Good synopsis of treatment options. No major surprises. Graphic Tables
have been omitted.

_/_/_/_/_/_/_/_/_/_/_/
Prostate Cancer in Older Men

Dorothy A. Calabrese, MSN, RN, CURN, CNP

Urol Nurs 24(4):258-264, 268-269, 2004. © 2004 Society of Urologic
Nurses and Associates

Abstract, Introduction, and Overview
Abstract

Prostate cancer (Ca P), the most commonly diagnosed male cancer, will be
a health care issue that will have a significant impact on the American
health care system as the population of the United States continues to
age. It is anticipated that the number of men diagnosed with Ca P will
continue to increase each year. Screening, diagnosis, and treatment
modalities for Ca P in men over 65 years of age are discussed.
Introduction

Cancer is a disease process that affects the older person at a higher
rate than other age groups (Ershler, 2003). Prostate cancer (Ca P) is
the most common male cancer excluding skin cancer, and it is the second
leading cause of cancer deaths in men (following lung cancer) (Jemal et
al., 2004). While most other cancers "peak," Ca P cancer incidence
continues to increase as men age (Presti, 2004).

To discuss Ca P and the aging man, a definition of the "elderly" or
"older" population is required. Literature often uses data from Medicare
to define the "elderly" as anyone above age 65. While there is
difficulty in using age (or numbers) to define the older patient, it may
be the easiest way. There are people younger than 65 who seem older due
to a variety of health problems, but there are also people older than
age 65 years who seem "young" due to genetics, a healthy lifestyle, and
a positive attitude. In this article, older patients will be divided
into two categories: those 65 to 74 years of age and those above 75
years of age. For each of these age groups, the treatment options and
outcomes for Ca P can be very different. An overview of prostate cancer,
treatment options, and side effects will provide a background for the
discussion regarding Ca P and older men.
Overview

Ca P is the most commonly diagnosed male cancer. The American Cancer
Society estimates that in the year 2004, there will be 230,110 new cases
of prostate cancer diagnosed (33% of male cancers diagnosed), and 29,900
deaths (or 10% of all male cancer deaths) (Jemal et al., 2004). How many
older patients will be diagnosed or die of prostate cancer is unknown.
Since the prevalence of Ca P increases with age and the population of
the United States continues to age, it is expected that a significant
number of older men will face this diagnosis. The dilemma becomes how to
best treat and care for the growing number of men who will seek
treatment for prostate cancer.

Risk Factors and Etiology

There are several known risk factors for prostate cancer. These include
increasing age, race, family history, and dietary intake of fats
(Presti, 2004). A man age 60 to 79 has a probability of 1 in 8 of being
diagnosed with prostate cancer, a significant increase compared to a
younger man age 40 to 59 who has a 1 in 103 chance of a prostate cancer
diagnosis (Presti, 2004). African-American men are at increased risk,
although the reason for the phenomena is unknown. Relatives diagnosed
with prostate cancer put a man at increased risk. The number of
relatives and their age at diagnosis increases the risk; the younger the
age of the relative at the time of diagnosis, the higher the relative
risk for the male relative (Presti, 2004). A diet high in fat is a
possible risk factor. Cadmium exposure (cigarette smoke, alkaline
batteries, and working in the welding industry) may increase the risk,
although this is a weak risk factor (Presti, 2004).

Published studies do not prove a cause-effect association for vasectomy
as a risk factor (Presti, 2004). The underlying reason for the possible
relationship is unknown. Elevations in antispermatozoa antibodies,
decreases in seminal hormone concentrations, and decreases in prostatic
secretion have been reported in men who have undergone vasectomy. How
these effects might relate to the development of Ca P is unknown (Platz,
Kantoff, & Giovannucci, 2000). There is also speculation that men who
have undergone vasectomy may seek medical care more frequently, leading
to earlier diagnosis of Ca P (Presti, 2004).

The etiology of Ca P is unknown. Many theories have been proposed
through the years, but none has ultimately been proven. Increased male
hormones and infections are two theories that continue to be discussed.
What is currently known is that the gene responsible for familial Ca P
resides on the long arm of chromosome 1 and PCAP and CAPB genes. In
addition, there are tumor-suppression genes in several areas of the
human genome that have been identified as possible areas involved in
developing Ca P (Presti, 2004). As scientific knowledge of Ca P
increases, the cause and natural course of the disease may be discovered.

Signs and Symptoms

Most patients with early-stage Ca P have no signs and symptoms. Patients
with locally advanced disease may experience obstructive or irritative
signs and symptoms (dysuria, straining, decreased force of stream,
hesitancy, increased night frequency) due to extension of the cancer
into the urethra or the bladder neck. Metastatic Ca P signs and symptoms
include bone pain, spinal cord compression, and/or weakness in the lower
extremities.

Pathology and Diagnosis

Pathology

More than 95% of Ca P are adenocarcinoma (Presti, 2004). Other types of
Ca P include transitional cell carcinoma, small-cell carcinoma, or sarcoma.

Diagnosis

Prostate cancer is diagnosed by examination of tissue retrieved during a
prostate biopsy. Most biopsies are completed because the patient has a
rising prostate-specific antigen (PSA) level in the blood. PSA is a
glycoprotein that is produced by the prostate gland, and it is elevated
with certain prostate conditions such as Ca P, benign prostatic
hyperplasia (BPH), prostatitis, and instrumentation of the genitourinary
tract (for example, the insertion of a Foley catheter for urinary
retention).

The PSA blood test is a valuable tool in detecting Ca P. Normal PSA
levels are less than 2.6 ng/ml (Gretzer & Partin, 2003). When the PSA
level is 2.6 to 10 ng/ml, the likelihood of Ca P is judged as moderate,
but values greater than 10 ng/ml indicate a high level of suspicion
(Gretzer & Partin, 2003). The American Urologic Association (AUA, 2000)
established variations of PSA levels based on ethnicity and age (see
Table 1).

A variety of factors should be considered when evaluating PSA results.
Several techniques have been developed to increase the PSA test's
ability to predict the presence of prostate cancer. Following the
increase in PSA values over time (PSA velocity), age-specific PSA (a
younger man should have a lower PSA), and assessing bound versus unbound
portions of PSA (free vs. total PSA) are all methods of helping to
identify a patient that needs a prostate biopsy to prove or disprove a
cancer diagnosis (AUA, 2000). A fractionated PSA measures free versus
protein-bound PSA in the blood. Men with Ca P have a higher proportion
of their PSA bound to protein, whereas the proportion of free PSA is
higher in men with BPH (Gretzer & Partin, 2003). Measurements of PSA
density (PSAD) are useful in men whose original values fall in the
moderate suspicion range. PSAD combines the serum PSA value and prostate
volume assessed via transrectal prostatic ultrasound. Scores are
calculated by dividing the PSA by the prostate volume; men with a score
above 0.15 are more likely to have cancer than men with lower values
(Gretzer & Partin, 2003).

The result of a digital rectal examination (DRE) also provides data for
the health care practitioner. The DRE may identify abnormalities of the
prostate, such as nodules, firmness, or subtle variations in the gland
that need further evaluation. PSA detects more prostate cancers earlier
than a DRE, but the combination of the DRE and PSA is more sensitive
than either PSA or the DRE individually.

Screening for Ca P in Older Men

Screening the general population is a controversial topic, and screening
older people is a topic that can generate much discussion and
disagreement. The question of screening the general male population for
prostate cancer has never been answered definitively. Recommended
screening consists of a yearly DRE and a PSA blood test. Evaluating
changes in the PSA or DRE allow the health care practitioner to evaluate
any variations and to make recommendations regarding the best course for
the patient (continued monitoring vs. a prostate biopsy).

When screening for Ca P should stop has never been identified; it is
generally felt that a person with a life expectancy of 10 years or less
does not need screening since Ca P is generally a slow-growing cancer.
The need for screening with its implications and/or stopping the yearly
screening process should be discussed by the patient and his health care
practitioner (Gerard & Frank-Stromborg, 1998).

Proponents of screening argue that this simple process allows Ca P to be
diagnosed at an earlier state, a stage that is potentially curable.
Since Ca P is such a prevalent diagnosis, early detection and cure can
reduce the risk of metastatic disease. Opponents of prostate cancer
screening argue that screening has not ultimately changed the outcome
for patients with prostate cancer. They also feel that the emotional and
financial costs of screening are unnecessary. Screening has resulted in
anxiety for men and their partners as well as unnecessary procedures
(for example, prostate biopsies and scans). Opponents also believe that
older men found to have prostate cancer through screening may be treated
unnecessarily. This can lead to significant sequelae that affect quality
of life (Vaughn, 1998).

While a PSA is a "simple" blood test, the implications of testing should
be discussed with the patient and his health care practitioner prior to
the process. A patient with multiple medical problems and/or one who
does not have a life expectancy of 10 years probably does not need to
subject himself to this process. Many older men may fit into this
category (Vaughn, 1998).

Grading and Staging, and Progression of Prostate Cancer

Grading and Staging

If a biopsy is positive, the pathologist identifies the two most
commonly occurring patterns (grades) of tumor in the biopsy tissue and
adds those numbers together to give the cancer a Gleason score. Gleason
scores range from 2 to 10, and are usually represented as a sum. For
example, 3 + 4 = 7 for a Gleason score of seven. This is an important
piece of information; the higher the Gleason score, the more aggressive
the cancer. It is an important factor for determining treatment options.
Table 2a and Table 2b further explain the Gleason scale.

Ca P is staged according to the TNM staging system. T refers to the
primary tumor, N relates to regional lymph node involvement, and M
refers to distant metastasis. Despite a relatively low PSA or favorable
Gleason score, accurately staging the disease enables a better
estimation of treatment options. See Table 3 for further description of
the TNM staging system.

Progression of Prostate Cancer

Prostate cancer can spread locally, lymphatically, or hematogenously.
Local spread means the cancer has spread outside the prostate
(extracapsular extension or into the seminal vesicles). Locally advanced
prostate cancer may invade the bladder trigone, the bladder neck, or the
urethra. Distant metastasis is usually to the regional lymph nodes or to
bone. Visceral metastasis may occur to the lung, liver, and adrenal
glands (Presti, 2004).

Treatment Options

The treatment of Ca P depends upon the patient's age, the stage and
grade of the cancer, severity of co-morbid conditions, and the patient's
preference. It is important for the patient to realize that all
treatment options for prostate cancer have side effects. Table 4 lists
treatment options available for the patient with Ca P.

Localized Ca P

For localized Ca P (cancer that is contained within the prostate), the
treatment options include observation ("watchful waiting"), surgery
(radical retropubic, perineal, laparoscopic, or da Vinci
robotic-assisted prostatectomy), radiation therapy (brachytherapy or
external beam radiation therapy [EBRT]), and cryosurgery. Brachytherapy
and EBRT may be done singly or in combination, and may also include
hormone therapy.

Locally Advanced Ca P

Locally advanced Ca P is not likely to be cured by a single treatment
modality alone (for example, surgery or radiation therapy).
Multimodality treatments are currently being studied as a part of
clinical trials, and these options may include chemotherapy followed by
surgery, surgery followed by external beam radiation therapy or
chemotherapy, or hormone therapy and radiation therapy (Zippe & Kedia,
2000).

Advanced Ca P

For advanced Ca P (cancer that has spread beyond the prostate), the
treatment involves decreasing or stopping the production of
testosterone, the "fuel" that can cause the cancer to spread.
Testosterone is a product of the testicles (primary source) and the
adrenal glands. Medical or surgical castration is an option available to
the patient.

Surgical castration (bilateral orchiectomy) involves the surgical
removal of the testicles, the primary source of testosterone. While this
may not be the preference of men in the United States currently, it is
the most cost-effective method of stopping the production of
testosterone and slowing the spread of Ca P.

Medical castration involves the use of medications to prevent the
production of testosterone by the testicles. Luteinizing hormone
releasing hormone (LHRH) agonists are injections of medications that the
patient receives at intervals (monthly, every 3 or 4 months, or yearly)
to block testosterone production. Anti-androgen medication blocks the
use of testosterone produced by the adrenal glands. In addition, there
are clinical trials involving the use of hormonal or nonhormonal
medications to decrease testosterone production.

Following definitive treatment for Ca P by surgery or radiation therapy,
each physician has a protocol to evaluate the patient. If the PSA begins
to rise, this indicates that the cancer has recurred, and the next step
in treating the patient depends upon the primary treatment that the
patient received. For the patient who has had surgery, treatment options
might include observation, radiation therapy (the patient with a
positive margin), or hormone therapy (the patient with metastatic
disease). For the patient who has undergone radiation therapy, the
treatment options might include observation, surgery (salvage
prostatectomy), cryotherapy, or hormone therapy. Enrollment in a
clinical trial may be an option if the patient meets the eligibility
requirements.

Hormone Refractory Ca P

Hormone-refractory Ca P occurs when hormone therapy has failed and the
PSA values continue to rise indicating cancer progression. Checking the
testosterone level to verify that the patient is at castrate level (less
than 50 ng/ml) is important. If the patient's testosterone is not at
castrate level, the patient should begin LHRH agonist therapy. If the
patient's testosterone is at castrate level, the patient should consider
enrolling in a clinical trial. The current methods to manage the patient
with hormone-refractory disease have met with limited success (Smith,
Dawson, & Trump, 2000).

Side Effects of Ca P Treatments

All treatments for prostate cancer have side effects. It is important
for the patient to be aware of these effects because the side-effect
profile may help the patient decide which is the best treatment option
for him. Observation or "watchful waiting" (monitoring the patient by a
PSA blood test and a DRE at a predetermined time period) may have a
psychological effect for the patient. It is often difficult for him to
know that he has cancer and is "doing nothing." The man may be
comfortable with this option, but his family and/or friends may not be.
They may encourage the patient to "do something" to treat the cancer
causing the man to suffer from additional psychological stress.

Surgical removal of the prostate is a major procedure with the potential
and side effects of any major surgical procedure such as the potential
for infection, pneumonia, blood clots, etc. Additional side effects of
radical prostatectomy may include postoperative incontinence and
impotence. Postoperative incontinence is usually temporary but stress
incontinence (such as leaking a few drops of urine when coughing,
laughing, lifting heavy objects) may persist indefinitely. Potency rates
vary postoperatively, even if a bilateral nerve-sparing procedure was
completed. For men between ages 60 to 69, potency rates with a bilateral
nerve-sparing procedure can range from 25% to 75% (Presti, 2004). For
men in that age range who have undergone a unilateral nerve-sparing
procedure, the potency rates can range from 10% to 50% (Presti, 2004).
Recovery of spontaneous erections can take a year or longer (Presti, 2004).

Brachytherapy (implantation of radioactive "seeds" into the prostate
gland) is a procedure that is done in the operating room with general
anesthesia. The side effects may include the risks of general
anesthesia, as well as specific side effects from the radiation.
Irritative voiding symptoms (urgency, frequency, dysuria) are common.
These symptoms can be treated with medications. The use of tamsulosin
HCl (Flomax®), doxazosin (Cardura®), or terazosin (Hytrin®) may help
relieve the symptoms. Phenazopyridine (Pyridium®) may be useful to
alleviate the burning feeling that the patient may also experience. A
small percentage of patients (usually less than 10%) will experience
urinary retention due to swelling of the prostate from the radiation
(Speight & Roach, 2004). This will usually resolve in time and is
treated in the short term with intermittent self-catheterization (ISC)
(Jhaveri & Klein, 2001).

External beam radiation therapy (EBRT) can be done by the conventional
3-D conformal method. This uses imaging and computerized treatment
planning software that allows a high-dose radiation to conform to the
prostate with greater sparing of the surrounding normal tissue. The
radiation is usually fractionated over 35 to 37 treatments. This same
technology allows the delivery of a higher dosage of radiation without
unacceptable toxicity, providing better local control of prostate cancer
in select patients; this technique is known as intensity-modulated
radiation therapy (IMRT) (Speight & Roach, 2004).

Common side effects related to either EBRT or IMRT include the
irritative urinary symptoms of urgency, frequency, and dysuria. These
may be treated with medications described earlier and usually subside
with time. Urethral strictures and radiation cystitis (in less than 10%
of patients) can occur (Speight & Roach, 2004). In addition, there may
be rectal discomfort (the prostate sits in front of the rectum and
radiation can affect the rectum) and/or rectal urgency. Treatment with
Anusol® (hydrocortisone) suppositories or Sitz baths provides relief for
these symptoms, which usually diminish over time. Anal stricture and
radiation proctitis are rare complications (Speight & Roach, 2004).

Side effects of a combination of brachytherapy and EBRT are the same as
described previously, but the effects may be intensified due to the
combined effect of the treatments (Speight & Roach, 2004). Cryosurgery
or freezing of prostate tissue is also a treatment option for Ca P. This
is done in the operating room under general anesthesia. The ice destroys
the Ca P tissue and prostate tissue. Side effects may include impotence
and urinary tract obstruction (due to necrotic prostate tissue).

The main side effect of hormone therapy with the LHRH agonist medication
is hot flashes. Vitamin E or Megace® may help to alleviate this symptom,
but if the hormone therapy is being done in conjunction with radiation
therapy, the use of vitamin E is not recommended. Vitamin E is an
antioxidant and radiation therapy works through oxygen radicals. There
could potentially be some scavenging of this which would negate the
effectiveness of the radiation therapy. It is commonly thought that this
effect decreases over time (Speight & Roach, 2004).

Other side effects may include erectile dysfunction, loss of libido,
increased appetite, weight gain (especially in the waist area),
decreased energy, muscle wasting, anemia, and mood changes. One of the
long-term sequelae of the LHRH agonists is osteoporosis. Diet and
exercise (especially weight-bearing exercises) are interventions that
may lessen the effects of LHRH therapy.

Anti-androgen therapy side effects vary according to the medication, but
all can result in some degree of feminization or regression of secondary
sexual characteristics, loss of libido, and erectile dysfunction.
Nilutamide (Nilandron®) can cause nausea, hot flashes, and affect night
vision. Flutamide (Eulexin®) can cause nausea, diarrhea, hot flashes,
and breast tenderness. Bicalutamide (Casodex®) can cause gynecomastia.
Rare cases of hepatotoxicity with flutamide have been reported (Daw &
Peereboom, 2001).

Older Men and Ca P Treatment

Older men diagnosed with Ca P can vary in age (from 65 years to more
than 85 years). Each man may experience a wide variation in co-morbid
conditions which requires that each man be individually assessed based
his overall health prior to any discussion regarding the best treatment
for Ca P. Health care practitioners must be aware of two situations that
may be more prevalent in older men. Some men may believe that "whatever
the doctor decides" is the thing that they will do because "the doctor
knows best." These men should be encouraged to ask pertinent questions
that will help them to understand what they will experience when they
agree to a specific treatment.

The patient and his spouse may be so overwhelmed by the diagnosis of
cancer that they hear nothing after hearing the word "cancer." For many
of these men the word "cancer" has a very negative connotation of great
suffering and death, and it is one of the most feared medical diagnoses
(Balducci, 2003). For this patient and spouse, there is no one way that
will guarantee that the patient makes an educated treatment decision.
Written material as well as a verbal discussion of treatment options may
be helpful. In addition, an identified resource person who can answer
questions as they arise can also help. As Ca P is typically a
slow-growing cancer, the patient and his family have time to consider
the treatment that will best suit the patient and his lifestyle.

Health care workers dealing with the older man and his partner need to
realize that the patient may experience difficulty in seeing and
hearing. Men may seem to agree to everything that is discussed, when in
reality, they have not heard and therefore have not understood what has
been presented. Assessing the patient for a hearing or sight problem
during the initial history and physical examination will help identify
men who have special needs. For the patient with limited sight,
information should be given verbally, and written information should be
in a larger-than-normal font. For the patient who has difficulty with
hearing, speaking slowly and distinctly will help and should be
supplemented with written information.
Ca P in Men Age 65 to 74

Many men between the ages of 65 and 74 years have the potential for a
long life, especially if they do not have multiple medical problems. For
those men, surgery or radiation therapy is a viable option that can
potentially cure their prostate cancer. Each man needs to identify what
is important to him and what side effects he is willing to endure to
meet those ends. Knowing the side effects may help the man decide which
option will be the best option for him.

The surgical treatment option for a man older than age 70 years without
significant medical problems becomes slightly less clear cut. This
patient may have unknown underlying medical problems that could affect
the surgical experience. Older men may take longer to recover from
surgery and may also experience a slower recovery of continence. In
addition, potency is less likely to be recovered in this population
(Presti, 2004). Whether this is due to the surgery or the likely
co-morbid conditions is unknown. If the patient understands the risks
and wishes to pursue surgery as his preferred treatment option, the
urologist is likely to recommend additional testing to rule out
co-morbid conditions and ensure that the patient is in optimal condition
to undergo a major surgical procedure.

For the 65 to 70-year-old man with multiple medical problems and/or and
an expected lifespan of less than 10 years, a form of radiation therapy
may be the recommended treatment option. This is especially true for the
patient with a high-grade prostate cancer. While radiation can have side
effects, a higher-grade cancer can potentially be cured with radiation
therapy, and prevent the significant effects that metastatic cancer
involves.
Ca P in Men Over 75 Years of Age

Older men have a great fear of cancer and the pain and suffering that
may occur with the diagnosis. For men with a low-grade cancer (Gleason
six and below), observation may be a very reasonable option. Many men
(or their partners) may not be comfortable psychologically with this
option, since they do not feel that they are actively treating the
cancer. Continued support and encouragement may help the man and his
partner understand that this cancer is not likely to be life
threatening. The man and his partner must be told that if there is a
need to institute treatment, the treatment will be started. The
treatment can be either radiation therapy or hormone therapy depending
upon the particular patient situation. For example, if the patient's
cancer spreads, hormone therapy would be appropriate. Likewise, if the
patient becomes psychologically uncomfortable due to a rising PSA,
radiation therapy might be the best treatment. Individual situations
will dictate the best treatment for this patient population.

For the patient over 75 years of age with an aggressive prostate cancer
(a Gleason score of seven or above), there needs to be a discussion of
treatment options because these men may die of their prostate cancer
(and not with the prostate cancer). Radiation therapy and/or hormone
therapy will be the treatment(s) of choice. Helping the man and family
understand what to expect, how to deal with side effects, and who to
call with questions or concerns will help these patients and families
through the difficult time.

Often the caregiver of this patient population is overlooked. An elderly
spouse may need to take care of matters that she never had to do before
such as assistance with ADL or managing the family finances. Helping the
patient deal with side effects of treatment, as well as dealing with the
suffering of the loved one can be very stressful. If the patient has no
spouse, these duties will fall to another family member such as a child
or grandchild who has responsibilities of his or her own. These issues
should be addressed when providing information regarding treatment
options and side effects (Haley, 2003).

Nursing Implications

There are many patient populations that struggle with decision-making
issues following a medical diagnosis; patients with prostate cancer
commonly fall into this category. There is not one treatment option that
is the best for every patient. What is very important is that each
patient understands what options are available for him, what the
potential side effects of those options can be, and how he will need to
deal with the side effects of the treatment. A urology nurse is in an
ideal situation to help the patient and family through education,
support, encouragement, and active listening. By performing these
actions, the nurse will be able to help the patient become an educated
consumer — one that makes the best treatment decision for a dreaded cancer.

The older patient has additional needs, such as sensory needs that
should be addressed. For a patient to be able to make a decision, he
needs to understand his options. If he cannot hear or see, it is more
difficult to make informed choices. If he has memory problems (short or
long term), the nurse may be asked to repeat the information or answer
the same questions repeatedly as the patient tries to understand his
diagnosis and options. In addition, this could represent a situation in
which there is a question of whether or not the patient is competent to
make treatment decisions. Identifying resources (written, tapes, and
people) will help the patient arrive at a basic understanding of his
disease and his treatment options. The nurse must help teach the patient
about co-morbidities (lung, heart, and/or kidney disease) that may
influence treatment options that are available. If the Ca P results in a
terminal diagnosis, the nurse must help the patient and his family
explore end-of-life (EOL) options (see the EOL manuscript by Paula
Forest in this issue).

Conclusions

There is much controversy regarding screening for Ca P and treatment
following a diagnosis of Ca P in the older male. Because the natural
history of Ca P is unpredictable, there is no way of knowing which
prostate cancer will be clinically significant and cause problems for
the patient. Nor is there a way to know which cancers will never cause a
clinical problem for the patient. As the knowledge regarding the natural
history of Ca P continues to evolve, some of these questions will be
answered which will make the decision about treatment easier. Until
then, health care practitioners need to educate, support, and listen to
patients and their families.
CE Information
The print version of this article was originally certified for CE
credit. For accreditation details, please contact the publisher, Society
of Urologic Nurses and Associates, Inc., East Holly Avenue Box 56,
Pitman, NJ 08071-0056.

Tables OMITTED
Table 1. Age-Specific PSA Reference Ranges
Table 2a. Gleason Score
Table 2b. Gleason Score
Table 3. TNM Staging System
Table 4. Treatment Options for Prostate Cancer

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Dorothy A. Calabrese, MSN, RN, CURN, CNP, is a Nurse
Practitioner/Clinical Nurse Specialist, Urology Oncology, Cleveland
Clinic Foundation's Glickman Urological Institute and Taussig Cancer
Center, Cleveland, OH