Decision Update - September 2003
I know you have all wondered when I am going to make
my decision on treatment for my prostate cancer. The exact answer is
difficult to say, but it will certainly be within the next month. Why
so long, you may ask. First the good news. Because I was diagnosed
so early, all options are open. I am an excellent "cure'' candidate
for all the treatment therapies. On this, all three urologists and
the oncologist I have seen were unanimous. What are these therapies?
Here are the primary treatments in no particular order, with a short
description. These are very rudimentary descriptions.
Watchful Waiting
No specific treatment, but the emphasis is on "watchful.'' Frequent PSA
tests to check on the progress of the cancer. Prostrate cancer generally grows
slowly. Many men never have symptoms and die from other causes. Most appropriate
for older men (short life expectancy).
Radical Prostatectomy
Surgical removal of the prostate gland. Also a check on whether there is any
spread of the cancer. Latest techniques use "nerve sparing procedure," which
minimizes urinary and sexual problems. This is the "Gold Standard''
treatment to which all others must be compared. For men in my category, the
statistical cure rate is very high. I am a prime candidate for this surgery.
It is major surgery, with several days in the hospital and a month or two
recovery time.
Hormone Therapy
It has been known for nearly a century that male hormones stimulate the growth
of prostate cancer. Hormone therapy stops and/or blocks the hormones. It
is effective in shrinking tumors and slowing the growth of prostate cancer.
Because hormone therapy is systemic, it also works on cancer cells that have
spread from the prostate. However, it usually doesn't kill the cancer, only
slows its growth. New (experimental) Total Androgen Blockade therapy appears
to be successful and may be a "cure,'' but there has yet to be a clinical
trial.
External Beam Radiation
This therapy uses high-powered X-rays to kill the cancer cells. Treatments
take 1-2 minutes, five times a week for 7-8 weeks. Modern X-ray treatments
use computer-controlled beams and considerable preplanning. This permits
high dosages in the prostate, with minimal dosage to other organs. Success
rate is claimed to be nearly as high as prostatectomy, but criteria used
are somewhat relaxed.
Radioactive Seed Implant
About 100 tiny radioactive seeds are permanently implanted in a preplanned
pattern in the prostate It is done as an out-patient procedure. The seeds
generally used (I-125) have a half-life of 60 days, which means that the
radiation is down to about 1 % after a year. The total dose that can be given
is much higher than with the external beam therapy. Because the radiation
is very short range (a few mm), damage to other organs is rare. Some oncologists
use high-dose-rate, temporary seed implants, but the permanent seeds are
the standard treatment. Success rate is high, especially for men in my risk
group.
There are other experimental treatments that I won't
discuss, because I am not considering them. Also, there are several
combined treatments that are too complex to go into here.
I have rejected several options:
Watchful Waiting: I'm too young. Given my parents'
life-spans, I can expect to live another 20 years+. The big risk here
is that I might wait too long and the cancer starts to grow aggressively.
That would preclude use of the most promising "curative'' therapies.
External-Beam Radiation: The physics is the killer.
No matter how smart we are with the preplanning, the radiation must
pass through other organs to get to the prostate. This means some radiation
damage will occur. Also, the "cure" rate improves as the
dose increases. The maximum dose in the prostate is set by how much
the oncologist is willing to damage the intermediate organs. Not for
me.
This leaves the prostatectomy, seeds, and hormones.
I prefer to not do the hormone therapy at this time. It is an excellent
backup if the other two "fail" after ten years. But taken
too early could leave me with cells that are hormone-immune and no
backup. I am currently leaning towards the seed therapy, because of
convenience, short recovery, and relatively low side effects. I have
talked to a number of men with various therapies. I will continue to
gather data. I have an appointment with the VA urologist on Sept. 24th.
The VA is also sending my biopsy out for a second opinion.
Mary has been by my side throughout all this and
has been a real "rock.'' She has heard all the medical opinions
and has taken great notes as I have asked questions. She is holding
up well, although I can't imagine how.
Decision Update #2 - October 2003
A quick review of where I am. First, my diagnosis
indicates that I have a very low stage tumor, with a very small probability
(<1%) that it has escaped from the prostate gland. Early detection
is the real hero here. The primary therapies in use today are: Watchful
Waiting, Radical Prostatectomy, External Beam Radiation, Radioactive
Seed Implant and Hormone. shave already rejected Watchful Waiting and
External Beam Radiation therapies. Hormone therapy I have set aside
for the time being as a salvage therapy for future use, if needed.
That leaves Radical Prostatectomy and Radioactive Seed Implants as
the remaining potential therapies. The urologists and oncologists I
have seen consider me to be a prime candidate for either. Here are
the basic "Pros'' and "Cons" of the two therapies:
Radical Prostatectomy
Pros
1. For a low stage tumor, there is a high probability
(>90%) that all the cancer has been removed and there will be no
recurrence. Expected survival rate is essentially equal to not having
had prostate cancer.
2 Modern "nerve-sparing'' surgery techniques
reduce the chance of incontinence and impotence.
3. Immediate inspection of the lymph nodes to make
certain that the disease was confined.
4 Post-operation resection of gland determines exact
nature of the tumor.
5. PSA immediately drops to zero, if successful.
6. Good data, extended back at least 20 years.
7. This is the "Gold Standard'' treatment.
Cons
1. It's major surgery. Will have to provide a (self)
blood donation. Several days of hospitalization are required. Recovery
time is typically two months.
2. A section of the urethra is removed, along with
one of the major urinary valves. A catheter is required for two-three
weeks until the urethra heals.
3. Incontinence occurs in a fairly high percentage
of patients. Some permanent incontinence persists in many cases, especially
older men. At least one-third of men require pads or diapers permanently.
4. Even with the best surgical techniques, some nerve
damage occurs. Nerve healing is highly age dependent. Impotence rate
is high, especially among older men with hypertension.
Radiation Seed Implants
Pros
1. Disease "cure'' rate appears to match Prostatectomy.
Database now extends to twelve years. For men with my stage of cancer,
the disease-free rate at ten years is in the 90-95% range.
2. Outpatient surgery. One-to-two days recovery (30
days for weightlifting). Catheter overnight, at worst.
3. Incontinence is rare.
4. Impotence rate significantly lower than prostatectomy.
Cons
1. Never certain that radiation killed all the tumor
cells.
2. PSA may take 5 years to reach its minimum value
(indicative of a "cure'').
3. No resection of the tumor or lymph nodes.
4. Major (albeit temporary) urinary problems are
common.
5. A small, but non-negligible potential for rectal
problems (usually temporary).
6. Impotence rates rise five years after the procedure
to levels somewhat less than surgery.
My Decision
Basically, the tradeoff is between 1) a near-certain "cure''
with a large potential for severe side effects and 2) an almost as
good "cure'' with a lower potential for side effects. We have
friends who have had surgery, with essentially no long-lasting side
effects. But they were all much younger than me (5-10 years) when the
surgery was performed. We have also heard of cases of botched surgery.
I have also talked to a number of men who have had the seed therapy.
Some had more problems than others. Those that had a "failure''
of the treatment started out with a considerably higher stage tumor
then mine. Those that "failed'' are now being successfully treated
with hormones. All had some urinary problems, lasting from a few weeks
to several months. But no incontinence. Impotence rates were what you
would expect from the age group.
One oncologist here, in Albuquerque, suggested that
I sign up for an ongoing study comparing the two techniques. Basically,
the choice would be made by a flip of a coin. I had rather make the
choice myself.
I have decided to go with the seed therapy. As you
know, I have been leaning this way for some tame. The most recent studies
that extended the data set out to 12 years really put me over the top
If I were five years younger, 30 pounds lighter, or not hypertensive
I might have gone the other way. The VA urologist agreed with my choice
as a rational one.
The next question is "Where?'' The local people
seem quite competent. But they are stall on the learning curve, with
only about five years of experience and about 500 procedures under
their belt. An acquaintance of ours had his done locally five years
ago and is doing well. The VA would set me up with their Centers in
San Francisco or Seattle. They have done thousands of the procedures.
An oncologist in Scottsdale, AZ, Dr. Gordon Grado,
was strongly recommended by a number of men in the local support group.
He has done several thousand procedures going back about 15 years.
It was his recent study, extending out to 12 years that was the clincher.
Consequently I have set up an appointment to do the therapy the second
week in November. Normally this is a 3-day procedure: Day One is the
initial meeting, discussion and pre-op, Day Two the planning, remaining
pre-op and the manufacture of the template, Day Three the actual procedure.
Either general or spinal anesthesia is used. The actual procedure takes
1-2 hours and is done as an outpatient procedure. A catheter is used
for an hour or two after the procedure, but may be required overnight.
They generally want you stay around the area overnight, "just
in case." This is usually done on a Tuesday-Thursday cycle. Because
of Dr. Grado's appointment schedule and the need to order the seeds
in advance, they asked me to come in on Monday, Nov 10th. We will probably
stay with Ann and Pete, except for Thursday night I will give you details
later. The cost of the procedure will be covered totally by my Military "TriCare
For Life'' insurance. It's a better deal than the VA.
Seed Therapy - November 2003
Now that we are back and I have had some time to
reflect it is probably a good time to give everyone an update on the
radiation seed therapy and my initial response to it. First, a quick
review. After my initial diagnosis, I had seen several urologists and
an oncologist for outside opinions. Also, the VA had sent my biopsy
out to Johns Hopkins for a second opinion. There was strong agreement
among all the doctors that I had an early stage cancer and was a prime
candidate for elder surgery or seed therapy. As you know, I did extensive
research and had settled on the seed therapy as most appropriate for
my situation. I had also decided to go to Scottsdale, AZ and have the
procedure done by Dr. Gordon Grado He was highly recommended by a number
of men in the local support group and had authored several papers on
the procedure (which I had read). His experience stretched back over
15 years and he had performed thousands of these procedures. The appointments
were set up with Dr. Grado for the week of November 10-15.
Mary and I left Albuquerque on Sunday, Nov 9th and
drove to Tucson. We enjoyed the afternoon and evening with our daughter,
Ann, and her family. We left some of our stuff in Tucson and drove
up to Scottsdale on Monday morning. It's about a two hour drive. We
checked into our hotel, ate lunch, then went to the first appointment.
Dr. Grado has a warm, friendly personality. He is also very confident
of his abilities. We hit it off well and Mary was impressed. He was
a bit cocky, but maybe that's just an MD thing.
He did a rectal exam and gave me some bad news. First,
he could feel the tumor, which none of the Albuquerque doctors (except
maybe my primary) had. This was not goodness, as it screamed my grade
from Tlc to T2b, although I remained within the overall Stage 2 (almost
no one is diagnosed Stage 1). Additionally, he said that my gland was
about 80 cc, versus the 30 cc at the time of biopsy and the estimated
40 cc by the oncologist. Once again, not good news. So either the Albuquerque
doctors had mode some bad errors or I had gotten worse in the past
three months. Either way, it wasn't the greatest news. Dr. Grado asked
me what my profession had been before I retired. I told him. He stated
that what he did wasn't "Rocket Science."
Grado then did an ultra-sound measurement of the
prostate. I was able to watch this procedure on a bed-side monitor.
He pointed out to me the size of the gland (which he measured two different
ways). It was 83-84cc. The ultra-sound was clear enough to see the
primary tumor and another, smaller tumor, on the other side. That one
was missed by the biopsy. More bad news, but nothing to change course.
I already knew, from my research, that this was a distinct possibility.
The most worrisome problem was the size of my prostate. Many doctors
won't do the seed procedure if the gland is larger than 60 cc. I already
knew that Grado had perfected the technique in even larger glands (over
100 cc), but there was a possibility that he wouldn't do it He then
had a CT scan done to determine the position of the gland and if there
was any interference from the pubic bone. Grado was confident that
I was well within the parameters of his experience. He felt that, because
of the size of my prostate, he would used the 103Pd seeds, rather than
the 125I. The Pd radiation will die away in about 3-4 months, while
I persists for nearly a year. Because the dose rate for Pd is three
times higher than I, the total dose required is about 20% lower than
that for Iodine. This was moderately positive, as the side effects
correlate with the total dose. Grado estimated that I would require
about 200 seeds. His tech was doing the actual calculation.
For several years, Dr. Grado has been giving a light
dose (~ 4%) of external beam radiation poor to the seed procedure.
He says that this is for prophylactic reasons to prevent any cancer
cells from escaped during the seed implantation. Several of his other
Albuquerque patients also had experienced this His explanation went
beyond what I had researched. It was to be given in two doses, with
the first being done that day. Prior to the CT scan, I had been marked
up for positioning. After a few additional marks and a couple of X-ray
photos, I was given the radiation dose. This procedure took about 30
minutes, with the radiation consuming only about 5 min. I opted to
do the second dose on Wednesday, since Ann's kids had Tuesday (Veterans'
Day) off.
Wednesday was also my "purge day," so I
couldn't eat anything solid after 2 PM and nothing after midnight.
We showed up for my radiation treatment at 3. It was all done in 15
min. Then we retired to the hotel to await Ann. She had graciously
offered to come up Wednesday and stay through Friday to help Mary drive
back to Tucson. She arrived in the afternoon via the shuttle bus. I
sat around the room, consuming Gatorade and water. Mary and Ann went
out to pick up jell-O and bouillon and do some "retail therapy." They
also picked up my prescription for a five day course of antibiotics
and pain medication. Then they went to dinner. We talked when they
came back and I finished my pre-op duties.
On Thursday, we got to the hospital at the prescribed
hour. Lots of paperwork-what a surprise! Lots of hurry up and wait.
Just like the military. I turned over the contents of my pocket to
Mary. Ann commented that since I couldn't carry anything heavy after
the procedure, SHE would hold my wallet. That got a big reaction out
of the nurses. In pre-op, more paperwork. The nurse had a hard time
starting the IV in my hand. Finally dropped back to the arm. They also
ran an EKG, which must have been fine, since there wasn't any frantic
scurrying around afterwards. Mary and Ann came in to hold my hand.
The anesthesiologist was very good. He had actually looked over my
medical records and asked pertinent questions. He started the drip
with a relaxant, then the nurse discovered that they had lost a page
out of my paperwork. Don't panic, it's only the permission paper to
do the surgery! Well, they whipped out another one and Mary signed,
since I was already light-headed. Time to wheel me into the operating
room. The last thing I remember was scooting off the Gurney onto the
operating table. Then lights out.
I woke up in recovery and after some initial fussing
by the nurse, Dr. Grado appeared. He repeated the Ann/Wallet joke and
I roared. The other patients in recovery gave me a sour look. After
a short tame, Mary came in. I was woozy, but feeling fine. About an
hour in recovery and I got dressed and was wheeled out to the entrance,
while Ann brought the car up. It was about 6 PM. We went to the Denny's
next door to the hotel and had dinner. Other than a moderately-sore
butt I felt okay.
I had some problems emptying my bladder and was up
most of the night. We checked out the next morning, after breakfast.
Mary & Ann did all the packing and hauling. Then we drove over
to Dr. Grado's office. He had to do a quick CAT scan to verify the
positioning of the seeds and do the post-procedure dosimetry. The technician
noted that I indeed had a VERY full bladder and would be getting prescription
for that problem. We saw Grado for a few minutes and he stated that
the procedure had gone very well, with no problems He was also impressed
by the lack of bruising on my body. He had told us that my abdomen
would be "black and blue" for a week, or more afterwards.
I had a little bruising, but it was already fading. Grado also retold
the Ann/wallet story and said that he had never heard such a hearty
laugh in the recovery room. He said that only major restriction was
no heavy lifting for a month. I could walk, play golf and generally
resume normal activities. That's great news, since I couldn't play
golf before the procedure. I have to cut back on caffeine and alcohol.
Mary defined "heavy" as a cup of coffee (decaf). I got my
prescription for "Flomax,'' along with two weeks free samples.
Also an appointment to return for follow-up in three months, on my
birthday, Feb. 17th.
Well, what does It look like from here on out. I'm
doing okay, with minimal side effects, so far. The Flomax works fine,
although I do get up 3-4 times a night. Thanks to the 17 day half-life
of the Pd, by the end of November I will have received half of the
total dose. By mid-December, three-fourths, and by the time I go back
to Scottsdale in February, 97 %. So I expect any side effects to peak
by then, although some may persist for a year or more. The key will
be my first PSA reading in February. I will actually have this before
we go back to see Dr. Grado. I have a follow-up appointment at the
VA in late-January. After that, it's a day-at-a-time The change in
the staging of my cancer lowers the treatment success probability.
Not catastrophic, but from the 90% range to the 80% range. Of course,
we will not truly know for ten years (I hope).
