would be problematic for their businesses. Under these circumstances, these men may consider robotic prostatectomy, after which they can get back to work sooner, perhaps within the week depending on the line of work they are in, or they may choose to undergo seed implantation, which is a one-day procedure, for the same reason. For the same reason, having external beam radiation therapy over the course of two months may also be significantly burdensome from a job standpoint. For men who are very physically active and who do not want to take a break in this activity, then seed implantation is a reasonable option. However, the majority of patients with prostate cancer are going to put their prostate cancer therapy ahead of everything else, including their careers, and taking a few weeks to recuperate from surgery is usually not a major concern for most men.
V. Information You Should Give Your Doctor
Whether you see one, two, or 10 doctors for a discussion regarding prostate cancer treatment, the information that you give them may significantly impact upon their advice to you regarding your management. Under these circumstances it is important that you are totally honest with the physician, whether surgeon, radiation therapist or medical oncologist, as his or her decision may vary based on your medical history and profile. These discussions are not the time and place to bury information regarding your medical history. Be honest and forthright with the physician and do not be afraid to ask questions and challenge the physician. Many physicians are put off by patients who walk into the office with large numbers of medical papers under their arms who have been on the internet daily for weeks and come in with a barrage of questions. Even though physicians are under major time constraints in the current health care environment, these conversations do not have to be completed in one session. In fact, it is not unreasonable for you to return to the same physician to ask more questions after your first discussion. Physicians who become defensive or argumentative are probably not a good match for you as a patient. However, it is worthwhile for you to be considerate of the physician and listen to what he or she has to say in response to each question before asking your next question. Prioritize your questions and keep less important ones for a second or third visit.
Besides your prior medical, surgical and medication history, getting the message across to your physician how important your urinary and sexual function is in the future is critical to him or her making a recommendation to you (Table 2). Many a physician will have a script (speech) to use for patients who walk into the office and will give you this spiel during your time with him or her. However, I advocate that all patients be proactive in their discussions with physicians regarding prostate cancer therapy and what is right for them as individuals.
There is no reason in the world why you cannot bring notes to make sure that all of your questions are answered if time allows, and likewise, it is perfectly reasonable for you to take notes during the discussion. Occasionally I have patients who come into the office with voice recorders so that they can go over the information given to them by physicians. Some physicians are turned off by this. I personally have no problem with it, and this is something for you to consider. If you do bring a recorder, it is always a courtesy to ask the physician if he or she would mind you using it to record the conversation. This is particularly useful if your partner could not come to the appointment with you.
Having confidence in your physician, irrespective of his or her specialty, is critical to your long-term satisfaction. It is important that you give informed consent for whichever procedure you choose, and so you should get an excellent feel from the physician what each of these procedures entails and what you are to expect. Often a patient bonds with a physician and chooses therapy based on this. However, whether you like your doctor or whether he or she is a nice person should be secondary to his or her experience and expertise in the management of prostate cancer. If any physician discourages you from having a second opinion be very wary. Expert physicians frequently see patients who have seen several other physicians for the treatment of a problem and should be accustomed to this.
Table 2 • Questions You May Be Asked by a Doctor about Your Sexual Health
| •For how long have you had difficulties? •Were these difficulties sudden or gradual in onset? •Have the difficulties been getting worse? •How often do you have sex with a partner? •How often do you masturbate? •How hard does your penis get during sex/masturbation? •Is there a difference in erection hardness between sex and masturbation? •How difficult is it for you to get an erection? •How difficult is it to maintain an erection? •How often do you fail to penetrate because you lose the erection? •Is erection painful for you? •Is penetration painful for your partner? •Does your penis bend/curve? •Do you ejaculate (semen)? •Do you ever see blood in your semen? •Do you have an orgasm (climax)? •Is it difficult for you to achieve an orgasm (climax)? •Is orgasm painful? •Do you leak urine at orgasm? •Have you noticed any loss of penis length? •How would you grade your sex drive? •How would you grade your partner’s sex drive? |
Having your partner with you if you have one is sometimes helpful. Indeed, even having a family member with you, if you are comfortable discussing urinary and sexual issues in front of them, is of some benefit. I tell patients that most patients remember no more than 50% of what is said to them during a medical interview and if the patient has somebody with them, then that will probably increase the amount of the discussion that is remembered. Under the stress of the diagnosis of prostate cancer and discussion regarding incontinence and erectile function, patients often forget what is told to them. If all the ground has not been covered in a single encounter, then a return visit to that physician is definitely worthwhile. Many physicians will be reluctant to conduct such a conversation by phone as a face-to-face encounter is usually far more effective in communicating key issues.
VI. Questions You Should Ask Your Doctor
Patients often ask us what would we do if we were in their shoes. This is not a useful question, particularly in the setting of prostate cancer. Unless the physician has had prostate cancer himself which has been treated, it is not likely that this question will yield any useful information. However, asking the physician what he or she would recommend to his or her brother or father is sometimes valuable. Remember that physicians are human and they will have biases toward or against particular treatments. It is important that you be the judge when talking to the physician.
Experience is a critical factor in outcome, particularly when it comes to sexual and urinary function recovery. So simply asking the physician how many brachytherapies, external beam radiation treatments or radical prostatectomies he or she has performed annually is a good starting point. Another major factor is how long he or she has been doing this. It is well recognized that there is a learning curve in all of these treatments. For example, it is recognized that the positive margin (some cancer cells left behind) rates at the time of radical prostatectomy are higher during a surgeon’s first 100 prostatectomies compared to those during surgeries performed afterwards. So if a surgeon is performing 20 prostatectomies a year, which is a significant number, and has only been doing it for a couple of years, then this is not the same level of experience as somebody who does 20 a year but has been doing it for a decade.
It is also worth asking about or finding out about the physician’s training, including the center he or she trained at and who he or she trained under. The experience with radical prostatectomy surgery or prostate radiation is highly variable from one residency training program to another. Asking your physician about his or her change in philosophy over time is also potentially useful. For example, for a physician who has been in practice for 10 years, has he or she changed his or her opinion regarding the role of prostatectomy versus brachytherapy if he or she is a urologist, or if your physician a radiation oncologist, has he or she changed their opinion regarding seed implantation versus IMRT? This may give you
