RESTORING QUALITY OF LIFE: RESTORING QUALITY OF LIFE: MANAGING SIDE-EFFECTSMANAGING SIDE-EFFECTS

Daniel Shevrin, MDDaniel Shevrin, MDDivision Hematology/OncologyDivision Hematology/Oncology

Northshore University HealthsystemNorthshore University Healthsystem

Pritzker School of MedicinePritzker School of Medicine

University of ChicagoUniversity of Chicago

ARS

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WHAT ARE THE CURRENT THERAPIES FOR WHAT ARE THE CURRENT THERAPIES FOR PROSTATE CANCER?PROSTATE CANCER?

• Early Early – Open radical prostatectomyOpen radical prostatectomy– DaVinci Robotic ProstatectomyDaVinci Robotic Prostatectomy– External Beam Radiation External Beam Radiation – Brachytherapy (Seeds)Brachytherapy (Seeds)– Active surveillanceActive surveillance

• Locally Advanced Locally Advanced – External Beam Radiation + Hormone TherapyExternal Beam Radiation + Hormone Therapy

• AdvancedAdvanced– Hormone therapyHormone therapy– ChemotherapyChemotherapy

SIDE-EFFECTS OF PROSTATECTOMYSIDE-EFFECTS OF PROSTATECTOMY

• AcuteAcute– Blood lossBlood loss

– Rectal injuryRectal injury

– Wound infection, hernia, DVTWound infection, hernia, DVT

– Robotic same with less blood lossRobotic same with less blood loss

• ChronicChronic– Urinary incontinence (< 5% long-term) Urinary incontinence (< 5% long-term)

– Impotence (50% long-term; better if nerve-sparing)Impotence (50% long-term; better if nerve-sparing)

– Urethral strictureUrethral stricture

ACUTE SIDE-EFFECTS OF XRTACUTE SIDE-EFFECTS OF XRT

• External Beam XRTExternal Beam XRT– Rectal irritation (frequent BMs, diarrhea)Rectal irritation (frequent BMs, diarrhea)– Bladder irritation (urgency, frequency, pain)Bladder irritation (urgency, frequency, pain)– FatigueFatigue

• Brachytherapy (seeds)Brachytherapy (seeds)– Same as external beam, but usually lessSame as external beam, but usually less– Urinary retentionUrinary retention– Infection, anesthetic complicationsInfection, anesthetic complications– Seed migrationSeed migration

CHRONIC SIDE-EFFECTS OF XRTCHRONIC SIDE-EFFECTS OF XRT

• BladderBladder– Urgency and frequency due to decreased bladder Urgency and frequency due to decreased bladder

compliance (5-10%)compliance (5-10%)– Urinary retention, urethral strictureUrinary retention, urethral stricture– Radiation cystitis: frequent or urgent urination, bleedingRadiation cystitis: frequent or urgent urination, bleeding

• RectalRectal– Change in bowel function (urgency, frequency, pain)Change in bowel function (urgency, frequency, pain)– Radiation proctatitis: diarrhea, fecal incontinence, bleedingRadiation proctatitis: diarrhea, fecal incontinence, bleeding– ~ 10% both EBRT, brachytherapy~ 10% both EBRT, brachytherapy

• Impotence (35-50%)Impotence (35-50%)– Worse if also receive hormone therapyWorse if also receive hormone therapy– Better with brachytherapyBetter with brachytherapy

MANAGEMENT OF URINARY INCONTINENCEMANAGEMENT OF URINARY INCONTINENCE

• MedicationsMedications• Endoscopic injection of bulking agents into Endoscopic injection of bulking agents into

sphincter: collagen, otherssphincter: collagen, others• Artificial urethral sphincter placementArtificial urethral sphincter placement• Pads, condom catheters, internal catheterPads, condom catheters, internal catheter• Urinary diversionUrinary diversion

MANAGEMENT OF RADIATION INJURY TO MANAGEMENT OF RADIATION INJURY TO BLADDERBLADDER

• Bladder symptoms: Bladder symptoms: – Medications Medications

• Bladder bleeding: Bladder bleeding: – Cauterize or laser treatment to abnormal vesselsCauterize or laser treatment to abnormal vessels

• Urinary retentionUrinary retention– Indwelling catheterIndwelling catheter– Intermittent self-catheterizationIntermittent self-catheterization– Surgical resection of prostate (TURP)Surgical resection of prostate (TURP)

MANAGEMENT OF ERECTILE MANAGEMENT OF ERECTILE DYSFUNCTIONDYSFUNCTION

• Oral medications Oral medications – Viagra®, Levitra®, Cialis®Viagra®, Levitra®, Cialis®– Work only in response to sexual stimulationWork only in response to sexual stimulation– Headache, flushing, drop in BPHeadache, flushing, drop in BP– ExpensiveExpensive

• Vacuum Erection DevicesVacuum Erection Devices– NoninvasiveNoninvasive– CumbersomeCumbersome

• Urethral suppositoriesUrethral suppositories– MUSE (increase blood flow)MUSE (increase blood flow)– Small pellet placed in tip of penisSmall pellet placed in tip of penis– May have painMay have pain

MANAGEMENT OF ERECTILE MANAGEMENT OF ERECTILE DYSFUNCTIONDYSFUNCTION

• Penile injectionPenile injection– Direct injection of Alprostadil Direct injection of Alprostadil – Very effective (75-85%)Very effective (75-85%)– No need for sexual stimulationNo need for sexual stimulation– Needles/painNeedles/pain– Risk of priapismRisk of priapism

• Penile prosthesis/implantPenile prosthesis/implant– Replaces erectile tissue with inflatable cylindersReplaces erectile tissue with inflatable cylinders– Easy to use and dependableEasy to use and dependable– Outpatient surgical procedure; low surgical riskOutpatient surgical procedure; low surgical risk– Non-reversibleNon-reversible

PENILE REHABILIATIONPENILE REHABILIATION

• Concept of preventing/decreasing damage to Concept of preventing/decreasing damage to erectile tissueerectile tissue

• Begins immediately after surgery/radiationBegins immediately after surgery/radiation– Daily or bi-weekly use of oral agentsDaily or bi-weekly use of oral agents– Weekly penile injectionsWeekly penile injections– Weekly MUSEWeekly MUSE

• Small randomized studies show significant Small randomized studies show significant improvement in normalization of erections and improvement in normalization of erections and QOLQOL

• Hindrances: compliance, “needle fear”, costHindrances: compliance, “needle fear”, cost

SIDE-EFFECTS OF ANDROGEN SIDE-EFFECTS OF ANDROGEN DEPRIVATION THERAPYDEPRIVATION THERAPY

• Side-effects due to reduction of testosteroneSide-effects due to reduction of testosterone• Hot flashes Hot flashes • Decrease in libidoDecrease in libido• Reduced stamina, muscle strengthReduced stamina, muscle strength• Weight gainWeight gain• Breast enlargement/painBreast enlargement/pain• FatigueFatigue• AnemiaAnemia• OsteoporosisOsteoporosis• Increase in cardiovascular eventsIncrease in cardiovascular events• Decrease in cognitive functionDecrease in cognitive function

MANAGEMENT OF ADT SIDE-EFFECTSMANAGEMENT OF ADT SIDE-EFFECTS

• Hot flashesHot flashes– Effexor® Effexor® – Megace® Megace®

• Stamina/strengthStamina/strength– ExerciseExercise– GET AHEAD programGET AHEAD program

• Weight gainWeight gain– Diet, exerciseDiet, exercise– GET AHEAD programGET AHEAD program

• GynecomastiaGynecomastia– Breast irradationBreast irradation– SERMS (Raloxifene, Toremifene)SERMS (Raloxifene, Toremifene)

MANAGEMENT OF ADT SIDE-EFFECTSMANAGEMENT OF ADT SIDE-EFFECTS

• OsteoporosisOsteoporosis– Fracture risk at 5 years ~20% (SEER data)Fracture risk at 5 years ~20% (SEER data)– Serious fracture risk (hospitalization) ~5%Serious fracture risk (hospitalization) ~5%– Most men have decrease in bone densityMost men have decrease in bone density– TreatmentTreatment

» Zometa® Zometa® » Denosumab – not yet FDA approvedDenosumab – not yet FDA approved» FosamaxFosamax®®» Ca/Vit D Ca/Vit D » ExerciseExercise

GET AHEAD PROGRAMGET AHEAD PROGRAM

• Program at NorthshoreProgram at Northshore– David Victorson, PhD (Psychology)David Victorson, PhD (Psychology)– Leslie Temple-Mendoza, MD (Integrative Medicine)Leslie Temple-Mendoza, MD (Integrative Medicine)– Dan Shevrin, MD (Oncology)Dan Shevrin, MD (Oncology)

• Men with ADT side-effects (weight gain, weakness/fatigue)Men with ADT side-effects (weight gain, weakness/fatigue)• 12-week intervention:12-week intervention:

– Passive Resistance TrainingPassive Resistance Training– Dietary programDietary program

• Careful monitoring of strength, body mass measures, QOLCareful monitoring of strength, body mass measures, QOL• Correlatives – markers of inflammation, lipid metabolism, Correlatives – markers of inflammation, lipid metabolism,

PSAPSA

MANAGEMENT OF CHEMOTHERAPY SIDE-MANAGEMENT OF CHEMOTHERAPY SIDE-EFFECTSEFFECTS

• Nausea/emesis Nausea/emesis –

• MyelosuppressionMyelosuppression– WBC: neulastaWBC: neulasta– RBC: procrit, darbeRBC: procrit, darbe

• Infection – early use of antibioticsInfection – early use of antibiotics• Neuropathy – neurontin, lyricaNeuropathy – neurontin, lyrica• Stomatitis – nystatin, “magic mouthwash”Stomatitis – nystatin, “magic mouthwash”• Fatigue – exercise, PT evaluation, ritalinFatigue – exercise, PT evaluation, ritalin• Tearing – FML eyedropsTearing – FML eyedrops• Alopecia – nice hatsAlopecia – nice hats

RESTORING QUALITY OF LIFERESTORING QUALITY OF LIFE

• Communicate problems with MD!Communicate problems with MD!• Don’t minimize symptomsDon’t minimize symptoms• Discuss how problems can be preventedDiscuss how problems can be prevented• Is active surveillance an option instead of surgery or Is active surveillance an option instead of surgery or

radiation?radiation?• If hormone therapy recommended, can it be given If hormone therapy recommended, can it be given

intermittently?intermittently?• Ask about bone healthAsk about bone health• Be as educated as possible and ask questions!Be as educated as possible and ask questions!

RESTORING QUALITY OF LIFE: RESTORING QUALITY OF LIFE: MANAGING SIDE-EFFECTSMANAGING SIDE-EFFECTS

Daniel Shevrin, MDDaniel Shevrin, MDDivision Hematology/OncologyDivision Hematology/Oncology

Northshore University HealthsystemNorthshore University Healthsystem

Pritzker School of MedicinePritzker School of Medicine

University of ChicagoUniversity of Chicago