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 cancer.gov 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.

Men Using T for a Cosmetic ‘Fix’ – Playing Roulette with Prostate Cancer

The news that five million American males are now brandishing their tubes of ‘Androgel’ and other testosterone-delivering gels, etc. is not surprising. The post-45 lot seem to believe they’ve found a new lease on life where biceps pump up, and flabby abdominals turn into hardened six-packs. Their brains work better, or so they claim, so what can go wrong?


Well, how about aggressive prostate cancer – then having to get a surgery or radiation treatment that leaves you with having to use penile implants, endless Viagra and penile injections?


It is amazing how many sites one finds on doing a Google search that pooh-pooh any evidentiary connection between testosterone increases and prostate cancer. One site I located actually referred to any such connection as a “myth”. I have news for them: they are living in a fool’s paradise and furthermore are encouraging male readers over 45 into taking immense risks that they’d be better off avoiding.  The truth is that "testosterone fuels prostate cancer growth" and prostate cancer is "the only type of cancer susceptible to testosterone inactivating pharmaceuticals" (According to Dr. Mark Scholz, in 'Invasion of the  Prostate Snatchers', p. 42).


Two nights ago on an ABC News segment on testosterone fixes, a muscle-bound 60+ year old was shown flexing his biceps and bragging about all his energy ….and so on. Hey, great! But I just hope you’re ready when you have to be treated for prostate cancer – whether radiation therapy or a radical prostatectomy leaving you dependent on penile shots, implants or PDE5 inhibitors, or worse, never being able to get it up again because the cancer is so aggressive that you’re put on female hormones. (With large breasts you will want to hide, to boot).


Dr. John P. Mulhall, author of an academic monograph entitled: "Sexual Function in the Prostate Cancer Patient," 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". He makes clear the extent men will have to go to in a process of “penile rehabilitation” to regain sex lives after prostate cancer. In this case, sex lives that can be hampered not only by erectile dysfunction, but painful orgasms and dry ejaculations – even if they do take enough Viagra or penile shots to get the machinery working.

As if that isn’t enough to terrify any macho fool idiot into halting an enhanced T -regimen unless absolutely necessary, there is the prospect of surgical error leading to infection (c. diff.)  and vesicularectal fistula such as reported  by Dr. George Rinaldi on p. 20 of 'Invasion of the Prostate Snatchers'. Rinaldi was not one of the lucky 50% who emerge from radical prostatectomy relatively unscathed. He ended up farting through his penis and saddled with other complications before having to get a colostomy!

Apart from such extreme consequences, something like 50% end up wearing diapers for the rest of their days. This is possible because in the course of the prostatectomy (the most frequently chosen treatment) the urethra has to be sliced in two different places (since it passes through the prostate) then the base of the bladder has to be resected to the remaining part of the urethra excised from the prostate base.


One problem with the above is the response that “it won’t happen to me” – resorting to the exceptionalist meme. But I have news for these guys – it can happen to you unless you’re lucky enough to get the skilled hands of a surgeon that can minimize the collateral damage. Oh, and if you’re thinking about using that fancy dancy da Vinci surgical robot to do it, think again. Accumulating evidence discloses this thing will actually produce worse results unless – I repeat – unless, the prospective surgeon using it has at least 600 such operations under his belt. You really want to take a chance with some clown who's only done 12 or even only 100? Good luck on that!


Radiation treatments, which many opt for instead of surgery, are also dependent on the soundness of the center's treatment planning system and the skill, experience of the radiation oncologists delivering the doses. One thing you don’t want is an excessive dose of radiation which occurs in what’s called an “administration error” which can leave your bowels suppurating and your bladder in a mess, or ulcerating. Oh, and if you’re game for that new method using a giant linear proton machine, just be sure the oncologists administering the treatments don’t have a “geographical miss” – where the proton beam misses the cancer site totally and uh, goes through your bowel or bladder instead! As for a geographical miss hitting your penis instead, well we won’t go there, but it could make a clever horror flick!


Apart from incontinence, the greatest risk that surgical patients face post-op is loss of erectile ability. .The incipient damage is called "atrophy" which increases in probability the longer a patient goes without erection post-surgery. (Mulhall, p. 98) Atrophy is, in fact (ibid.):

"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".


If any former Mr. T-using Muscleman has these effects post -surgery, and is also unable to sustain enough blood flow he has another little complication to look forward to: a misshapen penis! Mulhall invokes the "use it lose it" saying here. In some cases, indeed, prolonged disuse engenders organs which are badly misshapen (bent as in a U-shape) and essentially unusable because of unequal scarring in different tissues.


Any guy seriously thinking of aping the muscle-bound CEO spotlighted on ABC News (in his T-regimen) would be advised to watch the video below first and pay close attention! Note the particulars of treating low testosterone, including the fact: a) testosterone can vary during the day so the time you get the blood test is critical, and b) the low testosterone can be due to multiple other causes than natural, including stress, fatigue, diabetes or other hormonal imbalances.


http://www.webmd.com/prostate-cancer/video/testosterone-replacement-prostate-cancer


If a guy has no T-problems and just wants to “muscle up” to look better, I say just be prepared for what’s coming later. It might also help to imagine yourself long past the cancer treatment stage when your dick is U-shaped, your breasts are bigger than Mariah Carey’s (so much you want to hide from your wife) and you have to wear giant diapers just to go to the corner 7-11.

PSA Test Results Are Back: To Celebrate or Not?

Barely ten minutes ago a nurse phoned from my primary care doc and gave the results of the PSA test taken last Friday, and roughly 3 months after the conclusion of my prostate cancer radiation treatment. She reported the PSA as 2.0 - which is "within normal range". While wifey was ecstatic, and this was definitely a positive,  considering it had gone up to 6.1 in June (before the biopsy and radiation treatment in September, see e.g. http://brane-space.blogspot.com/2012/09/thge-longest-dayand-then-some.html) I noted we still had to wait to see what Dr. Hsu of UCSF made of it. Would he be satisfied with this first post-treatment result? We'd have to fax the lab report to him then see.

In the meantime, I am not hitting the panic button though I had hoped the PSA would have been closer to 1.5. But in a way it makes sense. As I noted before one can't compare a first PSA taken 3 mos. after radiotherapy (even high dose) with that taken after radical prostatectomy because in the latter case the whole gland is effectively removed, while in radiation it is left in. Thus, one still has production of prostate specific antigen by the remaining intact cells of the prostate, and one knows this is fueled by testosterone. (I haven't had a test for testosterone level, but if I had I am sure it would show close to normal levels.)

The other thing one must bear in mind is that the effects of radiation are progressive. Most statistics show that by five years after radiation high dose treatment the effects are almost identical to those after radical surgery. In other words, my time line will disclose increasing effects- many of them negative - such as damage to the erectile tissue, blood vessels etc. as the effect of the radiation dose continues on the cells. Over this increasing time line, one ought to see a decrease in PSA, though as I also noted before there may be aberrations which occur - temporary blips upward- and then declines. A "treatment failure" is only reported when there is no further decline. When I hit the lowest PSA over a timeline, say two years, that will be defined as the "PSA nadir". If it pops back up, we call it a "PSA bounce". Ideally we don't see too many bounces!

The "cure rates" reported in most studies tend to depend on two factors: 1) the quality of the treatment, and 2) the average risk type of the patient. Note most studies are "retrospective" or ex-post facto, only concluded after the fact. This is consonant with both the nature of the disease and also the treatment, especially radiation. The problem is that accuracy is limited by variations in "risk types" for different institutions. (Oncologists do their best to match risk types from institution to institution but for a number of reasons the matching process is less than perfect, introducing uncertainty.)

In one of the most notable studies, completed by Dr. Patrick Walsh (who invented the modern form of radical prostate surgery) at Johns Hopkins, the 15-year cure rates as reported in the journal 'Urology' in 2007, were 85%, 63% and 40%. These were for low-risk, intermediate risk and high risk disease, respectively. (Let's also bear in mind that even the best surgeons in one study group left cancer behind in 10% of cases - as determined by the "positive surgical margin rate". This is the frequency, usually given as a percentage, of leaving cancer cells behind over a number of 'n' surgeries performed.

Meanwhile, in the most prominent reported study for (low dose) seed implant brachytherapy, in the International Journal of Radiation Oncology (2007), the cure rates were 86%, 80% and 68% for low, intermediate and high risk cancer.  (By all considerations my high dose rate brachy results ought to compare even more favorably!) In other words, the two methods compare very well at least from these two studies. (A futher interesting point is that a Johns Hopkins study has shown that relapses after surgery occur on average five years earlier than seed implants.)

In the end, it's a waiting game. Over more time, perhaps at least two years, the chief oncologist will be able to definitely say that the battle has been "won" or perhaps only drawn, or lost. Right now I am just elated to have a much lower PSA than I had 6 months ago, and will take that as a 'W'.