Conversations With Prostate Cancer Experts

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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.

Subscribe to read the rest of this month’s conversations on erectile dysfunction after prostate cancer.


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Are Male Survivorship Treatments Experimental?


Dr. Martin Miner is the Co-Director of the Men’s Health Center at The Miriam Hospital in Providence, Rhode Island.

Prostatepedia spoke with him about how his center helps men who have erectile dysfunction after prostate

Miner Head PhotoHow common is ED in the general population? What causes it?

Dr. Miner: Most studies show that ED occurs in 50% or more of men. The public thinks it’s related to aging, but in truth, it’s more prevalent with aging because there are more comorbidities (meaning coexisting medical problems) that occur in men as they age. As men age, they tend to develop high blood pressure, elevated lipids, and type 2 diabetes. Many become obese, and specifically get visceral adiposity, or belly fat. Erectile dysfunction is related to all of these conditions.

Once present, ED is not only related to the issue of vascular filling but also to psychological issues. Men are devastated when their sexual function is impaired. They become anxious and performance-focused. That only makes attaining an erection more difficult.

What kind of an impact can ED have on a man?

Dr. Miner: For most men, ED affects every phase of their lives. We’re pretty simple creatures. From youth, we are used to waking with morning erections, and whether we used them or not, they can be validating, making us feel virile and healthy.

When that no longer happens or when we have difficulty achieving erections, it impairs our self-esteem. We can become depressed and frustrated, which can cause us to seek to blame and distance ourselves from those we love, especially our sexual partners. We no longer initiate lovemaking and are unreceptive to lovemaking because we don’t want to do something at which we consistently fail.

Most cases of ED begin with difficulty keeping erections and then progress to difficulty getting and keeping an erection. It’s a gradual process, almost insidious in nature. You know that your erections are no longer rigid or hard. Your partner is aware of it as well, so you can become ashamed.

Does that shame prevent men from seeking help?

Dr. Miner: At some point, most men will seek treatment. Medications like sildenafil have revolutionized the way we look at sexual functioning. They’ve allowed men who previously might have been quiet and accepted this as a normal part of aging to address an impairment that they no longer feel they need to accept.

They’ll bring it up to their clinician. It may be difficult for them to raise that issue with their clinicians, though, since they might feel embarrassed. Often it’s an end-of-the-visit discussion or what we call a backdoor complaint: “By the way, Doc, do you have any samples of Viagra?”

Studies show that patients appreciate when providers initiate discussions about their sexual functioning. Even if they have no problems, they feel validated because they know they can raise the issue of sexual functioning if necessary.

Women now outnumber men as primary care clinicians. While many women have no difficulties asking men about sexual function, some do. We need to retrain those female providers to help them feel comfortable.

How common is ED after prostate cancer?

Dr. Miner: We know that erections occur normally due to an increase in blood flow, or vasodilation, of the very small blood vessels that fill the penis. It’s also related to neurologic excitation, or release of a gas called nitric oxide, which is why meds like Viagra (sildenafil), Levitra (vardenafil), and Cialis (tadalafil) work; they prevent the breakdown of that gas. A neurologic, vascular, endocrinologic (hormonal) insult, or compromise, can cause ED.

In prostate cancer, there are insults in all three of those spheres, the most significant being the complete loss of erections following surgical treatment, which has an incidence of 98%. It is also associated with complete incontinence.

The nerve bundles around the prostate gland are like tendrils of a spiderweb, and it’s very difficult not to harm those bundles. When those bundles are even exposed to the atmosphere, opened, or touched, they go to sleep. Not even the best surgeons can spare them. After surgery, they have to return to function over time.

The first thing that happens after prostate cancer is men have an overwhelming fear about their incontinence. They wear pads, which can be very humiliating. Their first desire is to get dry and we recognize that. Then we work on a program to reawaken these nerve bundles to the penis while we continue to keep their penile tissue healthy until recovery.

There are some emerging treatments for less aggressive prostate cancer, like proton beam therapy, which may have less of an impact on sexual function. But most, if not all, therapies for prostate cancer have a significant and direct impact on sexual function. Male survivorship treatments, including the return of sexual function, are not covered by insurance because they’re termed experimental.

Subscribe to read the rest of the conversation.

(Subscribers were sent a copy of the issue on September 1!)


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Advances in ED Treatments

This month, Prostatepedia is talking about erectile dysfunction after prostate cancer treatment.

Yesterday, we posted an excerpt of an interview with Dr. Mohit Khera that appears in our September issue. But you may also want to watch a presentation he gave in 2015 at Dr. E. David Crawford’s annual Arizona conference for urologists and primary care physicians Perspectives in Urology: Point • Counterpoint. The presentation was geared toward other doctors, but it has a lot of valuable information for patients.

Watch Dr. Khera’s presentation from November, 2015.

If your doctor isn’t already planning to attend this coming November’s Perspectives in Urology: Point • Counterpoint, he or she should!