Factors Affecting Patient Selection for Prostate ...

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FEATURE ARTICLE

Factors Affecting Patient Selection for Prostate Brachytherapy: What Nurses Should Know Debra Zeroski, RN, OCN ®, Laurie Abel, RN, BSN, OCN ®, Wayne M. Butler, PhD, Kent Wallner, MD, and Gregory S. Merrick, MD

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is determined via transrectal rostate brachytherapy Prostate brachytherapy is a proven treatment for ultrasound, which visualizes commonly is used to and measures the prostate gland. treat prostate cancer. Alclinically localized prostate cancer; however, many The technical difficulty of seedthough this treatment is very efclinicians have multiple misconceptions regarding ing a large-volume prostate puts fective, predictable postoperative patient selection criteria. Although most patients are patients at higher risk for acute morbidities exist that primarily and long-term urinary difficulinvolve changes in bowel and candidates for the procedure, contraindications do exties. Before brachytherapy can urinary habits and sexual funcist. This article examines criteria for patient selection be considered, patients with tion (Merrick, Wallner, & Butler, and the need for adjuvant therapies, proposes managelarge-volume prostates are of2003b). Careful patient selecment philosophies, and discusses the impact of each fered androgen deprivation tion can result in a decreased therapy to shrink the prostate. incidence of postoperative moron treatment decisions. Nurses’ role in the decisionThis cytoreduction usually bidities. making process and how they can facilitate patients and takes three months and allows Radiation oncologists confamilies in making informed choices also are discussed. for an overall improved imsider many factors when deterClinical studies seek to further define patient selection plant. Patients who present with mining whether a patient is a small-volume prostate glands suitable candidate for prostate criteria and examine optimal choices for adjuvant treat(i.e., < 20 cm3) have shown no brachytherapy. Factors include ment and isotope preference. Expanding the knowledge prostate size, the presence of difference in urinary morbidbase of nurses helps enhance patient care. obstructive urinary symptoms, ity in several studies (Merrick, previous transurethral resection Butler, Dorsey, & Lief, 2001; of the prostate (TURP), median lobe hyper- competently deliver patient information and Merrick, Butler, Lief, & Dorsey, 2000; plasia, transition zone volume, age, obesity, care. By being aware of the risk factors for Merrick, Butler, Wallner, Galbreath, & Lief, tobacco use, diabetes mellitus, inflamma- individual patients, nurses can adapt a plan 2003). In addition, studies have shown that tory bowel disease, pubic arch interference, of care to fit each one. patients with larger prostate glands can adverse pathologic features, and elevated be implanted safely without subsequently prostatic acid phosphatase levels. Controexperiencing an overabundance of urinary Prostate Factors versy exists regarding which factors truly are dysfunction (Merrick et al., 2000; Merrick, contraindications for prostate brachytherapy. Butler, Wallner, Galbreath, et al., 2003; Size Determining which radioactive isotope is used and whether a patient needs supplemenTraditionally, patients with large prostal therapies, such as external beam radiation tates (i.e., volume > 50 cm3) have not been therapy and/or androgen deprivation therapy, considered to be candidates for prostate Submitted July 2004. Accepted for publicaalso is a consideration. Through continued brachytherapy because of the possibility of tion February 21, 2005. (Mention of specific research, suitable criteria can be developed to increased postoperative urinary symptoms, products and opinions related to those proddetermine acceptable candidates for prostate such as urinary retention, dysuria, and ur- ucts do not indicate or imply endorsement by brachytherapy. gency. These complications are caused by the Clinical Journal of Oncology Nursing or Nurses must stay up-to-date regarding the the higher number of seeds required to be the Oncology Nursing Society.) increasing body of knowledge in this area to

inserted into a larger prostate. Prostate size

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Sherertz, Wallner, Wang, Sutlief, & Russell, 2001; Stone & Stock, 2000). Therefore, prostate size should not impact the decision for or against prostate brachytherapy. The size of the transition zone of the prostate (see Figure 1) may be more closely related to lower urinary tract symptoms and urinary flow than the central or peripheral zones because of its anatomic closeness to the prostatic urethra (Merrick, Butler, Galbreath, Lief, & Donzella, 2001). The transition zone index, which is calculated by dividing the transition zone volume by the prostate gland volume, has a direct relationship to postoperative urinary symptoms (Merrick, Butler, Galbreath, et al.). Transition zone volume is determined during transrectal ultrasound of the prostate. The larger the transition zone preoperatively, the higher the likelihood of urinary dysfunction postoperatively (Thomas et al., 2000). The size of the median lobe of the prostate gland also is noted during transrectal ultrasound of the prostate. In patients with median lobe hyperplasia (i.e., protrusion of hypertrophied prostate tissue into the bladder), prostate brachytherapy is discouraged because of the technical difficulty involved in implanting intravesical tissue as well as the subsequent postoperative increase in urinary dysfunction (Merrick et al., 2003d). A bladder scan to measure postvoid residual, or the amount of urine left in the bladder after urination, is performed during patients’ initial visit and, ideally, should be zero. If any increase in prostate size occurs, urinary retention will be evident with a bladder scan. For patients who are retaining urine, an alpha 1-blocker will relax the smooth muscle of the urinary sphincter and improve urine flow (Abel et al., 1999). Tamsulosin hydrochloride is the drug of choice because it is an alpha 1-blocker that does not affect

Anterior, posterior, and left and right lateral aspects

FIGURE 1. TRANSITION ZONE OF THE PROSTATE 554

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blood pressure and can be dose-escalated safely. Urinary retention always is addressed at diagnosis because urinary obstructive symptoms are experienced as side effects postbrachytherapy (Abel, Dafoe-Lambie, Butler, & Merrick, 2003).

Pubic Arch Interference The skeletal design of the pelvis also is evaluated during transrectal ultrasound of the prostate. Prostate brachytherapy traditionally has been discouraged in patients with a narrow pubic arch because the anterior needles are mechanically difficult to insert. However, recent improvements in intraoperative techniques have allowed experienced physicians to put patients in an extended lithotomy position, allowing the anterior needles to veer around the arch (Merrick et al., 2003c). Therefore, the shape of the pubic arch is no longer a contraindication to brachytherapy.

Adverse Pathologic Features A higher likelihood of extraprostatic cancer extension has been associated with higher Gleason scores, perineural invasion, and tumor extension into the biopsy specimen. Almost all cases of extraprostatic extension are limited to within 5 mm of the prostate capsule. A high-quality brachytherapy implant would sterilize extraprostatic extensions (Davis et al., 1999) and include the delivery of therapeutic doses of the radioactive isotope to the prostate gland, the extracapsular region, and the base of the seminal vesicles (Merrick, Butler, Wallner, Burden, & Dougherty, 2003). Few patients with adverse pathologic features have subclinical distant metastatic dis-

Superior and inferior transition zone

ease at diagnosis. Using dose-escalated high dose rate brachytherapy or external beam radiation therapy, a five-year, cause-specific survival has been reported in hormone-naive patients (Martinez et al., 2002; Valicenti, Lu, Pilepich, Asbell, & Grignon, 2000). These findings indicate that an aggressive locoregional approach, including generous periprostatic brachytherapy treatment margins and/or the addition of supplemental external beam radiation therapy, can control the disease in patients with adverse pathologic features.

Patient Factors Preexisting Urinary Symptoms Some degree of urinary dysfunction (e.g., dysuria, frequency, urgency, weak and interrupted stream) is expected following prostate brachytherapy as a result of bladder irritation caused by radiation (Abel et al., 1999). In patients with a significant degree of urinary dysfunction before surgery, prostate brachytherapy usually is contraindicated because severe urinary dysfunction may occur (Landis et al., 2002). Traditionally, prostatitis also has been a contraindication for prostate brachytherapy because of the potential worsening of urinary symptoms in patients with already compromised urinary status. However, one study has indicated that no correlation exists between preoperative prostatitis and postoperative urinary morbidity (Hughes, Wallner, Merrick, Miller, & True, 2001). A patient’s urinary status always must be assessed before brachytherapy is performed. The American Urological Association (AUA) Symptom Index can be used to assess urinary habits and is completed prior to implant (see Table 1). Then, the same questionnaire is administered to patients at intervals after implant to assess urinary morbidity (Abel et al., 2000). By comparing a patient’s responses, nurses can gauge the extent of irritative symptoms a patient is experiencing. With the understanding that urinary symptoms most likely will not improve quickly postoperatively, nurses can implement appropriate teaching interventions regarding activity, diet, and medication changes as warranted (Abel et al., 2000). For patients with increased nocturia, ceasing fluid intake after 7 pm and taking a hot bath 30 minutes before bedtime may help alleviate symptoms. Curbing caffeine and alcohol intake also may be beneficial. Some irritative symptoms may be relieved by increasing dosages of tamsulosin hydrochloride or administering an anti-inflammatory or corticosteroid. Daily activity––ideally a 30-

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TABLE 1. THE AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX QUESTION

NOT AT ALL

LESS THAN 1 TIME IN 5

LESS THAN HALF THE TIME

ABOUT HALF THE TIME

MORE THAN HALF THE TIME

ALMOST ALWAYS

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

NONE

1 TIME

2 TIMES

3 TIMES

4 TIMES

5 OR MORE TIMES

0

1

2

3

4

5

1. Over the last month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 2. During the last month or so, how often have you had to urinate again less than 2 hours after you finished urinating? 3. During the last month or so, how often have you found you stopped and started again several times when you urinated? 4. During the last month or so, how often have you found it difficult to postpone urination? 5. During the last month or so, how often have you had a weak urinary stream? 6. During the last month or so, how often have you had to push or strain to begin urination? QUESTION 7. During the last month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

Note. American Urological Association symptom score = sum of questions 1–7. Note. From “The American Urological Association Symptom Index for Benign Prostatic Hyperplasia,” by M.J. Barry, F.J. Fowler, Jr., M.P. O’Leary, R.C. Bruskewitz, H.L. Holtgrewe, W.K. Mebust, et al., 1992, Journal of Urology, 148, p. 1555. Copyright 1992 by the American Urological Association, Inc. Reprinted with permission.

minute walk twice a day––also can alleviate urinary obstructive symptoms.

Previous Transurethral Resection of the Prostate Historically, patients who underwent a TURP prior to prostate brachytherapy generally were considered to be at higher risk for developing urinary incontinence postimplant approximately 50% of the time (Merrick et al., 2003c). Nurses must make a point of knowing whether patients have undergone TURP when having conversations with them postbrachytherapy to determine whether medical intervention by a physician is warranted. A technique using a peripheral source loading approach with a limitation of the radiation dose to 110% of the prescription dose to the TURP defect of the preoperatively resected area decreases the risk of incontinence to 6% (Wallner, Lee, Wasserman, & Dattoli, 1997). Some studies have shown that patients who have undergone TURP preimplant have a quality of life (QOL) approaching that of brachytherapy patients who have not undergone the procedure (Merrick, Butler, Wallner, & Galbreath, 2004). The use of spasmolytics may be indicated to relieve symptoms in patients

who complain of urgency and incontinence. However, caution must be used because spasmolytics may further aggravate urinary retention, which has a higher incidence postimplant (Spratto & Woods, 2004).

Age Age may be a stronger predictor of cancer curability than differences in preimplant prostate-specific antigen (PSA) levels (Carter, Epstein, & Partin, 1999). Physicians have been reluctant to recommend brachytherapy for younger patients even though outstanding biochemical outcomes, as shown by postoperative median PSAs of < 0.1 ng/ml, have been reported for hormone-naive men 62 years of age or younger undergoing brachytherapy (Merrick, Butler, Lief, & Galbreath, 2001; Merrick, Butler, Wallner, & Galbreath, 2004). Conversely, physicians have been hesitant to recommend brachytherapy for older patients because older men may be at an increased risk for extracapsular extension, have higher Gleason scores, and show a greater propensity for distant metastatic disease (Carter et al.). Research has shown that older patients tolerate brachytherapy as well as younger men (Merrick et al., 2000); therefore, age alone should not influence treatment decisions. However, prostate brachytherapy

generally is not recommended for patients 80 years of age and older because of the risks involved with general anesthesia. Age also can be a predictor of increased side effects. One of the most reliable predictors of impotence is age (Wallner, 2000). This knowledge can assist in determining when drugs or devices for erectile dysfunction should be implemented.

Obesity Obesity can present substantial procedural and technical difficulties for radical prostatectomy and external beam radiation therapy but poses only minor challenges for prostate brachytherapy (Merrick et al., 2002). For patients with grade II (i.e., body mass index [BMI] = 30.0–34.9 kg/m2) and grade III (i.e., BMI > 35.0 kg/m2) obesity who undergo brachytherapy, favorable dosimetric, biochemical, and QOL outcomes have been demonstrated (Merrick et al., 2002). From a nursing standpoint, obesity as a risk factor postoperatively is related to airway clearance, respiratory dysfunction, cardiovascular insufficiency, thromboembolic events, and delayed wound healing (Merrick et al., 2002). Obesity also is a preoperative consideration when determining risks for anesthesia.

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Tobacco Tobacco use has been associated with aggressive prostate cancer, prostate cancer-related death, and a trend for poorer biochemical progression-free survival following permanent prostate brachytherapy (Merrick, Butler, Wallner, Galbreath, Lief, et al., 2004). Adverse late urinary QOL changes and diminished late rectal function also have been associated with tobacco use. Tobacco use possibly decreases cure rates with all treatments but is not a contraindication to any treatment. Tobacco cessation should be encouraged by all healthcare professionals because of the possibility of subsequent respiratory and cardiovascular implications. Referrals to assist each individual with the cessation of tobacco use must be made appropriately.

Comorbid Conditions Diabetes mellitus and inflammatory bowel disease are two conditions to consider prior to prostate brachytherapy. These diseases can increase sexual, urinary, and rectal morbidity significantly for patients

considering treatment for prostate cancer. Diabetes is also a significant risk factor for brachytherapy-related erectile dysfunction, with a 100% incidence as measured by the International Index of Erectile Function (IIEF) (Merrick et al., 2003a), as shown in Table 2. The IIEF is a validated, selfadministered questionnaire that is used to assess sexual function. Because corticosteroids also are used postbrachytherapy, close monitoring of blood glucose levels in patients with diabetes is necessary. Rectal function can be assessed before and after surgery by using the self-administered Rectal Function Study Questionnaire (see Figure 2). The extent of rectal function can be assessed by comparing pre- and postsurgical responses. Generally, inflammatory bowel disease, ulcerative colitis, and regional enteritis (i.e., Crohn disease) are contraindications to external beam radiation therapy because of the increased risk of gastrointestinal and rectal complications. However, Grann and Wallner (1998) found no increased risk of gastrointestinal morbidity in this patient population when prostate brachytherapy was used to treat the disease. Nurses must

teach patients extensively pre- and postoperatively regarding bowel function. If the rectal mucosa becomes too distended (e.g., from constipation), the rectum is pushed against the prostate gland postoperatively and causes an increased risk for radiation exposure to the rectal wall, which makes the area more prone to postimplant complications, such as inflammation and bleeding. Patients must have regular daily bowel movements to avoid this situation. A highfiber diet and/or bulk-forming laxatives may be implemented if a patient is prone to constipation. Appropriate preimplant assessment is essential for patients undergoing permanent prostate brachytherapy. The AUA Symptom Index, IIEF, Rectal Function Study Questionnaire, and a thorough patient history are valuable tools in determining postoperative needs assessment, teaching, and implementation.

Prostatic Acid Phosphatase Prostatic acid phosphatase is a simple laboratory test that has been reported to be the strongest predictor of freedom from

TABLE 2. INDIVIDUAL ITEMS OF INTERNATIONAL INDEX OF ERECTILE FUNCTION QUESTIONNAIRE AND RESPONSE OPTIONS (U.S. VERSION) QUESTION*

RESPONSE OPTIONS

Q1: How often were you able to get an erection during sexual activity? Q2: When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

0 = No sexual activity 1 = Almost never/never 2 = A few times (much less than half the time) 3 = Sometimes (about half the time) 4 = Most times (much more than half the time) 5 = Almost always/always

Q3: When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner? Q4: During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

0 = Did not attempt intercourse 1 = Almost never/never 2 = A few times (much less than half the time) 3 = Sometimes (about half the time) 4 = Most times (much more than half the time) 5 = Almost always/always

Q5: During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

0 = Did not attempt intercourse 1 = Extremely difficult 2 = Very difficult 3 = Difficult 4 = Slightly difficult 5 = Not difficult

Q6: How many times have you attempted sexual intercourse?

0 = No attempts 1 = One to two attempts 2 = Three to four attempts 3 = Five to six attempts 4 = Seven to ten attempts 5 = Eleven+ attempts

(Continued on next page) * All questions are preceded by the phrase, “Over the past four weeks.” Note. From “The International Index of Erectile Function (IIEF): A Multidimensional Scale for Assessment of Erectile Dysfunction,” by R.C. Rosen, A. Riley, G. Wagner, I.H. Osterloh, J. Kirkpatrick, and A. Mishra, 1997, Urology, 49, pp. 829–830. Copyright 1997 by Elsevier Science Inc. Reprinted with permission.

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TABLE 2. INDIVIDUAL ITEMS OF INTERNATIONAL INDEX OF ERECTILE FUNCTION QUESTIONNAIRE AND RESPONSE OPTIONS (U.S. VERSION) (CONTINUED) QUESTION*

RESPONSE OPTIONS

Q7: When you attempted sexual intercourse, how often was it satisfactory for you?

0 = Did not attempt intercourse 1 = Almost never/never 2 = A few times (much less than half the time) 3 = Sometimes (about half the time) 4 = Most times (much more than half the time) 5 = Almost always/always

Q8: How much have you enjoyed sexual intercourse?

0 = No intercourse 1 = No enjoyment 2 = Not very enjoyable 3 = Fairly enjoyable 4 = Highly enjoyable 5 = Very highly enjoyable

Q9: When you had sexual stimulation or intercourse, how often did you ejaculate? Q10: When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?

0 = Did not attempt intercourse 1 = Almost never/never 2 = A few times (much less than half the time) 3 = Sometimes (about half the time) 4 = Most times (much more than half the time) 5 = Almost always/always

Q11: How often have you felt sexual desire?

1 = Almost never/never 2 = A few times (much less than half the time) 3 = Sometimes (about half the time) 4 = Most times (much more than half the time) 5 = Almost always/always

Q12: How would you rate your level of sexual desire?

1 = Very low/none at all 2 = Low 3 = Moderate 4 = High 5 = Very high

Q13: How satisfied have you been with your overall sex life? Q14: How satisfied have you been with your sexual relationship with your partner?

1 = Very dissatisfied 2 = Moderately dissatisfied 3 = About equally satisfied and dissatisfied 4 = Moderately satisfied 5 = Very satisfied

Q15. How do you rate your confidence that you could get and keep an erection?

1 = Very low 2 = Low 3 = Moderate 4 = High 5 = Very high

* All questions are preceded by the phrase, “Over the past four weeks.” Note. From “The International Index of Erectile Function (IIEF): A Multidimensional Scale for Assessment of Erectile Dysfunction,” by R.C. Rosen, A. Riley, G. Wagner, I.H. Osterloh, J. Kirkpatrick, and A. Mishra, 1997, Urology, 49, pp. 829–830. Copyright 1997 by Elsevier Science Inc. Reprinted with permission.

biochemical progression for intermediateand high-risk brachytherapy patients (Dattoli, Wallner, True, Cash, & Sorace, 2003). The test also is predictive of biochemical outcome and disease-specific survival following potentially curative radical prostatectomy (Han, Demel, et al., 2001; Han, Piantadosi, et al., 2001; Moul, Connelly, Perahia, & McLeod, 1998; Roach et al., 1999). Normal prostatic acid phosphatase levels may obviate the need for radiographic staging in patients as well as negate the need for androgen deprivation therapy. Elevated prostatic acid phosphatase may predispose patients to subclinical distant metastatic disease. These patients probably

would benefit from hormonal manipulation (Merrick et al., 2003c).

Isotope No definitive data exist to determine which isotope––iodine or palladium–– offers a more optimal cure for prostate cancer (Wallner et al., 2003). One prospective, randomized trial reported that scores on the AUA Symptom Index as well as bowel dysfunction improve more quickly with palladium-103, which has a shorter halflife (Wallner et al., 2002). With this study in mind, palladium would be the optimal choice. In patients receiving iodine, which

has a longer half-life, postoperative symptoms may be prolonged. Knowing which isotope is used can assist nurses with forming a plan of care. A more intense and lengthy follow-up may be necessary for patients receiving iodine.

Supplemental Therapies In patients with adverse pathologic and biochemical features, supplemental hormone therapy and external beam radiation therapy are accepted forms of neoadjuvant treatment when combined with brachytherapy. However, monotherapeutic brachytherapy has been shown to have favorable

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SCHIFFLER ONCOLOGY CENTER PROSTATE BRACHYTHERAPY RESEARCH STUDY Please fill out this short questionnaire to help us find out more about any problems you might be having with bowel movements. Answer these questions for your situation over the last week. 11). Frequency of stools per day: ˆ 0–1 stool per day ˆ 2 stools per day ˆ 3 stools per day ˆ 4 or more stools per day

17). Continence: ˆ Normal continence; able to control stool movements at all times ˆ Gas incontinence only; able to control stool movements but not gas ˆ Minor spotting or leakage of stool (up to coin size) about once per week ˆ Minor spotting or leakage of stool (up to coin size) more than once per week ˆ Significant leakage of stool (larger than coin size) about once per week ˆ Significant leakage of stool (larger than coin size) more than once per week

12). Consistency of stools: ˆ All stools formed ˆ Stools formed and loose ˆ Stools loose ˆ Watery stools 13). Urgency of stools: ˆ No urgency ˆ Somewhat urgent ˆ Urgent ˆ Very urgent

18). Nighttime Ni bowel movements (total number of nights in last week that you had to get up from bed to have a bowel movement): ˆ 0 ˆ 1 ˆ 2 ˆ 3 ˆ 4 ˆ More than 4

14). Abdominal discomfort: ˆ No discomfort ˆ Mild to moderate discomfort ˆ Somewhat severe discomfort ˆ Very severe discomfort 15). Hemorrhoidal discomfort: ˆ No discomfort ˆ Requires mild treatment (i.e., Tucks® [Pfizer Inc., New York, NY], sitz baths) ˆ Requires topical medication (i.e., Preparation H™ [Wyeth Consumer Healthcare, Madison, NJ], etc.) ˆ Requires oral analgesics or narcotics for relief 16). Rectal bleeding: ˆ No rectal bleeding ˆ Blood on toilet paper: 1 time per week ˆ 2–3 times per week ˆ > 4 times per week

19). Completeness of evacuation: ˆ Complete evacuation (requires one movement to completely empty bowel or feel you’re “all done”) ˆ Occasional multiple evacuations (about once a week feel like you’re not “all done” or it takes more than one movement to finish) ˆ Frequent multiple evacuations (more than once a week feel like you’re not “all done” or it takes more than one movement to finish) ˆ Requires enema to obtain complete emptying 10). My bowel movements after the implant are: ˆ Better ˆ Worse ˆ Same

FIGURE 2. RECTAL FUNCTION STUDY QUESTIONNAIRE Note. From “Rectal Function Following Prostate Brachytherapy,” by G.S. Merrick, W.M. Butler, A.T. Dorsey, R.W. Galbreath, H. Blatt, and J.H. Lief, 2000, International Journal of Radiation Oncology, Biology, Physics, 48, p. 669. Copyright 2000 by Elsevier Science Inc. Reprinted with permission.

biochemical outcomes, especially for lower clinical stages (i.e., T1–T2a, PSA < 10 ng/ml, Gleason score < 6). High-quality implantation with generous periprostatic margins may be the only therapy needed for low-, intermediate-, and selected highrisk patients (Blasko et al., 2000; Merrick, Butler, Wallner, Burden, et al., 2003). Patients receiving supplemental external beam radiation therapy and brachytherapy are at a greater risk for side effects, including hematuria, compromised late urinary function, compromised late rectal function, and erectile dysfunction. Ongoing prospective randomized trials at the University of Washington and the Schiffler Cancer Center in Wheeling, WV, are being conducted that will further define the role of external beam radiation therapy in patients with high-risk features.

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Hormone therapy, although implicated in brachytherapy-related morbidity, has produced conflicting results in the areas of urinary, rectal, and sexual dysfunction. In a large, retrospective, matched-pair analysis, no benefit for hormonal manipulation with brachytherapy was found for any risk group, Gleason score, pretreatment PSA, or clinical stage (Potters, Tore, Ashley, & Leibel, 2000). The use of supplemental therapies alerts nurses to expect potential increased side effects in patients who undergo external beam radiation therapy or hormonal deprivation therapy. Patients who have an increase in urinary dysfunction after receiving external beam radiation therapy may experience it to a greater degree postimplant. Patients may become fatigued more easily or have more frequent bowel

movements. Those undergoing hormone deprivation will experience an increase in sexual dysfunction, and the need may arise to initiate an erectile dysfunction drug such as sildenafil citrate (Stipetich et al., 2002). When nurses are aware, they can ask the right questions, make accurate assessments, and make recommendations tailored to fit individual patients. In the end, patients and their families can be assured of a higher quality of nursing care.

Conclusion Multiple factors should be taken into consideration before the decision is made to perform prostatic brachytherapy implantation. Improved intraoperative techniques and physician experience are essential components to overcoming patients’ anatomy. Age,

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obesity, and comorbid conditions always are considered before brachytherapy is performed; however, alone, they should not be a deterrent to the procedure. Increased Gleason scores, perineural invasion, and tumor extension in the biopsy specimen are factors that appear to be controlled by the use of an aggressive locoregional approach. Supplemental therapies, although readily used at present, may be found after further study to be an unnecessary component of treatment. The goal continues to be that patients remain disease free with minimal morbidity and improved QOL. Further investigation is necessary to provide the knowledge base necessary to accomplish this goal. Accurate nursing assessment has become an integral part of patient care. The increasing body of knowledge attained by physicians who perform permanent prostate brachytherapy must be examined by nurses caring for brachytherapy patients. Knowledge relayed from nurses to patients facilitates the decision-making process and helps alleviate patient and family fears. Side effects often are remedied in a timely manner as a result of thorough assessments that are relayed to physicians. The mutual goal of physicians and nurses is for patients to undergo successful implantations with as few side effects as possible and, ultimately, to cure the disease. Author Contact: Debra Zeroski, RN, OCN®, can be reached at schifflercancercenter @wheelinghospital.com, with copy to editor at [email protected].

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Rapid Recap Factors Affecting Patient Selection for Prostate Brachytherapy: What Nurses Should Know • For patients who undergo prostate brachytherapy, many factors are taken into consideration for patient selection, the most common of which are prostate size, patient anatomy, preexisting urinary signs and symptoms, previous transurethral resection of the prostate, age, comorbid conditions, obesity, tobacco use, adverse pathologic features, and elevated prostatic acid phosphatase. • Elements that are solely patient dependent, although always considered, have not been found to increase postoperative morbidity significantly in those who undergo prostate brachytherapy. • Controversy exists regarding whether iodine or palladium is more effective, the need for supplemental therapies, and the roles of both in patient morbidity and mortality. • Isotope selection and adjuvant treatment therapies warrant continued study to evaluate their necessity and impact on postoperative morbidity and mortality in patients who undergo permanent prostate brachytherapy. • Nursing care that has a solid knowledge base in prostate brachytherapy assists patients and their families with decision-making challenges, the brachytherapy procedure, and patients’ changing needs for weeks, months, and years postimplant.

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