In October 2005, my urologist sat me down in his office.
“Your prostate biopsy results came back positive for cancer,” he said.
The air went out of my lungs as feelings of dread and fear seized me.
“We’ve got many, many options,” he continued. “And you need not worry too much about …”
As he ticked off the actions I could take, I sat there listening-but not hearing. Composing myself, I asked him to repeat what he had said. “The needle biopsy you underwent last week revealed that one of the 12 tiny cores I extracted from your prostate gland contained cancer cells.”
The good news was that the disease had been caught early, before it had a chance to spread. “If we surgically remove the prostate now, there is a very high probability that you will be cancer-free,” he said encouragingly.
Having been a medic in the Vietnam War who assisted on surgical cases, I knew the risks. One of my immediate concerns was that the operation, called a radical prostatectomy, would leave me impotent because of possible damage during surgery to the tiny nerves that surround and inundate the prostate. Another negative side effect could be incontinence.
I am embarrassed to admit that my initial concerns about potency and incontinence worried me more than thoughts of the cancer, which is potentially fatal. After all, at 62 I expected and hoped for many more years of a healthy love life.
My urologist put me at ease. Huge strides in surgical techniques had been made in the last decade, he said. Nerve-sparing surgery, the groundbreaking work of urologist Dr. Patrick Walsh from Johns Hopkins Hospital, was one. Walsh pioneered a method in 1982 that removes the prostate while leaving intact the critical nerves that control potency and bladder function.
That was encouraging, and my urologist suggested that I obtain a second opinion.
In examining the options for treating prostate cancer, I found myself vacillating over what course of action would be best for me. I would decide first on one procedure, then switch to another as I learned more, and then another (see the guide to surgical options accompanying this story).
The prostate plays an important role in the male reproductive and urinary systems. A spongy, walnut-sized gland located just under the bladder, it produces the milky fluid that carries sperm during sex. The delicate nerve bundles connected to the gland are indispensable if it is to function properly.
In my late 40s or early 50s, my urinary patterns had begun to change. That led to a digital rectal examination, in which the doctor palpates the prostate to check for tumors or other growths. This is the test men hate and snidely joke about. Some refuse to undergo the exam, a choice that may jeopardize their health.
I also began regular checks of my PSA levels. The PSA, or prostate-specific antigen, is an enzyme produced in the prostate that can be measured in a simple blood test. Elevated levels of PSA may indicate prostate cancer-the higher the PSA level, the more likely the cancer. Urologists discovered in the late 1980s that simply checking a man’s blood regularly, and watching for a rise in his levels of PSA, can predict cancer years before it would be diagnosed by other means.
But Walsh, who pioneered the nerve-sparing technique, makes a crucial point in his book, “Guide to Surviving Prostate Cancer”: “Just as having a low PSA does not mean that you don’t have prostate cancer, having a high PSA doesn’t automatically mean you do.” But he adds: “If your PSA is high, you do have some form of prostate disease-trauma, enlargement, infection or cancer-and you need to see a urologist to figure out which one it is.”
In 2000, my PSA shot up to 6 from a reading of 3 in previous years, and I underwent a prostate biopsy. A minute amount of suspect tissue was removed to see if it was cancerous. The procedure was not excruciatingly painful, but it did hurt and was uncomfortable for the three minutes or so that it takes to extract the samples.
A few days later, my urologist called with the good news: The biopsy was negative. But in October 2005, my PSA again spiked, this time to 8-plus. I underwent a second biopsy and this time one of the 12 needle-cores contained cancer.
he job of finding the best treatment began the day I got the news. I researched the American Cancer Society Web site along with the sites of hospitals, several colleges and universities. I called my primary-care physician and set up an appointment at Advocate Good Samaritan Hospital in Downers Grove, which has an established cancer-treatment program.
Doctors there use tomotherapy, which targets radiation on the cancerous area. Patients can continue a nearly normal lifestyle during the course of the therapy, which is painless and non-invasive. It leaves most patients continent and potent, but subsequent scarring from the radiation, sometimes two to three years later, can cause problems in both those areas.
Was tomotherapy my best option? The physician at the hospital thought I was a good candidate for it, and I was strongly leaning toward that treatment.
A few days later, I called a relative in Atlanta (since he prefers to remain anonymous, I’ll call him Clyde). The first thing he said was that he had just been diagnosed with prostate cancer. It would be the first of several coincidences.
The next evening, I told a gathering of friends that I had prostate cancer. One woman said: “I’ve got to talk to you later. My husband has it and just came home from the hospital. He’s fine. He had the new robotic surgery.”
Robot?
She leaned closer: “At the University of Chicago. The doctors there are terrific. You would be shocked to see how well he is doing.” She smiled. “It’s like a miracle.”
Her husband had undergone the da Vinci laparoscopic robot prostatectomy, a procedure that uses a computerized robotic device (named after Leonardo da Vinci, who, among other things, invented the first robot) to do the surgery. It is said to reduce hospital time, pain and blood loss and to give excellent results for sparing the critical nerves, she said.
The latter was especially important, given my concern about the risks of nerve damage with other treatment methods. Open prostatectomy, the most common procedure, involves a long incision and delicate probing with sharp instruments. Radiation, as I had learned, can sometimes harm tissue around the prostate. The da Vinci method promised pinpoint accuracy, using five tiny punctures where precision-guided robotic arms and a high-magnification 3-D camera are inserted.
I told Clyde in Atlanta what I had learned. “You won’t believe this,” he said, “but I am on my way to see a doctor who does the da Vinci.” Someone had told him about Dr. Scott Miller, reputed to be one of the most skilled da Vinci surgeons in Atlanta. I made plans to talk to a doctor at the University of Chicago about the same thing.
My primary physician also wanted me to get a second opinion. “I’m not familiar with the da Vinci robot,” she said. “But I did call an outstanding urologist in our program, and he wants to talk to you. He knows about the da Vinci but he’s not too sold on the idea.”
I got a different view when I called Clyde in Atlanta the next day. He had decided to go with the da Vinci procedure after Dr. Miller said it would give him a better chance of removing the cancer without damaging other tissue because he would have a better view-magnified 10 to 12 times by the 3-D camera-of what he was doing. Clyde said the doctor had told him: ” ‘If I had to have a prostatectomy myself, and had a choice between open-method surgery and robotic, I’d choose the robotic, hands down.’ “
My first “second opinion” on surgery was on Oct. 20, 10 days after I had been diagnosed. A doctor at the University of Chicago said he had performed both open and robotic prostatectomies and he thought the da Vinci was my best choice. By the end of our discussion I had decided he would do my surgery. I had just flipped on my previous decision to have radiation therapy.
Then I saw another urologist, the one recommended by my primary physician-my “second” second opinion. He was opposed to the robotic method, believing the procedure was too new-it had received FDA approval for prostatectomy cases in 2000-and that not enough medical data had been gathered to know if it was better than open, nerve-sparing surgery, which has been practiced for nearly 25 years.
I was convinced. I would not risk undergoing a relatively untested procedure. I flip-flopped again and decided to go with this new urologist and his open method.
But as I focused on each alternative over the next several days, I began to vacillate once again.
As a combat medic in the 1960s, I had worked in the operating room and scrubbed for all kinds of surgeries, including prostatectomies. I know that the prostate, located deep in the groin, is difficult for the surgeon to reach. Seeing the small gland in a blood-covered site is even more difficult. As the assistant, I would sometimes hold the retractors which are used to spread open the incision; even then, seeing deep into the crowded, organ-filled pelvis, is difficult.
I recalled what the doctor at the University of Chicago had told me about the da Vinci robot and how he could see a magnified, 3-D camera image of the prostate in a near-bloodless field. Being able to see the tiny, nearly microscopic nerves with the robot has to give the surgeon an edge over barely seeing nerves with the naked eye, I reasoned.
So I finally decided: Go robotic.
I read up on the da Vinci procedure in medical journals and discovered papers discussing the advantages of not using cautery-a technique that stops blood vessels from bleeding with an electrical arc, which immediately coagulates the blood. Zapping a blood vessel so near a nerve couldn’t be good for the nerve, I thought, so I looked for da Vinci surgeons who did not cauterize.
Taking Clyde’s advice, I called Dr. Miller in Atlanta. He said he had learned open surgery first but had switched to the laparoscopic method and done hundreds of cases over several years.
What about cautery?
“I try to stay away from it,” he said. “I’m about to publish a paper describing my techniques for avoiding the nerves and using pressure, clamps and sutures to control bleeding instead of cautery.”
I now felt certain this was the way for me to go. “Based on what you tell me about your PSA and other statistics, I’m sure you will be pleased with your decision,” Miller assured me.
The surgery was scheduled for Jan. 3, nearly two months after my diagnosis. My medical insurance would cover 90 percent of the $30,000 cost for the da Vinci operation, a cost that is comparable to other surgical prostatectomy methods. I arrived at Northside Hospital in Atlanta with my wife, Sharon, and daughter, Karen, a week before for pre-operational tests. This was my first face-to-face meeting with Miller. He answered more questions and put me at ease.
The surgery was uneventful. I arrived at 5:30 a.m., the anesthesiologist started an IV and returned later with my pre-op sedative. That’s all I remember.
I awoke several hours later in the recovery room. My surgery had lasted a little more than three hours. A morphine injector was attached to my IV for pain. Surprisingly, I didn’t need it. I noticed there were no bandages on my lower abdomen. It turned out that the five dime-sized entry holes below my navel had been closed with surgical glue. This was really space-age stuff, I thought.
I was weak and had some discomfort, but no debilitating soreness. The next day I went to a relative’s house where I remained for the next week.
I went back to Miller’s office for a consultation and to have the catheter removed. I was recovering right on schedule. “I want to give you a prescription for Viagra to get the blood flowing back into the pelvic area,” he said. In my still-tender condition, sex was not one of the pressing considerations on my mind.
After a few days we flew back to Chicago. I was up and driving, feeling like new again. No heavy lifting or going beyond what my body was telling me I could do.
I flew back to Atlanta five weeks after surgery. Miller seemed happy with my progress. My bladder control was complete.
“What about sexual potency?” he asked. I told him everything was working fine and that I was waiting for his official approval before I tried anything too strenuous.
“Go for it,” he said.
Medical technology is undergoing a revolution that raises the question: Whose responsibility is it to provide patients with the latest information, especially if physicians themselves are not acquainted with the latest developments?
Judging from the conflicting advice I received about my treatment alternatives, the answer seems to be that we must assume responsibility for our own care. That means the less informed among us will probably suffer. Who will be the advocate for the poor, the elderly and the uneducated? I had to stumble onto the da Vinci technique, as did Clyde, who recovered quickly from the surgery and within weeks was back jogging several miles a day and lifting weights. We both feel very lucky. And that is one of the reasons I am writing this article.
The other reason is that men must become as smart as women when it comes to fighting cancer.
A decade or two ago, women who had breast biopsies or mastectomies would keep it a secret and hide in the shadows, fearing someone would find out about their struggles. Today the opposite is true. Women who have fought breast cancer revel in their victories. They march, sing and wear lapel pins proclaiming their freedom to express their joy in conquering a potentially fatal disease. Men must learn to do the same.
Prostate cancer used to carry a stigma for men who had it. Someone who had undergone a radical prostatectomy usually faced a drastically altered lifestyle. Today, because of procedures like the da Vinci robot, men are finding that life after a prostatectomy is not very different from the one before. They still work, exercise, have sex.
As Dr. Miller said to me: “After a man reaches the age when he doesn’t want to produce any children, a prostate gland is more of a nuisance than anything else.”
A postscript: Since I wrote this article, one of the urologists I talked to has now enrolled in a da Vinci class.
– – –
What are your chances of getting prostate cancer?
This quiz will help identify your risk for cancer of the prostate. The questions are based on widely accepted risk factors for the disease. It has no known cause, however, and this assessment tool is not intended to be conclusive. If you feel you’re at risk of prostate cancer, see your doctor.
1. How old are you?
A. Under 40 (-5 points)
B. 40-49 (0 points)
C. 50-59 (+6 points)
D. 60-70 (+8 points)
E. Over 70 (+10 points)
2. What’s your Body Mass Index (BMI)? (Calculate your BMI at nhlbisupport.com/bmi/)
A. 24.9 or lower (0 points)
B. 25-29.9 (+3 points)
C. Higher than 29.9 (+6 points)
3. What’s your ethnicity?
A. Asian/Pacific Islander (0 points)
B. White non-Latino (+5 points)
C. White Latino (+3 points)
D. Black (+8 points)
E. Other (0 points)
4. Where did you live mostly until age 21?
A. North America (+8 points)
B. Northern Europe (Scandinavia)/Western Europe (+8 points)
C. Southern Europe/Eastern Europe (+2 points)
D. Asia/Pacific Islands (-5 points)
E. Other (0 points)
5. Has your father or brother been diagnosed with prostate cancer?
A. Neither (0 points)
B. Father (+6 points)
C. Brother (+8 points)
D. Father & brother (+12 points)
(If you answered A to question 5, skip to question 7.)
6. How old was the family member who was diagnosed youngest?
A. 49 or younger (+8 points)
B. 50-59 (+6 points)
C. 60-69 (+3 points)
D. 70 or more (0 points)
7. Do you regularly take non-steroidal anti-inflammatory drugs, such as aspirin or ibuprofen?
A. Yes (-1 point)
B. No (0 points)
8. How often do you exercise each week ? (Twenty minutes of weight-lifting or cardio equals one session.)
A. 1-3 sessions per week (+2 points)
B. 4-6 sessions per week (0 points)
C. 7 or more sessions per week (-2 points)
9. How often do you eat foods high in saturated fats, such as fatty red or processed meats?
A. Once a week or less (0 points)
B. 2-3 times per week (+1 point)
C. 4-5 times per week (+3 points)
D. 6-10 times per week (+5 points)
10. Does your diet include foods high in vitamin D (fish oils, shrimp)?
A. Yes (-1 point)
B. No (0 points)
11. How often do you eat foods loaded with lycopene (grapefruit, mango, papaya, watermelon and tomato products)?
A. Once a week or less (0 points)
B. 2-3 times per week (-1 point)
C. 4-5 times per week (-2 points)
D. 6-10 times per week (-3 points)
12. How often do you eat food rich in cancer-fighting phytochemicals (soy products, broccoli and Brussels sprouts)?
A. Once a week or less (0 points)
B. 2-3 times per week (-1 point)
C. 4-5 times per week (-2 points)
D. 6-10 times per week (-3 points)
13. How often do you eat foods rich in omega-3 fatty acids (tuna, salmon, sardines, walnuts and flaxseed)?
A. Once a week or less (0 points)
B. 2-3 times per week (-1 point)
C. 4-5 times per week (-2 points)
D. 6-10 times per week (-3 points)
14. Does your diet include foods high in zinc (whole grains, poultry, fish, soy, lentils and beans)?
A. Yes (-1 point)
B. No (0 points)
15. Does your diet include foods high in selenium (mushrooms, cod, shrimp and tuna)?
A. Yes (-3 points)
B. No (0 points)
16. Does your diet include calcium-rich foods (milk, cheese and yogurt)?
A. Yes (+2 points)
B. No (0 points)
17. Does your diet include foods high in vitamin E (peanut butter, almonds, sunflower seeds)?
A. Yes (-2 points)
B. No (0 points)
18. Have you ever worked in an industry in which you might have been exposed to pesticides, herbicides, PCB, lead or asbestos?
A. Yes (+1 points)
B. No (0 points)
0-10 points: Low risk
Your lifestyle appears to be relatively healthy, which makes your risk for prostate cancer low. You can celebrate, but continue to aim for healthy diet and regular exercise.
11-20 points: Low to moderate risk
You are not out of the woods but on the fringes of the thicket. Review your answers, paying attention to where you scored high in factors you can control. Then control them.
21- 34 points: Moderate to high risk
You need to change your lifestyle, quickly. Increase your activity level to lose weight and look at your answers to see where you can improve your diet. Evidence shows that diet aids in prevention and in slowing the progression of the disease.
35 or more points: High risk
Don’t panic. Just because your risk for prostate cancer is high does not necessarily mean you will develop the disease. If you are 40 or older, you should have annual digital rectal exams and PSA tests. If you scored in this range, get your score down.
*Source: The Prostate Cancer Research Foundation of Canada for reprinting the Risk Assessment Tool. www.prostatecancer.ca and Men’s Health Magazine.
– – –
Decoding the PSA
Two methods are used to detect possible prostate cancer: a one-two punch of the digital rectal exam and the PSA. While neither test alone is sufficient to indicate the presence of prostate cancer, together their findings give doctors a “likely indication” of an abnormality.
Urologists like Patrick Walsh, author of “Guide to Surviving Prostate Cancer,” have established a sliding scale for grading PSA levels and understanding what the numbers indicate. They also have a standard recommendation for most men.
PSA test at age 40, then 45, and every year starting at age 50, until old age or ill health suggest that your additional life expectancy is less than 10 to 15 years. (If you are African-American or if you have a family history of prostate cancer, you should begin yearly testing at age 40.)
– If the rectal exam is positive: Have a biopsy even if your PSA is low.
– If the rectal exam is negative, the next step depends on your PSA:
You should have a biopsy if your PSA is:
Greater than 2.5 and you are age 40-49.
Greater than 3.5 and you are age 50-59.
Greater than 4.0 and you are 60 or older.
Lower than the above ranges, but has increased by more than 1.5 over the last two years.
–R.J.
PLANS OF ATTACK: HOW TO FIGHT BACK
WATCHFUL WAITING
This method calls for following any suspicious changes in the prostate carefully yet delaying definitive treatment until it becomes clear-through a digital rectal exam (DRE), a prostate-specific antigen (PSA) test, or both-that the tumor is growing.
CRYOTHERAPY
Uses extremely low temperatures (-190 1/4C) to freeze and destroy cancer cells. (This is still considered experimental by many doctors.)
BRACHYTHERAPY
Tiny radioactive seeds, smaller than grains of rice, are implanted in the prostate gland to destroy cancer cells.
CONFORMAL RADIATION THERAPY
(tomotherapy)Tailors radiation therapy to an individual’s body structures. Relying on computerized three-dimensional images of the prostate, the X-ray radiation beam is aimed precisely (“conformed”) to affect the diseased area.
RADIATION
Generally thought to be best for men over 70; men in poor health who may not be strong enough for surgery; or men in whom the disease has spread beyond the prostate and cannot be eliminated surgically.
NERVE-SPARING OPEN RADICAL PROSTATECTOMY
Surgical removal of the prostate gland to avoid injuring the critical, nearby nerves that send signals between the brain and genitourinary tract to allow normal sexual and urinary functioning. A six- to eight-inch incision is made from the navel to just above the pubic bone.
LAPAROSCOPIC RADICAL PROSTATECTOMY
Involves small punctures in the abdomen instead of longer incisions. A small camera inserted inside the body provides a clear, unobstructed view of the prostate and surrounding areas while the procedure is performed.
–R.J.
Source: The American Cancer Society
