I saw a patient recently as a second opinion regarding what to do about his newly diagnosed prostate cancer.
“What is most important to you?” I asked.
He said, ” I want my very best chance of cure regardless of the side effects. I also want to be able to do something curative if the first treatment fails.”
In my mind what this describes is a patient that wants the prostate removed and then if the PSA rises after treatment then curative doses of radiation is still an option. Certainly there are caveats in this scenario i.e. the parameters of the biopsy and the patient’s underlying health.
So this person helped me. He told me what is important to him. That, many ways, helped me advise him what to do. In other words, to me as the doctor, I need to know “who are you.”
Today, a patient told me after my having told him that his prostate biopsy showed small amounts of cancer, told me this.
“I have to work. I cannot risk something happening to me that will preclude me providing for my family or keeping my business going.”
That helped me. To me that took a prostatectomy off the table. I don’t feel there is enough of a difference in cure to push surgery in this patients situation. I told him he might have aggravating symptoms of radiation but that he probably would not have a major complication that would keep him from working. I mentioned that active surveillance, or seed therapy would have minimal impact on what was important to him i.e. his job. Customized care….that’s what I try to give my patients. It’s not about me, it’s about them.
So back to Ted Danson and his cancer on the show “Bored to Death.” Watch the trailer.
“Fiscally responsible, sexually out of control.”
Here is a patient that puts his sexual function to the forefront in the decision. You might think this odd. But prostate cancer is unique that way. Patients often put other issues ahead of cure. The reason is that in prostate cancer, if the parameters are favorable and we don’t know Ted’s, you can balance quality of life with chances of cure. So what to do with Mr. Danson and his cancer.
McHugh “Who are you ” factors and why they are important.
Let’s assume he has favorable parameters…low PSA, low volume and a Gleason’s of 6….what would I recommend if I am asked to be the second opinion on the show. (By the way I am available and would readily fly to the show free of charge and be on that particular episode.)
Favorable parameters: “Mr. Danson, your promiscuous lifestyle and the importance of sexual activity makes you an excellent candidate for active surveillance.” You would need a PSA twice a year and a prostate biopsy once a year. We would abandon this if any of your parameters progressed. If you can accept the small risk of “doing nothing” you are an excellent candidate for this.”
“If you are not comfortable with surveillance then I’d recommend external beam radiation. The reason I would not recommend surgery is that no surgeon in the world can promise you that after surgery you will regain your potency. With radiation you may experience a deterioration in your function but in most cases this can be corrected with medications. Seed therapy, I feel, has a slight higher chance of negatively affecting your sexual function so that might not be best for you.”
Here’s the caveat here….one can have perfect sexual function after prostatectomy, but you can’t promise that. There is risk with that from a purely sexual consideration. I feel I am very good at a Walsh Nerve Sparing Prostatectomy and my patients do well on all fronts as rule…but I cannot promise continence, cure, or in this case potency. No one can, I don’t care who tells you that.
If the advisors of the show consider all…Mr. Danson will not be having a prostatectomy. The only thing that will trump his concerns about sex, would be if he freaks out about cure. If a patient does this, in most cases they will choose to have the prostate removed.(Of course by the “robotic” method. If he chooses radiation it will be “Proton.” He’ll need to be trendy for sure. A thought just crossed my mind. He may be advised to have HIFU, and fly to Bermuda for the treatment. So very Hollywood like.) It could happen. Funny things happen to a man and his mind and the people who love him when he is told, “you have cancer. ”
Trust me. I’ve been there.
Prostate Diaries 
John,
I already made my decision and am 7 weeks post op robotic assisted, small volume, Gleason 3+4= 7 at biopsy and downgraded to 6 at path. Low PSA 6.4. If I had known pre-op I’d be Gleason 6 I would have probably elected active surveillance at age 57. This says to me we need better tests to separate AS disease from that needing treatment.
I read an abstract today on Uro Today about ED increasing with the number of biopsies one has. I had my first biopsy, 10 negative, in 2006. When my PSA rose recently I had 1/18 biopsies positive. Being Gleason 7, I worried what if I had Gleason 8 or worse and that prompted me to surgery. I do think my sexual function showed a decrease after that first biopsy, but could be normal aging, and it was very minor. Just wondered what you thought about the consequence of regular biopsies as is recommended in AS schemes. And when are we going to have a good test to know if you have indolent disease or the bad stuff ready to metastasize in a moment’s notice.
Russ
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I hope you are getting along well and the things that matter are coming back okay. On biopsies, I had not heard that. I have thought before that it would be possible at the time of biopsy samples where taken laterally and damaged the nerves responsible for erections. We also do our prostate blocks by injecting at the base of the prostate where the seminal vesiclses come in, so I would think it is possible. Some urologists are doing upwards of 50 samples at a time and certainly one could conceive damage.
On the upgrade stuff….It would be interesting to have your pathologist re-read the original biopsy. Gleason’s is a subjective call by the pathologist. It might be that a different person read each. Another pathologist may have confirmed the biopsy’s original Gleason’s. I worry more about a biopsy being upgraded, than down graded but I do see your point about that it may have influenced your decision.
They do need better markers for which cancers will behave badly, but for now, the Gleason’s score is the best we have. Gleason’s 6-7 can act benign or progress. But here’s the thing…. you can count on Gleason’s 8-10 placing a patient at risk for progression.
On the bright side, you don’t have to worry about having prostatitis, the voiding symptoms of BPH, and all the other things males deal with regarding the prostate as we age.
Again, I hope you do well, I wish you the best and I appreciate you visiting the site. Ps……your email address…I envision skyking the show and a single engine plane flying around out west. Are you a pilot? jm
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Yes, I teach people how to fly motorgliders in Arizona! Am continent, just awaiting return of erectile nerve function. Using injections, but my urologist uses a very low concentration of bimix (trimix caused me a lot of pain)- 18 mg/ml paparevine and only 0.6mg/ml Regitine/phentolamine. Dont’ get rigid even at 70 units. He says just be patient. Any tips on getting those nerves back to work asap?
Here’s the abstract on the article regarding biopsy side effects on the nerves:
Serial prostate biopsies are associated with an increased risk of erectile dysfunction in men with prostate cancer on active surveillance – Abstract
Wednesday, 11 November 2009
Brady Urological Institute, The Johns Hopkins University, Baltimore, Maryland.
We determined whether serial prostate needle biopsies predispose men to erectile dysfunction and/or lower urinary tract symptoms over time.
Men with prostate cancer on an active surveillance protocol were administered the 5-item Sexual Health Inventory for Men and International Prostate Symptom Score questionnaires on protocol entry, and at a cross-sectional point in 2008. All men had at least 1, 10 to 12-core prostate biopsy at protocol entry and yearly surveillance biopsies thereafter were recommended.
Of 333 men 231 returned the followup questionnaires. Correlations were found between biopsy number and erectile dysfunction, with increasing biopsy number associated with a decrease in Sexual Health Inventory for Men score (p = 0.04) and a history of 3 or more biopsies associated with a greater decrease in Sexual Health Inventory for Men score than after 2 or fewer biopsies (p = 0.02). Multivariable analysis for biopsy number, age, prostate volume and prostate specific antigen showed that only biopsy number was associated with decreasing Sexual Health Inventory for Men score (p = 0.02). When men were stratified by baseline Sexual Health Inventory for Men, those without preexisting erectile dysfunction (Sexual Health Inventory for Men score 22 to 25) trended toward steeper decreases in Sexual Health Inventory for Men score after 3 or more biopsies (p = 0.06) than did men with baseline mild to moderate erectile dysfunction (Sexual Health Inventory for Men score 8 to 21). No correlation was found between biopsy number and International Prostate Symptom Score.
Serial prostate biopsies appear to have an adverse effect on erectile function in men with prostate cancer on active surveillance but do not affect lower urinary tract symptoms.
Written by:
Fujita K, Landis P, McNeil BK, Pavlovich CP. Are you the author?
Reference:
J Urol. 2009 Oct 15. Epub ahead of print.
doi:10.1016/j.juro.2009.08.044
PubMed Abstract
PMID:19836757
Russ
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