My Treatment Choice

As I wrote previously, there is a difference between aging and getting old. Already under treatment for coronary artery disease, and now with a prostate cancer diagnosis, at sixty-nine which category am I in? When I found out from my urologist that incontinence and impotence were two potential side effects of a radical prostatectomy, my immediate thought was that those are conditions associated with getting old, no matter what circumstances lead up to them.

Guided, but not blinded, by the data

As Mark Twain wrote, there are lies, damn lies and statistics. So what do statistics say about my chances of being impotent or incontinent after surgery? Depends on which statistics you believe, but here are some that seemed consistent throughout the literature I reviewed and the personal testimony I received from friends:

• There’s at least a 60% chance that impotence will follow surgery, but more likely 75%. It occurs because of damage to, or removal of, the nerve bundles near the prostate that are essential for male potency. Because the seminal fluid vesicle is removed during the surgery, men who do not become impotent can experience only what is called a dry orgasm. They cannot ejaculate.
• Incontinency occurs in 20-40% of men following surgery, with at least 25% experiencing frequent leakage or no bladder control at six months. Up to 5% may require surgery to take care of severe urinary incontinence.

Weighing the choices

I spoke to two friends directly about their post-surgery experience. Both of them were, and still are, in fulfilling long-term marriages. The first had open surgery fourteen years ago. Impotence and incontinence followed. While the incontinence lasted for a brief time, the impotence was permanent. He chose surgery that restored his ability to have an erection and continue to have sex. The second had Laparoscopic surgery eight years. He still experiences some incontinence and his impotence was permanent, although from time-to-time he's able to have an erection. He tried all of the erectile dysfunction medications on the market and none of them worked.

But what was most important and consistent in their experience, despite the differences in their journeys, was that both adjusted to their situations, maintained intimate relations with their wives and have been cancer free since they had their prostates removed. They also agreed that the physiological changes that occur in men and women as they age alters the nature of intimacy regardless of the additional challenges they faced, that all aging couples make adjustments over time.

My active life

My wife and I have been married for thirty-six years. We still have an intimate physical relationship that includes satisfying sex, though less frequent than when we were younger. I don’t know how long the sex will last, but that doesn’t matter. To be suddenly faced with the possibility of losing that aspect of our relationship disturbed and upset me. That’s not aging, that’s getting old, sooner than I anticipated. The same goes for incontinency. I’m a rock climber and a long distance backpacker! Leakage? Pads? Old!

What I’m expressing is the cognitive dissonance I mentioned in my previous article. I may be sixty-nine, but I still lead an active physical life, and my mind resists choosing a treatment that may very well alter that reality, even though I know that surgery will remove cancer from my body, which seems like a rational choice to make. Who wants to walk around with cancer? Well, as it turns out, me, and, among men with prostate cancer, I’m not alone.

Making my choice

Here’s part of my journal entry for March 29th, 2017: “Because my PSA and Gleeson scores put me in the low grade category, I’m choosing Active Surveillance as my treatment option. I’ll have quarterly PSA tests, another biopsy in one year, with the option of having surgery at any time, either because my numbers go up or because I tire of walking around with cancer.” Active surveillance is an interesting term, kind of redundant. Is there such a thing as passive surveillance? But I get it. Action, and trust, is required, collaboratively, between my urologist and me. I may be obstinate, but I’m not ignorant. I will go where the numbers lead me.

Research published in the last few years indicates that more and more men are choosing active surveillance with their risk of dying from cancer ten years after diagnosis not increasing. According to an article published in Scientific American in September, 2016, “Men who received active monitoring had the same minuscule risk of dying of prostate cancer over the following 10 years—barely 1 percent—as men who underwent surgery to remove the prostate or radiation.”¹ This is especially true with Gleeson scores of six or lower.

So, given all the information I had available to me, the possible long terms effects of a radical prostatectomy, and the support of my wife, in March 2017 I chose active surveillance as my treatment plan. Almost one year later I am still following that plan, which I'll cover in detail in my next article.