Prostatecancerdecision.org

Michigan Cancer Consortium Recommendations for Prostate Cancer Survivorship Care
Download copies atevels of Evidence (LOE) indicated if research available: LOE I = Randomized Controlled Trial; LOE II = Non-randomized Controlled Trial; LOE III = Case Series; LOE O = opinion, observation, literature review, pilot study Primary Care Management Options
Confirm that PSA testing and digital rectal examinations are being done at appropriate intervals: PSA every 6-12 months after prostatectomy or radiation therapy; PSA every 3-6 months during androgen deprivation therapy. Any PSA >0.2 ng/mL or two consecutive rises after surgery are indications for referral to specialist. Referral to radiation therapist is indicated for PSA levels greater than nadir (i.e., lowest level) after radiation, plus 2 ng/mL. Assess the severity of symptoms due to prostate cancer and its treatments. Shared decision making may help ensure that symptom management is aligned with patient preferences and values. The Expanded Prostate Cancer Index Composite for Clinical Pract is a 1-page, 16-item questionnaire that takes <10 minutes for patients to fill out. It is easy to interpret and measures urinary incontinence, urinary irritation, and the bowel, sexual and hormonal health-related quality of life domains for prostate cancer survivors. Prostate cancer treatment summary and survivorship plans may facilitate transitions between specialty and primary care. Highlighted in such documents would be an information summary needed for the survivor’s care beginning immediately after treatment and continuing over time. For example, the treatment received, short and longer term treatment consequences, pharmacologic therapy, medical, surgical and self-management techniques for side effect management are important. Specific information regarding the timing of PSA testing, office visits and imaging (including who is responsible for each service), and instruments to monitor treatment-related symptoms support shared decision making to ensure optimal care coordination and adherence with the survivorship plan. After surgery
After radiation therapy
1,2 (LOE = 0,III)
1,2 (LOE = 0,III)
Pharmacologic
Pharmacologic
Self-management strategies
Avoid bladder irritants (coffee, acidic juices) 3 (LOE = 0) Self-management strategies
Keep a urinal next to the bed for nighttime problems Avoid bladder irritants (coffee, acidic juices) 3 (LOE=0) urethral stricture or other Pelvic floor physical therapy
Pelvic floor physical therapy
Pelvic floor exercises (stress incontinence) Pelvic floor exercises (urge incontinence) 2,4 (LOE = I), Incontinence pads/undergarments/bed liners For profound problems refer to urologist to
If persistent incontinence or gross hematuria, refer to
consider further surgery (bulking agents, urethral
urologist for possible urodynamic evaluation and
sling, urinary sphincter). 3,6-11 (LOE = II, 0, III, III, III, III,III) cystoscopy.
Primary Care Management Options
Evaluate for medications (eg, anti-depressants, beta-blockers) and treatable medical conditions (eg, poorly controlled diabetes, depression, smoking) that may be interfering with erectile function Assess status of marital/primary relationship to identify psychological issues that may contribute to ED.
Pharmacologic
Sildenafil12,13 (LOE = III, 0) (Viagra, Revatio) Tadalafil13(LOE = 0) (Cialis) Vardenafil13 (LOE = 0) (Levitra) If one is ineffective or side effects are not well tolerated then change to another Prostaglandin E114(LOE = I); Alprostadil (Caverject intracavernosal injection) (Muse- intraurethral pellet)
Self-management strategies
Minimize alcohol and tobacco use, schedule intimacy for when you are well rested and with an empty bladder, stay
close to partner through hugging, kissing and cuddling
Medical/surgical interventions
Vacuum erection device15,16(LOE = 0,0) Surgery to place penile prosthesis17 (LOE = 0) Counseling/therapy (general and/or
sexual) a
Dietary changes, evaluate for hemorrhoids and rectal fissure For blood in stool, referral to GI for colonoscopy to rule out colon cancer, especially if they have not had a screening colonoscopy, may check hemoglobin if there has been persistent blood loss Pharmacologic
For loose stools - consider short course of Immodium or Lomotil – titrate to effect For rectal pain/itching - Preparation H, Tucks, Anusol suppositories Self-management strategies
Stay well hydrated for constipation and diarrhea, keep stool soft and avoid straining, fiber for constipation Other Strategies18 (LOE = 0)
Assess for contributing co-morbidities (eg, IBD); Biofeedback, pelvic floor exercise
For intractable symptoms refer to prostate cancer or gastrointestinal specialist.
Pharmacologic
suppression/deprivation Consider antidepressant therapy, especially if there are elements of depression present [eg, venlafaxine [Effexor], fluoxetine [Prozac], paroxetine [Paxil])19 (LOE = 0) Gabapentin20 (LOE = I) (Neurontin); Megace (megesterol acetate) Self-management strategies
Wear layered clothing, use cooling fan
Other strategies
Alternative therapies (Acupuncture, soy, black cohash, ginseng, licorice, vitamin E) Check for possible interactions between alternative therapies and medications.
*For prostate cancer survivors treated with ADT, it is important to remember that they may be at increased risk for cardiovascular disease, diabetes, metabolic syndrome and osteoporosis. Prevention includes promoting healthy behaviors (exercise, smoking cessation, caffeine and alcohol reduction)23(LOE =0) and supplementation of calcium and vitamin D24(LOE =1). Consider bone density scan 2 years after ADT or earlier for patients at increased risk of osteoporosis.23 (LOE =0) Biphosphonates25 (LOE = III) (i.e. Fosamax, Boniva, Zometa) may be indicated in the setting of prolonged ADT. Men undergoing ADT are also at risk for gynecomastia and nipple tenderness. Refer to specialists for consideration of pre-treatment radiation or Tamoxifen, surgical reduction, or to manage the metabolic aspects of ADT (endocrinology). †Cancer survivors may be particularly prone to relationship issues and fear of the unknown. Consider appropriate medications to treat underlying depression/anxiety after appropriate evaluation. Healthy coping strategies should be encouraged. Support groups and counseling resources are also available. Local sexual therapy providers can be found ahe National Cancer Institute website on sexuality and cancer is also a good resource at or more information, go to

Source: http://www.prostatecancerdecision.org/PDFs/Algorithms2013/RecommProstateCancerCare-09182013.pdf

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