WeeklySA_AdminPSYCHOLOGICAL: Once medical diagnosis confirms the worst, the possible effects of treatments become a major consideration in deciding upon which route to take…
By WSAM Correspondent
When waiting for the annual medical examination results, the last word any man would want to hear is… the dreaded word “cancer”.
The lifetime risk for prostate cancer in men in South Africa, is 1 in 15, according to the 2019 National Cancer Registry. Prostate cancer is the most common male cancer globally and locally and showing significant increases. International and local research indicates that the risk for aggressive prostate cancer is higher in black men, according to Cancer South Africa.
“And when the diagnosis is prostate cancer, men experience the additional stress of having to contemplate their sexual wellness,” explains Vanessa Snow, medical affairs head at pharmaceutical giant Janssen South Africa.
Whether it’s through information gained by reading, the experience of friends, or researching on the net, it doesn’t take long for men diagnosed with prostate cancer to be confronted by the possible side effects of treatment and how it may impact their sexual performance.
A loss of sex drive, or the inability to achieve a firm, or long-lasting, erection, are two prominent concerns. Also linked to this, may be the inability to reach orgasm, or at least the discomfort that could accompany this stage of sexual activity, or worse, the possibility of there being minimal or no ejaculation after climax.
Apart from being the source of anxiety for the individual concerned, these side-effects could also cause stress in a relationship; and counselling, or even couples counselling should be considered as a pathway to psychological wellness. It would also be a good idea for patients in this condition to carefully interrogate the different treatments to discover the pros and cons of each method.
“Hormone treatments are a possible intervention in the early stages of detection,” says Snow, “Although even this can have a negative influence on sexual performance.”
Active surveillance
There are three mainstream approaches to treatment, and men with low-risk or early-stage cancer can avoid the possible cost, risk and inconvenience of more invasive treatments by opting for active surveillance, or close medical monitoring of the disease, as opposed to immediate treatment.
The choice leads to fewer possible disruptions of sexual activity, but isn’t necessarily the advisable route, as a recent study showed that these patients exhibited a higher incidence of disease progression (i.e. the cancer metastasising beyond the prostate) than those who chose more immediate and aggressive treatments.
Watchful waiting
This option is reserved for men who present with asymptomatic localised disease in whom curative treatment options are not suitable. Men with a life expectancy of less than 10 years because of age or co-morbidities are considered suitable candidates.
Unlike active surveillance, patients are not actively monitored, but rather watched for localised or systemic disease progression and treated palliatively when the need arises.
Prostatectomy (prostate removal)
This surgical procedure has largely been the most desired choice of patients, as it’s generally perceived to promise a greater chance for the preservation of sexual potency.
The nerve bundles that help control erections sit behind the prostate, and surgeons are at pains to leave these unaffected during surgery. If, however, malignancy has spread into these nerves, it becomes necessary for surgeons to remove the nerves entirely, and this will lead to permanent erectile dysfunction.
Radiation therapy
This treatment, which is delivered across many weeks to the entire prostate, has long been a standard approach, but it hasn’t historically been a very focused attack on the cancer, and hasn’t typically incorporated advances in the understanding of the drivers of sexual function. In addition to attacking the cancer, the radiation also tends to damage the vessels and nerves involved in erectile function, which many men find discouraging. The effects of treatments on sexual performance is a major consideration in deciding upon which route to take. “Radiation hasn’t always enjoyed the best reputation in this regard,” adds Snow.
Most recent advances in radiation technology could, however, swing the pendulum back in favour of this option. SAbR (also known as stereotactic body radiation therapy or SBRT), involves applying doses of radiation in a fashion that is more precisely targeted to the tumour.
“This,” notes Snow, “spares nearby healthy tissue, including the nerves and blood vessels that are involved in sexual function.” However, Snow adds a cautionary note: “Despite the generally favourable perception of prostatectomies, it isn’t necessarily the ‘silver bullet’ that many seek.”
Recent studies, in fact, continue to show a greater decrease in sexual function after surgery, when compared to other treatments. This may, however, improve with time. There is still, therefore, work to be done in finding the golden chalice of sexual potency preservation. The greatest hope in this area appears to lie in adapting lessons learned from nerve-sparing surgery in other treatments.
