A 52-year-old African American male presents to an urgent care center complaining of urinary frequency and nocturia.
Consider the following case study:
A 52-year-old African American male presents to an urgent care center
complaining of urinary frequency and nocturia. The symptoms have been present for several months and have increased in frequency over the past week. He has been unable to sleep because of the need to urinate at least hourly all day and night. He does not have a primary care provider and has not seen a doctor in more than 10 years. His father died when he was a child in an automobile accident, and his mother is 79 years old and has hypertension. The patient has no siblings. His social history includes the following: banker by profession, divorced father of two grown children, non-smoker, and occasionally consumes alcohol on weekends only.
To prepare:
- Review the case study and reflect on the information provided about the patient.
- Think about the personal, medical, and family history you need to obtain from the patient in the case study. Reflect on what questions you might ask during an evaluation.
- Consider types of physical exams and diagnostics that might be appropriate for evaluation of the patient in the study.
- Reflect on a possible diagnosis for the patient.
- Review the Marroquin article in this week’s Learning Resources. If you suspect prostate cancer, consider whether or not you would recommend a biopsy.
- Think about potential treatment options for the patient.
By Day 3
Post a description of the history that you need to obtain from the patient in the case study. Include a list of questions that you might ask the patient. Then, describe types of physical exams and diagnostics that might be appropriate for evaluation of the patient. Finally, explain a possible diagnosis, as well as potential treatment options for the patient based on this diagnosis.
Clinical Journal of Oncology Nursing•Volume 15, Number 1•Oncology Nursing 10197Debate about the use of prostate-specific antigen (PSA) tests to screen prostate cancer in men is ongoing. Prostate cancer is the mostcommon cancer after skin cancer in men and the second most deadly after lung cancer.An elevated PSA level can lead to this cancer’sdiagnosis and treatment even before the onset of symptoms. However, other causes also can create a high PSA level, which may lead tomen being unnecessarily treated for prostate cancer. This article will shed some light on the issue and discuss prostate cancer screening.Joanna Marie Marroquin, RN, MSN, OCN®, is a recent graduate of the Department of Nursingat the University of Pennsylvania in Philadelphia. The author takes full responsibility for thecontent of the article. The author did not receive honoraria for this work. No financial relation-ships relevant to the content of this article have been disclosed by the author or editorial staff.Digital Object Identifier: 10.1188/11.CJON.97-98To Screen or Not to Screen: Ongoing Debatein the Early Detection of Prostate CancerONCOLOGYNURSING101DEBRAWINKELJOHN, RN, MSN, AOCN®, CNS—ASSOCIATEEDITORJoanna Marie Marroquin, RN, MSN, OCN®For most Americans, simply saying orhearing the wordcancerbrings aboutterrible images and thoughts. Losing hair,undergoing chemotherapy treatment orsurgery, and becoming frail or possiblydying all are common associations. Aprostate cancer diagnosis leads manyindividuals down a path that includesnumerous painful procedures, inconti-nence and impotency issues, and a labelofcancer patientfor the rest of their lives(National Cancer Institute [NCI], 2010)(see Figure 1). However, for some men,diagnosis and treatment are unnecessaryand avoidable. Published studies haveshown that mass screening for prostatecancer with the prostate-specific antigen(PSA) blood test has led to overdiagnosisand subsequent overtreatment becauseof a high percentage of false-positiveresults (Albertsen, 2005).Results from two large trials have con-tributed to this debate. Andriole et al.(2009) looked at 77,000 men randomizedto annual screening (PSA testing plusannual digital rectal examination) or tono screening for six years. The resultsshowed that no difference was noted inprostate cancer-related deaths. Unfortu-nately, many of the men in the controlgroup received PSA testing outside ofthe trial. The second trial, conducted bySchröder et al. (2009), examined 182,000men randomized to PSA screening orto no screening. During the nine-yearfollow-up period, fewer prostate cancer-related deaths occurred in the screenedgroup than in the control group. How-ever, both of these studies were widelyconsidered flawed, either theoreticallyor methodologically.Problems With Prostate-Specific Antigen TestingPSA tests frequently are performedin numerous settings as a screening forprostate cancer, but the guidelines varyamong experts. The American CancerSociety (2010) recommends that menolder than age 50 have a discussion withtheir doctor about the pros and consof PSA screening, and then make an in-formed decision concerning the risks andbenefits of undergoing the screen. TheAmerican Urological Association (2009)suggests PSA screening for all men begin-ning at age 40, whereas the U.S. Preven-tive Services Task Force ([USPSTF], 2008)does not recommend the screening.An effective test to detect cancer forasymptomatic screening purposes shouldbe able to find a cancer when it is present(high sensitivity) and not miss it when itis present (high specificity). When used,the test should contribute to a reductionin mortality from the disease. PSA levelscan be elevated because of a number ofdifferent noncancerous causes, includingbenign prostatic hypertrophy, prostatitis,inflammation, or prostatic infection,which can lead to a false-positive diagno-sis (Lin, Lipsitz, Miller, & Janakiraman,2008). When an elevated PSA is found,the next step is to perform a biopsy todetermine whether the elevation is theresult of prostate cancer. Because somany false-positive test results occur,many men have biopsies only to find outthey do not have prostate cancer. Situa-tions also exist in which the biopsy resultis positive but, based on factors such asthe natural history of prostate cancer,aggressiveness and extent of disease, andthe patient’s age and overall health status,treatment would provide more harm thanbenefit. In this scenario, whether thisearlier detection and consequent earliertreatment affect overall mortality fromprostate cancer is unclear (NCI, 2010).PSA testing cannot be used to deter-mine stage of cancer. Stages are deter-mined with a prostate biopsy or othertests as indicated. Based on the stage,treatment options can range fromwatchful waiting or active surveillanceto surgery and radiation. PSA testing mayThis material is protected by U.S. copyright law. Unauthorized reproduction is prohibited. To purchase quantity reprints,please e-mail reprints@ons.org or to request permission to reproduce multiple copies, please e-mail pubpermissions@ons.org.
98February 2011•Volume 15, Number 1•Clinical Journal of Oncology Nursingbe used for treatment response and moni-toring. Treatment of prostate cancer cancause long-term difficulties for men. Un-fortunately, many experiencing these dif-ficulties from treatment may have neverdeveloped clinically significant prostatecancer during their lifetime. Althoughthe prevalence of prostate cancer andprecancerous lesions found at autopsysteadily increases for each decade of age,most lesions remain clinically undetectedand would not have affected the patient’soverall survival (Martin, 2007). USPSTF(2008) stated that “treatment for pros-tate cancer detected by screening causesmoderate-to-substantial harms, such aserectile dysfunction, urinary inconti-nence, bowel dysfunction, and death”(p. 185). This does not even address thenegative psychological effects that thediagnosis and treatment for prostatecancer can bring. Men endure increasedmedical visits, additional costs, anxiety,and the lifetime label ofcancer patient.One study even concluded that “PSAscreening is associated with psychologi-cal harms, and its potential benefits re-main uncertain” (Lin et al., 2008, p. 192).The PSA tests became widely used in1986, and a substantial increase has beenseen in the number of prostate cancerdiagnoses. A review of prostate cancerstatistics in the United States showedan increase in incidence from 94 per100,000 men in 1974 to 166 per 100,000men diagnosed with prostate cancer in2007 (NCI, 2009). Prostate cancer survi-vors in the United States to date numbermore than 2.2 million and represent 19%of all survivors, second only to breastcancer.The increased amount of prostate can-cer screening leads to an increased risk ofoverdiagnosing this cancer. Some wouldargue that “this benefit comes at the costof substantial overdiagnosis and over-treatment” (Barry, 2009, p. 1353)andthat the issue is not whether PSA screen-ing is effective but “whether it does moregood than harm” (Barry, 2009, p. 1353).The potential to help many people ex-ists; however, others may be harmed byunnecessary treatment—the key issue inthe harm versus benefits debate.Making InformedDecisionsInsufficient evidence exists to provethat treatment for prostate cancer de-tected after screening reduces mortality,which suggests that men should makeinformed decisions regarding the test.In the meantime, healthcare providersand researchers will need to wait for theresults of other studies that may yieldmore sensitive and specific tests for thiscancer. A trial is currently under waythat tests a computer-based decision aidfor use by men considering PSA screen-ing for prostate cancer (NCI, 2010). NCIalso has developed a program calledthe Early Detection Research Networkin hopes of accelerating the translationof cancer biomarker information intoclinical applications and of evaluatingnew ways of screening for cancer in itsearliest stages.Additional resources concerning pros-tate cancer can be found at NCI’s Website (www.cancer.gov/cancertopics/pdq/screening/prostate/healthprofessional)or at the American Cancer Society’s Website (www.cancer.org/Cancer/ProstateCancer). Oncology nurses can help edu-cate men and their loved ones about therisks and benefits of having a PSA test forscreening purposes.Author Contact:Joanna Marie Marroquin,RN, MSN, OCN®, can be reached at joannamariemarroquin@gmail.com, with copy to editor atCJONEditor@ons.org.ReferencesAlbertsen, P.C. (2005). Is screening forprostate cancer with prostate specificantigen an appropriate public healthmeasure?Acta Oncologica, 44,255–264.doi: 10.1080/02841860410002815American Cancer Society. (2010). Rec-comendations for prostate cancer earlydetection. Retrieved from http://www.cancer.org/Cancer/ProstateCancer/MoreInformation/ProstateCancerEarlyDetection/prostate-cancer-early-detection-acs-recommendationsAmerican Urological Association. (2009).Prostate-specific antigen best practicestatement: 2009 update.Retrievedfrom http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdfAndriole, G.L., Crawford, E.D., Grubb,R., Buys, S.S., Chia, D., Church, T.R.,. . . Berg, C.D. (2009). Mortality resultsfrom a randomized prostate cancer screen-ing trial.New England Journal of Medi-cine, 360,1310–1319. doi:10.1056/NEJ-Moa0810696Barry, M.J. (2009). Screening for pros-tate cancer—The controversy that re-fuses to die.New England Journal ofMedicine, 360,1351–1354. doi:10.1056/NEJMe0901166Lin, K., Lipsitz, R., Miller, T., & Janakiraman,S. (2008). Benefits and harms of prostate-specific antigen screening for prostatecancer: An evidence update for the U.S.Preventive Services Task Force.Annalsof Internal Medicine, 149,192–199.Martin, R.M. (2007). Prostate cancer is om-nipresent, but should we screen for it?International Journal of Epidemiology,36,278–281. doi: 10.1093/ije/dym049National Cancer Institute. (2009). SEERstat fact sheets: Prostate. Retrieved fromhttp://seer.cancer.gov/statfacts/html/prost.htmlNational Cancer Institute. (2010). Prostatecancer screening. Retrieved from http://www.cancer.gov/cancertopics/pdq/screening/prostate/healthprofessionalSchröder, F., Hugosson, J., Roobol, M.J.,Tammela, T.L., Ciatto, S., Nelen, V.,. . . Auvinen, A. (2009). Screening andprostate cancer mortality in a random-ized European study.New EnglandJournal of Medicine, 360,1320–1328.U.S. Preventive Services Task Force. (2008).Screening for prostate cancer: U.S. Pre-ventive Services Task Force recommen-dation statement.Annals of InternalMedicine, 149,185–191.Note.Additional structures depicted includethe bladder, urethra, and penis of an adultmale.Figure 1. Small CancerousTumor in the Prostate, SagittalCross SectionNote.Copyright 2011 by Nucleus MedicalArt, Inc./Phototake. All rights reserved. Usedwith permission.
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