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For the week following my diagnosis, the middle of the night was my Ground Hog Day. It kept repeating. A half Ambien would wear off by three a.m, when I would crawl out of bed in a fog to pee. I’d sit on the toilet, and the neon would flash….
Hey Bud, you have prostate cancer!
Talk about a morning jolt. It seemed like some mysterious internal mechanism was processing my new reality -- on my behalf -- and I was just sitting there, on the can, in the dark, being re-programmed. Night after night, I’d hear the words, shake my head, as if to say, You're screwed now -- and then shake off the last dribbles and go back to bed.
But the sleeping, that was over.
Eventually I’d get up and turn on the computer and continue to scale up the steep learning curve that is prostate cancer. I devoured PC research and websites and four books like saw palmetto tabs for my prostatitis (more later), and hung out on PC discussion boards, where posters talked of diapers and popping Viagra and penile implants. All nice guys, but they scared the crap out of me.
Oh sure, there were success stories too. But mostly not. Mostly I read more horror stories than even Stephen King could dream up.
Nevertheless…
My choices
Okay, here’s the smorgasbord of treatment choices that I discovered medical science had to offer me: open radical prostectomy, Da Vinci robotic surgery, brachytherapy, external beam radiation, androgen hormone therapy, crytotherapy, and watchful waiting. Waiting was not an option – because of my age, 55, the cancer was feasting on my testosterone and promising an early retirement.
I eliminated a couple of other options right off the bat. Crytotherapy freezes the prostate and kills malignant clusters, while ALSO destroying nerve bundles associated with an erection. We pass. Androgen deprivation therapy blocks production of testosterone, PC's favorite food -- but the Boys start shriveling up as you grow pointy tits. While reversible, this is not a good visual. Generally ADT is an adjunct therapy for men with advance-staged prostate cancer. If possible, we pass here too.
Which brings me to the big two entrees on the menu – surgery vs. radiation. There are different flavors of each.
What I quickly learned is that the medical community cannot tell me which treatment gives me my best shot for survival. Urologists are biased toward surgery, radiologists want to radiate it; but neither can brag on a superior cure rate. In terms of a survival, it’s a tie game. Catch it early, which I did with my annual PSA, and I have a 95 percent chance to remain cancer-free – with either treatment. And because there’s no consensus ‘gold standard’ therapy for prostate cancer, it’s up to the patient to choose.
Repeat: Up to the patient to choose.
Only problem here is, the choice I make in treatment – surgery or radiation – will determine the extent of collateral damage, in terms of incontinence and impotency, for the coming months, year and even longer.
If the biopsy invoked wariness and my Diagnosis Day (My Diagnosis) cool resolve, here I finally stumbled on a real fear: I choose my treatment – not a doctor who’d gone to med school for eight years. No no….let’s hand this one off to me, the English major.
Go with the alliteration: Save sex, protect peeing
With the survival question out of the way, I dwelled on two issues during my week of no sleep, middle-of-the night discussion board horror stories, and anxious indecision: Sex and peeing. Which treatment would deliver as little collateral damage as possible to both acts.
Simple. Focused. Real. I had a mission.
For 'younger' PC patients my age, open radical prostectomy surgery has been the ‘gold standard’ treatment for localized prostate cancer, if a bit medieval. Eight-inch incision. Dig the little bastard out. Be done with it for the next 20, 30 years.
More recently, a variation is the ‘nerve-sparring’ open prostectomy, where surgeons cut around the sensitive nerve bundles that cling to the sides of the prostate – all part of a guy’s delicate sexual apparatus. Still, this is a bloody operation, requiring anesthesia, at least a five-day hospital stay, and maybe two weeks wearing a catheter to pee.
My best case after – I’m off diapers in three months and boners return in a year. Worst case – I wait for Alzheimer's so I can forget this massive life-blunder.
For a full day, I considered Da Vinci robotics surgery, in which a machine performs the surgery awhile a surgeon remotely operates the machine. The idea is that by making smaller incisions and working with finer tools, the robot can do better than a surgeon in removing the prostate and minimizing the collateral damage. But when I talked with a local surgeon, he told me the procedure required such a high level of skill, even good surgeons (and thusly, their patients) had more problems with it than open surgery.
“Do you really want to be a data point on somebody’s learning curve?” he asked me.
Good point. Pass.
Moving on to brachytherapy seeds
There was immediate appeal here. About 40 permanent radioactive “seeds” – the size of a grain of rice – would be strategically implanted into my prostate, each radiating a bubble of death to malignant cells. It’s a few days of outpatient procedures, no extended hospital stay. No cutting. No catheters. No drugs to kill the post-procedure pain. I'd walk around for six weeks, radiating my cancer. (And no one's the wiser.) Just stay away from pregnant women. Side effects? Maybe a little rectal burning, or possibly some temporary incontinence, should the radiation in the seeds 'spill' outside the prostate.
Okay.....I’m thinking, seeds are a no-brainer compared to surgery. Then I discover brachytherapy without permanent seeds. Hey, even better. Again, it’s an outpatient procedure where a radiation oncologist can deliver higher doses of radiation in a more targeted fashion – MEANING….better outcomes with less chance of collateral damage.
I'm psyched.
But I know nothing
Finally, after my week-long PC crash course, I think the English major is ready to choose his fate. I know exactly what I want to do (temporary seeds), how to save my own life and my Guys and another 30 years of uninterrupted, diaperless peeing and on-demand, ah....my Mother's reading. But you get the Big Picture.
Until I meet Dr. BG.
Dr. BG is a radiation oncologist. He heads a large Cancer Care Center, in South Florida, which is also an affiliate of the prestigious H. Moffit Comprehensive Cancer Care Center in Tampa. All Big Dogs.
For over an hour, Dr. BG gave my wife, Lorraine, and me the most comprehensive rundown of my prostate cancer situation to date, reviewed my treatment options in detail....and then quickly shot down my idea of the brachytherapy seeds, telling me my Gleason 7 score is too high. I need high-dose radiation and he has the latest delivery system to get it done.
“The absolute cutting-edge,” he tells me. Image-Guided Radiation Therapy. IGRT. Dr. BG said it was perfect for my situation.
Based on the pathology report from my biopsy and subsequent CT and MRI scans on my bones and lymph nodes, Dr. BG tells us my cancer is likely localized to the prostate. This is great news but…I'm stuck on "likely." Reality is, scans can’t see cancer at the molecular level, just the bigger clusters. But based on my last PSA (5.6), Gleason score (7), cancer stage (T1c), and negative scans, there's a damn good chance it's localized.
Just no guarantees. Once you get cancer, you treat it, you go live your life, and you test regularly and forever.
What Dr. BG did assure me of, however, is that with IGRT, the usual side effects of conventional prostate surgeries and external beam radiation treatments are pretty much history. Shouldn't be any problems. Maybe a little rectal burning, he said, but that’s easy to treat.
I 'm still playing it cool and tell him I gotta think about it, but....ALRIGHT! IGRT. The cutting edge. YES! Save the sex, protect the peeing....This is good, real good.
By the way, what’s rectal burning?
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Next up. So Radiate Me: I Pick IGRT (Or, Betting All My Marbles On The Latest In High Dose Radiation for Prostate Cancer)
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