Editing Patient Pathways: Prostate Cancer

<span id="prostate-cancer"></span>
= Prostate cancer =

Prostate cancer is a malignant (malignant) tumor originating from prostate cells. A prostate tumor usually grows slowly and remains on the prostate for many years. During this time, the tumor produces few or no symptoms and/or external signs (abnormalities detected by physical examination).

As prostate cancer progresses in its growth, the possibility of its spreading beyond the prostate into the surrounding tissues (local spread) increases. In addition, cancer can also spread to distant organs and organ systems, which is called metastasis or the formation of grafts. The most common sites of prostate cancer metastases are bones, lungs and liver. The symptoms and signs of prostate cancer are actually more related to the spread of the disease to distant organs than to the localized disease in the prostate itself. treatment.

On February 1, 2024, the implementation of the Special Program for Screening and Early Detection of Prostate Cancer in Croatia began. The program is aimed at men aged 55 to 69 who have never suffered from prostate cancer and who have not had a PSA test (prostate specific antigen) in the last 12 months. This program will be carried out on the territory of the City of Zagreb, and the Health Centers of the City of Zagreb, KBC Zagreb and KBC Sestre milosrdnice participate in the implementation.

The goal of the Special Program is to conduct prostate cancer screening among 10,000 men at an age in which the incidence of prostate cancer is relatively high. Men from the target population will be invited by family doctors to a free PSA test and, in case of need, and according to the given guidelines, to free further tests.

<span id="patient-pathways"></span>
= Patient pathways =

Developing a comprehensive prostate cancer treatment plan includes steps from initial presentation and diagnosis to treatment and follow-up. Below is a detailed plan:

<span id="diagnostic"></span>
== 1. Diagnostic ==

The patient presents with symptoms such as: difficulty urinating, frequent urination, pelvic pain, blood in the urine or semen, or bone pain.

'''Consultation with a doctor''' general practice.

'''Medical history and physical examination:''' Detailed medical history of the patient, digital rectal examination (DRE).

'''Initial tests:''' Prostate-specific antigen (PSA) test, complete blood count (CBC).

'''Referral to a urologist''' for further evaluation.

'''Diagnostic evaluation'''

'''Magnetic resonance: MRI of the pelvis''' to assess the local extent of the cancer and the stage of the cancer. The MR scan shows whether a biopsy should be done and if so, where exactly the tissue sample should be taken.

'''Transrectal ultrasound:''' visualization for taking prostate tissue samples (biopsy). The biopsy sample is sent for pathological examination to confirm the diagnosis of cancer.

'''CT scan:''' chest, abdomen and pelvis to check the spread of cancer and the presence of metastases.

'''Bone scintigraphy:''' assessment of bone metastases.

'''Laboratory tests:''' further assessment of PSA levels.

'''Genetic testing for BRCA1 and BRCA2 mutations''' can show how aggressive the tumor is.

<span id="treatment"></span>
== 2. Treatment ==

'''Multidisciplinary Team (MDT) meeting'''

Review of diagnostic findings with experts including oncologists, urologists, surgeons, radiologists, pathologists and radiotherapy specialists. Development of a treatment plan based on the stage of the tumor, risk assessment and general health of the patient.

'''Active Surveillance:''' for patients with low risk and less aggressive cancer. Regular PSA tests, DRE and occasional biopsies.

'''Treatment procedures'''

'''Surgical treatment'''

'''Radical prostatectomy:''' a traditional surgical method with a larger incision to remove the prostate and surrounding tissue.

'''Laparoscopic prostatectomy:''' minimally invasive method with smaller incisions.

'''Robot-assisted prostatectomy:''' uses robotic technology for greater precision.

'''Radiotherapy'''

Radiotherapy uses ionizing radiation to damage the DNA of cancer cells, causing them to die. She can be:

'''External Radiotherapy (EBRT):''' external radiation source directed at the prostate.

'''MRT (intensity modulated radiotherapy):''' precise targeting of radiation to the tumor while minimizing damage to the surrounding tissue.

'''SBRT (stereotactic radiotherapy):''' highly precise targeting of a high dose of radiation in short intervals.

'''Brachytherapy:''' internal radiation by implanting radioactive sources directly into the prostate.

'''Hormonal therapy'''

Reducing the level of male hormones (androgens) that promote the growth of prostate cancer. It is often used in combination with radiotherapy for locally advanced cancer.

'''LHRH agonists/antagonists:''' Medicines that reduce testosterone production.

'''Antiandrogens:''' Medicines that block the action of testosterone.

'''Orchiectomy:''' Surgical removal of the testicles to reduce testosterone levels.

'''Chemotherapy'''

Using drugs to destroy cancer cells. It is usually used in advanced cancer that is resistant to hormone therapy.

'''Immunotherapy'''

A personalized vaccine that uses the patient’s own immune cells to fight prostate cancer.

'''Targeted therapy'''

Medicines that target cancer cells with certain genetic mutations (PARP inhibitors).

'''Radionuclide therapy'''

A radioactive drug that targets bone metastases in patients with advanced prostate cancer.

<span id="after-treatment-follow-up-rehabilitation-and-survival"></span>
== 3. After treatment: follow-up, rehabilitation and survival ==

'''Rehabilitation'''

'''Physical therapy''' for the recovery of pelvic function and general fitness.

'''Sexual health support:''' counseling and therapy for sexual function.

'''Psychosocial support:''' counseling and support groups for emotional well-being.

'''Follow-up after treatment'''

'''Regular control examinations with physical examinations and PSA tests.'''

Periodic CT or MR for relapse monitoring.

'''Long-term follow up'''

Monitoring of late effects of treatment.

'''Health promotion and lifestyle changes''' to improve general well-being.

'''Secondary prevention:''' Screening for other malignancies and maintaining a healthy lifestyle.

<span id="palliative-care-if-applicable"></span>
== 4. Palliative care (if applicable) ==

'''Palliative treatments:''' To relieve symptoms and improve quality of life in advanced cancer.

'''Pain management:''' Medicines, nerve blocks.

'''Symptom control:''' Management of shortness of breath, pain, etc.

'''Hospice care:''' For end-of-life care if curative treatment is no longer an option.

<span id="challenges-faced-by-prostate-cancer-patients-during-their-therapeutic-journey"></span>
= Challenges faced by prostate cancer patients during their therapeutic journey =

<span id="challenges-during-diagnostic-evaluation"></span>
== Challenges during diagnostic evaluation ==

A diagnosis of prostate cancer can be a stressful and challenging time for patients. Support during this phase can significantly improve the patient’s emotional and physical condition. Prostate cancer patients face various difficulties during diagnosis, such as physical, psychological, financial and professional difficulties and lack of information.

'''Physical challenges'''

'''Invasive tests:''' Discomfort and pain during prostate biopsy.

'''Psychological problems'''

Waiting for test results can increase anxiety. Fear of facing the diagnosis.

'''Financial problems'''

The price of a private MRI scan (if the patient decides to speed up the procedure).

'''Lack of information'''

Patients often have difficulty finding reliable and comprehensible information about the disease, diagnostic procedures, treatment options and their rights. Insufficiently clear communication with doctors: the complexity of medical terminology and the lack of time during consultations can make it difficult to fully understand the diagnosis and treatment options.

<span id="challenges-during-treatment"></span>
== Challenges during treatment ==

'''Physical complaints'''

'''Urological problems:''' Many patients experience urinary problems, including incontinence (uncontrollable urination) or frequent urination, especially after surgery or radiation.

'''Sexual dysfunction:''' Erectile dysfunction is a common side effect of prostate cancer treatment, whether it is surgery, radiation or hormone therapy.

'''Fatigue:''' Radiation, chemotherapy and hormone therapy can cause extreme fatigue and exhaustion.

'''Pain and discomfort:''' Pain in the pelvis or lower back can be present due to the disease itself or as a side effect of treatment.

'''Changes in weight:''' Hormone therapy can cause weight gain or loss of muscle mass.

'''Psychological problems'''

'''Depression and anxiety:''' Coping with a cancer diagnosis and the side effects of treatment can cause significant emotional and psychological problems.

'''Fear of relapse:''' The constant fear of the cancer returning can be emotionally draining.

'''Family relations:''' Changes in family roles and responsibilities due to illness can cause stress and tension in the family.

'''Isolation:''' Physical and emotional symptoms can lead to social isolation and feelings of loneliness.

'''Financial and professional problems'''

'''High costs of medicines, therapies and medical procedures''' they can represent a financial burden.

Due to inability to work or reduced work capacity, many patients may experience loss of income.

'''Lack of information'''

The need to understand complex medical information and make informed decisions. Difficulties in making treatment decisions due to lack of reliable and comprehensible information or conflicting advice.

'''Ignorance of patients’ rights.'''

Lack of information about medical care providers during treatment.

<span id="challenges-during-rehabilitation-and-disease-monitoring"></span>
== Challenges during rehabilitation and disease monitoring ==

'''Physical complaints'''

'''Urological problems: incontinence''' (urinary control problems may continue after treatment, caused by surgery or radiotherapy) and an increased need to urinate, often at night.

'''Sexual dysfunction: erectile dysfunction (problems achieving or maintaining an erection, often as a result of surgery or therapy) and decreased libido:''' loss of interest in sexual activities.

'''Chronic fatigue:''' long-term exhaustion that can be caused by treatment, anemia, or hormone therapy.

'''Hormonal problems:''' hot flashes (common in patients who have undergone hormone therapy) and weight gain (weight gain as a result of hormonal changes).

'''Psychological problems'''

'''Fear of relapse:''' continuous fear of the cancer returning.

'''Anxiety and depression:''' psychological distress and emotional problems associated with the cancer experience.

'''Changes in mood''' and emotional instability.

'''Social isolation:''' reduced social interaction due to fatigue, anxiety, or other symptoms.

'''Financial and professional problems'''

'''Return to work:''' physical and psychological difficulties with returning to the workplace. Long-term financial burden associated with ongoing medical expenses.

'''Lack of information'''

'''Insufficient education''' about life after prostate cancer treatment.

'''Complexity of Information:''' difficulties in understanding medical information and recommendations.

'''Erectile dysfunction''' it is a very common complaint that is a long-term consequence of treatment. Treatment of erectile dysfunction is important to ensure oxygenation of penile tissue. A large percentage of patients do not even seek the necessary information, which leads to the neglect of complaints and can consequently lead to atrophy and permanent structural changes.

<span id="challenges-during-palliative-care"></span>
== Challenges during palliative care ==

The problems faced by prostate cancer patients in Croatia and their families during palliative care are multiple and include several key aspects:

'''Limited access to palliative care:''' there is a significant gap between the demand for palliative care and the available resources. Insufficient capacities of specialized palliative care providers.

'''Psychological problems'''

'''Psychosocial and emotional burden''' patients and their families is often large. Family caregivers often face high levels of stress and emotional burden.

'''Cultural and ethical issues:''' reluctance to discuss end-of-life issues can hinder the provision of effective palliative care.

'''Ethical challenges''' in decision-making and caregiving can also create additional stress for families and healthcare professionals.

'''Financial problems'''

The cost of care can be a significant burden on families, especially when considering the long-term nature of palliative care. Economic strain can further exacerbate the stress experienced by patients and their families, affecting their overall well-being and quality of life.

'''Challenges with care coordination:''' Effective palliative care requires coordination among different health care providers. In Croatia, there are challenges related to the coordination of care between hospitals, palliative care units and home care services.

Addressing these challenges requires a comprehensive approach that includes improving access to palliative care, providing emotional and psychological support to families, addressing economic burdens, and ensuring effective care coordination. In addition, public education and awareness of the benefits of palliative care can help reduce cultural and ethical barriers.

<span id="supportive-activities-for-patients-suffered-from-prostate-cancer-during-the-course"></span>
= Supportive activities for patients suffered from prostate cancer during the course =

Supportive measures implemented by medical centers and non-governmental organizations play a key role in the overall process of treatment and recovery of prostate cancer patients. While medical centers provide professional medical care and therapies, non-governmental organizations provide emotional, psychological and practical support that is equally important for the well-being of patients.

These complementary measures ensure a holistic approach to treatment, helping patients to cope with the challenges of the disease and improve their quality of life. The implementation of supportive activities can significantly improve the quality of life of prostate cancer patients during treatment, allowing them to have better control over their health and sense of well-being.

<span id="supportive-activities-provided-by-health-care-institutions"></span>
== Supportive activities provided by health care institutions ==

'''Urological problems:''' urologists and physiotherapists help control incontinence.

'''Fatigue:''' nutritionists and physiotherapists help manage fatigue through tailored diet and exercise.

'''Psychological counseling:''' providing support from psychologists who help patients cope with anxiety, depression and stress related to the diagnosis and treatment of prostate cancer.

'''Nutritional counseling:''' individual nutrition plans adapted to the needs of patients, which helps to maintain health during treatment and reduce side effects.

'''Informing patients:''' distribution of educational materials and brochures about prostate cancer.

'''Physiotherapy:''' programs for rehabilitation and restoration of physical function after surgery or therapy.

'''Medications to control side effects:''' Medicines to reduce side effects such as nausea, fatigue and pain.

'''Erectile dysfunction:''' Counseling and treatments by sexual health specialists.

'''Pain specialist:''' postoperative pain control.

'''Erectile dysfunction:''' Counseling and treatments by sexual health specialists.

'''Pharmacological treatment of erectile dysfunction after the procedure:''' The first line of treatment is phosphodiesterase-5 (PDE5I) inhibitors. Unfortunately, only about 12-17% of men will respond to these medications in the first six months after surgery.

Despite nerve-sparing surgical techniques, oral medications are generally ineffective early after surgery because cavernous nerves are injured intraoperatively and sometimes take 24 months to heal.

'''Surgical installation of a penile prosthesis''' may be considered in patients who are unsuitable for various pharmacotherapies or prefer definitive therapy.

Although there are effective treatments for erectile dysfunction, many men avoid seeking medical attention for this condition. In men with prostate cancer, only 50% of men were interested in seeking treatment for erectile dysfunction and actually took steps to find treatment. Furthermore, there are very high dropout rates among those who seek help in the treatment of this condition. Considering the importance of penile rehabilitation after radical prostatectomy, difficulties in initiating and maintaining treatment could have a negative effect on men’s ability to regain an erection after the procedure.

'''Regular inspections:''' continuous monitoring of the patient’s condition after treatment for early detection of possible cancer return.

'''Management of chronic conditions:''' therapies to manage long-term side effects and comorbidities.

<span id="supporting-activities-provided-by-associations"></span>
== Supporting activities provided by associations ==

Patient associations play a key supporting role in the therapeutic and rehabilitation path of patients with prostate cancer. Patient associations can organize:

'''Support groups:''' groups where patients can share their experiences and receive emotional support.

'''Family counseling:''' to better understand and support the patient.

The availability of reliable and comprehensible information that is necessary for the patient to take an active role in his treatment and healing process and to make informed decisions about therapeutic steps. Associations can provide online resources to educate patients about the diagnosis process and treatment options.

'''Legal help:''' counseling on patients’ rights, assistance in accessing health services and legal assistance regarding labor rights.

'''Financial and logistical assistance:''' assistance in finding financial resources to cover treatment costs and assistance in organizing patients’ trips to therapy appointments.

'''Educational workshops:''' workshops for patients and their families on disease management and treatments.

'''Counseling programs''' for the organization of work and the involvement of employers in the process of patient reintegration into the working environment.

'''Education''' about a healthy lifestyle, prevention of relapse and management of long-term side effects of treatment.

'''Organization of social activities:''' events and activities for social integration and support for prostate cancer survivors.

'''Information campaigns:''' raising awareness of the importance of regular examinations and a healthy lifestyle for the prevention of relapse.

These supportive activities help prostate cancer patients face challenges throughout their treatment journey, improving their quality of life and increasing their chances of a successful recovery.

'''Consultation with a nutritionist:''' development of customized nutritional plans that support health during treatment.

'''Food workshops:''' education about the importance of proper nutrition during prostate cancer treatment.

'''Organizing workshops for the benefit of patients:''' yoga and meditation, programs to reduce anxiety and improve emotional stability.

<span id="examples-of-successful-supportive-activities-from-croatian-associations"></span>
= Examples of successful supportive activities from croatian associations =

Civil society organizations, patient associations play a vital role in providing support to prostate cancer patients. Patient associations also play an active role in the policies of the health system and the social care system by informing the public and political stakeholders about the needs of patients, and the patients themselves about their rights.

There are a large number of civil society organizations operating in Croatia that provide support to cancer patients. The address book lists a large number of associations in Croatia, while here we single out a few of them:

'''Croatian Society of Prostate Cancer Patients (HDBRP)'''

KBC Zagreb oncologists, Dr. Marija Gamulin and Dr. Mislav Grgić, motivated by problems from everyday practice, initiated the establishment of an association with the aim of improving the quality of life and treatment of patients with prostate cancer.

The goal is achieved through the following activities:

'''Gathering of patients treated for prostate cancer''' as well as doctors and other medical personnel dealing with prostate cancer, sharing experiences among patients and providing information about treatment methods and new drugs appearing on the market.

'''Exchange of information''' about the possible side effects of treatment and the possibilities of preventing them.

'''Discussing treatment options''' and giving comments and suggestions to the Croatian Institute for Health Insurance for the best possible treatment of patients with prostate cancer.

'''Cooperation with the Ministry of Health of the Republic of Croatia''' where we expect active participation in the discussions within the appropriate bodies of the Ministry in order to be actively involved in activities related to oncological problems.

'''Patient support:''' providing psychological support and counseling for patients and their families.

'''Education and information:''' organization of lectures, distribution of informative materials and booklets on prostate cancer.

'''Public campaigns:''' organization of public events and actions such as “All for him” to raise awareness about prevention and early detection of prostate cancer. Every year during this campaign, informative material is distributed about this malignant disease and its prevention.

'''Croatian league against cancer'''

The League is one of the oldest and most active associations in Croatia that deals with the fight against cancer, including prostate cancer. Through the work of counseling centers, education, and work with experts from the health care system, they provide understandable and verified information to oncology patients. They organize campaigns to raise awareness of preventive activities to prevent the occurrence of cancer, as well as the importance of screening in the early detection of cancer.

'''Association Everything for her'''

The association everything for her actively participates in the creation of educational content for cancer patients in cooperation with European experts. It provides a number of activities: Information about hereditary cancers, a center for psychological help, organization of group therapies, lectures and workshops, and telephone assistance. Members or associates of the association who provide psychological help are professionals.

Their website Knowledge Center (www.svezanju.hr/centar-znanja/) is a repository of a number of handbooks for cancer patients.

The Sve za nja association, in cooperation with the European Society for Medical Oncology, has translated a number of manuals for oncology patients (the list is at the end).

'''Coalition of Health Associations (KUZ) - Onkologija.hr'''

'''It is time''' - is the name of the public health campaign of the association of oncology patients whose goal is to gather all the most important stakeholders of the health system and encourage the implementation of the National Strategic Framework against Cancer. As part of the campaign, the '''vrijeme.hr''' website was launched, through which the implementation of the NSOPR will be systematically monitored and citizens are invited to share their experiences.

'''Advocacy of patients’ rights''' acts through organizations or individuals specialized in advocating patients’ rights, whether it is the general public and raising awareness of patients’ rights, individual groups of patients or individual patients.

'''Empowering patients''' it assumes placing patients in the central position of the health care system (Patient Oriented Health Care), by enabling the active role of citizens in the creation of health, medical and social services that best suit their needs.

By improving public health policies.

'''Creation of publications:''' Clinical Trials - a handbook for patients and their families, 2009, Leaflet Useful information on patients’ rights, 2008, Behavior of chronically ill patients with prescribed therapy - a handbook for patients and their families, 2011, European Charter on Health Equality, 2011.

'''Association for the Promotion of Patients’ Rights'''

'''Advocacy of patients’ rights:''' the association advocates for patients’ rights at all levels. This includes the right to information, access to quality health care, dignity and respect

'''Patient education:''' work to raise awareness among patients about their rights and obligations. Education about patients’ rights helps them make informed decisions about their own health.

'''Education of healthcare professionals:''' understanding of ethical and legal aspects of health care, how to respond to complaints, how to reduce the number of complaints and communication skills

'''Cooperation with health institutions:''' the goal is to establish constructive cooperation with hospitals, clinics and other health institutions. They work to improve communication between patients and healthcare professionals.

'''Promoting transparency:''' they stand for transparency in the healthcare system. This includes access to information about treatment, costs and quality of services.

'''Fight against discrimination:''' we actively oppose discrimination of patients based on gender, age, ethnicity or any other factor. All patients deserve equal treatment.

'''Counseling and legal assistance:''' according to available projects, we provide counseling and legal assistance to patients who are facing problems in the health care system. Our goal is to ensure that their rights are protected.

These non-governmental organizations play a key role in providing support to prostate cancer patients in Croatia through education, emotional and psychological support, legal advice and assistance in finding financial resources. Their activities significantly contribute to the improvement of the quality of life of patients and their families and make it easier to face the challenges brought by the diagnosis and treatment of prostate cancer.

<span id="available-supportive-contents-for-cancer-patients"></span>
= Available supportive contents for cancer patients =

'''Booklet for prostate cancer patients Information, answers to questions, help and perspective'''

The booklet is supported by: Prostate Center of KBC Zagreb, Croatian Andrological Society, Croatian Society of Prostate Cancer Patients, Croatian Society of Oncology and Radiotherapy, Croatian Oncological Society, Croatian Society of Urological Oncology, Croatian Urological Society, Reference Center of the Ministry of Health for Urological Oncology of KBC Zagreb

“With this manual, we intend to provide and consolidate the latest information on the diagnosis and treatment of prostate cancer in one place. The text is written simply and comprehensibly in order to get answers to the most common questions related to this disease. I believe that this manual will help you to expand your knowledge about this disease and understand the different treatment options, encourage you to ask questions to your doctors and, most importantly, give you the strength you need on the road to recovery. With the information you will find here, we hope you will be able to choose the optimal treatment method in collaboration with our multidisciplinary prostate cancer treatment team.” Academician Željko Kaštelan, assistant professor, Ph.D. Marija Gamulin.

Authors: Zrna Antunac Golubić, Marija Gamulin, Dinko Hauptman, Tvrtko Hudolin, Željko Kaštelan, Tomislav Kuliš, Maja Drežnjak Madunić, Dean Markić, Ivica Mokos, Jure Murgić, Oliver Pavlović, Luka Penezić, Ante Reljić, Mladen Solarić

The '''Croatian translation''' of several Patient Guides was realized by the '''Association of Women Patients and Treated with Cancer SVE for NJU''' based on the approval of the '''European Society for Medical Oncology (ESMO).'''

'''ESMO Personalized medicine in oncology: A guide for patients'''

This patient guide was launched by the ESMO Working Group on Personalized Medicine to help patients, their family members and friends better understand the factors that can influence a personalized approach to cancer prevention, diagnosis and treatment.

This brochure presents the current knowledge of the basic principles of personalized medicine, illustrating its application to several tumor types. Personalized medicine represents the future of cancer treatment, and in order for it to become a reality in the near future and enable better tumor therapy, the role of the patient is crucial. In this expanding and evolving approach, ESMO is committed to educating patients so that they can better understand its main principles and their own contribution to the advancement of therapy. Well-informed patients and their informed choices are important.

The Croatian translation of the Guide was made possible by the '''Association of Women Patients and Treated with Cancer SVE for NJU''' based on the approval of the '''European Society for Medical Oncology (ESMO).''' The text of the Croatian translation was reviewed by: prof. Ljiljana Šerman, prof. Floriana Bulić-Jakuš and Mrs. Ljiljana Vukota.

https://www.esmo.org/content/download/385655/7486427/1/HR-Personalizirana-Medicina-u-Onkologiji-Vodic-za-Bolesnike.pdf

'''ESMO Guide for patients living with cancer'''

This guide for patients on living with cancer has been produced by the '''European Society for Medical Oncology (ESMO)''' and the '''European Cancer Patient Coalition (ECPC)''' in collaboration with the '''International Psycho-Oncology Society (IPOS)''', to help you and people like you in this important period of your life. In this Guide, you can find information about support in dealing with the new reality of life, life after basic treatment, preventive care and long-term follow-up. He will also help you in keeping a personal health record, i.e. planning your health care during your life with cancer.

The guide was translated by Ph.D. Dea Ajduković, and the translation was reviewed by Assoc. Ph.D. Natalija Dedić Plavetić, prim. Dr. med. narrower spec int. of oncology and on behalf of the patient psychologist Ljiljana Vukota from the association SVE for NJU.

https://www.esmo.org/content/download/131276/2458900/1/ESMO-Vodic-za-Bolesnike-Zivot-s-Rakom.pdf

'''ESMO Adverse events related to immunotherapy and their management: A guide for patients'''

This guide has been prepared to help you and your family, friends and carers better understand the side effects associated with immunotherapy and how to manage them. It contains information about the most common toxicities associated with modern immunotherapies (known as “immune checkpoint inhibitors”), how your oncology team can manage these symptoms, and several approaches you can take yourself to reduce their effects. The medical information described in this document is based on the ESMO clinical practice guidelines for the treatment of immunotherapy toxicities, which are designed to assist clinicians in the diagnosis, treatment and monitoring of these events. All ESMO clinical practice guidelines are prepared and reviewed by leading experts using evidence from the latest clinical trials, scientific research and expert opinion.

The Croatian translation of the guide was reviewed by: representative of the '''Croatian Society for Internal Oncology:''' doc. Ph.D. Natalija Dedić Plavetić, representative of the '''Croatian Thoracic Society:''' prof. Ph.D. Marko Jakopović, representative of the '''Association of women suffering from and treated for cancer SVE for her:''' Ljiljana Vukota.

'''ESMO Cancer treatment during the Covid-19 pandemic: A guide for patients'''

The guide contains information about the disease COVID-19 and its symptoms, as well as measures you can take to reduce the risk of infection. Also, the guide provides information about the impact of the COVID-19 pandemic on various aspects of cancer treatment, including possible changes to your treatment plan and medical examinations that may be necessary to protect yourself from infection.

The Croatian translation was reviewed by: Prim. Ph.D. Paula Podolski, president of the Croatian Senological Society, doc. Ph.D. Borislav Belev, internal oncologist, National representative of the Croatian Society for Internal Oncology at ESMO and Ljiljana Vukota, representative of the association SVE for NJU.

http://www.svezanju.hr/lijecenje-raka-tijekom-pandemije-covid-19-esmovodic-za-bolesnike/

'''ESPEN practical guideline: Clinical Nutrition in cancer'''

Malnutrition is a common feature in cancer patients and is a consequence of the presence of tumors and medical and surgical anticancer treatments.

Malnutrition negatively affects the quality of life and the toxicity of treatment, and it is estimated that up to 10-20% of cancer patients die as a result of malnutrition, not from the tumor itself. Therefore, nutrition plays a key role in multimodal cancer treatment.

Strong evidence shows that nutritional problems should be taken into account from the moment of cancer diagnosis, within the diagnostic and therapeutic pathway, and should take place in parallel with antineoplastic treatment. However, worldwide, cancer-related malnutrition is still largely unrecognized, underestimated and undertreated in clinical practice.

These evidence-based guidelines were developed to translate the current best evidence and expert opinion into recommendations for multidisciplinary teams responsible for the identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients.

'''Guidelines for the treatment of cancer pain'''

Clinical guidelines offer recommendations for diagnostic and therapeutic procedures, medications and treatment strategies for the “average” patient with a disease. The guidelines should make it easier for both doctors and patients to decide on diagnostic tests, treatment or treatment strategy. At the heart of every decision must be benefit or utility for the patient: cure, prolongation of life while improving or preserving the existing quality of life, reduction of symptoms or morbidity. They should also take into account possible (later) unwanted side effects. The guidelines with their recommendations should, on the one hand, lead to an improvement in the quality of treatment, and on the other hand, to the exclusion or reduction of the use of unproven, inappropriate and irrational procedures in clinical practice. They also directly or indirectly promote the rational use of medicines, equipment, and human and financial resources.

Clinical guidelines ideally contain “all” relevant information on prevention, diagnosis, treatment, prognosis, side effects, cost and effectiveness analyses, and all other treatment options. All this information helps to solve the individual medical problem. Clinical guidelines define recommendations that canbe applied to the majority of patients, and be suitable in all circumstances, but the decision on their application is made for each individual patient according to his particularities.

Prim. Dr. Marijana Persoli – Gudelj, Prof. Ph.D. Antonio Juretić, Prim. Dr. Mirjana Lončarić – Katušin, HDLB – HLZ

<span id="advice-for-patients-with-prostate-cancer"></span>
= Advice for patients with prostate cancer =

Coping better with the physical symptoms of prostate cancer can significantly improve patients’ quality of life.

'''Urological problems'''

'''Incontinence (Uncontrolled urination):''' use incontinence diapers or pads to control leaks.

'''Kegel Exercises:''' regularly perform exercises to strengthen the pelvic muscles.

'''Medications:''' Consult your doctor about medications that can help control your bladder.

'''Catheterization:''' In some cases, temporary or permanent catheterization may be necessary.

'''Frequent urination'''

'''Avoid caffeine and alcohol:''' they can irritate the bladder and increase the need to urinate.

'''Urination schedule:''' try to urinate at regular intervals to reduce the sense of urgency.

'''Sexual dysfunction'''

'''Erectile dysfunction'''

'''Medicines:''' Medicines such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) can help.

'''Vacuum devices:''' devices that create a vacuum can help achieve an erection.

'''Injections and urethral suppositories:''' Medicines injected directly into the penis or inserted into the urethra can be effective.

'''Consultation:''' Sex therapy can help address the emotional and psychological aspects of sexual dysfunction.

'''Fatigue'''

'''Vacation planning:''' schedule activities so that you have enough time to rest between them.

'''Light exercise:''' regular, light exercise such as walking can help increase energy.

'''Diet:''' eat a balanced diet rich in nutrients.

'''Hydration:''' drink enough fluids to avoid dehydration, which can make fatigue worse.

'''Pain and discomfort'''

'''Medicines:''' consult a doctor about pain medications, including NSAIDs and opioids.

'''Warm compresses:''' applying warm compresses can help reduce pain and discomfort in the pelvic area.

'''Physiotherapy:''' a physical therapist can recommend exercises to improve mobility and reduce pain.

'''Hormonal changes'''

'''Weight gain:''' watch your diet and exercise regularly to maintain a healthy weight.

'''Loss of muscle mass:''' incorporate strength training into your exercise regimen to prevent muscle loss.

'''Heat waves:''' wear light clothing and use fans or air conditioning to reduce discomfort caused by heat waves.

'''Diet'''

'''Balanced diet:''' eat a varied diet that includes fruits, vegetables, whole grains, lean meats and dairy products.

'''Dietary supplements:''' Consult a nutritionist about the need for nutritional supplements.

'''Hydration:''' drink enough water during the day.

'''Emotional support'''

'''Join support groups''' where you can share experiences and get emotional support.

'''Talk to a therapist''' about your feelings and ways to deal with them.

'''Social and professional support'''

'''Communication with the employer:''' talk to the employer about the possibility of adjusting working hours or tasks.

'''Family support:''' involve family members in your care and share your needs and feelings with them.

These strategies can help patients better manage the physical symptoms of prostate cancer treatment and improve their quality of life.

<span id="directory-of-associations-offering-supportive-activities-to-patients-suffering-from-cancer"></span>
= Directory of associations offering supportive activities to patients suffering from cancer =

<span id="zagreb"></span>
== Zagreb ==

'''Croatian league against cancer''' '''Offer:''' Psychological support, support groups, education, financial assistance. '''Contact:''' '''Address:''' Ilica 197, 10000 Zagreb '''Phone:''' +385 1 3775 572, 099 5361 386 '''E-mail:''' info@hlpr.hr '''Web:''' https://www.hlpr.hr

'''Association Institute for Gastroenterological Tumors (Iget)''' '''Activities:''' counseling, education, campaigns for the promotion of healthy lifestyles, connecting patient associations and medical professionals, development of informative content for patients '''Contact:''' '''Address:''' Ilica 197, 10000 Zagreb '''Phone:''' +385 95 5578 587 '''E-mail:''' info@iget.hr '''Web:''' https://iget.hr

'''Association SVE for HER''' '''Offer:''' Psychological support, education, information, support groups. '''Contact:''' '''Address:''' Kneza Mislava 10, 10000 Zagreb '''Phone:''' +385 1 641 8765 '''E-mail:''' info@svezanju.hr '''Web:''' http://svezanju.hr

'''Coalition of Healthcare Associations (KUZ)''' '''Representation of Patients’ Rights:''' KUZ deals with protecting the rights of patients and representing their interests before health institutions. '''Education:''' Organization of workshops and lectures on patients’ rights. '''Public Campaigns:''' Campaigns to raise awareness about patients’ rights and better access to health services. '''Consultation:''' Providing legal and administrative support to patients. '''Contact:''' '''Address:''' Trpimirova 11, 10000 Zagreb '''Phone:''' +385 1 4572 100 '''E-mail:''' President Ivica Belina: ivica.belina50@gmail.com '''Web:''' https://www.kuz.hr/

'''Croatian Society of Prostate Cancer Patients (HDBRP)'''

'''Activities:''' Provision of psychological support, counseling and information to patients suffering from prostate cancer and their families, organization of lectures, distribution of educational materials, and campaigns to raise awareness about prevention and early detection of prostate cancer, organization of support groups where patients can share their experiences and receive emotional support, campaigns to raise awareness about prostate cancer and the importance of regular examinations. '''Contact:''' '''Address:''' Ilica 65/1, 10000 Zagreb '''Phone:''' not listed '''E-mail:''' info@hdbrp.hr '''Web:''' https://www.hdbrp.hr

'''Association for patients with thyroid disease'''

'''Activities:''' Providing individual and group psychological support to patients suffering from thyroid diseases, organization of workshops, lectures, and distribution of educational materials about thyroid diseases, counseling and support for patients in the rehabilitation process after treatment, campaigns to raise awareness about thyroid diseases and the importance of early detection and treatment, Informative a platform that provides advice on nutrition, treatment and symptom management. '''Contact:''' '''Address:''' Frane Petrića Street 5, 10000 Zagreb '''Phone:''' +385 1 3464 723 '''E-mail:''' udruga.stitnjaca@gmail.com '''Web:''' https://stitnjaca.eu/

'''Association of Fireflies''' '''Offer:''' Psychological support, legal assistance, financial assistance, workshops. '''Contact:''' '''Address:''' Approach to Gjura Dežalić 50, 10000 Zagreb '''Phone:''' +385 1 3770 477 '''E-mail:''' info@krijesnica.hr '''Web:''' https://krijesnica.hr/

<span id="split-dalmatia-county"></span>
== Split-Dalmatia county ==

'''County League against Cancer - Split''' '''Offer:''' Education, support groups, psychological help. '''Contact:''' '''Address:''' Spinčićeva 1, 21000 Split '''Phone:''' 021 556 476 '''E-mail:''' office@zlpr.hr '''Web:''' https://www.zlpr.hr/liga/

'''Croatian Association for the Promotion of Patients’ Rights''' '''Activities:''' counseling on patients’ rights and assistance in accessing health services, education and information '''Contact''' '''Address:''' Zrinsko Frankopanska 2b, 21000 Split '''Phone:''' +385 915027861 '''E-mail:''' info@pravapacijenata.hr '''Web:''' https://pravapacijenata.hr/

<span id="primorsko-goranska-county"></span>
== Primorsko Goranska county ==

'''Association Nada Rijeka''' '''Offer:''' Psychological support, education, workshops. '''Contact:''' '''Address:''' Milana Smokvina Tvrdog 5/1, 51 000 Rijeka '''Phone:''' 051 371 062, 097 613 9715 '''E-mail:''' klub.nada.rijeka@gmail.com '''Web:''' https://klub-nada-rijeka.hr/

<span id="osijek-baranja-county"></span>
== Osijek-Baranja County ==

'''Association Mammae Osijek''' '''Offer:''' Psychological support, information, support groups. '''Contact:''' '''Address:''' J. Leovića 4 (Dom zdravlja “Drava”), 31000 Osijek '''Phone:''' 031 373366, 091/480-1102 '''E-mail:''' klubmammaeos@gmail.com '''Web:''' https://mammae-klub-osijek.hr/

<span id="istrian-county"></span>
== Istrian County ==

'''League against cancer Pula, Stoma club Pula''' '''Offer:''' Education, support for patients, information. '''Contact:''' '''Address:''' Nobileova 1, 52100 Pula '''Phone:''' 052 222 795 '''E-mail:''' liga.protiv.raka@pu.t-com.hr '''Web:''' https://www.ilco.hr/index.php/drustva/pula

<span id="zadar-county"></span>
== Zadar County ==

'''League against cancer Zadar''' '''Offer:''' Psychological support, education, information. '''Contact:''' '''Address:''' Veslačka 12, 23000 Zadar '''Phone:''' +385 23 627 783 '''E-mail:''' info@ligaprotivrakazadar.hr '''Web:''' https://ligaprotivrakazadar.hr/

<span id="sibenik-knin-county"></span>
== Sibenik-Knin County ==

'''League against cancer of Šibenik-Knin County''' '''Offer:''' Education, support groups, psychological help. '''Contact:''' '''Address:''' Trg Nikola Tomase 2, 22000 Šibenik '''Phone:''' 022 218993 '''E-mail:''' liga.sibenik@gmail.com Find them on Facebook League against Cancer Šibenik-Knin County

<span id="varazdin-county"></span>
== Varazdin county ==

'''Association Mammae club Varaždin''' '''Offer:''' Psychological support, education, workshops. '''Contact:''' '''Address:''' Graberje 33, 42000 Varaždin '''Phone:''' 042/206-900 '''E-mail:''' mammae.klub.varazdin@vz.t-com.hr '''Web:''' https://rakdojke.com/

<span id="vukovar-srijem-county"></span>
== Vukovar-Srijem County ==

'''League against cancer Vinkovci''' '''Offer:''' Education, support groups, information. '''Contact:''' '''Address:''' Trg bana Josipa Šokčevića 1, 32100 Vinkovci Find them on Facebook League against Cancer Vinkovci

<span id="međimurje-county"></span>
== Međimurje County ==

'''County League Against Cancer Association - Čakovec''' '''Offer:''' Psychological support, education, information. '''Contact:''' '''Address:''' A. Schulteissa 19, 40000 Čakovec '''Phone:''' - '''E-mail:''' liga.protiv.raka.medjimurje@gmail.com '''Web:''' https://www.zlprck.hr/