Australian researchers undertook a five year study to investigate the extent and duration of one of the most common side-effects of prostate cancer treatment: impotence.

Transcript

This transcript was typed from a recording of the program. The ABC cannot guarantee its complete accuracy because of the possibility of mishearing and occasional difficulty in identifying speakers.

Norman Swan: good morning and welcome. Today on the Health Report a radical way of operating on your liver, what you and me as health consumers, not to mention doctors and nurses, might learn from the recent Qantas A380 emergency in Singapore and…

The results of a five-year follow-up of 2,000 Australian men who have been treated for prostate cancer to see what complications endure and how they’ve survived. and as you’ll hear, the findings are a bit troubling.

The person who coordinates this study is Dr David Smith, who presented the results at a cancer conference in Melbourne last week.

David Smith: most men are diagnosed with localised prostate cancer, that’s an early type of prostate cancer, so in our cohort we had 88% were diagnosed with localised prostate cancer, potentially curable and 63% of our men were diagnosed with no symptoms.

Norman Swan: They were diagnosed having had a PSA test?

David Smith: This is very much a group of men who represent men diagnosed as a result of PSA, yes.

Norman Swan: a year or so ago you published the three-year follow-up and now what you did this week at the Clinical Oncology Society of Australia meeting in Melbourne was actually look at the five-year follow-up of these men. So just take us through how they are going in terms of what many men are concerned about, with complications such as impotence and incontinence.

David Smith: what I presented this week was the men with localised prostate cancer and in general they are going pretty well. When you look at their overall quality of life they don’t differ in many respects from the control group that we studied, so that’s a normal group of men from the general population who don’t have prostate cancer. But in certain areas there are risks that are being attributable to the type of treatment they had. and the biggest risk that men who have prostate cancer treatment face is in sexual function. and the group that we looked at overall about 70% to 75% of men were impotent five years after the treatment for prostate cancer.

Norman Swan: Now there are degrees of erectile dysfunction; what are we talking about here?

David Smith: The single measure that we’ve used was whether men were able to achieve an erection sufficient for sexual intercourse.

Norman Swan: Without a drug?

David Smith: That includes with drugs.

Norman Swan: Right, so you could take a Viagra like drug?

David Smith: That’s correct. if you’ve had a drug or any other aid, a penile implant, or a vacuum erection device and you could get an erection, we include you as being potent.

Norman Swan: Now that’s probably higher than many urologists think it is?

David Smith: That is higher than most urologists think it is. we took our three-year results to a group of urologists and before we presented the results we said what do you think the impotence rates are? and they recorded levels quite a bit lower than our results, our population whole results.

Norman Swan: did it vary by surgeon or you didn’t analyse by surgeon?

David Smith: we haven’t analysed by surgeon, I think there are some good studies overseas that show that surgeon experience and volume are important but we haven’t analysed by surgeon.

Norman Swan: Does it vary by surgical procedures? So some surgeons do it with a robot, or say they try and spare the nerves around the prostate which might help erection to occur. When you had a nerve-sparing operation did that seem to make a difference, or what the surgeon claimed was a nerve sparing operation?

David Smith: The robots were not in great use at the time of our study. But the second part of that question is whether nerve sparing intent was offered compared with non-nerve sparing intent with radical prostatectomy. we found that nerve-sparing intent did improve sexual outcome but not greatly and men who had nerve-sparing intent were often the most disappointed when it didn’t work.

Norman Swan: So how does this marry with the fact that when you look at the psychological profile they didn’t vary from controls when they were having quite significant sexual dysfunction: three out of four of them?

David Smith: The measures we used to look at overall psychological wellbeing aren’t specific enough to pick out the fine details that affect a man’s sexual life.

Norman Swan: Men are offered more than just surgery if they’ve got prostate cancer. They could be offered radio therapy, two forms of radio therapy — one is where you get the machine aimed at your prostate gland and the other is where they put radioactive seeds inside the prostate: so-called brachytherapy, which is claimed to have a lower rate of sexual dysfunction although it causes other problems as well, such as irritation in the bowel and the bladder. what did you find there?

David Smith: we looked at external beam radio therapy and we looked at whether men had androgen deprivation therapy as well and we also looked at high dose rate and low dose rate of brachytherapy. by five years the men on low dose rate brachytherapy had almost returned to a normal control group sexual functioning. So low dose rate brachytherapy in our group certainly showed the best sexual outcomes at five years.

Norman Swan: and of course the one issue with low dose rate brachytherapy is that it’s yet to be shown to perform as well as surgery in terms of survival and recurrence.

David Smith: That’s right.

Norman Swan: Incontinence?

David Smith: Incontinence is a lower level of risk in the group that we looked at but in radical prostatectomy there were about 12% of men who had persistent incontinence.

Norman Swan: and the predictors of erectile function after surgery, are they the same as people have said that if you were strongly potent before, you stand to be in the one in four who are going to have it afterwards?

David Smith: Men who are younger certainly had much better potency than the older men in our group. Men with good baseline sexual function had better sexual function at five years. Men with less co-morbidities, so other diseases that might affect sexual function…

Norman Swan: Like heart disease or diabetes?

David Smith: Absolutely, but also some interesting socio-economic issues, so men from regional and rural parts of Australia had worse sexual function and men with lower incomes had worse sexual function.

Norman Swan: how do you explain that?

David Smith: I think it’s an issue about access to large centres, perhaps private health insurance as well.

Norman Swan: So you’re suggesting less experienced urologists are operating on them?

David Smith: That could be the case.

Norman Swan: The other issue with rural people from data from the Cancer Institute of NSW is that they get diagnosed later. did rural men in your sample have less localised cancer?

David Smith: yes, there was a small but significant difference in the stage of presentation in our group.

Norman Swan: So what are the immediate implications of your findings? Presumably informed consent needs to change a little bit.

David Smith: we think that better communication is needed in the consultation about when men are deciding the type of treatment for prostate cancer. The group of men when asked stated that they would have liked to have a bit more time to consider the type of treatment that they had and they would have liked to have had more information about the likely consequences. So we think that’s the initial priority.

Norman Swan: and to be fair to Australian urologists, or at least the ones who specialise in this kind of surgery, they are found to say to people ‘look, you’ve got time, this is not necessarily something you’ve got to decide tomorrow’.

David Smith: Absolutely. and I think there’s a growing feeling now that active surveillance which is a wait and see approach and not hopping straight in and treating prostate cancer radically is a very good alternative for men with the right type of disease which gives them time to think about the best way to treat it in the long term.

Norman Swan: Given this was done in NSW you think the results are applicable elsewhere in Australia, much less internationally?

David Smith: there are subtle differences between the states in the way in which treatment is offered. some differences that we’ve seen in terms of survival may be partly a result of…

Norman Swan: oh spit it out, what are you actually trying to say David?

David Smith: Look we know that in some of the smaller states, there are only a few urologists and they treat prostate cancer differently from some other areas. So there are lots of regional differences.

Norman Swan: what you’re trying to say here is that in smaller states the skill level might not be up to scratch?

David Smith: oh no, not at all, I think…

Norman Swan: So there’s a smaller number of urologists doing all the work therefore they are getting quite good at it?

David Smith: That could well be the case and the problem is there is no other data like this in Australia, let alone in the world, this is one of the few studies that has got a large group of men with prostate cancer from the whole population not just from one centre of excellence and also has a control group to compare them with across all the treatment types.

Norman Swan: So this data are not a reason for not having the operation it’s just have the information at hand when you make the decision?

David Smith: Absolutely, talk to your doctor about the best options for you and if you’re not happy with what you’re being offered by the first doctor you go and see ask for a referral.

Norman Swan: Dr David Smith is a research fellow at the Cancer Council of NSW and you’re listening to the Health Report with me Norman Swan here on ABC Radio National.

Smith DP et al. Quality of life three years after diagnosis of localised prostate cancer: population based cohort study. British Medical Journal 2009 Nov 27;339:b4817.doi:10.1136/bmj.b4817