Hi everyone, a lot of you have been submitting YouTube comments,
and a lot of you guys have questions on prostate cancer that you would like us to ask Dr. Scholz,
and today we're going to answer those questions.
So, our next question is regarding Cialis and Viagra. They would like to know if it would
be a helpful solution after radiation treatment to help with any potential permanent ED issues?
We don't know, yet, if taking Cialis and Viagra as a preventative measure will
improve the long-term recovery rates for people that are on radiation or have had radiation.
We do know, of course, if people develop erectile dysfunction that
some of them will respond very nicely to Cialis and Viagra, others won't.
So, this concept of preventative maintenance for people having radiation is really not clear at
this point. Perhaps a little bit more convincing is people that are taking hormone therapy along
with the radiation probably do benefit by taking some Cialis or Viagra during the time that
they're getting hormone therapy. Hormone therapy causes temporary loss of libido and often the
loss of capacity to get erections and then these men that are having long-term absence of erections
can develop atrophy, so we typically put everyone on Cialis when they're taking hormone therapy.
Our next question is how likely is someone to be impotent 1, 5, 10, 15 years after radiation
treatment with brachytherapy and 25 sessions of EBRT (external beam radiation therapy)? So,
this patient says his brachytherapist says it's unlikely he will have problems but his
radiation oncologist doing the EBRT says he will lose function very soon,
so he would like to know which is it?
Neither one. The the number you pull out of the air for people getting any type of radiation,
whether it's seed implants, IMRT, proton therapy is about 50/50 in say a 70 year
old man and the numbers are better when you get younger and worse when you get older.
The onset of erectile dysfunction after any type of radiation
seed implants, IMRT, proton therapy is usually within the first two years after treatment.
So, people that make it out two years and haven't run into trouble have the same risk of developing
erectile dysfunction as other men the same age. As we know, as men get older they also develop ED
unrelated to radiation therapy. So it doesn't matter what type of radiation you get unless it's
some sort of focal radiation and in men that are not radiating the whole prostate there is a lower
risk of developing ED, but for standard seed implants, proton therapy, IMRT,
SBRT it's about 50/50 in a 70 year old and it's probably about 1 in 3 in a 60 year old.
Another question regarding radiation side effects—it says that we did a video on radiation
side effects but we never really covered the seriousness of delayed side effects as far
as I—like the person can tell—is there a way to assess the degree of delayed side effects
several years out? Does any data exist? It seems like surgery,
you kind of know the side effects immediately whereas with radiation
you don't know what the next day will bring and that's kind of concerning.
Well, I mean the whole issue of radiation side effects is a complex
issue. The PCRI has a nice video by Dr. Mike Steinberg that goes through and talks about these
things and this question focuses on long-term side effects and that's really what matters.
Short-term side effects, you know, they go a couple months and they're you're past it. This is
a moving target. Older radiation caused a lot more long-term side effects than modern radiation does
and these days the main concern is the development of erectile dysfunction which as we've mentioned
occurs in anywhere from a third to a half of men depending on their age. The other ugly terrible
things that used to happen like burned rectums has been pretty much eliminated with SpaceOAR and
the other problem, of course, is bladder issues because the urethra goes right through the middle
of the prostate and that problem is fairly rare but it can be problematic especially in men that
need some sort of treatment later on—let's say they need to have a TURP or a laser-TURP
because they've developed urinary problems. That becomes a very dicey situation. So, long-term
side effects have become less and less frequent with the advent of better and better technology.
The one concern to think about is if you're going to need some sort of treatment for an
enlarged prostate like a TURP down the line, it's better to have it before the radiation than after
the radiation because radiated prostate tissue doesn't heal as well. Other than that, we're not
seeing a whole lot of long-term issues with the most modern types of prostate cancer radiation.
So, our next question is if beam radiation is so accurately pinpointed, why do they tell us that
impotence is imminent down the road because the margins (nerve bundles) will be collateral damage?
Well, it is accurate, but they accurately target the whole prostate and the nerve bundles are
right on the surface of the prostate. So there's for people that are getting standard radiation
treatments, they as we've mentioned before, will have a risk of impotence—not everyone will become
impotent but there's certainly a risk—and this of course is the attraction of more modern thinking
about doing some sort of focal radiation where the tumor itself with the margin is targeted rather
than the whole prostate and, in those individuals, the risk of erectile dysfunction is less.
The next patient is asking does IMRT have the same cure rates as surgery?
In intermediate-risk disease and in low-risk disease,
the cure rates are the same with modern IMRT and surgery.
As you get into the high-risk category IMRT alone probably has about the same cure rates, but if you
do standard IMRT plus brachytherapy, which should be done for all high-risk cases,
the cure rates are going to be better with radiation than they will be with surgery.
Our next question says, does the location of the tumor within the prostate affect the
recommendation for treatment—so surgery versus radiation—and the potential side effects? I
realize that either radiation or surgery would be to treat the entire prostate but suppose the
example of a tumor is at the apex of your the urethra, could this not increase the likelihood
of long-term incontinence with either treatment or would this alter the treatment recommendation?
Well, I'm not much of fan for surgery under any circumstances but people that have tumors down
near the apex are particularly bad candidates for surgery because the surgeons want to leave
a little bit of prostate in the lower part of the gland so that they don't
cause impotence when they take the prostate out. If the tumor's right there, they're going
to have to be cutting through tumor to take the gland out they're going to leave cancer behind.
So that's one situation—particularly—you don't want to do surgery is when the tumor is down
in the apex of the gland. Again, I'm not a fan of surgery for anyone these days given
the side effects of radiation are much less than surgery, but but that's probably the only
real particularly bad type of situation for doing surgery is apical cancers.
Other than that, the location of the tumor doesn't matter that much—as pointed out by
the questioner—because the whole gland is covered. This raises the issue, though,
if there is a localized area at the edge of the gland why not start thinking about
doing focal therapy for the patients that want to try and preserve sexual function?
Hi everyone, this is my dog Hunter. He's kind of our little PCRI mascot here and he's going
to help us do our outro today. So go ahead and subscribe to our YouTube channels, he wants you
to do it a lot. "Subscribe!" And visit our website pcri.org for more information on prostate cancer.