The double trouble of radiating the prostate

Dear Dr. G,

I understand you are highlighting the aftermath of prostate cancer in the month of November, and I am hoping you can shed some light on my problem as well.

I was diagnosed with stage III prostate cancer a year ago.

My Prostate-Specific Antigen (PSA) was 25, and the scans showed the disease was locally invasive.

As I was 68-year-old then, and my general health was not exactly brilliant, I was advised to accept Radical Radiotherapy as a mode of cancer treatment.

The doctor started me on hormonal injections before the radiotherapy.

He said the injections were necessary for at least three years, apparently to maximise the success of the radiotherapy.

I accepted the treatment and underwent sixty cycles of radiation to the pelvis.

The first year following the treatment was reasonably uneventful. However, I am sad to experience the aftermath of the hormonal and radiotherapy now.

The hormonal suppression has rendered me feeling tired, and I’ve lost interest in sex altogether. On many occasions, I also feel horrible hot flashes at night.

On the other hand, the impact of the radiotherapy also kicked in a year later.

I initially thought it was amusing when I lost my pubic hair following the first few cycles of treatments.

However, the real impact was frequent bloody urination accompanied by problems of a weakening erection.

I am devastated by the double trouble I faced following the radiotherapy and therefore would like to put Dr. G on the spot for some advice.

Are there general guidelines in the treatment of prostate cancer?

Why was the hormonal treatment necessary?

Do I really need the injections for a further three years as my cancer has been cured by radiotherapy?

Finally, when will my double-trouble complications end?

Regards,

Double-Trouble David

THE overall treatment algorithm for prostate cancer can be broadly divided into three categories. Stage I and II localised disease are generally amenable to complete eradication with radical prostatectomy, Stage III locally advanced cancer is generally treated with Radiation Therapy, and finally, stage IV metastatic prostate cancer can be controlled with hormonal suppression treatment. Although this is a generalised guideline for prostate cancer treatment, patient-orientated and age-appropriate individualised interventions are often warranted.

Younger patients with more aggressive cancers are often advised for radical prostatectomy to avoid disease progression in the future. Early and less aggressive cancers in older men are amenable to active surveillance. Monitoring PSA is an accurate way to determine disease progression, allowing decisions for intervention in later stages. Future PSA elevation will require further staging of the disease, and subsequent treatment options include radical surgery or radiotherapy, depending on overall patient health and choices.

Radiotherapy is a treatment modality that has been around for many decades. The application of radiation to the diseased tissues has the intention to destroy the cancerous cells without significant damage to the surrounding tissues. The earlier generation of radiotherapy has a bad reputation for causing significant collateral damage to other organs, such as the rectum and bladder. In recent years, accurate mapping using advanced CT scans and cutting-edge accurate delivery of radiation has increased the efficacy of cancer elimination. However, due to the proximity of the prostate to the nerve and vessels supplying the pelvis, complications such as erectile dysfunction and urinary incontinence are still unavoidable.

Another method of maximising radiation to the prostate without disruption of neighbouring tissues is brachytherapy. The implantation of the seeds into the prostate allows constant delivery of radiation to destroy cancerous tissues. Although the lifespan of the radiation is only up to two years, the seeds are left in situ without any additional complications. Such intervention has been proven to be very effective in men with small prostates and without obstructive symptoms.

Regardless of which type of radiotherapy, the additional treatment with hormonal manipulation is known to be more effective in the treatment outcome. The injection of hormones reduces the size of the prostate to ensure better delivery of radiation. The hormonal treatment also eliminates testosterone, which can cause a complete reduction of libido. In most cases, the sufferers will also experience erectile dysfunction over three years of hormonal treatment after radiotherapy.

After radiotherapy, men suffering from erectile dysfunction most likely will respond to medications such as the blue pills. The success rate of the medical treatment is around 70%. For those failing medical treatment, other treatment options for erectile dysfunction include intra-cavernosal injections, vacuum pump devices or even penile prostheses. The treatment for urge urinary incontinence is medications to make the bladder less sensitive to contraction, with success rates as high as 90%.

The double-trouble aftermath of radiotherapy for prostate cancer is a necessity of short-term pain for long-term gain. The hormonal suppression during and shortly after the radiotherapy can ensure longer survival. On the other hand, radiation-induced erectile dysfunction is also well-recognized to be transient in nature and responding well to the current modality of treatment.