Читать книгу Saving Your Sex Life: A Guide for Men With Prostate Cancer - John P. Mulhall - Страница 26

Patients often ask us what would we do if we were in their shoes. This is not a useful question, particularly in the setting of prostate cancer. Unless the physician has had prostate cancer himself which has been treated, it is not likely that this question will yield any useful information. However, asking the physician what he or she would recommend to his or her brother or father is sometimes valuable. Remember that physicians are human and they will have biases toward or against particular treatments. It is important that you be the judge when talking to the physician.

Experience is a critical factor in outcome, particularly when it comes to sexual and urinary function recovery. So simply asking the physician how many brachytherapies, external beam radiation treatments or radical prostatectomies he or she has performed annually is a good starting point. Another major factor is how long he or she has been doing this. It is well recognized that there is a learning curve in all of these treatments. For example, it is recognized that the positive margin (some cancer cells left behind) rates at the time of radical prostatectomy are higher during a surgeon’s first 100 prostatectomies compared to those during surgeries performed afterwards. So if a surgeon is performing 20 prostatectomies a year, which is a significant number, and has only been doing it for a couple of years, then this is not the same level of experience as somebody who does 20 a year but has been doing it for a decade.

It is also worth asking about or finding out about the physician’s training, including the center he or she trained at and who he or she trained under. The experience with radical prostatectomy surgery or prostate radiation is highly variable from one residency training program to another. Asking your physician about his or her change in philosophy over time is also potentially useful. For example, for a physician who has been in practice for 10 years, has he or she changed his or her opinion regarding the role of prostatectomy versus brachytherapy if he or she is a urologist, or if your physician a radiation oncologist, has he or she changed their opinion regarding seed implantation versus IMRT? This may give you a sense of his or her ability to keep up with new techniques and medical literature.

The surgeons work as part of a team, so asking them about the facilities at the medical center is also important. The surgeons work in an operating room alongside residents or fellows as well as alongside operating room nurses and anesthesiologists. It may be worthwhile asking the physician for a reference of one, two or three names of anesthesiologists that he or she likes to work with. Unfortunately, historically, there have been surgeons who spend very little time in the operating room other than being present for the most important part of the procedure and much of the surgery is done by a resident or fellow. As an academic physician, I am fully committed to the training of residents and fellows, and it is my intention to train future leaders in sexual medicine and urology. However, there are critical portions of the operation that an experienced surgeon should be closely involved in, for example, the nerve sparing portion of a radical prostatectomy. As for the radiation oncologist, he or she works very closely with a physicist and radiologist, and asking about the experience of these personnel may also be of some benefit.

While experience is important, it is not the only factor important in defining outcomes or complications with these treatments. Indeed, it has now been well documented that even surgeons with high volume may have poor outcomes. The concept is that you either do good nerve sparing at the time of surgery or you don’t. And whether you are doing 20 or 200 radical prostatectomies a year may not impact directly upon this. To do nerve sparing, for example, at the time of radical prostatectomy requires a very meticulous nature and great patience. The top surgeons at Memorial Sloan-Kettering take anywhere from two and a half to three and a half hours to perform nerve sparing surgery. Much of this time is spent teasing the nerves away from the prostate, not using any electrocautery, and applying nothing more than gentle traction to the nerve bundles. Thus, expertise is a critical factor, although admittedly, this is particularly difficult to glean from a discussion with the physician. I recommend that you ask your treating physicians what the specific figures on continence, erectile dysfunction and PSA recurrence are in their particular patients. It is easy to quote the literature, but remember that this literature is usually generated from so-called centers of excellence with vast experience. Such figures may not be replicated at smaller centers. Along with that, they should be able to define what they believe to be the potential outcomes for somebody of your age, your medical condition and with the cancer factors that were previously mentioned. Experienced physicians should be able to tailor the discussion and the risk for complications and outcomes to your particular case.

I encourage all of my patients who are undergoing a surgical procedure performed by me to speak to one of my patients who has previously undergone that procedure. I think it is entirely reasonable for you to ask the surgeon or radiation oncologist if you can speak to patients who have undergone such treatment. Speaking to a single patient may be of limited benefit, however, as it is not likely that the physician is going to have you speak with a patient who had a less than excellent outcome. The quality of the physician is not just assessed in his or her ability to evaluate a patient or conduct the procedure. It is also directly linked to how he or she manages any complications that occur during or after the procedure, and his or her accessibility and willingness to spend time in discussion with you. When choosing a surgeon, it is important to evaluate not just the erectile function recovery rates in his or her experience, but also the surgical margin positivity rate. High rates of erectile function recovery can be obtained at the risk of leaving cancer behind along the nerve, and likewise, excellent cancer control with very low levels of positive margins can be accomplished at the risk of causing significant nerve damage and future erectile dysfunction.

There are a number of prediction models used to predict survival with prostate cancer that are beyond the scope of this book. Memorial Sloan-Kettering Cancer Center, in particular Michael Kattan PhD and Dr. Peter Scardino, has been at the forefront of the development of these prediction models known as nomograms. I encourage you to go to our website at www. nomograms.org to survey the nomograms available for a variety of cancers, including prostate, bladder, kidney and breast. We have developed a prediction model for erectile dysfunction after radical prostatectomy and are in the process of developing one for radiation therapy also.

Appended at the end of this chapter are three nomograms. The first is a preoperative nomogram which helps men who come into the office before their surgeries to define what the long-term erectile function will be. The second is a postoperative nomogram used when a patient comes in after surgery knowing what his nerve sparing status has been. And finally, the 12–month nomogram is for men who return 12 months after surgery, and this uses their 12 month-function to predict their long-term erectile function. These nomograms predict erectile function recovery 24 months after surgery and all of them include the patient’s age at the time of surgery, the patient’s erectile function at the time of surgery, the number of other medical problems (high blood pressure, cholesterol problems, diabetes, coronary artery disease) a patient has, the nerve sparing status of the patient for the postoperative nomogram and the erectile function at 12 months after surgery for the 12–month nomogram.

The erectile function before surgery and the predicted erectile function at two years after surgery is based on the score from the International Index of Erectile Function, which has been appended to this chapter. This is a six-question questionnaire, which asks you about your ability to get and keep erection as well as your confidence in your ability to function sexually. Each question is scored on a 15–point scale, and the higher the overall score (maximum score is 30), the better the erectile function. To be able to have sexual intercourse consistently, a score of around 24 is required. While the official normal score is 26, there are many patients who are able to have intercourse with scores just below this level. You can score yourself and then you can use the nomograms to predict what your long-term erectile function recovery will be. It is important to understand that there is approximately a 10% error rate in nomograms, but they give you at least a crude guide as to what the potential is for erectile function recovery after surgery.

Thus, you can already get a feel for the complexities that go into not just the decision about which treatment you will pursue, but also whom you are going to have perform the procedure. I recommend you sit and make a decision in a thoughtful manner without rushing to get rid of the cancer, which is often the gut reaction immediately after the diagnosis of prostate cancer has been given to you.

APPENDIX 2

Nomograms for the prediction of recovery of erectile function after radical prostatectomy

For each nomogram, the left-hand side has the factors that you will need to plug into the prediction model. Your baseline IIEF score you can glean from Appendix 1 in this chapter. My advice is to use your IIEF score based on your erection function during sexual sactivity (partner of self) from a time-point before your prostate cancer diagnosis. Your age should be age in years (rounded up) at the time of surgery. You should then add up how many comorbidities (medical conditions associated with erectile dysfunction) you have. For example diabetes, high blood pressure, cholesterol problems, coronary artery disease, stroke, cigarette smoking. Add this number up and this is the number of comorbidities you have (having diabetes and cigarette smoking, now or in the past gives you a score of 2). For the postoperative and the 12–month nomogram an added factor is your nerve sparing score. For a guide on the Memorial Sloan Kettering Cancer Center nerve sparing score see the text in this chapter. If you have been told you had nerve sparing surgery your score should be between 2 (perfect nerve sparing) and 4 (reasonable nerve sparing). Finally for the 12–month nomogram there is one further extra factor, which is the 12 month IIEF score (that IIEF score at 12 months after surgery).

Each factor will give you a point score by drawing a vertical line from each horizontal line up to the points line at the top of the nomogram. For example, in the preoperative nomogram, an age of 50 years at the time of surgery will give approximately 73 points, an IIEF score of 24 will yield 46 points and 3 comorbidities will yield 0 points. Next, add up all of these points (for the example above, a total of 119 points). Then draw a line down from total points line to the 24 month IIEF score. For the example cited above, this gives an IIEF score of 19 (mild erectile dysfunction). This is your predicted erectile function 2 years after surgery.