EDmedblog

The bottom line, based on studies of hundreds of men who have had this procedure, is that radical prostatectomy cures the vast majority of men with cancer confined, to the prostate. It also cures most men even if cancer has reached or penetrated the prostate wall, if—and this is a big if—two crucial conditions are met: If the tumor cells are pretty well differentiated (a Gleason score of 6 or lower), and if surgeons are able to cut out all the cancer. In surgical terms, this is called getting a “clear surgical margin.” On the other hand, when a high-grade tumor has penetrated the prostate wall, or when the cancer has reached the seminal vesicles, the chances for a cure are not as certain.

One long-term study at Johns Hopkins, of 955 men with clinical stage Ti and T2 (A and B) cancer, found these results ten years after surgery: Only 4 percent had local recurrence of cancer, and 7 percent had distant metastases. And, using the PSA test, which is a highly sensitive measure for cancer recurrence, they found that 70 percent of the patients were cancer-free at ten years.

This study underlined the importance of the pathologic stage (the extent of cancer, determined at the time of surgery. At 10 years, the odds of being cancer-free, as measured by PSA levels, were 85 percent for men with disease confined to the prostate or who had very limited “capsular penetration,” or cancer that has just barely penetrated the prostate wall.

At eight years after surgery, all patients with capsular penetration but “negative surgical margins”—this means the doctors were able to cut out all the cancer—and a Gleason score of 6 or less had an undetectable PSA. Fifty percent of men with capsular penetration and “positive surgical margins”— which means the surgeon’s ability to cut out all the cancer is uncertain—and a Gleason score of 6 or less had an undetectable PSA at eight years. So did 50 percent of men with capsular penetration, negative surgical margins and a Gleason score of 7 or higher. And 25 percent of men with capsular penetration, positive surgical margins and a Gleason score of 7 or higher had an undetectable PSA eight years after surgery. (For more on positive surgical margins, see “Radiation after Prostatectomy,” in Chapter 6.)

Some of the men who had an elevated PSA score went ahead and had radiation treatment; in 10 percent of these men, the radiation seemed to work—PSA plummeted to the undetectable range and stayed there for at least two years.

Why doesn’t radical prostatectomy cure every man? Because the cancer has escaped the prostate before surgery, either locally, to the point where surgeons can’t remove it all, or through impossible-to-detect, distant metastases. This is why many urologists make such a painstaking effort to figure out the exact stage of a man’s cancer before surgery. They believe it’s important to operate only on the patients who are going to benefit most and have the greatest long-term survival.

*113\201\8*

Better understanding of the anatomical terrain also led to another important bonus: Surgeons now knew exactly where the scalpel could and could not go. So, depending on the extent of a man’s cancer, it became possible for them either to save these nerves deliberately, or to remove more tissue by cutting these bundles away—in surgical terms, to create “wider margins of excision”— than they previously had believed possible. (Before this discovery, surgeons routinely gave this area a wider berth because they were afraid of injuring the patient’s rectum.) Which means that with these anatomical techniques, surgeons now have a better chance of removing all the cancer.

Today at Johns Hopkins (the hospital is noted here because results vary worldwide, depending on a range of factors including the surgeon’s skill and the selection criteria for patients), in men aged 50 to 59 who undergo anatomical radical retropubic prostatectomy, 75 percent regain potency. (Overall, at ten years or more after surgery, only 4 percent have local recurrence of cancer, and only 7 percent develop distant metastases; and 70 percent have an undetectable level of PSA.) Important determinants in the return of sexual function include age, the stage of cancer, and the extent of nerve loss—whether one or both nerve bundles remain, or whether they had to be removed during surgery.

We used to say, “If we make a diagnosis and you’re going to need surgery, it may make you incontinent and impotent.” And patients said, “Hold the phone! I’d rather have the disease.” Now, when we talk to patients, we tell them we have three goals: Removing all of the tumor, preserving urinary control, and preserving sexual function. Sexual function is number three because, if it is lost, there are many ways to restore it.

Men who are impotent following radical prostatectomy have normal sensation, normal sex drive, and can achieve a normal orgasm. The one element they may be lacking is the ability to have an erection sufficient for intercourse, and that can be restored by means including a vacuum erection device, injections, even a penile prosthesis.

*105\201\8*

Although some men appear to have clinically localized cancer, there’s a good chance that their cancer has spread beyond the prostate (see table 3.3).

For these men, the combination of radiation and surgery might sound like a promising option. However, it is not yet certain whether radiation after prostatectomy is ultimately helpful. Note: Radical prostatectomy is definitely not very successful in men who have undergone radiation treatment, and in the minds of many urologists, surgery after the fact is not an option. However, men who have undergone radical prostatectomy can go ahead and have radiation therapy later.

Some surgeons recommend hormonal treatment to shrink the prostate (and, they hope, the tumor) before radical prostatectomy, believing that this will make the cancer more curable. But, as one Johns Hopkins scientist explains, “hormone therapy is not a vacuum cleaner—it can’t suck the cancer cells back into the prostate once they’ve escaped.” There is no reason to believe that hormone treatment before radical prostatectomy will make it possible for surgeons to retrieve and eliminate cancer cells that have strayed from the prostate. Also, this approach may mislead a surgeon into thinking the cancer picture is rosier than it actually is, and thereby encourage a less-aggressive cancer operation.

*97\201\8*

When 5 percent or less of the tissue was cancerous, only 17 percent of the men went on to develop more advanced cancer; this is now the classification for stage T1a, or A1, disease. But when more than 5 percent of the resected tissue was cancerous, 68 percent of these men went on to develop cancer progression; this now is the classification of stage T1a, or A2, disease. “It is felt that the amount of cancer in almost all of these patients is significant enough to warrant therapy,” says one of the investigators.

Further analysis has shown that when men with stage T1a disease undergo radical prostatectomy, about 25 percent of them turn out to have a significant amount of cancer in the prostate—the kind of cancer that’s found in men with palpable tumors.

So: Some men with stage T1a cancer require treatment. Some don’t. How to tell the difference? Our old friend PSA comes back to help us again. As it turns out, the level of PSA three months after TUR can be helpful in identifying the men at highest risk of cancer progression. If the PSA is less than 1.o, virtually all of the men with stage T1a (A1) disease have an insignificant amount of cancer. “And we feel that these men can probably be followed with careful digital rectal examinations and PSA tests every six months or a year,” says one of the study’s chief investigators.

*89\201\8*

Prostate cancer grows relatively slowly. When it is localized, it takes two or three years to double in size. And the confounding fact is that cancer can stay in the prostate indefinitely. It takes a long time and many steps involving subde genetic changes before a normal cell, which is designed to live and die, becomes a cancer cell—before some switch is activated that makes the cell think it’s immortal—and before such cells start dividing endlessly. (In high-risk men, some of these steps may be shortened.

If localized prostate cancer is found in a 65-year-old man, for example, it could stay localized for years and he may die with prostate cancer, not of it. This is what happens to hundreds of thousands of men, and it’s one of the factors that can make treatment decisions so cloudy.

But—and this is the crux of the issue—once it escapes the prostate, cancer’s growth is relentless. It can no longer be cured. Once the cancer has spread to bone, the average life expectancy for a man is about three years.

*81\201\8*

Should you wait until you’re married? Is it OK to have sex if you’re really in love, even though you’re not married? Are teenagers mature enough to handle sex? Why do people make such a big fuss about sex? I mean, if two people want to have sex, why shouldn’t they just go ahead and do it?

Even though each of these questions is phrased a bit differently, they are all about the same

thing — when is it all right for a person to have sex and when isn’t it all right? Here again, there isn’t one set of agreed-upon rules; different people have different ideas on this subject.

Some people feel it’s acceptable for two people to have sex with each other as long as they’re both adults or have reached a certain age. Some of these people consider a person to be an adult once he or she has reached a specific age, such as 18 or 21. Others think you’re an adult once you’re out on your own, that is, once you’re no longer living with your parents and/or you’re earning your own living and supporting yourself, still others have what we call the legal point of view. These people feel it’s all right for people to have sex as long as they are over 16 because the law says it is illegal for a male to have sex with a girl under the age of 16 even if she has given her consent (agreed) to have sex with him. There is no legal age of consent for boys, except for homosexual relationships, and then the age is 21. This law was designed to protect young girls from being seduced – that is, being led or talked into sex, by older men. But technically, it is illegal for a male of any age to have sex with a girl under the age of 16. (Apparently the lawmakers didn’t feel it was necessary to protect young boys from older women, perhaps because it’s much less common for an older woman to seduce a young boy, though this does happen.) This law was designed for protection purposes. The people who made this law didn’t intend to suggest that being over 16 automatically means you’re old enough to have sex.

Very few of the people who have definite ideas about when it’s all right for a person to have sex are actually concerned about the law. In fact, for most people it’s not how old you are that’s important. For instance, many people feel that you shouldn’t have sex until you’re married, regardless of your age.

People may have the ‘wait until you’re married’ point of view for a variety of reasons. For some, it’s a religious principle. They feel that the Bible tells us very clearly that people should not have sex unless they’re married to each other. For others, it has more to do with pregnancy. These people are concerned about what will happen if an unmarried couple has sex and a pregnancy results. Such people are often morally opposed to abortion. They feel that a decision to have sex isn’t just a decision between two people but a choice that involves the responsibility for a third person, the baby that might be conceived. For this reason they feel that you shouldn’t have sex until you’re married and are able to take on the responsibility of raising a child.

There are also other reasons why people have the ‘wait until you’re married’ point of view. One man we interviewed, who we’ll call Charlie, explained his reasons particularly well. Charlie was not a religious person but, as he explains, he decided not to have sex until he was married:

My wife and I waited until we were married to have sex, which was a different decision than many people make nowadays. But I think it was a good one. Maybe if we’d had sex with other people or with each other before we were married, we’d have been more experienced or knowledgeable. But learning about sex together, with each other, made it that much more special. Also, we didn’t have to worry if either of us was as good as the other lovers either of us might have had before. So we didn’t have the jealous, uncertain feelings some couples have.

By being willing to wait until we were married, I felt I was showing her that it wasn’t just sex that I wanted from her but real, true love and lifelong commitment with her. And she was showing me the same thing, that we really mattered to each other as people, beyond just a physical, sexual wanting or desire. We really trusted each other, and that made us feel safe enough for us to really let go. We didn’t have to worry that if we did it wrong or it wasn’t great the first time that it would be all over. And, really, it wasn’t so great the first time. It was kind of awkward and embarrassing. But I knew and she knew that we’d both be around tomorrow. So we were able to be free and open and to make mistakes and to learn how to make love. If we hadn’t been married and hadn’t already promised to be there through thick and thin with each other, I think it would have been harder to learn to have good sex. We might have had hurt feelings or uncertainties or shynesses that we couldn’t have got beyond. But by the fact of marrying, we had already promised ourselves to ‘work things out, come what may’. This trusting and promising made us able to grow to be better lovers than we might have been otherwise.

While some people emphasize waiting until you’re married or until you’ve reached a certain age, others put more emphasis on being mature enough or on the nature of the relationship. For instance, some people feel it’s all right to have sex if you’re really in love. Some say it’s all right even if you’re not in love as long as you’re really committed to a serious, long-term relationship. Some say it’s all right as long as you’re both mature enough to handle it. Of course, it’s not always easy to know for sure if it’s really love, just how serious or long-lasting the relationship will be or whether you’re really mature enough to handle it. People who have these kinds of guidelines are concerned about the emotional feelings involved in sex. Having sexual intercourse involves very intense emotional feelings, and it’s very easy for people to be hurt. When parents don’t want teenagers to have sex, many times they’re concerned not only about morality or the possibility of pregnancy, but also about the possibility of the emotional pain that can result when two people have sex and the relationship then ends. Also, as Charlie pointed out, sex is something that takes some time to work out. If two people aren’t in love or in a long-term relationship that guarantees that the other person will be around to work things out with, one or both people may suffer emotionally.

One young woman we interviewed had something especially interesting to say about why she thought it was important to wait to have sex until you were involved in a serious relationship:

I have girl-friends who think if you get into heavy petting with a boy, it’s stupid or artificial or something not to go all the way and have sex with him. They say sex isn’t such a big deal… Maybe I’m too romantic or too idealistic, but I think sex is a big deal – or should be. I want it to be very deep and very emotional… I know you can go round having sex all the time and it won’t be a big deal for you. If you do that too much, though, I think you get… well, hard and cold and kind of callous. It’s like you deaden yourself. You keep having sex without it touching your deep emotional places and you start thinking that’s how it is. You’re no longer even capable of having it be deep or emotional. That’s what I mean by saying you deaden yourself. The part of you, inside yourself, that can have it be deep and emotional dies or starves to death or gets all lost.

The emotional aspects and the nature of the relationship (that’s being in love or at least in a serious relationship) influences many people’s answers to questions about when you should or shouldn’t have sex. There are also some people who don’t place much importance on being in love or in a serious relationship. These people feel that if two people are attracted to each other and want to have sex, then it’s perfectly acceptable for them to do so. Such people often feel that society is ‘too uptight’ or ‘too hung up’ about sex. They often think moral rules about sex are silly or old fashioned. They argue that sex is normal and natural and that people should be free to enjoy it whenever they want to, provided, of course, that both people consent to do so.

Some people who have these more casual attitudes about sex even say that it’s all right for two people to have sex even if they’ve just met or hardly know each other. Some feel that ‘one-night stands’ (that is, having sex with someone you don’t necessarily expect to see again after the one night you spend together) are perfectly OK. However, not everyone who approves of casual sex is quite this casual about it. Most people who favour casual sex don’t think it’s OK to have sex with ‘just anybody’, or to have sex on a one-night stand basis. Still, they are willing to have sex without waiting to find out if they’re really in love or if they’re at least going to have a serious relationship with the other person.

*142\95\2*

Not going out when most of your friends are can make you feel awfully ‘out of it’. Sometimes young people get to feeling that they should pair up with anyone who seems willing just so they won’t feel left out. If you feel this way, you need to think carefully about getting involved with “just anybody’. Is it really worth being paired up with someone you don’t truly care about just so you won’t feel left out? Do you really need to be going out in order to feel good about yourself? Is it really fair to the other person to get involved when you aren’t really interested in him or her?

Instead of going out with someone you don’t really care about, you might decide to make friends with a crowd of young people who haven’t started going out yet. Or, you could decide to go along when your friends are paired up to do things like going to parties, dances or the cinema, even though you don’t have a date. Or perhaps you could ask someone you’re ‘just friends’ with to be your partner in these sorts of situation. Most importantly, remember that it’s not going out with someone that makes you a special person; it’s being who you are. With or without a boy-friend or girl-friend, you’re still the same, special person.

*131\95\2*

The skin of your penis, just like the skin on other parts of your body, is subject to spots, bumps, warts, irritation and so on. The white spots this boy describes are probably just blocked oil glands. Such spots aren’t anything to worry about, but you can always have it checked by your doctor.

I have this lump in my scrotum. It doesn’t hurt, but it’s there. What is it? Can boys get cancer of the scrotum?

Most lumps or bumps in the scrotum are the result of cysts—collections of fluid. Some cysts will go away by themselves. Some require an operation.

It is possible for boys to get cancer of the testicles and scrotum, but it is rare. When it does happen, the first symptom is often a lump in the scrotum. This doesn’t mean that all, or even most, lumps in the scrotal sac are cancerous. But because a few are, it is always a good idea to have any lump checked by a doctor.

Although it can happen to older and younger men, cancer of the testicles most often occurs and is one of the most common cancers in men between the ages of 20 and 3 5. It is forty times more likely to occur in men whose testes never descended or descended after the age of 6. The earlier it is found, the easier it is to cure. For this reason doctors recommend that boys and men practise regular testicular self-examination.

It’s best to examine your scrotum immediately after a hot bath or shower. The scrotal skin is most relaxed at this time and the testicles can be felt more easily. Examine each testicle gently with the fingers of both hands. Put your index and middle fingers on the underside of the testicle and your thumb on the top. Roll your testicle gently between your thumb and fingers, feeling for a small lump about the size of a pea. Repeat this procedure with the other testicle.

You should learn what the epididymis feels like at the back of the testicles so that you won’t confuse it with an abnormality. If you do find anything abnormal, it will most often be a firm area on the front or side of the testicle.

*120\95\2*

Also known as haemophilus. In females this infection causes an abnormal, foul-smelling, greyish vaginal discharge and sometimes redness or itching of the vulva. Males may harbour the germs that cause this infection in their bodies, but they are usually asymptomatic. If untreated, gardnerella may cause infertility problems. But these problems usually clear up once the infection is treated, so gardnerella is generally considered less serious than some of the other STDs. Treatment is by means of oral medications.

Trichomoniasis-Also called trich and TV, the chief symptom in females is an abnormal, foul-smelling, greenish-yellow discharge which tends to be frothy and may cause redness or itching of the vulva. Males nay harbour the germs in their bodies, but they are usually asymptomatic. Treatment is by means of oral medication. Though bothersome, trich doesn’t lead to major medical problems and therefore isn’t considered as serious as some other STDs.

*106\95\2*

Abortion is not a method of contraception – it does not prevent pregnancy. It is a means of ending, or terminating, a pregnancy, and is also called a termination. Most abortions are done before the twelfth week of pregnancy. The woman is given an anaesthetic and when she is asleep, the cervical opening is widened enough to allow for insertion of a small suction tube. The contents of the uterus are then gently sucked out through the tube. Abortions may be done up to the twenty-eighth week of pregnancy, but somewhat different procedures are required.

A properly performed abortion is very safe, with few physical side effects. Although some women do experience pain and bleeding during the first two weeks after an abortion, these side effects are usually not severe. Occasionally, they will be severe, will last for more than two weeks or will be accompanied by a fever or rash, in which case the woman should see her doctor, as this may be a sign of infection or some other problem. Some women feel sad after an abortion, even if they are relieved not to be pregnant anymore. They may benefit from counselling, but serious depression requiring a doctor’s care is rare.

*95\95\2*