What Will Happen After Treatment for Prostate Cancer?

Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer.

It may take a while before your confidence in your own recovery begins to feel real and your fears are somewhat relieved. You can learn more about what to look for and how to learn to live with the possibility of cancer coming back in the American Cancer Society document, Living with Uncertainty: The Fear of Cancer Recurrence, available at: (1-800-227-2345).


Follow-up care

After treatment for prostate cancer, your doctor will want to watch you carefully, checking to see if your cancer recurs or spreads further. Your doctor should also outline a follow-up plan. This plan usually includes regular doctor visits, PSA blood tests, and digital rectal exams, which will likely begin within a few months of finishing treatment. Most doctors recommend PSA tests about every 6 months for the first 5 years after treatment, and at least yearly after that. Bone scans or other imaging tests may also be done, depending on your medical situation. This is the time for you to ask your health care team any questions you need answered and to discuss any concerns you might have.

Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be permanent. Don't hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them.

It is also important to keep medical insurance. Even though no one wants to think of their cancer coming back, it is always a possibility. If it happens, the last thing you want is to have to worry about paying for treatment. Should your cancer come back the American Cancer Society document, When Your Cancer Comes Back: Cancer Recurrence gives you information on how to manage and cope with this phase of your treatment. You can get this document by calling: (1-800-227-2345).

Prostate cancer can recur many years after initial treatment, which is why it is important to keep regular doctor visits and report any new symptoms (such as bone pain or problems with urination). Should your prostate cancer come back, your treatment options will depend on where it is thought to be located and what types of treatment you've already had. For more information, see the section, "How is prostate cancer treated?"


Seeing a new doctor

At some point after your cancer diagnosis and treatment, you may find yourself in the office of a new doctor. Your original doctor may have moved or retired, or you may have moved or changed doctors for some reason. It is important that you be able to give your new doctor the exact details of your diagnosis and treatment. Make sure you have the following information handy:

*A copy of your pathology report from any biopsy or surgery

* If you had surgery, a copy of your operative report

* If you had radiation therapy, a copy of your treatment summary

* If you were hospitalized, a copy of the discharge summary that every doctor must prepare when patients are sent home from the hospital

* Finally, since some drugs can have long-term side effects, a list of your drugs, drug doses, and when you took them

Lifestyle changes to consider during and after treatment

Having cancer and dealing with treatment can be time-consuming and emotionally draining, but it can also be a time to look at your life in new ways. Maybe you are thinking about how to improve your health over the long term. Some people even begin this process during cancer treatment.


Make healthier choices

Think about your life before you learned you had cancer. Were there things you did that might have made you less healthy? Maybe you drank too much alcohol, or ate more than you needed, or smoked, or didn't exercise very often. Emotionally, maybe you kept your feelings bottled up, or maybe you let stressful situations go on too long.

Now is not the time to feel guilty or to blame yourself. However, you can start making changes today that can have positive effects for the rest of your life. Not only will you feel better but you will also be healthier. What better time than now to take advantage of the motivation you have as a result of going through a life-changing experience like having cancer?

You can start by working on those things that you feel most concerned about. Get help with those that are harder for you. For instance, if you are thinking about quitting smoking and need help, call the American Cancer Society's Quitline® tobacco cessation program at: (1-800-227-2345).


Diet and nutrition

Eating right can be a challenge for anyone, but it can get even tougher during and after cancer treatment. For instance, treatment often may change your sense of taste. Nausea can be a problem. You may lose your appetite for a while and lose weight when you don't want to. On the other hand, some people gain weight even without eating more. This can be frustrating, too.

If you are losing weight or have taste problems during treatment, do the best you can with eating and remember that these problems usually improve over time. You may want to ask your cancer team for a referral to a dietitian, an expert in nutrition who can give you ideas on how to fight some of the side effects of your treatment. You may also find it helps to eat small portions every 2 to 3 hours until you feel better and can go back to a more normal schedule.

One of the best things you can do after treatment is to put healthy eating habits into place. You will be surprised at the long-term benefits of some simple changes, like increasing the variety of healthy foods you eat. Try to eat 5 or more servings of vegetables and fruits each day. Choose whole grain foods instead of white flour and sugars. Try to limit meats that are high in fat. Cut back on processed meats like hot dogs, bologna, and bacon. Get rid of them altogether if you can. If you drink alcohol, limit yourself to 1 or 2 drinks a day at the most. And don't forget to get some type of regular exercise. The combination of a good diet and regular exercise will help you maintain a healthy weight and keep you feeling more energetic.


Rest, fatigue, work, and exercise

Fatigue is a very common symptom in people being treated for cancer. This is often not an ordinary type of tiredness but a "bone-weary" exhaustion that doesn't get better with rest. For some, this fatigue lasts a long time after treatment, and can discourage them from physical activity.

However, exercise can actually help you reduce fatigue. Studies have shown that patients who follow an exercise program tailored to their personal needs feel physically and emotionally improved and can cope better.

If you are ill and need to be on bed rest during treatment, it is normal to expect your fitness, endurance, and muscle strength to decline some. Physical therapy can help you maintain strength and range of motion in your muscles, which can help fight fatigue and the sense of depression that sometimes comes with feeling so tired.

Any program of physical activity should fit your own situation. An older person who has never exercised will not be able to take on the same amount of exercise as a 20-year-old who plays tennis 3 times a week. If you haven't exercised in a few years but can still get around, you may want to think about taking short walks.

Talk with your health care team before starting, and get their opinion about your exercise plans. Then, try to get an exercise buddy so that you're not doing it alone. Having family or friends involved when starting a new exercise program can give you that extra boost of support to keep you going when the push just isn't there.

If you are very tired, though, you will need to balance activity with rest. It is okay to rest when you need to. It is really hard for some people to allow themselves to do that when they are used to working all day or taking care of a household. (For more information about fatigue, please see the document, Cancer-Related Fatigue and Anemia.)


Exercise can improve your physical and emotional health.

* It improves your cardiovascular (heart and circulation) fitness.

* It strengthens your muscles.

* It reduces fatigue.

* It lowers anxiety and depression.

* It makes you feel generally happier.

* It helps you feel better about yourself.

And long term, we know that exercise plays a role in preventing some cancers. The American Cancer Society, in its guidelines on physical activity for cancer prevention, recommends that adults take part in at least 30 minutes of moderate to vigorous physical activity, above usual activities, on 5 or more days of the week; 45 to 60 minutes of intentional physical activity are preferable.


How about your emotional health?

Once your treatment ends, you may find yourself overwhelmed by emotions. This happens to a lot of people. You may have been going through so much during treatment that you could only focus on getting through your treatment.

Now you may find that you think about the potential of your own death, or the effect of your cancer on your family, friends, and career. You may also begin to re-evaluate your relationship with your spouse or partner. Unexpected issues may also cause concern -- for instance, as you become healthier and have fewer doctor visits, you will see your health care team less often. That can be a source of anxiety for some.

This is an ideal time to seek out emotional and social support. You need people you can turn to for strength and comfort. Support can come in many forms: family, friends, cancer support groups, church or spiritual groups, online support communities, or individual counselors.

Almost everyone who has been through cancer can benefit from getting some type of support. What's best for you depends on your situation and personality. Some people feel safe in peer-support groups or education groups. Others would rather talk in an informal setting, such as church. Others may feel more at ease talking one-on-one with a trusted friend or counselor. Whatever your source of strength or comfort, make sure you have a place to go with your concerns.

The cancer journey can feel very lonely. It is not necessary or realistic to go it all by yourself. And your friends and family may feel shut out if you decide not include them. Let them in -- and let in anyone else who you feel may help. If you aren’t sure who can help, call your American Cancer Society at: (1800-227-2345) and we can put you in touch with an appropriate group or resource.

You can't change the fact that you have had cancer. What you can change is how you live the rest of your life -- making healthy choices and feeling as well as possible, physically and emotionally.


What happens if treatment is no longer working?

If cancer continues to grow after one kind of treatment, or if it returns, it is often possible to try another treatment plan that might still cure the cancer, or at least shrink the tumors enough to help you live longer and feel better. On the other hand, when a person has received several different medical treatments and the cancer has not been cured, over time the cancer tends to become resistant to all treatment. At this time it's important to weigh the possible limited benefit of a new treatment against the possible downsides, including continued doctor visits and treatment side effects.

Everyone has his or her own way of looking at this. Some people may want to focus on remaining comfortable during their limited time left.

This is likely to be the most difficult time in your battle with cancer -- when you have tried everything medically within reason and it's just not working anymore. Although your doctor may offer you new treatment, you need to consider that at some point, continuing treatment is not likely to improve your health or change your prognosis or survival.

If you want to continue treatment to fight your cancer as long as you can, you still need to consider the odds of more treatment having any benefit. In many cases, your doctor can estimate the response rate for the treatment you are considering. Some people are tempted to try more chemotherapy or radiation, for example, even when their doctors say that the odds of benefit are less than 1%. In this situation, you need to think about and understand your reasons for choosing this plan.

No matter what you decide to do, it is important that you be as comfortable as possible. Make sure you are asking for and getting treatment for any symptoms you might have, such as pain. This type of treatment is called palliative treatment.

Palliative treatment helps relieve symptoms, but is not expected to cure the disease; its main purpose is to improve your quality of life. Sometimes, the treatments you get to control your symptoms are similar to the treatments used to treat cancer. For example, radiation therapy might be given to help relieve bone pain from bone metastasis. Or chemotherapy might be given to help shrink a tumor and keep it from causing a bowel obstruction. But this is not the same as receiving treatment to try to cure the cancer.

At some point, you may benefit from hospice care. Most of the time, this is given at home. Your cancer may be causing symptoms or problems that need attention, and hospice focuses on your comfort. You should know that receiving hospice care doesn't mean you can't have treatment for the problems caused by your cancer or other health conditions. It just means that the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult stage of your cancer.

Remember also that maintaining hope is important. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends -- times that are filled with happiness and meaning. In a way, pausing at this time in your cancer treatment is an opportunity to refocus on the most important things in your life. This is the time to do some things you've always wanted to do and to stop doing the things you no longer want to do.

Last Revised: 08/25/2008

Prostate Cancer Patients Pick Treatments That May Worsen Quality of Life

Men with early-stage prostate cancer frequently choose treatments that worsen problems they already have, according to a new study published in Cancer.

Researchers from Boston University School of Public Health, Dana-Farber Cancer Institute, Harvard Medical School, Harvard Radiation Oncology Program, and Massachusetts General Hospital found that of 438 men who completed the study, 389 (89%) reported pre-existing urinary, bowel, or sexual problems, yet more than one-third opted for treatments that made them more vulnerable in those areas.

"Prostate cancer patients experience the same fears and hard decisions as all cancer patients do, but prostate cancer treatment directly affects very personal things that most people aren't comfortable talking about—urinary, bowel, and sexual function," lead researcher James Talcott, MD, SM, of the Center for Outcomes Research at Massachusetts General Hospital (MGH) Cancer Center, said in a statement. "In this case, however, having that information matters because the 3 major treatments available to patients have different patterns of potential side effects. Knowing if patients already have problems in these areas should help guide treatment options."


A High Degree of Mismatch

The 3 most common active treatments for prostate cancer -- brachytherapy, external beam radiation therapy, and radical prostatectomy -- have been shown to be about equally effective in clinical trials. But each has its own unique set of urinary, bowel, and sexual side effects that need to be taken into consideration when choosing a treatment.

A man with urinary irritation or difficulty passing urine, for example, might be advised against brachytherapy because it can make these symptoms worse. Likewise, men with bowel problems would likely be discouraged from external beam radiation therapy because it can affect the rectum as well as the prostate. Nerve-sparing radical prostatectomy is typically done in an effort to preserve sexual function. In some cases, though, this approach might reduce the chance that a surgeon can remove the entire tumor, so for men who already have erectile dysfunction, the risks of this procedure might outweigh any quality-of-life benefits.

The men in the study were recruited from Boston-area multi-specialty treatment centers. They answered questions about their urinary, bowel, and sexual function before they underwent treatment.

The researchers then classified the men into 4 groups. The first 2 groups had a urinary, bowel, or sexual problem that would likely make 1 of the 3 most common prostate cancer treatments inappropriate. The inappropriate treatment was more clear-cut for men in Group I than those in Group II. Patients in Group III had problems in several areas, but were felt to have at least one "appropriate" treatment option. Men who had problems that would be further aggravated by all of the treatments fell into Group IV.

The researchers found a surprising number of mismatched treatments among the study participants, regardless of the clinical complexity of their cases. About 34% of Group I patients received a treatment that might have worsened a pre-existing problem, compared to 37% in Group II and 40% in Group III.

Not surprisingly, choosing a mismatched treatment had negative effects. More men who had bowel problems prior to external beam radiation therapy reported diarrhea, pain with bowel movements, bowel urgency, and rectal bleeding. Patients who had urinary problems prior to brachytherapy were more likely to report painful urination. They also reported more need to urinate at night, though the difference did not reach statistical significance. Nearly all men with sexual dysfunction continued to have trouble in that regard after radical prostatectomy, regardless of whether a nerve-sparing procedure was used.


Emphasizing Quality-of-Life Concerns

The authors offer several hypotheses to explain why many men didn't seem to take these problems into account as part of their treatment decision-making. Some men may make decisions hurriedly and base their decisions on anecdotes and misconceptions (see "Fear, Anecdotes Often Trump Facts When Men Make Prostate Treatment Decisions.")

Another explanation is that men might have a hard time talking to their doctors about sensitive issues, making it harder for physicians to determine the extent of any dysfunction. Talcott and his co-authors suggest physicians consider using questionnaires to get more candid responses to sensitive quality-of-life questions.

The authors also note that there are other factors that might legitimately enter into treatment decisions. For example, some men might not consider external beam radiotherapy if radiotherapy centers are not close enough for daily treatments to be practical.

Mark S. Litwin, MD, professor of urology at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), and the UCLA School of Public Health and a researcher at UCLA's Jonsson Comprehensive Cancer Center, calls this a "great study that provides real opportunities for quality improvement." He agrees that there's a real need for a standardized pre-consultation questionnaire. "We should use any tool we can to better understand and better inform our patients," says Litwin, who was not involved in the research.

But Litwin sees the problem in a slightly different light: "It's not that men don't tell their doctors about their pre-existing problems, but that they have a skewed perspective of them, and as a result, of their treatment outcomes. We in medicine need to do a better job of sitting down with our patients and explaining how these treatments are going to affect quality of life."

Only around 5% of the men in each group chose "watchful waiting," or "active surveillance," a percentage Litwin and the researchers suggest reflects the tendency in the United States to over-treat prostate cancer in some cases. "We need to lay out the quality-of-life compromises associated with active treatment and help guide patients who should embrace active surveillance," Litwin said.



Citation: "Treatment 'Mismatch' in Early Prostate Cancer." Published online Nov. 26, 2007, and in the Jan 2008 issue of Cancer (Vol. 112, No.1). First author: James Talcott, MD, SM, Center for Outcomes Research at Massachusetts General Hospital (MGH) Cancer Center.

Landmark Studies Show Survival Benefit to Treatment in Advanced Patients

While patients with Advanced Prostate Cancer [AIPC] have limited treatment options, two landmark clinical studies presented at the American Society for Clinical Oncology (ASCO) scientific conference in 2004 and published in the New England Journal of Medicine later that year. demonstrated for the first time that chemotherapy treatment could extend the survival of patients with this advanced disease.

Taxotere (docetaxel) was approved in 2004 by the U.S. Food and Drug Administration (FDA) for the treatment of Advanced Prostate Cancer [AIPC] based upon data from these studies. Currently, extensive scientific and clinical research is underway at several biopharmaceutical companies and academic research institutions to further improve the survival benefit for patients with advanced disease and to enhance the quality of life, efficacy and safety of these treatment regimens.

In the sections that follow, this informational package will provide additional background information and an overview of the:

(1) Four classifications (categories) of Advanced Prostate Cancer
(2) Currently approved treatment options for advanced patients
(3) Experimental treatments in clinical testing
(4) Information on accessing investigational products through clinical trials

Four Categories of Advanced Prostate Cancer [AIPC]

The four most commonly encountered disease categories of prostate cancer are summarized below. They range from prostate cancer confined to the prostate glad to prostate cancer that has spread to lymph node and bone.


Locally Advanced Prostate Cancer

Cancer that has grown to fill the prostate or has grown through the prostate and may extend into the glands that help produce semen (seminal vesicles), or the lymph nodes.

Occurs in men who have been treated for early prostate cancer, but the prostate specific antigen is rising. A bone scan and cat scan in these patients is usually shows no evidence of cancer


Biochemically Recurrent Prostate Cancer (Rising PSA)

Patients who have a rising PSA after treatment, but do not have any evidence of disease spread to bone or other organs. This can occur after local treatment, or after hormone therapy. The management of such patients is controversial, and may include investigational treatments, radiation therapy, or chemotherapy.


Metastatic Prostate Cancer (Hormone Sensitive)

Cancer that has spread (metastasized) to the bone , lymph nodes or other parts of the body.. Depletion of the male sex hormone, testosterone, results in improvement of tumor related symptoms such as bone pain or inability to urinate. This can be achieved by either surgical removal of the testosterone, as well as with medications such as lupron and zoladex.


Hormone Refractory Prostate Cancer

Prostate cancer that continues to grow despite the suppression of male hormones that fuel the growth of prostate cancer cells.

A Team Approach to prostate cancer is very important. Your Prostate Cancer Treatment Team may include a urologist, a radiation oncologist, a medical oncologist, your family and nurses, patient navigators and others.

Before a diagnosis of advanced androgen- independent prostate cancer:
Your doctor will ensure your testosterone level is zero.

Ensure that there’s a consistent rise in PSA, tested several times over several months.

Perhaps offer a secondary hormonal therapy in addition to the hormone suppression therapy you may already be taking to possibly control you PSA for an additional amount of time


Secondary hormonal therapies could include:

(1) Antiandrogen withdrawal (AAW)
(2) Antiandrogen addition (Low vs. High)
(3) Estrogens (I.V., oral, transdermal…)
(4) Ketoconazole (Nizoral)
(5) Aminoglutethimide (Cytadren)
(6) Corticosteroids

Currently Approved Treatment Options for Advanced Patients

There is no single treatment for advanced prostate cancer. Yet, there are ways to slow the course of the disease.

In addition to these new therapies, you are usually advised to stay on hormone-lowering therapy, even though it no longer stops your PSA from rising. The reason for this is that some of your prostate cancer cells remain sensitive to testosterone, and stopping hormone therapy may make them grow again.


Hormonal therapy

Treatments for cancer that has spread to the bones

(1) Salvage radiation therapy
(2) Chemotherapy
(3) Adjuvant Therapy

The correct treatment choices are different for each man and are based upon many factors which should be discussed in detail with medical experts.


Treating Metastases

Doctors today have many tools to treat metastases. The broad categories include:

(1) Chemotherapy. Anti-cancer chemicals that kill tumors
(2) Secondary Hormonal Treatment – compounds that change hormone levels, but are not the first testosterone-suppression treatment to be used.
(3) Radiopharmaceuticals. Drugs linked to radioactive compounds which can target cancer spreac to the bone as well as other specific targets. These radioactive elements are delivered to or near tumor cells. This approach is effective in controlling bone pain. Bone seeking radioisotopes such as strontium and samarium are effective in treating patients who have multiple sites of bone pain.
(4) External Beam Radiation. Targeted beams of radiation. Most useful when a man has just one or two specific sites painful sites.
(5) Surgery. Cutting the tumor out.
(6) Bisphosphonates. Drugs that help bones from breaking down. These drugs can prevent the thinning of bone, otherwise know as osteoporosis, which can increase the risk of bone fractures.

Within each of these treatment areas, there are several options. Your doctors will help choose the right treatments for you.

Side effects. You are probably aware that cancer treatments may have unpleasant side effects, such as nausea, weakness, and hair loss. While that’s true, it’s less true than it used to be. Today, side effects of treatment are usually short term, and most can be managed. In many cases, you can take a medication before your radiation or chemotherapy treatment, to keep the side effect from affecting your daily routine.


Alternative and Complementary Therapies

In addition to the medical options your doctors prescribe, other therapies can help you fight prostate cancer. Sometimes these are called “alternative” or “complementary” treatments. The National Institutes of Health (NIH) has an entire division devoted to research in these areas, called the National Center for Complementary and Alternative Medicine (NCCAM).

The nation's leaders in treating advanced disease recommend patients keep a diary of their medications and supplements.


Pain Management

Men with advanced prostate cancer may experience pain. The pain can have a lot of different sources, doctors have may different effective ways to releive pain, so that you can enjoy your life and fight the disease with energy.


Treat the underlying cause

When pain is caused by a tumor, treatment to reduce the tumor can also reduce the pain. Radiation, chemotherapy and bone-building drugs that shrink tumors can all be effective in controlling pain. Sometimes they are even more effective than heavy pain drugs. (abstract J. Clin Oncology 2004: 22: 3587-3592).


Narcotics

These powerful drugs mimic the body’s own pain-killing chemicals. Narcotics may be given as a pill, a patch, or as an intravenous (IV) drip by health-care professionals, for severe pain.


Pain pills and patches

Doctors have a wide range of drugs to choose from in treating pain. Different drugs work in different ways. If one does not work for you, tell your doctor, and ask about others.


Alternative therapies

Acupuncture has been proven in clinical studies to help relieve pain. Meditation, prayer, and hypnosis also help some people.

Sexual Function After Treatment

Introduction

Treatment for prostate cancer can affect your sexual function. This information sheet describes what may happen and why, and what is available to assist you. Not all aspects of male sexual problems are covered here - just the ones you may encounter with treatment.

When a man has trouble gaining an erection, doctors call this "erectile dysfunction" or ED. Many factors can influence normal sexual function and one of the most important is simply growing older! But others are diabetes, smoking or a history of smoking, high alcohol intake and some medications. Emotional or psychological stress can also cause a decline in sexual activity. Many men will have a combination of these influential factors, and so there is a wide variability in sexual function as men grow older.

There is a wide variability in sexual function as men grow older; however a gradual decline is normal.

Prostate cancer therapy is an additional negative influence on whatever your normal level of function is. Thus men who had frequent sexual activity before their treatment are more likely to continue this after treatment, than men who were only occasionally sexually active. Similarly those who have weak erections before treatment are likely to have weaker or no erections afterwards. The prostate cancer itself rarely has a direct effect on reducing erectile function.

But let us now look more closely at what sexual activity involves.


Normal Sexual Function

There are four parts to normal sexual function in men - sex drive (also called libido), erection, ejaculation (emission of fluid), and orgasm.


What causes sex drive?

At puberty, the brain increases production of hormones that stimulate greater production of testosterone by the testicles. Testosterone is the main hormone responsible for the development of male sex organs and sexual behaviour. When testosterone levels drop, sex drive diminishes. This occurs naturally with aging, but may also occur with illness, some commonly used medications and with hormone treatment for prostate cancer.


What happens when you have an erection?

The penis contains nerves, smooth muscle and blood vessels in three spongy chambers called sinusoids. When a man is sexually stimulated, the nerves release a substance which causes the smooth muscle to relax. This causes the spongy chambers to dilate and blood is pumped in. The penis elongates shutting off the veins so that blood doesn't leave the penis.

After ejaculation, the nerves stop releasing the smooth muscle relaxing substance, blood flow to the penis is reduced, blood flow out of it increases and the erection subsides. It follows that both nerves and healthy blood vessels are important for erections. The nerves necessary for erections are separate from those involved in the skin sensation from the penis and those involved in orgasm.

Maintaining a healthy blood flow to the penis is essential for successful erections and lifestyle factors can improve it: quitting smoking, reducing alcohol intake, eating a healthy diet, and engaging in regular exercise and physical activity - all can help improve blood flow.


What happens during ejaculation?

Sperm mature and are stored in a structure close to each testis called the epididymis and structures close to the bladder called the seminal vesicles (Figure 1). During ejaculation, semen, which contains sperm and fluid from other sources (such as the prostate and seminal vesicles), is propelled by muscular contractions along tubes into the urethra (urine tube). During ejaculation, a muscular valve at the bladder outlet closes, blocking the outflow of urine and forcing semen out of the penis.

What happens during orgasm?

Orgasm mainly happens in the brain and has little to do with the prostate. As long as normal skin sensation is intact, orgasm can occur even in the absence of an erection and ejaculation. This is the key reason why satisfactory sexual function can be restored to most men after prostate cancer treatment involving surgery or radiotherapy. The common exception here is men receiving hormone therapy, because this frequently causes loss of libido (sexual desire) as well as function.


Why are erections affected by treatment to the prostate gland?

The prostate is not particularly important for normal sexual function. It adds secretions to the ejaculate, which help the sperm to survive. However it does not control the ability to have an erection.

Nevertheless, structures which are important to erectile function lie in close proximity to the prostate and can be damaged when the prostate cancer is treated. A series of fine nerves which assist in the ability to have an erection lie in bundles against the prostatic capsule. During sexual arousal, blood fills the penis to create an erection, and small blood vessels expand in order to deliver enough blood. Prostate cancer treatment such as radiotherapy and surgery can damage both the nerves and the blood vessels.


Trans-urethral resection of the prostate gland

A trans-urethral resection of the prostate (TURP) is an operation to remove prostate tissue through the urine outflow tube (the urethra). It can improve urine flow when the tube is blocked by benign enlargement of the prostate, or by prostate cancer. Only a part of the prostate is removed and so some men call this a "re-bore".

During this operation, the constricting "valve" at the urinary bladder outlet is often opened - so that during ejaculation (because there's no barrier to keep semen from going back into the bladder), semen is propelled into the bladder rather than along the penis to the outside. This results in a "dry ejaculation". It is neither painful nor dangerous and the semen is passed out when the bladder is next emptied.


Radical prostatectomy

During this operation for cancer, the entire prostate and the seminal vesicles are removed. After a radical prostatectomy, initially the focus of attention is on the return of urinary control (continence), as the nerves and muscles controlling urination also lie close to the prostate area.

A man will normally lose the capacity to have erections immediately after the operation, however with time, there is usually some return of erections. In part, the return of erections depends on the extent to which the nerves which lie close to the prostate have been spared during surgery. This in turn depends on how far the cancer extends into this area and so is a choice that the surgeon can make only at the time of surgery. To spare the nerves and also leave cancer behind would defeat the purpose of the operation.

However if it is considered safe to do so, techniques are available to preserve these nerves. More recently some surgeons have been reconstructing the pathway by grafting nerves taken from another part of the body, into the area. Nevertheless, although the nerves are important they are not essential. After a radical prostatectomy, approximately 10% of men who did not have nerves spared have some return of erections.

You may be advised by your doctor to "give it time". After surgery your body needs time to heal. Erections may return gradually. The erection you may have 4 months after surgery is not necessarily as good as the one you will have 2 years later. Many men experience improved natural erections over time with continued improvement reported for up to 4 years postoperatively! Aids to assist with an erection after surgery may improve your long-term function and so you may want to consider these quite early - only a few weeks after your operation.

It is not necessary to achieve erection or penetration in order to achieve orgasm!

After a radical prostatectomy, the stimuli that cause an erection may need to be altered. Visual stimulation may not be as important as direct stimulation of the penis. No damage can be done through experimenting with your sexual activity. If you have a partial erection, go ahead and attempt intercourse - vaginal stimulation will encourage further and better quality erections. Continue with sexual relations even though erections may not occur. Don't wait for the time when they "just happen".

Natural erections can improve for up to 4 years after a radical prostatectomy.

Soon after surgery traditional vaginal penetration may not be easy. Some men have found that if they attempt sexual activity standing up, they can achieve a much firmer erection. Sexual activity can continue either while a man remains standing, or while he's kneeling. Lubrications, such as K-Y jelly, may also help.


Radiotherapy

After radiotherapy to the prostate, sexual function is not usually affected in the short to medium term. Several years after radiotherapy erectile function typically declines gradually. This is thought to be due to the progressive damage to the nerves and small blood vessels near the prostate that are important for erections. It is reported that brachytherapy (interstitial radiotherapy) to control prostate cancer carries a lower risk of erectile dysfunction in comparison to conformal radiotherapy delivered by external beam (see Mr PHIP no 3) or surgery.

Further research is needed on this issue. Intensity modulated radiotherapy is a newer delivery technique that may reduce damage to healthy tissues adjacent to the prostate. Remember also that aging itself has an effect on sexual function!


Hormone Treatment

Control of prostate cancer using hormone therapy usually results in the reduction of testosterone, and sex drive will be diminished for most men. However, continuation of simple physical expressions of love and concern between you and your partner can be very important in the ensuing years.


What you can do

Medications

A group of drugs available in Australia called PDE5 inhibitors (Table 1) can help men achieve an erection or better quality erection. If the medication doesn't work at the first attempt, it may be worthwhile retrying a month or so later. These are not aphrodisiacs (ie do not increase sex drive) and typically direct penile stimulation is required to stimulate an erection when using these drugs. Men on hormone therapy may be helped, but their sexual desire is usually low. These drugs are not subsidized by the Government Pharmaceutical Benefits Scheme (PBS).

Men taking nitrate medication (eg. anginine) for a heart condition must not use these medications as the risk of low blood pressure and sudden death is increased. Your doctor will advise you on your risk or may recommend you seek advice from a heart specialist. Sexual activity is indeed a form of exercise and heart attacks are more likely to occur during exercise than otherwise.




Side effects

Headaches, facial flushing, indigestion and visual disturbances (not reported with Cialis) may be experienced by a few men. There are a small number of medications that if taken at the same time may increase the risk of these side effects, eg. the antibiotic erythromycin and antifungals such as ketoconazole.


Other products and ways of taking them will be made available in the future.

Injection therapy

Direct penile injections are the most effective form of therapy to achieve erections after a radical prostatectomy. A drug is injected each time an erection is required - this occurs without any direct sexual stimulation - it is a chemical response. Caverject ImpulseTM (alprostadil) is the most freely available but, as with PDE5 inhibitors, it is not supported by the PBS scheme.

It is important to start by injecting small doses (eg 2.5 - 5 micrograms) and then gradually increase the dose until a satisfactory result is achieved. This reduces the risk of one of the uncommon side effects - a painful prolonged erection, called priapism. Any erection lasting more than 4 hours with this type of medication requires urgent medical intervention. Typically blood is drained from the penis and an "antidote" injected into the penis. Some doctors prescribe a tablet to help deflate the erection, should it last for 3 hours or more, eg. pseudoephidrine 60 - 120 mg orally.

Most doctors recommend a maximum of 3 injections per week because more frequent use may lead to scarring within the penis. The correct technique of injection therapy can be learned by most men, provided their eyesight and dexterity are reasonable.

There are injectable medications other than Caverject ImpulseTM that have been used, some in combination. As all rely on a relatively normal blood supply to the penis, injection therapy can fail if this is inadequate. Caverject ImpulseTM is in a powder form that can be stored or transported at room temperature. When required it is mixed to a solution in the syringe. Other agents usually require refrigeration to store.





Vacuum erection devices (VEDs)

An erection can be created by drawing blood into the penis by way of a vacuum pump placed over the penis. Once the erection is created, a constrictive band is placed onto the penile base close to the pubic bone to maintain the erection during sexual activity. The band should be released within 30 minutes to reduce the risk of damage to the penis itself. A VED is reusable. Education and personal experience with these devices is very helpful and most companies have video tapes which demonstrate their use. VEDs are not available on the PBS and cost between $500 and $800 each.





Penile prostheses

Devices can be placed within the penis to create a mechanical erection. Such an operation is normally not performed until 2 years after radical prostatectomy since recovery may occur naturally prior to this. During the operation, the normal spongy penile structure is destroyed to allow the device to be placed. Most of the cost of inserting these devices is covered by private health funds.





In conclusion

Most men are able to enjoy a sexual relationship following surgery and radiotherapy, since their sensation of arousal, excitement and orgasm is typically unchanged. What is often lacking is the spontaneous event of a rigid penis. A number of options for achieving an erection have been mentioned and one or more of these is often successful. You can experiment also with other forms of sexual intimacy - there may be new discoveries to be made!

Remember there is no potential for harm to your sexual partner from either the cancer or from any potential urinary leakage during a sexual encounter. Your partner, wherever possible should be included in discussions about your sexuality and treatment choices.

Check out these useful websites:
www.impotence.org www.prostatehealth.org.au www.prostatehealth.org.au

Keep in mind the larger picture. There is far more to a fulfilling relationship than an erect penis, even though the latter often becomes the focus of attention during consultations with doctors! There are many resources available to assist you to explore and develop your relationship (see below). The ultimate goal is to continue a fulfilling relationship and to be rid of a life threatening disease.

Prostate Cancer

Emerging Therapies

In labs around the world, researchers are busy identifying new drugs, new regimens, and new treatment approaches that might prove beneficial to men with prostate cancer. Most of these investigational agents are being tested in men with advanced prostate cancer: Therapy options for men at this stage of disease are often not effective enough to halt progression of the disease, and men are typically affected by side effects from the disease and/or the medications that they’re taking. It’s therefore the perfect stage at which to test out new drugs because any improvement will likely be rapidly noticed and much appreciated.


The Goal of Targeted Therapies

Chemotherapy drugs can play an important role in improving the lives of men with advanced prostate cancer, but they often don’t distinguish between tumor cells and healthy cells and can kill off some normal cells along the way. So-called targeted therapies, by contrast, are drugs that are specifically designed to interfere with the way cancer cells grow, with the way cancer cells interact with each other, and/or with the way that the immune system interact with the cancer.

There are a number of different kinds of targeted therapies being investigated for prostate cancer. As of yet, none have been approved by the FDA for use in prostate cancer, but the excitement generated by some of the early studies have led many researchers to believe that it’s only a matter of time before a targeted therapy is found that can result in better outcomes overall.


Interfering With Cancer Cell Growth

All cells in the body, including cancer cells, rely on a complex communication system to know when to grow, when to divide, and when to die. This system uses specialized proteins, fats, and other substances to tell the different cells or parts of cells how to act. Over the years, cancer researchers have been studying ways to interfere with the signaling system that regulates the growth of cancer cells.

So far, interfering with cellular signaling to halt cancer cell growth hasn’t yet proven to be a very effective strategy in prostate cancer. But in the process of learning which drugs might work and why, researchers found that the strategy of adding a "targeted therapy" to other effective drugs in order to see better results than with either drug alone is an important part of cancer research. The idea is to exploit the synergy between the two drugs, or the ways in which the two drugs might work together to fight off the cancer.


Interfering With Cancer Cell Spread

As cancer cells divide and start to spread, new blood vessels sprout from the old ones to help supply the necessary nutrients to the new tumor site via a process called angiogenesis. If angiogenesis could be inhibited, researchers theorized, the new tumor cells would die and the cancer’s growth would be halted.

In 2004, the angiogenesis inhibitor bevacizumab (Avastin) was approved by the FDA for use in colorectal cancer. Since then, it has been shown to improve outcomes in women with breast cancer, and is currently being studied in a number of other cancer types, including prostate cancer. Although no other drugs currently available were designed to specifically act as an angiogenesis inhibitor, researchers have found that the drug thalidomide (Thalomid) has some anti-angiogenic properties, and is also currently being tested in men with prostate cancer.


Harnessing the Immune System to Fight Off Cancer Cells

In order for the immune system to fight off foreign invaders, it has to learn to recognize what’s normal and what’s not normal. Unfortunately, because cancer cells start out as normal healthy cells, the immune system never has a chance to learn to distinguish between the normal cell and the cancer cell.

Unlike preventive vaccines, which are designed to teach the immune system to develop a way to fight off a specific virus should it come into contact with that same virus again, therapeutic vaccines stimulate the immune system to recognize and fight certain proteins specific to cancer cells. Each of the therapeutic vaccines currently being tested in men with advanced prostate cancer works in a slightly different fashion, but all are designed to harness the immune system’s ability to fight off disease and teach it to fight off prostate cancer cells.

Painkillers Lower PSA Test Readings

By Ed Edelson
HealthDay Reporter

MONDAY, Sept. 8 (HealthDay News) — Taking aspirin or other commonly used painkillers can lower blood levels of prostate-specific antigen (PSA) and possibly confuse the results of a common screening test for prostate cancer, a study finds.

Data on 1,319 men in a national health study showed that men who took non-steroidal anti-inflammatory drugs (NSAIDs) had PSA levels about 10 percent lower than men who didn't take the drugs.

A similar lowering effect was seen for regular use of acetaminophen (Tylenol), although it did not reach statistical significance.

It's also possible that the lowered PSA levels indicate that regular NSAID use reduces the risk of prostate cancer, the report said, citing studies showing a relationship between NSAID use and lower incidence of the cancer. The new study results "are consistent with previous reports that NSAID use is a protective factor for the development of prostate cancer," the researchers wrote.

"This raises questions that will have to be answered in a larger clinical trial," said Dr. Eric A. Singer, chief resident in urology at the University of Rochester, New York, and lead author of the report, which is in the Sept. 8 issue of Cancer.

Until now, the only drugs known to affect PSA levels were those used to treat an enlarged prostate, Singer said. "Other than that, PSA levels are not usually interpreted with medications in mind, so that raises that question," he said.

PSA screening tests commonly are done in the offices of primary care physicians, Singer said, and those doctors usually have information on which medications a man is taking. Whether men should be asked about NSAID use isn't clear now, he said.

"In terms of changing medical practice, I don't think so right now, not on the basis of this study," Singer said.

He and his colleagues are exploring the possibility of a trial that might clarify the issue, he said. Such a trial would follow men who regularly take NSAIDs and see how they affect the risk of prostate cancer.

"It is a trial that would go on for many years involving many men," Singer said.

NSAIDs reduce inflammation, and chronic inflammation has been linked to many malignancies, including prostate cancer. The cyclooxygenase enzymes, which are inhibited by NSAIDs, play an important role in inflammation.

"I would be very cautious about drawing any conclusion about what message men should take away from this study," said Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society. "We should not take aspirin or NSAIDs as protection against prostate cancer."

The cause of the lower PSA levels is not clear, Lichtenfeld said. "Whether it is because the medicines have a positive effect in reducing the risk of prostate cancer or mask a possible sign of prostate cancer is unknown," he said.

Doctors should ask men about aspirin and NSAID use before PSA screening, Lichtenfeld said. "Doctors should ask patients about all their medications, prescription and over-the-counter," he said. "That conversation should always occur between health-care providers and their patients."


SOURCES: Eric A. Singer, M.D., chief resident, urology, University of Rochester, N.Y.; Len Lichtenfeld, M.D., deputy chief medical officer, American Cancer Society, Atlanta; Sept. 8, 2008, Cancer

PSA Test

Well the results are in!

I received the results of my PSA and Testosterone levels a couple of weeks ago, but have been too busy/pre-occupied to post them! Just this morning, I had a gentle nudge from my niece Kathy and decided that it was time to post the results.


Firstly to recap; we were hoping for a PSA result that was very close to zero. Such a result would mean that I could discontinue the anti-androgen (and therefore reduce the number of side affects) but still continue the Zoladex implant for a further period - two to three years is recommended.

The Testosterone level too, it was hoped, would be very close to zero. This would confirm that the Zoladex was suppressing the testosterone nicely and therefore starving any cancer that may still be present.


Testosterone

A 'normal' reading for adult males in regard to Testoterone is: 2.8 to 8.0ng/ml. For an adult FEMALE, the range is: 0.06 to 0.82ng/ml.

My result ... 0.51ng/ml!!

That means, I fit neatly into the 'normal' range for an adult female! Which explains a few things!! (Long term readers would be aware of the 'feminising affects of my meds).

But all is not lost, my result also puts me squarely in the range of a pre-pubescent male (7 to 12 years)!!

I've managed to turn back the clock!

Now before you scoff, such a proposition is not as fanciful as you might think - consider.

1) I no longer have any hair under my armpits!
2) My skin complexion is that of a pre-teen!
3) The hair ALL over my body (except on my head) is falling out!
4) The hair on my head is thickening and growing back!
5) My testicles are 'shrinking'!

I think you get the picture...


PSA level

The normal range of PSA (Prostate Specific Antigen) in an adult male aged 50-60 years, is 0 to 3.5ng/ml. Remember, I started this battle against cancer with a PSA of 84.8ng/ml just 11 months ago!!!

Well my test showed a level of 0.66ng/ml, a negligible amount of PSA and an excellent result!

Coupled together, these results are a 'shot in the arm' in regard to my quest for a complete cure!! These tests will be repeated in early November and I expect a similar result.