Nurse Practitioners Discuss AE Management With Prostate Cancer Treatments

A key component of caring for patients with prostate cancer is helping them manage the adverse effects (AEs) of their anticancer treatments, according to Leah Shaw, MSN, APRN, AGPCNP-BC; and Jessica Deinert, MSN, APRN, FNP-BC.

“As anybody who treats men with prostate cancer knows, there are lots of [adverse] effects associated with the therapies that we give,” Shaw said at the 2023 JADPRO Live Conference.

As part of their presentation on improving prostate cancer care in the clinical setting, Deinert and Shaw, who are both nurse practitioners at The University of Texas MD Anderson Cancer Center within the Genitourinary Medical Oncology department, highlighted some key AEs that oncology nurses and nurse practitioners should be aware of—and clinical pearls for managing them.

Hot Flashes

“Hot flashes are a very bothersome [AE] for a lot of men,” Shaw said. “There are a number of medications and approaches that your [patients] can take to help counter the hot flashes.”

Leah K. Shaw, MSN, APRN, AGPCNP-BC

These medications include a 75-mg dose of venlafaxine (Effexor XR) every evening before bed, or a 20 mg megestrol tablet twice a day (10 mg every other day once responsive)—although megestrol should be weighed against the risk for clot development.

Gabapentin and acupuncture are also used to manage hot flashes in this setting.

Erectile Dysfunction

Erectile dysfunction can have a significant impact on a man’s quality of life. There are medications for erectile dysfunction, for example, tadalafil at a 10 mg daily dose as needed or 2.5 to 5 mg daily dosing; vardenafil at a 10 mg dose as needed, or sildenafil at a 50 to 100 mg dose as needed. But Shaw said that these medications are less effective when used in conjunction with testosterone-suppressing therapies.

In these cases, alternative approaches such as vacuum assistive devices, surgical interventions, and injections may be appropriate.

Gynecomastia

Gynecomastia, or the overdevelopment of the breast tissue, can occur because of the testosterone suppression.

As Shaw explained, it is important to conduct a breast exam is patients are noting differences in their breast tissue—this is especially important for those with BRCA1/2 mutations, as they are more likely to develop male breast cancer.

Shaw said that although this AE is uncomfortable and can alter a man’s self-image, it is usually harmless. She noted that for some patients, preventative radiation may be considered to prevent gynecomastia, but that after 12 months of the symptoms, the tissue will become more fibrotic, and radiation will become less effective.

Hypertension

Hypertension is a very common AE with many of the 5α-reductase inhibitors (ARIs) used to treat prostate cancer, Shaw explained.

“Make sure that you are monitoring and managing as appropriate,” she said.

Hypercholesterolemia

According to Shaw, is it important to assess for hypercholesterolemia prior to starting androgen deprivation therapy and to continue managing as needed.

She noted that with darolutamide (Nubeqa), the newest ARI to be approved by the FDA, interacts with statins, or medications used to lower the level of low-density lipoprotein cholesterol in the blood.

“So, if somebody is on 20 milligrams of rosuvastatin [Crestor], we may consider reducing the dose to 5 milligrams to reduce the complications of potential side effects,” she explained.

Further, exercise is also important in managing hypercholesterolemia, she added.

Urinary Obstruction/Dysuria

Urinary obstructive symptoms and dysuria can be a problem at the time of surgery as well as at the time of radiation treatment, Shaw explained.

Tamsulosin (Flomax) can treat an enlarged prostate and is often used to address urinary obstructive symptoms. Shaw shared that her team often recommends that patients take ibuprofen in the evenings throughout their radiation treatment to reduce the inflammatory changes these treatments can cause.

Bone Health

“Long-term suppression of testosterone can result in osteoporosis,” Deinert explained, noting that her team will try to get DEXA scans, or bone density assessments, at baseline and approximately a year after starting hormone therapy.

Jessica Deinert, MSN, FNP-C

Within the first year of starting hormone therapy, patients will often lose about 4% to 6% of their bone density. If this does occur, Deinert’s team will often refer them to their primary care provider to undergo management. There are several injections and oral agents that can be used to manage this AE.

“We will also monitor their vitamin D levels and encourage exercise,” she added, explaining that exercises like resistance training and weight bearing activities help increase bone density.

Preventing Skeletal-Related Events

“Things shift a bit once a patient develops castration-resistant disease with bone metastasis,” Deinert said. “Our goal with treatment is really to prevent skeletal-related fractures, pathologic fractures, or compression fractures related to their cancer.”

At this point, she explained, regardless of bone density status, all patients will start taking bone strengthening medications. Denosumab and zoledronic acid are the 2 FDA-approved drugs indicated in this setting.

Of note, although they are approved on monthly basis, there has been research suggesting that a 12-week extended dosage interval may also be effective, especially with denosumab, she said. The benefits of a 12-weel interval are that it is more convenient for patients with less financial toxicity.

“Our practice has really transitioned to that every 3-month dosing,” she said.

Reference

Deinert J, Shaw LK. Improving prostate cancer patient care in the clinical setting. Presented at: 2023 JADPRO Live. November 10-12, 2023; Orlando, FL.