Left Problem Based Learning (PBL) Case 1: Lamar Wilson  
 
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A 59 Year Old African American Man With Prostate Cancer

PBL Case As Presented to Learners

Lamar Wilson: First Scenario

Mr. Wilson. is a 59 year African American man who presents with weight loss and fatigue of four months duration. He is married and works full time as an auto mechanic. His job involves lifting heavy objects. He lives in a triple decker in Dorchester with his 38 year old second wife and three teenage children. His past history is remarkable for alcoholism and heavy smoking, both of which he discontinued 15 years ago upon marriage to his second wife. The patient now attends church regularly. He has not seen a physician since he was seen for an employment physical ten years ago. He noted vague discomfort in his pelvis over the last six months, aggravated by standing and lifting. Patient states routine weight is 180 lbs. and is 6 feet tall; his present weight is 150 lbs. Patient has not noted any change in bladder or bowel function but has noted a loss of appetite. Physical examination is unremarkable except on digital rectal exam. A large, stony prostate is detected. Stool for occult blood is negative. The primary care provider (PCP) assess Mr. Wilson’s pain and prescribes mediation. Arrangements for further evaluation are made.

Lamar Wilson: Second Scenario

The following week, Mr. Wilson undergoes a transrectal ultrasound which confirms a large mass involving both lobes of the prostate. He has a prostate specific antigen (PSA) which is elevated at 150 g with an elevated prostatic acid phosphatase. Plain films of the pelvis are normal. Biopsy reveals adenocarcinoma of the prostate. The primary care physician meets with the family to discuss the diagnosis and further evaluation. Appropriate radiological imaging and consults were obtained.

Lamar Wilson: Third Scenario

Bone scan reveals diffuse uptake in the pelvic bones and MRI of the pelvis reveals pathologic lymphadenapathy with potential involvement of the lumbar plexis. The patient has advanced disease and the urologist recommends chemical castration with leuprolide and flutamide. Mr. Wilson asks what the treatment options are for his cancer, and is particularly concerned about side effects of treatment. His pelvic pain is worsening and he requests medication. As his PCP, the patient asks you to manage his pain and to discuss the side effects of the treatment and the prognosis for prostate cancer.

Lamar Wilson: Fourth Scenario

Therapy with leuprolide and flutamide are instituted. The patient’s pain improves and his PSA drops but he develops a lack of interest in his family and general loss of appetite and sleep disturbances. Additional therapy is instituted. The patient does well for several years but then develops increasing bone pain. Because of his stoic nature, he denies his pain until he requires hospitalization. He achieves good pain control on a morphine drip at 5 mg/hr. A bowel regimen is instituted. A bone scan reveals diffuse metastatic disease to the spine and pelvis. Neurologic examination is unremarkable. As the PCP, you are asked to convert him to an oral pain regimen so that he may be discharged.

Lamar Wilson: Fifth Scenario

Mr. Wilson’s wife reports for several weeks he was doing well with the long acting morphine preparation. However, in the past two days the patient has been complaining of constipation and numbness and tingling in his feet. His ability to ambulate is impaired and he has developed increasing pain in his back in the mid-thoracic region. Appropriate therapy is instituted and Mr.Wilson is stabilized, but for the past three weeks he has developed a lack of interest in his family, become lax about hygiene, and complained about sleeplessness.

Facilitator's Guide

PBL objectives:

Population Perspective

  1. Describe and discuss the epidemiology of prostate cancer (sensitivity, specificity and predictive value). Discuss the effect of age, race, and lifestyle (diet, smoking, and stress) on the incidence and prevalence of prostate cancers in the population.
  2. Describe and discuss vague symptom complexes associated with a broad spectrum of neoplasms (pain, fatigue, loss of appetite).
  3. Describe and discuss impact of prostate cancer on the health care system (cost, prevalence, incidence) and in specific sub-populations (age, race, ethnicity, and SES)
  4. Cost effectiveness and efficacy of different treatment and management plans for the prostate cancer based on outcomes data.
  5. Describe and discuss inherited predisposition to prostate cancers and how you would interview the patient. What aspects of their history would suggest an inherited cancer syndrome, and what aspects of history taking can alert the primary care provider (PCP).
  6. Describe the legal and cost issues involved in screening for and early detection of prostate cancer (knowledge of timing, frequency and screening and the cost effectiveness of common cancers).

Behavioral Perspective

  1. Describe and discuss the role of the family, patients and PCP in determining the appropriate treatment plan. Describe the psychosocial reaction to the diagnosis and consequences of the disease and the various treatment plans for the individual and his family.
  2. Describe and discuss the ethical issues of the treatment and the consequences of prostate cancer, including functional status consequences of specific treatments, advanced directives, and euthanasia.
  3. Describe and discuss the role and function of the interdisciplinary health care team in caring for someone with prostate cancer.
  4. Describe and discuss cancer pain guidelines.
  5. What are some of the pain management issues with someone with a history of substance abuse. Describe the difference between tolerance and psychological addiction and understand the myth and fear of addiction.
  6. Describe and discuss the cultural issues involved in the screening, diagnosis and treatment of prostate cancer.
  7. Describe and discuss the potential pain syndromes and their treatment associated with prostate cancer.

Biological Perspective

  1. List the diverse etiologies of fatigue and weight loss including those which arise from psychological as well as biologic problems.
  2. List the elements in the patient's and family's social history (age, ethnicity, gender, work status and occupation, family dynamics) which are important considerations in history taking.
  3. Describe and discuss the components of a physical exam for someone with fatigue and weight loss.
  4. Describe and define the appropriate laboratory and radiologic test, taking in to account their indication, limitations and cost.
  5. Construct a treatment plan based on laboratory findings, history, and physical findings.
  6. Describe and define the prognosis of the prostate cancer given various stages in the disease process and treatment plans.
  7. Describe and discuss the pain syndromes that might be associated with the common cancers, detection of specific causes of pain and potential symptom management.

Case Description

Lamar Wilson: First Scenario

Mr. Wilson. is a 59 year African American man who presents with weight loss and fatigue of four months duration. He is married and works full time as an auto mechanic. His job involves lifting heavy objects. He lives in a triple decker in Dorchester with his 38 year old second wife and three teenage children. His past history is remarkable for alcoholism and heavy smoking, both of which he discontinued 15 years ago upon marriage to his second wife. The patient now attends church regularly. He has not seen a physician since he was seen for an employment physical ten years ago. He noted vague discomfort in his pelvis over the last six months, aggravated by standing and lifting. Patient states routine weight is 180 lbs. and is 6 feet tall; his present weight is 150 lbs. Patient has not noted any change in bladder or bowel function but has noted a loss of appetite. Physical examination is unremarkable except on digital rectal exam. A large, stony prostate is detected. Stool for occult blood is negative. The primary care provider (PCP) assess Mr. Wilson’s pain and prescribes mediation. Arrangements for further evaluation are made.

What are possible causes of weight loss?

What could explain his symptoms of pelvic pain

Lamar Wilson: Second Scenario

The following week, Mr. Wilson undergoes a transrectal ultrasound which confirms a large mass involving both lobes of the prostate. He has a prostate specific antigen (PSA) which is elevated at 150 m g with an elevated prostatic acid phosphatase (PAP). Plain films of the pelvis are normal. Biopsy reveals adenocarcinoma of the prostate. The primary care physician meets with the family to discuss the diagnosis and further evaluation. Appropriate radiological imaging and consults were obtained.

What is the significance of his transrectal ultrasound?

What is the significance of his PSA?

What is included in a staging evaluation for prostate cancer?

What other imaging or consults would be obtained?

Lamar Wilson: Third Scenario

Bone scan reveals diffuse uptake in the pelvic bones and MRI of the pelvis reveals pathologic lymphadenapathy with potential involvement of the lumbar plexis. The patient has advanced disease and the urologist recommends chemical castration with castration with leuprolide and flutamide. Mr. Wilson asks what the treatment options are for his cancer, and is particularly concerned about the side effects of treatment. His pelvic pain is worsening and he requests medication. As his primary care provider (PCP), the patient asks you to manage his pain and to discuss the side effects of the treatment and the prognosis of prostate cancer.

How would you evaluate this patient’s weight loss?

How would you tell the patient about his diagnosis?

What would you tell the patient about his prognosis?

What are the goals of therapy?

What would you tell the patient about side effects of treatment?

How would you manage his pain?

Are there issues in the patient’s past history that make pain medication an issue?

How would you manage this situation?

How would you manage issues of treatment costs with the patient?

Lamar Wilson: Fourth Scenario

Therapy with castration with leuprolide and flutamide. are instituted. The patient’s pain improves and his PSA drops but he develops a lack of interest in his family and general loss of appetite and sleep disturbances. Additional therapy is instituted. The patient does well for several years but then develops increasing bone pain. Because of his stoic nature, he denies his pain until he requires hospitalization. He achieves good pain control on a morphine drip at 5 mg/hr. A bowel regimen is instituted. A bone scan reveals diffuse metastatic disease to the spine and pelvis. Neurologic examination is unremarkable. As the PCP, you are asked to convert him to an oral pain regimen so that he may be discharged.

What additional therapy might have been instituted when the patient demonstrated somatic symptoms?

How will you make the conversion from parental to oral morphine?

What dose will you use for breakthrough medication?

Are there any adjuvant therapies you might recommend?

Are you concerned about a ceiling beyond which his opioid dose will be ineffective?

What non-pharmacologic interventions might be useful for his pain management?

Are there other treatments or problems that you would consider?

Lamar Wilson: Fifth Scenario

Mr. Wilson’s wife reports for several weeks he was doing well with the long acting morphine preparation. However, in the past two days the patient has been complaining of constipation and numbness and tingling in his feet. His ability to ambulate is impaired and he has developed increasing pain in his back in the mid-thoracic region. Appropriate therapy is instituted and Mr. Wilson’s. is stabilized, but for the past three weeks he has developed a lack of interest in his family, become lax about hygiene, and complained about sleeplessness.

How would you assess this new pain?

What is the most appropriate course of action?

How would you treat this pain?

If high dose parenteral morphine is not adequate to control the pain, what other methods might be considered?

What cultural factors may be related to his lethargy and response to pain?

How would you utilize the health care team to optimize the patient’s care at home?

Discussion

This case study of an African American 59 y.o. male who presents with weight loss and fatigue evolves into an assessment and treatment of pelvic pain secondary to metastatic prostate cancer. This symptom complex provides an opportunity to review the epidemiology and pathophysiology of weight loss associated with common cancers. It allows the learner to review the treatment and economic implications of prostate cancer and pain associated with prostate cancer.

As weight loss is a non-specific symptom, the student is provided the opportunity to consider the genetic, environmental, social and behavioral factors associated with weight loss. Weight loss is often a symptom of advanced cancer. Furthermore, weight loss can be a manifestation of chronic cancer pain. This also affords the learner the opportunity to explore appropriate weight for given age and height and what is a significant weight loss.

Prostate cancer is the most common cancer in males in the United States. The probability of developing prostate cancer increases with age. The probability of men developing prostate cancer is 1.74% for those 40-59 (1 in 57), at 60-79 it is 16.4% (1 in 6) and from birth to death it is 18.85% (1 in 5). Seventy five percent of all prostate cancers occur in men over 65; the median age is 72 years at time of diagnosis. The prevalence of latent or incidental tumors appears to be a unique characteristic of a prostate gland. It has been estimated that in 90% of men who develop prostate cancer remain undetected and clinically unimportant for decades. There are significant racial and geographic differences in the incidence of clinically significant prostate cancer. African American men have the highest rate of prostate cancer in the world. The incidence of prostate cancer among African American men in the US is almost two times higher than for whites; it is 93 per 100,000 for African American men and among Caucasians is 58 per 100,000The incidence in Chinese men is significantly lower than in other ethnic groups. Significant clustering of prostate cancer in families suggest a role for genetic factors which may account for 5-10% of prostate cancers. Dietary fat may also be a factor.

Early prostate cancer is usually asymptomatic and thus can be detected only by routine rectal examination and PSA (prostate specific antigen). The American Cancer Society recommends digital rectal examination and PSA annually for men over 50 and to younger men at higher risk (strong family disposition or African American).

The most common clinical symptom for prostate cancer is bladder outlet obstruction, hesitancy, urgency, nocturia, retention, and hematuria. The second most common presentation is bone pain due to metastatic disease, usually in the pelvis and axial skeleton. These symptoms are often nonspecific and may be attributed to other benign conditions. Over half of the patients with a palpable nodule usually have cancer. Such nodules are usually stony, firm, and non-tender on rectal exam.

The patient should undergo a transrectal ultrasound (TRUS) evaluation and serum test for prostatic specific antigen (PSA). TRUS has been shown to be about twice as effective as digital rectal examination in detecting prostate cancer. TRUS guided biopsy permits a more precise sampling of suspected areas. The lower limit of detection is about 5 mm. About 20% of the digitally detected prostate cancer will be missed on ultrasound because they are isoechoic rather than hypoechoic.

Prostate specific antigen (PSA) is a cytosolic glycoprotein produced only in prostate cells, both benign and malignant. Elevated levels can occur with benign prostatic hypertrophy but levels >10 ug have a false positive rate for prostate cancer of less than 2%.

Any prostate that feels abnormal on digital rectal examination should undergo a biopsy, A useful guideline based on recent studies is that for a PSA level>10, a TRUS with biopsy of any hypoechoic lesion should be considered. If the PSA<4, routine follow-up is usually adequate if the digital rectal exam is normal. If directed biopsies prove to be negative for cancer and PSA levels are greater than 30ug, suspicion of a clinically relevant prostate cancer is high. In such cases multiple random biopsies should be performed with special attention directed to transitional zone lesions.

The differential diagnosis includes acute prostatitis, which is usually accompanied by dysuria, fever, and pain. PSA would normalize with antibiotic treatment. Benign prostatic hypertrophy (BPH) and granulomatous prostatitis may present with moderately elevated PSA and nodules distinguished from cancer only on biopsy.

Initial evaluation for someone newly diagnosed with prostate cancer includes: EKG, complete blood count, calcium, serum electrolytes, creatinine and a bone scan. A positive bone scan indicates advanced disease and usually correlates with a high PSA level and high Gleason histologic grade. High PAP levels also correlate with a high incidence of surgically unresectable or metastatic disease. If the bone scan is negative then CT or MRI of the pelvis is done to evaluate possible involvement of the pelvic lymph nodes. As a result, clinical staging generally underestimates pathologic staging. About one-fifth of the patients with clinical disease limited to the prostate and not invading the capsule will have positive lymph nodes. Half the patients with large tumors or those extending to the seminal vesicles or pelvic wall will have positive nodes on surgical staging despite no evidence of adenopathy on CT.

Two staging systems are commonly used: the Jewett system (stages A-D) and the TNM system (stage 0-IV). Stage 0 is any tumor found incidentally in <5% of tissue. Stage A is clinically undetectable tumor confined to the prostate gland and is an incidental finding at prostatic surgery; Stage I is any clinically inapparent tumor not palpable or visible by imaging, without lymph node or metastatic disease. Stage B or Stage II is any tumor confined to the prostate gland. Stage C or Stage III is tumor clinically localized to the periprostatic area extending through the prostatic capsule; seminal vesicles may be involved. Stage D or Stage IV is local, regional or distant metastatic disease.

Ninety-five percent of all prostate cancers are adenocarcinomas. The Gleason grading system is a histologic grading system that correlates well with other prognostic factors in prostate cancer. Tumors are assigned to one of five distinct histologic patterns ranging from the most to the least differentiated-Gleason 1-5. The grades of the two predominant patterns in the surgical specimen are added to yield the final Gleason grade. Patients with scores <5 have relatively well differentiated lesions with good prognosis. Conversely scores closer to 10 have a poorer prognosis.

With the introduction of the PSA, an increase in new cases was seen between 1989 and 1992 but rates have declined since then. Men with localized prostate cancers (58% of those diagnosed) have a 5 year relative survival rate of 100%. Survival rate for all men diagnosed with prostate cancer is 67% at 10 years and 50% at 15 years. Mortality among African American men is more than two times higher than for white men.

Knowledge about and refinements in treatment continue to evolve. Surgery is usually reserved for patients with the cancer confined to the prostate, in good health, under 70 and who choose this approach. Radiation, either external or internal, is an option for men with Stage I-III prostate cancers. Outcome or prognosis are influenced by extent of disease, PSA level, and Gleason score. Sequelae from either of these treatments include sexual and urinary dysfunction; however the pattern and timing differ. Asymptomatic patients that are older, have well differentiate tumors, or have concomitant illness may warrant "watchful waiting".

Prostate cancer is a testosterone sensitive tumor. Therefore, hormonal therapy is still the mainstay of treatment for advanced prostate cancer. Androgen deprivation either through orchietcomy or inhibiting the pituitary lutenizing hormone either with estrogens or with hypothalamic lutenizing hormone-releasing hormone analogs (LHRH). Impotence is the end result of this option. Orchiectomy, while unacceptable to most men, has the least side effects and lowest cost. Estrogen therapy carries the risk of thromboembolism and gynecomastia. LHRH analogs can cost about $300 per month. Chemotherapy of prostate cancer has been disappointing and should be reserved for the younger patient who hormonal therapy has failed in the setting of a clinical trial.

For metastatic prostate cancer, the effect of a hormonal manipulation on survival is unclear. Therefore this therapy must be considered palliative. Up to 80% of the patients will respond initially to androgen ablation, but within 1-2 years half of them will develop hormone-independent disease progression. With disease progression survival is usually months. Response to therapy can be monitored by serum PSA.

Pain and symptom control are increasingly achieving importance in the medical setting, in this era of "patient-centered care". As with any other medical issue, sensitivity to the patient's (and family's) cultural context and expectations are key to formulating an approach to individual diagnosis and therapy. Increasing research protocol and interventions for cancer pain have taken culture into account. It has been suggested that in an environment of undertreatment of pain, some cultural styles of pain expression may be more susceptible to undertreatment than others. Patient education materials that are culturally specific and linguistically appropriate are available as a patient education tool for patients in pain. The Massachusetts Division of the American Cancer Society published (1996) cancer pain education booklets for eleven different ethnic groups in eleven different languages. These booklets, Taking Control Of Your Pain, were developed by the Boston Cancer Pain Education Program in collaboration with community based representatives and organizations.

Considerable literature on the distinctions between nociception, pain, and suffering is summarized in the International Association for the Study of Pain (IASP) core curriculum. Failure to assess pain preemptively is recognized as a major barrier to its control in any setting, particularly in patients with cancer who may deny the severity of their symptoms for many reasons including their perception that it heralds recurrent or progressive disease.

Awareness of the costs and side effects of proposed therapies are also important to pain management, particularly since the most commonly used drugs for analgesia include NSAIDs--a common cause of GI bleeding in the US--and opioids, whose use is potentially fraught with difficulties such as constipation, sedation, or stigmatization.

The selection of newly recognized metastatic prostate cancer as the underlying diagnosis in the fifth scenario of this case allows the facilitator to have learners keep in mind that sometimes back pain is due to serious conditions that require emergency therapy. The differential diagnosis of serious causes of low back pain includes not only neoplasia but also musculoskeletal (e.g., osteoporotic vertebral fractures, disc herniation), infectious (epidural abscess or vertebral osteomyelitis), and vascular (aortic dissection) causes. As the case is described, it reinforces the need to specifically and preemptively inquire about the patient's pain on a widely used, validated 0--10 scale. The importance of prompt diagnosis and therapy is also emphasized in this case through the illustration of spinal cord compression whose treatment requires emergency radiotherapy and high-dose glucocorticoids. Neuropathic pain may be related to nerve injury or dysfunction which produces the combination of numbness and/or diminished sensation, together with a burning pain along the same distribution. Therapy of pain due to nerve injury is typically accomplished by the use of adjuvant agents such as tricyclic antidepressants or anticonvulsants in addition to opioids. Bisphosphonates (pamidronate) are being used increasingly in patients with bone metastases to reduce pain and skeletal complications such as fractures (including cord compression) and hypercalcemia.

Cancer pain affects approximately 8 million Americans, reflecting one million new cases per year and an average survival across all diagnoses of 8 years. It has enormous economic impact that has been poorly studied as it is multidimensional, involving not only the direct costs of treatment but also lost wages of family caretakers. Cancer pain often co-exists with other morbidities which are equally important to evaluate preemptively and systematically (e.g., depression, hypercalcemia).

The World Health Organization has fashioned a clinical algorithm for cancer pain relief that was later adapted for use in the U.S. by the American Pain Society as well as the Agency for Health Care Policy and Research (AHCPR) Cancer Pain Panel. It emphasizes a staircase or ladder approach in which simpler, pharmacologic measures are used fully and individually titrated before selection of more costly or invasive ones. In this ladder approach, NSAIDs are given first, together with adjuvant medications as the first step in pain control. Later, opioids of increasing strength are used. An important clinical advance has been the advent of time-release oral morphine and oxycodone, or transdermal fentanyl patches. Another clinical option, if these measures do not work, is implantation of a catheter for intraspinal or intracerebral opioid delivery. For certain lesions (such as the well-defined, single area of involved bone in this patient's rib) local injection of a neurolytic agent can be helpful. Other options specific for bone pain include radioactive strontium or bisphosphonates. For these latter, more specialized interventions, specialist consultation is necessary, raising the question as to when is such consultation appropriate and what should be the goals and objectives of such consultation (as well as the expectations of the referring physician). Non-pharmcologic approaches are useful alone for mild pain or as an adjunct to pharmacologic therapy.

As the clinical course of the patient progresses, this provides an opportunity to address the increasingly important issues of health proxies, symptom control at the end of life and terminal care, management of complex problems such as pain in the era of managed care and case management. Methods to sustain alertness in the face of opioid therapy can also be addressed (e.g., use of nonpharmacological measures such as TENS, heat or cold; or pharmacological approaches such as co-administration of dextro-amphetamine along with opioids, or central administration of opioids). Finally, the impact of providing terminal care upon all health care providers can be approached through discussion of the terminal phases of this patient's care.

PBL References

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  3. Fields, H.L. (Ed) Core Curriculum for Professional Education in Pain, International Association for the Study of Pain, 1991 IASP Publications, Seattle
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  8. Rosin, E.J. Ethnic and Cultural Dimensions of Work with Hospice Families. The American Journal of Hospice Care, July/August: 16-21, 1988
  9. Streltzer, J. and Wade, T.C. The Influence of Cultural Group on the Undertreatment of Postoperative Pain.Psychosomatic Medicine, 43(5): 397-403, 1981
  10. Zborowski, M. Cultural Components in Response to Pain. Journal of Social Issues, 8(4): 16-30, 1952
  11. Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline. AHCPR Pub.No. 920032. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services, Feb. 1992
  12. Quick Reference Guide for Clinicians. Acute Low Back Problems in Adults: Assessment and Treatment. AHCPR Pub. NO. 95--0643. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Dec. 1994