robotic prostatectomy appears
Whitmore-Jewett Staging classifi-        incision, and decreased pain. This     to be slightly more efficient at re-
cation is similar to the TNM classi-     approach has two potential disad-      ducing complications related to
fication. Stage A is a clinically        vantages. First, because lymph         impotency, urinary incontinence,
undetectable tumor, usually found        node sampling is not possible, an      and recovery time (Starnes &
incidentally. Stage A1 is focal and      additional procedure will be re-       Sims, 2006). Robotic prostatecto-
well-differentiated. Stage A2 is dif-    quired. In addition, this approach     my is slightly more expensive than
fuse or poorly differentiated. Stage     cuts the prostate during removal,      other surgical procedures and
B is limited to the prostate upon        which may pose a risk of tumor         may not be available at all treat-
rectal examination. Stage B1             seeding.                               ment centers.
implies one solitary nodule, less             Potential side effects or com-         External beam radiotherapy.
than 1.5 centimeters, and involves       plications associated with a radi-     External beam radiotherapy treat-
only one lobe. Stage B2 involves         cal prostatectomy include tempo-       ment (EBRT) has similar efficacy
one whole lobe or both lobes.            rary urinary incontinence and          to surgery with some differing
Stage C extends locally outside the      impotence. Urinary dysfunction         complications. EBRT usually is
prostatic capsule or into the semi-      subsides within the first year after   performed every weekday for 4-6
nal vesicles. Stage D implies            surgery, and potency is regained       weeks. This procedure affects nor-
metastatic disease; Stage D1             for approximately 80% of patients      mal tissue, resulting in temporary
involves pelvic lymph node metas-        (Bott et al., 2003). Return of these   adverse effects that include diar-
tases, while Stage D2 involves dis-      physical functions is dependent        rhea, tenesmus, proctitis, dysuria,
tant metastases (Stutzman, 2003).        on patient age, the disease stage,     frequency, and lethargy. Long-
                                         and if nerve bundles are intact        term effects of EBRT include impo-
Treatment Options                        postoperatively.                       tence in 10%-30% of men. In addi-
    Watchful waiting. Watchful                Many men who do not regain        tion, chronic proctitis may lead to
waiting, or active surveillance, in-     potency can benefit from an oral       bleeding and fibrosis. Incontin-
volves routine observation of a          phosphodiesterase type 5 inhibit-      ence usually is not a side effect
patient’s prostate cancer clinically     or such as sildenafil (Viagra®)        from this treatment. Disturbances
with routine PSA testing. Ac-            (Bott et al., 2003). Sildenafil has    in stool frequency are reported
cording to Bott and associates           the best results for patients less     among fewer than 20% of men
(2003), a link exists between            than age 60 who had a bilateral        (Bott et al., 2003).
Gleason scores and PSA levels at         nerve-spare procedure and had               Brachytherapy. Brachytherapy
time of diagnosis to rate of pro-        some spontaneous return of erec-       involves the insertion of a radioac-
gression. Higher grades of pro-          tile function after surgery. The       tive source directly into the
state cancer increase the risk of        effect of sildenafil increased over    prostate gland. This procedure
metastases and death. The risk of        time, generally requiring 12-24        provides a high dose of radiation
having a known prostate cancer           months following surgery for max-      delivered locally, which spares
progress, other health care con-         imum results; 35%-75% of patients      surrounding normal tissue. Brachy-
cerns, and co-morbidities, along         regained potency after a nerve-        therapy may be performed using
with other demographic data that         sparing surgery, compared to 0-        either iodine-125 seeds or iridium-
may place this person at risk for        15% of those who underwent non-        192 rods. Iodine-125 seeds are
disease progression, should be           nerve-sparing surgery (Briganti et     placed permanently and recom-
included when treatment is               al., 2007).                            mended for patients with a life
selected.                                     Robotic prostatectomy. Robotic    expectancy of at least 10 years, a
    Radical prostatectomy. This sur-     prostatectomy is a laparoscopic        Gleason score of 6 or less, a
gical procedure requires removal         prostatectomy aided by a surgeon-      prostate volume of less than 50
of the entire prostate gland, along      assisted robot. This procedure         milliliters, and no previous
with the seminal vesicles and usu-       increases visualization of delicate    prostate surgery. Potential compli-
ally the obturator lymph nodes.          structures that surround the           cations associated with this proce-
These nodes are obtained for can-        prostate, adds dexterity to the sur-   dure include irritation to the ure-
cer staging purposes. Surgical           gical removal, and eliminates sur-     thra, which results in inconti-
approaches can include a trans-          geon-dependent hand movements.         nence and impotence.
perineal route, a laparoscopic ap-       Data on the effectiveness of robot-         Iridium-192 rods are placed
proach, or a transurethral resec-        ic prostatectomy are reported to       temporarily and recommended for
tion of the prostate. Each ap-           be comparable to open and laparo-      patients with PSA results greater
proach has obtained similar out-         scopic prostatectomy in terms of       than 10 or a Gleason score of 8-10.


262                                                                             MEDSURG Nursing—August 2008—Vol. 17/No. 4
                                                  An Overview of Prostate Cancer: Diagnosis and Treatment
                                                                                                                     SERIES

Along with iridium-192 rod place-           recurrent prostate cancer. If can-            Berger, A., Deibl, M., Strasak, A., Bektic, J.,
ment, EBRT is delivered over 4              cer recurs, additional treatment                   Pelzer, A., Klocker, H., et al. (2007).
                                                                                               Large-scale study of clinical impact of
weeks. Potential complications              may be recommended.                                PSA velocity: Long-term PSA kinetics
associated with this procedure                                                                 as method of differentiating men with
include incontinence and impo-              Patient and Family Education                       from those without prostate cancer.
tence.                                          Education, knowledge, and un-                  Urology, 69(1), 134-138.
                                                                                          Bott, S., Birtle, A., Taylor, C., & Kirby, R.
     Radiation damage to the ure-           derstanding are critical factors in                (2003). Prostate cancer management:
thra can result in both irritating          making an informed decision with                   An update on localized disease. Post-
and obstructive urinary symp-               respect to treatment decision                      graduate Medical Journal, 79, 575-580.
toms. These symptoms may last               making (Lepore, Helgeson, Eton, &             Briganti, A., Salonia, A., Gallina, A., Chun,
up to 60 days, which is the half-life       Schulz, 2003). Education should                    F., Karakiewicz, P., Graefen, M., et al.
                                                                                               (2007). Management of erectile dys-
of the iodine rods. Approximately           include accurate information,                      function after radical prostatectomy in
10%-15% of men who undergo                  pathophysiology, grading and                       2007. World Journal of Urology, 25(2),
brachytherapy experience erectile           staging, treatment options, and                    143-148.
dysfunction. Use of phosphodi-              potential short-term and long-                Catalona, W., Smith, D., Ratliff, T., Dodds, K.,
                                                                                               Coplen, D., Yaun, J., et al. (1991).
esterase type 5 inhibitors may              term side effects and adverse                      Measurement of prostate specific anti-
help them regain sexual function            effects (Held-Warmkessel, 2002).                   gen in serum as a screening test for
(Bott et al., 2003).                        Fagerlin and associates (2004) per-                prostate cancer. New England Journal
     Hormonal manipulation. Pa-             formed a critical review of existing               of Medicine, 324, 1156-1161.
tients with a Gleason score of 8-10         patient education materials for               Coley, C., Barry, M., Fleming, C., & Mulley, A.
                                                                                               (1997). Early detection of prostate can-
can benefit from at least 2 years of        localized prostate cancer. They                    cer: Part 1: Prior probability and effective-
adjuvant luteinizing hormone-               concluded that few materials were                  ness of tests. Annals of Internal Medi-
releasing hormone agonist thera-            available which provided assis-                    cine, 126, 394-406.
py following EBRT, according to a           tance in making treatment deci-               El-Hakim, A., & Tewari, A. (2004). Robotic
                                                                                               prostatectomy – A review. Medscape
review by Bott and associates               sions. Most of the reviewed docu-                  General Medicine, 6(4), 20.
(2003). Significant increases have          ments failed to describe all treat-           Fagerlin, A., Rovner, D., Stableford, S.,
been documented in disease-spe-             ment options, did not contain                      Jentoft, C., Wei, J., & Holmes-Rovner,
cific survival and overall survival         complete information with respect                  M. (2004). Patient education materials
with a median follow up of over 5           to potential adverse effects of                    about the treatment of early-stage
                                                                                               prostate cancer: A critical review.
years. The use of adjuvant hor-             treatment, and required a high                     Annals of Internal Medicine, 140, 721-
monal therapy in conjunction with           school reading ability to compre-                  728.
standard treatments is being                hend. Regarding Internet sources              Gong, G., Oakley-Girvan, I., Wu, A., Kolonel,
researched. The results at this             for health information, patients                   L., John, E., West, D., et al. (2002).
                                                                                               Segregation analysis of prostate can-
time seem promising, but further            and their families should be                       cer in 1,719 white, African-American,
research is needed to determine             encouraged to visit nationally rec-                and Asian-American families in the
the long-term effects on bone den-          ognized sites to receive accurate                  United States and Canada. Cancer
sity and endocrine metabolism.              information. The five highest-rated                Causes and Control, 13, 471-482.
The disease-specific survival fig-          patient education Web sites are the           Gretzer, M., & Partin, A. (2003). Campbell’s
                                                                                               urology updates: PSA and PSA molec-
ures also must be known before an           ACS (www.cancer.org), AstraZeneca                  ular derivatives, 1(2), 1-12.
approach such as this can be con-           (www.prostateinfo.com), Memorial              Hamilton, W., & Sharp, D. (2004). Symptom-
sidered standard.                           Sloan-Kettering Cancer Center (www.                atic diagnosis of prostate cancer in pri-
     Follow-up care. Serum PSA is           mskcc.org), Cancer Care, Inc. (www.                mary care: A structured review. British
                                                                                               Journal of General Practice, 54, 617-
synthesized almost exclusively by           cancercare.org), and University of                 621.
the prostate gland, making its              Toronto (www.prostatecentre.ca)               Hampton, T. (2006). New virus linked to
assessment an excellent method              (Fagerlin et al., 2004). These sites               prostate cancer. JAMA, 295(13), 1503.
to determine treatment response.            may provide education, guide                  Harris, R., & Lohr, K. (2002). Screening for
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