Showing posts with label RP. Show all posts
Showing posts with label RP. Show all posts

Sunday, December 12, 2021

Gay men should never* have a prostatectomy

After over 10 years with gay prostate cancer support groups, I have come to believe that radical prostatectomies (RP) cause special and needless suffering in gay men and should never be used in them. Two great resources for gay men faced with this decision are these:

The Effects of Radical Prostatectomy on Gay and Bisexual Men's Mental Health, Sexual Identity and Relationships: Qualitative Results from the Restore Study

Threat of Sexual Disqualification: The Consequences of Erectile Dysfunction and Other Sexual Changes for Gay and Bisexual Men With Prostate Cancer

Gay men suffer more from prostate cancer

The distress caused by a prostate cancer treatment is worse for gay men than for straight men (HartUssherRosser). The excess distress among the "boomer" cohort may be rooted in a lower perception of societal status to begin with (discussed in The Velvet Rage), and the adoption of dominant culture point-of-view of gay men as hypermasculine or effeminate, and hypersexualized. The greatest threat to the identity of gay men with prostate cancer is the loss of erectile function.

"Just cut it out"

"Cancer panic" is a type of anxiety familiar to everyone who has had a cancer diagnosis. It is often followed by generalized depression and grieving over one's mortality. Anxiety and depression are the enemies of understanding. There is very little input that can occur. From the doctor's point of view, a great deal of information is imparted. But from the patient's point of view, all he may hear is "cancer blah blah blah."

For most of us, cancer seems to be an unvaryingly lethal disease. We all have loved ones who have died, sometimes painfully, from various types of cancer. The fact that prostate cancer is uniquely slow growing and we have biomarkers and diagnostic tests that often allow it to be cured is lost on many of us, if not intellectually, at least emotionally.

"Just cut it out" is a very natural first reaction. Often, well-meaning family and friends reinforce that initial reaction.

Results the same or better with radiation or active surveillance

The ProtecT clinical trial randomized men with localized prostate cancer to either active monitoring, radical prostatectomy (RP), or external beam radiation (EBRT). After 10 years there was no difference in oncological outcomes. While ProtecT didn't break down results by risk level (almost everyone was favorable risk), we now know that 55% of low-risk men are able to go without treatment for 20 years so far without grade progression (Klotz). Favorable intermediate-risk men have similar 10-year results with RP or SBRT. Unfavorable intermediate-risk men seem to have superior results with radiation (see this link), and high-risk men have much better results with brachy boost therapy than surgery (Kishan et al. 2018).

There were marked differences, however, in quality-of-life in ProtecT. There was higher risk of lasting incontinence and erectile dysfunction after prostatectomy.

Among men who were previously potent, only 35% maintained potency 2 years after nerve-sparing prostatectomy (Sanda et al, 2008). It was similar to EBRT in men who were 10 years older. Using better radiation techniques (like SBRT) has resulted in 2-year potency preservation of 79% (Chen et al.). Of course, active surveillance results in no incremental potency loss.

Age

Younger men do better with any therapy - RP or RT. When we are younger, our tissues are more resilient. Some have used that as an excuse for younger men to avoid active surveillance. In fact, there is no age at which active surveillance is not preferable in terms of long-term side effects (see this link and Lee et al.).

It has been argued that the risk of a second primary malignancy due to radiation is a major risk factor in younger patients. This recent study found that the "Probability of Second Malignancy was similar between SBRT and radical prostatectomy." It is tremendously difficult to attribute second malignancies to radiation. Hensley et al. has shown that men who have had bladder cancer (removed by cystectomy) are more prone to prostate cancer. The best estimates of risk are less than 1% (see this link and this one). Arguably, younger men have more intact DNA repair mechanisms.

Young, unpartnered and gay men are particularly impacted by "marginalisation, isolation and stigma—relating to men's sense of being “out of sync”; the burden of emotional and embodied vulnerabilities and the assault on identity." (Matheson et al.) A recent Pew study reported that gays are much more likely to be single than straights, especially gays over 45 (AARP). Gay men of all ages do not have the social support system of their straight counterparts.

Aging without expected erectile function is especially a problem for gay men (Ussher et al.)

Erectile Dysfunction

Even among men who are able to regain erections sufficient for vaginal penetration, they are seldom able to regain erections sufficient for anal penetration. At Memorial Sloan Kettering, arguably one of the best institutions at providing quality RP, "only 4% of men who were ≥ 60 years old with functional erections pre-surgery achieved back-to-baseline erectile function." (Nelson et al.) I would guess that drops to near zero for anal penetration.

As mentioned, erectile dysfunction is the single largest emotional and social problem for gay men, who are mostly single at the age when they are treated for prostate cancer. Gay men more than straight men face an identity crisis because their identities have been sexualized. With only 35% maintaining potency after RP, and even fewer left with erections sufficient for anal intercourse, they are effectively excluded from the dating market and face a lifetime of social isolation. Ussher et al. (2017) calls it "sexual disqualification"- exclusion from gay life.

The sudden loss of potency destroys many pre-existing relationships. Partners look for sexual satisfaction elsewhere, and often leave relationships as a result. Depression is a common result. There have been no studies of suicide following RP among gay men, an unmet need.

While orgasm is still achievable without an erection, many men do not find it worth the bother.

Loss of Ejaculate

While women can fake orgasms, men can't. We either ejaculate at orgasm, or we don't have an orgasm. Ejaculation is how men communicate that "it was good for me." Men are disappointed when their partners do not "cum." RP removes all ejaculate except for Cowper's gland secretions. RT reduces ejaculation, but in a recent trial of SBRT patients at Georgetown, only 15% were without ejaculate after 2 years. Anejaculation excludes men from relationships with other gay men. It is more bothersome to gay men (Wassersug et al.)

Ejaculation is how we've signaled orgasm to ourselves since puberty. Getting used to orgasms without ejaculation takes some psychological readjustment, whether gay or straight.

Perceived size loss

Another rarely discussed adverse effect of RP is size loss. Men are very conscious of size and compare themselves to others. Size is seen as a surrogate for masculinity, and many think that sufficient size is necessary for mutual pleasure. Size loss is difficult to measure objectively, but the perception of size loss can be patient-reported (but usually isn't). In a patient-reported study of 1411 men, 55% of men report size loss after RP (Carlsson et al.)That loss had a negative effect on their quality of life. Some patients complain that even sitting down to pee they are unable to point their micropenis into the toilet. Gay men with such size loss universally do not undress in front of others.

Climacturia

Shooting urine at orgasm (climacturia) is another non-regularly reported side effect of RP. Incidence was as high as 44% at 3 months post RP and 36% at 24 months post RP (Mitchell et al.). For many men, gay or straight, it is embarrassing and bothersome. Many give up sex because of it.

Penile sensitivity/dysorgasmia

Because of damage to the pudendal nerve during RP, some men report penile pain (usually temporary) or loss of sensitivity (maybe permanent). Perhaps related is reported pain during orgasm(this seldom occurs). This is often not reported.

Anal Pleasure

I've heard mixed reports about whether receptive anal sex (bottoming) is as pleasurable post-prostatectomy. Some feel that pushing against the prostate and pushing out cum is an important source of pleasure. Others feel that filling the rectum is all that's necessary. Ussher reports that many men who are in relationships who previously enjoyed "topping" switched to bottoming when they could no longer perform. Many were unhappy about switching roles. This has only been qualitatively researched.

Myths

There are two myths that are prevalent about radiation, and they affect decision-making among gays and straights equally. The first myth is that salvage after radiation is nearly impossible. While it is true that surgery after radiation is fraught with peril and should never be done, it is untrue that no salvage is possible. In fact, salvage after RT often has better results both oncologically and in terms of side effects compared to salvage RT after surgery (see this link). More to the point, with 10-year biochemical recurrence-free survival after RT over 95% for favorable risk, and over 80% for the highest risk patients, and with better PSMA PET patient selection, salvage should not be an overriding concern. It is a mistake to think that one can always have salvage. Side effects are always worse than if RT had been given originally.

The other myth is that with radiation, side effects crop up with time. One need only look at the patient-reported outcomes in the 6 years of the ProtecT trial to see it isn't true (see this link). With radiation, acute side effects are highest in the first 6 months and decrease afterward. That is not to say there are no late-term effects, but it is extremely rare for an entirely new side effect to occur later that has never occurred before. Erectile dysfunction naturally increases over time as men age. In a very elegant study, Keyes et al. showed that half of the long-term decline in erectile function among men getting brachytherapy was due to normal aging. ED does occur with radiation, but there is significantly less.

ADT

It is worth mentioning that those with advanced prostate cancer who must use ADT, often complain of their loss of masculinity. When RT is used for high-risk localized prostate cancer, adjuvant ADT is temporary. However, if proper preventive measures aren't taken (e.g., penis pump), there could be permanent size loss.

Lack of Research

The major instruments/questionnaires for evaluating quality-of-life after treatment, EPIC and SHIM, do not ask about most of the above adverse effects of treatments. Indeed, they do not ask men if they have sex with other men. What does not get measured, does not get acted upon. If there are any solutions to the above adverse effects of RP, they are not being studied intensively, if at all.

Most urologists have no idea if their patients are gay or straight. Sometimes they bring their male partner if they have one. But most often they are not out to their doctor because they are fearful that their doctor may have anti-gay attitudes and will somehow provide lesser treatment.

Advice

Slow it down!: For men diagnosed with localized prostate cancer, there is ample time to make a decision. Treatment delays have been studied (see this link), and treatment delays of 3 months, even in high-risk men, do not make a difference in outcomes. Your initial cancer panic will subside with time, and you will be able to make a more reasonable decision. Doctors should never accept a treatment decision within one month of diagnosis, and probably not even within 3 months, especially with the approval of PSMA PET scans for unfavorable risk patients. If your diagnosis is low-risk, join an active surveillance program. Even some favorable intermediate-risk men with small amounts of pattern 4 can buy time on active surveillance.

Tell your doctor that you're gay. Very few are bigots in major cities. If you live in Buttfuck, KY you should not have a prostatectomy there anyway. Remember that your doctor is of limited use in helping you grapple with the emotions necessary or even provide much of the information necessary to make this decision, and won't be there to pick up the pieces afterwards. A recent NY Times article described a novel program at Nothwestern University in Chicago to help gay men after prostate cancer treatment.

Join a support group. One can read all about this stuff, but things like loss of ejaculate and size loss won't be real to you unless you experience them. The next best thing is talking to a live person who has experienced them. (This is called the "availability heuristic," by the way.) It is one thing to understand intellectually, but quite another to feel it. Seeing a grown man cry about his micropenis has more impact than reading that penile shortening occurs.

Go into psychotherapy/ learn mindfulness: We all have baggage about cancer. Learn what kind of baggage you are carrying and whether you are hampered by it. If you can, take a class in mindfulness. With practice, it will help you stay in the present moment instead of ruminating endlessly about low probability future outcomes.

Talk to a Radiation Oncologist: We all started with a urologist. Sometimes, he did your biopsy. Many are trained as surgeons. Some surgeons are "hot dogs" who believe they can cure the common cold. They usually recommend surgery, because it's what they do. (If they don't believe in surgery, they wouldn't be a surgeon.) Get out and find a radiation oncologist before you make a treatment decision.

Don't ask the doctor what he would do if you were his father! This is probably the question patients most often ask, but shouldn't. You are asking one specialist to also be a specialist in another therapy. A doctor well-trained in shared decision-making will deflect your question: "what more can I tell you, so that you feel able to make this decision for yourself?" Even if the doctor is gay, he is not you - he has his own set of concerns and biases.

*OK, there are exceptions, but very few.

(1) There are very few men who are super-sensitive to radiation cannot have it. 

(2) Some men have BPH to such a degree that radiation will inflame the prostate and cause the urethra to close up. Most such men can have a TURP procedure before radiation. TURPs usually cause reverse ejaculation (semen goes up into the bladder). But it is also necessary to wait several months before radiation begins; otherwise, there is risk of incontinence. 

(3) Men with a history of intractable relapsing prostatitis. 

Sunday, December 3, 2017

Questions to ask (and not ask) on a first urologist visit after a biopsy


  1. Am I a good candidate for surgery? What about anatomic abnormalities, previous hernia, effects of anesthesia, cardiovascular disease, diabetes or other comorbidities?

  2. I would like to get a second opinion on my biopsy slides from Epstein's lab at Johns Hopkins. (Here's the link.)

  3. What is my highest Gleason score? How many cores were positive? What was the highest percent of cancer in any core?

  4. What is my stage, and risk level? (You should  know your PSA – if you don’t, ask). How big is my prostate, and what is my prostate density?

    • If stage is T3 or T4: How can surgery be a good option if only the prostate capsule is taken out, leaving the rest behind? Aren’t the side effects of adjuvant radiation worse than if I had radiation at the start? (he may not know this.)

  5. Am I a candidate for active surveillance (why, why not), and if so, what are your Active Surveillance criteria and protocol? Why those and not something more or less stringent? Should I get a genetic test before deciding? Will that be covered by insurance?

  6. How many of the surgery technique you practice (whether robotic, laparoscopic or open) have you performed? (1000+ would be a good answer)

  7. Are you going to be doing all of the really important parts of my procedure yourself? (You need to be particularly careful about this at major training institutions where residents may be doing some parts of the surgery, or even the whole operation, while “your” surgeon is overseeing it.)

  8. In the last year, what was your positive surgical margin rate? (Should be less than 10% among men with stage pT2)

  9. What is your "trifecta" rate? (tricky because you don't want cherry-picked patients)

  10. What is your estimate of my risk for lasting incontinence; i.e., a pad or more after a year?

  11. What about lasting stress incontinence? climacturia? penile shrinkage? inguinal hernia? Peyronie’s? orgasmic pain or dysfunction?

  12. What kind of anastomosis technique do you use? (total - not just anterior)

  13. Will the bladder neck be spared? How will you maximize the urethral sparing?

  14. If you have positive biopsy cores near the apex: How will you ensure that all cancerous tissue is removed there?

  15. Will you take frozen sections and have a pathologist standing by to determine margins and how much of neurovascular bundles can be spared?

  16. What measures will you take to assure the integrity of the neurovascular bundles?

  17. What kind of penile rehab do you suggest?

  18. What kind of imaging (Bone scan, CT or MRI) is necessary for men at my risk level?

  19. Will you sample lymph nodes (PLND) or take extended lymph nodes (ePLND), or does it seem unnecessary for my risk level? If so, how will you find them (fluorescent dye)? How will you minimize risk of lymphocele and lymphedema?

  20. What kind of aftercare (including sexual rehab) will you provide, and how will we monitor side effects, and for how long? Will you regularly monitor my urinary and erectile recovery progress with validated questionnaires like EPIC and IPSS?

  21. How will I be monitored for recurrence? Will I get an ultrasensitive PSA test? How will you decide the point at which you would recommend I see a radiation oncologist? Do you use the Decipher test?

Questions not to ask:

  1. Is my age a factor in whether active surveillance is right for me? (only you can decide whether you are willing to live more years with the side effects of treatment, or whether you prefer to be treated while younger when side effects are apt to be less - see this link)

  2. What treatments should I consider and which is the best for me? (this would be asking your doctor to be an expert in treatments outside of his specialty, and also to know which benefits and risks are most important to you – he doesn’t have time or inclination to be expert in all therapies, and he’s not a mind reader.)

  3. If I were your father, what would you recommend? (You don’t know how he feels about his father (lol), and more importantly, what he would feel most comfortable with is not necessarily what you would feel most comfortable with. This is your decision to make and live with – don’t give up your power!)

Monday, February 13, 2017

For very high-risk patients, EBRT + BT is superior to surgery or EBRT only (Redux)

In August, Kishan et al. showed a preliminary analysis of oncological outcomes among Gleason score 9 and 10 patients treated with brachy boost therapy (EBRT+BT), external beam radiation therapy alone (EBRT) or surgery (see this link). Because of the limited sample size, some of the differences were not large enough to be statistically significant. Kishan et al. have now expanded their analysis to include 1,001 patients treated between 2000 and 2013, who were treated at several of the top institutions in the US: UCLA, Fox Chase, Cleveland Clinic, Mt. Sinai, and Wheeling Hospital. So far, only an abstract of the study has been presented at the GU Conference. The patient characteristics were as follows: 
  • 324 were treated with radical prostatectomy (RP).
  • 347 were treated with EBRT only.
  • 330 were treated with EBRT + BT (BT was either low dose rate or high dose rate).
  • All patients were Gleason 9 or 10 on biopsy.
Treatment specs
  • Among the RP patients, 40% had adjuvant or salvage radiation therapy (68 Gy).
  • Among radiation patients, 90% had adjuvant ADT
  • Median dose of EBRT was 78 Gy.
    • adjuvant ADT continued for 18 months, median.
  • Median equivalent dose of EBRT+BT was 90 Gy
    • adjuvant ADT continued for 12 months.
Oncological outcomes

After a median follow-up of 4.8, 6.4 and 5.1 years for EBRT, EBRT+BT and RP, respectively, the oncological outcomes were as follows:
  • The 10-year rates of distant metastases were
    • 39.9% for RP 
    • 34.2% for EBRT
    • 19.7% for EBRT + BT
    • Differences between EBRT + BT and the two others were statistically significant.
  • The 10-year rates of prostate cancer-specific mortality (PCSM) were
    • 20.3% for RP
    • 25.2% for EBRT
    • 14.1% for EBRT + BT
    • Differences between EBRT + BT and the two others were statistically significant.
The authors conclude:
Extremely dose-escalated radiotherapy offered improved systemic control and reduced PCSM when compared with either EBRT or RP. Notably, this was achieved despite a significantly shorter median duration of ADT than in the EBRT arm. 
Prostate cancer-specific mortality rates were cut in half by combining EBRT with a BT boost. While this does not prove causality (only a randomized clinical trial can do that) it is highly suggestive that escalated dose can provide lasting cures. There may be good reasons why some high risk patients may have to forgo brachy boost therapy in favor of high dose EBRT or RP with adjuvant EBRT, but for most, brachy boost therapy with ADT will probably be the best choice.

Sadly, a recent analysis of the National Cancer Database showed that utilization of brachy boost therapy for high risk patients has declined precipitously from 28% in 2004 to 11% in 2013. If a patient sees anyone other than the first urologist, he often only sees a single radiation oncologist who only informs him about IMRT. In most parts of the US, there is a dearth of experienced brachytherapists.

Saturday, September 17, 2016

Patient-reported outcomes from ProtecT - the first randomized trial comparing surgery, radiation, and active surveillance

While there were no differences in 10-year mortality when patients were randomized to surgery (RP), external beam radiotherapy (EBRT), and active surveillance (AS) (see this link), the side effects patients suffered from those treatments differed markedly. Johnson et al. have published the patient-reported outcomes of the ProtecT trial in the New England Journal of Medicine (see this link).

In the ProtecT trial, all participants (or actually 85% of them) filled out a series of validated questionnaires (EPIC and others) that probed issues of urinary function, rectal function, sexual function, and general health. I will ignore the overall health, vitality and mental status questions for now. Suffice it to say that they did not differ among therapies, nor were they very much affected by them. Questionnaires were filled out before the biopsy (the baseline), and at 6 and 12 months after randomization, and annually thereafter until 6 years from the initial biopsy.

What is especially interesting is seeing how equivalent patients (they are equivalent because they were randomized to the 3 treatments) did over the 6 years after receiving each treatment. This means that, for the first time, the side effect profiles are completely comparable (well, almost) and almost without bias.

Some messy data

I say "almost" because there was some switching of treatments that did occur. 22% of the men did not get the therapy they were originally randomized to, and they self-selected some other therapy or no therapy. However, in the analysis they are treated as if they got therapy that they were originally intended to get. Strange, huh?

In addition, they may have received salvage therapy after biochemical failure, and 55% of those assigned to AS did get a radical therapy eventually. So for each intended therapy:
  • Among those 291 men who started on AS but got radical treatment: 49% had surgery, 33% had radiation as specified, and 18% had another kind of radiation or HIFU
  • Among those 391 men who started on RP, 14 (4%) had adjuvant or salvage radiation, and 1 went on lifelong androgen deprivation therapy (ADT) within a year.
  • Among those 405 men who started on EBRT,  3 had salvage RP, 14 (3%) went on lifelong ADT, and 1 had HIFU.
Whether men had the assigned therapy or not, and irrespective of any other therapy they had, they are included with the group they were originally assigned to. It's messy.

Fortunately, there's hope in sight. In one of the Appendices (Section S3), they added the note:
"In future analyses, we intend to present patient-reported outcomes according to treatment received and an economic evaluation including assessment of therapies received for treatment impacts, as well as details about the reasons for change of management in the active monitoring arm to further inform individual and clinical decision-making"

That will give us a much truer picture of the side effects associated with the treatments they actually received.

The treatments

RP was open and nerve sparing. While most men now have robotic surgery rather than open surgery, it seems to make little difference, except for some higher incidents of issues arising during the operation (see this link).

AS did not have required follow-up biopsies, so their side effects may be a little better than on contemporary AS programs. Biopsy complications are never long-lasting anyway.

EBRT was different from contemporary standards. The dose was lower (74 Gy vs. 80 Gy), so there may have been fewer complications due to dose. They used an older delivery technique (3D-CRT vs IMRT) which had higher rates of side effects. And it was given together with short term (3-6 months) of ADT, which would certainly increase the early sexual side effects. ADT is seldom given to favorable risk patients today.

note: all of the patient-reported outcomes include the effect of whatever remedies they used to treat them.

1. Urinary Adverse Outcomes

a. Incontinence

This was a big issue for RP, of course, but not for AS or EBRT. The percent using one or more pads per day is one commonly used measure. As one can see in the following table, incontinence was highest at the 6-month time point, but had gotten somewhat better by the end of the first year. 20% were incontinent by the end of two years, with little improvement from that point.

For EBRT, incontinence peaked at 5% at 6 months. Remember, this was 3D-CRT - a technology that has greater toxicity than the IMRT predominantly in use now. It hovered around 3-4% thereafter.

For AS, incontinence also peaked at 4% at 6 months, and stayed at that level for the next couple of years. From then, it steadily rose to 8% by the end of the 6 year study. Remember that for the purposes of this trial, men were still included in the AS cohort whether they were eventually treated or not. By 6 years, more than half the men had been treated, primarily with surgery.

Table 1. Incontinence: The percent who used one or more pads per day

Time point
AS
RP
EBRT
Baseline
0%
2%
0%
6 months
4%
46%
5%
1 year
4%
26%
4%
2 years
4%
20%
4%
3 years
5%
20%
3%
4 years
7%
17%
4%
5 years
7%
17%
3%
6 years
8%
17%
4%


b. Urinary Irritation/Obstruction

The researchers examined the question of whether urination become more difficult or more frequent after therapy. One way to look at this is a set of questions on the EPIC questionnaire asking about urinary frequency and retention. On that questionnaire, a score of 100% means that function is perfect in that regard, no issues whatever.

On this dimension only EBRT had a clinically detectable effect, and it was only at the 6 month mark. EPIC score dropped from 93% to 84%. After that, it returned quickly to baseline levels.

Table 2. Urinary Irritation/Obstruction EPIC scores, where 100% would be the best possible score.

Time point
AS
RP
EBRT
Baseline
93%
92%
94%
6 months
92%
89%
84%
1 year
93%
93%
93%
2 years
92%
93%
93%
3 years
91%
93%
93%
4 years
91%
94%
93%
5 years
92%
94%
93%
6 years
92%
94%
93%

2. Rectal Adverse Outcomes

The researchers asked the trial participants about their bowel function at baseline and after treatment. There were no discernable effects of AS or RP. Bowel function among the men enrolled for EBRT declined by 6 months (from a score of 93% to 86%). Thereafter, bowel function scores returned to near baseline levels. Other than the 6 month time point, there were no significant differences among the 3 treatments.

Table 3. Bowel function EPIC scores, where 100% would be the best possible score.

Time point
AS
RP
EBRT
Baseline
92%
91%
93%
6 months
91%
92%
86%
1 year
92%
93%
90%
2 years
92%
93%
90%
3 years
92%
93%
91%
4 years
92%
93%
91%
5 years
92%
93%
90%
6 years
92%
92%
91%

3. Sexual Adverse Outcomes

This is one of the few trials that asked men detailed questions about their sexual function at baseline and for 6 years thereafter. One of the key measures of sexual function is the ability to have erections firm enough for intercourse. At baseline, about two-thirds of these 62 year old men (range 50-69), some with other comorbidities like diabetes, cardiovascular disease, and smoking, had suitable erectile function. 

None of the questionnaires asked about perceptions of penile shrinkage in length and girth, climacturia (urination at orgasm), or Peyronie's (abnormal penile curvature), which are often symptoms that affect sexual function post-prostatectomy. Nor do they ask about how the loss of ejaculate has affected sex. That is a certainty with surgery, a near-certainty after radiation, and is not affected by AS. Their definition of erectile function includes the effect of any erectile function aids (e.g. ED meds, injections, pumps, or implants) they may have been using.

For those randomized to RP, erectile function was reduced to 12% at 6 months (remember: they all had nerve-sparing surgery). It recovered somewhat to as much as 21% at 3 years but did not recover beyond that. At every time point, their erectile function was significantly worse than the other treatment cohorts.

For the AS cohort, erectile function declined by 6 months and continued to deteriorate thereafter as they elected to have radical therapies, predominantly surgery. 11% of this cohort had already elected to have radical treatment by the 6-month mark.

For the EBRT cohort, erectile function had dropped to a minimum value of 22% at 6 months. This may be largely attributable to the fact that all of the men in the EBRT cohort had 3-6 months of ADT. It is unknown how much, if any, of their testosterone came back after that and how long it took to recover. Erectile function snapped back a bit post-ADT, getting as high as 38% at 1 year, and declined to 27% by 6 years. Again, this was based on the 3D-CRT technology, and is below the rates usually seen for this age group with IMRT, brachytherapy, or SBRT.

Table 4. Erectile function - the percent who had erections firm enough for intercourse

Time point
AS
RP
EBRT
Baseline
68%
65%
68%
6 months
52%
12%
22%
1 year
49%
15%
38%
2 years
47%
19%
34%
3 years
41%
21%
34%
4 years
37%
20%
32%
5 years
35%
20%
27%
6 years
30%
17%
27%


Myths Exploded by this study:

Myth #1: The side effects end up about the same for surgery or radiation

That's clearly not true for incontinence or erectile function, It is true for urinary irritation and rectal function, which are at baseline levels and similar in all cohorts at 6 years.

Myth #2: With surgery, you get the side effects all at once and steadily recover; with radiation, the side effects come on steadily and may hit you many years later.

What we've seen here belies that myth. There is some recovery of continence up to two years later, but not thereafter. After radiation, incontinence was a minor symptom (except to those who had it, of course), but it did not increase over the years. Urinary irritation/obstruction increased at 6 months for EBRT, but returned to baseline permanently thereafter. Rectal function scores also permanently returned to baseline levels after the 6-month time point.

Myth #3: Over time, erectile function is about the same for surgery and radiation. 

As we've just seen, erectile function is much worse after surgery, and it never recovers much beyond 2 years. It is worth tracking this myth down to its source. I have even heard John Mulhall, the eminent Memorial Sloan Kettering sex specialist quote this myth.

I believe this myth started with the PROSTQA study published in 2008. Until the ProtecT trial, it was our best source of patient-reported outcomes after the various treatments. The patients were not randomly assigned, however, and differed markedly in their characteristics. Those characteristics, especially age, varied greatly with the treatments they chose. In the following table, hidden in an appendix (all the good stuff is usually back there), we can extract the following table:

Table 5. Percent with preserved erectile function sufficient for intercourse 2 years after treatment, broken down by age at treatment 



Age
RP
EBRT
BT
<50
55
100*
75*
50-59
43
52
67
60-69
27
39
44
70+
8*
30
24
Total
35
37
43
Median Age
60 years
70 years
66 years

small sample size

Although the potency doesn’t seem to vary much between treatments in total (range 35% to 43%), it is only because the men who received EBRT and BT were older than the men who were treated with RP. Within every age group, potency preservation was higher with radiation.

There are other differences between the two studies, such as: 
• this table only includes men who were potent before therapy, which would exclude about a third of men in the ProtecT trial. This would lower all the percentages in Table 5 relative to Table 4. 
• ProtecT included only men in the 50-69 age range, while half of the findings in ProstQA came from men treated with radiation over the age of 70. 
• Finally, ProtecT didn't yet report erectile function according to the therapy or therapies they actually received.

It is gratifying to see these myths shattered. Patients are the beneficiary.