Caveat emptor (Let the buyer beware): Focal therapy for Gleason 6 diagnosis

Also, Dr. Anne Katz's on mourning loss of sexual function

By Howard Wolinsky

Focal therapy has become a hot topic—using high-energy sources to partially eradicate prostate glands to treat cancers,

There is a raging debate over whether this partial gland approach is an effective strategy situated in the no man’s land between active surveillance (AS)/monitoring on one side and active full-gland treatment with radical prostatectomy and radiation therapy on the other. Focal therapy is an “intermediate approach” potentially for those with intermediate-risk cancers, such as Gleason 3+4, which can be monitored with AS, and even for as high as Gleason 4+3 with some more aggressive surgeons.

The experts may disagree on the benefits and durability of focal therapy with cryotherapy, HIFU and other approaches.

But there is one thing they agree on—focal is NOT for men with low-risk Gleason 6/Grade Group 1 patients.

So watch out for flimflammers with an aggressive sales pitch who may try to talk you out of $25k out-of-pocket for a first focal and then $15,000 more if the treatment doesn’t stick.

Read my article just published in Medscape on this topic: https://www.medscape.com/viewarticle/focal-therapy-prostate-cancer-evidence-based-or-oversold-2024a10003do?src=

Mourning the loss of sexual function —even as you tried to preserve it with AS

(Editor’s note. Most of us opted for active surveillance at least in part or maybe mainly to avoid the risk of impotence as a side effect from aggressive treatment. But still, aging can take its toll as sexuality counselor Dr. Anne Katz previously warned us: Time is not kind to the penis. Here, Dr. Katz discusses the mourning process for the loss of sexuality. HW)

By Anne Katz PhD, RN

As a registered nurse and certified sexuality counselor who practised in a large cancer center, I have seen hundreds of men with prostate cancer over the years. No matter what treatment they chose, including active surveillance, the loss of erectile function is devastating. The impact goes beyond the physical and commonly his primary relationship is affected, resulting in a range of emotions from depression to anger to confusion.

I have often heard from both the man and his partner that they didn’t believe that this could happen, that it was other men who experienced this, and what could be done to reverse this common side effect. The men had tried the pills and the pump, and even penile injections, stopping short of a penile implant.

Some of these men were treated 10 years before and had suffered for all that time and only now were asking for my opinion and specifically, my help improving the situation.

It is well known that the lasting effects of a prostate cancer diagnosis and treatment has a significant negative impact on quality of life for both the man and his partner. Along with the physical changes, distress is not uncommon. What is often not mentioned however is the grief that accompanies the loss of sexual function. Actively mourning the loss is an important and increasingly recognized as part of psychosocial counselling and a path to recovery (Wittman et al., 2015). This incorporates acknowledging the loss, experiencing the emotions related to this, creating a perspective of what sexual functioning used to be like, and then finally starting to create a new view of sexuality based on the reality of what one is able to do (Wittman 2011).

So, what could I offer them?

There are rituals for most of the other losses that we experience. These often include aperiod of mourning during which others acknowledge the loss, offer condolences andsupport, and mark the occurrence in a tangible way. But the loss of sexual function is for most men, both a loss of masculinity and also a loss of pleasure and emotional intimacy with their sexual partner(s). It is associated with shame for many men and discussing the loss remains a taboo, even with their partner(s). In my clinical experience, many men don’t mention this to their oncologist, especially the one who performed the surgery or radiation!

In the blog I wrote for the American Society of Clinical Oncology (ASCO) cited below, I encouraged one man to write a letter to his penis; this was met with a quizzical lookfrom the man! But what the blog did not mention is that when I saw the man one month later, he admitted that he had indeed written the letter and his wife had found it, much to his embarrassment. What he had not anticipated was that it began a conversation with her about her loss and they had continued the conversation, with a focus on what they could do sexually, rather than on the loss of erections.

REFERENCES

Katz, A. (2020). Mourning the Loss of Sexual Function https://connection.asco.org/blogs/mourning-loss-sexual-function

Wittmann D, Foley S, Balon R. A biopsychosocial approach to sexual recovery after prostate cancer surgery: the role of grief and mourning. J Sex Marital Ther. 2011;37(2):130-44. 10.1080/0092623X.2011.560538 PMID: 21400337.

Wittmann D. Coping with losses, grief, and mourning in prostate cancer. Adv Psychosom Med. 2015;34:109-22. doi: 10.1159/000369089. Epub 2015 Mar 30. PMID: 25832517.

Dr Katz is available for virtual counseling appointments. She can be reached at:counselling@drannekatz.com

(Send your questions about AS and urology, radiology, pathology, sexual health, genomics, and lifestyle via email to mailto:pros8canswers@gmail.com, or just cut and paste pro8canswers@gmail.com )

Here’s what the NCI’s chief prostate cancer researcher told me about Dr. Loeb’s study on plant-based diet

By Howard Wolinsky

I recently ran an article on the potential benefits of a plant-based diet based on research of Dr. Stacy Loeb, the NYU Langone urologist, lifestyle medicine guru and columnist in this newsletter.

I reached out for comment from Howard Parnes, MD, top prostate cancer researcher at the National Cancer Institute. I was on a panel with Parnes where he said NCI had been searching for benefits from diet for 30 years and had came up empty.

He responded to me after my deadline, But I thought was important to share what he had to say. He was more upbeat than I anticipated.

Here’s his letter to me from Dr. Howard Parnes. (Don’t be confused by all the Howards.)

I am so sorry I missed this and now I see that you wrote to me twice! I actually saw the first email, read the article and was trying to formulate a response when life got in the way (I was under a deadline to give NCI urology grand rounds on prostate cancer active surveillance) and I completely forgot about it. 

Regarding this study, I do think it is reasonable to let men know that there could be some benefit in terms of QOL, in addition to the other potential health (and planetary) benefits, in moving toward a more plant-based diet. At the same time I always caution people against any extreme diet and try to be sensitive that diet can become a major source of stress between couples, as it is one of the few things people dealing with stressful medical issues have control over, and so you don’t want your advice to put a spouse in the position of becoming the food police. 

Sorry, if this response came too late to be any use to you. Always happy to talk.

Best regards,

Howard (Parnes)

(I plan to take Dr. Parnes up on his offer. Let me know if you have any questions for him. Write to: pros8canswers@gmail.com. Please cut and paste: pros8canswers@gmail.com )

Still time to join the ASPI program on AI this Saturday

By Howard Wolinsky

AI, short for artificial intelligence, is in the headlines increasingly. Medical care is expected to receive the biggest benefits in the field, including prostate cancer.

Join Active Surveillance Patients International (ASPI) on Feb. 24 at noon-1:30 p.m. Eastern to hear a panel talk about AI and how it will be affecting our lives as prostate cancer patients in a program entitled “How AI will decrease overdiagnosis and overtreatment of prostate cancer.”

CLICK HERE TO REGISTER

More information: https://aspatients.org/events/

Sign up for ZERO support group on AS on March 12

By Howard Wolinsky

For the past three years, I have run a special Active Surveillance (AS) support group for ZERO. Last year, our virtual support meeting drew 60 patients to talk about AS. By far, it was the biggest session of any at the annual ZERO Summit.

It will be on at 11 a.m. Eastern on March 12, 2024.

Register:
https://us02web.zoom.us/meeting/register/tZUsfuqgrjIoG9AWf7voMhzT_UjdqbQQbQPA