Biting the Bullet

BY RALPH BLUM

The idea of  “biting the bullet”—enduring a painful or otherwise unpleasant situation that is seen as unavoidable—has a lot of history in the folklore of American cowboys, Indian soldiers and other embattled warriors. I found the first literary reference to the phrase in Rudyard Kipling’s 1891 novel, The Light that Failed.” As a call to courage under duress, the Kipling character advises his wavering friend, “'Bite on the bullet, old man, and don't let them think you're afraid.” By 1926, the term had moved from the battlefield to the drawing rooms of upper class England in P.G. Wodehouse’s comic novel The Inimitable Jeeves, with Bertie Wooster advising Jeeves, “Brace up and bite the bullet. I’m afraid I have bad news for you.” 

For me, the “bullet” is the decision (after almost 25 years of living with prostate cancer with only one brief excursion into hormone therapy) to give up active surveillance and undergo some form of more radical treatment. My lurking fear is that whatever treatment I choose could produce significant “collateral damage.” That’s the downside. The upside is the possibility of a cure.

This uncertainty is nothing new. Many years ago, I decided that for me, surgery was not an option. I had interviewed too many men who, after surgery, found themselves living with irreversible side-effects, or worst case scenario, on chemo and miserable when the cancer had returned. (The irony of attacking the cancer with a deadly poison was not lost on me.

Then one day, when I was doing research on the two most effective radiation options—seed implants, and intensity modulated radiation therapy (IMRT)— Mark Scholz said, “You still could go for a knockout with IMRT. It’s the best treatment choice in your case. You might want to check it out.” For “knockout” read “cure.”  And frankly, I am worn down from co-existing with prostate cancer.

So it’s time to move on. The cancer has been in the right seminal vesicle for over five years. Which to many urologists means out of the capsule, and therefore likely to be heading for my bones. Plus even though Combidex testing indicated that the lymph system was clean, that was four years ago!

What is measurably different in my situation? I can think of three things that weigh on my thinking. For a start, I am almost a quarter of a century older than when I was first diagnosed. Second, my 80 year old immune system may no longer be the potent ally it was when I began the “watchful waiting” protocol. And third—and most chilling—for no obvious reason, my PSA has just spiked from 14 to above 34.

Considering Mark’s advice, I realize that my generation is blessed to have Medicare in its undiminished form. Add to that a chunk of backup insurance offered by AARP. So for less than $500 a month, I am covered for almost any situation. Which is hugely lucky, since IMRT, the treatment on which I am about to embark, will cost the taxpayers around of $500 per treatment—of which there will be 44!

I am not looking forward to starting the treatments, but of all the four-letter words in the language, the word “cure” is most appealing one to me right now.

Time to bite the bullet.

Xofigo—A Wonderful New Treatment for Men with Advanced Prostate Cancer

BY MARK SCHOLZ, MD

It’s a special event when the FDA approves a new treatment.  Xofigo, otherwise known as Radium 223 or Alpharadin, is now commercially available.  The FDA approved Xofigo based on the results of a large, prospective, placebo-controlled trial that demonstrated significantly greater survival in Xofigo-treated men compared to placebo-treated men.  The trial also shows a very low incidence of side effects and good relief of bone pain. The treatment is easy to administer, consisting of monthly intravenous injections.

How Xofigo Works
Cancer treatment falls into four major categories. Chemotherapy selectively targets fast growing cells. Unfortunately, since chemotherapy works as a nonspecific cell poison, it frequently causes prominent side effects. Hormonal and targeted agents work by blocking the internal mechanisms of the cancer cell, thus forestalling growth. These treatments tend to have fewer side effects than chemotherapy.  However, by nature cancers are genetically variable, so resistant clones eventually appear. Immunotherapy stimulates the patient’s immune system. New forms of immunotherapy are promising and development is progressing very rapidly but this area of study is still in its infancy. Lastly, there is radiation consists of high energy particles that blast cellular DNA. A cancer cell with disabled DNA can’t reproduce.

Radiation needs to be given in a dosage sufficiently large enough to be effective. However, it also has to be targeted accurately to spare the surrounding healthy tissue. Xofigo addresses both of these demands elegantly. In terms of power, just one of the alpha particles emitted by radium 223 can cause irreversible cell damage because alpha particles are large enough to sever double-stranded DNA (typical beam radiation with photons requires multiple hits on DNA because it only damages one of the two DNA strands).

Xofigo Targets the Bone Metastasis
When cancer invades the calcium matrix of the bone it stimulates the bone to accelerate its rate of calcium uptake.  Radium 223 has structural similarities to calcium so Xofigo is “mistakenly” taken up by the bone cells adjacent to the cancer in lieu of calcium. So after Xofigo is injected, it travels through the blood stream and concentrates in the irritated areas of the bone where the cancer is most active.

Xofigo would be effective against almost any type of cancer since most cancers that spread to the bone increase calcium turnover in the bone cells adjacent to the cancer. However, the manufacturers and distributors, Algeta and Bayer Pharmaceuticals, were wise to seek FDA approval for prostate cancer before pursuing development in other types of cancer. Prostate cancer has an extremely fastidious pattern of spread. Metastases occur almost exclusively in bone. The major organs like lung, liver, kidney or brain are almost always spared. Since prostate cancer spreads almost exclusively to bone, Xofigo targets most if not all of the disease.

Alpha Particles Only Travel a Few Micrometers
To most everyone, the thought of radiation easily conjures up horrible visions of toxicity. The concept of radiation by injection is not new. Strontium and samarium are two radioactive elements that also concentrate in areas of increased bone activity. However, they emit a different type of radiation, beta radiation, which acts over a much longer distance and induces collateral damage to the surrounding cells in the bone marrow, the cells of the all-important immune system. Fortunately, bone marrow toxicity appears to be rare in men treated with Xofigo because alpha particles characteristically dissipate over the distance of a couple of micrometers, restricting the radiation effect to the active area of the cancer where it is invading on the surface of the bone.

Potent, Highly-Targeted Therapy—Just What the Doctor Ordered
Advanced prostate cancer in the bones eventually becomes resistant to other treatments. Historically, external beam radiation therapy has been a potent method for killing cancer cells, particularly to control pain, when the effectiveness of other options seems to be failing. However, beam radiation must be used very judiciously because it also causes irreversible damage to the surrounding bone marrow. Xofigo is likely to rapidly gain widespread acceptance with both doctors and patients because it simultaneously targets multiple metastases yet spares the closely adjacent bone marrow.

Value of a Single erection

BY RALPH BLUM

For many men who have trouble achieving potency— keeping an erection firm enough for sex—erection dysfunction (ED) medications--Viagra, Cialis, Levitra--work well and cause few side effects.

Sildenfil (Viagra), vardenfil (Levitra), and tadalafil (Cialis) are all medications that reverse ED by increasing nitric oxide, a chemical naturally produced by the body that opens and relaxes the blood vessels in the penis. While helping to get and keep an erection, these medications do not increase sex drive, and only cause erections if you are sexually stimulated.

In an article in My Generation magazine, Hal Ackerman wrote that after 12 months of hormone-deprivation therapy, his libido was totally gone, an empty balloon, with the result that women whose bodies in the past would have stimulated longing and desire, generated no more response than the sight of uncovered furniture. However Ackerman claims that “via the miracle of modern pharmacology” he was able to perform sex with his new girlfriend for her pleasure—though with little personal gratification.

Although they work in similar ways, each of the ED medications has a slightly different chemical make-up. These minor differences affect the way each medication works, such as how quickly it takes effect and wears off, as well as the potential side effects.

Viagra and Levitra can be taken without food, no more than once a day, about 30-50 minutes before sex, and are effective up to 5 hours. Cialis can be taken as a small daily dose, anytime, with or without food, and is effective anytime between doses. The 36 hour Cialis can be taken with or without food, no more than once a day, about 30 minutes before sex, and is effective for up to 36 hours.

Not all men can take these ED medications. They may not be safe if you have any kind of heart problems, high or low blood pressure that is not controlled, a history of stroke within the last six months, eye problems, severe liver disease, or kidney disease. Always check with your doctor, and be sure he knows any other drugs you are taking as ED medications can interact dangerously with a number of other drugs—including alpha blockers, antibiotics, anti-seizure drugs, blood thinners, and various heart medications. And a final caveat: as I wrote in a previous blog, if you have had a prostatectomy, ED medications only work if the nerves located close to the prostate have not been removed or damaged.

Most men who take Viagra, Levitra or Cialis are not bothered by side effects, but when they do occur they can include headache, flushing (Viagra and Levitra), indigestion, stuffy or runny nose, back pain and muscle aches (Cialis), temporary vision changes (Viagra and Levitra), and rarely, dizziness or fainting. Also rarely, priapism (an erection that doesn’t go away) can occur and requires medical treatment.

ED medications can be purchased over the Internet, but beware of scams. Check to see if an online pharmacy is legitimate—never order drugs if the pharmacy gives no phone number, if prices seem too good to be true, or if you are told no prescription is necessary. Make sure you get the exact dose and type prescribed by your doctor. And don’t be fooled into buying “herbal” or non-prescription equivalents. They are not as effective, and some can contain harmful substances. You may find yourself paying as much as $20 per dose. But then some of us would consider the restoration of potency a bargain at twice the price.

Potency

BY RALPH BLUM

One of the most worrying questions men diagnosed with prostate cancer face is: What are my chances of losing sexual function after treatment? The truth is all forms of prostate cancer treatment carry significant risk of impotence—defined as the inability to maintain an erection hard enough to penetrate. However, your chances vary greatly depending on a number of factors including your age, general health, potency prior to treatment, PSA levels, and last but not least, your treatment choice. Not surprisingly, regardless of which treatment they choose, older men whose sexual function is already low have the worst chance of good results.

While some men are willing to choose a therapy that offers a shorter life expectancy but better potency following treatment, for others the most important factor is curing the cancer. As one man said, “If you’re not alive, you don’t have to worry about sex.” Clearly it is a very individual choice as each man experiences sexual dysfunction in a profoundly personal way.

Since most men treated for early-stage prostate cancer typically live for decades, the choice of treatment is of paramount importance when it comes to quality of life issues. Surgery is still the preferred treatment for many men. But being operated on by less than the very finest surgeon dramatically increases the chances of impotence. The popularity of robotic surgery would lead one to believe that extensive studies have shown superior results compared to the traditional prostatectomy. However, according to Dr. Michael Barry of Massachusetts General Hospital in Boston and President of the Foundation for Informed Decision Making, it is not yet clear whether a robot-assisted laparoscopic prostatectomy is better or worse for maintaining sexual function than the older surgical techniques.

If retaining potency is your primary goal, IMRT or brachytherapy appear to give you the best results.  However, Dr. Durado Brooks, prostate cancer director for the American Cancer Society, cautions that sexual problems can show up later for men who also have either type of radiation therapy.

If you are like the gentleman in his early eighties who told me, “I’d rather be dead than unable to have another erection,” there are no easy answers. As far as I am concerned, the monastery beckons.