Abstract
Prostate cancer is characterized by carcinoma of a gland in the male reproductive system and it typically develops in men over the age of 65. There is an assortment of treatment options in managing prostate cancer including: chemotherapy, hormone rehabilitation, surgical removal, brachytherapy, and external beam radiation therapy (Clinical Journal of Nursing). In external beam radiation therapy, it is essential for urologist to obtain consistency in the position of the prostate from the planning period before treatment to the initiation of radiotherapy to attain superior results. This study examines the efficiency of bladder filling and rectum emptying protocols and reveals room for improvement in scheduling and educating patients. It also explores central patient issues and policies in this current organization that pertain to the importance of proper bladder filling and rectum evacuation from simulation to daily treatment.
A prostate cancer diagnosis can amount to a life-changing experience. It may compel individuals to make some challenging decisions about therapies that can alter the lives of the affected individual and his family members. Almost half a million men in North America were diagnosed with prostate cancer in 2015. It occurs more frequently in men of African descent than men of European descent, and it usually manifest in men older than 65 years old. Family genetics, lifestyle choices, and environmental factors can contribute to an individual’s likelihood of developing the disease. Depending on the situation at hand, treatment possibilities can range from vaccines and hormones to radiation or surgery. For those men who undergo radiation therapy, the side effects and overall treatment process can prove challenging to say the least. Radiotherapy can cause bladder inflammation, which leads to difficulty in passing urine accompanied with a burning sensation. It can also cause diarrhea, sore genital skin, and loss of pubic hair. Additionally, radiotherapy can have long-term side effects such as erection dysfunction, loose bowel movements, and procitis. Nevertheless, radiation therapy is a proven option for successful treatment.
A 67-year-old retired male spent his life working as a pharmacist for his local community where he dispensed medications and gave recommendations to people in need. He taught his three children and community so much about well-being and fitness. Therefore, he made it a point to lead by example with healthy lifestyle choices and regular checkups with a general practice physician. Needless to say, his medical history was remarkable. In 2010, he came to the doctor with complaints of dysuria. The physician prescribed an antibiotic medication to him thinking that the dysuria came from a urinary tract infection. The antibiotic treatment failed to alleviate the dysuria after a year of prescription. In 2012, his regular checkup turned into a referral to the urology department after the general practice doctor found the prostate-specific antigen test or PSA showed signs up steady incline. For this test, a blood sample was taken and sent to a medical laboratory for examination. The doctor confirmed the prostate-specific antigen levels in the patient’s blood were of concern after taking a tissue sample or biopsy for a closer look. Thereafter, the patient was placed under active surveillance whereby cancer progression can be carefully monitored via prostate-specific antigen blood tests, digital rectal exams twice a year, and a biopsy once a year. Digital Rectum Exams are important to check enlargement, soreness, and abnormalities. The positive side of things is that the cancer is clinically diagnosed as confined to the prostate.
Unfortunately, the patients’ prostate cancer disease state continued to worsen overtime. In 2014, upon visiting the medical urologist, the patient found out he will have to go through radiotherapy treatment to fight the prostate cancer disease and avoid a radical prostatectomy. His Gleason score was 6. The first step is to attend an information session. It is crucial the patients understand why preparation for therapy is important. People may not realize that bladder is actually closely related to the rectum. In fact, they are physiologically positioned adjacent to one another. If the substances of the bladder and rectum disagree between the day the patient has their computerized tomography (CT) scan and the daily treatment, the prostate could potentially be situated in a different position than the one the physician expected it to be.
The advice from the information session is geared toward ascertaining consistent bowel movements and boosted hydration in order to ensure the inside material of the rectum are even in size, and lessen intestinal gas accumulation to provide the most accurate treatment and diminish the long-term risks associated with bowel effects. The session is complete with handouts and written and verbal instructions for bladder filling and rectal empting prior to prostate radiation therapy. The doctors emphasize that a well-hydrated, “comfortably full” bladder is necessary for treatment. The directions ask patients to drink 2.5 to 3 liters of fluid every day and this amount can be distributed throughout the day so that patients aren’t forced to wake up to use the bathroom at night. Of course, it is essential patients refrain from carbonated and alcoholic beverages. Patients should also eat frequently to avoid twisting of the bowels. Typically, the rectal emptying protocol is the aspect of the information session that becomes most uncomfortable for people because you may be instructed to use a micro-enema to empty your back passage.
Presently, the majority of radiation therapy centers employ the full-bladder protocols for treatment of individuals with prostate cancer. The reason for this decision is well proven and based upon evidence but there is a lack of data indicating the reproducibility of patient perception of a full bladder. However, it is clear that the bladder filling changes throughout the radiation treatment process. It is not uncommon to have prostate cancer patients that have a challenge with maintaining a full bladder during the course of treatment. This could be caused by old age or vexing urinary symptoms (Moyer, 2012). Since we know filling the bladder affects the position of the prostate, empty bladder radiation is only encouraged in individuals receiving care for solely the prostate since there’s no need for accuracy. This technique allows for greater comfort and is gaining popularity.
Now the 67-year-old prostate cancer patient drives an hour from his home five days a week for radiotherapy treatment. The treatment was suppose to last 7 weeks but was extended to 10 weeks due to complications with rectum emptying and bladder filling. The first five appointments require a scan in which you must follow the previously mentioned procedure to empty your rectum and fill your bladder.
The second scan could not be completed because the patient’s rectum was not empty enough. The rectum must be void to reduce the dose and prostate movement. This creates a problem because it is not recognized until after the CAT scan and before actual radiation treatment. The doctor removed the patient from the treatment room and asked him to use the restroom and try to move his bowels and void then drink at least three cups of water and sit for 20 minutes in an effort to rescan later that day. Thereafter, the patient still showed no bowel movement and a lot of emotional frustration, so the doctor sent him home with an aperient to loosen the stool and increase bowel movement then rescheduled his appointment for the following week. This creates traffic in the treatment room and delays the scheduling of other patients waiting for their appointments.
When the 67-year-old prostate cancer patient drove down for his third visitation, he promised he followed the instructions from the information closely and took his laxatives as instructed so there should be no reason why the radiation treatment cannot begin. His appointment was for 3:30pm but due to radiation treatment time postponement of scheduling in the patient before his appointment, he did not get called back for treatment until 4:20pm. By this time, the patient found it difficult to hold his consumed water any longer due to his old age and had to release his bladder. The bladder must be full in order to reduce the dose to the bladder. Realizing that postponing and rescheduling treatment can be a pain for not just the patient but the doctors and nurses as well, the man quickly tried to refill his bladder. This of course created further scheduling delays that day but he ended up completing a successful computerized tomography scan by 5:30pm. There are ways medical personnel can alleviate some of these issues. The first appointment could consist of planning for full bladder scans and empty bladder scans in case of impediments. There needs to be a protocol for the patient in all possible situations especially when dealing with individuals that have a lot of issues affecting their ability to come to radiation therapy with the empty rectum and full bladder. That means outlining situations in which a patient was planned on treatment on a full bladder but ended up being treated on empty bladder and vice versa.
The level of success of a treatment plan is contingent upon appropriate coverage of target sections by using the points of equal percentage depth dose (PDD) and choosing techniques, procedures, and therapies that circumvent entire removal of the diseased organ and retain proper organ function. A universal standard for prostate radiation treatment is that the planning target volume (PTV) should be totally limited within the 95% isodose surface (Talvitie et al, 2011). The organs at risk are rectum and bladder, and since prostate cancer commonly metastasizes to bone, femurs are also at risk. As aforementioned, the rectum is the principle dose-limiting organ because it exhibits significant internal movement and shifting. The Radiation Therapy Oncology Group (RTOG) is the national headquarters for cancer treatment studies and results to be amassed and analyzed. The RTOG has a list of recommendations for dose- volume benchmarks and restrictions to maintain low toxicity levels based upon the collected evidence from various studies nationwide.
The 67-year-old prostate cancer patient complained to the doctor about the difficulty of avoiding obstacles with radiation therapy, and went on to inquire about alternatives. The oncologist thought to develop a major case study simulation for the patient to see if and what potential alternative options there may be. A total of 30 men including the 67-year-old patient were included in the study. All of the participants suffer from prostate cancer to varying degrees. The first simulation would be in the case of the doctor expecting a full-bladder but the patient shows up with their bladder empty. In this case, the full bladder multileaf collimator configuration and the isocenter adjustment are utilized in empty bladder treatment. Thus, two computerized tomography scans were performed for this experimental protocol, one with an empty bladder and empty rectum and another scan with the rectum and bladder full. All organs at risk were by measured by volume.
In order to effectively compare and contrast the treatment plans; data is collected valuing the prostate motion and prostate volumes. The scanner used is a PQ 2000 form Phillips Medical Systems. Patients are directed to lie facing upward with a pillow for knee support and a cast acrylic sheet for ankle support. The full bladder, prostate, minor bowel, and rectum were outlined in each image captured. Rectum length measurements were taken. Dosage computations were achieved using Batho methodology. The main query is not about if the dose volume histograms for a full bladder are better than the dose volume histograms for an unfilled bladder, but instead it is a question of whether or not the empty bladder dose volume histograms are considered good clinical practice.
Even though the study participants were given a thorough list of instructions for preparation for both the full and empty bladder scans, we found an assortment of bladder volumes. This implies that not only are there disparities in distinct patients bladder volume, but a “full” bladder may be a matter of individual perception. Prostate motion and shifting between full and void bladder contouring is evident. The results show the average full bladder volume was 350 cm3 and the average empty bladder volume 110cm3. Overall, data depicts a decrease of 239cm3 form full to empty. It is noteworthy to mention that the results show no other organ volumes were disturbed by the full or empty status of the bladder. Besides the bladder, variances between the two tests in the other affected organs can only be credited to the organ movement. Some patients exhibited zero prostate movement in shifting from full to void. The most significant shift observed was 1.3 cm. Out of 30 men tested, 24 exhibited prostate movement of more than half a centimeter.
Altering dosages in organs other than the bladder must be handled with great detail even though the study reveals no OARs were affected in position or direction. In participants who displayed changes in prostate location greater than a half interval, PTV coverage was disrupted but it did not alter dosage supply to the patient’s prostate. Thus, bladder filling and rectum evacuation are still the best-known treatment protocol for achieving the best chance of successful radiotherapy. Until better alternative options arise, patients should adhere to this.
The 67-year-old patient with prostate cancer who sparked the major case study learned to deal with the complications in preparing for radiation therapy. On top of radiotherapy, the patient was administered an androgen deprivation drug that causes cancer tissue to diminish by blocking testosterone. Four years later, now in his seventies, the patient has regular consultations with his radiation oncologist and receives consistent DREs. His PSA went from a 9 to a 1.2 which is a positive result bearing in mind normal cells still generate PSA after radiation so the level will never amount to zero. Today, the patient has no complaints. He plays golf twice a week, runs trails, and gardens. Additionally, the patient began volunteering his time and blog to educating people about prostate cancer and encouraging the afflicted to fight to survive by sharing his story. In the latest post on his blog, “Prostate Cancer Sucks”, he talks about preparation for radiation therapy from the patient’s prospective. He admits rectal emptying and bladder filling are important in achieving the most accurate results in treatment and limiting the chance of long-term side effects from the radiation therapy occurring.
The aging population is steadily inclining due to scientific advances, and the frequency of prostate cancer diagnoses correlates with this incline. Almost thirty percent of novel cancer findings in men in North America are prostate related. Despite the growing incidence of the disease, the death rates remain the same. This means that screening and treatment planning are improving and will continue to improve in the future as medical personnel and researchers continue to work together to enhance treatment options and find cures.
In the mean time, there are a few recommendations one can make based upon the major case study discussed in this paper to help patients better prepare for radiation therapy. The first recommendation is for hospitals and radiation treatment centers to generate scheduling that accounts for any potential issues. In other words, the patient coordinator should allot time for error between patients to avoid “traffic” in the office. The second recommendation is to schedule the patients who have difficulty holding consumed water due to old age or pressure from tumor involvement in the mornings at the head of the other patients for that day. Lastly, information sessions on preparation for radiation therapy should be grasp the patient’s attention. It should also be a mandatory policy because a lot of patients don’t take the time to read the instructions when simply handed to them. The instructions could be better communicated by including images next to the steps for preparation.
References
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