We have discussed radical prostatectomy and are now in the midst of discussing radiation therapy as definitive treatment for prostate cancer. I’d like to take a break from discussing specific treatments today in order to discuss complications and side effects of prostate cancer treatment in general. In our next discussion we will address specific types of radiation therapy treatments.

With radical prostatectomy (removal of the prostate gland and its associated structures such as the seminal vesicals and ampulae of the vas) there are a number of common complications that are frequently encountered. In our discussion about the procedure a few weeks ago, we specifically mentioned the big “I’s,” of impotence and incontinence. Impotence is common after radical prostatectomy. A man with excellent erectile function prior to surgery will have some degree of impotence anywhere from 30% to 70% of the time after radical prostatectomy. Much of it depends upon the technique and experience of the surgeon and exactly how you define impotence. One of the real issues with reporting potency percentages after surgery is that different studies look at different definitions and you will often end up comparing apples and oranges. Any man with marginal erections prior to surgery will very likely be impotent afterward.

As we discussed before, incontinence while less common than impotence is for many men much more socially bothersome. Incontinence can be classified as stress (cough, laugh, strain and leak), urgency (oh my gosh if I don’t get to the bathroom I’m going to urinate on myself), and mixed (components of stress and urge.) While this is not a complete list it does cover the large majority of continence problems.

Other complications of radical prostatectomy include heavy bleeding (requiring transfusions), deep venous thrombosis of the legs and its potential life threatening cousin the pulmonary embolus, penile shortening, and scarification of the bladder neck where the anastomosis of the bladder and urethra is made. All of these potential complications while unusual do occur and for the man that gets the complication it can be life altering. For example, the man that develops scarring of the bladder neck will often need to go back to surgery (done through a cystoscope) multiple times and it significantly increases his rate of profound incontinence by having to cut up the neck of the bladder that has scarred down.

As with surgery, radiation has a series of well documented complications or side effects. Incontinence is much less frequent, but frequency of urination and urinary urgency is much more common than with surgery. Impotence is another complication of radiation although most sources will quote a lower likelihood than with surgery. With seed implantation, slowing of the urinary stream is common and then need to take a medicine like Flomax for a few months after the implantation to assist with urination is pretty much standard practice. Some men can develop urinary retention after radiation. This is rather uncommon and is typically found in men that have enlarged prostates (separate from their cancer) and significant voiding issues prior to the prostate cancer treatment. Radiation to the prostate can affect the bowels as well as the bladder. Rectal urgency, loose stools, and occasional blood from the rectum is not uncommon after radiation to treat prostate cancer but typically subsides within a few weeks to months after completion of the treatment course.

The bottom line is that any definitive treatment option for prostate cancer has a number of side effects and complications that can run the gamut from minimally annoying to profoundly troubling. Unfortunately, there is no free lunch. You as the patient are obligated to research these issues and ask your urologist about them if you have questions. All decisions for treatment involve what we call a risk benefit ratio. What are you as the patient willing to put up with in order to “cure” your cancer? Are there other methods of treatment that offer similar “cure” rates with a side effect/complication profile that is more acceptable to you? As I have said before, when you see six or seven different methods to treat the same problem you have to realize that none of them are perfect. If one was heads and tails better than the others, everybody would be doing one thing. But obviously that is not the case.

At the risk of getting flamed again for dragging politics into this discussion, your treatment options will undoubtedly be affected if this Congress passes the health care legislation that is currently proposed. One of the main tenants that is not being discussed is the creation of government panels to determine the most cost effective treatment for specific disease processes. There is no assurance that these panels will be staffed by physicians, let alone physicians in the specialty involved in the disease process.  A lot of big words are being tossed around, but lets tell it like it is. In order for this proposal to work, there will without doubt be rationing of care. Right now you have the choice of having a DaVinci Robotic prostatectomy. It is an incredibly expensive tool to do what can be done as an open procedure but it is highly sought after as a treatment modality in the public. Do you want your government telling you the following…. “Mr Jones, you are 67 years old. Your life expectancy is 9.8 years by insurance actuarial tables. Because of this you are not eligible to have a radical prostatectomy or radiation therapy. You are only eligible for watchful waiting. Have a nice day.”

I have been a practicing physician for over 20 years. My decisions are based on the best practice of medicine as determined by peer reviewed studies in conjunction with patient preference, expectations and medical history. In my view, it will be a sad and dangerous day when we allow our government to intrude into the doctor patient relationship to the point that real medical decision making is taken out of the hands of the people who are most directly affected by the decision.

Finally, I would be remiss if I did not mention that that Ravens have a huge game this Sunday against the Broncos. At the beginning of the season this was penciled in the win column as most people saw the Broncos as a rebuilding football team. Well, six games later, we are treading water and the Broncos are on a roll. Our secondary needs to step up to the task. Dawan Landry needs to remember where he is in space and recreate the thumper that we saw in his rookie year. Most importantly, our defensive coordinator needs to shed the vanilla schemes he has been tossing out on the field all year and design plays for our front seven to get to the quarterback. If we can’t pressure Kyle Orton, he will pick us apart with Brandon Marshall and his other receivers. We can score with anyone in the NFL. The question is can we stop anyone?

Have a great Shabbos. Looking forward to a wonderful Hannukah.

Today’s discussion will open the topic of radiation therapy as definitive treatment for prostate cancer. Just as there are multiple ways to perform extirpative surgery, there are also multiple ways of treating prostate cancer with radiation. What differs between them is that extirpative surgery removes the prostate irrespective of the approach, whereas the multiple methods of radiation therapy differ in their theoretic rationale for how to treat the disease.

There are multiple methods of dispensing radiation into the prostate gland and while I do not plan to go in-depth with each method, I will take at least a couple of the treatment options and discuss them specifically. This may not be a fully inclusive list but at the present the following are currently the most utilized methods of dispensing radiation to the prostate:

Prostate Brachytherapy - also call prostate seed implantation. Radioactive seeds about the size of a grain of rice are implanted directly into the prostate typically using ultrasonic guidance. This is also referred to as interstitial therapy as the radiation is placed directly into the prostate gland rather than being directed from an outside source.
IMRT (Intensity modulated radiation therapy) A mode of high-precision radiotherapy that utilizes computer-controlled linear accelerators to deliver radiation doses to a the prostate. This is an external radiotherapy treatment.
IGRT (Image guided radiation therapy) The process of frequent two and three-dimensional imaging, during a course of radiation treatment, used to direct radiation therapy utilizing the imaging coordinates of the actual radiation treatment plan. Again, this is an external radiotherapy process.
Proton Beam Therapy - like IMRT and IGRT in that the source is directed externally the difference is that the radiation source is protons rather than photons. There are only a handful of centers in the United States currently offering Proton Beam Therapy.
Cyberknife Sterotactic Radiosurgery - this is the newest treatment that has Medicare approval. While conventional radiation therapy (radiotherapy) administers a broad beam of radiation from one or two directions through normal tissues and requires between over 40 treatments to complete the course, stereotactic radiosurgery delivers highly focused beams from many directions so that the normal tissues experience less radiation and the treatment can be completed in only five sessions.

While it may be a simplistic way of looking at the options, I believe that a helpful way of thinking about the treatment is in the number of treatments needed to complete your course of therapy. Seed implantation in the majority of cases is completed in one treatment. Cyberknife is completed in five treatments typically over the course of one week. The other treatment options all require typically over forty sessions over the course of anywhere from six to eight weeks.

Each of the above mentioned treatments has their proponents and naysayers. All will claim results as good as surgery with less complications. Because of the expense of the external radiation therapy units, typically one center will only perform one type of treatment and there have been cases of financial conflict of interest that are currently being evaluated by CMS (Center for Medicare and Medicaid Services) for privately owned units.

There is no argument that radiation has the ability to eradicate prostate cancer. Like the older version of the radical prostatectomy, the old version of external beam radiotherapy was fraught with serious complications. Modern day radiation treatment has become much more focused and like surgery the goal has become to decrease the morbidity of the treatment while maintaining its efficacy. Over the next few blogs, I will discuss the complications and side effects that are most common to radiation therapy as well as the two versions of radiation therapy that I have used extensively. And while I will not specifically discuss the other radiation treatment options, there is a tremendous amount of information available on the web for those interested in more than I can offer in this forum. Remember however, that many of the sites you will come to are dedicated to their treatment option as the best available to treat prostate cancer. So you will need to look at the information they present and realize that there is very likely some bias in their presentation. I do not mean to imply that they are not being truthful, but there is no oversight of what is presented on the web, so be careful and if you have questions write them down and ask your urologist.

Ravens aside - as a football fanatic, I listen to a lot of sports talk radio. The talk of the week is how the Ravens lost the New England game because of officiating. Personally, I think that’s a copout. And while I will agree that the officiating of the game was poor, if you are going to beat a team like the Patriots and do so in their home you have to play a perfect or near perfect game. Unfortunately, the Ravens did not fill that prescription. Fumbling the opening kickoff, throwing a pick as you are driving to score before the half, and dropping a perfectly thrown pass at the end of the game on a 4th down just doesn’t get it. The fact that we were in position to win the game with 45 seconds left tells us that we have the ability to play with and beat the elite teams in the NFL. We just can’t afford to leave that much on the table and expect to win against the upper echelon of the NFL. That may fly when we are playing the Browns, but to beat the Pats, the Colts, and the Steelers in their home we have got to bring our best. Unfortunately, we came eight yards short last week. Now let’s go take out our anger on the Bengals.  Go Ravens!!!!!!