Prostate cancer patients have the sex talk

Prostate cancer patients have the sex talk

After biopsies confirmed a diagnosis of prostate cancer several years ago, Robert Budd of Treasure Island, Fla., opted to undergo surgery to remove the walnut-sized gland located beneath the bladder in men.

Before the radical prostatectomy procedure, which health insurers cover at an average cost of roughly $25,000 today, Budd and his surgeon, Dr. Byron Hodge, talked frankly about the effect it would have on sexual function.

“He warned me right off the bat there was a pretty good chance I would be impotent when I got done with surgery,” Budd says. To extract the cancer, the highly rated urologic oncologist with Lakeland Regional Cancer Center removed nerves on either side of the prostate that are integral in achieving erections, in addition to the prostate itself. “It’s unfortunate that I lost it,” says Budd, now 70, of erectile function. “But the fortunate thing is I’m alive.”

With the exception of lung cancer, prostate cancer kills more men than any other cancer, but the normally slow-growing disease’s most sensitive legacy plays out behind closed doors for many survivors. To varying degrees, experts say, advancing prostate cancer and cancer treatment affects sexual function in most men, including inhibiting ejaculation, diminishing libido and causing erectile dysfunction.

Fortunately, doctors say less invasive treatments, such as nerve-sparing surgery for men with more localized cancers and targeted radiation that causes less scarring of blood vessels and nerves that play a role in achieving erections, reduce the extent of impotence and incontinence, and shorten recovery times. But short- and long-term effects remain and some men never regain certain sexual functions.

“You obviously have to educate the patient about expectation — things won’t be the same as before,” says Dr. Frank Franzese, a radiation oncologist with highly rated St. Anthony’s Hospital in St. Petersburg and a physician-owner of the highly rated Pinellas Park cancer center WellSpring Oncology. But that doesn’t mean men can’t return to intimacy with their partners, he adds. So experts say men and their significant others should talk openly with providers about treatment options, risks and side effects, including effects on sexual function.

Tough choices

“In today’s environment, I think a second opinion for prostate cancer is probably more important than it ever has been,” says Hodge, pointing to the dizzying array of treatment options. For some prostate cancer patients, sex proves less of a priority, while for others it remains paramount, but he cautions men not to lose sight of the very real, life-threatening potential of some cancers. “The one thing we don’t ever want to do is be cancer sparing, when we’re trying to spare other things,” Hodge says.

That said, non-treatment — namely active surveillance in which doctors monitor less dangerous, localized prostate cancer, rather than treating it right away — remains a viable option for many men with slow-growing cancer, says Dr. Julio Pow-Sang, chair of the genitourinary oncology department at highly rated Moffitt Cancer Center in Tampa. The watchful waiting approach skirts the potential for treatment side effects, he says, but not all patients qualify, including those with aggressive cancers who require more immediate treatment.

“In most of the cancers we treat today, there’s not a single treatment that’s best or worst,” Pow-Sang says. “Each one has advantages and disadvantages so a man has to be aware of that.” To get a broader view of treatment options, experts suggest starting with providers experienced in multiple modalities, rather than a physician who specializes in one approach. And don’t expect simple answers.

“It’s very difficult to make a calm, rational decision when dealing with a cancer diagnosis,” says Dr. Durado Brooks, director of prostate and colorectal cancers with the American Cancer Society. For that reason, he suggests men talk to their doctors before deciding whether to get screened for prostate cancer in the first place. “The vast majority of men who have prostate cancer die from something else, not cancer,” Brooks says.

The U.S. Preventive Services Task Force recommended last year against screening healthy men, while the American Cancer Society neither advocates for nor against prostate cancer screening, noting research hasn’t proven whether potential benefits outweigh potential harms of testing and treatment of the typically slow-growing cancer. Other doctors, like Hodge, say healthy men should definitely get screened starting at age 50 — or age 40 for African-American men and those with a family history of the disease — and that fewer die today from prostate cancer thanks to testing. “Much fewer,” Hodge says, adding that in the majority of cases, the cancer is curable.

Rehab reaches the bedroom

A suspicious tingling pain first sent Robert Budd to the doctor and led to his prostate cancer diagnosis in 2006. Two years after undergoing surgery, tests confirmed Budd’s cancer had resurfaced and he underwent 38 treatments of targeted radiation known as TomoTherapy, which Franzese administered.

Insurance paid $17,800, while he paid $3,600 out of pocket. The treatment proved a success, and subsequent prostate-specific antigen, or PSA, blood tests show no signs of cancer. “I’m 100 percent [and] my PSA is zero,” he says.

Prior to undergoing radiation, Budd also saw Hodge to have a penile implant placed for around $16,000, which was mostly covered by insurance and allows him to be sexually active. “It works pretty good [though] not as good as the original,” Budd jokes.

“There’s a lot of sexual rehabilitation that we go into with patients before surgery and after surgery to help them regain their function,” Hodge says. That includes addressing existing erectile dysfunction, which increases with age, and focuses on helping men stay sexually active to the extent possible after the prostate cancer diagnosis.

Hodge concedes post-treatment mechanical fixes — such as medical grade vacuum erection devices that cost about $350 to $400, which insurance typically covers — leave something to be desired.

“It’s not terribly romantic,” he says. But he contends that such interim measures help some patients maintain sexual health and avoid “disuse atrophy” until they can achieve erections on their own or with the help of erectile dysfunction drugs like Viagra. ED drugs cost about $15 to $22 per pill, which insurers only partly cover, if at all, depending on the plan, Hodge says.

“It has to be brought up,” says Budd of having the sex talk with doctors. He adds that his wife Sandi’s support throughout the process reduced his fear of the unknown, both in terms of the cancer and its impact on their sex life. “She knew how much I needed but not more and not less, and how she could determine that, I have no idea,” he says.