HOW I CHOSE MY PROSTATE CANCER TREATMENT

By: Amnon Ben-Yehuda, October 30, 2007
San Diego, Ca.
AmnonBY@aol.com

“The results of your prostate biopsy are positive ... I would like to see you at my office later this afternoon”. This was my urologist informing me by phone that cancer cells were discovered in the recent biopsy of my prostate. It was the beginning of November 2006 and my saga with prostate cancer had begun.

It actually began six years earlier when my PSA level reached 4.0 and my personal physician referred me to the care of a urologist. During the following years my PSA level continued to climb gradually and I went through two biopsies, both with negative results. DRE’s (digital rectal exams) were also negative. At least twice I was treated with antibiotics to rule out prostate infection. During 2006 my PSA level fluctuated in the 10 - 12 range.

That afternoon my wife and I sat at the urologist’s office as he was giving us the bad news. The cancer was detected in the right side of the prostate in two samples out of twelve. The Gleason scale was 8, meaning in the aggressive range. He then proceeded to outline the various treatment options available, which was like reading from a textbook: Surgery, seeds, and radiation. Due to my age of 77 years he recommended strongly that I be treated by radiation. To paraphrase, he stated “The top ten experts in the country would recommend treatment by radiation over surgery for men over age 70. I myself am a surgeon but I feel you should be treated by radiation”.

I was too overwhelmed to make a decision at that moment, yet I felt I needed to act without delay. One week from that day my wife and I were scheduled to leave on a seven day cruise out of San Diego. I asked the doctor if I should cancel it. “No”, he said, “there is no great hurry, go ahead with it. In the meantime we’ll schedule for you a full body bone scan and pelvic area MRI tests for when you return from the cruise”. “But”, he added, “in the meantime you can also go ahead and learn more about the subject on the Internet”.

Upon our return from the cruise I had a full body scan and a pelvic area MRI. To my relief, the results did not show any cancer cells outside the prostate capsule. This would now allow me to spend several weeks studying my treatment options under less time pressure.

The first decision I made was not to keep my condition secret. I wanted to be able to receive feedback from as many people as possible. Sure enough, later that week at our Rotary club meeting I mentioned my condition at the lunch table. The fellow Rotarian sitting next to me responded: “Welcome to the club, I had my prostate taken out several years ago and two weeks later I was back on the job. I wanted the cancer out of my body so I chose surgery over radiation”. As well as I thought I knew this person, I had no idea he had this medical condition. Amazingly, by discussing the subject openly I quickly discovered how many other club members had been through the same ordeal and I was able to learn a great deal from their experience. Speaking openly opened the doors to many resources that were otherwise hidden away from me, like an old friend in Los Angeles I had not seen in almost 40 years. Through a mutual friend I learned he had dealt with prostate cancer some years earlier and I was able to learn from his story and experiences as well.

The second decision I made was to obtain several second opinions before making a decision on a course of treatment. Additionally, within reason, that I got treated by the most competent doctor. I realized quickly it was not only a question of what mode of treatment I chose but also who was going to administer it.

I cleared my calendar of all non-critical activities and began my campaign on the next day. This was a “full court press” and I left no stone unturned. I called friends, acquaintances and old friends that I had not seen in decades, both local, national and overseas. For second opinions I made appointments with three local radiation laboratories and two additional urologists for later in the month after returning from the cruise. I also solicited advice from personal friends in the medical field, both locally and nationally.

Going on the cruise the following week was a blessing in disguise. It gave me time and space to gain perspective and think clearly about my course of action in the coming weeks. I also set a deadline for myself to have a decision made no later than December 31, preferably before then.

Google became my main gateway for information and I quickly learned to discern between anecdotal and truly scientific medical sources. Johns Hopkins, Mayo Clinic, Henry Ford and other major university and medical centers provided a wealth of up-to-date information on prostate cancer treatments. I also subscribed to the various publications authored by Johns Hopkins. I compiled my own database of all the information and articles that I gathered.

What did I learn? -- First and foremost that surgery was the Gold Standard by which all other forms of treatments were being measured. The measurements fall into two main categories:

1. Mortality, or years of cancer-free survivability following treatment.

2. Side effects induced by the treatments, such as damage to urinary function, erectal dysfunction, and bowel disorder.

The challenge in radiation treatment is two-fold. First, accuracy, or the ability to target the prostate and other tissues being radiated, such as lymph nodes. The treatment is spread over a period of 41 weekdays, or 8 weeks plus one day. Since the prostate can move within the body about 1/2” in any direction, a sophisticated targeting system is required to track it. Much progress has been made in this area by several manufacturers while additional research is still underway. The second challenge is the need to minimize the effects of radiation on healthy tissues. Here, too, much progress has been made through the use of I.M.R.T. as well as by spreading the direction of the radiation source. Still, by definition, to reach the internal organ the radiation must pass through healthy tissues with unquantified effects. These side effects may occur immediately or show up at a future date.

The big surprise about radiation treatment, which I discovered only when interviewing the three prospective labs, was that it came in combination with hormone treatment beginning two months prior to the start of radiation and lasting from six to twelve months. For me it represented a potential serious problem due to the hormones’ negative impact on bone density. My current bone density was somewhat marginal despite the fact that for the past thirteen years I have been doing strength training with a personal trainer. I can only guess the deficiency was the result of treatment with Prednisone for a lung condition I had some thirty years ago. I certainly had no appetite for any extensive treatment with hormones that was likely to contribute to loss of bone density.

I began to pay more attention to the surgical option, again, primarily though Google searches. I learned about the nerve-sparing technique developed by Dr. Patrick Walsh of Johns Hopkins. Then, almost by accident, I discovered the new “robotic” Da Vinci Surgical system. The benefits were obvious: Great precision, no major incision -- only five tiny holes in the abdomen, very limited loss of blood, and quick recovery. Henry Ford hospital in Detroit has been using it for several years and their results were as good as or better than with the conventional radical prostatectomy. I was beginning to wonder: “Could this be the new Gold Standard”?

I also learned that with rare exceptions, once treated by radiation, the surgical option was no longer available for subsequent treatments if needed. Conversely, radiation remains a viable treatment option if needed following surgery.

At about the same time I discovered the web page of Dr. Thomas E. Ahlering, Professor and Director, Urological Oncology, at U.C. Irvine, California. He has performed prostate surgery some 500 times and is now specializing with the Da Vinci Surgery system. Like at Henry Ford, his statistical results were most impressive, particularly when I saw “over 95% cancer-free”. That was the clincher for me; “Yes, that’s what I want, that’s my top priority, a good statistical chance to get rid of the cancer”. The location was also a huge advantage, a 90-minute ride north from our home in San Diego.

By this time the decision-making was almost automatic. Radiation coupled with hormone therapy had a clear health risk for me. On the other hand, with robotic surgery I stood a good chance of being cured while still preserving a fallback option with radiation. I knew my search did not fully cover some other treatment options, such as Proton radiation and Brachytherapy (seeds), but once I saw the good odds I could have with the robotic surgery I was eager to be treated before the cancer had a chance to metastasize.

As to the age limit of 70, I could not accept it as a strict rule, only as a rough guide. 70 is only a chronological number and is not a complete indicator of a person’s state of health. During the period I was studying my options I met a 74 year old gentleman who just had his prostate removed surgically here in San Diego using the Da Vinci Surgical System. And how would they treat an elderly person for a broken hip -- without surgery?

I was ready for surgery both emotionally and physically. I am generally in excellent health, eating a healthy diet and exercising regularly. After passing the preliminary physical and health exams and obtaining clearance from my cardiologist, Dr. Ahlering scheduled me for surgery.

On January 15, 2007, my wife and I checked into a hotel across the street from the medical center at U.C. Irvine. Early the next morning I was admitted to the hospital and was operated on. The operation lasted approximately four hours. In addition to the prostate, the surgeon also removed the right-side nerve bundle, lymph nodes and the seminal vesicle.

Late in the evening I took my first walk in the department’s hallway and was released by noon the next day. My wife and I chose to stay an extra day at the hotel instead of driving straight home to San Diego, which we did the following morning. I spent the next week at home, mostly because I felt I could do all the walking I needed indoors around the house. On the eighth day my urologist in San Diego removed the catheter and I felt free again to move about without the hindrance of a bag. Now I could walk and drive freely.

Four weeks after surgery I was back in the gym working out with my personal trainer.

It took me about three months to become continent again. Initially I was totally incontinent and was wearing diapers day and night. Of course, I kept doing my Kegel exercises, which I began before going into surgery. After about one month I began to urinate some by squeezing the bladder muscles. I also began to sleep uninterruptedly for 4 to 6 hours at night without wetting the diaper. By two months I slept straight for 7 hours and I had full urinal start/stop control standing over the toilet bowel. After three months, at the suggestion of Dr. Ahlering, I stopped wearing diapers at night. During the day I was wearing one pad. After three and a half months I stopped wearing a pad. I discovered my vulnerable moment was when getting up from a sitting position, losing what I call a droplet. I have been able to overcome it by making a mental point of it before standing up.

It’s nine and a half months now since surgery. My most recent PSA test was “undetectable” <0.05 ng/mL. and I am fully continent. I am back to leg-pressing 1,000 lbs. in the gym and feeling as good as ever.

The main lessons I learned was that the patient must not rely on the advice of a single physician and must take charge and seek second, third and additional opinions. Valuable information is available on the Internet through search engines and the patient must become educated on the available treatment choices and respective consequences before making the decision. There is more than one school of thought in medicine and newer modes of treatments continue to evolve. The “rules” serve only as general guidelines and there is no one solution that fits all. The choice of treatment must be consistent with the patient’s physical condition, emotional make-up and sense of priorities. Finally, it’s vital to have a physician who is open minded and willing to have an open dialogue with his or her patients.