Treatment: Overview
IV.Factors to Consider when Deciding on Treatment
V.Information You Should Give Your Doctor
VI.Questions You Should Ask Your Doctor
I. Deciding on a Treatment
After the initial shock of being given a diagnosis of cancer, you will need to start grappling with decisions regarding treatment. The treatments outlined in this book include watchful waiting (where no specific therapy is undertaken), radical prostatectomy surgery and radiation therapy, either in the form of implantable seeds (brachytherapy) or external beam radiation in a number of forms.
It is prudent to take your time when making decisions about prostate cancer treatment. While patients are understandably stressed and distressed by their diagnoses, the good news is that prostate cancer is a relatively slow-growing cancer in the vast majority of cases. Once you have been biopsied, your surgeon will be able to tell you how many of the cores on the biopsy were positive and what the volume of cancer is within each core and in the entire set of specimens.
The pathologist will also grade the cancer. The grading system most frequently used is the Gleason grading system, which identifies the major and the minor patterns and is scored from 1 to 5, where 5 is the most aggressive cancer and 1 is the least aggressive cancer. The majority of men are in the Gleason 6 (3+3) range, a large number are 7 (3+4 or 4+3), very uncommonly we see Gleason 8, 9 and 10, and likewise, rarely do we see Gleason 5 or 4. Gleason cancers that are 5 or 6 are moderately differentiated. Gleason 7 cancers are deemed to be of intermediate aggressiveness, and Gleason 8, 9 and 10 are highly aggressive cancers. In general, the higher the Gleason grade, the greater the concern the physician will have about the prostate cancer growth.
It is important to understand that the vast majority of men who have prostate cancer are curable and may go on to live many years after treatment. These men may also live with the complications of their treatments. The literature comparing radiation, surgery and watchful waiting is largely murky. There is evidence from a large Swedish study that shows that there is a survival advantage to men undergoing radical prostatectomy. There is also evidence that seed implantation is less effective for patients with intermediate-or high-grade cancers, Gleason grades 7 through 10.
Only you and your partner, should you have one, can make the final decision. It is likely that a good physician will give you options and you will have to make decisions regarding these based on a risk-benefit analysis. Risk benefit analysis means that you will review the extent and the aggressiveness of the cancer and compare it to the side effects of the respective treatments.
II. Impact of Prostate Cancer Diagnosis on Sexual Function
I have outlined the mechanisms by which erections occur in the first chapter of this book, but to recap, blood flows into the penis under the stimulation of a chemical known as nitric oxide. Nitric oxide comes predominantly from the erection nerves and results in relaxation of the erectile tissue, which is combined smooth muscle and endothelium. Blood flows into the penis, the penis enlarges, the valve mechanism closes and erection occurs. Therefore, erection nerves, erection tissue and a properly functioning valve mechanism are critical to the generation of a good erection. The penis is kept flaccid during non-aroused states, and after orgasm it returns to flaccidity by the action of adrenaline. The erection nerves supply adrenaline, which is the most potent anti-erection chemical that exists. It is not unusual for a prostate cancer patient soon after diagnosis to experience fear, anger, stress, frustration, thus leading his life in a state of high adrenaline. In the bedroom, adrenaline is the enemy of good erections, and in this high-stressed state, it is very common for men to notice significant reduction in their erection hardness during sexual relations.
As previously stated, the confidence that a man has in his erectile ability is critical to his erectile function. Clinical experience has shown me that as men, we often believe that we are only as good as our last erection, and if our last erection is not good, the majority of men will walk into the bedroom on the next occasion remembering the failed attempt and being worried about the next attempt.This lack of confidence leads to high levels of adrenaline in the penis.This restricts blood flow into the penis,opens up the valve mechanism, and a man has difficulty getting an erection or just gets a short-lived erection (often this erection comes and goes during the sexual event). As many men take several months to make a final decision regarding treatment, they may experience several months of poor erections.
What is interesting about erectile dysfunction is that the longer it goes on, the greater the degree of distress, the greater the adrenaline level and the lower the confidence a man has in his erection. The typical male response to such a scenario is avoidance behavior, which often appears the same to a partner as a reduced libido. Men hate to fail, especially in the bedroom, and when a man lacks confidence in his ability to get and keep an erection, he will avoid any possible sexual encounter. Not only will he avoid sex, but he will also avoid any physical intimacy, such as kissing and cuddling and sometimes even hand-holding.The reason for this is simple. It is essentially ingrained in our male biology that such activities as adults often lead to a sexual scenario. Given the low level of confidence in such men, they are concerned that such activity will lead to sex, and they will be frustrated and embarrassed, and their partners will be upset. Thus, it is common in my practice to see couples after surgery where the partner complains about the absence of any physical attention by the other partners.
Adrenaline can also cause premature ejaculation. Secondary premature ejaculation is a condition where men acquire rapid ejaculation at some point later in life when they previously experienced normal ejaculation. One of the most common reasons for this in my practice is the presence of erectile dysfunction. Practically two-thirds of the patients in my practice who have lost erection sustaining capability have developed decreased ejaculation time. Once the erectile dysfunction is adequately treated, the majority of men will improve, if not completely correct, their ejaculatory function.
CASE HISTORY 1
Impact of Diagnosis of Prostate Cancer on Sexual Function
Brian is a 55–year-old man who is married to Joan, his 40–year-old wife. Brian is generally healthy, although he has mild high blood pressure for which he uses a medication. He has been having his PSA level checked annually for the past five years, and this has always been normal. His prostate exams have also been normal, but this year his family doctor found a nodule on the right side of his prostate. He was referred to his local urologist, who did prostate biopsies and found a small area of cancer within one of the cores. He had been trying to make up his mind whether he should proceed with watchful waiting, radical prostatectomy, or radiation therapy. He comes to see me saying that, over the course of the last month since the diagnosis of prostate cancer, his erections are worse. Prior to his diagnosis of prostate cancer, he says his erection hardness was a 10/10 and currently it is 6–7/10, just about good enough for penetration. He has also noticed that he has had a significant reduction in his sex drive. Hormone blood tests and a duplex Doppler ultrasound of his penis are both normal, suggesting that his erectile problems are psychologically based. He was prescribed Viagra and responded beautifully to this. Brian eventually chooses to undergo radical prostatectomy surgery.
This case history illustrates the negative impact of any stressor, including a new diagnosis of prostate cancer, on a man’s erectile function. Adrenaline, which is generated under stress, during anxiety or in association with frustration, has a potent negative impact on erectile function. The penile ultrasound demonstrate normal blood flow confirms the diagnosis of psychologically based erection problems. This case also illustrates the negative impact of erection problems on a man’s libido; roughly two-thirds of men having erection problems will have loss of libido also. His normal testosterone blood test confirms that there is no hormonal cause for his low sex drive.
Some men may experience the exact
