Wednesday, September 25, 2013

Post-Prostate Cancer Treatment One Year Later: How Are Things Different?

A remote brachytherapy afterloader of the type that delivered my cancer radiation treatment exactly one year ago, Sept. 25, 2012. It's an electro-mechanical system by which 16 transfer tubes  with radioactive Iridium -192 needles are inserted into catheters in a fixed template (stitched to the perineum) to deliver radiation directly to the prostate gland. I received a total dose of 1930 cGy (centigray), in a treatment delivering one single high dose.

One year ago today at this time, I entered the UCSF Helen Diller Cancer Center, in San Francisco, for treatment of stage T1c prostate cancer. Within an hour of my sign -in I was in a hospital gown and given last minute checks before being wheeled into the OR on a gurney. Thus began an "adventure" I never thought I'd ever have, and yes, a life-changing experience.

Only in retrospect did I realize it was even more of an adventure than first believed, since I had received a novel brachytherapy treatment still relatively rare up to that time: one single high dose of radiation delivered through 16 Iridium -192 needle sources. Only 6 months earlier the standard protocol called for  three administrations of lower dose radiation delivered over two days. So, yes, I was something of a "guinea pig". What makes it more interesting, is that - according to  number of sites, as well as research articles (e.g. in Urology Times): "little is known about the sexual outcomes of the treatment, particularly ejaculatory function."

Well, I definitely found out more about that in the aftermath. I had also attempted to learn about it before the treatment, but there was nothing there.....a total information vacuum. Evidently, whoever did get the single high dose therapy wasn't talking.  I did converse with a guy (friend of Janice's from her days working at Nucletron) about what he experienced, but then he had the earlier standard 2-day lower dose therapy. What he told me is that he generally got on ok, except for the fact of having "dry orgasms"- which he was trying to get used to.

This phenomenon, as noted in an earlier blog from last October, was explained by Dr. John P. Mulhall thusly:

"Radiation therapy results in reduced ejaculate volume as the function of the  prostate and the seminal vesicles is to produce ejaculatory fluid, and in most men, will result in loss of  ejaculation completely".

He also observed:

"The amount of radiation needed to cause endothelial damage is tiny, ranging from 0.1 to 1 Gy. It is estimated that between 15 to 20 Gy is required to injure large blood vessels (when given in a single dose).  This damage to blood vessels is known as endartertitis obliterans and may take up to a decade to manifest itself maximally."

Both of these after effects are confirmed in the literature, including for both low dose brachytherapy and high dose brachytherapy.  I have not experienced any "dry orgasms" yet, but Mulhall notes that - despite oncologists' attention to sexual function after 12 months, it is preferable to only begin to examine it closely after 2 years. He observes:

"Any study looking at erectile function outcomes should really assess these outcomes at no sooner than 24 months, if not 36 months, after the completion of radiation."

Perhaps Mulhall's most salient point is:

"Radiation attacks the DNA in our cells. It causes breakages in the DNA, and when this occurs, the cells commit suicide, a process known as apoptosis. Normal cells have better repair machinery to fix some radiation damage while cancer cells do not.  As well as killing off the actual prostate cancer cells, radiation causes injury to the blood vessels that supply the cancer."

The last effect is confirmed at a site (of the National Cancer Institute) which states:

 "Radiation damage to nerves and blood vessels may occur with brachytherapy, and higher doses of radiation may cause more damage"

In addition, there is this difference noted in comparing effects of the radical prostatectomy and radiation therapy (ibid.):

"Radical prostatectomy damages nerves that make blood vessels open wider to allow more blood into the penis. Eventually the tissue does not get enough oxygen, cells die, and scar tissue forms that interferes with erectile function. Radiation therapy appears to damage the arteries that bring blood to the penis."

Well, maybe not much to choose between there! What I've found basically is these effects are manifest and they translate into: much more difficulty in sustaining erections (though not in getting them) and pain sometimes as an accompaniment. PDE 5 inhibitors are not much use, what with blood pressure issues. Another effect not accounted for any place, despite bringing up  dozens of Google pages, (or available literature) is burning semen on ejaculation. Not only does it burn, like my urine - if I fail to hydrate enough on a given day - but it acts as a skin irritant.  Fail to wash it off thoroughly after an ejaculation and the skin becomes red and inflamed. Why has this  side effect not been reported anywhere? Are men too embarrassed to do so? Or is it simply rare and varying person to person?

 Has the high dose radiation produced "radiated semen"? My inclination is to say 'Maybe', but I'd like to know if the burning sensation of the urine, and that for semen,  arise from the same mechanism.  There also appears to be some relationship - certainly of the urine burn - to extreme urgency. More than once while in Europe, for example, I had to suddenly make a mad dash to any accessible RR to empty my bladder. While most men are aware of how desperate it can be when the bladder is full, now imagine multiplying that sensation by two or three times - as you find yourself say in Salzburg, and the only rest room is one for pay that requires exactly one half euro!

I think I have to agree with many observers (including Dr. Mulhall) who insist more longitudinal studies of the post-treatment effects need to be done, and those results documented and circulated. Maybe lots of the effects are age-dependent, who knows? Maybe a younger male (hopefully) doesn't have to fret over something like burning semen  for whatever reason. But whoever the prospective patients may be, all deserve to know more about what lies ahead and how they will be affected. Also, what they can do about them, if anything.

Re: the effects on the arteries, I've tried to counteract those by going to a diet heavy on veggies and fish (salmon, etc.) and limited in red meat.  Needless to say, I am hoping such a strategy will help me cope when the enhanced, longer term effects of the radiation start kicking in within another twelve months or so.  As Mulhall has noted, and despite radiation therapy being "less invasive" (some consolation!) the erectile success rates are the same for surgery and radiation after 24 months.

In the end, any given prostate cancer treatment has a cost, and it seems like it's only a matter of whether one pays it sooner or later.

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