So our next patient is asking how is erectile function affected long term after
mono-therapy with ADT in a man with normal pre-existing function. So, non-metastatic
and then temporizing intent. Well, there are no good studies
that have actually quantified how frequently men end up with erectile dysfunction after hormone
treatment. Of course, this is predicated on how long they stay on hormone treatment,
how old they are when the treatment starts. It seems to me that most men recover erectile quite
well, especially if they maintain the policy of having erections during the time that they're on
the hormone therapy with Viagra and other methods, but one of the concerns I have is that the
the male libido which disappears during hormone therapy and does return after
hormone therapy is stopped seems like it can be left somewhat stunted after hormone treatment,
especially for prolonged periods. I don't know if there's a memory component that people take
a holiday from all sexual thoughts for 18 months, and then try and rejuvenate those passions that
have been somewhat forgotten, but that again is also very hard to quantify. So,
it seems like most men will maintain erections normally when they recover,
especially if they've taken precautions during the hormone treatment but that—and particularly
in older men—that they can be left with somewhat diminished libido, that is sexual desire, after
the treatment is stopped and the testosterone returns. This is something that comes with aging
anyway but it seems like it might be somewhat accelerated by exposure to hormone therapy.
Is there anything else they can do besides
taking something like Viagra and Cialis in order to help maintain?
Well men that are determined to keep their function normal
and who have tried Viagra and Cialis and aren't getting any erections while they're on hormone
therapy should talk to a urologist about learning how to give themselves injections.
These guarantee periodic erections. They work by stimulating the muscles that cause erections.
It's a difficult proposition especially when men's libidos are at an all-time low,
but if they can think ahead to the time when their libido is going to come back they should talk to
the urologist about getting an injection therapy which they can learn how to do themselves and
artificially induce erections once or twice a week while they're on hormone treatment.
Our next question is in a video a while ago you mentioned Cipro
and Levaquin which are antibiotic treatments for prostatitis, and prostatitis as we know,
is an infection. They would like to know if these antibiotics are in any way dangerous?
Any antibiotic is potentially dangerous. There's a infection called c. diff, these are spores that
live in our intestines and that are kept and abeyance by the normal flora in our intestines
and when you take antibiotics, if you get rid of the normal flora, c. diff can proliferate and
cause chronic diarrhea and serious problems. So that's with any type of an antibiotic Cipro and
Levaquin have also been implicated in weakening of the achilles tendon. If someone breaks a tendon
obviously that's a very serious development. I may have seen one case of that and I've been
exposed to hundreds of patients that have taken Cipro and Levaquin, so it's not a common problem,
but anytime someone wants to implement antibiotics he has to look at the upside and the downside
to have a real a serious justifiable reason for the antibiotics or are we just doing them
on a whim? The situation that I no longer do is testing men with high PSA levels with a course of
antibiotics to determine if they have prostatitis as an explanation for their high PSA. I just
think you can get the same information by waiting. If there is prostatitis, it will tend to
get better on its own over time and we can avoid the potential danger of exposure to antibiotics.
So our next question is what is the risk of recurrence after focal therapy
and how does it compare to radical therapy, so surgery?
So focal therapy means instead of treating the whole prostate as is routinely done when someone
has surgery or radiation — patients sometimes mistakenly think that they're targeting the
tumor but they're just taking the whole prostate as a target and historically we weren't entirely
sure where the cancer was in the gland, so to be safe the whole gland was treated and continues to
be to this day. Focal treatment argues that with modern imaging and biopsies and whatnot that we
have a sense of where the tumor is, therefore, why don't we just treat the section of the gland where
the tumor is so that men don't have such high risk of erectile dysfunction after treatment, and
I would say that the cure rates after focal therapy approach the cure rates of men who have
their whole prostate treated. The problem is that you need a master to target a small section of
the gland and make sure you get all the cancer and still not damage surrounding structures,
and it's hard to find those people and there's no quality control, so I would say properly
perform focal therapy works pretty much as well as standard whole prostate therapy does
but finding someone who knows how to properly do focal therapy is a real challenge.
We've talked about finding somebody—quality doctors—who can perform these types of
treatments, so in a focal setting for treating partial gland,
how many treatments would you say a doctor needs to do in the end if for a patient if they said,
"how many treatments has this guy done" and they're starting to question and try to dig in
and discover whether this guy is quality or not, how many would you say they should do?
Oh, I'd hope that they'd practice on at least 50 other people before they're
going to start practicing on you, but that doesn't guarantee that any of those 50 were,
well, had good results because we're talking about very early stage cancer and even if they
missed the tumor altogether, you may not know for three or four years that they missed
and so it's hard to — the quality control issues are are hard to fare it out. Also
they may have gotten lucky a couple times and a few patients did great whereas others, you know,
we just don't know. So that's the big challenge is the quality control.
As a medical oncologist when you send patients out for that
are you sending these patients to major universities like UCLA, USC, City of Hope?
Usually just specific individuals. The — for years we favored a cryo surgeon up in Ventura
director Duke Bahn. Unfortunately, just recently just retired, but the the idea that universities
harbor uniformly above average people is ridiculous. So it's okay for a doctor
to be at a university but it's the individual that you want to go visit, not the university.
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