The Staging Guide Video Series | Transcription:

Hi, I'm Dr. Scholz. Let's talk about prostate cancer.

In today's video, we're going to talk about treatment-related side effects for surgery or radiation therapy for prostate cancer. The prostate gland is within millimeters of the nerves that control erections, the rectal wall, and the urinary passage which goes directly through the middle of the gland.

So specifically, we're talking about three types of side effects that men may have to deal with after surgery or radiation; Impotence - loss of ability to get erections, incontinence - some degree of leaking urine, or gastrointestinal problems, because the rectums right near there's a possibility for burns and things like this that can create difficulties with bowel movements. So, side effects from treatment then, can be a pervasive problem on a daily basis, since men's normal physiologic function incorporates urinary, gastrointestinal, and sexual activity. The reason we can talk about side effects in the context of prostate cancer treatment is because in many men with prostate cancer, it's not necessary to have treatment. About 50% of men with prostate cancer are diagnosed with a low-risk variant we call Sky, it doesn't spread and can be safely watched.

Let's take a minute and define a few terms. Impotence, meaning the inability to get an erection, in the prostate cancer world, interestingly, means that if you can get an erection using Viagra, you're not impotent. So most of the men out there thing that if you need Viagra to get an erection, that you have a problem with erectile dysfunction or impotence. But when you're looking at studies of outcomes after treatment, the doctors that publish these studies don't consider you impotent if you have to take Viagra. In fact, most men after treatment do need to take Viagra. So, as you evaluate the side effects of treatment you have to put that in context, that the majority of men are going to need Viagra to be able to function at all, and that isn't called impotence. It's only called impotence if men are taking Viagra and they can't get an erection.

The other interesting definition in this realm, where all these studies are done looking at side effects, is that any type of erection that can be achieved with Viagra is considered an adequate erection. Men get varying quality erections after surgery or radiation, and very, very few men describe the quality of their erections as matching what it was like before treatment. So there's a lot of loss of erectile quality after treatment that also needs to be considered, and isn't factored into the studies. When your doctor tells you that there's an 80% chance that you're going to have sexual activity afterwards, he's not revealing that you'll be taking Viagra and that the quality of your erections will be greatly reduced.

 When we talk about incontinence, the loss of urinary flow, they're only talking about where men have gross constant leakage, and that means that they're using pads. Even using one pad a day for minor leakage isn't considered incontinence in many of these studies. More importantly, stress incontinence, where men are coughing, jumping, or sneezing and having squirts or leaks, is not considered in the equation when doctors quote the risk of incontinence after surgery. So, typical top notch surgeons will tell you that the risk of incontinence is anywhere from 5-15% depending on your age. But that is only for the men that are using two or more pads a day; it doesn't include stress incontinence. And it doesn't include another type of incontinence that is rarely mentioned called climacturia, which means ejaculating urine after treatment, which occurs in about 20% of men who have surgery. So it's very important to nail down the definitions when you're talking to different practitioners about the potential side effects.

The third thing that men can run into, and it's much less common, 'cause it's more commonly related to radiation than surgery, and that has to do with burns of the rectum. And, this used to be a big problem with older technology and, even prior to the recent advent of something called SpaceOAR, which moves the rectal wall away from the radiation field, the doctors were reducing the incidence of proctitis - that is inflammation of the rectum - to a very dramatic degree. And so, in the past proctitis used to be a big risk, it continues to be a risk in unskilled hands. That risk can usually be eliminated altogether with the use of this new product called SpaceOAR.  

So as you can see, treatment for prostate cancer is fraught with a number of problems. The men that have the low-risk Sky variant of prostate cancer shouldn't be pursuing treatment and being faced with all these risks. They can safely watch the condition, and if there's a sign that the disease is changing, consider therapy at that point. And for the men that do need treatment, consider that all these physicians have different skill levels. Good practitioners have a lower risk of side effects, but it never is zero risk. And certainly, the old claim that surgery or radiation are essentially the same is not true. You have to carefully look at the side effects of each type of treatment and decide which one is best for you.  

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