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Prostate Cancer Issues
Ernest H. Rosenbaum, MD

Bone Complications of Prostate Cancer
Sexual Problems With Prostate Cancer
Sexual Dysfunction in Men with Prostate Cancer: Psychosocial Issues

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Androgen-deprivation therapy (ADT) has been one of the standards of treatment for many years. The use of LHRH (leutinizing hormone-releasing hormone) agonists have been one of the backbones of ADT therapy for locally advanced prostate cancer or asymptomatic and symptomatic metastatic patients. ADT treatment is frequently continued indefinitely, and often, in symptomatic patients, there is a survival of about two years. This is also regularly used for minimal disease, where the prostate specific antigen (PSA) is elevated and is often used for many years and sometimes decades.1

There is toxicity from the use of ADT, and programs with intermittent androgen blockade have also been used. Some of the side effects include:
1. Loss of libido, sexual dysfunction.
2. Hot flashes (shortly after starting ADT therapy).
3. Gynecomastia (enlarged breasts).
4. Decrease in lean body mass with increased body fat.
5. About 13% have depression or emotional debility and some cognitive dysfunction.

The hot flashes are often a severe problem, and Megastrol 20 mg b.i.d., diethylstilbestrol or estradiol patches have been of help. Cardiovascular problems and thrombophlebitis often become a problem, and a non-hormonal approach using ventafaxine and clonidine have also been tried.

There is also an increase in bone problems due to excretion of bone metabolites with occasional fractures. The use of calcium and vitamin D supplements with bisphosphonates is one of the solutions to help control this problem.

Additional problems include diabetes mellitus, hyperlipidemia (elevated blood cholesterol fats), hypertension (elevated blood pressure) and cardiovascular disease with increase in myocardial infarction (heart attack) and occasional sudden cardiac death.

Those treated with orchiectomy are at increased risk of diabetes but do not have the cardiovascular risks.

Those with many co-morbidities are more likely to have cardiovascular disease, as it is age related as well.

Thus, making lifestyle changes with diet and exercise, as well as calcium, vitamin D supplements and bisphosphonates, as indicated, can make a difference.

Bone Complications of Prostate Cancer
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Bone complications are not uncommon (approximately 80%) with advancing prostate cancer. Skeletal complications, such as fractures, are not uncommon, and this does affect the outcome in conjunction with the other side-effects of ADT.

With longer-term follow up, five to fifteen percent develop androgen-resistant metastatic cancer with spinal cord compression, and early observation and diagnosis, often requiring surgery which can be effective.

Prolonged exposure to ADT promotes the osteoporotic fracture risk. Fractures were noted in 76% and vertebral fractures in 18% of ADT-treated patients. Costs for the LHRH hormonal treatments can also be a problem, depending on the patient's insurance - up to $3-5,000.00 every three months with additional costs for bisphosphonate treatments.

Recent reports have verified that bisphosphonate treatment side-effects caused osteonecrosis (bone damage) of the jaw and renal insufficiency.

Sexual Problems With Prostate Cancer
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Sexual dysfunction is not an uncommon problem. These include erectile dysfunction, anejaculation, anorgasmia and dysorgasmia (painful ejaculation), urinary leaks, and alteration in penile length and curvature. These problems affect quality of life and in some patients can be an unacceptable side effects. It is not uncommon that patients having radical prostatectomy even with a nerve-sparing procedure. In one study, where 81% had a baseline of an erection adequate for intercourse following surgery had reduced success with only 17% at twelve month and 22% at 24 months having successful intercourse. Younger patients fared better than older patients. 2

Sixty-one percent of the patients reported distress about erectile dysfunction (ED), and 38% found that sildenafil (Viagra) had about a 38% response rate for improved sexual function.

In studies on Sildenafil, there were improved erections in 50% of men after unilateral nerve-sparing surgery and 72% after bilateral nerve-sparing surgery. In another study, 52% effectiveness was found with tadalafil (Cialis) in patients with some residual erectile dysfunction. Of note is that after age 60, the use of Sildenafil becomes less effective.

In patients with unilateral nerve-sparing surgery, functional erections were reported in 13% without medication, and an additional 6% with medication following radical prostatectomy, 5-6% for brachytherapy, and 19% and 7% respectively for functional erections.

Other treatments, including penis intracavernosal injections, with a 60-70% success rate, and a transurethral penis prostaglandin suppository had a 40% effectiveness. The use of nightly Sildenafil for 36 weeks after surgery helped reduce erectile dysfunction.

Sexual Dysfunction in Men with Prostate Cancer: Psychosocial Issues
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In Dr. Schover's study, she noted that younger patients did better if sexually successful before cancer therapy. A treatment modality was chosen based on the preservation of sexual function. They were more successful If they had undergone bilateral nerve-sparing surgery or brachytherapy (radiation), and had not received concurrent hormone therapy, and were in good mental and physical health. 2

Psychological counseling for sexual distress can be helpful in the rehabilitation process for both partners. The goal is to reduce negative thoughts about sex and improve sexual communication and lovemaking skills to cope with incontinence and vaginal dryness of the partner and to help improve affection and coping with the illness.

By adopting these practices there was generally an improvement in erectile dysfunction.

Dr. Schover's conclusion was that six months of psychological supportive treatments improved sexual function and satisfaction for both men and women and diminished the men's emotional stress, although, benefits were not always sustained over time. A web-based program is also available through M. D. Anderson Hospital, which has also been found to be helpful. Face-to-face counseling was superior to telephone and web support, but she felt that a combination of both website and brief counseling showed promise.

Counseling should be made available.

1. Roth, B. J., Hamilton, P. V., Howard, V. E., Journal of Supportive Oncology, "Managing the Side Effects of Androgen-Deprivation Therapy", vol. 5, 2, February, 2007, pg. 87-89.
2. Schover, L. R., Professor of Behavioral Science at the M. D. Anderson Hospital, Journal of Oncology, vol. 5., 2, February 2007, pg. 91-92

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