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Half of long-term erectile function loss after brachytherapy is due to aging

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Posted 2/23/2015 7:30 PM (GMT 0)
My first urologist told me "the ED rate is the same for surgery and radiation - it just occurs sooner with surgery and often gets better, and comes on gradually with radiation and gets worse." Like most of his assertions, there was some truth to it, but it was mostly false. (There's a website called PolitiFact that rates politician's statements on a scale from "True" to "Pants on fire" - I should do this with things our doctors tell us.)

The truth is that there is some radiation-induced ED, but radiation patients are older (hopefully, this will change) and treated at an age when ED naturally sets in, and the longer you track them, the older they get, the more ED is detected.

For the first time, to my knowledge, researchers have been able to separate the effect of treatment from the effect of aging. You can read about it here:

Half of long-term erectile function (EF) loss after brachytherapy (BT) is due to aging

There are a whole lot of other variables that affect erectile function, and it will be impossible to compare treatments on this dimension until there is a randomized comparative clinical trial (which will never happen). The best we can hope for is that registries will collect the data uniformly across the population. I hope that researchers reach a consensus about how to measure it.
Posted 2/23/2015 8:20 PM (GMT 0)
Allen, this is good stuff and an excellent contribution to the body of knowledge on the subject. This is not totally surprising to those of us who have spent some time studying BT and is directionally similar the the study reported in the NEJM several years ago wherein the authors reported on sexual satisfaction scores pre- and post-procedures. They reported that, despite the fact that the BT patients were considerably older (65 vs. 59), the BT patients had much less decline in their sexual functionality two years post procedure when compared to surgical patients. The study did not control for age as you did but clearly the results would have been even better.

For those of us for whom sexual performance is an important decision making issue, these are critical facts.

Jim
Posted 2/23/2015 9:07 PM (GMT 0)
Thank you Allen.

A true or false section going over what doctors/surgeons/urologists/radiologists tell us is an excellent idea. I am not sure how it would work but it sure would be a help to men.

My urologist told me the same thing re: radiation. At that time, I knew even less about PCa, than I do now (not a lot), but took his word because he was the doctor. From what I can see, yes he was right but he was also wrong? Something like that.
Posted 2/23/2015 9:37 PM (GMT 0)
Something I've wondered about the last couple of years is, how much of my current ED issues are related to my RT and how much is related to the blood pressure and other meds I take. and how much is due to that evil word, "age." Long before PC my GP had warned about possible ED issues with my various medical issues. It did get worse after RT and my URO's answer to my question was, "Yup, you're on that slippery slope. Let's try the pills first." He wasn't that interested in figuring out the source, just a treatment.

There are days I like that and days I wonder if that is enough.

and then there are days when everything works just right and wonder what I'm worried about.

Guess it's time for some herb tea.
Andrew
Posted 2/23/2015 9:54 PM (GMT 0)
I agree with Andrew. Undoubtedly, some of my problems are attributable to the surgery, and losing one nerve bundle. At the same time, the onset of Type Two diabetes, blood pressure meds, and four and a half years of aging haven't helped.

As for the idea of a PolitiFact approach to truth/falsehoods, I would point out that these "fact checkers" have their own biases, and that truth is an elusive son of a gun. It's quite possible to take a "fact" and color it in such a way that the "lie" or "falsehood" becomes almost truthful. Did politician "X" do such and such? Well, yes, it's true on the surface that he did, but in this case the opposition forced his hand. So now the bad thing politician "X" did sounds kind of OK, whereas if politician "Y" had done the same thing, maybe the fact checkers would simply say, "Yep, that's what he did."

I sometimes wish we lived in a world where what is true is so obvious that mankind would be unable to turn away from it, but it just isn't that simple.
Posted 2/23/2015 10:00 PM (GMT 0)
I believe I was very active for my age and have never been "with" any woman other than my Mrs. (Just had 54th anniversary).
Also, I will admit that frequency was not like it was back in my 50's, 60's or early 70's but when I received the results of my Bx back in year 2010, ALL interest in marital physical relations suddenly totally disappeared. Of course, the shot of LUPRON really did the number on me. Now with more worries about the frequent, almost daily appearance of gross hematuria and having another urteroscopy scheduled next week, the "urge" is totally out of my mind. It is frequently said that getting old is not for the weak folks and I can attest to that FACT.
The bottom line is that there is absolutely no ED involved and that's for certain, it's just that the interest is no longer there/here.
Posted 2/24/2015 2:02 AM (GMT 0)
If my questionnaires ever make into a study, that's one study I'd rate as "suspect"

Unmarried and aging can make filling these forms out trickier than with a steady wife or long term partner.

And as with erbob, my state of mind (stress, or lack of, etc) ....

All of these variables total up to a night of no holds barred "let's get it on" to almost total lack of desire.

The questions I've been asked do not take any of these variables into account...at least that's how I've been feelin it.

I guess my bottom line is that I'm unsure how accurately alot of this stuff can quantified in the first place? I guess smarter minds than mine can do it but...if the questions I've been being asked is any indication....

Anuway, I've been told the same thing..."Pay me now or pay me later".

After meeting with this proton guy today I'm leaning towards the "Pay me later" options.
Posted 2/24/2015 1:16 PM (GMT 0)
I like the Politifacts idea.

Seems there is more and more "spinning" of medical facts. Companies/organization paying for and "spinning" results of their studies to support their failing product. I've even heard medical commercials that would be considered attack ads, where unsupported claims are made.

Heck, all you have to do is look at the advertisements on this forum and you will see the favorable spin companies put on their products in an attempt to sell them. Probably not good or bad .... It's just that the buyer must beware.

Politifacts would help.
Posted 2/24/2015 1:20 PM (GMT 0)
Thanks, again, for sharing another great study Allen - lots of details there and when you get down to it, it certainly makes sense.
Posted 2/24/2015 1:37 PM (GMT 0)
I agree, Yooper, it certainly does make sense. Further, and speaking as someone who will be 70 years old this summer, I don't think there's a whole lot of sexual activity going on among the men I know who are in my age group who DID NOT have any form of prostate cancer treatment.

First, there wives are no longer all that receptive to sexual overtures.
Second, their libido is naturally declining as they age.
Third, most are on beta blockers or have Type Two Diabetes or other physical problems that inhibit sexual desire/activity. In my case, having a prostatectomy at 65 coincided with the onset of diabetes and an increase in blood pressure medication, two certain killers of EF. I suspect that situation has affected quite a few men on this forum.
Fourth, our culture places such a premium on youth and physical beauty that they may no longer be "turned on" by their aging wives (and the same holds true for women not being all that turned on by balding, pot-bellied, old men).
Also, a cold, hard look in the mirror might reinforce the idea that we no longer present ourselves as a virile young stud, and, let's, face it, sex is to a large extent a mental activity. A poor self image is a real turn-off.

We who have been treated for prostate cancer, whether by radiation or by surgery, seem to stress out more over what is really a quite natural phenomenon....the loss of sexual appetite and ability as we age...and so we blame all of it on our cancer treatment. Wrong.

Thanks, Allen. Yes, I lost a lot of my sexual ability because of my surgery, and I suppose others have lost function because of other therapies, but there's a whole lot of B.S. out there by old guys bragging about sexual prowess that only exists in their imaginations. We may not be as different in this regard as we sometimes think we are.

Obviously, these comments are directed at those of us who are in the older age group here on the forum. The younger guys in their 40's and 50's are a different story.

Post Edited (clocknut) : 2/24/2015 7:21:39 AM (GMT-7)

Posted 2/24/2015 1:55 PM (GMT 0)
I would also agree with the basic premise of this report. Aging is a big part of it all. A guy about my age put it this way, "It's not that I don't like it as much as I always did, it just doesn't bother me as much when I don't get it."

And, even before bx and dx, a not uncommon bedtime conversation went like this, "Do you want to?"--"We could, I guess, but I'm really tired, it's been a long day."--"I don't really need it"--"Ok, maybe another day."--"Good night (kiss)" (and either of us could have started the conversation)

I'm sure I'm not the only one who has had that conversation.
Posted 2/24/2015 2:24 PM (GMT 0)

clocknut said...
Further, and speaking as someone who will be 70 years old this summer, I don't think there's a whole lot of sexual activity going on among the men I know who are in my age group who DID NOT have any form of prostate cancer treatment.

Clock, I beg to disagree on this point. A study published in the NEJM a few years back showed that 73% of folks ages 57-64 were still sexually active. It was 53% for ages 65-74 and 26% for the 75-85 year old group. Just Google almost any line about sex and the elderly and you will find that sex remains an important part of life for many of us as we age.

So, while it may be true that aging takes a toll on our heretofore perfect sexual abilities, many of us are far from "done". That's why a lot of us on this forum chose SBRT or HDR Brachy or LDR Brachy instead of surgery simply because we wanted to preserve our sexual abilities as well as possible rather than rationalize that we were eventually going to lose it anyway.

Jim
Posted 2/24/2015 2:33 PM (GMT 0)
".... Rather than rationalize that we were eventually going to lose it anyway" .... nice slam Tud.
Posted 2/24/2015 2:47 PM (GMT 0)
Tudpock said, "A study published in the NEJM a few years back showed that 73% of folks ages 57-64 were still sexually active. It was 53% for ages 65-74 and 26% for the 75-85 year old group."

Heck, I'm still sexually active. My wife and I still have an active sex life. Intercourse isn't the be-all and end-all of "sexual activity." ED doesn't end all the fun. So, Jim, how does the study define "sexually active"? Are those 80-somethings all having erections and sexual intercourse?

I didn't mean to imply that ED equates to sexual inactivity. There's more than one way to skin a cat. But, what I've seen here on the forum over the years is a continuing lament over the ability to get an erection, and that's simply not a necessity for being "sexually active."

My previous comment did a poor job of distinguishing between EF and "sexual activity." The study was talking terms of Erectile Function, and my feeling is that EF is only part of the sexual equation. A man may not be able to get an erection for a variety of reasons, but he can still be sexually active.

Post Edited (clocknut) : 2/24/2015 7:51:04 AM (GMT-7)

Posted 2/24/2015 3:00 PM (GMT 0)
At no time did my internal conversation and my decision making process include the attitude of "I'm going to lose it anyway, so I'll go the surgery route". Did I weigh the fact that I've been married 35 years to the same woman, and I'd like to be around a good many more years to torment her? Sure. Did I weigh also the fact that she's one of those women who finds sex painful in her post-menopause years, and that she can't do many of the common hormone based treatments because of her family history of BC? Yeah.

For what it's worth, I have every intention of being sexually active for a long time to come.
Posted 2/24/2015 3:28 PM (GMT 0)
Clock, I don't mean to diminish the fact that sex without an erection is possible and sometimes necessary. I'm simply making the point that, for many of us, erections are still important (even an an advanced age!) and our decision making maximized the possibility of continuing to have erections. Assuming that we were going to "lose it eventually anyway" seems to me a defeatist attitude that is not based in the fortunate reality for many, many seniors.

Hal, it seems you had circumstances that made intercourse less important and that's fine. I am lucky enough to have a partner who has no such issues, hence my decision making that maximized our opportunities for our future.

Jim
Posted 2/24/2015 3:49 PM (GMT 0)
Tudpock (Jim), I don't think we disagree, really. I'll readily concede that I, like most men, would prefer to be able to have erections and function as I did prior to surgery.

What I'm not understanding is where the idea that some men who choose surgery are "assuming that we were going to "lose it eventually anyway" came from.

Actually, I chose surgery and went in assuming I would see a relatively quick resumption of sexual function. That sort of defeatist attitude had absolutely nothing to do with my choice. I was actually astounded that ED turned out to be a long-term situation. I'll bet that's the case with most men, but sometimes things just don't work out the way we hoped.

What are you referring to when you speak in terms of men assuming they were going to lose it anyway? I've looked through the thread again and don't see anyone to whom this might apply.
Posted 2/24/2015 4:39 PM (GMT 0)
Clock, I took the totality of your remarks as a rationalization that loss of EF due to PCa treatment is not such a big deal since (1) we are going to lose it because of age anyway and/or (2) our other meds may make EF impossible anyway and/or (3) our partners may no longer be desirable so what the heck do we need EF for, etc. If I misinterpreted your meaning I apologize.

What I intended to convey is that erectile function is still very important to a large number of seniors and it should not be minimized. And, that choice of treatment is a major factor in the maintenance (or lack thereof) of that EF.

Jim
Posted 2/24/2015 4:56 PM (GMT 0)
Jim, no need to apologize. I suppose what you term a "rationalization" does pretty well sum up my feelings now, at age 69, four and a half years post surgery. But, I don't think it's an unrealistic approach to putting my situation into context. If the majority of guys our age, even those who've never dealt with prostate cancer, aren't dealing with sexual performance issues, why is the evening news sponsored, in large part, by Viagra and Cialis.

But, that kind of thinking had nothing at all to do with my mindset going into, or choosing, surgery as my treatment option. Rather, I was feeling pretty much invulnerable and bulletproof, and quite confident that loss of sexual function would be, at most, a very temporary situation.

Post Edited (clocknut) : 2/24/2015 10:16:04 AM (GMT-7)

Posted 2/24/2015 5:33 PM (GMT 0)
I was going to write a rant in response to the last few comments, and thought better of it. I suggest, calmly, that it is highly risky to assign motives to others. The SE data is a lot less black and white than some suggest, and there are a great many men who have had surgery who had a brief period of ED followed by full recovery.
Posted 2/24/2015 5:49 PM (GMT 0)

I'm gonna agree with ya, halbert...

halbert said...
The SE data is a lot less black and white than some suggest, and there are a great many men who have had surgery who had a brief period of ED followed by full recovery.

I'm an anecdotal story of one, but in my case I happen to be having a lot more sexual intercourse/activity in the last 5 years after surgery than in the 5 years, or 10 years, preceding surgery.  I mark that down to a conscious decision and choice to more fully enjoy the life I have...an active sex life committed to my wife happens to be one of the ways. 

I'm saddened by the unfortunate willingness by some to accept the notion clocknut espoused in this thread that "our culture places such a premium on youth and physical beauty that they may no longer be "turned on" by their aging wives (and the same holds true for women not being all that turned on by balding, pot-bellied, old men)."  This is, in my view, "giving-up."  My wife is about the same age as me, and we aren't spring chickens, but she certainly turns me on.  She gives it some effort, and so do I.

As expected, sex was non-existent for a few weeks immediately following surgery, slow for a few months following surgery, and good after that.  In the big-picture, those weeks of RP recovery are fading into the distance.  I use a PDE-5 inhibitor since surgery.

The short-term convenience of a radiation therapy treatment (followed by the slow, steady decline in EF and other late-term effects) was trumped, in my decision-making process, by this type of bigger-picture perspective/opportunity which was important for my age at diagnosis (49) and treatment (50).

I think that this study in the OP does not bode well for further promotion of BT amongst younger men.  It says that the rate of ED by BT equals the rate of ED that older men experience anyhow...not a great perspective.

-Norm

 


Post Edited (NKinney) : 2/24/2015 11:49:20 AM (GMT-7)

Posted 2/24/2015 6:56 PM (GMT 0)
Let me say that I don't have a problem getting it up, just two months after HDR Brachytherapy.  Now, it's not "top of mind" in my life right now as it was exactly one year ago when I was taking a T shot every two weeks.  I haven't had it checked, but I figure my testosterone is back down to 300 +/-.

Here's what I don't get, and granted science was my poorest subject in school:  Why would side effects such as ED start later for HDR Brachytherapy recipients?  The radiation is over in a day and the residual effects of that radiation surely don't last for years and just keep spreading and frying cells?

Why would it "show up later"?

Seems to me if the nerve bundles got burned one would experience the effects immediately.

Posted 2/24/2015 6:59 PM (GMT 0)

Norm said...
I think that this study in the OP does not bode well for further promotion of BT amongst younger men. It says that the rate of ED by BT equals the rate of ED that older men experience anyhow...not a great perspective.

I think the data show the opposite. If you read the article carefully, it starts with the fact that in every age group, radiation preserves erectile function better than surgery. The sample sizes are very small for the under 50 age group, but the same pattern holds within every age group: 55% of those youngest men getting nerve-sparing surgery had functional erections two years later. This compares to 100% for EBRT and 75% for BT in that age group. This might be a fluke because of the low data. The data are more reliable in the next older age group, 50-59 y.o., where preservation of functional erections was 43% two years after surgery vs 52% after EBRT and 67% after BT.

(SBRT and HDR brachy were not included in that study)

Erectile function preservation deteriorates with age for all treatments, but is always better for radiation.

In the BT study among men under 60, 78% of the treated men had full erectile function preservation over the next 5 years, while 13% had loss of erectile function due to aging 5 years, and only 9% had loss of erectile function due to BT treatment. Pretty impressive!

I think one of the key points made in the BT study is that the bulk of the deterioration of erectile function due to BT treatment occurred early, whereas most of the deterioration due to age occurred later. So if you're going to have a negative impact on erectile function after BT, you'll know it within a couple of years. This disproves the conventional wisdom on the subject.

- Allen
Posted 2/24/2015 7:14 PM (GMT 0)
Dewayne said... Here's what I don't get, and granted science was my poorest subject in school:  Why would side effects such as ED start later for HDR Brachytherapy recipients?  The radiation is over in a day and the residual effects of that radiation surely don't last for years and just keep spreading and frying cells?   Why would it "show up later"?   Uh...yeah.   The side-effect profile for surgery and radiation treatments for PC are just about opposite .   Surgery has an immediate, radical effect…in the short-term.   Long-term, some men continue to experience effects but many/most improve within weeks, months, or the first year or so.   Some men have enduring issues.   On the other hand, radiation therapy tends to have fewer short-term effects, but long-term, which are sometimes called late-term effects tend to gradually show up later, if they do show up…and they don’t in all men.  ED is one of the late-term effects.      Is this news a surprise to you?   Or not previously understood?
Posted 2/24/2015 7:21 PM (GMT 0)
Norm, the point you seem to be missing from the BT study is that the "gradual long term decline" (but of only an additional 10% in the SBRT case) was due to aging, not treatment.

Dewayne, radiation doesn't cause nerve damage. It may cause scar tissue formation in the blood vessels that supply the penis. In younger men, the healing process is more efficient - less scar tissue buildup. It takes longer for scar tissue buildup to occur (after radiation) than it takes for nerve damage to occur (after surgery). So the ED after surgery is immediate, while it may take some time for scar tissue to build up after radiation.

- Allen
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