Dr. Mack Roach has been involved in clinical trials on the role of radiation therapy in the treatment of intermediate and high risk newly diagnosed prostate cancer. We recently asked him where he saw that area going in the future and what ideas excited him.
Dr. Roach said: “One area I’m excited about is the value of radiotherapy to stimulate the immune system, particularly in people with metastatic disease. I think another exciting area with a lot of potential is the use of robotics to do brachytherapy under real time MR guidance. One of the problems with brachytherapy is that while brachytherapy could be the least expensive way to treat prostate cancer it’s technically challenging to do a good job on a consistent basis. I think it would be exciting if you created a robotics system that ensured every implant was well done and were able to document that it was well done. I think some of the newer agents might have additional benefit. But primarily that would be for people who have very much advanced disease. I think some of the new molecular assays that help us determine which patients have lower risk disease and may not benefit from treatment are interesting. Using those assays, we could tailor aggressive treatment to the appropriate patient. We could determine whether people need hormone therapy or not. If they need hormone therapy, we could determine whether they needed short-term hormonal therapy or long-term hormonal therapy. Another exciting area is multi-parametric imaging that helps us selectively target areas of the prostate, allowing us to reduce the morbidity of treatment.”
In September, Prostatepedia is talking about erectile dysfunction after treatment with Drs. Mohit Khera, John Mulhall, Arthur Burnett, and Jean-Francois Eid. We also talk with Kathie Houchens, the wife of a prostate cancer patient, and Paul Nelson, the man behind online support group franktalk.org.
This month, we’re talking about erectile dysfunction (ED) in men with prostate cancer. The three major prostate cancer treatment tools—surgery, radiation, and hormonal therapy—all result in serious sexual dysfunction in a majority of men. And ED treatment options each pose serious issues with side effects, effectiveness, and cost.
Viagra and related drugs can be helpful for many men. There is extensive medical literature that supports using these drugs after surgery or radiation. Most medical oncologists do not focus on sexual function. I think this may, in part, explain why we do not have well-established programs to counter sexual dysfunction in men on hormonal therapy. With that in mind, I thought it might be worthwhile to mention what has worked in my clinic.
Hormonal therapy can cause severe ED. As a result, the Viagra drug family often does not pose sufficient activity to facilitate vaginal penetration. Fortunately, two drugs have been shown in randomized trials to significantly improve the effectiveness of Viagra. The first drug is losartan, a blood pressure drug that blocks angiotensin, a hormone that causes blood vessels to contract. By blocking the action of angiotensin, losartan causes blood vessels to relax. As erections require relaxation of the arteries to the penis, the benefit of losartan is obvious.
Cabergoline is the second drug that has been shown to improve the effectiveness of Viagra. Cabergoline is a long-acting, very potent dopamine agonist that has been shown to act as an aphrodisiac in both men and women. A randomized trial comparing Viagra alone to Viagra in addition to cabergoline showed improved sexual performance in the cabergoline arm.
While there are a range of other treatment options for men who have been on hormonal therapy and for whom Viagra is not sufficient, I have seen the most success with penile injections and penile implants. Both approaches have a high success rate in our patients, but many men are reluctant to inject their penises and even fewer have elected to get a penile implant. However, those patients who have elected to get penile implants have been very satisfied with the result.
As one patient said, “I push a bulb in my scrotum and I get an erection. It stays up until I push a second time. I wasn’t that good at 17!”
The bottom line? Talk to your doctor about erectile dysfunction after treatment.
Patient Conference: Sept 9-11 in LA
Dr. Snuffy Myers talks further about CT scans and cancer risk.