NEWSLETTER
No. 55 March, 2007
Editor: Mark Tweeddale
1. COMING EVENTS
NOTE: Meetings are normally held at 6.30 pm on the first Tuesday of each month in the Palliative Care Cottage, Mona Vale Hospital (unless otherwise advertised)
Tuesday 3 April: Mr Bruce Robertson (Counsellor and Psychotherapist): Emotions and Living with Prostate Cancer
Bruce is located at the White House Medical Centre, Mosman, where he focuses on men's issues, whether they are individual or relationship issues stemming from health problems. He worked as a volunteer at Hope Healthcare, gaining experience of the acute end of depression, and also in community palliative care and rehabilitation units. This is sure to an interesting session and helpful discussion.
Tuesday 1 May: Fifth Birthday Meeting: Members' Open Forum & Carers' Open Forum, followed by a light supper.
Tuesday 5 June: Dr Lisa Horvath (Garvan Institute for Medical Research): Update on Chemotherapy
Contacts
If you want to chat to someone between meetings (for example of you are confused about a decision you have to make, or if you are anxious about the future, or for any other reason) please don't hesitate to ring:
Cancer Council Help Line Tel 13 11 20 or, for someone you know,
John Conroy Tel 9918 9358 or
Mark Tweeddale Tel 9440 8184
Naturally we cannot give you medical advice, but you can chew over your situation or your thoughts with us and, if you wish, we may be able to put you in touch with someone who can give you more specific help. Over to you!
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2. Report on our march MEETING
2.1 "New Treatment for Incontinence following Radical Prostatectomy" by Dr Phillip Katelaris on Tuesday 6 March at 6.30 p.m.
Dr Katelaris started by noting that urinary incontinence (or wetting oneself) can range from just an occasional dribble to total loss of control. Any such loss of control, whether in a man or a woman, can be distressing, even to the point of the sufferer being almost unable to leave home.
First the urologist must determine the cause. There are a variety of such causes, but in the case of prostate cancer patients this typically may result from surgery (radical prostatectomy) or radiotherapy, or salvage radiotherapy following surgery.
The most common type of incontinence in prostate cancer patients is called "stress incontinence". This is not psychological stress, but muscular stress such as is caused by coughing, or lifting a heavy weight. This increases the pressure on the bladder and may lead to urine being forced past the sphincter.
There are two sphincters (valves) controlling the flow of urine. The first is formed by the muscles of the bladder neck and the prostate together.
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This sphincter holds the urine except when voiding, when it relaxes as the bladder muscle tightens. (This sphincter has a particular role during sexual intercourse, when it closes during ejaculation, allowing seminal fluid to flow down the urethra from the prostate, but not urine.) The second sphincter is formed by the muscles at the floor of the pelvis. They stretch between sections of the pelvic bone, and tighten around the urethra and the rectum to prevent release of urine and faeces. Because the prostate surrounds the neck of the bladder, after radical prostatectomy or radiotherapy the bladder neck sphincter is less effective. Total reliance is then placed on the second sphincter at the pelvic floor. After surgery or radiotherapy these muscles may need to be exercised to enable them to retain the urine without the bladder neck sphincter, and in the event of muscular effort, such as when coughing, the pressure on the bladder may result in leakage. In a small proportion of cases there may be total loss of control of urine.
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1. Dr P M Katelaris is a Consultant Urologist at the Sydney Adventist Hospital and Director of: the Prostate Cancer Foundation of Australia; the Prostate Cancer Research Division of the Institute of Magnetic Resonance Research; and of the Prostate Cancer Rehabilitation Centre
2. Manufactured by American Medical Systems (AMS)
Sometimes, even with exercise and help from a continence nurse or physiotherapist, full continence does not return. Dr Katelaris described two basic types of device. For mild to moderate incontinence, a male "sling" can be fitted by surgery, supporting the urethra and providing a degree of pressure on it, so assisting in keeping the urethra closed. There are two forms of sling. One is the InVance sling, which is a synthetic mesh secured to two sides of the pelvic bone, supporting the urethra in between. In some men, however, the shape of their pelvic bone is such that insufficient support can be given with this sling. A variation of the InVance sling is being developed and tried, the AdVance2 sling, in which the sling is designed differently and located differently in the pelvis to provide better support and pressure.
In the case of severe urinary incontinence, a different system can be used: the AMS 800 prosthetic sphincter2 (see picture above). An inflatable cuff is placed around the urethra inside the scrotum. This is pressurised by a saline solution from a small storage balloon placed in the pelvis. The pressure in the cuff keeps the urethra closed. When the man wishes to urinate, he gently squeezes a silicone rubber bulb (or "pump") placed inside the scrotum. This pumps liquid from the cuff back to the storage balloon, allowing the cuff to relax and urine to pass. A very small bypass passage inside the pump allows the saline solution gradually to flow back to the cuff, closing the urethra again after a couple of minutes. The entire device is internal, and easily and unobtrusively operated. It is regarded as the "gold standard" of treatments for male urinary incontinence.
Dr Katelaris also spoke about sexual rehabilitation following radical prostatectomy, in particular, the treatment of impotence. It is important that treatment start soon after the radical prostatectomy, and outlined the team available, including a continence nurse and a sex psychologist. He said that the patient should speak to his urologist and to his spouse about what they both want and need. They should then discuss the various treatment options together, and solve the problem as a team. AMS supply a prosthetic device that has some similarity to the urinary sphincter. Instead of a cuff around the urethra, there are two long narrow balloons that are surgically inserted into the penis alongside the erectile tissue. When the couple wish to make love, the man squeezes a silicone rubber pump in his scrotum, which fills the balloons with saline solution from a storage balloon in his pelvis. This creates a very satisfactory erection, which is maintained as long as the couple wish. The erection is then collapsed by a similar process of pumping the solution back to the storage balloon. This device has the great benefit of allowing spontaneity in love-making.
Our thanks to Dr Katelaris for his very interesting and informative talk.
HELP !!!
I would like to put together a short article for this Newsletter on the positive things about the cancer experience. At first sight this may seem an impossible "ask", but I am aware that many have found that the experience has not been all bad, and that they have gained unexpected benefits. Our experiences could help others …
I would very much appreciate hearing from you. Please don't be shy! I won't use your name!
You can contact me via e-mail at hmarktw@bigpond.net.au or by regular mail at 26 Burraneer Avenue, St Ives NSW 2075. Thanks, Mark Tweeddale
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3. Reports on meetings held elsewhere
3.1 Radiotherapy: by Dr Michael Izard A summary of the presentation at Jacaranda Lodge, the Cancer Support Centre, Sydney Adventist Hospital, on Monday 26 February 2007 at 7.00 p.m.
Radiotherapy for prostate cancer can be subdivided into a number of classes:
External Beam Radiotherapy (EBRT) as the initial treatment
"Salvage" EBRT after surgery when not all the cancer has been removed
Brachytherapy: Low Dose-Rate, or permanent
High Dose-Rate, or temporary, given in conjunction with EBRT
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3. This is certainly my experience. I have had an AMS 800 for almost two years now. It is excellent! Ed.
4. Dr Michael Izard MB BS FRANZCR is a Radiation Oncologist with Radiation Oncology Associates, Mater Medical Centre, Crows Nest, with its treatment centre at the Mater Hospital, Crows Nest. He is also a clinical lecturer with the University of Sydney.
Dr Izard started by explaining that the physical law, the "inverse square law" is fundamental in understanding radiotherapy of any type. This law, which applies to all sorts of radiation including X-rays, light and heat, states: "the intensity of the radiation at any point is inversely proportional to the square of the distance from the source". This means that if you double the distance from the source, you do not get half the intensity, but a quarter. This is shown in the table below, and in Figure 1 below.
The significance of the figures in the table and the shape of the graph (Figure 1) is that, when close to the source, moving a short distance further away from the source greatly reduces the radiation intensity. For example, in the table, moving from 1 unit distant to 5 units distant reduced the intensity by 96%, whereas at a distance of 101 units from the source, moving to 105 units (the same amount of movement) reduces the intensity by only around 7%. It is this variation in the "gradient" (or speed) of loss of dose that makes the two delivery techniques so different.
Distance from Source
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Radiation Intensity %
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1
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100
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2
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25
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3
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11.1
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4
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6.25
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5
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4
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101
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0.0098
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102
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0.0096
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103
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0.0094
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104
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0.0092
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105
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0.0091
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External Beam Radiotherapy: In EBRT the prostate is irradiated from several directions, typically between 4 and 6, so as to limit the total dose received by the tissue other than the prostate, as shown in the diagram below. This shows that the skin and tissue between the source of radiation and the prostate is exposed, but only the prostate and its immediate surrounds receive the radiation from all directions, and thus receive the full dose. Care is taken to minimise exposure of the rectum although, because it is so close to the prostate, the region nearest to the prostate unavoidably receives a moderate dose. By attempting to have the bladder full and the rectum empty at each radiation session the exposure of these and other tissue can be reduced. See Figure 2.
The radiation is typically delivered in many small doses, e.g. each week day for 6 - 7 weeks. This is called "fractionation", and it greatly assists in minimising damage to healthy tissue. While both healthy tissue and cancerous tissue are damaged by each dose, healthy tissue recovers better between doses, whereas the cancer cells recover less. This is illustrated in the graph (Figure 3.). The downward slope is determined by the sensitivity of the cells compared with their ability to repair damage. As shown in the diagram, the cancer cells have less ability to repair, so their slope is more steeply down.
In EBRT, the dose given to the prostate may range from around 66 to 78 Gray (Gy). The limit is influenced by the need to limit damage to other tissue. This is usually given in 1.8 - 2.0 Gy per day, five days per week.
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Until fairly recently, the field (i.e. the cross section of the beam) was basically rectangular, with adjustments being made by cutting off corners as needed (Figure 4). The extent of damage to other tissue is now even less than before, using a "multiple leaf collimator" (Figure 5) which enables the field to be adjusted very flexibly to match the target very closely. This is called "Conformal Radiotherapy". Care has to be taken to ensure that the prostate is precisely located for each treatment, as it can move in the abdomen slightly from time to time.
A further development is Intensity Modulated Radiotherapy (IMRT). In this technique the boundaries of the field are blurred by moving the leaves of the collimator during the radiation. However this technique requires exact knowledge of where the target is (in this instance the prostate) on a day by day basis. At present this is difficult to determine with confidence.
The risk of a second cancer being caused by radiotherapy is small: a lifetime risk of between 1 in 200 and 1 in 4000. While at first this may sound high, it should be compared with the lifetime risk of getting a cancer of some sort (not including common skin cancers) of around 1 in 3. The risk of getting a second cancer in one's lifetime following successful treatment of the first is about 1 in 10. Thus the additional risk from radiotherapy is relatively very small.
In the case of salvage EBRT, it is usually started around 3 months after surgery to allow the wound to heal fully. The start time may be later, if the PSA only rises after a while, but ideally the lower the PSA at the time of starting treatment, the better. Ideally it should be started with a PSA value below 0.2-0.5ng/ml as the bulk of the recurrence is still small. One problem however is choosing the right patient - with such small values, the chances of actually identifying the position of the recurrence is small, and there is a risk of giving radiotherapy to someone who has recurrent disease away from the prostate bed. This needs to be discussed on an individual basis with the Urologist and the Radiation Oncologist.
Brachytherapy: In brachytherapy, the radiation dose is sourced from radioactive "seeds" placed (either temporarily or permanently) in the prostate. The dose can be higher than 90Gy because, as the seeds are either inside or alongside the cancer, their effect is very high there but drops away sharply outside the prostate. This is illustrated by the steep part of the curve in Figure 1. Thus, while the local dose can be very high, the total dose absorbed by the body is very low. Currently the aim is to deliver a dose to the whole gland that is 10-20% higher than any dose that can be delivered by any form of external beam radiotherapy. Parts of the gland will receive doses that are 200-300% higher.
In low dose-rate brachytherapy (LDR, or permanent, implant) the radioactive seeds are placed in the prostate permanently under anaesthetic. Typically 80-120 seeds may be implanted. The dose to the prostate accumulates over the weeks and months, but reaches its designed total level as the radioactivity of the seeds decays effectively to zero. Because the seeds remain in place, as a precaution it is recommended that men should not place children in their laps for some weeks until the radioactivity has decayed substantially. (The "half life" of radioactive iodine (I125) is 59 days, so after 8 months its radioactivity has reduced to around 6% of the initial level, and it continues to halve each 2 months after that.). Other forms of contact with adults are fine; sex should be with a condom for the first month (in case a seed comes out in the ejaculate), but otherwise there is no risk to his partner. Men who have had such an implant are not allowed by law to be cremated within two years of the implant date in the unlikely event of their death in that timeframe (which wouldn't be from prostate cancer or its treatment).
Low dose-rate brachytherapy is only suitable for slow growing cancers, as the dose accumulates slowly. It is only appropriate for T1 and T2 (i.e. confined to the prostate) cancers, with a Gleason score of less than 7 and a PSA less than 10ng/ml.
In high dose-rate brachytherapy (HDR, or temporary, implant) a number of hollow needles are inserted into the prostate, under anaesthetic, from the perineal region (between the legs, between the scrotum and the anus). They are located very precisely using ultrasound and X-ray. Then wires carrying highly radioactive seeds are slid into the needles until the seeds are in precisely the required position. They are left there for typically 10-20 minutes and then removed. This is repeated to a total of three occasions over 24 hours.
High dose-rate brachytherapy can be used in any prostate cancer, and it may be followed by EBRT of a wider zone over the following weeks. The addition of this EBRT dose occurs routinely if this technique is used; but the volume will be tailored depending upon the aggression and extent of the cancer
All brachytherapy requires very detailed planning of the placement of the seeds, using more equipment and extensive "hands-on" involvement of the radiation oncologist. It is thus substantially more costly than EBRT.
Side-effects of treatment: The side effects of radiotherapy vary from person to person. In the case of EBRT the short term side effects build up progressively, first starting to become evident after a couple of weeks and peaking at the end of treatment. They generally start to subside at that point, and by a month later patients generally report that they have improved substantially. Some side-effects may take months or even years to appear and then subside.
Typical short-term side effects of EBRT include:
Bladder: burning/stinging/frequent urge (This usually settles in a few weeks, and is helped by reducing the acidity of the urine e.g. by
"Ural", or by an anti-spasmodic eg Minipress or Flomaxtra). Urgency may be helped by pelvic floor exercises.
Rectum: burning/stinging/frequency; loose motions (controllable by diet or by medication such as "Lomotil"). Rectal bleeding is
an uncommon side-effect that can occur. If it does, one's specialist should be contacted.
Tiredness (this seems less in those who make point of exercising moderately during the period of treatment)
Some slight loss of pubic hair
Some slight local redness
Mood swings (possibly contributed to by having cancer or hormone treatment or both)
Nausea is not a side-effect of treatment to this area
Typical longer term side effects of EBRT (which may not develop for some months to over a year) include:
Bladder: incontinence (very rare, and may be helped by pelvic floor exercises)
Bowel: bleeding; changed bowel habit
Loss of libido, and impotence (depends on how well everything was working beforehand, and if this is important, it must be discussed
with the specialist early in the program).
The side effects of brachytherapy are similar to EBRT, but more focussed on the bladder and away from the rectum. They can include:
Bladder: burning/stinging/frequent urge (usually settling in a few weeks, helped by reducing urine acidity e.g. by "Ural", or by an
anti-spasmodic eg Minipress or Flomaxtra). Urgency may be helped by pelvic floor exercises. Incontinence is very rare e.g. less than
0.5%. Retention can occur as an immediate effect of the implant but usually settles very quickly. Rarely (<1%) it may last for weeks.
The specialist attempts to identify those people who are at risk of retention and avoid using the technique with them. (Predominantly
these are people with significant urinary problems before starting treatment.)
Loss of libido, and impotence. These depend on how well everything was working beforehand, and if this is important, it must be
discussed with the specialist early in the program. It depends especially on whether hormones were used as part of the treatment
program. Dr Izard's data on his patients suggest continuation of erections (with and without support) in over 60%.
Radiotherapy takes time to have an effect on the cancer and the PSA. For example, if the PSA were 13 at the start of treatment, after one month it may fall to 5, after three months to 1, and after six months to 0.5. Again this will vary if hormones have been included in the treatment program, and so it will help to measure serum testosterone as well in such cases.
Sexuality: surgery, radiotherapy and hormone therapy all can, or do, have an impact on the sex life of the partners. It is essential that this be discussed between them, and with their medical team. Various sorts of help are available, but the patient and his partner should always remember that they are a very important part of the team involved in treating the cancer, and the medical team relies on their input at all points in the process.
Our thanks to Dr Izard for his most interesting and informative talk.
(Mark Tweeddale)
4. GENERAL NEWS
4.1 Cancer voices Cancer Voices NSW is a prominent advocacy organisation which speaks for people with cancer and their carers. As a forum it enables people affected by cancer to share issues, ideas and experiences. It works closely with the Cancer Institute NSW and the Cancer Council. At their AGM at Parliament House on Wednesday 21 February they launched their new-look website www.cancervoices.org.au .
4.2 PUBLICATIONS RECEIVED (Copies of all of the following are available for borrowing from our Lending Library.)
(i) Prostate News. Prostate Cancer Foundation of Australia, Issue 29, March, 2007. Focus: Quality of life; new PCFA publication for carers.
(ii) The Healthy Male. Newsletter of Andrology Australia. Issue 21, Summer, 2007. Focus: Cultural and language barriers in health care.
(iii) Cancer Support News. The Cancer Council, NSW. Issue 6, February 2007. The Focus: economic cost of cancer; complementary therapies; HIFU for Prostate Cancer.
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Tell your friends!
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(You know you are a cancer survivor when, on running out of dental floss, you buy 1000 yards of it.)
4.3 Newspaper report in Chile: "A New Technique Against Urinary Incontinence Arrives in Chile"
Between 5 and 10% of men operated on for Prostate Cancer in Chile are left with problems of urinary incontinence. El Mercurio, the Chilean national daily, reported on its Life and Health page on Saturday, 27 January, 2007 how two men were enjoying a radical improvement in their quality of life following treatment the previous week with a new, non-invasive, out-patient technique. The men, both over 60 years of age, and who had been using around five pads per day for the past three years, were the first Chileans to be fitted with a new device to treat severe urinary incontinence, the side effect of radical prostatectomy.
The technique used is called Pro-Act (Therapy of Adjustable Continence of the Prostate). It consists of implanting two small balloons of silicone rubber on either side of the urethra at the level of the neck of the bladder without the need for a large incision. The balloons exert pressure on the urethra, preventing urine escaping from the bladder without control. The only alternative previously available in Chile for severe urinary incontinence has been the artificial sphincter, the cost of which borders on $US10,000. This new alternative will be around one third cheaper and its results are 70% (reportedly, Ed.) superior to similar figures for the artificial sphincter.
The components of the implant are the two balloons, each at the end of a silicone tube about 14cm long and with a titanium outlet at the other end. The balloons are filled with 1.5 to 2.0ml of a contrasting solution. When the balloons expand, they compress the urethra preventing urine from escaping. Liquid is added or removed through the outlets to adjust the pressure in the balloons. These adjustments are made with a subcutaneous injection at the level of the scrotum.
The surgery was carried out by Dr Octavio Castillo, chief of the Unit of Minimally Invasive Urology in the Indisa Clinic, Santiago, and the Brazilian Urologist, Flevio Trigo-Rocha of the Hospital Das Clinicas, University of Sao Paulo. Dr Castillo explained that as well as costing less, it is a simple, out-patient procedure lasting only about half an hour, and the system begins functioning immediately.
Once the implant is in place it is invisible from the outside. What's more, the patient doesn't have to manipulate it to make it function, as distinct from the artificial sphincter. And adjustments can be made in the surgery by the urologist guided by radiological images.
In May, 2006, Dr Trigo-Rocha published a study of 23 patients in the journal "Urology", in which he reported that after an average of 22 months, 65% of patients already used no pad or wore only one per day, 13% had improved but were not fully satisfied, while 22% had not shown any improvement. "If this procedure fails, the system may be removed and an artificial sphincter put in. This opens the possibility that the surgery can be used as a first option before resorting to the traditional technology", says Dr Castillo.
ProAct has been an available technique in the world for about six years. It has already been approved by the European Agency for the Evaluation of Medical Products and is in the process of certification by the FDA, its equivalent in the USA. Brazil is the only Latin American country where, until now, this surgery has been performed. In Chile, Indisa Clinic and the firm Promedic Ltd have organised a workshop on the technique in which more that 30 urologists from clinics and hospitals in Santiago participated. "The reception has been extraordinary", says Dr Castillo, who believes that this year could see the spread to various health institutions, marking the definite entrance of the procedure into Chile.
(From John Conroy)
4.4 INFORMATION ABOUT OTHER ACTIVITIES
From time to time there are activities related to Prostate Cancer in the general northern beaches area. Normally we would announce these at meetings or in the Newsletter, but sometimes we do not get sufficient notice to do so. If you would like to be notified of these, could you please e-mail John Conroy so he can build up an e-mail group address list.
5. BOOK REVIEWS
5.1 It's not about the Bike Lance Armstrong, with Sally Jenkins. Published by GPPutnam's Sons in 2000. 275 pages ISBN 1 86508 375 5, (Borrowed from the library at the Cancer Support Centre, Sydney Adventist Hospital.
This widely recommended book by Lance Armstrong, the world champion cyclist who overcame testicular cancer to go on to win the Tour de France more times than anyone before, tells a remarkable story. But it did not appeal to me as much as I had expected.
In 1996, at the age of 24, when Armstrong was ranked first in world cycling, he was diagnosed with advanced testicular cancer, with secondaries in his lungs and brain. After surgery and aggressive chemotherapy he recovered his health, but took time to readjust to survival, with the same experiences of depression, shortened temper and revised priorities that are often experienced by cancer patients.
The account of his cancer journey is sandwiched between that of his early life and rise to cycling prominence, and that of his efforts to get fit and rise to the pinnacle of cycling athleticism. So, unavoidably but contrary to the title, the book actually contains a great deal "about the bike". To anyone, like me, not interested in the highly competitive and commercial business of professional bicycle racing, much of it may be about as interesting than reading someone else's golf scores. But that is an extreme view!
His cancer story, to those of us who have had cancer, or still have it, will sound familiar. He had the same shock at diagnosis, the same anguish in deciding which treatment to adopt (in the face of conflicting specialist advice), the same apprehension when facing surgery, the expected hammering of his body by the chemotherapy, and the same heightened experience of the importance of the genuine things in life such as family.
I first heard of this book when an amateur cycling enthusiast recommended it to me as an encouragement: illustrating the ability of powerful positive thinking to defeat cancer. There is no doubt that Armstrong's highly developed competitiveness helped his drive to find treatment, to carry it through in spite of his fears, and to cope with the survival "blues". However, I have been advised that testicular cancer can respond well to treatment, so the credit should mainly go to the researchers who developed the treatments and the medical and hospital teams who treated him. In fact, the book does not speak about positive thinking, giving credit where it is due, so the adoption of Armstrong's cure by the "positive thinking" brigade may be doing it a disservice.
Many people have found this book inspirational. I didn't. I was personally a bit put off by the self-centredness which may be inevitable in someone who has succeeds in such a competitive field. Nevertheless the book is a good read. Cycling fans will love it.
My very personal rating for prostate cancer patients: «««
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You know you are a cancer survivor when you no longer have an urge to choke the person who says,
"All you need to beat cancer is a positive attitude!"
5.2 Intimacy with Impotence - The couple's guide to better sex after prostate cancer: by Ralph and Barbara Alterwitz. Publisher; Da Capo Lifelong Books, Perseus Books Group, Cambridge MA USA 2004. 220 pages, ISBN 0-7382-0789-6; (Borrowed from the library at the Cancer Support Centre, Sydney Adventist Hospital.
This book is written by a couple of lay people, with help from medicos and other professionals. It draws on their experience, and that of many other couples. It is easy to read, non technical, straightforward yet sensitive.
Their message is that sexual intimacy and orgasm do not need to stop after removal or radiotherapy of the prostate. They set out the principles appropriate to a renewed, mature, considerate sex life, even though erection may not be possible.
It is difficult in a short review to convey the sensitivity and delicacy with which the book is written. The chapter headings give an indication of the subject matter.
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5. In case there is any misunderstanding, I should make it clear that I am all in favour of finding a way to think positively in the middle of one's cancer journey (and it often is difficult to do), but there are dangers in placing too much emphasis on its reputed ability to cure. Some people, whose cancers are bound to progress in spite of the best medical efforts and their own attempts to think positively, can be weighed down by a feeling of guilt that it is all their fault for not being "positive enough". Similarly, religious people can unreasonably blame themselves for not having enough faith. Ed
They are:
 Impotence: an opportunity to intimacy |
Facts about impotence
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Talking with your partner
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Reviving loving
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Sensual sex
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Getting into shape for sex
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Talking to your doctor
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Commercial therapies and medications
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Putting it all together
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Appendix A: Treatments for erectile dysfunction
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Each chapter starts with a list of the key points made in it. Some that seemed particularly appropriate in this short review are:
The only thing a couple loses when impotence strikes is the ability for penetration. Both partners can still have the desire, arousal, sexual
touching, orgasm and sexual pleasure and satisfaction.
Erectile dysfunction means change and an opportunity to revitalise a couple's relationship and lovemaking.
The three key words for romantic and sexual health are communicate, communicate, communicate.
After years of togetherness, the emotional vibrancy that brought the partners together can get lost.
Bring back the romance you had before marriage to revive the relationship.
Focusing on the erection takes away from the pleasure of intimacy. Instead, focus on giving each other pleasure and showing your love.
There is clear and useful practical guidance on use of the various techniques, both mechanical such and pharmaceutical. However the discussions of romantic and erotic love may be, for many couples, the most helpful content of the book.
My rating for prostate cancer patients: ««««1/2
6. Contacts
Program Co-ordinator: Dr Peter Moore, Northern Beaches Palliative Care, Tel 9998 0222
NSW Cancer Cancer Council Support Helpline Tel 13 11 20
Prostate Cancer Foundation of Australia: Tel 1800 22 00 99
Commonwealth Carelink Centres Tel 1800 052 222
Northern Beaches Neighbourhood Service, Inc.: Tel 9982 3044
