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Dr. Arthur Burnett On Erectile Dysfunction + Cancer Treatment

Dr. Arthur Burnett is the Director of both the Basic Science Laboratory in Neurourology and the Sexual Medicine Fellowship Program at Johns Hopkins University in Baltimore, Maryland.

Prostatepedia spoke with him about erectile dysfunction (ED) and prostate cancer treatments.

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Why did you become a doctor?

Dr. Arthur Burnett: I was inspired by seeing other individuals through either the media or just personal contacts who were physicians at the time. I was a young man, perhaps in my teenage years, when I was inspired by the impact the profession allowed a physician to have on people’s lives. I sensed that I had a talent for that sort of thing and certainly had an aptitude for science and medicine as the years went on. That was the groundwork for my continuing on to do the appropriate academic training to become a physician.

Have you ever had any particular patients whose cases changed how you see yourself as a doctor or how you approach the art of medicine?

Dr. Burnett: I think patients, in general, have been reinforcing in many respects. There are certainly patients whose case stories inspire you by their humanness and just by the fact that they connect with you as a person and show compassion and caring themselves. That is what has been inspirational about being a physician.

How common is ED after prostate cancer?

Dr. Burnett: Prostate cancer in and of itself is not necessarily connected with ED; it’s more the treatments unless the cancer really is at a more advanced stage. Advanced prostate cancer can have either local effects because of cancer progression on structures of the pelvis or systemic effects—that is, it progresses and then weakens the person’s body.

Treatments that reflect either local treatments or more systemic, or body-wide, treatments can have a negative impact on one’s sexual function, including erectile physiology or erectile functions. Local treatments include surgery and radiation as conventional interventions. More systemic therapies include various kinds of hormone suppressive agents, or even chemotherapies, that can adversely affect the physiology of the erection and impact how nerves, blood vessels, and hormones interact to bring about an erection response.

Are there any steps a man can take before he starts treatment that might help prevent problems after?

Dr. Burnett: I certainly believe that’s so. I think patients need to be informed about the factors that can adversely affect erectile function. I think patients assume all too often that the physician is responsible for their best health. But patients also need to recognize that their best health status is also key to retaining function in the face of any treatments we can bring.

Being healthier and physically fit— not out of shape, not overweight, not a cigarette smoker—can increase your likelihood of preserving better health in the face of our treatments. Those patients who do not observe these kinds of health habits are setting themselves up to have less reserve function in the face of our treatments.

Not just in terms of ED, but in terms of general recovery?

Dr. Burnett: Absolutely. Even more specifically, because we’re talking about erectile function, those patients who are out of shape, who are smokers, who have adverse health conditions that they may not have control over, are not helping themselves with regard to their erection function as well as to their overall body health.

What could you say to a man who brings up the subject of ED with his doctor and finds that the conversation isn’t as in-depth as he would like? What do you suggest he do? See another doctor? See a specialist in ED?

Dr. Burnett: I think that’s an all-too-often scenario, that sometimes the care provider is neglectful about some of the basic aspects of a person’s health status. As the care provider himself is certainly attentive to his own sexual function, he should be aware of that for the patient. All too often, that’s not done. My advice would be to tell the patient that he should go ahead and be assertive or proactive about asking about these sorts of things and really inquire.

An informed patient, perhaps with this kind of communication I’m sharing, will be empowered to communicate that this is important to him. While he is seeking the best intervention for his cancer management, all aspects need to be put on the table for discussion. Ask that care provider to help address these things. If that care provider is not able to address it, ask him who else can be of service, as part of the care team perhaps, to address these problems or potential problems as they may arise expectedly with interventions.

What treatments are available for men suffering from ED after prostate cancer treatment? Are there some treatments that are more effective after surgery or radiation or hormonal therapy?

Dr. Burnett: We have a host of treatments that are available and can be offered for managing ED in this scenario, as much as for any presentation of ED in our modern times. We’re certainly much better in terms of what we can offer medically than where we were a generation ago, but we still have interventions that largely are addressing the symptom presentation of erection dysfunction; they don’t necessarily correct the erection disorders. They treat the symptomatic presentation of a man saying, “I cannot get an erection, and what do you have to offer?” These interventions, more or less, are used on demand to help him achieve an erection response when needed.

These therapies range from the oral medications that are very effective and are FDA approved, to semi-intrusive interventions brought to the genital area in the form of penile injection therapy or vacuum erection device therapy. We also have penile prosthesis surgery, which obviously is much more invasive. Some patients either prefer this approach or they find that the other options are just ineffective or contraindicated.

We have to understand the patient’s case, his preferences, and the severity of his ED. Certain men who’ve had prostate cancer treatments may have more severe erection dysfunction and may not respond well to oral therapies such as Viagra (sildenafil) and Cialis (tadalafil). That patient may be inclined to move forward with some of these somewhat more intrusive, or even invasive, surgical options if needed.

Do you have any advice for men who either are worried about ED before treatment or who are already suffering from ED after treatment?

Dr. Burnett: The sobering truth is that some of the interventions for managing prostate cancer can have adverse effects on your sexual function. At the same time, understand that we have interventions to address ED. Fear of losing one’s erections hopefully should not lead one to avoid proper treatment.

As one patient quipped to me once in the past: “The ultimate form of ED is death.” Not addressing your cancer and not being around for your loved ones is certainly not the best option to pursue. You have to be attentive to addressing your disease but also recognize that we can address your ED or other sexual dysfunctions. Know that these interventions can be sought amidst the treatment for the prostate cancer.

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Erectile Dysfunction + Cancer

Dr. David Houchens introduces this month’s conversations about erectile dysfunction for prostate cancer.

I have 35 years of experience in preclinical and clinical cancer research. I started having PSA tests done when they first became available and noted that my PSA was going up over time. Ultimately, I had a biopsy in 2001 that was positive for prostate cancer with a Gleason score of 7 (3+4) and with positive margins. The gold standard for treatment at that time was to have a nerve-sparing prostatectomy. Mine was an open surgery because robotic surgery was not readily available in 2001. After a number of months, my PSA did not go to nondetectable, and it started a slow but steady rise. With the treatment guidance of Dr. Charles “Snuffy” Myers, the PSA rise was slowed significantly and held in check for three years. After that time, a steady rise led to a year of androgen deprivation therapy (ADT). As expected, the PSA became nondetectable; however, nine months after going off ADT, when my testosterone started rising again, so did my PSA. The newer scans available in the US today were not available in 2008, so I flew to the Netherlands for a Combidex scan to locate possible areas of spread. One distant node area was found that was suspicious. Back in the US, I had salvage radiation plus ADT. In addition to the usual treatment of the prostate bed and surrounding area, the suspicious area plus some areas found with color Doppler ultrasound were also radiated. Since that time nine years ago, my PSA has remained nondetectable and, of course, I will continue to have regular PSA checks throughout my life. My wife has been a very supportive caregiver and has participated in my decisions and treatments. She and I have been active in support groups and in leading discussions on intimacy at support groups and conferences.

The conversations in this month’s issue of Prostatepedia point out the problems that many men have with side effects after their treatment for prostate cancer. Although most urologists and radiologists mention the possibility of incontinence and erectile dysfunction (ED), the usual statements indicate that those issues are probably transient and clear up over time. Some follow-up programs include penile rehabilitation but this is usually only available in large academic centers and thus not accessible to a large number of the cases throughout the country. At the time of prostate cancer diagnosis, most men focus on combating the cancer and assume that they can manage any side effects. It is only later that they realize some of those effects have become a life-long matter.

In this issue of Prostatepedia, Drs. Khera, Burnett, and Kaplan give clear summaries of the approaches that can be used to treat ED after surgery or radiation. One thing most men do not realize is that ED can be the result of conditions other than treatment for prostate cancer. These include diabetes, heart condition, blood pressure issues, obesity, and age. These comorbidities need to be considered in treatment. If men have some degree of ED prior to prostate cancer treatment, recovery will not lead to fewer effects of ED than the patient had before treatment. There are suggestions in the conversations of what should be discussed with your doctor prior to prostate cancer treatment, and these should include addressing side effects as well as experience with the selected therapy. As with any medical or surgical treatment, if you do not feel comfortable with your physician, you may want to consider finding one who can address your questions comfortably and has the expertise and experience to give excellent care for your condition.

Also in this issue is a conversation with a patient, Brian M. He gives a clear description of what he went through on his prostate cancer journey including penile rehabilitation and therapy for ED. Much of what he experienced is seen by a number of men facing this diagnosis, although each case has its own issues, and there are not necessarily common factors for each man. He points out the advantage of having a spouse or partner go with you to medical appointments since the questions and answers heard by the caregiver can sometimes be different from those heard by the patient. He also found his participation in a local support group to be helpful.

An important conversation in the issue is with a caregiver, R. She describes what she and her husband went through with ED after his treatment. Since prostate cancer has been described as “a couple’s disease” due to the effects on intimacy, it is important for the man and his partner to be fully aware of what to expect with the side effects from, not only the surgery or radiation but also the longer-term effects that may exist especially with additional therapy such as ADT or chemotherapy. The selection of a doctor should not be based solely on expertise with the primary treatment but also their knowledge and ability to discuss and manage side effects.

In most cases, there is not a critical need to have treatment immediately, so there is time to study and read information on the disease and to talk to others who have or are going through treatment. For those with high-grade, more aggressive cancer, treatment may be necessary more quickly. In those cases, a medical oncologist who specializes in prostate cancer should be brought on the team.

Here are some points to consider when addressing your next steps after a diagnosis of prostate cancer:

  • Ask for copies of all medical records (such as lab tests, scans, and treatment notes) and keep those in a file or binder.
  • Take a spouse/partner with you to medical appointments.
  • Make a list of questions to ask when meeting with the doctor or medical team.
  • Talk to the doctor or medical team about any side effects you are having related to procedures or medications.
  • Ask clear questions about what to expect regarding ED and incontinence, including what treatments are suggested or used to reduce the effects or to aid in correcting the problems. If you do not feel comfortable with the responses or the fact that the physician does not consider these as something to worry about, you may want to consider a second opinion or different doctor.
  • Attend a support group if there is one in your geographic area. If not, participate in a phone support group.

Here are some suggested resources for support:

  • Visit Us TOO [http://www.ustoo.org/] to find a support group. Each state is listed with information on meeting time, place, and contact person.
  • If you are not near a local support group, the link to a nationwide phone support group is https:// http://www.ancan.org/support-calls. There are calls specifically for early-stage and more advanced-stage prostate cancer and a separate call-in for caregivers.
  • Us TOO International-Prostate Cancer Support and Education has a private women-only Facebook page called “A Forum for Her.” Women can join by contacting TerriL@ustoo.org.

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Talking About Erectile Dysfunction

In September, we’re talking about erectile dysfunction after prostate cancer treatment.

Many men with prostate cancer have concerns about the potential impact of treatment on their sexual function, whether they voice those thoughts or not. This isn’t vanity: sexual function—or the loss of it —can cut to the heart of what it means to be a man for many. Who am I if I can’t function as I have always have? What does it mean for my marriage—or if I’m not married, my ability to attract a partner? Or more fundamentally: what does it really mean to be a man?

This is why each year, Prostatepedia dedicates an issue to discussing erectile dysfunction with prostate cancer experts, men with prostate cancer, and patients’ partners. The treatment options don’t really change much from year to year, but the openness with which men and their significant others talk about these issues is in evolution—or rather: revolution. More doctors are also talking about steps men can take before and after treatment to help function return at a faster clip. Pay particular attention to the advice our experts give this month.

For the first time, our Guest Commentary features a patient who also happens to be a former cancer researcher and an active member of his local UsTOO support group. Dr. David Houchens offers his thoughts on dealing with erectile dysfunction after prostate cancer and offers some valuable resources you may want to review.

Drs. Arthur Burnett and Mohit Khera each help us put erectile dysfunction after prostate cancer into context. They offer insight into which treatments might be effective and outline the pros and cons of each.

Dr. Irving Kaplan talks to us about erectile dysfunction after radiation

Dr. Neil Desai talks about his clinical trial on sex after stereotactic ablative body radiotherapy.

Dr. Sarah Hawley discusses her work on self-managing side effects like erectile dysfunction in prostate cancer patients within the Veterans Administration.

Mr. Jamie Bearse of Zero – The End To Prostate Cancer talks about the financial impact a prostate cancer diagnosis can have.

Brian M discusses his own struggles with ED after treatment and the impact it had on his marriage.

Finally, R. gives us a spouse’s perspective and offers her own advice for caregivers.

It used to be that both patient and doctor were uncomfortable even bringing up erectile dysfunction after cancer. Shouldn’t I just be grateful that I’m alive, many would think. Certainly, this is still true for some— but as with many things in our world, things are changing.

The bottom line is that if you are struggling, no one can help you if you don’t talk about what’s happening first: with your partner, with your friends, and most importantly with your doctor.

Silence is a dead end.

Read this month’s conversations about erectile dysfunction after treatment.


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Dr. Snuffy Myers On ED After Treatment

In September, we’re talking about erectile dysfunction after prostate cancer treatment.

Dr. Charles Snuffy Myers frames this month’s conversations.

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Most men with prostate cancer have concerns about sexual function because diminished erectile dysfunction is a frequent side effect of the most widely used treatments. Additionally, as men get older they often have issues with erectile dysfunction even if they do not have prostate cancer. In fact, prostate cancer and its treatments are not the major cause of male sexual dysfunction. The two most common causes are diabetes and cardiovascular disease.

One of the more common mistakes physicians make is to attribute all medical problems to the cancer and its treatment. Men with prostate cancer often suffer from undiagnosed or under-treated diabetes or cardiovascular disease. For this reason, newly diagnosed prostate cancer patients should be evaluated for these two diseases. This is especially true if you are likely to need hormonal therapy, as this treatment can exacerbate both diseases.

Several drugs used to treat cardiovascular disease and diabetes may well have a favorable impact on the clinical course of prostate cancer, including the statins used to lower cholesterol, ARBs used to treat hypertension, and metformin used to treat diabetes. With this in mind, there should be no hesitation to treat diabetes and cardiovascular disease appropriately in men with prostate cancer.

Standard treatment of erectile function often centers on the use of Viagra (sildenafil), Levitra (vardenafil), Cialis (tadalafil), or related drugs. Erections are normally triggered by dilation of the arteries that supply the penis. This is caused by the release of nitric oxide, a powerful vasodilator. Viagra (sildenafil) and related drugs make the arteries to the penis more sensitive to the action of nitric oxide. However, this effect is not limited to arteries in the penis but also develop in arteries elsewhere. As a result, some patients experience symptoms of low blood pressure and facial flushing. Drugs that release nitric oxide, such as nitroglycerine, can cause severe hypotension when co-administered with Viagra (sildenafil) or related drugs.

These drugs can be administered in a single dose shortly before sex or at much lower doses chronically. There is some evidence that chronic low dose administration is more effective for penile rehabilitation after surgery or radiation. There is a biochemical rationale for this. Arterial health appears to be at least partially supported by chronic release of nitric oxide and these drugs may augment that effect.

There are men who do not adequately respond to oral drugs, the vacuum pump, or penile injections. In this situation, the penile implant offers a reasonable option. In skilled hands, this procedure is usually very effective. Unfortunately, too few patients select this path.

Treatment for erectile dysfunction has improved dramatically over the past two decades. Most men with erectile dysfunction after prostate cancer treatment can recover sufficient function to have a sex life, but treatment needs to be initiated in a timely fashion. It is also important to not ignore aggressive options like penile injection or penile implant.

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