Mariano Marcos State University

College of Health Sciences

Department of Nursing
Batac City

PROSTATE CANCER

In Partial Fulfillment of the Requirements in the Subject

NCM 106

Presented by:

Angel Austine B. Agliam

Fe C. Pascua
Jeacelyn Diao
Jerico A. Malaqui
Joan Rala
Noreeka Nia J. Tamayo
Sheena Marie Macatumbas

BSN IV-B

Presented to:
Prof. Gileen I. Lagadon

AUGUST 2017
 PROSTATE CANCER
I. BRIEF DESCRIPTION
- means that cancer cells form in the tissues of the prostate (a small
walnut-shaped gland in men that fluid produces the seminal that nourishes
and transports sperm);
- Prostate cancer tends to grow slowly compared with most other cancers.
- cell changes may begin 10, 20, or even 30 years before a tumor gets big
enough to cause signs and symptoms
- Prostate cancer is usually multifocal, and can spread by local extension,
by lymphatic or through the bloodstream. Most prostate cancers are
adenocarcinoma and are palpable on rectal examination because they are
arising from the posterior portion of the gland.
- it is one of the most common types of cancer in men

II. INCIDENCE
- Prostate cancer is the third most common male cancer in the entire world
and half a million new cases continue to be diagnosed every year.
(MMHRDC, 2012).
- According to DOH, number of prostate cancer cases in the Philippines
continues to increase, leading health experts to believe that this silent
killer will claim one life every hour. Prostate cancer is now the third leading
cause of death among Filipino men. Also, the National Kidney and
Transplant Institute said 19.3 out of every 100,000 Filipino men are
afflicted with the disease.
- Records from the Department of Health (DOH) in 2013 showed that
around six million men over the age of 50 were at risk of developing
prostate cancer. The DOH said that half of the men aged 50 and above
has developed prostate cancer and was only detected on their 80s to
which the cancer is already in stage 3 or 4.

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III. ETIOLOGY
The exact cause of prostate cancer is unknown but there are etiologic
factors associated with prostate cancer as identified by medical experts.

a. AGE
- Advancing age is the most important risk factor for cancer overall.
- Prostate cancer is rare in men younger than 40, but the chance of having
prostate cancer rises rapidly after age 50. About 6 in 10 cases of prostate cancer
are found in men older than 65. According to studies, this may be associated with
degenerative changes and length of exposure to different carcinogens, the older
the person, the greater the exposure to carcinogens.

b. DIET
- Intake of charred meat
- Heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs)
are chemicals formed when meat, including beef, pork, fish, muscle or poultry,
is cooked using high-temperature methods, such as pan frying or grilling
directly over an open flame. In laboratory experiments, HCAs and PAHs have
been found to be mutagenicthat is, they cause changes in DNA that may
increase the risk of all types of cancer to include prostate cancer.
- Eating fats raises the amount of testosterone in the body, and testosterone
speeds the growth of prostate cancer.

c. HORMONES
- High testosterone levels: Men who use testosterone therapy are more likely
to develop prostate cancer, as an increase in testosterone stimulates the
growth of the prostate gland.

d. GENETICS
- DNA mismatch repair genes (such as MSH2 and MLH1): These genes
normally help fix mistakes (mismatches) in DNA that are made when a cell is

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 preparing to divide into 2 new cells. (Cells must make a new copy of their DNA
each time they divide.) Men with inherited mutations in these genes have a
condition known as Lynch syndrome (also known as hereditary non-polyposis
colorectal cancer, or HNPCC), and are at increased risk of colorectal, prostate,
and some other cancers.
- Inherited mutated BRCA2 gene: this mutated gene can cause prostate
cancer.
- HOXB13: This gene is important in the development of the prostate gland.
Mutations in this gene have been linked to early-onset prostate cancer
(prostate cancer diagnosed at a young age) that runs in some families.
Fortunately, this mutation is rare.
- Family history: Men with an immediate blood relative, such as a father or
brother, who has or had prostate cancer, is twice as likely to develop the
disease. If there is another family member diagnosed with the disease, the
chances of getting prostate cancer increase.

e. INFLAMMATION of the PROSTATE (prostatitis)

- Some studies have suggested that prostatitis (inflammation of the prostate
gland) may be linked to an increased risk of prostate cancer. It is believed that
inflammation can cause damage in DNA of cells especially if its chronic.
(American Cancer Society, 2017)

f. SEXUALLY TRANSMITTED DISEASES

- Researchers have looked to see if sexually transmitted infections (like
gonorrhea or Chlamydia and others) might increase the risk of prostate
cancer, because they can lead to inflammation of the prostate. (American
Cancer Society, 2017)

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IV. MANIFESTATIONS
Early prostate cancer usually has no clear symptoms, because compared
with most other cancers; Prostate cancer tends to grow slowly, by the time signs
appear, the cancer may be already advanced. However, prostate cancer does
cause symptoms, often similar to those of diseases such as benign prostatic
hyperplasia.
These include:
Urinary problems (the most COMMON)
o Needing to urinate urgently
o Needing to urinate more often than usual, especially at night
o Urinary retention (inability to completely empty the bladder;
sudden and painful feeling that cant urinate)
o Trouble starting or stopping when urinating
o Urinary incontinence (involuntary leakage of urine)
o Hematuria
Other symptoms include:
Pain and discomfort when sitting
Pain in the prostate areas
Pain in the lower back that radiates to anterior thigh or in the
postero-lateral leg and buttocks
Back pain or bone pain characterized by shooting, stabbing,
burning, tingling or numbness.
Sexual Dysfunction
o Pain when ejaculating
o Inability to maintain or sustain erection
Kidney problems
o Associated symptoms can be the following:
Tiredness or lack of energy
Swollen ankles and feet or edema
Poor appetite

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V. DIAGNOSTIC PROCEDURES
1. Digital rectal examination (DRE).
A digital rectal examination is a type of physical examination during which
a doctor or nurse inserts a finger into the rectum (back passage) to feel for
abnormalities.
A man is often examined while he stands, bending forward at the waist. A
man can also be examined while lying on his left side, with his knees bent toward
his chest. The doctor gently puts a lubricated, gloved finger into the rectum. He
or she may use the other hand to press on the lower belly or pelvic area to feel
for tenderness or problems, such as enlargement, hardness, or growths.

If a digital rectal exam (DRE) is being done to screen for prostate cancer,
the examination may be combined with a blood test for prostate-specific antigen
(PSA). The two tests are often done together to check for prostate cancer. If the
prostate gland is enlarged this may mean benign prostatic hypertrophy (BPH) or
inflammation of the prostate gland (prostatitis) or tumors are felt in the prostate
gland itself.

2. Prostate-specific antigen (PSA) test.

A blood sample is drawn from a vein in the arm and analyzed for PSA, a
protein substance that's naturally produced by the cells of prostate gland. It's
normal for a small amount of PSA to be in the bloodstream. However, if a higher
than normal level is found, it may indicate prostate infection, inflammation,
enlargement or cancer.
The results are usually reported as nanograms of PSA per milliliter
(ng/mL) of blood. A normal PSA level is considered to be 4.0 nanograms per
milliliter (ng/ml) of blood.

3. Ultrasound.
If other tests raise concerns, the doctor may use trans-rectal ultrasound
(TRUS) to further evaluate the prostate. A small probe, about the size and shape

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 of a cigar, is inserted into the rectum. The probe uses sound waves to create a
picture of the prostate gland. A healthy adult prostate weighs about 2025 grams
(2/3 to 3/4 of an ounce). It measures 4 x 2 x 3 centimeters (1.6 x 1 x 1.2 inches).

4. Biopsy or collecting a sample of prostate tissue.

If initial test results suggest prostate cancer, the doctor may recommend a
procedure to collect a sample of cells from the prostate (prostate biopsy).
Prostate biopsy is often done using a thin needle that's inserted into the prostate
to collect tissue. The tissue sample is analyzed in a lab to determine whether
cancer cells are present and to grade the tumor. The most commonly used tumor
grading system is the Gleason score.

5. Gleason Grading System (Gleason Scoring)

This is used to help evaluate the prognosis of men with prostate cancer
using samples from a prostate biopsy. This system assigns a grade of 1 to 5 for
the most predominant architectural pattern of the glands of the prostate and a
secondary grade of 1 to 5 to the second most predominant pattern. The Gleason
score is then reported as, for example, 2 + 4; the combined value can range from
2 to 10. With each increase in Gleason score, there is an increase in tumor
aggressiveness.

Lower Gleason scores indicate well-differentiated cells and less

aggressive tumor cells while higher Gleason scores indicate undifferentiated cells
and more aggressive cancer. A total score of 8 to 10 indicates a high-grade
cancer. (AUA, 2007).

Once a prostate cancer diagnosis has been made, the doctor works to determine
the extent (stage) of the cancer. If the doctor suspects that the cancer may have spread
beyond the prostate, one or more of the following imaging tests may be recommended:

Bone scan
Ultrasound

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 Computerized tomography (CT) scan
Magnetic resonance imaging (MRI)
Positron emission tomography (PET) scan

VI. MEDICAL MANAGEMENT

1. Active Surveillance
Active surveillance or active monitoring is an observation and regular monitoring
without invasive treatment. Active surveillance is a way of monitoring prostate cancer
that hasnt spread outside the prostate (localized prostate cancer), rather than treating it
straight away. This is recommended for the patients with low-risk disease whose PSA
levels are below 10ng/ml.
In active surveillance, the patients will have regular follow-up blood tests, rectal
exams and possibly biopsies to monitor progression of the cancer. The patient wont
have any treatment unless these tests show that the cancer may be growing, or the
patient decides for treatment to avoid or delay the side effects of treatment.

2. Watchful Waiting
Watchful waiting may be an option for much older men and those with other
serious or life-threatening illnesses who are expected to live less than 5 years. With
watchful waiting, routine PSA tests, DRE, and biopsies are not usually performed. If a
patient develops symptoms from the prostate cancer, such as pain or blockage of the
urinary tract, then treatment may be recommended.

3. Medical Treatment Drug Options

a. Hormone therapy
Removing or blocking the action of hormones which allows the
progression of prostate cancer cells is the main aim of hormone therapy.
Different hormonal drugs reduce the production and level of male hormones like
testosterone and androgens in the patient and therefore stun the growth of
cancer cells.

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 The hormonal drugs used to treat prostate cancer are as follows:
LH releasing hormone agonist: Drugs like leuprolide, buserelin, and
goserelin prevents the male testicles from producing testosterone.
Anti-androgen drugs like flutamide, enzalutamide, and
bicalutamideantagonise the action of androgens like testosterone and
therefore hampers the promotion of male sex characteristics.
Drugs like ketoconazole and aminoglutethimide are also used to
antagonize adrenal glands and therefore reduce the production of male
hormones.
Abiraterone: A new drug approved by US FDA in the year 2011, Abiraterone
inhibits the production of androgens by testicular, adrenal and prostatic tumor
tissues. Since androgens are precursor for testosterone, inhibiting them
reduces circulating levels of testosterone and thus reduces the progression of
prostate cancer.
Female sex hormone, estrogen prevents the production of testosterone.
However, these drugs are rarely used considering the serious side effects
associated with them.

b. Chemotherapy
Chemotherapy (chemo) uses anti-cancer drugs injected into a vein or
given by mouth. These drugs enter the bloodstream and go throughout the body,
making this treatment potentially useful for cancers that have spread
(metastasized) to distant organs.
Chemotherapy is also used for castrate-resistant prostate cancer. Two or
more chemotherapeutic agents are administered to the patient on multiple
sittings. The drugs kill the cancer cells by hampering their division and
multiplication. However, the drugs also affects the normal cells and the most
common adverse effects thus observed are nausea, alopecia, anorexia, fatigue,
and reduced blood cell counts. These adverse effects are resolved after
completion of chemotherapy.

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 Drugs used for chemotherapy are docetaxel or cabazitaxel, given along
with steroids or using combination of bevacizumab, thalidomide and steroids.

c. Bisphosphonate therapy for Bone Pain

Bisphosphonate group of drugs aids in reducing pain as well as lowering
high serum calcium levels occurring due to metastasis of prostate cancer to
bones. The drugs mainly act on osteoclasts, which are cells responsible for
breaking down the mineral structure of bone in order to keep them healthy.
However, in case of bone metastasis, these cells become overactive and
therefore lead to pain, thinning of bone, and development of osteoporosis.
Zoledronic acid is most used bisphosphonate class of drug which is administered
via intravenous route (IV route) every 3 or 4 weeks. The treatment is also used
for preventing development and progression of osteoporosis in prostate cancer
patients taking hormone therapy.

The common side effects are flu-like symptoms and joint pain. The
treatment is contraindicated in patients with poor kidney function. The rare but
extremely serious complication of the treatment is osteonecrosis of the jaw
(ONJ). The treatment can hamper the blood supply to jaw bone and thus lead to
tooth loss and open sores. Often infection is developed in the open sores which
are hard to treat.

d. Denosumab
Denosumab is a targeted monoclonal antibody for the treatment of
osteoporosis in men with metastatic prostate cancer spread to bones and/or who
are taking hormone treatment. The antibody also aids in relieving bone pain.
Denosumab prevents maturation of osteoclasts which are bone-scavenging cells.
Denosumab therapy is contraindicated in patients with low serum calcium
levels and can be resumed only after treatment of calcium and vitamin D
deficiency. Common side effects are joint and bone pain. The treatment

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 increases the risk for bone infections, hypersensitivity allergic reactions, skin
allergy and infection, hip fractures, and osteonecrosis of jaw.

e. Radioisotope Strontium-89
Strontium-89 is a radiopharmaceutical agent which is similar to calcium
and therefore is readily taken up by bone-forming cells called osteoblasts. The
radioactive isotope is selective for bone and therefore provides better results and
lower side effects than systemic radiotherapy for the treatment of bone
metastasis of prostate cancer.
Strontium-89 is given intravenously to the patient which is then absorbed
by bone cells. Unabsorbed agent is excreted in urine within 2-3 days of
administration. The agent remains on the bone target for 100 days and kills
metastatic cells by emitting beta radiations. Minimal irradiation to healthy tissues
and longer duration of target specific activity are the main advantages of this
treatment. Since the agent penetrates deep inside the bones, often there is no
need to isolate the patient in a separate room.

4. Radiation Therapy
This uses high-powered energy to kill cancer cells. This is sometimes called
palliative radiotherapy. Palliative radiotherapy doesnt aim to cure cancer but it can help
to slow down its growth. Prostate cancer radiation therapy can be delivered in two ways:

External Beam Radiation (Radiation that comes from outside of the

body)

During external beam radiation therapy, patient will lie on a table while a
machine moves around the body, directing high-powered energy beams, such as
X-rays or protons to the prostate cancer. Patient with prostate cancer typically
undergo external beam radiation treatments five days a week for several weeks.

Brachytherapy (Radiation placed inside the body)

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 Brachytherapy involves placing many rice-sized radioactive seeds in the
prostate tissue. The radioactive seeds deliver a low dose of radiation over a long
period of time. The doctor implants the radioactive seeds in the prostate using a
needle guided by ultrasound images. The implanted seeds eventually stop
emitting radiation and don't need to be removed.

5. Biological therapy (Immunotherapy)

This therapy uses the body's immune system to fight cancer cells. One type of
biological therapy called sipuleucel-T (Provenge) has been developed to treat
advanced, recurrent prostate cancer. This treatment takes some of the patients own
immune cells, genetically engineers them in a laboratory to fight prostate cancer, and
then injects the cells back into the patients body through a vein.

6. Surgery
Prostatectomy
Surgical removal of the prostate is a common treatment either for early stage
prostate cancer or for cancer that has failed to responds to radiation therapy.
2 types:
Radical retropubic prostatectomy- this is when the surgeon removes
the prostate through an abdominal incision
Radical perineal prostatectomy- this is when the surgeon removes the
prostate through an incision in the perineum, the skin between
the scrotum and anus.

Transurethral Resection of the Prostate

This is commonly called "TURP." This is a surgical procedure performed
when the tube from the bladder to the penis (urethra) is blocked by prostate
enlargement. In general, TURP is for benign disease and is not meant as
definitive treatment for prostate cancer. During a TURP, a small instrument
(cystoscope) is placed into the penis and the blocking prostate is cut away.

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 Cryosurgery

This is another method of treating prostate cancer in which the prostate

gland is exposed to freezing temperatures. Cryosurgery is less invasive than
radical prostatectomy, and general anesthesia is less commonly used.

Orchiectomy

In metastatic disease, where cancer has spread beyond the prostate,

removal of the testicles (called orchiectomy) may be done to decrease
testosterone levels and control cancer growth.

VII. NURSING CARE PLAN (NCP)

NCP #1
NURSING DIAGNOSIS
Acute pain related to compression of nerve plexus secondary to enlargement of
the primary prostatic tumor as manifested by pain in the lower back that radiates to
anterior thigh or in the postero-lateral leg and buttock, guarding behavior, grimacing of
the face and discomfort.

NURSING INFERENCE
In Prostate Cancer, the normal semen-secreting prostate gland cells mutate into
cancer cells. Eventually, this may cause abnormal growth of tissue giving rise now to
primary prostatic tumor. As the disease progresses, the primary prostatic tumor may
enlarge causing compression in the pelvic soft tissues near the prostate gland,
particularly the psoas muscle, which contains the lumbo-sacral plexuses, hence
irritation to the nerves. Thus, pain in the lower back that radiates to anterior thigh or in
the postero-lateral leg and buttocks, guarding behavior, grimacing of the face and
discomfort.

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NURSING GOAL
After 30-45 minutes of rendering appropriate nursing interventions, the patient
will be able to verbalize relief of pain as would be manifested by absence of discomfort,
guarding behavior, grimacing of the face and with a verbalization of hindi na
masyadong masakit itong likod ko.

NURSING INTERVENTIONS
Nursing Interventions Rationale
1. Encourage the patient to do deep To release tension and promote relaxation.
breathing exercises.
2. Schedule rest periods for the patient To not intensify the pain, to decrease
and provide quiet and calm environment fatigue, to conserve energy and enhance
like limiting the number of visitors. coping abilities.
3. Encourage patient to talk with significant To divert patients attention from the pain
other or to listen to favorite music. felt.
4. Provide comfort measures such as back To promote relaxation, release tension,
rub, and helping patient to assume refocus attention and enhance coping
position of comfort. abilities.
5. Apply cold ice pack. Cold reduces pain by decreasing the
release of pain-inducing chemicals and
slowing the conduction of pain impulses
and to simply numb the area.
6. Encourage use of sitz baths, warm To release tension and promote relaxation
soaks to perineum.
7. Prepare patient for radiation therapy if Radiation therapy may be effective in
prescribed. controlling pain.
8. Administer analgesic or opioid agents at Analgesic agents alter perception of pain
regularly scheduled intervals as and provide comfort. Regularly scheduled
prescribed. analgesics around the clock rather than
PRN provide more consistent pain relief.
9. Prepare patient to possible surgery for To relieve compression of the nerve

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removal of tumor as ordered. plexuses thereby, reducing pain.

NURSING EVALUATION
After 30-45 minutes of rendering appropriate nursing interventions, the patient
was able to verbalize relief of pain as manifested by absence of discomfort, guarding
behavior, grimacing of the face and with a verbalization of hindi na masyadong masakit
itong likod ko.

NCP #2
NURSING DIAGNOSIS
Impaired urinary elimination related to urethral obstruction secondary to prostatic
tumor growth as manifested by needing to urinate urgently, trouble starting or stopping
when urinating, nocturia, and dysuria.

NURSING INFERENCE
In prostate cancer, there is the abnormal growth of tumor within the prostate due
to uncontrolled cell division. Since the prostate is situated below the bladder, and the
urethra runs through the center of the prostate, from the bladder to the penis allowing
flow of urine out of the body, presence of enlarge or growing tumor may obstruct the
urethra making a person experience troubles in urination, hence, impaired urinary
elimination as manifested by needing to urinate urgently, trouble starting or stopping
when urinating, nocturia, dysuria, retention and incontinence.

NURSING GOAL
After 1-2 hours of rendering appropriate nursing interventions, the patient will be
able to verbalize improved pattern of urinary elimination as would be manifested by not
needing to urinate urgently, no trouble starting or stopping when urinating, absence of
nocturia, dysuria, retention, incontinence, and to void in sufficient amounts.

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NURSING INTERVENTIONS
Nursing Interventions Rationale
1. Prepare patient for surgery if indicated. Surgical removal of obstruction may be
necessary.
2. Catheterize patient to determine amount Determines amount of urine remaining in
of residual urine. bladder after voiding.
3. Consult with primary provider regarding Catheterization will relieve urinary
intermittent or indwelling catheterization; retention.
assist with procedure as required.
4. Encourage oral fluids up to 3000 mL Increased circulating fluid maintains renal
daily, within cardiac tolerance, if indicated. perfusion and flushes kidneys, bladder,
and ureters of sediment and bacteria.
Note: Initially, fluids may be restricted to
prevent bladder distension until adequate
urinary flow is re-established.
5. Initiate measures to treat retention. Promotes voiding:
Encourage assuming normal Usual position provides relaxed
position for voiding. conditions conducive to voiding.
Administer prescribed cholinergic Stimulates bladder contraction.
agent.
Monitor effects of medication. If unsuccessful, another measure
may be required.

6. Monitor vital signs closely. Observe for Impaired urinary elimination may lead to
hypertension, peripheral and dependent loss of kidney function results in
edema, changes in mentation. Weigh decreased fluid elimination and
daily. Maintain accurate I&O. accumulation of toxic wastes; may
progress to complete renal shutdown.
7. Recommend sitz bath as indicated. Promotes muscle relaxation, decreases
edema, and may enhance voiding effort.
8. Monitor catheter function; maintain Adequate functioning of catheter is to be

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sterility of closed system; irrigate as ensured to empty bladder and to prevent
required infection.

NURSING EVALUATION
After 1-2 hours of rendering appropriate nursing interventions, the patient was
able to verbalize improved pattern of urinary elimination as manifested by not needing
to urinate urgently, no trouble starting or stopping when urinating, absence of nocturia,
dysuria, retention, incontinence, and to void in sufficient amounts.

NCP #3
NURSING DIAGNOSIS
Imbalanced nutrition: less than body requirements related to increased
metabolism (proliferation of cancer cells), inadequate intake secondary to the disease
process as manifested by nausea, vomiting, loss of appetite and weight loss.

NURSING INFERENCE
In cancer, there is an increased metabolism due to rapid proliferation of cancer
cells. In an effort to fight the cancer, the body produces substances called the cytokines
to which it has the capability to induce weight loss. Also, cancer cells use up much of
the bodys energy supply, or they may release substances like anorexigenic agents that
may lead to nausea, vomiting, primarily loss of appetite and eventually weight loss.
Thus, Imbalanced nutrition: less than body requirements.

NURSING GOAL
After 7 days of rendering appropriate nursing interventions, the patient will
be able to maintain optimal nutritional status as would be manifested by absence of
nausea and vomiting, improved appetite and increased weight.
NURSING INTERVENTIONS
Nursing Interventions Rationale
1. Routinely weigh patient on the same This can help monitor changes in weight (if
scale under similar conditions. it has improved or not) and will serve as

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 baseline for other appropriate nursing
interventions
2. Cater to the patients individual food The patient will be more likely to consume
preferences. larger servings if food is with his/her
preference, palatable and appealing.
3. Provide frequent small meals and a Smaller portion of food are less
comfortable and pleasant environment. overwhelming to the patient
4. Avoid overly sweet, fatty, or spicy foods. This can trigger nausea and vomiting
response.
5. Encourage use of relaxation techniques, May prevent onset or reduce severity of
visualization, guided imagery, moderate nausea, decrease anorexia, and enable
exercise before meals. patient to increase oral intake.
6. Recognize effect of medication or Many chemotherapeutic agents and
radiation therapy on appetite. radiation therapy promote anorexia.
7. Refer to dietician or nutritional support Provides for specific dietary plan to meet
team. individual needs and reduce problems
associated with protein, calorie
malnutrition and micronutrient deficiencies.
8. Encourage patient to take vitamin To maintain patients nutritional status
supplements as prescribed

NURSING EVALUATION
After 7 days of rendering appropriate nursing interventions, the patient was able
to maintain optimal nutritional status as manifested by absence of nausea and vomiting,
improved appetite and increased weight.

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References:

Brunner &Suddharths, Textbook of Medical-Surgical Nursing.Volume 2 (12th Ed.)Lippincott

Williams & Wilkins a Wolters Kluwer business.

Deglin, J. and Vallerand, A. (2009). Daviss Drug Guide for Nurses.(11th Edition). F.A. Davis
Company.

Doenges, M., Moorhouse, M., Murr, A. (2012). Nurses Pocket Guide (13th Edition).

Porth, C. M. (2007). Essentials of PATHOPHYSIOLOGY Concepts of Altered Health States

(Second Edition). Lippincott Williams & Wilkins a Wolters Kluwer business.(1029-1031).

Wolters Kluwer. Lippincott Williams and Wilkins. Understanding Diseases.

http://emedicine.medscape.com/article/1967731-treatment

http://www.cancer.net/cancer-types/prostate-cancer/treatment-options

http://www.mayoclinic.org/diseases-conditions/prostate-cancer/diagnosis-
treatment/treatment/txc-20318002

https://prostatecanceruk.org/prostate-information/treatments/radiotherapy-for-advanced-
prostate-cancer

http://www.medindia.net/patients/patientinfo/medical-management-of-prostate-cancer.htm

https://www.cancer.org/cancer/prostate-cancer/treating/chemotherapy.html

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