Who Asked You for Your Opinion Anyway?

BY RALPH BLUM

Unsolicited Advice from Survivors for the Newly Diagnosed

In 2014, approximately 233,000 men in the U.S. were told they had prostate cancer and to many of them it sounded at best, like the end of their sex life, and at worst like a death threat. In reality, the majority of them turned out to have an indolent form of the disease that was not life threatening and could safely be monitored without any immediate treatment.

 

Having said that, a diagnosis of prostate cancer is not a walk in the park. Just when you are most vulnerable you are obliged to confront so much complex and conflicting information that to say it leaves you reeling would be an understatement. So your first and most important decision is not to make a pressured decision, not to rush the treatment selection process or allow anyone else—including any doctors you consult—to rush you into undergoing an irreversible treatment until the shock has worn off and you have had time to carefully analyze all the data that applies to your particular case.

 

The first step after being diagnosed is to understand the concepts of staging and grading. The grade of your cancer will tell you how aggressive the cancer cells are. The stage tells you how extensive or advanced the cancer is. This information, together with your PSA level, will help determine your prostate cancer’s risk factor—whether you are in the low-risk, intermediate-risk, or high-risk category.

 

If your cancer is low-risk it can be safely monitored with “active surveillance” and does not require any immediate treatment.  If you are in the intermediate-risk category, you have many treatment choices, and in order to make the best decision you will need to get opinions from specialists with state-of-the-art knowledge.

 

You will already have seen a urologist who, if you are a candidate for surgery, is likely to have recommended a prostatectomy. If this is the case, it is essential to ask him the tough questions: What are the risks? How many prostatectomies has he performed overall and how many has he done in the past twelve months? Does he perform nerve-sparing surgery, and if so what is his success rate with preservation of potency and continence? And if you are over seventy, please consider prioritizing  almost any other treatment option ahead of  going through a major surgical procedure.

 

Before making a treatment decision you should consult a radiation oncologist about brachytherapy (radioactive seed implantation), and IMRT (Intensity Modulated Radiation Therapy), a precisely targeted type of radiation that delivers high doses to the prostate without damaging surrounding organs. In my opinion both these options are at least as effective as surgery at curing the disease and both are associated with significantly lower risk of long-term toxicity.

 

You should also consult a medical oncologist about hormone therapy, a treatment that blocks the male hormone testosterone and significantly slows the spread of the cancer, often for years. Hormone therapy does not promise a cure, but it is a viable, non-invasive alternative to surgery, an effective delaying action. A medical oncologist is a good doctor to consult with as they have no vested interest in either surgery or radiation and can often be helpful in sorting out the conflicting opinions you likely have heard.

 

If your cancer is in the high-risk category you will usually need two or more different kinds of treatment—probably hormone therapy plus radiation. Some centers even may mention chemotherapy such as commonly done for patients with colon cancer or for women with breast cancer.  And there are many new treatment methods in the pipeline, so even if your cancer is aggressive, you are not looking at an imminent death threat.

 

So do your research and take your choice. And always remember: Prostate cancer is about the best possible cancer to deal with.

Selecting Prostate Cancer Treatment

BY MARK SCHOLZ, MD

"You mean you have never heard of diffusion-weighted imaging” Exclaimed a recently-diagnosed prostate cancer patient to his doctor.  How could his doctor be unacquainted with this important aspect of modern prostate imaging? It’s shocking when a patient realizes he possesses more medical information than the “expert.” 

No One Can Be an Expert in Everything
Actually, in this modern era, this situation is being encountered more and more frequently. It’s not so surprising when considering the explosive growth rate of new medical information. It’s humanly impossible for anyone to stay abreast of every new medical development.  For example, even though urologists “specialize” in diseases of the urinary system, their area of responsibility demands expertise in a wide variety of unrelated but important areas such as urinary infections, prostate enlargement, prostate infections, sexual dysfunction and kidney stones. They also have to be expert at the surgical treatment of such problems as congenital defects, bladder cancer, testicular cancer and kidney cancer… just to name a few.

Prostate Cancer by Itself is Quite Complex
Prostate cancer alone is intricate enough to keep a specialist occupied full time. For example, simply staging prostate cancer is complicated. Prostate cancer staging uses a multimodality profiling system that estimates the likelihood of microscopic metastases outside the prostate using PSA, Gleason grade, and a percentage of cancer-containing biopsy cores.  Now, new imaging techniques are providing further information about the size and location of the cancer within the prostate gland. And even more recently molecular profiling has become commercially available.  Staging prostate cancer properly has become a continually developing art form.

Seeking Advice—Delivered from a Level Playing Field
Equally important is the need to seek out unbiased treatment advice. Unfortunately, the process of rendering advice about treatment options is usually very slanted. Urologists (who are surgeons) usually recommend surgery.  Radiation therapists usually recommend radiation. This is not to imply that these physicians have less than the best intentions.  Over time they just become convinced that what they do is the best option for their patients who are consulting them.

What You Don’t Know Can Hurt You
The number of treatments available for men with newly-diagnosed disease is rapidly expanding.  For example, what was previously known simply as “radiation” now includes IMRT, Proton therapy, Cyberknife, two types of Brachytherapy as well as various combinations of these different radiation modalities.  Hormone therapy options have now expanded beyond traditional Casodex and Lupron to include Zytiga and Xtandi. The management of the potential side effects of hormone therapy requires special training in diet physical fitness, bone integrity and sexual health to limit the risk of lingering damage after treatment is completed. These days, relapsed or advanced prostate cancer requires physicians who are conversant in genetic typing, modern PET scans, immunotherapy and injectable radiation.

Every Journey Begins with a Single Step
So newly diagnosed prostate cancer patients are faced with daunting situation. Clearly there is no simple answer to this tangle of complicated issues. However, the newly diagnosed cancer patient is far from helpless. He has two overriding responsibilities. First, he must learn as many facts as possible by getting thoroughly educated about the different treatments for his specific type of prostate cancer. Second, he must use discernment in the selection of which physicians to consult.

There is Time to Learn
With prostate cancer there is rarely a need to rush into making a treatment decision because it is usually slow growing.  There is plenty of time for the shock of diagnosis to wear off, giving you enough time to get educated about the scientific facts.  Published studies comparing outcomes are available. The PCRI in particular publishes articles that translate scientific information into a patient-friendly format.  Ultimately, all claims about treatment should be supported by references published in the scientific literature.  Selecting treatment for prostate cancer is a high stakes proposition, potentially risking sexual function, urinary function, even life itself.  I want to encourage patients to take a leadership role in the treatment-selection process.

Surgery vs. Seeds vs. IMRT

BY MARK SCHOLZ, MD

 

Many men with Intermediate-Risk prostate cancer consider treatment with radiation or surgery. Treatment selection is influenced by age and preexisting status, especially as regards baseline sexual and urinary function. These days “surgery” usually means robotic surgery rather than the older, “open” procedure. Brachytherapy (radioactive seeds), and intensity modulated radiation (IMRT) are the most widely used types of radiation.

 

Cure Rates

All treatment options result in similar cure rates assuming the best physicians and technology are used. If any single treatment can be considered to have a slight advantage, it is brachytherapy. Seed implants deliver a somewhat higher dose of radiation, possibly with slightly better accuracy. All types of radiation have a slight cure-rate advantage over surgery because radiation treats a small margin around the gland. Surgery, especially when extra-capsular disease is present, may leave cancer behind, an unfortuante situation called “a positive margin.”

 

Quality of Life

Since cure rates are equivalent, the main criteria for selecting treatment are side effects. Table 1 lists the risks faced by a 65-year-old with good erectile function and without preexisting prostate problems. Risks are adjusted up or down based on a man’s age and his sexual and urinary function prior to treatment.
 

Table 1 Long Term Side Effects

Impotence Incontinence Climacturia* Urethritis Stricture** Proctitis Surgery 50% 8% 15% - 5% - Seeds 30% 1% - 10% 2% 1% IMRT 30% 1% - 4% 2% 2% *Climacturia is the ejaculation of urine rather than sperm **Stricture is a urethral scar

Short Term Side Effects
Some of the long-term effects noted in Table 1 also occur short term. All men are impotent after surgery though 50% eventually recover some functionality. Urinary symptoms, termed “urethritis,” occur in two-thirds of men who undergo brachytherapy, usually lasting a couple months. Proctitis symptoms lasting one to two months occur in about half of the men who are treated with IMRT.

Treatment for Long Term Side Effects

Shrinkage and shortening of the penis due to surgery may be partially averted with early use of Viagra, Cialis or Levitra, and when necessary, the injection of prostaglandins. For treating impotence or incontinence, patient satisfaction is about 85% with a surgically implanted penile prosthesis and 60% with a surgically implanted artificial urinary sphincter. Chronic urethritis, a non-healing radiation burn of the urinary passage, manifests as pain, frequent urination, and a compelling urge to urinate right now. Proctitis side effects can be described similarly, but affecting the rectum. Palliative treatments for chronic urethritis and proctitis are only partially effective.

 

Further Aspects of Surgery and Radiation

 

Surgery: The surgical skill of urologists varies and is measured by how frequently cancer is left behind after the surgery, termed a positive margin. The best surgeons average a 10% rate. Studies show that many urologists, even at reputable centers, leave cancer behind up to 50% of the time. Prostate removal gives information about the size and grade of the cancer, helping to improve the accuracy of projections about future relapse. Surgery also simplifies PSA monitoring, since unlike radiation, there is no residual prostate gland producing PSA.

Seeds: Brachytherapy with permanent seeds is an outpatient procedure. Temporary, high-dose-rate (HDR) brachytherapy requires an overnight stay in the hospital. Men with preexisting urinary problems or glands over 60cc are more prone to develop urethritis from brachytherapy. A benign PSA rise after the implant, termed a “PSA Bump,” occurs in 30% of men and can engender considerable anxiety.

IMRT treatment requires two months to deliver. Radiation beaming through surrounding organs may increase the risk of bladder and rectal tumors, though the risk is clearly less than one percent. The biggest risk besides impotence is proctitis. In the future, the injection of hydrogel between the prostate and the rectal wall may eliminate this risk (Hydrogel is pending FDA approval).

Cyberknife and Proton Therapy: Cyberknife is like IMRT but treatment is over one to two weeks rather than two months. Proton therapy is also similar to IMRT except it fires heavier subatomic particles (proton vs. photon). Proctitis rates are reported to be slightly higher with either of these two modalities.

Combination Radiation with Seeds and IMRT: Men with High-Risk disease and even some with Intermediate-Risk are treated with a combination of Seeds and IMRT. The side effects of Seed/IMRT combinations are similar to those of seeds alone.

The Outdated Sequencing Argument
As stated at the outset, cure rates are high with both radiation and surgery. Arguments touting surgery as the “Gold Standard” were true ten years ago when suboptimal radiation resulted in lower cure rates. Regrettably, to this day, many surgeons are still claiming that sequencing surgery before radiation is advantageous. This outdated thinking prioritizes planning for relapse, forgetting about the need to focus on quality of life. The goal is to be cured with the first treatment and be spared the side effects of additional rounds of therapy.

Taking Time to Decide
Prostate cancer is slow moving condition. There is no need rush to a decision. Radiation or surgery cures men with Intermediate-Riskprostate cancer 70-90% of the time. Even if a relapse occurs, salvage therapy usually gives a normal life expectancy. Additional options, besides surgery and radiation, can also be considered for men in the Intermediate-Risk category including active surveillance, focal therapy and intermittent hormone blockade. However, these treatments are outside the medical mainstream and beyond the scope of this short blog.

 

Erection? Who said “Erection?”

BY RALPH BLUM

Although most men, when they are diagnosed with prostate cancer, are primarily concerned with staying alive, there is a surprisingly large constituency who, as my psychiatrist friend put it “vote with their dicks.” For these men, not being able to have an erection is literally a fate more awful than death. But for almost all of us, the degree to which sexual function returns—or fails to return—is a matter of serious concern.

The three basic questions doctors hear when discussing treatment options are:

Will it cure me?

Will I have to wear diapers?
And the big one:  Will I be able to get an erection?

No doctor can answer any of these questions with an unequivocal “Yes.” The reality is that there are no guarantees. It’s a tough call whether to go for a cure, or for quality of life—which for many of us means being able to get an erection.

“I gotta tell you, Betsy is so much younger than I am. She’s right at the peak of her sexuality,” my friend Calvin pointed out. “My ability to perform still matters a lot to her. And there are plenty of folks like us—the May and September couples. Far as I’m concerned, quality of life isn’t an option. It’s the name of the game."

 

Compared to other treatment options such as active surveillance or hormone therapy, surgery and radiation have one clear advantage: closure. But surgery is also the chief culprit when it comes to ruining your sex life. The nerve bundles that control erections are located perilously close to the prostate gland, so you’re cutting past a lot of delicate apparatus, and even with nerve-sparing surgery performed by an experienced and talented surgeon, it’s very easy for things to go wrong. Once those nerve bundles are cut, it’s goodbye to erections.

However, the two modern radiation options—permanently implanted radioactive seeds (Brachytherapy) and intensity modulated radiation therapy (IMRT)—are at least as effective as surgery at curing the disease. And more importantly, the precise targeting means less risk of “collateral damage.” In other words, Calvin has a better chance of keeping Betsy happy—especially with a little help from the wonders of modern pharmacology.  Calvin and Viagra are now wedded at the hip!

 

According to the TV commercials, part of the cure for erectile dysfunction appears to be lounging with your sweetie in adjacent bathtubs while holding hands and watching the sunset. Providing, of course, you have taken the pill that does increase blood flow to your penis.

 

Bottom line: While the use of Viagra and Cialis to prevent ED after treatment is still not totally proven, and despite the fact that these pills can be very expensive, most of us guys, when we find out that using them will probably contribute to sustaining our long term sexual function and keeping the physical side of our relationships sweet and nourishing, we feel that using these pills regularly is a must. Like an insurance policy for intimacy.