Historically, 10 to 20 years ago, six cores were obtained; now, at least 12 to 14 cores are routinely obtained during a prostate biopsy. Nevertheless, there are areas of the prostate that may harbor cancers that are not touched by the needle during biopsy. The extent of the cancer is important. This is often difficult to define on prostate biopsy and much more easily defined if the patient has had a radical prostatectomy and the pathologist examines the entire prostate. However, the volume of the prostate biopsy cores that are involved with cancer should be easily measured by the pathologist. It is important that you define how many cores are positive, and within each core, what is the volume of the cancer. Both of these factors can be factored into a prediction model (nomogram) that gives you an idea of whether the prostate cancer is confined to the prostate. As previously mentioned, a large Swedish trial recently found that radical prostatectomy had an advantage over watchful waiting in men with localized tumors of intermediate or high grade. Furthermore, the medical literature suggests that seed implantation may be less effective in patients with high-risk prostate cancers.
Another factor to consider is your life expectancy.This is impacted upon by many factors, probably the most important one of which is your general health. Medical conditions such as other cancers, coronary artery disease, diabetes, high blood pressure, high cholesterol or any other chronic illness may significantly negatively impact your life expectancy. A 40–year-old man has approximately a 37–year life expectancy. A 60–year-old man, on the other hand, has a life expectancy of about 20 years, and an 80–year-old has a life expectancy of about 7 years. These are purely statistics, and these figures may not apply directly to you depending on your genetic makeup, your family history of longevity and your medical and surgical history.
Your choice of treatment for prostate cancer may be further impacted upon by your current sexual function and sexual activity. For men who have poor sexual function before treatment and for men who are not particularly sexually active, sexual dysfunction tends not to be a major concern or factor that they consider when choosing a treatment. Patients see me frequently before they choose whether to have surgery or radiation and want to know which I would recommend. I say to all of them that they should never base their decisions regarding treatment on their future sexual function. While there does not exist any study directly comparing surgery and radiation in a randomized, controlled fashion, my review of the literature suggests at this time that the erectile dysfunction rates at three years after surgery and three years after radiation are approximately the same.
You should be very wary of a radiation oncologist who touts radiation therapy as being associated with lower rates of sexual dysfunction. Saying that, good radiation is probably better than poor surgery, and good surgery is probably always better than poor radiation. So choose a physician that has experience and expertise in whichever treatment you are receiving. Likewise, be cautious of robotic prostatectomy surgeons who tell you that erectile function recovery is better or quicker using the robot compared to the open approach. At this point in time, there is zero evidence to support that statement, although these statements appear on some robotic prostatectomy websites. My research of these websites has shown that about 50% of the sites devoted to robotic prostatectomy state or infer that erectile function recovery is better after robot surgery than open surgery. This is not true based on the best available evidence at the moment.
The older the patient, the less likely sexual function will play a role in deciding which treatment to undertake, as older men often have more baseline erectile problems and are generally with partners who are less interested in sex. However, for older men who have younger partners, sex often has a significant impact on the choice of treatment. If you have erectile dysfunction at the time of diagnosis and should sexual intercourse be an important part of your life, it may be worthwhile having this investigated and treated before you undergo treatment for prostate cancer. If you have been diagnosed with prostate cancer, you have several months at least to make a decision regarding which treatment to pursue, unless the cancer is very high grade. If you have erection problems during this“decision-making”time period,you may want to consider trying erection pills. If you try them and have significant side effects or they do not work, then you may wish to pursue some other treatment such as penile injection therapy or urethral suppositories. Men for whom pills and suppositories and/or shots fail and for whom sexual intercourse is important, may be considered candidates for simultaneous radical prostatectomy and placement of a penile implant reservoirs (see Chapter 13).
Another factor that plays a role in your decision is your lifestyle. For example, there are men who run small businesses, are self-employed and have a small number of employees, for whom taking four to six weeks off after radical prostatectomy would be problematic for their businesses. Under these circumstances, these men may consider robotic prostatectomy, after which they can get back to work sooner, perhaps within the week depending on the line of work they are in, or they may choose to undergo seed implantation, which is a one-day procedure, for the same reason. For the same reason, having external beam radiation therapy over the course of two months may also be significantly burdensome from a job standpoint. For men who are very physically active and who do not want to take a break in this activity, then seed implantation is a reasonable option. However, the majority of patients with prostate cancer are going to put their prostate cancer therapy ahead of everything else, including their careers, and taking a few weeks to recuperate from surgery is usually not a major concern for most men.
V. Information You Should Give Your Doctor
Whether you see one, two, or 10 doctors for a discussion regarding prostate cancer treatment, the information that you give them may significantly impact upon their advice to you regarding your management. Under these circumstances it is important that you are totally honest with the physician, whether surgeon, radiation therapist or medical oncologist, as his or her decision may vary based on your medical history and profile. These discussions are not the time and place to bury information regarding your medical history. Be honest and forthright with the physician and do not be afraid to ask questions and challenge the physician. Many physicians are put off by patients who walk into the office with large numbers of medical papers under their arms who have been on the internet daily for weeks and come in with a barrage of questions. Even though physicians are under major time constraints in the current health care environment, these conversations do not have to be completed in one session. In fact, it is not unreasonable for you to return to the same physician to ask more questions after your first discussion. Physicians who become defensive or argumentative are probably not a good match for you as a patient. However, it is worthwhile for you to be considerate of the physician and listen to what he or she has to say in response to each question before asking your next question. Prioritize your questions and keep less important ones for a second or third visit.
Besides your prior medical, surgical and medication history, getting the message across to your physician how important your urinary and sexual function is in the future is critical to him or her making a recommendation to you (Table 2). Many a physician will have a script (speech) to use for patients who walk into the office and will give you this spiel during your time with him or her. However, I advocate that all patients be proactive in their discussions with physicians regarding prostate cancer therapy and what is right for them as individuals.
There is no reason in the world why you cannot bring notes to make sure that all of your questions are answered if time allows, and likewise, it is perfectly reasonable for you to take notes during the discussion. Occasionally I have patients who come into the office with voice recorders so that they can go over the information given to them by physicians. Some physicians are turned off by this. I personally have no problem with it, and this is something for you to consider. If you do bring a recorder, it is always a courtesy to ask the physician if he or she would mind you using it to record the conversation. This is particularly useful if your partner could not come to the appointment with you.
Having confidence in your physician, irrespective of his or her specialty, is critical to your long-term satisfaction. It is important that you