Dr. Myers,

I was told Monday my biopsy is positive for PC.

I just turned 64 and I am fit, trim, healthy and sexual(every day).
I hike, bike, jog, and walk a lot and occasionally ski.

I currently have no ED and my erect penis is the same size as it was in my teens. By Internet standards it is larger than norm, (14.5cm circumference 17.5cm length) so I would think the muscles, blood supply and nerves must be in good shape to still have no problem getting it all the way up.

My urologist has recommended radiation therapy. He said they don’t recommend surgery for patients over about 55yo because the outcome isn’t good leading to incontinence and ED. Do you agree?

He says they have very good outcomes with few side effects from radiation therapy, but progressively over a period of a few years the side effects of radiation causes ED. He was not specific as to how I would cope with the ED and I really didn’t ask. Any thoughts?

I asked is I should try to go the our NIH designated Cancer Center at UCSD and he said their experience at their hospital based Cancer Center with their radiologist was very good and the equipment is state-of-the-art. It is an Accredited Hospital based Cancer Center but not our NIH designated.

He was very negative about robotic da Vinci and said after a few years they have to do a lot of artificial sphincter replacements trying to control incontinence and those patients usually also end up with about the same ED as they see from radiation – particularly when they are over 60yo. He was a bit more positive about the open procedure with a really good surgeon, but still implied that long term patient response was iffy regarding ED and incontinence. Do you agree?

He did get me referral to a surgeon and radiologist (both next week).

The surgeon he referred me to has been recognized as one of the best urologist in San Diego County (Dr. McIntyre) and he has done some 500 da Vinci procedures plus open.

These doctor practice at a Sharp Healthcare, a very large community network with several mega hospital complexes and numerous patient clinic throughout the county, but their hospital based Cancer Centers are not NIH designated – So, do you recommend I try to go to the NIH CCC at UCSD?

Also should I be exploring Proton Therapy or is IGRT/IMRT Photon Therapy still considered about equivalent?

Thank you


You may be aware, but screening for prostate cancer has become controversial because many men are being diagnosed with cancers that do not need to be treated with surgery or radiation therapy. So, the first question you need to ask is whether you need to do aggressive treatment. In general, if your Gleason is 3+3=6 or less and is 5% or less of the biopsy cores, then you may not need either surgery or radiation therapy. In this case, you may be better served with watchful waiting or active surveillance. If you do need aggressive treatment, then surgery or radiation are the two best established treatment approaches. Radiation therapy has indeed advanced dramatically in the last decade and is a reasonable choice. After radiation, there is a gradual loss of erection quality in many men. Fortunately, this usually responds well to Viagra, Cialis or Levitra. If this problem develops, I usually place men on Levitra Monday, Wednesday and Friday to rehabilitate them. The alternative is low dose daily Levitra or Cialis. The other major problem men can have after radiation is urgent urination. This can be minimized by avoiding coffee or citrus fruit.

I find it a bit strange that I, as a medical oncologist, am more enthusiastic about surgery than your urologist seems to be. This is controversial, but I am very enthusiastic about robotic prostatectomy with one major reservation. It takes a lot of experience for a surgeon to really master this technique and there are a few genuine experts in the field. In their hands, the surgical outcomes are really extraordinary. You should definitely look into this. My practice is on the East Coast and so my experience with surgeons from your area is very limited. I have heard very good things about the robotic surgery program at the City of Hope.

NCI designation is largely based on research productivity of a Cancer Center and is not based on the clinical care given at the center involved. The usual measures are the amount of NIH-funded laboratory work and the number of patients entered into clinical trials. It is not based on the quality of the surgery, radiation therapy or medical oncology care. Sometimes the NIH-designated Cancer Center will offer the best care in a region, but more often the best clinical care is provided by physicians with a passion for clinical care rather than publishing papers.