Erectile Dysfunction After Treatment

Transcription

1 Erctil Dysfunction Aftr Tratmnt Prostatpdia_Sptmbr 2016 Volum 2 No. 1 Sptmbr 2016 Volum 2 No. 1 P1

2 In this issu... This month, w r talking about rctil dysfunction (ED) in mn with prostat cancr. Th thr major prostat cancr tratmnt tools surgry, radiation, and hormonal thrapy all rsult in srious sxual dysfunction in a majority of mn. And ED tratmnt options ach pos srious issus with sid ffcts, ffctivnss, and cost. Viagra and rlatd drugs can b hlpful for many mn. Thr is xtnsiv mdical litratur that supports using ths drugs aftr surgry or radiation. Most mdical oncologists do not focus on sxual function. I think this may, in part, xplain why w do not hav wll-stablishd programs to countr sxual dysfunction in mn on hormonal thrapy. With that in mind, I thought it might b worthwhil to mntion what has workd in my clinic. Hormonal thrapy can caus svr ED. As a rsult, th Viagra drug family oftn dos not pos sufficint activity to facilitat vaginal pntration. Fortunatly, two drugs hav bn shown in randomizd trials to significantly improv th ffctivnss of Viagra. Th first drug is losartan, a blood prssur drug that blocks angiotnsin, a hormon that causs blood vssls to contract. By blocking th action of angiotnsin, losartan causs blood vssls to rlax. As rctions rquir rlaxation of th artris to th pnis, th bnfit of losartan is obvious. Cabrgolin is th scond drug that has bn shown to improv th ffctivnss of Viagra. Cabrgolin is a long-acting, vry potnt dopamin agonist that has bn shown to act as an aphrodisiac in both mn and womn. A randomizd trial comparing Viagra alon to Viagra in addition to cabrgolin showd improvd sxual prformanc in th cabrgolin arm. Whil thr ar a rang of othr tratmnt options for mn who hav bn on hormonal thrapy and for whom Viagra is not sufficint, I hav sn th most succss with pnil injctions and pnil implants. Both approachs hav a high succss rat in our patints, but many mn ar rluctant to injct thir pniss and vn fwr hav lctd to gt a pnil implant. Howvr, thos patints who hav lctd to gt pnil implants hav bn vry satisfid with th rsult. As on patint said, I push a bulb in my scrotum and I gt an rction. It stays up until I push a scond tim. I wasn t that good at 17! Th bottom lin? Talk to your doctor about rctil dysfunction aftr tratmnt. Charls E. Myrs, Jr., MD P2 Sptmbr 2016 Volum 2 No. 1

3 Contnts: Contributors: P4 Mohit Khra, MD: Erctil Dysfunction P8 John P. Mulhall, MD: Erctil Dysfunction Aftr Hormonal Thrapy P14 Jan-Francois Eid, MD: Th Pnil Implant Aftr Prostat Cancr P18 Clinical Trial: Arthur Burntt, MD Erythropoitin + Erctil Function Aftr Surgry P20 Paul Nlson: Onlin Erctil Dysfunction Support P22 Kathi Houchns: Wivs Talk About Erctil Dysfunction Mission: W aim to provid usful currnt information about prostat cancr and its tratmnt. This information and th products and mdia advrtisd in this publication ar advisory only. Individuals picturd ar modls and ar usd for illustrativ purposs only. Plas consult your physician for spcific mdical or thraputic advic. Subscriptions: $55.00/12 Elctronic Subscription $110.00/12 Print Subscription Prostatpdia is publishd in Charlottsvill, Virginia by Rivanna Halth Publications, Inc. Editor-in-Chif: Charls E. Myrs, Jr., MD Publishr Jssica Myrs-Schctr Copyditor Grir McCain Proofradr Robrt M. Protz, MS Transcriptionist Sarah Mason Dsignr Vrity Burgss Community Outrach Corinn Halada Sals Consultant Rod Schctr Businss Consultant Ros Sgarlat Myrs, PT, PhD Editorial + Billing Offics 274 Rdwood Shors, #739 Rdwood City, CA Administrativ Offics PO Box 655, Earlysvill, VA Copyright Sptmbr Rivanna Halth Publications, Inc. All rights rsrvd. ISSN: Sptmbr 2016 Volum 2 No. 1 P3

4 Mohit Khra, MD Erctil Dysfunction Dr. Khra, a urologist spcializing in mal infrtility, mal and fmal sxual dysfunction, and dclining tstostron lvls in aging mn, is th Dirctor of th Laboratory for Andrology Rsarch and th Mdical Dirctor of th Excutiv Halth Program at Baylor Collg of Mdicin in Houston, Txas. Prostatpdia spok with him rcntly about rctil dysfunction aftr prostat cancr. How did you com to focus on prostat cancr? Dr. Mohit Khra: I am a urologist by trad, but I did not initially go into mdicin. First, I got my MBA and Mastrs in Public Halth. I workd as an analyst for two yars in Boston bfor going to mdical school. Whn I got to mdical school, I fll in lov with urology bcaus I lik to oprat and I lik to s patints. As mor mn ar gtting oldr, thr is going to b a ral nd for urologists. In acadmic urology, you r askd to supr-spcializ, which mans you pick on ara of spcialty. For xampl, in my practic, w hav on prson who spcializs in prostat cancr, bladdr cancr, and kidny stons. For th last nin yars, my ara of spcialization has bn sxual dysfunction for mn and womn and hormon rplacmnt thrapy. I also hav a passion for rsarch: I conduct a lot of clinical trials. I also startd a lab calld th Laboratory for Andrology Rsarch. W do basic scinc rsarch and run studis looking at ways to improv sxual function and tstostron dlivry. If you don t us th pnis, it will atrophy. How common is rctil dysfunction aftr prostat cancr? Dr. Khra: If you look at th litratur, th data can vary significantly: anywhr from 10% to as high as 90%. You s such a wid fluctuation, bcaus thr ar so many variabls. A critical factor is surgon skill. Surgons who hav mor skill in prsrving th cavrnosal nrvs hav bttr outcoms. But thr ar othr factors, such as patint comorbiditis; som popl bliv th tstostron lvls mattr or whthr th man has a willing partnr. Our rsarch was on of th first to show that patints with a partnr who wants to ngag in sxual activity tnd to rcovr thir rctil function fastr. That maks sns: thy hav somon to hav sx with. Mn without a willing partnr may not rcovr as quickly bcaus thr is lss motivation to rcovr. Think of th pnis as a muscl, lik your bicps muscl muscl in your arm. If I put your arm in a cast today and thn took th cast off aftr six months, thr would b significant atrophy of that muscl. It would b withrd. Th pnis is th sam. If you don t us th pnis, it will atrophy. Erctil dysfunction rats start to incras significantly in mn in thir 50s. What ls happns in th livs of mn in thir 50s? Thir partnrs usually go through mnopaus. Ths mn ar not having sx; that s whn you start sing a significant amount of rctil dysfunction. Mn who hav a willing partnr ar mor motivatd to us th mdications to ngag in sxual activity and to xrcis thos muscls. That tnds to rsult in bttr rctil function down th road. P4 Sptmbr 2016 Volum 2 No. 1

5 Ar som prostat cancr tratmnts associatd with a highr rat of rctil dysfunction than othrs? Dr. Khra: Cryothrapy tnds to hav th highst rat of rctil dysfunction. Cryothrapy basically mans frzing th prostat. Whn you frz th prostat, you also gnrally frz th nrvs and if you frz th nrvs, you gt rctil dysfunction. Th rat for rctil dysfunction following cryothrapy is quit high, but thn most patints don t do cryothrapy. Th majority of mn in this country choos ithr surgry or radiation. Surgry has a highr rat of rctil dysfunction in th immdiat postopration priod. Ovr th cours of 12 months, mn tnd to rgain thir rctil function. Radiation tnds to affct th patint latr, say fiv to 10 yars down th road, and can incras th rctil dysfunction rats in this population. What about hormonal thrapy? Dr. Khra: Hormonal thrapy is not considrd a primary thrapy; it is an adjuvant or noadjuvant thrapy. Hormonal thrapy can hav a dvastating impact on rctil function. It significantly rducs tstostron lvls. That is how it works. Whn you rduc tstostron lvls, you rduc a man s ability to gt an rction. W us hormonal thrapy in mn with high-grad disas whn w giv thm radiation. W also us hormonal thrapy in mn with mtastatic prostat cancr. Somtims w us hormonal thrapy in mn with highgrad cancr with a rising PSA aftr radical prostatctomy. Again, hormonal thrapy is not considrd primary thrapy. Ths ar adjuvant thrapis. Is rctil dysfunction aftr prostat cancr a rsult of th tratmnts a man gts, or is thr somthing about th cancr itslf that causs rctil dysfunction? Dr. Khra: Th diagnosis itslf can caus psychognic rctil dysfunction. In othr words, many mn can hav an incras in rctil dysfunction rats aftr thy rciv a diagnosis, but bfor surgry. Many womn ar also concrnd. (I had th wif of a prostat cancr patint call m to ask if sh could gt cancr if sh had sx with hr husband.) Th fact that you hav a cancr in th gnital rgion has a psychological impact and can ffct sxual function. You r worrid about what is going to happn. Howvr, mor svr rctil dysfunction usually happns aftr surgry. Today, most patints hav nrvsparing prostatctomis, which mans that w spar th nrvs during surgry. Aftr surgry, many patints xprinc a procss calld nuropraxia, which mans tmporary paralysis of th nrvs bcaus thy v bn manipulatd. It can tak som tim for thos nrvs to rcovr. W know that full rcovry of rctil function typically occurs about 12 months aftr surgry. Ar thr othr rasons, asid from th sxual lif of a coupl, to b concrnd about rctil dysfunction aftr prostat cancr? Ar mn with rctil dysfunction mor pron to dprssion or hart disas, for xampl? Dr. Khra: Mn with rctil dysfunction ar much mor likly to hav a hart attack or strok. Erctil dysfunction can b th first sign of a hart attack or strok. This is finally a potntial cur for rctil dysfunction. Th thory is basd on artrial diamtr thory, first dscribd by Dr. Francsco Montorsi. Dr. Montorsi xplaind that th pnil artris ar 1 to 2 mm. Th coronary artris ar 3 to 4 mm. Th carotid artris ar 5 to 6 mm and th priphral artris could b slightly largr. Th pnil artry usually bcoms occludd or blockd first bcaus it s th smallst. Th Prostat Cancr Prvntion Trial dmonstratd that 15% of mn who dvlop rctil dysfunction today will hav a hart attack or strok within svn yars. Othr studis hav shown th sam. Anothr study by Dr. Montorsi dmonstratd that mn who hav a hart attack or strok, on avrag, dvlop rctil dysfunction thr yars prior to having a hart attack or strok. Dpnding on which study you look at, most show that rctil dysfunction is th first sign of hart disas. If a man walks into my clinic with rctil dysfunction and has two cardiac risk factors say hyprtnsion and obsity thn I snd him for a cardiac valuation, bcaus I far h may hav occult cardiovascular disas. Isn t it tru that most mn with prostat cancr hav cardiovascular disas as wll? Dr. Khra: Not ncssarily. Kp thos sparat. Mn, as thy gt oldr, ar likly to hav cardiovascular disas. Sptmbr 2016 Volum 2 No. 1 P5

6 And it is tru that prostat cancr is a disas of oldr mn, but prostat cancr in itslf has nothing to do with cardiovascular disas. Th disass ar compltly sparat. If somon has prostat cancr, cardiovascular disas is not a risk factor for prostat cancr. Now, mn with rctil dysfunction ar much mor likly to b dprssd. Erctil dysfunction can b th first sign of a hart attack or strok. What concrns most mn with rctil dysfunction is that thr isn t a cur for it. Almost vrything that w currntly do to trat rctil dysfunction dosn t solv th problm. Th disas gts wors vry yar; w r just putting a Band-Aid on th problm, masking it. Viagra dosn t fix it. Viagra just covrs your problm whil th disas procss gts wors vry yar. Evntually, Viagra stops working. All of ths mdications stop working. What ar som of th tratmnts availabl? Dr. Khra: W can divid thm into thr lvls. Lvl 1 is typically associatd with Viagra-lik drugs: Viagra, Lvitra, Cialis, and Stndra. Ths mdications ar ffctiv. Svnty-fiv prcnt of patints with rctil dysfunction tak ths mdications. Thy ar ffctiv, but thy r not ffctiv forvr. And thy do hav som sid ffcts, such as hadachs, flushing, nasal congstion, and back pain. Othr first-lin thrapis includ th vacuum rction dvic, which is litrally a vacuum. It brings th blood into th pnis. You plac a band at th bas of th pnis to kp it rct. Th urthral suppository is anothr option. A urthral suppository is mad of a vasodilator calld prostaglandin; th suppository is placd into th urthra. It causs th pnis to dilat and thrby inducs an rction. In ths Lvl 1 thrapis, I usually us sx thrapy for patints. Somtims I also us amino acids such as arginin, carnitin, and citrullin. Ths amino acids hav bn shown to b hlpful bcaus thy ar prcursors to nitric oxid. Lvl 2 thrapis includ an injction to th pnis. Ths Lvl 2 mdications dilat th blood vssls. A man injcts his pnis a maximum of vry othr day, altrnating sids so h dosn t dvlop a scar. Ths injctions ar ffctiv. But if th Lvl 2 options don t work, w turn to Lvl 3. I prform a surgry calld an insrtion of a pnil prosthsis whr I implant a dvic into th man s body with a pump in th scrotum and two cylindrs in th pnis. Th surgry is vry ffctiv and allows a man to ngag in sxual activity without bing dpndnt on mdications. How do you dtrmin which of ths tratmnts is appropriat for which patint? Dr. Khra: Cost, complianc, convninc, and fficacy. W also look at th advrs safty profil, or advrs ffcts. Som popl will tak Viagra, but gt vry bad hadachs. Othrs tak Cialis and gt back pain. P6 Sptmbr 2016 Volum 2 No. 1

7 Also, rmmbr that Viagra is vry xpnsiv. Now many patints gt thir mdications onlin at compounding pharmacis, but typically, Viagra is xpnsiv. Ar ths mdications usually covrd by insuranc? Dr. Khra: Usually thy r not covrd by insuranc. That is why thy r so xpnsiv. Unfortunatly, vn aftr prostat cancr thy r not covrd by insuranc. Why do you think that is? Dr. Khra: Erctil dysfunction is not rcognizd as a tru mdical condition, which is unfortunat. It s considrd rcrational, so th mdications ar not covrd. This is rally unfortunat. Espcially sinc so many mn with rctil dysfunction also xprinc dprssion Dr. Khra: Absolutly. Ar thr any nwr tratmnts for rctil dysfunction on th horizon? Dr. Khra: I think th way of th futur will b stm clls for th tratmnt of rctil dysfunction. W ar currntly conducting ths studis at Baylor. In this nw thrapy, w tak abdominal fat and procss th stm clls. W thn injct ths procssd stm clls back into th pnis. Thus far, thr hav bn two stm cll studis on post-radical prostatctomy patints that had vry promising rsults. This is a cur. This is finally a potntial cur for rctil dysfunction. I am currntly conducting an FDAapprovd trial assssing stm clls to trat ED. Sptmbr 2016 Volum 2 No. 1 P7

8 John P. Mulhall, MD Erctil Dysfunction Aftr Hormonal Thrapy Dr. John Mulhall is th Dirctor of th Mal Sxual and Rproductiv Mdicin Program at Mmorial Sloan Kttring Cancr Cntr in Nw York City and th author of Saving Your Sx Lif: A Guid for Mn with Prostat Cancr. Prostatpdia spok with him rcntly about rctil dysfunction aftr prostat cancr. How did you com to focus on rctil dysfunction aftr prostat cancr? Dr. Mulhall: I m from Irland. I cam to th Unitd Stats to do my urology rsidncy. Part of th way through my rsidncy, I rad an articl in th Nw England Journal of Mdicin about impotnc, as it was calld thn, by a chap namd Dr. Irwin Goldstin. H was in Boston. I had som rsarch tim lft during rsidncy, so I wnt to Boston to do rsarch with Dr. Goldstin. Bfor I lft, and bfor I finishd my rsidncy, I knw I wantd to do sxual mdicin. At th nd of my rsidncy, I rturnd to Boston to do a fllowship in sxual and rproductiv mdicin. Aftr that, I wnt to Loyola Univrsity in Chicago, Illinois, for six yars. (Thy hav a vry big cancr cntr and a big prostat cancr population at Loyola.) I workd with Dr. Robrt Flanigan, a famous urologic oncologist, whil I was thr. Aftr Loyola, I cam to Nw York to work at Mmorial Sloan Kttring Cancr Cntr, whr I hav bn for th last 14 yars. Hr at Mmorial Sloan Kttring Cancr Cntr, w s about six hundrd nw prostatctomy patints a yar. W s about a hundrd tripl thrapy patints a yar srving radiation and hormon thrapy. I m a big blivr in survivorship. It isn t good nough to just say, Mr. Jons, w took your prostat out. You should b happy. I m intrstd in trating quality-of-lif issus associatd with a prostat cancr diagnosis, as wll as trating th cancr. That is my motto. How common is rctil dysfunction aftr prostat cancr? Dr. Mulhall: It is fairly common that som mn hav a dip in rctil function with a diagnosis of prostat cancr. Th diagnosis of any cancr is vry strssful. Mn gt high lvls of adrnalin. Adrnalin is an anti-rction chmical. Mn start doing mor poorly in th bdroom. Erctil dysfunction bcoms a slf-fulfilling prophcy. Hormonal thrapy is lthal to sxual function. From a thraputic standpoint, it is vry difficult to answr how common rctil dysfunction is aftr prostat cancr. But ssntially 100% of mn on hormon thrapy hav rctil dysfunction. Narly all will fail to hav an orgasm. Most ar going to nd up with pnil shortning. Narly vryon will hav no significant libido. Thr is about a 50% chanc of a man bing functional with or without a pill two yars aftr prostatctomy. (Undrstand that thr ar many factors that go into that, including th patint s ag, baslin rctil function, and marital status.) Erctil function prsrvation rats ar about th sam thr yars aftr radiation tratmnt as aftr prostatctomy. Whn patints com to s us bfor surgry or radiation, I tll thm, I could do radiation or surgry. Which would you lik? I add, Nvr bas your dcision on rctil function, bcaus unfortunatly, th rctil dysfunction rats ar P8 Sptmbr 2016 Volum 2 No. 1

9 about th sam thr yars aftr both, providd you had a good tratmnt at a cntr of xcllnc. Ths ar broad figurs, but again, othr factors wigh in: a patint s ag, baslin rctil function, comorbiditis, what kind of radiation or prostatctomy th patint had, and whthr or not h also had hormon thrapy. All of ths factors wigh in. W hav no programs to prdict whthr or not a man will hav rctil dysfunction aftr tratmnt. So it is vry difficult to giv a blankt numbr. Lt s talk about rctil dysfunction aftr hormonal thrapy. Why is thr such a high prcntag of rctil dysfunction aftr hormonal thrapy? Bcaus th tratmnt rmovs tstostron? Dr. Mulhall: Ys. You nd tstostron for rctil tissu halth. You don t nd a hug amount of tstostron for rctil tissu halth, but you do nd som. You may hav hard of hypogonadism, which is th mdical trm for low tstostron. Whn you ar agonadal, whn you hav no tstostron or you v castratd all th tstostron, your rctil tissu undrgos dgnration ovr tim. It turns to collagn a scar. It is stimatd that somwhr btwn four and six months of androgn dprivation thrapy (ADT) lads to prmannt structural damag to rctil tissu. You dvlop a condition calld vnous lak. (Vnous lak was first studid in castratd rats. You castrat a rat and th rctil tissu turns to collagn. You can thn analyz that collagn and study it as a modl.) Whn you don t hav tstostron, rctil muscl dgnrats. Whn rctil muscl dgnrats, you ar nonfunctional. Sptmbr 2016 Volum 2 No. 1 P9

10 But you also nd tstostron for drugs lik Viagra to work. Whn you hav no tstostron, drugs lik Viagra or Cialis don t work vry wll at all. Is rctil dysfunction aftr hormonal thrapy prmannt? Dr. Mulhall: That dpnds on how long you v bn on hormonal thrapy. If you r on ADT for two to four months and you v had minimal rctil tissu damag, thn th xpctation is that you ll gt back to bing at last as functional as you wr bfor you wnt on hormon thrapy. If you wr on ADT for a yar, it s xtrmly likly that any rctil tissu damag is prmannt. Whn I spak at patint confrncs, I tll th audinc that whn sombody says you nd ADT, your first qustion should b: What is th survival bnfit? A good oncologist should b abl to tll you, Th survival bnfit in somon lik you is six months or six yars. You thn hav to dcid if you want to pursu hormon thrapy. Mdical oncologists gt wrappd up in th whol concpt of undtctabl PSA. PSA is undtctabl bcaus you hav no tstostron; you nd tstostron to mak PSA. To m, undtctabl PSA is an artificial scurity. Of cours, thr is a prcntag of mn who bcom ADT-rsistant. Thy r on ADT, but thir PSA starts to go up. Hormonal thrapy is lthal to sxual function. Ovr 90% of mn on hormon thrapy hav no sx driv. Th 10% of mn with sx driv hav what is calld intllctual libido, but thy rally hav no visual libido. (Visual libido is whn you s somthing rotic and bcom arousd. Intllctual libido is: I v bn with my wif for thirty P10 Sptmbr 2016 Volum 2 No. 1

11 yars. I lov hr. W usd to hav a grat sx lif and w rally should b making mor lov.) Most mn nd tstostron for thir visual sx driv. Mn on hormon thrapy ar in a stat calld sxual nutrality. Sxual nutrality rfrs to th concpt: I don t think about sx, but I hav it and it s a positiv xprinc. Vry much lik a postmnopausal woman. Kp going back until all your qustions ar answrd. Ar diffrnt kinds of hormonal thrapy associatd with highr or lowr rats of rctil dysfunction? Dr. Mulhall: Thr is no had-to-had data on that. W do hav a currnt projct looking at it, though, and ar about to gt som data. But if you look at th litratur, it s rally bizarr. Thr ar thr ndpoints that ar lookd at. Th first is rturn to noncastrat lvl. That is simply dfind as whn th man gts back to a tstostron lvl of ovr 50. This is clinically maninglss: if his tstostron lvl dips to four thn rturns to 50, h still has all th symptoms of almost no tstostron.) Th scond ndpoint is a rturn to normal. Normal tstostron is variably dfind as high as 200, to 300. Th final ndpoint, which w practically nvr s in th litratur, is rturn to baslin. Th man who, bfor ADT, has a tstostron lvl of 700, but aftr tratmnt has a tstostron lvl of 300. His tstostron lvl may b considrd normal, but h has had a 400-point drop. H is going to b profoundly symptomatic. But thr ar no had-to-had studis looking at on hormonal thrapy tratmnt vrsus anothr. Thr would probably b no significant diffrnc btwn th various forms of hormonal thrapy, bcaus all hormonal thrapy is about lowring tstostron lvls. If Drug A and Drug B both rduc a man s tstostron to castrat lvls, thn h is going to hav problms with both. It dosn t rally mattr whthr h is on an agonist, antagonist, Zytiga (abiratron), or Xtandi (nzalutamid). Th qustion that is not vry wll answrd is th impact of bing on an antiandrogn lik Casodx (bicalutamid). You would imagin that if you wr going to block th tstostron rcptor that would b as bad for rctil function as bing on Lupon (luprorlin). If th tstostron can t function, thn it dosn t mattr what your tstostron lvl is. But thr is vry littl data on it. Why do you think that is? Dr. Mulhall: Th focus is on what can w do to prolong your lif so you can b around for your grandchildrn. Most oncologists don t hav any training in sxual halth. In gnral, oncologists giv poor xpctations to patints. Thy don t talk about th sxual and nonsxual sid ffcts of hormon thrapy. I m th on who oftn has to talk to patints about thir glycmic control, bon dnsity, or cardiovascular risk. If an oncologist is going to talk about Sptmbr 2016 Volum 2 No. 1 P11

12 sxual function, invariably that discussion is about sx driv. It s not about rctil function. It s not about jaculation. It s not about achiving orgasm. Most oncologists look at th fiv-yar or disas-fr survival rats. Thy r not talking to you about quality of lif. Why do you think most mn arn t talking to thir doctors about rctil dysfunction aftr prostat cancr? Or is it that th doctors arn t talking to mn about it? Dr. Mulhall: I think it s both. Thr is a famous cartoon in our fild: th patint is sitting on th tabl and th doctor is standing narby. A thought bubbl abov th patint s had rads: I hop h brings it up. A thought bubbl abov th doctor s had rads: I hop h brings it up. How can you mak a doctor comfortabl talking about sxual function and sxual halth whn thy gt an avrag of two hours of training in mdical school on sxual halth? What should patints do about this? Dr. Mulhall: Patints nd to b proactiv. If sxual halth is important in your lif and you r discussing tratmnt with your surgon, your radiation oncologist, or your mdical oncologist, you nd to bring it up. If your doctor is smart, h or sh will say, This isn t what I do, but I snd patints to a spcialist namd Dr. Jons. Why don t you go talk to him about that bfor you mak your dcision about your tratmnt. That is what rally nds to happn. W nd dirct-to-consumr advrtising. Why dos Pfizr do so much dirct-to-consumr advrtising for PD-5 inhibitors? Bcaus physicians arn t asking qustions. W nd to mpowr patints to start th convrsation. If a patint is going to talk to his doctor bfor tratmnt, what kinds of qustions should h ask? Dr. Mulhall: Th first thing a patint should say is, I want to dclar to you that my sxual halth is critically important to m. I hav a loving wif. W r sxual bings. Sx is a critically important componnt of our rlationship. Gt that out on th tabl. Thn ask, I want you to tll m how your tratmnt is going to affct my sxual function: my rction, my sx lif, my orgasm, and my jaculation. B proactiv. If th doctor is bing honst and rasonabl, h or sh will discuss it with you. If h or sh won t discuss it with you, find somon who will. Fight for your sxual halth, particularly aftr prostatctomy and radiation. In thr yars tim, whn your prostat cancr has bn curd and you r lft with no rctions and a short or crookd pnis, you ll think you should hav don som work bforhand to optimiz your rcovry. Proactivity is critically important. Patints think doctors will tll thm vrything thy nd to har, but doctors tll patints vrything doctors think patints nd to har. Go in with a sris of qustions. If th doctor says, w r running out of tim, thn ask whn you can mak your nxt appointmnt to talk. Kp going back until all your qustions ar answrd. Many patints spnd mor tim choosing a plumbr than a doctor. Th cancr is diagnosd. Th lights ar flashing. Mn think, I m going to di of cancr! But th rality is that most popl with Glason 6 or Glason 7 cancrs ar not going to di of prostat cancr. P12 Sptmbr 2016 Volum 2 No. 1

13 But thr ar vry fw popl in this world who har thy v bn diagnosd with cancr and ar not immdiatly afraid thy r going to di. Dr. Mulhall: Absolutly. That is why w nd to mpowr patints. Almost vry wk, I hav a man sitting in my offic with tars in his ys saying, If I had known it was going to b lik this, I would nvr hav don it. I would hav not tratd my prostat cancr. First thing is to tak a big dp brath, thn gathr information. You hav to hav your ys wid opn. Know what you r gtting into. If you go to a prostatctomist first, you v got a 95% chanc of gtting a prostat surgry for your prostat. If you go to a radiation oncologist first, you v got an 85% chanc of gtting radiation. That is why a sxual mdicin spcialist should s vry patint. Thr ar plnty of us. W don t hav a dog in th fight. W don t car if you do surgry. W don t car if you do radiation. W r going to tll you how to gt th bst out of your surgry or radiation and rmind you to ask your radiation oncologist why you nd hormon thrapy. If sxual halth is an important part of your lif, particularly if intrcours is an important part of your lif, thn talk about how you can maximiz prsrvation of sxual function. I suppos if you hav a plan in plac bfor tratmnt vn starts, you r bttr abl to dal with any sid ffcts. I just publishd a papr for which w askd mn within two months of thir prostatctomy about thir rcollction of what thy wr told bfor th procdur. Forty prcnt said, I nvr rcall bing told I d nvr jaculat again. This is th most basic sxual consqunc of a prostatctomy and yt 40% of patints don t rmmbr bing told about it. Now, mayb thy wr told and thy just wr focusing on thir cancr. Or mayb thy wrn t told. But you nd to b proactiv. Ar rctil dysfunction tratmnts covrd by insuranc? Dr. Mulhall: A third of mn hav dcnt covrag; a third hav no covrag; and a third hav som covrag. Th avrag numbr of pills covrd pr month for insurd patints is about six. W also hav a gnric Viagra. W ll hav a gnric Cialis nxt yar. Didn t you say that Cialis and Viagra don t rally work for mn on hormonal thrapy? Dr. Mulhall: Ys. If you r on hormon thrapy and your tstostron lvl is zro, you r not going to rspond wll to Cialis or Viagra. You may nd up having to do pnil injctions, or somthing lik that. Any final advic for patints? Dr. Mulhall: If sx is important to you, dclar that. Hav a good discussion with your doctor. If you think your doctor can t talk to you about it, find a sxual mdicin doctor who will. Dr. Mulhall: Th most important thing is ralistic xpctations. Sptmbr 2016 Volum 2 No. 1 P13

14 Jan-Francois Eid, MD Th Pnil Implant Aftr Prostat Cancr Dr. Jan-Francois Eid, of Nw York City s Advancd Urological Car, is a urologist who spcializs in trating advancd rctil dysfunction. Prostatpdia spok with him rcntly about pnil prosthss aftr prostat cancr. How did you com to focus on rctil dysfunction? Dr. Eid: I bcam intrstd in rctil dysfunction as a mdical studnt. Back in th arly 1980s, I hard a urologist lctur about pnil implants. During my rsidncy at NwYork- Prsbytrian Hospital, w had an ultrasound machin in th dpartmnt of urology. Nobody was using it, so anothr Urology Fllow and I startd using th machin to do blood flow studis on patints with rctil dysfunction. I bcam intrstd in using pnil injctions to provid patints with rctions. I wnt from bing intrstd in th diagnosis of rctil dysfunction to bing intrstd in trating patints with pnil injctions. Back in th 1980s, w didn t hav pills lik Viagra and Cialis. W didn t rally hav any options that workd. Throughout my training, I always prfrrd dlicat rconstructiv procdurs that ndd fin, prcis work, rathr than xtirpativ procdurs to rmov a big tumor. I found xtirpativ procdurs to b lss tchnically challnging. My work continus to fascinat m. Th patint valuation rquirs thorough history-taking and som psychological insight, which is somthing I njoy doing. At th sam tim, you want Whn a man has rctil dysfunction, h thinks about it all th tim. to mak th patint fl comfortabl; rctil dysfunction is a somwhat prsonal and dlicat issu. Thr is a littl art and mpathy involvd in communicating with somon suffring from rctil dysfunction. I find it xtrmly gratifying to mak sombody potnt again without laving any tracs of th surgry. My goal is to concal and hid th implant so th patint fls compltly normal. Whn a man has rctil dysfunction, h thinks about it all th tim. It s not somthing that affcts him only in th bdroom. Aftr a whil, it fatigus, occupis, and dprsss th brain. Evry tim h ss a lov scn in a movi thatr or h gos out to hav drinks with frinds or sombody maks a jok or h ss an attractiv prson, h is rmindd that h has rctil dysfunction. It dprsss mn trmndously. Th first thing a patint will say aftr h gts a pnil implant is, I m a nw man. I fl so fr. You gav m a nw lif. It s sort of bizarr, bcaus you would think that sombody would say that if you savd thm from cancr or from a hart attack and not from rctil dysfunction. How dos a pnil prosthsis work? Dr. Eid: Thr ar two typs of pnil implants. On typ of pnil implant, is always firm and is calld a smimallabl implant. Th othr is a salin-filld inflatabl implant. Th inflatabl implant was invntd in 1973 and FDA-approvd in It consists of two cylindrical plastic tubs that ar placd insid th shaft of th pnis and ar connctd to a pump that is concald insid th P14 Sptmbr 2016 Volum 2 No. 1

15 scrotal sac. Th pump is connctd to a small rsrvoir th siz of a pingpong ball that stors th salin whn an rction is not ndd. Th salin fluid is transfrrd into th cylindrs by activating th pump whn th patint is intrstd in bing sxually activ. It s a hydraulic dvic that is manually activatd. It mimics a physiological rction, whil also allowing th pnis to bcom flaccid whn an rction isn t ndd. Thr ar two manufacturrs, both in th stat of Minnsota. Boston Scintific is in Minntonka. Coloplast is in Minnapolis. In which patints is th inflatabl pump usd? Dr. Eid: This is a grat tratmnt for advancd ED that dos not rspond to mdications such as Viagra or Cialis. In ordr to optimiz th outcom, w hav vry possibl dvic siz availabl in th oprating room; th pnis is masurd during th procdur, and th corrct cylindr siz placd in ordr to maximiz th siz and quality of th rction. It s difficult to tll which implant is appropriat for which patint until thn. Th choic of dvic brand dpnds on th patint s anatomy, his ag, his partnr s ag, his manual dxtrity, whthr h has scar tissu, his body habitus, tc. Thr ar som spcial considrations for prostat cancr patints rgarding rsrvoir placmnt (th littl pingpong-ball-lik structur that stors th salin fluid). Aftr robotic prostatctomy, surgons do not clos th pritonum, which is a layr of tissu that sparats th abdominal cavity from th plvis. Thrfor, in ordr to safly plac th rsrvoir, I prform a scond sparat incision about on to onhalf inch ithr on th right or th lft sid of th lowr abdomn. Th rsrvoir is thn placd from abov, undrnath th abdominal muscls, and th tubing is tunnld into th scrotal sac to connct with th pump tubing. A sparat incision is unncssary for patints following radiation thrapy and is only ndd for patints following robotic prostatctomy. Ar thr any othr considrations for prostat cancr patints? Dr. Eid: Th data on potncy aftr prostat cancr surgry varis trmndously. If you look at th Europan data publishd by indpndnt third partis, post-surgry rctions rturnd to normal in fwr than 10% of mn. Anothr 20% rspondd to pills lik Viagra or Cialis. Svnty prcnt of mn aftr robotic prostatctomy do not rspond to oral mdication. Patints nd to know that if thy wait for mor than two yars aftr surgry and rcovry of rctions hasn t occurrd, thn it s appropriat to considr a pnil implant. Som patints do us pnil slfinjctions. Thr ar two typs of pnil injction mdication. Cavrjct and Edx ar FDA-approvd and can b purchasd in drug stors. Ths injctions ar saf for longtrm us. Thr ar othr typs of mdications, such as Trimix (mixtur of papavrin, phntolamin, and prostaglandin E1), which ar not FDA approvd for pnil slf-injction but ar most oftn usd by post-prostatctomy patints. Pnil scarring, dformity, and shortning will occur ovr th long run. Trimix should only b usd for a coupl of yars whil waiting to s if rcovry of potncy will occur. How long dos a pnil implant last? Dr. Eid: Pnil implants will last anywhr from 15 to 20 yars. But whn thy brak, thy ar asily rplacd. Infction of th dvic is th most dradd complication and occurs bcaus of bactrial contamination of th implant during th surgical procdur. Th rat of infction varis according to surgon s talnt, xprinc, and surgical volum. This can b as high as 15% or as low as 2%. Our infction rat is 0.47% basd on 3,028 conscutiv implants sinc January W updat our data on a rgular basis. Spcialists will hav a much lowr infction rat. It s important for patints to sk out th most xprincd doctor. Think of a pnil implant as on would a root canal procdur. You want to s a root canal spcialist, rathr than a gnral dntist for it. Sing a spcialist is vry important, bcaus it minimizs th risk of infction, maximizs th siz of th pnis, and optimizs th placmnt of th pump and concalmnt of tubing and incision. Spcialists also mak smallr incisions, which rduc aras of skin numbnss, prsrving snsation and ability to achiv orgasm. Do you advis patints to spcifically ask about infction rats whn valuating doctors? Dr. Eid: Ys, but vry fw placs actually track thir infction rats and it s oftn difficult to obtain this data. How should patints valuat a spcialist? Dr. Eid: Thr ar clus to look for. If you walk into a doctor s offic and you don t s any information on Sptmbr 2016 Volum 2 No. 1 P15

16 pnil implants, thn you can guss that not a lot of implants ar bing prformd by that practic. If th doctor ss fmal patints as wll as mal and prforms mostly gnral urological procdurs, thn this automatically indicats that th physician hasn t don a lot of pnil implants. (Thr just isn t nough tim in th day to do all ths things.) If th doctor has assistants do som of th ED valuation and som of th mdical tratmnt of rctil dysfunction a physician assistant dos th pnil injctions thn you know that th doctor is not rally involvd and intrstd in trating rctil dysfunction. H will not hav th opportunity to discuss pnil implants with many patints. If you ask about pnil implants and th doctor dosn t voluntr a list of patints who alrady hav had a pnil implant placd by his practic that you can talk to, this also would indicat that not a lot of implants ar bing prformd thr. If th doctor dosn t hav modls of all th diffrnt typs of implants that you can look at and manipulat, and if you ask for information on pnil implants and all you gt is a pamphlt from th company itslf and nothing writtn by that physician, thn this also indicats that th procdur is not frquntly prformd in that practic. If you schdul th procdur and find that th staff dosn t rally know about insuranc rimbursmnt, that s also a clu that thy r not frquntly schduling th implant procdur. If you ask th doctor, Do you lik to hav a rprsntativ from th company thr during th procdur? and h says ys, thn, you know that h is not going to hav a choic of which implant to us. (If a rprsntativ from on company is thr, th doctor is lss likly to us an implant from anothr company, vn if th othr company s implant fits you bttr.) If you ask dirctly about infction rats, h may say, My infction rat is vry low. But looking for clus is a much clvrr way of finding information about how many implants a doctor actually dos. Sk th most xprincd physician you can find in ordr to maximiz chancs of succss. How much dos an implant cost? Is it usually covrd by insuranc? Dr. Eid: Ths dvics hav bn around sinc 1973 and th procdur is rimbursd by most commrcial insurancs including Mdicar. Mor rcntly insuranc plans hav incrasd thir dductibls and som will play gams. Thy claim to covr th procdur, but won t pay for th implant dvic. This is a nwr occurrnc and is absurd. If a patint is paying cash, th dvic itslf costs from $8,000 to $10,000. Whn you add th cost of th oprating room, ansthsia, and th surgon s f, it can add up to about $25,000, dpnding on th facility usd. It is rcommndd to hav this procdur prformd in a clan P16 Sptmbr 2016 Volum 2 No. 1

17 outpatint ambulatory surgry cntr and to avoid a hospital stay. Ambulatory facilitis charg lss than hospitals. (Th oprating room and ansthsia fs ar much chapr.) Patint and partnr satisfaction with pnil implants is gratr than 90%. I suppos if th dvic lasts 20 yars, $25,000 isn t a bad dal. Dr. Eid: No, it s not. Thr ar a lot of othr mdical procdurs that ar much mor xpnsiv. Is thr anything ls mn should know about th pnil implant or othr options availabl to trat rctil dysfunction aftr prostat cancr? Dr. Eid: On fls compltly normal with a pnil implant. Evrything is prsrvd; nothing is rmovd from th patint to put in th pnil implant. Also for many, th implant rstors a fullr pnil anatomy. Th pnis dosn t rtract whn th implant is not in us, so th flaccid pnis appars largr. Aftr prostatctomy, som patints will hav difficulty with urination if th patint is ovrwight and th pnis rtracts. A pnil implant will also hlp in this situation. Patint and partnr satisfaction with pnil implants is gratr than 90%, but as with any mdical procdur, sk th most xprincd physician you can find in ordr to maximiz chancs of succss. Sptmbr 2016 Volum 2 No. 1 P17

18 Clinical Trial: Arthur Burntt, MD Erythropoitin + Erctil Function Aftr Surgry Dr. Arthur Burntt is th Dirctor of both th Basic Scinc Laboratory in Nuro-Urology and th Sxual Mdicin Fllowship Program at Johns Hopkins Univrsity in Baltimor, Maryland. Prostatpdia spok with him rcntly about a trial h s running that offrs mn rythropoitin bfor surgry to improv th spd at which thy rcovr sxual function aftr surgry. What ara of prostat cancr tratmnt do you spcializ in? Dr. Burntt: I spcializ in cancrs in th plvic ara, as wll as plvic rconstructiv surgris as thy rlat to th urognital systm. I hav a uniqu prspctiv and hav mad som major scintific contributions in th ara of sxual mdicin. I combin a solid undrstanding of surgry for prostat cancr with an undrstanding of th functional (sxual, urinary, tc.) aspcts aftr prostat cancr. Som urologic surgons just do prostat cancr surgris and thn mov on to th nxt patint. Thr ar also urologists involvd in sxual mdicin who offr tratmnts, but don t rally undrstand what nrv-sparing is all about or what is rally going on with plvic surgry. Thy mak suggstions basd on what thy think thy know without rally bing quit as ddicatd and knowldgabl as othrs. I cross both sids, which is not as common as popl might think. How long dos it tak a man to rcovr his ability to hav an rction aftr prostatctomy? Dr. Burntt: Patints who undrgo prostat cancr surgris, or any intrvntion for localizd prostat cancr, will ndur som aspct of rctil dysfunction or urinary control problms, bcaus th prostat is in a vry prcarious part of th body. Evn though w do prostat cancr surgry bttr than w did 25 yars ago with rgard to prsrving nrvs and blood vssl tissu crucial for th functioning of pnil rction, mn still don t hav th bst immdiat outcoms, maning it taks a long tim to rcovr th ability to hav an rction dspit improvd surgical tchniqus. In gnral, though, patints do rcovr from surgry bttr now. W r mor proficint at th surgry and so mn gt thir continnc back fastr. Thir fatigu lasts not a yar, but a fw wks. Soon thy r back to thir normal daily activitis. Thy r lft wondring whr thir rctions ar. But lack of rctions has mor to do with th shock th nrvs and blood vssls surrounding th nrv tissu undrgo vn with vry dlicat surgris. Many patints ar rally unhappy with that fact. Thy think, I v had a supposdly nrv-sparing opration. I m back to normal activitis, but I m haring it may tak months for my rctions to com back? Whil w v improvd on all othr aspcts of this surgry, I considr rction rcovry to b th last frontir of rcovry from prostat cancr surgry. Whil w stratgiz with mdications lik Viagra, rction rhabilitation or pnil rhab, and things of that sort, nothing has rally com forward to hlp mn rcovr rctions bttr and fastr. Somtims it taks a yar or two for a man to rcovr his rctions. Thr rally has bn a major mov afoot to scintifically undrstand why rction rcovry taks so long, and to think scintifically about what can b don about it. Thr is a lot of misinformation and misconcption out thr that taking Viagra or Cialis vry day is going to rjuvnat th rction rspons aftr prostat cancr surgris, or vn aftr radiation. Th truth of th mattr is that trial rsults on ths mdications ovr th past 15 yars hav not bn imprssiv. P18 Sptmbr 2016 Volum 2 No. 1

19 It s nic that w hav som intrst in nwr surgical approachs lik robotic prostatctomy, but thr is nothing inhrnt about robotic surgry that guarants you ll gt function back any fastr. Thr is still potntial trauma to th surrounding nrvs and blood vssls undr any form of surgry. Most likly you ll hav th bst rspons with a mastr surgon, whthr th surgon is doing opn or robotic procdurs. But th rality is that ths nrvs will b traumatizd vn in th bst hands. W nd to continu to think about nw ways to hlp th nrv tissu rcovr. What is th thinking bhind giving rythropoitin to mn bfor surgry? Dr. Burntt: Almost 10 yars ago, w discovrd that rythropoitin, a hormon mad in th kidny that hlps mak rd blood clls, is a vry potnt hormon and growth factor. W v also discovrd that rythropoitin has som amazing ffcts on tissu halth, rcovry, and rgnration. W v mad som original contributions to that undrstanding in my laboratory: 10 yars ago, I studid rythropoitin in animal modl studis that mimic nrv rgnration in mn undrgoing prostat cancr surgris. W r now bringing rythropoitin to patints in this stting. Erythropoitin is an FDA-approvd drug that can b prscribd. Whil it s bn usd to hlp driv rd blood cll count in thos with anmia, w hav askd if it could b usd in mn undrgoing prostat cancr surgris to rjuvnat th tissu, nrvs, and blood vssls in th plvic ara inadvrtntly traumatizd by this opration. W hav givn rythropoitin to som patints and just followd thm. Many sm to do bttr and that has promptd us to go back and do a formalizd controlld blindd study. (Any tim you giv somon a mdication, and both patints and invstigators know thy r on it, thr is potntial for bias. That is why th ultimat form of a study is a randomizd controlld trial don in a blindd fashion.) W had a bit of a stback about two or thr yars ago whn w startd th trial. Thr wr som rports of thrombombolic vnts in popl chronically taking ths mdications at high doss. Thr wr rports of som complications bcaus th dosing was possibly too high with long-trm dosing. Tratmnt includs a fw prioprativ doss th day bfor, th day of, and th day aftr surgry. W think w r not using xcssiv dosing, but you can imagin rgulatory agncis wr concrnd, basd on othr studis and clinical obsrvations, that our patints might b prdisposd to gtting blood clots. W wr on hiatus for a good yar or two to gt FDA approval aftr w rvampd th trial with lowr dosing. W hav now rstartd nrollmnt. What can patints xpct during th trial? Dr. Burntt: This trial is only offrd at Johns Hopkins Univrsity in Baltimor, Maryland. Patints nd to considr having th surgris don by myslf, or on of my collagus involvd in th trial. W do th rythropoitin dosing proprativly, around th tim of surgry. A patint can t hav th surgry lswhr and thn com to m six months latr and ask for rythropoitin. That is not what th How To Gt Involvd If you r intrstd in participating or would lik mor information, contact Dr. Arthur Burntt at aburnt1@jhmi.du or trial is about. Aftr th surgry and dosing, you go hom lik anybody ls. W s how you rcovr within th nxt yar or two with srial survys that w snd to you. So patints don t ncssarily nd to liv within a commutabl distanc to Baltimor, do thy? Thy could hav th surgry and thn rturn hom. Dr. Burntt: Ys. Patints at a grat distanc away might b possibl participants. What kind of patints ar you looking for? Dr. Burntt: W want patints who ar proprativly potnt and hav opportunitis for sxual activity aftr surgry. Somon who is in poor halth, but still ligibl for prostat cancr surgry; who dos not hav a partnr or who is not sxually activ; or who has poor rctions bfor surgry would not b somon w can nroll. Rathr, w r looking for mn btwn 50 and 60 or youngr, with no compting mdical illnsss, who ar proprativly potnt, and hav partnrs. What about mn who hav had prvious tratmnts lik radiation thrapy or focal thrapy? Dr. Burntt: Thn thy r xcludd, bcaus ths othr tratmnts confound any assssmnt of what w r doing. W d lik to try to protct from acut trauma to th nrv and blood vssl tissu. What about xisting cardiovascular disas? Dr. Burntt: W ll hav to judg. In gnral, if sombody is halthy nough to go through th surgry, is othrwis proprativly potnt, has a partnr, and has an arly nough stag disas that w r not rmoving any nrv tissu, thy could possibly b a candidat. Sptmbr 2016 Volum 2 No. 1 P19

20 Paul Nlson: Onlin Erctil Dysfunction Support FrankTalk.org, an onlin discussion group for mn with rctil dysfunction, is th brainchild of prostat cancr patint Paul Nlson. Prostatpdia spok with Paul about his journy and th thinking bhind FrankTalk. Why did you start FrankTalk? Mr. Nlson: I was diagnosd with prostat cancr th day bfor my fathr did of th sam disas. I was 46. I had surgry vry quickly, bcaus that s what vryon said I had to do givn that I was so young. In rtrospct, I m glad it s out and that it s ovr. That was ight yars ago. I discovrd thr is a lot of onlin support for cancr patints. Aftr I had th surgry, I assumd thr would b onlin support for th sxual sid ffcts of cancr. I wnt onlin and sarchd and sarchd. I just kpt coming up with on commrcial aftr anothr, or on scam aftr anothr. Evn th mdical information sits all said th sam thing. It was vry vagu. I was frustratd and said to my wif, Thr s nothing onlin about rctil dysfunction! Sh s a librarian. Sh said, You r just sarching for th wrong trms. On day at work sh txtd m: My God! You r right. Thr is nothing onlin. Thr wr prostat cancr discussion boards, but thy wrn t focusd on rctil dysfunction. Thy ar for mn fighting prostat cancr! I thought that surly thr must b a patint organization for mn with rctil dysfunction. Wrong again. Amrica is uncomfortabl with sx. Aftr I complaind about it for svral months, my wif told m to shut up and start my own onlin group. Hr w ar ight yars latr. FrankTalk is a patint support sit. W ar an onlin community of mn talking about our xprincs with rctil dysfunction. W talk about what rctil dysfunction dos to your viw of yourslf as a sxual prson and how you cop sxually and motionally. It is not a mdical sit. You can gt mdical information from othr patints how to do a pnil injction or how to us a pnis pump but th hart and soul of th sit is mn discussing th frustrations, triumphs, and disappointmnts of daling with sxual dysfunction. Do you includ only mn with rctil dysfunction aftr prostat cancr? Mr. Nlson: W now hav mn with rctil dysfunction who do not hav prostat cancr, as wll, but w startd off with only prostat cancr patints. Whn I startd th sit, I was a patint at Mount Sinai Hospital. Dr. Natan Bar-Chama was th urologist in charg of rctil dysfunction following surgry. Whn h found out what w wr doing, h said, This is much biggr than prostat cancr. Thr ar millions of mn out thr with rctil dysfunction who hav no rsourcs. And so w opnd up to thos without prostat cancr. W still hav a hug numbr of prostat cancr patints on th sit, but by no mans is it a prostat cancr/rctil dysfunction-only sit anymor. That s just whr it startd. That was actually a big discussion on th sit for a long tim: it dosn t P20 Sptmbr 2016 Volum 2 No. 1

21 What ar som of th psychological problms associatd with rctil dysfunction? W hav doctors who shouldn t b xpctd to b sxual mdicin xprts forcd into playing that rol. mattr what your rctil dysfunction coms from, you still nd hlp. No mattr what th caus, th pain of having it is still th sam. Do you think mn with rctil dysfunction ar rluctant to sk hlp? Mr. Nlson: Amrica is uncomfortabl with sx. Th world is uncomfortabl with sx. Mn in our cultur bliv thir mal idntity is firmly rootd in th pnis. It s tragic. Unfortunatly, most physicians ar uncomfortabl as wll. Thy gt zro training in sxual mdicin in mdical school. Popl don t raliz that urologists ar surgons first and formost. Thy r traind to cut; thy do not gt classs in human sxuality in mdical school. Thy don t tak classs on rctil dysfunction. It rally puts thm in an awkward spot to hav mn ask for hlp with rctil dysfunction. W hav doctors who shouldn t b xpctd to b sxual mdicin xprts forcd into playing that rol. It s a doubl whammy. W v got a cultur of mn for whom it s scary to talk about sx and about sxual failur or sxual difficultis. Thy r thn prsnting thmslvs to doctors who rally don t hav much training in sxual mdicin. It s a complicatd problm. Mr. Nlson: Dprssion is first and formost. Whn mn can t hav intrcours, or th trial and th pain of going through injctions or pills is too much, thy tnd to withdraw. Thy avoid sx. Mn stop having sx. Thir wivs mostly just want intimacy. But bcaus mn ar hardwird in our cultur to just want intrcours, thy just stop having sx. Thy stop touching thir wivs compltly, bcaus it maks thm fl lik a failur or brokn or dysfunctional. It s asir to just avoid it compltly. It dstroys marriags far mor frquntly than anyon talks about. Manwhil, thir partnrs ar thinking, What happnd? H dosn t h lov m anymor. I m not attractiv. I m too old. Womn will oftn say, It dosn t mattr that you can t hav an rction. But ys, it dos mattr to mn. Th man fls stupid that it bothrs him. It s rally a complx problm. Part of th problm is that coupls don t know how to talk about it. Thy don t hav th tools to talk about it. Thy don t hav th vocabulary. It dstroys marriags far mor frquntly than anyon talks about. It s tragic. That s why support groups lik ours ar important. It s worth sking hlp. Sptmbr 2016 Volum 2 No. 1 P21

22 Kathi Houchns: Wivs Talk About Erctil Dysfunction Kathi Houchns s husband, Dav, was diagnosd with prostat cancr in Sh now lads a support group for th wivs, partnrs, and cargivrs of prostat cancr patints in Columbus, Ohio. Prostatpdia spok with Kathi rcntly about how to cop whn your partnr has rctil dysfunction. What was your husband s struggl with rctil dysfunction aftr tratmnt lik? Ms. Houchns: My husband s initial tratmnt was surgry. For that first yar of rcovry, I was afraid I would hurt him if w wr too activ too soon. It was difficult to know what to do, but w wr abl to trust that w could rdiscovr ways to stay connctd physically in spit of this nw normal. W had bn marrid almost four dcads thn, so w knw that w could maintain our clos rlationship, vn if it mant making adjustmnts. Physical touch contributs to a fling of unity and accptanc. It is mor than just body awarnss. It is also a spiritual and motional bond. Dav is a scintist and cancr rsarchr. H has spnt a carr looking for and finding answrs. Prostat cancr bcam his nw focus as h lookd into options for additional hlp with sxual function. In 2001 fw, if any, cancr cntrs offrd programs in pnil rhabilitation. If your doctor or clinic offrs it, tak advantag of it. It can mak a diffrnc. W did not hav that option, so our first stp was to ask for a Viagra prscription. For many yars, Viagra was fin. Ys, it had sid ffcts that could b bothrsom. I somtims flt guilty if h viwd th world through a blu haz or suffrd a stuffy had that mad slping difficult. But h was willing to mak that sacrific to hav th physical rlationship w wantd. Th Viagra pills kpt gtting mor and mor xpnsiv, though. At on point, it was about $35 a pill and it wasn t covrd by our insuranc. It s rar for most popl to find it covrd by insuranc. W gav Cialis a try, too. For a whil it smd to b an improvmnt. Anothr advantag was that taking it nar maltim was not a problm, as it was with Viagra. Th pric, howvr, was about th sam as Viagra. P22 Sptmbr 2016 Volum 2 No. 1

23 Our tratmnt journy also includd two sparat yar-long courss of Lupron hormon ablation, as wll as salvag radiation, in It all taks its toll on sxual function. In th last yar, w hav bn using pnil injctions: Trimix, prpard at a compounding pharmacy. Pnil injctions ar fficint. Thr ar no sid ffcts. It s affordabl. For us, for right now, it s th bst of all worlds. It may not b th right choic for vrybody. Thr ar inconvnincs involvd, bcaus it has to b rfrigratd. W v just bn on a two-wk trip. It would hav bn a challng to carry th prparation along and kp it cold during air travl, in B&Bs, or vn whn visiting family. But two wks is two wks. A longr trip would hav bn mor difficult, but thr ar many othr ways to kp th intimacy of a rlationship aliv. W ar all aging, with or without prostat cancr. Our bodis dclin and diminish in spit of all w do to at right, xrcis, and kp mntally fit. W would lik to think w could stop th aging procss, and thr ar markting gniuss that would lik to convinc you it is possibl, but thr coms a point whn coupls find that intimacy issus for mn and for womn call for som xtra hlp. Thr is som psychology involvd. Somtims it is hlpful to gt counsling to hlp to stay on track, or at last jump-start what may sm lik low battry powr. Th brain is actually th most important sx organ. Whn w talk about tratmnt for rctil dysfunction, w r not just talking about rprogramming th pnis, but also about rprogramming thought procsss. Bing abl to rlax, to fl chrishd, to b fr to play togthr in a mindst of happy possibility can produc miracls. An anxious mind signals adrnalin to b pumpd into your bloodstram and that will shortcircuit an rction. Dr. John Mulhall s book, Saving Your Sx Lif, has bn th most informativ sourc w hav found to undrstand th mystrious world of rctil dysfunction. Do you hav any advic for womn concrnd about rctil dysfunction aftr prostat cancr? Ms. Houchns: Evry coupl has a diffrnt ida of whr thy want to b on th othr sid of trating prostat cancr. But, almost univrsally, womn start out by saying, Sav my husband s lif; sx isn t th most important thing. As I larnd arly on, that is th last hlpful thing you can say to your husband. To say, It will b okay if w can t hav sx anymor is lik saying, It wasn t vr any good anyway so I won t miss it. Evn if your intntion is to hlp tak th prssur off and allow that pnil prformanc loss may b th toll you pay for his staying aliv. In our support group, w hlp ach othr larn to say, Ys, w v got som challngs ahad, but kping our intimat lif nourishd and crativ is prim to our rlationship. I m willing to do what I nd to do to hlp you gt back to whr w want to b. Unfortunatly, many coupls rport that thir urologist or surgon nvr warnd thm about rctil dysfunction. Or if thy wr told, it was in gntl trms hopful, and promising good outcoms. Doctors don t want mn to not choos tratmnt out of far of losing sxual function, vn for a short trm. Thy may mntion rctil dysfunction, but in a positiv way that mphasizs a high prcntag of rturn to prtratmnt function. In youngr mn, that is mor likly, but thr will b som adjustmnt in most mn. Radiologists, too, nd to hav this discussion with patints and thir partnrs. Initially, Dav wnt to his urologist on his own. Th books h brought hom from th post-biopsy appointmnt laid out all th tratmnt choics. It was ovrwhlming to m, but I trustd his choic sinc h is a scintist with a carr in rsarching cancr tratmnt. H dcidd what h wantd to do and schduld surgry for th nxt month. Womn don t usually go to thir husband s dntal or y appointmnts, so it may fl strang to think you would go to a urology appointmnt with him. I rcommnd it, though. Two pairs of ars haring what th doctor is saying and two qustioning minds wanting to gt answrs will bnfit you both in th long run. Prostat cancr is a coupls disas. Womn nd to b a part of vry convrsation rgarding tratmnt and rcovry. Mayb you both hard th doctor say that most of his patints hav rctions back by th nd of th first yar. Mayb thy say six months. Whatvr it is, you don t think to ask how that is masurd. W want to think positiv thoughts, so naturally w say to ourslvs, to ach othr, Ys! W can do this. W will b normal again, soon. W want to bliv that all will b wll. W ar strssd out at this point and grab at any hop. Unfortunatly, w don t think to ask (how could w know?) by what standard do you masur an rction for your statistics? It may not b an rction good nough for pntration. Thr ar lvls of succss. B inquisitiv. Kp opn to rality. Th crisis kicks in whn, posttratmnt, things ar not working out as promisd or as w imagind thy would. I think Dav and I wr ralistic in our xpctations, so rctil Sptmbr 2016 Volum 2 No. 1 P23

24 dysfunction did not com as a surpris. Howvr, in support groups w hav facilitatd, it is a big topic of concrn that thr is so much to figur out about rctil dysfunction. It can b a challnging larning curv. For us, th now 15-yar procss of adapting to lif with cancr rcovry and, currntly a durabl rmission of th disas, has bn an opportunity to xplor flings that in arlir yars got lost in our busy livs. (W raisd thr childrn and wr involvd in our carrs.) Whn cancr ntrs your lif, somthing shifts. W wr awaknd to th importanc of honst communication and dp sharing of hops, drams, nds, and valus. Th cancr journy and all that cam with it has brought us vn closr togthr. Whr do you suggst womn find information and support for thmslvs and thir partnrs? Ms. Houchns: I would start by asking your doctor, but don t stop thr: look to othr sourcs. If you don t want to go to a doctor s offic, gt onlin hlp. B carful, though, as thr ar both good and not-sogood wbsits. A trustd local doctor or support group facilitator could point you to som rliabl ons. Knowldg is powr. Stay informd. Nw thrapis ar coming along all th tim, so find out whr and whn thr ar confrncs you can attnd to larn about th latst innovations. Rad articls and books that rlat to your nds. You ar your own bst advocat. If you har of a spakr somwhr, mak th ffort to go, vn if it mans a two-hour driv. If it mans a wknd in Nw York to har a lctur, thn mak it a holiday. Go to a support group. If you r in a support group, you may find popl whos shard P24 Sptmbr 2016 Volum 2 No. 1

25 xprincs will inform your dcisionmaking. Start your own womn s support group if you nd to. I think womn do bttr whn thy hav sombody thy can talk to, whn thy can opn thir harts and b hard and undrstood and not judgd. It is important to b rmindd that you ar not alon. Womn ar strong, and as I hav sn thm xprinc a support group for th first tim, somtims thy just cry. Thir tars ar a mix of rlif (sombody rally undrstands m); of sadnss (I hav bn holding all this insid bcaus I didn t want to upst my husband, partnr, or childrn, tc.); and xhaustion (I can lay my burdn down with this group. I am not alon anymor.) From that point coms nw nrgy to fac whatvr coms nxt. I rmmbr my vry first support group mting. Th group shard xprincs and storis as w wnt around th small circl of womn. On lady was in tars bcaus hr husband was daling with both rctil dysfunction and incontinnc. Th urin lakag smd to b a hug hindranc to thir intimacy. Th othrs prsnt wr abl to hold th spac for hr to fully xprss hr anguish ovr th situation. Whil problm-solving is not th work of a support group, hlping ach prson go into thir own dp knowing of what might improv a situation is. Othrs, who shard thir own xprincs, opnd a discussion that informd us all. In th nd it hlpd us know that w can kp our ft on th ground, b opn to whatvr our situation is, and, with a sns of humor and hop, b prsnt to our partnr s nds to build a futur togthr that brings plasur to us both. Sptmbr 2016 Volum 2 No. 1 P25

26 XTANDI taks on advancd prostat cancr whil you tak on what mattrs to you. Who is XTANDI for? XTANDI is a prscription mdicin usd to trat mn with prostat cancr that no longr rsponds to a mdical or surgical tratmnt that lowrs tstostron and that has sprad to othr parts of th body. FIND OUT HOW YOU CAN FIGHT BACK. Talk to your doctor and visit XTANDI.com/info Important Safty Information Who should not tak XTANDI? XTANDI is not for us in womn. Do not tak XTANDI if you ar prgnant or may bcom prgnant. XTANDI can harm your unborn baby. It is not known if XTANDI is saf and ffctiv in childrn. Bfor you tak XTANDI, tll your halthcar providr if you: Hav a history of sizurs, brain injury, strok or brain tumors. Hav any othr mdical conditions. Hav a partnr who is prgnant or may bcom prgnant. Mn who ar sxually activ with a prgnant woman must us a condom during P26 and Sptmbr for 3 months 2016 Volum aftr tratmnt 2 No. 1 with XTANDI. If your sxual partnr may bcom prgnant, a condom and anothr form of birth control must b usd during and for 3 months aftr tratmnt. Talk with your halthcar providr if you hav qustions about birth control. S Who should not tak XTANDI? Tak any othr mdicins, including prscription and ovr-th-countr mdicins, vitamins, and hrbal supplmnts. XTANDI may affct th way othr mdicins work, and othr mdicins may affct how XTANDI works. You should not start or stop any mdicin bfor you talk with th halthcar providr that prscribd XTANDI. How should I tak XTANDI? XTANDI is four 40 mg capsuls takn onc daily. Tak XTANDI xactly as your halthcar providr tlls you. Tak your prscribd dos of XTANDI on tim a day, at th sam tim ach day. Your halthcar providr may chang your dos if ndd. Do not chang or stop taking your prscribd dos of XTANDI without talking with your halthcar providr first. XTANDI can b takn with or without food. Swallow XTANDI capsuls whol. Do not chw, dissolv, or opn th capsuls. If you miss a dos of XTANDI, tak your prscribd dos as soon as you rmmbr that day. If you miss your daily dos, tak your

27 prscribd dos at your rgular tim th nxt day. Do not tak mor than your prscribd dos of XTANDI in on day. If you tak too much XTANDI, call your halthcar providr or go to th narst mrgncy room right away. You may hav an incrasd risk of sizur if you tak too much XTANDI. What ar th possibl sid ffcts of XTANDI? XTANDI may caus srious sid ffcts including: Sizur. If you tak XTANDI you may b at risk of having a sizur. You should avoid activitis whr a suddn loss of consciousnss could caus srious harm to yourslf or othrs. Tll your halthcar providr right away if you hav loss of consciousnss or sizur. Your halthcar providr will stop XTANDI if you hav a sizur during tratmnt. Postrior Rvrsibl Encphalopathy Syndrom (PRES). If you tak XTANDI you may b at risk of dvloping a condition involving th brain calld PRES. Tll your halthcar providr right away if you hav a sizur or quickly worsning symptoms such as hadach, dcrasd alrtnss, confusion, rducd ysight, blurrd vision or othr visual problms. Your halthcar providr will do a tst to chck for PRES. Your halthcar providr will stop XTANDI if you dvlop PRES. Th most common sid ffcts of XTANDI includ waknss or fling mor tird than usual, back pain, dcrasd apptit, constipation, joint pain, diarrha, hot flashs, uppr rspiratory tract infction, swlling in your hands, arms, lgs, or ft, shortnss of brath, muscl and bon pain, wight loss, hadach, high blood prssur, dizzinss, and a fling that you or things around you ar moving or spinning (vrtigo). XTANDI may caus infctions, falls and injuris from falls. Tll your halthcar providr if you hav signs or symptoms of an infction or if you fall. Tll your halthcar providr if you hav any sid ffct that bothrs you or that dos not go away. Ths ar not all th possibl sid ffcts of XTANDI. For mor information, ask your halthcar providr or pharmacist. You ar ncouragd to rport ngativ sid ffcts of prscription drugs to th FDA. Visit or call FDA Plas s th Brif Summary on th following pag and th Full Prscribing Information on XTANDI.com. QUESTIONS ABOUT XTANDI? Call XTANDI ( ) XTANDI, Astllas, and th flying star logo ar tradmarks Sptmbr 2016 of Astllas Volum 2 Pharma No. 1 Inc. P Astllas Pharma US, Inc PM 8/15

28 PATIENT INFORMATION XTANDI (x TAN d) (nzalutamid) capsuls What is XTANDI? XTANDI is a prscription mdicin usd to trat mn with prostat cancr that no longr rsponds to a mdical or surgical tratmnt that lowrs tstostron and that has sprad to othr parts of th body. It is not known if XTANDI is saf and ffctiv in childrn. Who should not tak XTANDI? XTANDI is not for us in womn. Do not tak XTANDI if you ar prgnant or may bcom prgnant. XTANDI can harm your unborn baby. What should I tll my halthcar providr bfor taking XTANDI? Bfor you tak XTANDI, tll your halthcar providr if you: hav a history of sizurs, brain injury, strok, or brain tumors hav any othr mdical conditions hav a partnr who is prgnant or may bcom prgnant. Mn who ar sxually activ with a prgnant woman must us a condom during and for 3 months aftr tratmnt with XTANDI. If your sxual partnr may bcom prgnant, a condom and anothr form of ffctiv birth control must b usd during and for 3 months aftr tratmnt. Talk with your halthcar providr if you hav qustions about birth control. S Who should not tak XTANDI? Tll your halthcar providr about all th mdicins you tak, including prscription and ovr-th-countr mdicins, vitamins, and hrbal supplmnts. XTANDI may affct th way othr mdicins work, and othr mdicins may affct how XTANDI works. You should not start or stop any mdicin bfor you talk with th halthcar providr that prscribd XTANDI. Know th mdicins you tak. Kp a list of thm with you to show your halthcar providr and pharmacist whn you gt a nw mdicin. How should I tak XTANDI? Tak XTANDI xactly as your halthcar providr tlls you. Tak your prscribd dos of XTANDI on tim a day, at th sam tim ach day. Your halthcar providr may chang your dos if ndd. Do not chang or stop taking your prscribd dos of XTANDI without talking with your halthcar providr first. XTANDI can b takn with or without food. Swallow XTANDI capsuls whol. Do not chw, dissolv, or opn th capsuls. If you miss a dos of XTANDI, tak your prscribd dos as soon as you rmmbr that day. If you miss your daily dos, tak your prscribd dos at your rgular tim th nxt day. Do not tak mor than your prscribd dos of XTANDI in on day. If you tak too much XTANDI, call your halthcar providr or go to th narst mrgncy room right away. You may hav an incrasd risk of sizur if you tak too much XTANDI. What ar th possibl sid ffcts of XTANDI? XTANDI may caus srious sid ffcts including: Sizur. If you tak XTANDI you may b at risk of having a sizur. You should avoid activitis whr a suddn loss of consciousnss could caus srious harm to yourslf or P28 Sptmbr 2016 Volum 2 No. 1 othrs. Tll your halthcar providr right away if you hav loss of consciousnss or sizur. Your halthcar providr will stop XTANDI if you hav a sizur during tratmnt. Postrior Rvrsibl Encphalopathy Syndrom (PRES). If you tak XTANDI you may b at risk of dvloping a condition involving th brain calld PRES. Tll your halthcar providr right away if you hav a sizur or quickly worsning symptoms such as hadach, dcrasd alrtnss, confusion, rducd ysight, blurrd vision or othr visual problms. Your halthcar providr will do a tst to chck for PRES. Your halthcar providr will stop XTANDI if you dvlop PRES. Th most common sid ffcts of XTANDI includ: waknss or fling mor tird than usual back pain dcrasd apptit constipation joint pain diarrha hot flashs uppr rspiratory tract infction swlling in your hands, arms, lgs, or ft shortnss of brath muscl and bon pain wight loss hadach high blood prssur dizzinss a fling that you or things around you ar moving or spinning (vrtigo) XTANDI may caus infctions, falls and injuris from falls. Tll your halthcar providr if you hav signs or symptoms of an infction or if you fall. Tll your halthcar providr if you hav any sid ffct that bothrs you or that dos not go away. Ths ar not all th possibl sid ffcts of XTANDI. For mor information, ask your halthcar providr or pharmacist. Call your doctor for mdical advic about sid ffcts. You may rport sid ffcts to FDA at FDA How should I stor XTANDI? Stor XTANDI btwn 68 F to 77 F (20 C to 25 C). Kp XTANDI capsuls dry and in a tightly closd containr. Kp XTANDI and all mdicins out of th rach of childrn. Gnral information about XTANDI. Mdicins ar somtims prscribd for purposs othr than thos listd in a Patint Information laflt. Do not us XTANDI for a condition for which it was not prscribd. Do not giv XTANDI to othr popl, vn if thy hav th sam symptoms that you hav. It may harm thm. This Patint Information laflt summarizs th most important information about XTANDI. If you would lik mor information, talk with your halthcar providr. You can ask your halthcar providr or pharmacist for information about XTANDI that is writtn for halth profssionals. For mor information go to or call What ar th ingrdints in XTANDI? Activ ingrdint: nzalutamid Inactiv ingrdints: caprylocaproyl polyoxylglycrids, butylatd hydroxyanisol, butylatd hydroxytolun, glatin, sorbitol sorbitan solution, glycrin, purifid watr, titanium dioxid, black iron oxid Manufacturd by: Catalnt Pharma Solutions, LLC, St. Ptrsburg, FL Marktd by: Astllas Pharma US, Inc., Northbrook, IL Mdivation Inc., San Francisco, CA L082-XTA-BRFS 2015 Astllas Pharma US, Inc. XTANDI is a rgistrd tradmark of Astllas Pharma Inc PM This Patint Information has bn approvd by th U.S. Food and Drug Administration. Rvisd: August 2015

29 REGISTER NOW! Rgistr using th cod PCAS for 20% off all onlin rgistration fs, xcpt Snooz for Duds. 94 NATIONAL SPONSORS Sptmbr 2016 Volum 2 No. 1 P29

30 WHAT IS ZYTIGA (abiratron actat)? ZYTIGA is a prscription mdicin that is usd along with prdnison. ZYTIGA is usd to trat mn with castration-rsistant prostat cancr (prostat cancr that is rsistant to mdical or surgical tratmnts that lowr tstostron) that has sprad to othr parts of th body. IMPORTANT SAFETY INFORMATION Who should not tak ZYTIGA (abiratron actat)? Do not tak ZYTIGA if you ar prgnant or may bcom prgnant. ZYTIGA may harm your unborn baby. Womn who ar prgnant or who may bcom prgnant should not touch ZYTIGA without protction, such as glovs. ZYTIGA is not for us in womn or childrn. Kp ZYTIGA and all mdicins out of th rach of childrn. Bfor you tak ZYTIGA, tll your halthcar providr if you: Hav hart problms Hav livr problms Hav a history of adrnal problms Hav a history of pituitary problms Hav any othr mdical conditions Plan to bcom prgnant (S Who should not tak ZYTIGA? ) Ar brastfding or plan to brastfd. It is not known if ZYTIGA passs into your brast milk. You and your halthcar providr should dcid if you will tak ZYTIGA or brastfd. You should not do both. (S Who should not tak ZYTIGA? ) Tak any othr mdicins, including prscription and ovr-th-countr mdicins, vitamins, and hrbal supplmnts. ZYTIGA can intract with many othr mdicins. P30 Sptmbr 2016 Volum 2 No. 1 If you ar taking ZYTIGA : Tak ZYTIGA and prdnison xactly as your halthcar providr tlls you. Tak your prscribd dos of ZYTIGA on tim a day. Your halthcar providr may chang your dos if ndd. Do not stop taking your prscribd dos of ZYTIGA or prdnison without talking to your halthcar providr first. Tak ZYTIGA on an mpty stomach. Do not tak ZYTIGA with food. Taking ZYTIGA with food may caus mor of th mdicin to b absorbd by th body than is ndd and this may caus sid ffcts. No food should b atn 2 hours bfor and 1 hour aftr taking ZYTIGA. Swallow ZYTIGA tablts whol. Do not crush or chw tablts. Tak ZYTIGA tablts with watr. Your halthcar providr will do blood tsts to chck for sid ffcts. Mn who ar sxually activ with a prgnant woman must us a condom during and for on wk aftr tratmnt with ZYTIGA. If thir fmal partnr may bcom prgnant a condom and anothr form of birth control must b usd during and for on wk aftr tratmnt with ZYTIGA. Talk with your halthcar providr if you hav any qustions about birth control. If you miss a dos of ZYTIGA or prdnison, tak your prscribd dos th following day. If you miss mor than 1 dos, tll your halthcar providr right away. ZYTIGA may caus srious sid ffcts including: High blood prssur (hyprtnsion), low blood potassium lvls (hypokalmia), and fluid rtntion (dma).

31 rs. fi s u o r ang d g n i t s figh r a y IS. 5 E 3 t H n O p H H s GE W N A H C ON T W T L *. N E M ER WIL E H R T R I I E E T N C RE CAN TE ED, THINK AGAIN. A T S O IMIT ED PR S ARE L NC TREATMENT OPTION ADVTHA UR INK YO ttrraatt tto o n o n s i o s n dni prrd d iitthh p w w g vvaannccd n g d o n a l d o a f a l o a f d o d s p u i giccaall iicciinn us ccaannccrr,, aa ttyyp naall)) o rr ssuurrg d d o m m n o o mon paarrttss o pttiion tanntt p off orrm ossttaattcall ((g prro rrssccrriip g,, hho p rr p p a a s i t s h a a i i s s t i c s h d o i i s t r A d o o onn-r GA m s sp d tto om *ZZYYTTIIG ccaassttrraattiiot iss rrssiissttaanntt tto sprraad a c s i h a t c i h a d t t n a d s a t i n a m onn a mttas ccaannccrr tthhaat tsstto ossttrro t r a t t t r a s t w o s p ow or you. f prro nttss tthhaatt llo t h g i r is mn ttrraattm YTIGA Z f i. y. d s to ody bo tthh b doctor r u o y o...talk t Tll your halthcar providr if you gt any of th following symptoms: Dizzinss Fast hartbats Fl faint or lighthadd Hadach Confusion Muscl waknss Pain in your lgs Swlling in your lgs or ft Adrnal problms may happn if you stop taking prdnison, gt an infction, or ar undr strss. Livr problms. You may dvlop changs in livr function blood tsts. Your halthcar providr will do blood tsts to chck your livr bfor tratmnt with ZYTIGA and during tratmnt with ZYTIGA. Livr failur may occur, which can lad to dath. Tll your halthcar providr if you notic any of th following changs: Yllowing of th skin or ys Darkning of th urin Svr nausa or vomiting Th most common sid ffcts of ZYTIGA includ: Waknss Joint swlling or pain Swlling in your lgs or ft Hot flushs Diarrha Vomiting Cough High blood prssur Shortnss of brath Urinary tract infction Bruising Low rd blood clls (anmia) and low blood potassium lvls High blood sugar lvls, high blood cholstrol and triglycrids Crtain othr abnormal blood tsts Tll your halthcar providr if you hav any sid ffct that bothrs you or that dos not go away. THESE ARE NOT ALL THE POSSIBLE SIDE EFFECTS OF ZYTIGA. FOR MORE INFORMATION, ASK YOUR HEALTHCARE PROVIDER OR PHARMACIST. Tll your halthcar providr about all th mdicins you tak, including prscription and ovr-th-countr mdicins, vitamins, and hrbal supplmnts. ZYTIGA can intract with many othr mdicins. You should not start or stop any mdicin bfor you talk with th halthcar providr who prscribd ZYTIGA. Know th mdicins you tak. Kp a list of thm with you to show to your halthcar providr and pharmacist whn you gt a nw mdicin. Call your doctor for mdical advic about sid ffcts. You ar ncouragd to rport ngativ sid ffcts of prscription drugs to th FDA. Visit or call FDA-1088 ( ). Janssn Biotch, Inc. 800 Ridgviw Driv Horsham, PA USA Janssn Biotch, Inc Sptmbr 06/ Volum 2 No. 1 P IF YOU

32 PATIENT INFORMATION ZYTIGA (Zy-t-ga) (abiratron actat) Tablts Rad this Patint Information that coms with ZYTIGA bfor you start taking it and ach tim you gt a rfill. Thr may b nw information. This information dos not tak th plac of talking with your halthcar providr about your mdical condition or your tratmnt. What is ZYTIGA? ZYTIGA is a prscription mdicin that is usd along with prdnison. ZYTIGA is usd to trat mn with castration-rsistant prostat cancr (prostat cancr that is rsistant to mdical or surgical tratmnts that lowr tstostron) that has sprad to othr parts of th body. ZYTIGA is not for us in womn. It is not known if ZYTIGA is saf or ffctiv in childrn. Who should not tak ZYTIGA? Do not tak ZYTIGA if you ar prgnant or may bcom prgnant. ZYTIGA may harm your unborn baby. Womn who ar prgnant or who may bcom prgnant should not touch ZYTIGA without protction, such as glovs. What should I tll my halthcar providr bfor taking ZYTIGA? Bfor you tak ZYTIGA, tll your halthcar providr if you: hav hart problms hav livr problms hav a history of adrnal problms hav a history of pituitary problms hav any othr mdical conditions plan to bcom prgnant. S Who should not tak ZYTIGA? ar brastfding or plan to brastfd. It is not known if ZYTIGA passs into your brast milk. You and your halthcar providr should dcid if you will tak ZYTIGA or brastfd. You should not do both. S Who should not tak ZYTIGA? Tll your halthcar providr about all th mdicins you tak, including prscription and ovr-th-countr mdicins, vitamins, and hrbal supplmnts. ZYTIGA can intract with many othr mdicins. You should not start or stop any mdicin bfor you talk with th halthcar providr that prscribd ZYTIGA. Know th mdicins you tak. Kp a list of thm with you to show to your halthcar providr and pharmacist whn you gt a nw mdicin. How should I tak ZYTIGA? Tak ZYTIGA and prdnison xactly as your halthcar providr tlls you. Tak your prscribd dos of ZYTIGA 1 tim a day. Your halthcar providr may chang your dos if ndd. Do not stop taking your prscribd dos of ZYTIGA or prdnison without talking with your halthcar providr first. Tak ZYTIGA on an mpty stomach. Do not tak ZYTIGA with food. Taking ZYTIGA with food may caus mor of th mdicin to b absorbd by th body than is ndd and this may caus sid ffcts. No food should b atn 2 hours bfor and 1 hour aftr taking ZYTIGA. Swallow ZYTIGA tablts whol. Do not crush or chw tablts. Tak ZYTIGA tablts with watr. Mn who ar sxually activ with a prgnant woman must us a condom during and for 1 wk aftr tratmnt with ZYTIGA. If thir fmal partnr may bcom prgnant, a condom and anothr form of birth control must b usd during and for 1 wk aftr tratmnt with ZYTIGA. Talk with your halthcar providr if you hav qustions about birth control. If you miss a dos of ZYTIGA or prdnison, tak your prscribd dos th following day. If you miss mor than 1 dos, tll your halthcar providr right away. Your halthcar providr will do blood tsts to chck for sid ffcts. P32 Sptmbr 2016 Volum 2 No. 1

33 ZYTIGA (abiratron actat) Tablts What ar th possibl sid ffcts of ZYTIGA? ZYTIGA may caus srious sid ffcts including: High blood prssur (hyprtnsion), low blood potassium lvls (hypokalmia) and fluid rtntion (dma). Tll your halthcar providr if you gt any of th following symptoms: dizzinss confusion fast hartbats fl faint or lighthadd hadach muscl waknss pain in your lgs swlling in your lgs or ft Adrnal problms may happn if you stop taking prdnison, gt an infction, or ar undr strss. Livr problms. You may dvlop changs in livr function blood tst. Your halthcar providr will do blood tsts to chck your livr bfor tratmnt with ZYTIGA and during tratmnt with ZYTIGA. Livr failur may occur, which can lad to dath. Tll your halthcar providr if you notic any of th following changs: yllowing of th skin or ys darkning of th urin svr nausa or vomiting Th most common sid ffcts of ZYTIGA includ: waknss joint swlling or pain swlling in your lgs or ft hot flushs bruising diarrha vomiting cough high blood prssur shortnss of brath urinary tract infction low rd blood clls (anmia) and low blood potassium lvls high blood sugar lvls, high blood cholstrol and triglycrids crtain othr abnormal blood tsts Tll your halthcar providr if you hav any sid ffct that bothrs you or that dos not go away. Ths ar not all th possibl sid ffcts of ZYTIGA. For mor information, ask your halthcar providr or pharmacist. Call your doctor for mdical advic about sid ffcts. You may rport sid ffcts to FDA at FDA How should I stor ZYTIGA? Stor ZYTIGA at room tmpratur btwn 68 F to 77 F (20 C to 25 C). Kp ZYTIGA and all mdicins out of th rach of childrn. Gnral information about ZYTIGA. Mdicins ar somtims prscribd for purposs othr than thos listd in a Patint Information laflt. Do not us ZYTIGA for a condition for which it was not prscribd. Do not giv ZYTIGA to othr popl, vn if thy hav th sam symptoms that you hav. It may harm thm. This laflt summarizs th most important information about ZYTIGA. If you would lik mor information, talk with your halthcar providr. You can ask your halthcar providr or pharmacist for information about ZYTIGA that is writtn for halth profssionals. For mor information, call Janssn Biotch, Inc. at (1-800-JANSSEN) or go to What ar th ingrdints of ZYTIGA? Activ ingrdint: abiratron actat Inactiv ingrdints: colloidal silicon dioxid, croscarmllos sodium, lactos monohydrat, magnsium starat, microcrystallin cllulos, povidon, and sodium lauryl sulfat. Manufacturd by: Pathon Inc. Mississauga, Canada Manufacturd for: Janssn Biotch, Inc. Horsham, PA Janssn Biotch, Inc This Patint Information has bn approvd by th U.S. Food and Drug Administration. Rvisd: May Sptmbr 2016 Volum 2 No. 1 P33

34 Hr. Right. Now. Erctil Dysfunction affcts half of all mn ovr ag Evn if othr thrapis havn t workd for you bfor, th Coloplast Titan Touch pnil implant can hlp you rgain your confidnc in th bdroom. Pnil implants ar custom-fit dvics that ar surgically placd to allow you to obtain an rction whn dsird. Th Coloplast Titan Touch is dsignd to mimic th look and prformanc of a natural rction. It s discrt, rliabl, and it has a rcovry tim of four to six wks. Pnil implants hav alrady hlpd millions of mn and thir partnrs gt back to njoying ral intimacy again, vn at th drop of a hat. Or a sho. CONTROL THE MOMENT Th Titan Pnil Implant for ED To find a physician nar you who spcializs in rctil dysfunction visit ColoplastMnsHalth.com 1. Nuns KP, Labazi H, Wbb RC. Nw insights into hyprtnsion-associatd rctil dysfunction. Currnt Opinion in Nphrology and Hyprtnsion. 2012;21(2): Important Safty Information: A pnil implant, also calld a pnil prosthsis, is concald ntirly within th body to addrss rctil dysfunction (impotnc). Th implant rquirs som dgr of manipulation bfor and aftr intrcours to mak th pnis rct or flaccid. Pnil implants ar surgical solutions rquiring a haling priod and hav risks associatd with surgry such as pain, ansthsia ractions, rpat surgry du to infctions, or mchanical problms with th dvic. Th implant liminats th possibility of a natural rction. Considrations in choosing a pnil implant may includ your mdical condition, lifstyl, prsonal prfrnc, and cost. This tratmnt is prscribd by a physician. Although many patints bnfit from th us of this dvic, rsults may vary.discuss th tratmnt options P34 with Sptmbr your physician to 2016 undrstand Volum th risks 2 No. and bnfits 1 of th various options to dtrmin if a pnil implant is right for you. For furthr qustion, call Coloplast Corp at and/or consult th company wbsit at Th Coloplast logo and Titan ar rgistrd tradmarks of Coloplast A/S All rights rsrvd Coloplast Corp.

35 CURRENTLY RECRUITING: NCT # A Phas II Study to Evaluat Outpatint Magntic Rsonanc Imag-guidd Lasr Focal Thrapy for Prostat Cancr, a 20-yar Survival Study Location: Indian Wlls, CA, USA Contact: Brnadtt M. Grnwood, BSc RT(R)(MR) brnadtt.grnwood@dsrtmdicalimaging.com (760) Choosing to participat in a study is an important prsonal dcision. Talk with your doctor and family mmbrs or frinds about dciding to join a study. To larn mor about this study, you or your doctor may contact th study rsarch staff. Coming Up! Octobr Prostat Cancr Surgry Novmbr Activ Survillanc Dcmbr Salvag Thrapy January Immunothrapy Sptmbr 2016 Volum 2 No. 1 P35