Sutter Health Cancer Service Line: Prostate Committee Resource Book 8/2012 Chapter 16. Frequently Asked Questions & Answers

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1 Chapter 16. Frequently Asked Questins & Answers By Claire Barnaba and D. Jeffrey Demanes, CET; James Bassett, M.D., Grdn Ray, M.D., and Frank DelaRama, R.N., Pal Alt Medical Fundatin; and Patrick Swift, M.D., Alta Bates Summit Medical Center. Yu will receive handuts t prepare yu fr the specific treatment and recvery prcess yu have chsen. Please read thse handuts; they cntain very valuable infrmatin. In additin t thse handuts, many patients we spke with wanted a Q&A sectin and had questins abut when t call the dctr. The fllwing questins were develped by nurses and are divided int fur sectins: a) diagnsis; b) decisin-making; c) treatment; and d) recvery. Diagnsis Q. Why d they ask me thse questins every time I cme in? Weak r interrupted flw f urine Difficulty starting r hlding back urinatin Urinating frequently, especially at night Pain r burning when yu urinate Bld in the urine Painful ejaculatin General pain in the lwer back, hips, r upper thighs A. These questins help clinicians evaluate the disease prgress and yur recvery. Q. Why des the PSA value g up? A. Befre treatment, PSA is prduced by benign and cancerus prstate tissue, and the level tends t be higher in larger prstates, as the prstate cancer grws r if the prstate is inflamed r irritated. Even sex can increase PSA by 10 percent. If it rises after treatment, the timing and rate f increase, as well as the stage and grade f the prstate cancer are helpful in predicting whether the cancer is recurring where it was r if it has metastasized. (Nte: if the PSA dubles ver mre than ne year, the tumr is prbably grwing slwly.) Q. Why des the PSA vary s much? A. The PSA level can be affected by many things ther than the cancer itself. The PSA level will rise with any stimulatin r irritatin f the prstate, such as bike riding, digital examinatins, hrseback riding, mtrcycling, sexual activity and even lng plane rides. These rises are usually temprary, but may last fr several days, s getting a PSA at that time may cause an unrelated rise in the level. It is best t try t abstain frm these activities fr abut 4-5 days prir t getting the PSA tested. Q. Hw des the dctr knw if the cancer has spread? A. Radilgical tests such as bne scans, CT r MRI scans may be rdered. Pelvic lymph ndes can als be sampled frm the pelvis. 95

2 Q. What is the difference between the ttal PSA and free PSA value? A. Free PSA is the PSA nt bund t prteins. It is ften expressed as a rati f free PSA t ttal PSA in terms f percent, which is (free PSA/ttal PSA) x 100. Fr each level f ttal PSA, lw levels r free PSA are indicative f a greater risk f prstate cancer. PSA levels alne d nt make the diagnsis f prstate cancer r prstate cancer recurrence. Q. Why des the dctr want me t take additinal tests? A. Yur dctr is trying t determine if yur prstate cancer is cnfined t the prstate gland, and if nt, where it may have spread. Q. What is invlved in a bne scan? A. A bne scan invlves injecting a small amunt f a radiactive chemical thrugh a vein int yur bldstream. The chemical is absrbed by areas f fast bne grwth that may be assciated with cancer, and then the "picture" shws this t the dctr. Q. Am I mre at risk if a family member has had prstate cancer? A. In certain cases, it seems that the risk fr prstate cancer is passed n t males in the family. The yunger the family member is when he is diagnsed with prstate cancer, the higher the risk fr male relatives t have prstate cancer. Q. Are there genetic markers fr prstate cancer? A. Yes. Sme genes appear t increase risk. A great deal f research is being dne n this tpic. Q. Wh gets an MRI using an endrectal cil? A. Endrectal cils can be used with an MRI t help yur dctr evaluate hw advanced yur cancer is. The cils are inserted int yur rectum during the MRI. This study is available as a supplement t ther diagnstic tests. It maybe rdered t determine if the disease has spread utside the prstate, and therefre, may affect the treatment recmmendatins. Yur dctr will discuss with yu if this test is recmmended in yur case. Decisin-Making Q. Why wn't anyne tell me what t d? A. Prstate cancer in its early stages can be apprached with a number f different therapies, including surgery, radiatin, crytherapy and hrmnal manipulatin. Within the medical cmmunity, there are differences f pinin abut which treatment may be superir in an individual case. Unlike sme cancers, where there is a clearly superir treatment apprach that can be recmmended by all physicians, the chance f beating yur prstate cancer may be similar with a number f different treatments, depending n yur particular disease characteristics. The treatment appraches, hwever, will each differ in terms f the ptential side effects that may ccur (sexual dysfunctin, urinary issues and rectal issues in particular). It is understd that yu may have different cncerns abut these ptential side effects cmpared t ther patients, and yu may be willing t accept sme risks mre than thers in rder t achieve cntrl f the disease. Therefre, many physicians may give yu their pinins f what they think is the best ptin fr yu, but the final decisin is ultimately yurs, based n yur understanding f the chance f success and the risks f side effects yu are willing t accept. 96

3 Q. If they d nt get all f the cancer during surgery, can I have radiatin afterward? A. Yes, pstperative radiatin can be given fr patients with cancer left behind after surgery. There is, hwever, an increased risk f side effects such as incntinence and imptence in patients wh underg bth surgery and radiatin. Q. Why can't they d surgery after radiatin? A. In selected cases, surgery can be perfrmed after external radiatin if highly cnfrmal radiatin, such as IMRT, has been used. It is nt rutinely used after brachytherapy (permanent seeds r temprary implants) r after less cnfrmal frms f external radiatin. The reasn is that there is a high risk f incntinence and pr wund healing in these patients wh underg surgery after radiatin due t the high dses f radiatin that these tissues have received. Treatment Radiatin Q. Why des the dctr want me t take hrmnes befre I start radiatin? A. Tw majr indicatins: 1. Part f a prtcl in certain stages f disease that cmbined treatment had been shwn t prduce better cure rates; and 2. Patients wh have very large gland and/r bstructive urinary symptms may be put n hrmnes prir and during treatment t shrink the gland in rder t decrease treatment related symptms Q. What are the chances that I will be imptent? A. Incidence rise with age but in general ranges between 20 t 50 percent; half these patients will be helped by Viagra and the rest by ther erectile aids. This change in sexual functin may be gradual ver years. Q. What are the chances that I will experience incntinence and will it g away? A. Lng-lasting incntinence is unusual (less than 1 t 2 percent) after brachytherapy r external beam radiatin. If it ccurs temprarily, it is usually is f limited extent. Incntinence is mre likely t ccur after prstatectmy r if a prcedure is dne after radiatin therapy in any frm. Q. What if I miss sme treatments? D the treatments have t be cnsecutive? A. It is best if treatment is cnsecutive, but missing tw t five treatments during an eight-week curse f treatment can be accmmdated by usually adding sme additinal treatments. Missing treatments unnecessarily shuld be avided if pssible. Q. What abut three-day weekends? A. Missing a day des nt interfere in verall success rate. Overall time is imprtant, but treatment prtcls takes int accunt pssibility f interruptins f tw t five days ver a fur-t eight-week treatment perid. If it extends beynd that timeframe, yur dctr can use apprpriate frmulas t adjust the dse if necessary. Hwever, it is best t keep interruptins t a minimum. 97

4 Q. Hw lng will the urinary frequency last? Will it get better? A. Acute side effects shuld decrease ver a three-t-six week perid. Abut 10 percent will cntinue t have prblems fr anther six mnths, and abut 3 t 5 percent may have sme cntinued prblems n a chrnic basis that are usually mild. Q. Hw lng will the bwel prblems last? Will they get better? A. If related t EEBRT, mst symptms are gne three t six weeks after cmpletin f treatment, 10 percent can last up t three t six mnths, and 2 t 5 percent can be chrnic. Symptms are usually mild but deserve mentin t yur dctr s they can be prperly evaluated. Q. I am fur weeks pst radiatin. Is it nrmal t be experiencing frequent urinatin and bwel prblems? Will these things get wrse? A. Acute side effects shuld decrease ver a three-t-six week perid. Abut 10 percent will cntinue t have prblems fr anther six mnths, and abut 3 t 5 percent may have sme cntinued prblems n a chrnic basis that are usually mild. Q. Why am I getting that dse f radiatin? A. Dses are determined by clinical experience and are individualized depending n stage and ther factrs. The dse is chsen that has the highest chance f cure while causing the least amunt f side effects. Q. Hw lng d I have t stay n the medicatin fr urinary frequency r diarrhea? A. Until symptms begin t imprve. Q. Why am I experiencing rectal irritatin? A. It is due t the effect f radiatin n the anal and rectal tissue near the prstate. If it is very uncmfrtable, yu can sit in a warm tub fr five t 10 minutes three r fur times a day, especially after bwel mvements. Diarrhea during radiatin therapy shuld be reprted t yur radiatin dctr r nurse. It can be managed with diet and medicatin. Q. Hw will my diet have t change during my radiatin treatments? A. Yu will want t eat a lw-fiber diet fr a while. Call the Health Educatin Department and ask if they have a nutritin class related t prstate cancer. Q. Hw much diarrhea is OK? A. Anything mre than fur lse stls a day. Call us, and we can recmmend sme ver-the-cunter drugs r prescribe a medicatin. Q. Hw many fiducial seeds are used, and hw are they placed? A. Dctrs use between three t five fiducial markers. They are usually inserted a cuple weeks befre treatment starts s the tissue has a chance t recuperate frm the prcedure. Q. When are fiducials used with radiatin therapy? Wh gets fiducials and wh des nt? A. Fiducial seeds are used in cases where it is felt the anatmy allws ne t place the seeds safely and effectively, and is ften used when it is felt that daily reprducibility culd be a prblem fr varius reasns. 98

5 Q. Will yu take the fiducial seeds ut? A. Fiducial seeds are inserted and nn-radiactive and remain permanently. Radiatin: Permanent (Lw-Dse) Seeds Sutter Health Cancer Service Line: Prstate Cmmittee Q. Is there anything I shuld wrry abut having permanent seed implants? A. Yur physician shuld discuss with yu the risks f the prcedure and expected radiatin effects. In the 24 hurs after the permanent seed brachytherapy prcedure, fevers, inability t urinate r severe pain are unusual and shuld be discussed with the physician r nurse right away. There may be sme small amunt f bld in the urine fr three t fur days after the prcedure, which is nrmal. Difficulty with urinatin (mre frequent urge t urinate, increased nighttime urinatin, sme burning n urinatin and slwing f the stream) is cmmn ver the next three mnths after an implant. Sme difficulty achieving an erectin may als ccur during this time due t the swelling frm the implant. Q. Can I pass the radiatin t my sexual partners? A. During the act f intercurse, it is pssible that a stray seed culd be passed in the ejaculate. It is therefre recmmended that a cndm be used fr the first three mnths after a permanent seed implant has been perfrmed. Q. I am having sme burning with urinatin after surgery r radiatin implant (permanent seed r HDR brachytherapy prcedure). Is this nrmal? A. It is nrmal fr the first 24 t 48 hurs after brachytherapy r surgery. It is frm the manipulatin f the prstate and is frm the urinary catheter. If it lasts lnger than 48 hurs, r the pain is intense, call yur physician. In the next several mnths after an implant, burning n urinatin can ccur due t irritatin f the urethra in r arund the prstate r sphincter muscle. It can be treated with medicines as needed. Q. What cunts as frequent urinatin? A. Urinating mre than every tw hurs. Q. I have t urinate frequently. Is this nrmal? A. It is cmmn t experience sme frequent urinatin immediately after permanent seed implantatin r HDR brachytherapy. It will imprve significantly during the next seven t 14 days. Over the next three mnths, frequent urinatin can ccur due t the effect f the radiatin n the urethra and bladder base. It is usually mst intense fr the first mnth, and then begins t diminish. It shuld be discussed with yur physician, as it can be treated with medicine. Q. My scrtum is bruised. Is this nrmal? A. There can be sme bruising f penis, scrtum and the perineum (the space between the anus and the scrtum) due t needles that were used t implant the seeds. This will heal nrmally, usually after a week, and is usually painless. If there is pain assciate with this, yu shuld discuss it with yur physician. 99

6 Q. I am having sme bld in my urine. When d I wrry and call smene? A. Passage f dark bld clts r bright red bleeding with urinatin ccurs after permanent seed r HDR brachytherapy. It is due t the irritatin f the bladder and urethra frm implant needles r the urinary catheter. When the bleeding is extensive (mre than just bld tinged urine), please cntact yur physician. It may be necessary t place a catheter r (n sme ccasins) t lk in the bladder t find the surce f bleeding. Q. I cannt seem t urinate. Shuld I call the nurse? A. If yu cannt urinate, especially if yu have been unable t urinate fr ver fur hurs and are having pain r discmfrt, call us immediately, and we will ask yu t cme in t see us r we will direct yu t g t the emergency rm. High Dse Rate (HDR) Brachytherapy Q. What is HDR brachytherapy (temprary seeds)? A. It is cmputer directed precisin directed placement f a tiny Iridium 192 radiatin surce temprarily int the prstate. Q. Hw des high-dse radiatin (HDR) wrk? Hw des it kill the cancer and what des it d t nrmal tissue? A. It is similar t all frms f radiatin in that it causes disruptin f the cancer cell DNA. Q. What are the side effects f HDR brachytherapy? A. The ptential side effects f HDR are similar in nature t all frms f radiatin, namely rectal, bladder, and erectile dysfunctin. The rectal cmplicatin rate with HDR, like ther frms f brachytherapy, is extremely lw. Urinatin prblems are ften a cnsequence f pre-existing benign prstatitic hypertrphy (BPH). The rapid delivery f HDR reduces the duratin f the acute side effects after treatment. The urlgist and radiatin nclgist shuld manage any late urinary prblems tgether and urinary prcedures kept t the necessary minimum because they ften reslve withut surgery. The incidence f erectile dysfunctin depends upn baseline status and can be treated in a variety f ways described elsewhere. Q. Hw is it different frm seeds? A. Permanent seeds are inserted by hand directly int the prstate tissue. HDR is inserted by a cmputer cntrl device called an "afterlader." The size f the radiatin surce size is abut the same, but with HDR the "seed" is attached t the end f a fine wire that is inserted fr abut 20 minutes, in several separate sessins, int a hllw catheter scafflding in and arund the prstate. Bth prcedures are usually perfrmed as an utpatient withut a surgical incisin. Q. Why dn't peple knw abut HDR brachytherapy and use it mre? Is it new? A. HDR requires cmplex equipment and facilities. There are fewer physicians trained in HDR and it is newer than seeds. Ten-year utcme data has been published fr bth frms f brachytherapy shwing excellent cancer cntrl and few majr side effects has been published fr bth frms f brachytherapy. HDR may be applied t cancer that has extended beynd the prstate as well as rgan cnfined disease. 100

7 Q. Has HDR been shwn t be safe and effective treatment fr prstate cancer? A. Ten-year utcme date published fr HDR brachytherapy shws excellent cancer cntrl and few majr side effects fr all stages and grades f cancer. HDR may be applied t rgan cnfined disease cancer r t cancer that has extended beynd the prstate. Q. Can I wrk during treatment? A. Except fr the several days during the treatment, and depending upn the type f wrk, mst patients are able t functin immediately upn cmpletin f the implant. Q. Hw lng will I have t be ut f wrk? A. Yu will nt be able t wrk during the day f the prcedure r the next day. There are usually tw implants prcedures separated by ne week. Yu may r may nt be able t d sme wrk in between sessins. Q. D I need disability? A. Yu d nt generally need disability fr prstate brachytherapy seeds r HDR, but sme patients prefer t take ne mnth ff during the treatment prcess. Q. Hw lng d treatments last? When I am actually in the bth? A. Treatments typically last 20 minutes in the treatment rm. Yu will be fully mnitred during treatment. Q. Can I exercise between treatments? A. Exercise within yur cmfrt zne and within the range f recent previus experience is nt a prblem. Start slwly, and wrk up t yur usual activity. D nt ride a bike fr at least ne mnth after any frm f prstate brachytherapy. Discntinue the activity if discmfrt r urinary symptms develp and cnsult yur physician. Q. Hw d I knw if I am cured and if the cancer is gne? A. The wrd cure is nt easy t define fr prstate cancer patients because the disease can be extremely slw t prgress. Hwever, with radiatin therapy (unlike radical prstatectmy, where it is hped that there will be n detectable PSA), reductin f PSA t lw but still detectable levels is the gal f therapy. There are many definitins f PSA prgressin and the PSA level may vary frm patient t patient. It may take many years fr the PSA t reach its lwest pint (nadir) after radiatin therapy. Cnsultatin with yur radiatin nclgist is very imprtant befre a diagnsis f recurrent r persistent disease is made. Regular PSA tests and digital rectal exams (every three t six mnths) are the primary means f fllw up. Other tests may be rdered as needed. A large percentage f patients with prstate cancer have lng-term cntrl r cure f their disease. Q. Hw lng d I stay n hrmne therapy after the treatment? A. The need fr hrmne therapy may vary accrding t the type f prstate cancer. Patients with favrable r lw-risk grup cancer prbably d nt need hrmne therapy in mst cases. Patients with intermediate- and higher-risk grup disease may have hrmne therapy fr variable perids frm fur mnths ttal t indefinitely. In general, high-risk grup patients receive tw years f hrmne treatments when receiving external radiatin therapy withut brachytherapy. The value r lack f value f hrmne therapy with HDR is currently under investigatin. 101

8 Q. During treatment, d I need t be fllwing a special diet? Are there supplements I shuld take? A. There is n special diet assciated with HDR r permanent seed brachytherapy if it is used withut external beam radiatin therapy. If external beam is used, the recmmendatins listed elsewhere in this guide shuld be fllwed. Hrmnes Q. Hw many peple d hrmne therapy? A. Depending n stage f disease and extent f symptms hrmnes may be prescribed. In cases where metastases have develped, mst patients will be treated with andrgen deprivatin therapy (ADT) i.e. hrmne therapy. Fr patients receiving external beam, abut 10 t 20 percent f patients receive ADT as part f their treatment. Overall, abut 15 t 20 percent f patients have ADT, but it depends n the type f presentatins. While we ften refer t patients being treated with hrmnes, the actual gal is andrgen ablatin r remval either surgically by remval f the surce f teststerne by remving the testicles, r antiandrgen medicatins described elsewhere in this guide. The ral (pills) agent is ften given fr 10 t 30 days prir t Luprn t avid an inflammatry reactin in the cancer that is smetime seen with injectins alne. Q. What are ht flashes? Why am I getting them? A. Ht flashes result frm withdrawal f hrmne, and in this case, it is related t teststerne withdrawal. Ht flashes are felt t be cmplex in rigin but prbably reflect autnmic nervus systems respnse t the withdrawal f hrmnes. Q. Once I start hrmnes, will the ht flashes be the wrst at the beginning, middle r end f the treatment? A. It is variable but ccurs mst prminently early in the curse f treatment (first few mnths). Q. What can I d abut the ht flashes? A. Taking vitamin E, sy, and Effexr seems t wrk. Talk t yur dctr because there may be sme restrictins with radiatin therapy. Q. Why is ne hrmne therapy chsen ver the ther? A. Dctrs may use mntherapy (ne therapy) r cmbinatin therapy (several different therapies at the same time), r intermittent therapy (n and ff). The decisin abut which medicatins are used is based n pssible side effects, chance f a teststerne flare (temprary surge) and preference (e.g., as a temprary treatment until anther therapy begins, while a patient makes a decisin abut surgery r radiatin), and fr ther reasns. Q. I feel like I am gaining weight. Is it the hrmne therapy? A. Chances are that yu are nt really gaining weight, but yur bdy is changing because f the hrmne therapy. Yu may be feeling a little sfter and runder arund the abdmen than usual. 102

9 Q. Are the imptence and lack f libid due t hrmne therapy permanent? A. N, these side effects shuld disappear within three t fur mnths after stpping treatment if the curse f treatment is less than six mnths. Lng-term hrmne therapy (> ne year) may be assciated with a higher risk f failure t recvery libid and sexual functin. It takes frm three t six mnths after cessatin f hrmne therapy t recver. Q. Is penis shrinkage related t my dwindling teststerne level? A. Yes. Nrmal penis size shuld return slwly if andrgen blckade is stpped. Recvery: Surgery Q. After surgery, when shuld I call the nurse (talk with a urlgy nurse)? A. Recvery after surgery will take at least fur weeks. Yu will spend a few days in the hspital with a drain that remves the lymph fluid r urine that may temprarily leak int yur pelvis, and then g hme with a catheter fr ne t tw weeks. Yur urine may be a little bldy fr several days, which is fine. If it stays bldy lnger a few days, r is dark red, bright red, r yu find clts in it, call the nurse. Yu shuld als call the nurse if: There are any bld clts in the catheter; Yu have any leg swelling, especially if the swelling is sudden, significant r limited t ne side f yur leg; Yu have pain, tenderness r redness n yur leg; Yu have sudden chest pains, shrtness f breath, a cugh, bldy saliva r mucus; Yu see signs f infectin (e.g., if wund is red r pus cmes ut, r yu have a fever and chills); Yu are cnstipated (i.e., n bwel mvement fr tw r mre days); r After the catheter is remved, yu have truble urinating r if there is a gradual weakening f yur urine stream. This may be a sign f bladder neck cntracture. Q. When d the drains cme ut? A. The drains usually cme ut ne t three days later, befre yu leave the hspital. Q. Catheter questins? A. If yur penis gets sre, make sure the bag is stabilized. If the catheter falls ut, call the nurse and g int yur dctr's ffice t have it replaced. Q. What if surgery des nt wrk? What if the PSA des nt fall t undetectable? A. Raditherapy with r withut andrgen ablatin is an ptin. Q. What if PSA starts rising again after falling t undetectable? A. Raditherapy with r withut andrgen ablatin is an ptin. 103

10 Recvery: Radiatin Q. If yu have had IMRT, can yu then d prtn therapy? A. Prtn therapy wuld nt be apprpriate fr a previusly treated patient. The dses f radiatin with IMRT are t high t allw further treatment with prtns. Brachytherapy may be an ptin if the interval frm treatment is lng (measured in years). Q. I had radiatin and d nt seem t be having any prblem with imptency. Will I have any future prblems? A. Imptence may gradually get wrse ver time. Sexual functin may als decline as a result f ther illnesses and with age. Recvery: Brachytherapy Q. I am having sme burning with urinatin and truble starting my stream. Is this nrmal? A. Burning with urinatin r inability t get stream ging is fairly cmmn three t fur mnths after brachytherapy. Talk t yur dctr abut ptins. Q. Hw will I knw if I can stp taking the Flmax? A. T knw if yu still need it, yu can try nt taking it fr a few days. Such a trial is dne in cnjunctin with cnsultatin with yur dctr. Q. I have decided t have brachytherapy and EBRT. Hw lng will I wait between having the implant and starting the EBRT? A. Usually patients with permanent seed implants wait three t six weeks (depending upn the radinuclide being used and recvery frm the prcedure) befre starting the EBRT. The seed implant can als be dne after the EBRT. With HDR brachytherapy, the preferred apprach is t have the implant first and then start the EBRT abut tw weeks later. EBRT can be given first as well. Discuss the reasns with yur dctr. Q. I have a dry, irritated area n my butt cheek. What is that? A. Sme men get a rash, and it shuld g away in a few days. It may be due t the sterile preparatin slutin r a medicatin. Keep it dry, clean, and put Nesprin n it (if necessary), and baths might help. Ntify yur dctr if it blisters r gets wrse. Q. I have hemrrhids. Is it frm the radiatin? A. Yes, yu can temprarily use ver-the-cunter creams and baths t help with burning and itching. Q. My penis is a little numb in ne spt (r n ne side). Is it frm the radiatin? A. There may be a little nerve irritatin that ccurs (mre cmmnly with brachytherapy). It may take a mnth r year, but it will likely g away. Q. Will I becme imptent with radiatin therapy? A. Radiatin therapy has a lw rate f imptence (less than 30 percent), and 15 percent f thse can have imprved erectins with medicatin r ther aid. 104

11 Recvery: PSA Q. Hw fast will my PSA value drp? A. It is variable and depends n the treatment. It drps quickly after surgery, but slwly after external beam and brachytherapy. The lwest value may nt be reached until tw t fur years after cmpleting treatment. There is ften n majr change fr three mnths after radiatin. Hrmne therapy (ADT) causes a rapid decrease in PSA within a mnth. Q. Why dn't they check my PSA n the last day f treatment? A. Results are variable and can be misleading. The PSA can actually rise immediately after EBRT because f inflammatin and depsitin f PSA int bld. Q. Hw ften will my PSA be mnitred? A. The first PSA test is usually dne fur t six weeks after treatment, and then every fur t six mnths fr the first year r tw, and then yearly r every six mnths thereafter. Q. Will my PSA keep drpping? A. Smetimes there is a bunce r temprary rise in PSA. In ther wrds, the PSA level may rise and fall fr the first several years after radiatin. Althugh n ne is quite sure why, it is a cmmn ccurrence and shuld nt cause alarm. After surgery, if the disease is eradicated, yur PSA will be 0.1 ng/dl r less. A diagnsis f prgressin f prstate cancer requires that the PSA rise be sustained ver a perid f bservatin (many mnths) and that it be cnfirmed by repeated testing. It is the lng-term trend that cunts and nt a single rise that leads t the cnclusin f persistent prstate cancer. There are many ways t define PSA prgressin, s discuss the PSA values with yur surgen (if yu have a prstatectmy) and yur radiatin nclgist (if yu have EBRT r brachytherapy befre a cnclusin f disease prgressin is made. Recvery: Imptence Q. Is there anything I can d t prevent future imptence? A. After the first mnth f treatment, sme peple prescribe lw-dse Viagra r Levitra r injectin therapy n a regular basis t increase bld flw and xygen t the tissue and prevent imptence. Q. Hw are Viagra r Levitra usually prescribed? A. These drugs are t be taken by muth ne hur befre intercurse. Q. What are the differences between Cialis, Levitra and Viagra? A. All f these drugs have the same mechanism, but sme wrk better than thers. If yu take nitrates, yu shuld nt take Viagra, Levitra r Cialis. Fr Viagra, dses abve 25mg shuld nt be taken within fur hurs f taking an alpha-blcker. Cnsult with yur physician befre taking these medicatins. Q. Why wn't the insurance cmpany pay fr mre than six pills a mnth? A. Yu will need t ask yur insurance cmpany. 105

12 Fllw-Up Q. If I have any urlgical prblems in the future, shuld I call yu? A. Yes, if there is a prblem, it is imprtant that the dctr talk t us as prcedures can damage tissue after they received radiatin. We will encurage them t avid instrumentatin in the urethra r bladder. A thrugh discussin that includes input frm the radiatin nclgist is helpful befre prceeding with prcedures. Sme radiatin-assciated prblems may ccur many mnths r years after treatment. They frequently reslve with patience and cnservative medical management. Q. Will I have t have repeat bne, MRI r CT scan? A. Yu will nly need t have these scans if there is a rise in PSA that is interpreted by yur dctr as suspicius fr persistence f the cancer. The bne scan is ften psitive lng after the initial rise f the PSA in cases where the cancer recurs. Q. Wh will fllw my care - the urlgist r the radiatin nclgist? A. Bth. Yu will prbably be seen by bth specialists. The emphasis may vary in different medical cmmunities and it may depend n what kind f treatment yu have received. Q. There is a little bit f bld in my ejaculate. Shuld I wrry r call? A. Hematspermia (bld in the ejaculate) can ccur fr sme time after treatment (even up t a year r mre after treatment). It is usually f n significance, but it shuld be reprted t yur dctr. Q. I seem t have less ejaculate. Is it related t treatment? A. Ejaculate fluid decreases after radiatin because the prstate and seminal vesicles are nt making as much fluid as befre, and the cnsistency may be mre watery. Q. The dctr tld me t stp taking my vitamins and antixidants befre I started radiatin treatment. When can I g back n them? A. Yu can resume yur regimen three weeks after yur last treatment. Q. When can my diet g back t nrmal? A. Yu can resume a nrmal diet right after cmpletin f radiatin treatment. Yu can start adding things slwly. Stp if the diarrhea starts up again. Q. When can I expect my urinary functin will be back t nrmal? A. Urinary functin will usually be back t nrmal by three mnths after treatment ends. Q. What happens if I have bld in my urine mnths r years after radiatin treatment r brachytherapy? A. Bleeding in the urine shuld be evaluated by yur urlgist. Occasinally, many mnths r years after radiatin therapy, a small bld vessel may break and spill bld int the urine. On the ther hand, it is imprtant t rule ut unrelated serius prblems unrelated t the prstate cancer r treatment. There als may be bleeding frm an area f radiatin injured bladder r urethra. The urlgist will perfrm cystscpy (lk int the bladder) r rder varius radilgical studies as needed. Again, a cnservative apprach t management f radiatin effects may avid cmplicatins. 106