Sexuality and Intimacy after Prostate Cancer Treatment

BY MARK SCHOLZ, MD

My life is turning into an evangelistic crusade to raise awareness about the risks of prostate cancer treatment.  Tens of thousands of men are undergoing unnecessary radical prostate cancer therapy with dire sexual consequences. These inappropriate and often fatefully wrong treatment choices are made because men are often completely unaware of the irreversible effects of the treatment itself.

Thankfully, I am not alone in this battle to inform men about the harm associated with prostate surgery. Another prostate oncologist, Dr. Celestia Higano from the University of Washington, recently published a scientific review on this very topic in the Journal of Clinical Oncology (JCO). For those of you who haven’t heard of the JCO, I consider it to be the most prestigious scientific cancer journal in the world.

Today’s blog will offer quote seven selected sections from Dr. Higano’s important article. To add some gravitas to the eye opening statements you are about to read, please realize that every one of her comments was referenced to a specific scientific report.  In other words, these statements have nothing to do with opinions. They are genuine outcomes from published scientific studies.

So without further ado let’s start with the first quote from the article:

Quote #1: “Unfortunately, many couples believe that even if they have problems with erectile dysfunction (ED) … they will be able to resume their normal sexual practices through the advances of modern technology.4 They are not informed that sexual function will never be the same after any form of therapy and they are often unprepared for the changes in their sexual and intimate relationship.” (Italics mine)

Quote #2: “PDE5 inhibitors (Viagra, Cialis) and other erectile aids are not successful for all patients with ED and, even when effective, half the patients stop using them within one year.11 Why couples stop using ED therapies has not been adequately investigated , but disappointment that sex life is not the same … likely contributes to this outcome.”

Quote #3: “In a Memorial Sloan-Kettering series of 475 men … 20% of men who had radical prostatectomy (RP) had climacturia at one year, and climactauria as associated with both painful orgasm and penile shortening.13” (Climacturia means that orgasm results in the ejaculation of urine instead of semen).

Quote #4: “At the Karolinska Institute, 1,288 patients had either open or robotic-assisted laparoscopic RP, and of the 691 men who were sexually active, 38% reported climacturia at least sometime during sexual activity. Of the men who reported climacturia, 72% had climacturia less than half the time, 17% more than half the time, and 11% all the time.14”

Quote #5: “In a review of 1,459 men who had RP at New York University, climacturia was found to decrease from 44% at 3 months to 22% at 24 months after surgery. Climacturia is a common complication of RP but is often overshadowed by concerns about ED and overt urinary incontinence.14-16”

Quote #6: “In a study of VED (vacuum erectile device) use after RP, the length and circumference of the penis decreased in 63% of patients who did not use a VED after RP compared with only 23% who did.18-20”

Quote #7: “Surgery can also result in Peyronie’s disease (also called, “crooked penis”) in up to 16% of patients.23"

When patient are informed of the dire consequences of surgery they are often mystified as to why urologists, who must be aware of the damage surgery causes, continue vigorously to recommend it. I have heard many patients voice the opinion that urologists are driven by a selfish desire for financial gain.   

The financial motive, however, fails to ring true. As medical procedures go, prostate surgery is poorly reimbursed. Also, when urologists are diagnosed with prostate cancer they themselves often proceed with a radical prostatectomy. So money is not the primary issue. Rather, consider that performing surgery is part of the very fabric of a surgeons’ persona. From a surgeon’s point of view, if you are not operating, you are not a surgeon.

Men considering surgery for prostate cancer need to be aware of its substantial risks. And when getting advice about which treatment to select, patients also need to realize that surgeons usually can’t provide balanced advice. They are too close to the trees to see the forest.   

The Healing Power of Laughter

BY RALPH BLUM

If you have just been diagnosed with prostate cancer you are not alone. The American Cancer Society estimated that there would be over 241,000 new cases in the U.S. in 2012. And those men probably received a ton of information and advice from multiple sources to help them choose the best treatment.

Obviously their choice had to be guided by the clinical stage of their cancer, the extent of the disease, and their age and overall health. Undoubtedly they asked dozens of questions before making a final treatment decision.  But a question seldom asked is: “What are the psychological implications of the treatment?”

My prostate cancer journey began in 1990, and I monitored the cancer for 12 years before my PSA bumped up to a point that made some form of treatment necessary.  I chose hormone blockade, because being deprived of testosterone seemed more appealing than having my prostate sliced out or fried by electrons. However, I discovered that every cancer treatment comes with a stiff price—both physically and psychologically. So what is the best way to help combat the fear and stress of dealing with prostate cancer?

For me, the great “home remedy,” the ultimate anti-oxidant, is laughter. And that is not some demented form of denial. Over the past ten years, I have found that of all the things people have recommended to help get me through the bad times, laughter is at the top of the list.

“The best doctors in the world are Doctor Diet, Doctor Quiet and Doctor Merryman.” So wrote Jonathan Swift (1667-1743). Norman Cousins emphasized the healing power of laughter in his book, Anatomy of an Illness. Cousins called laughter “internal jogging.” And in his book, Peace, Love & Healing, Bernie Siegel wrote that, “love, laughter and peace of mind are physiologic.”

Without a doubt, laughter is the ultimate antioxidant. Here’s how the Discovery Health Web site describes the impact of laughter on the immune system: “When we laugh, natural killer cells which destroy tumors and viruses increase, along with Gamma-interferon (a disease-fighting protein), T cells (important for our immune system) and B cells (which make disease-fighting antibodies. As well as lowering blood pressure, laughter increases oxygen in the blood, which also encourages healing.”

Believe me when I say that my somewhat warped sense of humor has been a blessing to me in devastating moments. Time and again I have seen the relief and release that even stupid jokes or bawdy humor can provide to men who are under the gun. Cousins claimed he laughed his way back to health with old Groucho movies. For me, it was the amazing Carol Burnett, with the Marx Brothers a close second.

So find what works for you, because studies have shown that the debilitating emotion of fear can’t coexist with laughter, and that the relaxation response following a good laugh is worth its weight in gold. The message is clear: Lighten up!

Research at the PCRI

BY MARK SCHOLZ

As Executive Director for the Prostate Cancer Research Institute, I am often asked about our research focus. The PCRI has given unrestricted grants to various institutions over the years. These institutions are listed on the website at www.PCRI.org.   In addition, since the inception of the PCRI, Dr. Lam, Dr. Strum and I have published at least ten scientific articles relevant to prostate cancer in peer-reviewed journals This blog very briefly summarizes the most useful conclusions that can be drawn from this body of work (the article titles are in italics).

1. Anemia associated with androgen deprivation in patients with prostate cancer receiving combined hormone blockade:  We were the first to report that blocking testosterone can result in anemia, i.e. a drop in red blood cell (RBC) counts. The anemia caused by low testosterone resolves spontaneously when testosterone levels are restored to the normal range. Doctors need to be aware of the cause of this phenomenon or else men are unnecessarily subjected to treatment with iron (which may stimulate prostate cancer growth) or to uncomfortable diagnostic studies such as bone marrow biopsy.

2. Low-Dose Weekly Docetaxel (Taxotere) in Elderly Men with Prostate Cancer:  Rather than giving a standard dose of Taxotere every three weeks, which can be associated with low white blood cell counts, infection and excess fatigue, we evaluated 20 elderly men (average age 78) with a 1/3 dose of Taxotere administered weekly.  We found the anticancer effect to be maintained (twelve of the twenty men in the study had more than a 50% decline in PSA).  However, side effects were reduced: Only three of the patients stopped treatment for reasons of fatigue.  No patients experienced low blood counts or infections.

3. Using Splines* to Detect Changes in PSA Doubling Times: We collaborated with two mathematicians from UCLA, Robert Jennrich and Ray Redheffer, to develop a mathematical model for measuring the change in the rate of PSA rise after starting a new therapy.

4. Modified Citrus Pectin (MCP) Increases the Prostate-Specific Antigen Doubling Time in Men with Prostate Cancer: A Phase II Pilot Study:  This study used the statistical methods developed in the previous study to measure PSA doubling times before and after starting MCP. We showed a significant slowing in the rate of PSA rise in seven of the ten men who were administered MCP in the study.

5.  Long-Term Outcome for Men with Androgen Independent Prostate Cancer Treated with Ketoconazole and Hydrocortisone: Ketoconazole was the best treatment for men resistant to Casodex and Lupron before FDA approval of Zytiga and Xtandi. In 2005 we published a report of 78 patients showing PSA suppression for an average of 14.5 months.  Even longer responses occurred when treatment was initiated when men were in the earlier stages of androgen independence.

6. Intermittent Use of Testosterone Inactivating Pharmaceuticals (TIP) Using Finasteride Prolongs the Time Off Period: This study of 101 men treated with intermittent TIP reported a number of interesting findings: The “Holiday Period” after TIP is stopped is doubled [twice as prolonged] when finasteride (Proscar) is employed. Longer holiday periods were also associated with advanced age and lower Gleason score.

7.  Preventing and Treating the Side Effects of Testosterone Inactivating Pharmaceuticals in Men with Prostate Cancer: This article reviewed effective methods to reduce or eliminate common side effects of TIP such as fatigue, weakness, anemia, muscle loss, weight gain, penile atrophy, dry skin, breast enlargement, blood pressure changes, hot flashes, osteoporosis, joint aches and urinary symptoms.

8. Prostate Cancer-Specific Survival and Clinical Progression-Free Survival in Men with Prostate Cancer Treated Intermittently with Testosterone Inactivating Pharmaceuticals: 160 men were treated with TIP and monitored for survival over 10 years. We found that the single most powerful factor for predicting extended survival was to have attained a PSA less than 0.05 within eight months of starting TIP.

9. Primary Intermittent Androgen Deprivation as Initial Therapy for Men with Newly Diagnosed Prostate Cancer: This study was an observational report on 73 men who were eligible to have surgery or radiation but instead elected to initiate TIP. After an average observation period of 12 years, three men died of prostate cancer. Of the remaining 70 men, none developed metastasis. 28 men underwent delayed surgery or radiation. On average, the delayed surgery or radiation occurred 5.5 years after TIP was first initiated.

10. Primary Androgen Deprivation (AD) Followed by Active Surveillance (AS) for Newly Diagnosed Prostate Cancer (PC): A Retrospective Study:   This study evaluated 102 men treated with initial TIP to determine how often a single course of TIP for 12 months resulted in durable remission (defined as more than 7 years).  Durable remission occurred in 94% of men in the Low-Risk category, 47% of men with Intermediate-Risk prostate cancer and only 29% of men with High-Risk disease. There were no prostate cancer deaths.

Conclusion

One consistent theme in our published research is that stand-alone hormonal therapy is a reasonable option for men with Intermediate-Risk category prostate cancer. Men with Low-Risk disease are best managed with initial observation, i.e., without any initial therapy at all.  Men with High-Risk disease should be treated with a combination of TIP plus radiation.

Another important conclusion is that while the side effects of TIP can be managed, they tend to be more notable than the side effects of other popular treatments for Intermediate-Risk prostate cancer such as radioactive seed implants or intensity modulated radiation therapy (IMRT). The main exception being a somewhat lower risk of permanent erectile dysfunction with TIP compared to radiation.

Lastly, the overriding theme of all modern prostate cancer research is that over-enthusiasm for curative treatments that extend life must be tempered by the potential negative impact that treatment can have on quality of life.

* A “spline” is a bent line, i.e. a line with an angle. When rising PSA levels are represented graphically the dots can be connected creating a line.  If there is a change in the rate of rise, an angle in the line occurs.   

 

Nervous-Making Moments

BY RALPH BLUM

I’m interrupting my series of Blogs on “Stress” to give you a bulletin from the front. It concerns my latest PSA. It caught me off guard and gave me a bad moment.

I talk about these nervous-making moments often enough with men who contact me after reading “Snatchers.” But that’s them. This is me, my prostate.  And there it is: the sinking feeling in the gut, half-panic, half “Oh s--t!” Not that this toxic cocktail is new to me. But it is never quite something that even my long experience with prostate cancer never lets me to take in my stride.

This time, the moment is triggered by an email from Mark: 

Hi Ralph, 

I have been away on vacation.  Just got back.  Did anyone discuss your elevated PSA with you?  It was elevated to 26.  Can you give me a call today? 

Mark

I realized I had stopped breathing. No, no one has discussed my elevated PSA with me. 26! Ouch! In less than three months—for no reason I can think of—that’s up by more than 40%!

Dialing Mark, I thought what my friend, Harvey, would say: “Well, my PSA is 60—and I don’t even have a prostate! Consider yourself blessed. . . . You’re going to die in your sleep in 20 years after dinner out and a good movie.”  

Yeah, well, I still feel like I’ve eaten rotten fish.

Mark doesn’t sound concerned. He wants to know if I’ve noticed any symptoms of an enlarged prostate. No. Done any heavy lifting? Negative. “Well, let’s put you on an antibiotic for ten days—you tolerate Cipro alright—and then have you see Duke Bahn_for a Doppler MRI. He’s taking Medicare again. Then in about three weeks we’ll do a repeat PSA.”

Makes sense. But the panic is still there; the fear that perhaps I have tempted fate one too many times by not going for a cure.

When I tell my wife, Jeanne, who has a degree in Traditional Oriental Medicine and practices an ancient form of acupressure, her reaction is professional and predictable, but hardly comforting. “You’ve got to stop eating pork. And start eating tomatoes; you’re getting no lycopene. Diet, diet diet.”

And then it occurs to me: There may be an obvious explanation for the PSA spike.  I’ve had the flu for two weeks. Some fever along with the usual symptoms. Was that enough to spike my PSA? It happened once before when we were living in Hawaii. Or is this my body telling me it is finally time to do something?

I remember something Mark wrote in “Snatchers” that is somewhat reassuring: “How the cancer behaves over time is the most important predictor. It supersedes Gleason score, it supersedes stage and PSA. . . In your case, Ralph, we’ve had two decades to observe its behavior, and that behavior has to trump all the stats. 

In Mark’s experience, cancers do not tend to change their stripes after twenty years. “It’s like having new neighbors,” he once said. “With time you learn that they keep their property neat, that their dog won’t poop on your lawn, and that if you want to borrow a cup of sugar, sugar is what you’ll get. Well, the same with prostate cancer.”

Well, maybe prostate cancer has been my closest neighbor for long enough. I am once again in uncharted waters, and ultimately, there is risk in whatever I do. If I do nothing, I risk the cancer progressing. If I chose treatment, I risk unpleasant (or worse) side effects.

What’s the old-time carnival barker’s challenge? “You pays your money and you takes your choice.”

Time for long thoughts.