Is there sex after cancer? Patients must focus on the power of love and understanding, rather than the actual mechanics of lovemaking, to enjoy a life of intimacy once again - Medicine & Health

Patients must focus on the power of love and understanding, rather than the actual mechanics of lovemaking, to enjoy a life of intimacy once again.

WHEN THEN -- NEW YORK City Mayor Rudolph Giuliani was diagnosed with prostate cancer at age 55, the press tried hard to be tactful. Articles were sympathetic, and often used his situation to educate the public about the disease and its treatments. Giuliani's father had died of prostate cancer at age 73, and it was clear that the Mayor was weighing his decisions seriously. Would he pick the treatment most likely to spare his potency? Would that treatment also be the one most likely to spare his life? Five months later. Giuliani announced he was having radioactive seeds implanted into his prostate, to be followed by five weeks of radiation therapy. He took hormones for a number of months before and during the radiation, acknowledging that preserving his sexual function figured into his choice. Giuliani, like many men with localized prostate cancer, faced confusing options in trying to find the ideal treatment.

Statistics suggest that many men in their 50s retain the capacity to have erections after radical prostatectomy, the surgical removal of the prostate and the small, seminal vesicle glands behind it. Surgeons like to cite research suggesting that radiation therapy often fails to eradicate some cancer cells in the prostate, allowing an eventual recurrence. Since prostate tumors typically grow slowly, it may take many years of follow-up research to show a disadvantage of radiation therapy compared to surgery. On the other hand, radiation therapy to the site, whether using tiny implanted pellets, or delivered from an external machine, is now computer-enhanced for accuracy. The more narrowly the dose is focused on the prostate, the greater the ability to kill prostate cancer and yet leave erectile function intact. The scientific data available today cannot resolve this competition between treatments, since the long-term results of newer radiation techniques developed in the past 20 years are unknown.

Radical prostatectomy eliminates erections in almost every man for the first few months because of temporary or permanent damage to the nerves that direct blood flow into the penis. These pathways lie on either side of the prostate gland, perilously close to the areas that need to be excised. Some men gradually recover firm erections after surgery, but generally these patients are under age 60 and have small tumors, where the surgeon can spare the nerves on the left and right sides of the prostate. A promising new procedure grafts the sural nerve from the ankle to replace those around the prostate that need to be sacrificed. The grafted nerve forms a kind of superstructure to guide the regrowth of severed endings. This healing method may take more than a year, however.

Radiation therapy appears to affect erections in a gradual scarfing process that begins toward the end of treatment, and may progress for years. This scarring injures tiny blood vessels, which not only can decrease blood flow to the penis, but may deprive some nerves of their needed blood supply. While the surgical patient's erections become firmer and more reliable, the radiation therapy survivor often experiences diminishing returns. Most studies of men's sexual function after treatment do not extend two years, therefore, that surgery and radiation cannot be compared fairly. One reason for the lack of longer-term follow-up is that researchers tend to focus on the newest treatment rather than on what was being done five years ago. It also is challenging to enroll men in a study at the time of treatment, and to follow them for more than a year or two.

Hormone therapy controls prostate cancer by reducing the amount of testosterone in the bloodstream. Testosterone and related hormones, called androgens, nourish prostate cancer cells, yet these chemicals also act in the brain to promote sexual desire in both men and women. Thus, hormonal intervention dampens sexual appetite, Hormone therapy usually has been prescribed for life, or at least for as many years as it could hold advanced prostate cancer at bay. Eventually, those cells that are not sensitive to hormones begin to grow, and a man's symptoms worsen. In an attempt to improve the final out come of these treatments, physicians have begun using hormone therapy for some months before and after surgery or radiation in those whose cancer has not escaped the local area. Even men with advanced prostate cancer use antiandrogen medications long enough to get the cancer under control, and then take a "vacation" until blood tests suggest that the cancer is starting to grow again. Once off the drugs, a man's testosterone levels should bounce back within several weeks. In practice, however, not all men regain their" previous levels of sexual desire.

What does happen to the sex life of the "average" prostate cancer survivor over time? A study I conducted with my colleagues of more than 1,200 patients was designed to provide some answers. All men had been treated at the Cleveland (Ohio) Clinic Foundation and surveyed an average of four to five years alter their surgery or radiation therapy for localized disease. The results are not promising. Less than 20% of men who had both right and left nerves spared during surgery or who had radiation seed implants ended up with normal erections. Men with the best sexual outcomes were younger (especially those under age 62), reported good mental health, had put a high priority on preserving erections in choosing their cancer treatment, were more likely to have a new sexual partner--Giuliani, for example, has divorced and remarried since his treatment--and had partners who did not have sexual problems.