Was the Cancer Cryotherapy Successful? Good Question (The PCA-3 Test)

On arriving at UC Health in Aurora on Oct. 11 for my 4 month post op assessment, following the prostate salvage cryotherapy treatment in June, see. e.g.

 

http://brane-space.blogspot.com/2017/06/fighting-prostate-cancer-at-90-c-my.html

I was optimistic that the  PSA test would reveal a reading lower than  2.0 mg/ dl which was the level one month after the therapy. We had to arrive by 1: 30 so I could first go to the on site Oncology hematology lab for the PSA and % free PSA test.. I had to wait about 30 minutes and this meant the results would be roughly an hour delayed in getting to the urology professional assistant (Kristen) with whom I had to meet by 2:30.  

The test was done expeditiously by a medical tech and she said it would immediately be sent for analysis.  Meanwhile I went up to the 2nd floor Urology center to wait to be called for my appointment with Kristen. 

On being called right on time, I first had to have weight and BP taken by the RN assistant, then turned in a sheet with ratings for different urological -sexual functions, e.g. frequency of urination, retention of urine, erectile quality etc.  This data was then entered by her into a computer for the Urological PA to access.

Ten minutes later, Kristen appeared with her computer screen open and we went through the responses. She remained concerned about the urinary and erectile difficulties but assured me this was often a side effect of the cryotherapy - especially for older patients undergoing a salvage treatment (i.e. a second treatment, usually after a primary radiation treatment).  In my case, the primary treatment - the HDR brachytherapy done in September, 2012 at UCSF.

Again, she reiterated the erectile issues were not merely sexual but the importance of getting blood into the tissues, to remain healthy.  Hence, she prescribed a  low dose (5 mg) PDE inhibitor .  Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells. This promotes relaxation of smooth muscles and erection. An enzyme known as PDE5 prevents this,  else there may be a prolonged erection. Hence, a PDE5 inhibitor works to suppress secretion of the PDE5 enzyme.

About fifteen minutes later after the free PSA and PSA test results arrived on her laptop, she informed me of the results: 2.09 PSA and 4.8 % free PSA.  As she explained to wifey and me these results were not sanguine, especially the latter. In the case of free PSA you want the % as high as possible to indicate most of the prostate specific antigen is bound up with normal prostate cells.  The combination of the two results, she noted - using an on site software program developed by Dr. David Crawford - yielded a 55 percent probability the PSA was due to malignant cells.

This then led to her doing a urine test called the PCA-3, which is well explained by this UK site,

http://www.cancerresearchuk.org/about-cancer/prostate-cancer/research-clinical-trials/research-diagnosing-prostate-cancer/pca3-test

Noting:

"The test is in two parts. You have a rectal examination and then a urine test. A rectal examination is where the doctor puts a gloved finger into the back passage (rectum). It is possible to feel the prostate gland by doing this. You need to have a rectal examination because this massages the prostate gland and helps the PCA3 to go into the urine. You have to give the urine sample straight after the rectal examination. You normally get the results within a few days"

So with this in mind, she had me prepare and bend over her examination table, warning me in advance this would entail not only the usual DRE but also a prostate massage to force the biomarker into the urine tract.  Hence, there would be a degree of discomfort.  In this she wasn't kidding, and  while the entire procedure lasted just  over three minutes it felt like three hours.  While not painful like a trans-rectal biopsy it was definitely no 'walk in the park' - even a short one.

As she massaged the gland she told me what she felt, including "lumpiness" which was a "result of the cryotherapy".  She said that the process of the massage should also relieve pressure on the nerves as well as pushing fluids into the urinary tract.

Immediately following the procedure she handed me the specially labelled cup to produce a urine sample, using the bathroom across from the exam room. I confess it took seven or eight minutes to produce a stream of urine even adequate to get 1/3 the cup filled.  She later explained this was normal and was a result of the massage.

With the sample delivered, we left - prescription in hand - and booked the next three month visit on the way out. As I mentioned to wifey, I just hoped the numbers - including from the PCA-3 test- would be much better next time. Else, what was the point of going through yet another prostate cancer treatment?

Any positives? Anything? Well, after turning in on the night of the procedure I experienced the first nocturnal emission in nearly fifty years.  While irritated about having to change underwear, sheets, I did consider that the prostate massage -though extremely uncomfortable- did produce at least one  seeming positive "return".  In fact, on four successive nights I also experienced nocturnal erections that had been absent since the cryotherapy on June 20.  As wifey joked, "the trick is to translate them into day time erections".  Well, one step at a time!


See also:

https://emedicine.medscape.com/article/1948091-overview
 

And a detailed published paper on the PCA-3:

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1677-55382011000600006

'Penile Rehabilitation' After Cryo Surgery - Not Like After Radiation

In a blog post five years ago I cited the work of cancer specialist Dr. John P. Mulhall, and the need for "penile rehabilitation" in prostate cancer patients who've undergone surgery or radiation, e.g.

http://brane-space.blogspot.com/2012/10/penile-rehabilitiation-what-most-docs.html

Mulhall is the author of an academic monograph entitled: "Sexual Function in the Prostate Cancer Patient,"  and also wrote a less technical book for actual prostate cancer patients and their significant others, entitled: "Saving Your Sex Life: A Guide for Men with Prostate Cancer".  In this book, Dr. Mulhall takes the 'bull by the horns' and shows that men who've had prostate cancer treatments - whether radical prostatectomy, radiation or hormone therapy, actually face immense work to overcome the attendant sexual problems.

The incipient damage is called "atrophy" which increases in probability the longer a patient goes without erection,  post-surgery. (p. 98) Atrophy is, in fact (op. cit..):

"a scarring of the erectile tissue, and if the erectile tissue scars, the patient will never get his own erection back and will always struggle with medication".

Dr. Mulhall goes on to note (ibid.) that "the incidence of erectile tissue damage, as measured by the presence of venous leak is very uncommon before the fourth month after surgery. However, at eight months after surgery it "occurs in about 30% of men and at one year 50% of men".  This also occurs or can occur after high dose radiation which I had in September, 2012.

Radiation attacks the DNA in 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."

As Mulhall notes later, these blood vessels- many of them - also supply blood to the erectile tissues. Most shocking to me was to read that erectile success rates are the same for surgery and radiation after 24 months, and while radiation oncologists tend to look at sexual function after 12 months or so, Mulhall indicates it needs to be 3-5 YEARS after (p. 83) . He refers to this as a "glaring deficiency" (ibid.) and adds:

"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."

So, bottom line, I knew going into focal cryosurgery salvage treatment (treatment after initial radiation) the chances were not good to recoup erectile success. What I wasn't prepared for after the cryo is that this would plummet even more than after the high dose radiation (5 year mark). Of course, you are informed that though the targeted cryo can eliminate the localized tumor there is no assurance that adjacent nerve networks can't be damaged. This is because, unlike the tumor, these nerves branch out and aren't so localized.  The risk is also much greater for older patients, i.e. over 65 (I am 71).

On Monday I returned to UC Health in Aurora for the follow up appointment (after the procedure done on June 20th). This was with Dr. Crawford's professional assistant, Kristen -  a 26- year old woman and Columbia University grad. She had me fill out a "sexual and urinary function" form and then went over it with me afterward. The form covered about 15 aspects, i.e. urinary frequency, urgency, erectile quality, maintenance etc. - each on a 0 to 5 scale.  

I also, since I reported urinary frequency beyond the norm, had to submit to a bladder ultra sound in the office, performed by a medical assistant. Kristen noted that if the urinary retention was too high in the bladder (over 100 ml, after urinating) I might have to have a bladder dilation performed. Naturally then, I was relieved the retention volume was barely 30 ml.

In terms of the sexual -erectile aspect, and interestingly connected to the urinary issues as well, Kristen pointed out that both could be improved by taking 5 mg of Viagra or Cialis each day. As also noted by an American Cancer Society website., this is not enough to produce erections but it is sufficient to keep some blood flow going to those tissues which otherwise would receive little or no oxygen.  Thus, she sent in a prescription for our pharmacy.

The ACS site in relating similar information, points out that - typically - erectile quality, if it is to return at all, usually happens after two years. It takes the nerves roughly that long to heal, so we see that cryosurgery, like radical prostatectomy - is not exactly without its issues (including some incontinence).  In the meantime, it is important to be doing the low dose PDE inhibitor .  Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells, which promotes relaxation of smooth muscles and erection. An enzyme known as PDE5 prevents this, since else there may be a prolonged erection. Hence, a PDE5 inhibitor works to suppress secretion the PDE5 enzyme.

In terms of orgasms, Kristen pointed out that these were still possible even without erections.  As noted on a UCLA website:

"An erection is not necessary for orgasm or ejaculation. Even if a man cannot have an erection or can only get or keep a partial erection, with the right sexual stimulation you can experience an orgasm. Your orgasm has little to do with your prostate gland. As long as you have normal skin sensation, you can have an orgasm."

As far as "supplementary aids", Kristen did mention possibly using special vibrators which "we could discuss at a later date", which was fine with me.

The session lasted about an hour, including the ultrasound, and the takeaway I came away with was that I was certain most men didn't have clue one what they were sacrificing when they opted to have prostate cancer treatments of any kind.  It also helped me understand the many thousands of men who refused to have any treatments, opting to do "watchful waiting" instead. (Alas, as Dr. Crawford had told me in our November meeting, that wasn't an option for me given the Prolaris score)

The tragedy is that this cancer can wreak so much havoc especially on younger males, some in their early 40s, who've reported serious marital problems, e.g. on the 'Team Inspire' group.   Once you're in your 70s this isn't so much of an issue, but still you don't want to see certain organs just waste away....so you kind of do whatever the dr. (or his P.A.) suggests.

My primary hope is that the physical (also mental - see my post on memory loss) sacrifices are worth it and this is the final end of this damned cancer. Kristen said I need to get a first PSA test done early next week and then another in three months. I hope that all future PSA test results are as close to 0.0 as possible!

When I jokingly told Kristen: "No more biopsies!"  She laughed and said "We'll see."