Surgery and prognosis

Surgery

Lying on the gurney, wheeled down a corridor, pausing for the elevator, in we go, doors close... Asleep... Awake, parked in a recovery room, hearing various electronic beeps, clicks, nurses voices. Look around, privacy curtains partially drawn. Intravenous tubes attached. I'm not groggy, quite alert actually. I presume the surgery has been done, more than six hours have passed, unnoticed.

Less than an hour later I'm transported to my room. My wife Lisa is there to greet me. We exchange smiles.

She reports to me a quick summary: the 'radical prostatectomy' was successful. My prostate, some surrounding tissue, and several lymph nodes on the left side were removed. I have not bled to death nor had other major complications. They unexpectedly found and repaired an old navel hernia. Visually, the lymph nodes appear clear of cancer.

This Monday (June 9th) started simple enough, albeit not real comfortable. Having followed the required instructions for 'bowel prep' via laxatives the day before and no solids for 12 hours, not to mention general anxiety, I'm pretty achy and cranky in the morning. Lisa and I left the house around 8 am, an hour-fifteen minute drive to the Dartmouth Hitchcock Medical Center hospital, checked in pre-admissions, and by 11:30am I was in my medical gown in a private pre-op room. My vital signs were measured. We met with the nurses, anesthesiologists, and doctors who would be with me during the operation. A little after 1pm I had my IV, and was ready to roll...

The procedure is performed using a laproscopic robot. Dr. Heaney and his team have been using the device since January (2008), and seem pretty proud of their state-of-the-art facilities. I haven't looked into it much, but my impression is this: with regular laproscopic procedures, they make several small incisions ('ports') and insert prolonged instruments into you, including a camera, knife, and forecepts (or whatever), which the surgeon manipulates directly. With a robotic device, the surgeon's motions are first interpreted by the 'robot' which in turn controls the instruments. This affords greater three-dimensional control, reduces any 'shakiness' or other human hand errors, and delivers better results overall. However it does tend to require more time in the operating room. And certainly laproscopic methods, in general, are superior to out-dated open surgery which have significantly higher blood loss, other risks, and recovery time.

The tumor was known to be on the left side of the prostate. As planned, the surgeon removed the prostate, along with an extra swath of surrounding fatty tissue on the left side. But on the right side, he cut close along the edge of the prostate and spared the nerve bundle on that side. He also removed several lymph nodes on the left side (near the pelvis) for evaluation.

Recovery

I stayed overnight at the hospital. Everyone was extremely attentive and competent. I never laid wanting. Remarkably I really had no pain, and just needed Ibuprofen to relieve discomfort. Well, except for one extremely sharp bladder spasm (perfectly normal, I was later told) which subsided after a few minutes.

Released the next day, Tuesday, we headed home early afternoon.

For the next few days, I basically just hung out, read a book, watched TV, and was fairly mobile enough to go for some short walks. I was given some prescription pain relievers which I used to help me sleep the first couple nights (and got a good buzz on).

I adapted to the urinary 'indwelling catheter' pretty readily. I also came home with a drainage tube and bag on the side of my belly. Otherwise my surgical 'ports' were stitched and ready to heal. I kind of felt like a Borg with all these tubes and things sticking out of me!

Perhaps my scariest encounter, and a true test of my courage, occurred the next morning when I braved to take a shower! Hobbling into the stall, I set the water to lukewarm, and slowly immersed myself. I didn't recognize myself, especially my abdomen largely bloated and swollen. Stitches, tapes, tubes, weird.

Everyone was happy to see me home. As John Lennon said, "Life goes on within you, and without you." My kids were just starting summer vacation. Steven, graduating 8th grade, had a plethora of "mandatory" parties, including 20 or so kids at our house on Thursday. Hey, at least I had an excuse to stay out of their way and not have to help out. Lisa landed a string of media interviews and public presentations for her work as well during these days. No problem, everyone here was well behaved and self-sufficient.

My immediate and extended family, as expected, were warmly tracking my progress, yet respectful of my privacy. Lisa handled most of the calls. All were glad to hear I was progressing well.

The only complication had to do with my drainage, it was not letting up as expected. In fact, normally they remove the tube before you leave the hospital the day after surgery. On several return visits, they advanced the tube a couple inches at a time (ouchers!). A minor infection and fever were relieved with antibiotics.

The following Tuesday we met again with Dr. Heaney to finally remove my tubes, and more importantly, get the results of the laboratory biopsy of my extracted prostate and lymph nodes.

Pathology report

The pathology report confirmed there was no cancer in the the lymph nodes (very good news). Also none in the seminal vesicles (also good news).

Prior to surgery, the biopsy staged my cancer at T2a with Gleason 8 (4+4). The post-surgery biopsy staged it at T3a with Gleason 7 (4+3). The post-surgery biopsy is more accurate because it's determined from whole slices of the actual tissues rather than selective tiny core samples (as they took from me in April).

T2 means the cancer is completely contained within the prostate; T3 means it has breached the boundary and extends into the surrounding fatty tissue. The Gleason score is an indicator of the aggressiveness of the malignancy. So, the "real" findings (post-op) show my cancer has actually protruded outside the prostate (extracapsular extension, or ECE) (not good), but is slightly less aggressive than thought.

The pathologist also tests the "margins" to determine whether the surgeon left any 'tentacles' of the tumor behind. Fortunately that was negative. (A big thumbs up for Dr. Heaney!)

The biopsy also revealed additional previously undetected small 'tumor foci' on the right side, one reason they always remove the whole prostate rather than part of it.

For the next couple weeks, my foci will be on fully recovering from the surgery.

Recurrence statistics

It's been said, "If you're going to get cancer, prostate cancer is the one to get," because it's relatively slow growing. Perhaps. But. When you're 85, five years is a lifetime; when you're 50, five years is just a snippet.

Next month I get my PSA checked again. We expect it to be zero (less than 0.02), meaning so far so good, we successfully removed the cancer. But in reality there's fair odds it could come back at some time in the future.

So, how do you measure those chances? You take all these findings, and plug them into a website (www.mskcc.org), and get back your chances of recurrence in some number of years. (hurray for the web! Ugh.) Assuming my PSA measures zero next month, my chances of having the cancer come back within 5 years is 15%, and 10 years is a whopping 24%. Fuck you. Pretty high odds given the severity of the risk. According to the calculator, if I remain cancer-free for two years, my chance of recurrence in 10 years drops to 18%.

What can I do about it? Basically two courses of action are: A. wait and see if the PSA starts to rise and then deal with it, if necessary; or B. take preemptive radiation to reduce the chance of recurrence, but perhaps needlessly suffer side effects of this treatment (e.g. messy stuff including urinary, sexual, and/or digestive degeneration).

It's a bizarre numbers game. At this point if there's no evidence of cancer still inside, we're dealing with "chances" of recurrence. A fuzzy concept in itself. Then if we consider a preemptive treatment, we're compounding chances with chances of reducing the chances (by, say, 5 points). Fuzzier. Or if you wait until the PSA starts to rise, you run another calculator on the effectiveness of "salvage radiation therapy". The what-if's can go on forever.

At the same time, you have to wonder the accuracy of the data sets used in the calculators. Here's my non-professional impression. You'd think the more specific your inputs to the calculator, the more accurate the predictions. But in fact, the more specific you are, the smaller the population of patients in these specific situations, so the statistical analysis become less reliable and more ambiguous.

And who knows what these calculators will spit out in a few years with the same inputs. Who knows what new treatment options may be available in 5 or 10 years making all this data moot anyway. And, are 10 year predictions based on people who were treated 10 years ago? I imagine surgical experience, knowledge, and techniques have improved over time. Finally, the MSKCC site has a note, "some studies suggest that more experienced surgeons have better outcomes than do less experienced surgeons." I had a more experienced surgeon. That's promising, and still fuzzy.

So to me, the bottom line is, preemptive radiation is treating a 'concept', a probability, not a specific condition. And the calculator does say chances are 76% I am (prostate) cancer-free for life.

Maybe I'll meet with a radiologist in a few months to hear his suggestions. Most likely we'll decide to just keep monitoring my PSA.

Moving on

OK, so what now? Start worrying about heart disease instead? Go for a colonoscopy? Fill my schedule with more doctor's appointments? Bah! It never ends.

Perhaps I should be grateful my lymph nodes came back clean. After all, everyone knows someone (or knows someone who knows someone) in that gravely unfortunate situation.

Perhaps I should be grateful for the medical establishment, and insurance industry, for making this whole process as remarkably painless, smooth going, and professional as it's been.

Perhaps I should honor every moment I have now to spend with my family.

Perhaps I should regain my focus on work and other projects that have been left in limbo for the past month or so.

Perhaps it's time to get on with life, and stop obsessing...

Comments should only further the discussion for others' benefit. Please do not leave personal comments here, this is not a 'guest book'. If you leave a comment that I consider too personal, I will read it and then delete it. Thank you.