Nurses Are Key to Patients Navigating Genitourinary Cancers
Nurses must serve as care coordinators for patients with genitourinary cancers because of the many tests, procedures, and self-care instructions they require, Clara Beaver, MSN, RN, AOCNS®, ACNS-BC®, and Joan Livingstone, BScN, RN, OCN®, both of Karmanos Cancer Institute at Wayne State University in Detroit, MI, said during a session at a ONS BridgeTM virtual conference on September 9, 2021. They emphasized the complexity of genitourinary cancers throughout diagnosis, treatment, and survivorship. Key nursing responsibilities include communicating with the care team, referring patients to other members of the interprofessional team, and advocating for patients’ needs.
At diagnosis, patients with prostate cancer present with urinary, sexual, and pain symptoms and undergo a prostate-specific antigen (PSA) test. If PSA is elevated, they are given a digital rectal exam, pelvic ultrasound, and magnetic resonance imaging of the pelvis, if indicated. If a tumor is identified and patients require biopsy, provide patient education on preparation and follow-up care, including reporting any heavy bleeding or fever. The biopsy identifies a Gleason score, which is used to grade the disease; a Gleason score of 7 is intermediate, and 8 or more is high grade.
Patients with low-risk disease are often followed with active surveillance, whereas those with high-risk disease and long-life expectancy may require surgery, radiation therapy, or a combination of both and androgen deprivation therapy (ADT), which decreases testosterone or blocks androgens. Patients receiving ADT are at increased risk for bone fracture. Livingstone also discussed a treatment that Karmanos Cancer Center uses to help patients maintain sexual function and bowel control (http://doi.org/10.1001/jamanetworkopen.2020.8221) called SpaceOAR Hydrogel.
Patients with urothelial carcinoma also present (https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf) with urinary problems and often have (https://www.us.elsevierhealth.com/campbell-walsh-wein-urology-9780323546423.html) a history of smoking, environmental exposure, obesity, or diabetes. Cystoscopy, which involves inserting a camera through a tube through the urethra into the bladder, is the gold standard for diagnosis. High-grade disease usually is managed with intravesical treatment, which instills immunotherapy or chemotherapy into the bladder via catheter for two to three hours. Surgical candidates may receive (https://bcan.org/what-is-bladder-cancer) chemotherapy followed by cystectomy; if surgery isn’t an option, patients are usually treated (https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf) with chemotherapy plus radiation followed by surveillance cystoscopy.
After cystectomy, patients will either wear a bag for urine and mucus to drain continuously, or they may be candidates for continent diversion (https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-diversion), in which the surgeon creates an internal pouch so patients can urinate normally or via catheter. Nurses are instrumental in assisting patients with placement, obtaining supplies, and reinforcing teaching, including changing, cleaning, and using comfort items such as an ostomy belt, skin barrier, and stoma adhesive. Find more information on bladder cancer in the ONS Learning Library (https://www.ons.org/learning-libraries/cancer-genitourinary-tract).
Patients with kidney cancer may present (https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf) with hematuria and low back pain, as well as a mass or lump on the side or lower back, fatigue, loss of appetite, and weight loss. Diagnosis requires a computed tomography scan of the abdomen and pelvis, with possible biopsy if an identified mass is small. Depending on size and location, patients usually undergo surgery; no adjuvant treatments are currently approved, but several agents can be used for systemic therapy.
Patients may undergo molecular testing to find mutations, narrow treatment options, and discover DNA germlines that can affect other family members. Nurses are responsible for coordinating sample collection, delivery, watching for and reporting on results, and serving as a resource for patients and families.
A key nursing role is to provide care for various tubes and catheters, such as a ureteral stent, nephrostomy tube, nephroureterostomy tube, antegrade stent, and catheterization. The nurse’s role in catheterization includes insertion and removal, as well as patient education around self-care, cleaning, and observing for signs of infection or other problems.
“As the coordinator of an interprofessional team that includes the medical oncologist, radiation oncologist, urologist, and specialty staff, oncology nurses are a patient’s direct point of contact. They rely on us to help them manage these complicated diagnoses,” Beaver said.