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Prostate Cancer Treatment: External Beam Radiation versus Proton Beam Therapy

Posted Jun 25 2010 12:00am

Reader question:   

Which prostate cancer treatment produces less side effects, especially sexually: Proton beam therapy or external beam radiation? I have heard conflicting reports on the value of one over another.

I elected to do external beam radiation and now am experiencing sexual side effects. Later on, after I had finished my radiation, I heard of another patient who went to Loma Linda in California for proton radiation, and he says he has experienced no loss of sexuality.

If I had known this beforehand I would have investigated proton radiation a lot more aggressively. I did see a video clip on the internet from a Boston doctor, who said there was no advantage in doing proton beam therapy over external beam radiation. This really influenced my decision-process so I did not look into it further. And of course, my doctor favored the external beam radiation approach since he is associated with a radiation center.                                          

I know I cannot do anything about my situation, but I wish there was more information out there on both radiation approaches for men could make the right decision for them. And it would be kind of a therapeutic for me to hopefully help other men get the right information to make the right decision.   ---B. A. (Houston, Texas)  

Rabbi Ed’s Answer:

I’m sorry you’ve come to the point where ED has become a part of your life as it has for most patients after radiotherapy (external beam and seeding) as well as after surgical removal of the prostate, - a prostatectomy.  

To answer your question, most proton radiation patients who have prostate cancer treatment (about 6,000 a year in six U.S. locations thus far) seem to complain of fewer sexual side effects, compared to patients who have undergone other treatments.   However to my knowledge, most proton therapy patients, like those who choose other treatment options, will exhibit some degree sexual dysfunction, especially in terms of eventually being incapable of ejaculation.

So, while it’s true that using a proton beam enables doctors to destroy a prostate tumor with pinpoint accuracy, a substantial number of proton beam patients (though perhaps the minority) will also eventually lose their prostate's capacity to produce semen (1/3 is from the prostate and 2/3 from the seminal vesicles.).   

It’s also true that up to half of external beam patients will eventually get ED within 5 years of their treatment, and the other half won’t!  How that breaks down for proton therapy patients has not been determined to my knowledge, though it wouldn’t surprise me if at least ¼ of proton therapy patients eventually ended up with ED as they get older.  

It's true that unlike most proton beam therapy efforts, external beam radiotherapy – even IMRT, can affect some surrounding tissue, although less so than the original external beam radiotherapy.   However, a couple of years ago a Johns Hopkins report indicated that while proton therapy might cause less sexual dysfunction, it can lead to the loss of bone density in the hip area and hip fractures; so it may be a bit of a trade-off for some men, who may end up with better sexual function, but could be worse off in terms of their bone health.

Another report indicates that “Lateral overshoot in the region of the neurovascular (=nerve) bundles is …necessary to avoid the risk of under-dosage. In the future, this potential disadvantage will likely be mitigated by the use of intensity-modulated proton therapy, although at present only one center in the world is using this.” ( ).

In simpler terms, proton therapy has a greater chance of destroying nerve bundles that allow for erection, situated on either side of the prostate as the tumor is eradicated. That will happen until further technological developments have helped lessen this possibility.

Finally you have to ask yourself if your ED would have transpired anyway, regardless of your type of treatment. ED is also a function of aging, diabetes, neuropathy, depression, or plaque in your arteries, not to mention “losing it (sexual function) because of not using it.”  In addition it's the consequence of certain medications such as chlorestorol drugs like Lipitor or anti-depressions like Cymbalta.

Besides, if you had any symptoms of ED before your treatment, you’re likely to be worse off sexually than those who were in good shape before treatment; on the contrary you are less likely to be fully functional sexually after the treatment ends. That applies as well to surgical patients who had a tough time before surgery and then had a prostatectomy – and that includes me!  

How can you and the rest of us get around ED and a lower libido? Explore with your doctor if you are a candidate for supplemental testosterone two  years after the treatment if not earlier. Also try to reframe “having sex” and seek to “make love”, which is a broader goal that can enhance intimacy. Involving yourself in sensate focus with your wife or partner with "whole body sex." In other words put greater emphasis on touching each other physically apart from intercourse, as that can reduce frustration, increase pleasure, and therefore make a big difference in enhancing intimacy.  

I hope that answers your question even though others might bring more medical details to this discussion. For an even more definitive response consult some urologists who do proton therapy to see what the outcomes of proton beam therapy have been in their experience. Still, be aware that like most patients, doctors, - regardless of the treatment option they favor,  tend to “root for the home team," so some proton beam specialists might understate proton beam therapy’s potential hazards.   

In addition check out  my book or other parts of this blog – Conquer Prostate Cancer (.com), or consult a couple of books on prostate cancer and proton therapy at One book, called “You Can Beat Prostate Cancer” by Bob Marckini, describes proton therapy and its impact at length.  

If you learn anything more definitive, please let me know.  Meantime I wish you all the best for improved health.  

 --Rabbi Ed Weinsberg




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