ASTRO 2015

Managing late and ongoing effects of treatment in prostate cancer survivors

Dr Bridget Koontz - Duke University Medical Center, Durham, USA

I’m a clinician and I see patients every day and there are side effects that they come in prior to radiation and particularly in men who have had surgery. I think the main side effect that they are concerned about is incontinence and sexual dysfunction. We also see patients after radiation who have not had surgery who also can have a very high rate of sexual dysfunction, particularly when we use hormone therapy. So those are really the three issues. When I see a patient I think of three things: I think of bladder dysfunction, erectile dysfunction, we actually also look at rectal injury which is a unique side effect of radiation that surgical patients don’t have, and then the hormone therapy, what we do to the patient that manipulates the hormones that has side effects as well.

What were the main points made at the nursing session you moderated?

At that nursing session what we did was we brought in experts from other fields outside of radiation oncology who were experts in the issues of sexual dysfunction, incontinence and hormonal therapy. It was really interesting and the participants enjoyed the discussion very much because we talked about different ways of addressing those with patients that maybe we aren’t doing right now in our day to day clinic. The discussant on sexual dysfunction, Daniela Wittmann, is a licensed social worker and a sex therapist and so her entire job is to talk to patients who have prostate cancer and talk about alternative ways to have sex, how to talk about their issues with their partner. What I really liked about her strategy and why I invited her is that she actually considers it from a couples perspective so she’s not just treating men with pills, she’s looking at it from a behavioural standpoint, she’s looking at it from what the partner is experiencing and is really trying to help build not just sex but also intimacy.

What can radiation oncologists learn from the talk on sexual dysfunction?

The important thing that Daniela told us is that we shouldn’t be afraid to talk to our patients. That’s the way that I approach it and I think at first, as a woman, when I bring up the issue of sexual function with a male patient he may be a little nervous. But it’s very easy to diffuse that and if they trust you as a care provider then they are open. Men want to talk about what’s happening, they want to understand why they have the side effects that they have and what you can do for them and if you don’t know what they’re experiencing then you can’t help.

Could radiation therapy make things worse for those with a degree of sexual dysfunction or incontinence?

That’s part of the discussion process when we were talking about options of therapy is we want to explain to the gentlemen what could happen down the road and what options there are to treat it. That also, again by opening that conversation before therapy, before they have the side effect, then it’s easier when they come back to you to ask those questions about how you’re doing, are you having trouble with leakage, are you having trouble with erections, are you having hot flashes, and to address those issues early when they’re very manageable.

What about incontinence, is that a side effect of radiotherapy?

It’s a very unusual side effect of radiotherapy when that’s the only treatment that men have but it’s very common if they come to us after surgery and they have an indication for post-operative radiation that they’re still dealing with incontinence. The discussion on Saturday about incontinence really did some bit of explaining to do in terms of how many men are incontinent and what the typical time course is. It can take somewhere between three months to twelve months to recover that continence, to recover control. So we laid the information out about what patients can expect so you can educate them, make sure that they understand that it is a process, there are things that they can do to improve it. Then we also talked a little bit about surgical management. So for those men who are not improving to the extent that they would like where they’ve hit a plateau and we wanted to educate our radiation oncology colleagues about what surgical options there are, just so that they understand when the patient goes to the urologist what they’re going to hear.

How was hormonal therapy discussed in the presentation?

Hormonal therapy is most commonly used with radiation for more aggressive cancers. Radiation oncologists in the US often are the ones that are prescribing that hormonal therapy. So it is very important that we discuss what the side effects of that treatment is, just like we all know the side effects of radiation we need to be aware of the side effects of the hormonal therapy. There are actually two ways that we can look at those side effects: side effects that people notice, patients notice, and then side effects that patients don’t. So patients commonly talk about having hot flashes and they have a decreased libido and sex drive. But then the other side effects which may be silent but have very significant problems in men’s health are issues of weight gain, muscle mass loss, osteoporosis and then a metabolic syndrome issue where they’re at increased risk for diabetes and cardiovascular disease. So, again, the purpose of the session was to help educate the providers so that they can educate the patients on what the side effects are and then how to minimise those through behavioural modification, primarily for the issues of osteoporosis and weight gain. And also just prepare the patients for the issues of the hot flashes and the sexual dysfunction.

What are the priorities for treatment?

The number one priority is that we want to cure the cancer when we can but we also want to make sure that patient’s quality of life afterwards is as good as it possibly could be. It’s really a balance, I think you want both: you don’t want to over-treat because then you’re getting side effects that aren’t necessary and then, of course, you don’t want to under-treat because you want to make sure you’re maximising the patient’s chance of cure.

Do you have some practical advice or suggested questions clinicians could be asking patients?

From a hormonal standpoint the main question is how active are you. It’s really important to just encourage daily physical activity which actually addresses many of the issues of the hormone therapy in terms of the metabolic syndrome, it strengthens the bones and then it increases the amount of muscle and reduces the weight gain. So it’s really just a matter of asking how active they are, reminding them that physical activity is important and that will go a long way to minimising the hormone effects.

Do you have a take home message from the session?

The important thing was to really think about what the other disciplines within the prostate cancer field, what the urologists, what the social workers, what the medical oncologists are doing in their clinic and that way we can bring that back to ours and serve our patients in that way by bringing information home.