Supportive, Palliative Care & Survivorship in Prostate Cancer

12.04.2022

CPP 102: PROSTATE CANCER PRECEPTORSHIP, UNIT CODE 041222

Zipporah Ali, MD, MPH, MPC, HonDUn

Kenya Hospices and Palliative Care Association
(KEHPCA)
Executive Director
zippy@kehpca.org
International Cancer Institute 2020.
www.intercancer.com
 Palliative Care
• specialized medical care for people living with
serious illnesses.

• It is focused on providing patients with relief

from the symptoms and stress of a serious
illness— alleviation of suffering whatever the
diagnosis.

• The goal is to improve quality of life for both

the patient and the family.

• Provided by a team of doctors, nurses, and

other specialists who work with a patient’s
other doctors to provide an extra layer of
support (TEAM WORK).
(Center to Advance Palliative Care) 
International Cancer Institute 2020.
www.intercancer.com
 OLD VS NEW APPROACH
(Continuum of care) Hospice
Life Prolonging Care Care Old
(EoLC)

Disease Progression

Life Prolonging New

Hospice Care

Be
Care

re
av
em
Palliative Care

en
t
Diagnosis of serious illness Death
Palliative Care in Prostate Cancer
• Extremely important and with an aging
population is likely to become more so
• Despite an increase in early detection, a large
number of patients will have advanced disease
at presentation.
• Average survival at this point is approximately
3 years, but may be considerably longer. 
• Any treatment at this stage is palliative
 Palliative care
 Relationship building with patient and family
caregivers
 Symptom, distress, and functional status
management
 Exploration of understanding and education about
illness and prognosis
 Clarification of treatment goals
 Assessment and support of coping needs
 Assistance with medical decision making
 Coordination of, and referrals to, other care providers
 Benefits of Palliative Care
• Will improve the
management at all phases
of the illness
• Allows better decision
making at End of Life (EOL)
• Will potentially reduce
frequent hospital visits /
admissions-thus cost
effective for patient and the
health care system
• May prolong survivorship
 Patient and caregiver outcomes

• Better patient and caregiver outcomes

include:
– improvement in symptoms
– QOL
– Patient satisfaction
– Reduced caregiver burden.
– More appropriate referral to and use of hospice
– Reduced use of futile intensive care.
 Research
• A retrospective review at MD Anderson found that the most common symptoms reported by
men with advanced prostate cancer included
• Fatigue
• Drowsiness
• Pain.

• After palliative care intervention patients had statistically significant improvement in those
symptoms as well:
– Sleep
– well-being
– Anxiety
– Depression

(Yennu rajalingam S, Atkinson B, Masterson J, et al. The impact of an outpatient palliative care

consultation on symptom burden in advanced prostate cancer patients. J Palliat Med 2012;15:20-
4_

( Rabow et al. found that men with prostate cancer undergoing palliative care in addition to their
oncologic or surgical management had significant improvements in fatigue (P=0.02), anxiety
(P<0.01), depression (P<0.01), quality of life (P<0.01) and spiritual well-being (P<0.01)
 Symptoms in Prostate Cancer
Disease specific morbidity worsens as prostate cancer
progresses and can include:
• Bony metastases -PAIN
• spinal cord compression
• Lymphedema
• Urinary obstruction
• Fatigue
• Anemia
• Anorexia/cachexia
 Symptoms

• Symptomatic prostate cancer that progresses despite optimal

hormonal therapy can be extremely disabling.
• Symptoms include:
– bone pain
– bone fractures,
– fatigue,
– anorexia,
– urinary outflow obstruction
– anaemia
– oedema
– coagulation disorders (such as chronic DIC)
– spinal cord compression.
 Psychical Pain
• In order to manage cancer pain, the cause of the pain must
be assessed adequately.
• Some patients have more than one pain with different causes.
• As prostate cancer is more prevalent in the older age group,
due to comorbidities, patients may additionally have pain
that is noncancer in origin.
• An effective assessment and systematic approach to choice of
analgesics should be taken.
• Equal consideration should be given to treating the
underlying cause of the pain such as hormonal therapy,
radiotherapy, chemotherapy and surgery
 Bone disease
• Bone disease is present in 90% of patients with
metastatic prostate cancer and consequently bone
pain is very common.
• The mainstay of treatment is oral analgesia and
should be started in accordance with the WHO
analgesic ladder.
• The principles are to aim for simplicity, both in
choice and route of analgesics and to titrate
appropriately to maximize pain control and minimize
adverse effects.
• The focus of care should be on
rehabilitation where possible
• Set realistic, achievable goals for
pain control.
• Assurances should be made for
relieving at least one aspect of
the pain such as
– pain at night
– during the day
– at rest
– pain on movement.
 WHO 3-step Ladder
3 severe
Morphine

2 moderate Hydromorphone
Methadone
Levorphanol
A / Codeine
Fentanyl
1 mild A / Hydrocodone
A / Oxycodone
Oxycodone
± Adjuvants
A / Dihydrocodeine
ASA
Tramadol
Paracetamol /
± Adjuvants
Acetaminophen WHO. Geneva, 1996.
NSAID’s
± Adjuvants
 Pain Mgt……
Adjuvant analgesics
• Bisphosphonates.
• NSAID
• Steroids
• Gabapentin
• Amitriptyline

Anaesthetic-in patients with refractory pain-

often very useful when systemic treatment is suboptimal
 Pain Mgt…..
•  Disease modifying treatments can be very
useful in the management of pain and other
symptoms in advanced cancer.
• Radiotherapy, chemotherapy, hormone
therapy and surgery (especially in long bones)
can all play a part in reducing morbidity and
increasing patient autonomy
 Cord compression

• Spinal cord compression affects 1–12% of patients with metastatic

prostate cancer and is an oncological emergency.

• Prevention of cord compression is important

• Disability arising from delay is associated with decreased survival and any

function lost before treatment is rarely regained.
• Speed is of the essence and investigation and management should not
wait for classical signs to develop.

• Treatment should initially be with high dose steroids followed by early

radiotherapy or surgery depending on performance status and prognosis.

•  Decompressive surgery plus postoperative radiotherapy has been shown

to be more effective than radiotherapy alone
 Gastrointestinal Symptoms

• Anorexia
– Megestrol acetate is used commonly to treat a
combination of anorexia and fatigue, the effects of
which can be seen after 1–2 weeks of treatment,
and appears to be independent of tumour response.

– Corticosteroids are an alternative treatment for

anorexia and fatigue- but their effect is usually
temporary and often subsides after about 4 weeks.
Most patients will be started on 4 mg
dexamethasone daily
 Nausea and constipation
• Nausea- Treat the underlying cause as much as
possible and use an antiemetic that is appropriate
to the most likely cause.
• Constipation –
– affects a large majority of patients with advanced
prostate cancer
– -can exacerbate other symptoms such as nausea,
urinary retention, lethargy, abdominal pain and
anorexia.
– Give Laxatives
 General debility

Feeling of generalized weakness and debility in patients with

metastatic prostate cancer. Many causes

Anaemia (Tired & breathless)

• Causes: chronic disease, poor nutrition, treatment with
chemotherapy or radiotherapy, haematuria or bone marrow failure
secondary to metastatic invasion OR a combination of these
causes.

• Treatment options include:

– symptomatic treatment (blood transfusion)
– treat the underlying cause
 Lymphoedema
• Can be painful
• Prone to infection
• Can affect relationships with family and friends and cause feelings of isolation and exclusion.
• Penile and scrotal oedema -distressing,
• Affects sexual intercourse is often impossible
• Impairment of proper hygiene of the perineal region, the patient's quality of life and self-esteem are often
severely affected.

Causes:
• lymph node enlargement, inferior vena caval (IVC) obstruction or large tumour load in the pelvis \t.

Treatment can include:

• Bandaging
• manual lymphatic drainage
• skin care
• prompt treatment of cellulitis
• IVC stenting if appropriate
• scrotal support
• emotional support.

Drug therapy- largely ineffective and diuretics do little to reduce swelling.

Caoution-Watch out for DVT

 Delirium

• More than 85% of patients with cancer will experience progressive confusion
before death.

• Causes include opioid analgesics, psychoactive drugs, sepsis, dehydration,

renal failure and other metabolic abnormalities.

• In some cases, simple interventions such as antibiotics, intravenous fluids and

treating reversible metabolic abnormalities may be helpful.

• Confusion secondary to opioids

– Hallucinations
– myoclonic jerks
– drowsiness.

• Opioid rotation for pts with these symtoms- change to an alternative opioid to
allow better titration to adequate analgesia while avoiding the accompanying
adverse effects.
 Effects of prostate Cancer

Psychological Social
• Depression/discouragement • Feelings of isolation
/despair
• Financial impact
• Anxiety, fears
• Poor coping ability
• Role shifting
• Altered view of self and future • Family/community
• Lack of empowerment/ perception
dependence
• Disrupted partner intimacy
(sexuality)
• Concerns about recurrence Spiritual needs /Why
(Rabow MW, Lee MX. Palliative care in castrate-resistant
Me/meaning of life
prostate cancer. Urol Clin North Am 2012;39:491-503 )
 Supportive Care
The prevention & management of the adverse effects of cancer and its treatment.
Minimizes treatment toxicity /addresses negative effects of cancer treatment
(febrile, neutropenia, anti-emetics, mucositis, and dermatologic toxicities)

This includes management of:

• physical & psychological symptoms
• side effects across the continuum of the cancer experience from diagnosis through treatment
to post-treatment care.
• Enhancing rehabilitation
• Secondary cancer prevention
• Survivorship
• End-of-life care

Supportive care interventions can improve quality of life and health outcomes of
advanced prostate cancer survivors. Despite the high prevalence of unmet needs,
supportive care for this population is sparse.

International Cancer Institute 2020.

(Multinational Association of Supportive Care inwww.intercancer.com
Cancer (MASCC). 
 Palliative and Supportive Care
• Usually used interchangeably
• Both Palliative Care & Supportive care – ensuring that patients
live:
– as well as possible- (Focus is on Good Quality of Life-QoL)
– for as long as possible- (Quality & Quantity).

• Studies have shown that patients and providers have a more

favorable impression of the term “supportive care” than
“palliative care.”

• Many patients and providers hesitate to seek “palliative care”

because they mistakenly fear it is akin to giving up on treatment.

International Cancer Institute 2020.

www.intercancer.com
 Side effect of cancer treatment
• Pain
Life prolonging treatment in advanced PC (Chemotherapy,
• Urinary incontinence
Androgen Deprivation Therapy) may prolong life but associated
• Bowel
with additional physical effect. Localized treatment with surgery
and/or radiation is associated with side effects including: • Sexual dysfunction/ED
• Fatigue

• Hot flashes
treatment toxicity,
• Depression
 deteriorating bone health,
• Distress
 increased fat mass,
• Dysuria
 reduced vitality.
• Hematuria (gross)
• Urethral stricture
Treatment impacts can also increase the susceptibility for certain Dvelopment
psychological problems, such as
• risk for suicide
• cognitive decline.

Altogether, these challenges affect advanced PC survivors’

quality of life (QOL) and functional well-being beyond their
physical needs 
 Prostate Cancer Treatment
• Vary by stage but all may be associated with
morbidity.
– Pain
– Erectile dysfunction
– Incontinence
– Bowel dysfunction
– Fatigue
– Dysuria
– Hematuria (gross)
– Urethral stricture development
Teamwork is necessary to achieve good palliative
and supportive care

International Cancer Institute 2020.

www.intercancer.com
 What is Cancer Survivorship?

• A person who has had cancer is commonly called a

cancer survivor.
• “Co-survivor” is sometimes used to describe a person
who has cared for a loved one with cancer.
• Not everyone who has had cancer likes the word
“survivor.” They may simply identify more with being
“a person who has had cancer.”
• Or if they are dealing with cancer every day they may
describe themselves as “living with cancer.”
Therefore, they may not think of themselves as a
survivor.
 Understanding Survivorship

Cancer survivorship
• Having no signs of cancer after finishing treatment.

• Living with, through, and beyond cancer.

This means that cancer survivorship starts at diagnosis. It

includes people who receive treatment over a longer
time. Their treatment can lower the chance of the cancer
coming back or help to keep the cancer from spreading.
 The phases of survivorship

• Acute survivorship starts at diagnosis

and goes through to the end of initial Higher survival rates may be
treatment. Cancer treatment is the due to major improvements in
focus.
cancer prevention and
treatment (PSA).
• Extended survivorship starts at the
end of initial treatment and goes
Screening- (PSA)
through the months after. The effects Existing treatments are being
of cancer and treatment are the focus. used in better ways
Less side effects, which keeps
• Permanent survivorship is when years planned treatments on
have passed since cancer treatment schedule
ended. There is less of a chance that Newer treatments such as
the cancer may come back. Long-term
effects of cancer and treatment are
targeted therapy &
the focus. immunotherapy
 Psychological issues Anxiety
 Challenges in availability and use of colostomy bags
 Fear of the future-fear of dying
 Fear of being dead
 Worsening symptoms
 Loss of independence
 Concern for the carer,
 Financial issues
 Failure to adjust to loss of function
 Feeling of should be doing more
 Reluctance to ‘give in to the illness’
International Cancer Institute 2020.
www.intercancer.com
 End of Life Care (Approaching death)

• The ability to recognise dying. 

– Increasing weakness
– Immobility
– Drowsiness
– difficulty swallowing
– reduced intake of food and drink.

• Care of dying patients should be a priority

• Their social, cultural and spiritual/religious backgrounds
should be acknowledged and taken into consideration with
care planning.
 Sexuality in PC
• Erectile Dysfunction
• Decreased libido
• Anejaculation
• Changes in orgasm
• Changes in penile length
• Prostate Cancer itself
• Treatments for PC (Radical
treatments ,
prostatectomy/radiation,
Hormonal treatment)
• PC can cause ED if associated with LUTS (LUTS
are storage disturbances, such as daytime
urinary urgency and nocturia, and/or voiding
disturbances, such as urinary hesitancy, weak
stream, straining, and prolonged voiding).
• Psychological impact of a diagnosis of cancer
• No reports that Ca prostate causes ED
 ED Treatment
• PDE5 inhibitors
• Penile rehabilitation
• Continuous daily dosing , on demand
dosing
• Avoid covernosus fibrosis & maintain
penile length
• Vacuum Erection Device
• Intracavernosal injections
• Topical/intra-urethral PGEi
• Combination therapy
– oral & intracaversonal
– Oral & Vacuum Pump
• Penile prosthesis
• Testosterone Replacement Therapy (TRT)
 Conclusion
• Palliative care used in conjunction with prostate cancer
treatment can significantly improve patient quality of
• it is imperative initiate symptom-modifying palliative
care along with disease-modifying therapies.
• We provide psychosocial and spiritual care alongside
treatment and at end of life-(Throughout the continuum
of care)
• A palliative care approach, alongside possible life-
prolonging treatments, that focuses on QoL and
symptom relief, may serve as an important frame to give
the best support to these men in their final years of life.
 References
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