prostate cancer!

Young at heart makes one young, not. Then again, prostrate problems are usually associated with retired old men, not someone like me. OK, in some circles I may be "the old guy", like techie forums where many folks are half my age. But I'm not that old...

Joining the medical system

In July 2007, I turned 50, and figured I ought to go for a 'regular' doctor's checkup. It took a few months to finally get around to making the appointment. Actually I procrastinated 'til my wife Lisa finally made the call for me; and the next available slot wasn't for another couple months out, in December.

The last time I had a physical was when I turned 40; I figured at the time I'd get a baseline into my medical records. Nothing significant came up, just some recommendations to watch my cholesterol and stress. OK, sure, no problem.

During the ensuing decade nothing of any significance changed in my health. Sure, I gained some weight, but continued to eat fairly healthily: limited red meat, lots of pasta and legumes, fresh fruit and veggies, perhaps indulging in chips and desserts more than I should. I've enjoyed an occasional beer or bottle of wine, even a pack of smokes now and then, but nothing too outrageous. Perhaps regular exercise lapsed from time to time, but generally I'd walk, run, or hike at least 5 miles per week.

Lots of good things happened in my 40's too: raising my kids (4 in all), started and worked with numerous tech businesses and volunteer organizations, bought a farm and moved to the country, and generally enjoyed my wife, family, career, and sense of adventure.

I go to the dentist every 6 months, because I know my teeth can develop problems. But there never seemed a necessity to go for a medical checkup. After all, I'm pretty self-aware and watchful of symptoms, so I would have certainly gotten checked should something come up.

Now, 50 seemed like a good time. After all, chronologically I'm at the crest of the hill, if not already over it. Isn't 50 that age where they recommend you start getting checked regularly for age-risk related problems?

So when I went to visit Dr. Preiss, an internist at the Dartmouth Hitchcock Medical Center on December 11, I didn't have any complaints, nor expect much. I figured the worst thing they might find (and did) were blood pressure and cholesterol issues. Pretty normal for someone my age and family history. My blood pressure was high and he put me on Lisinopril and aspirin for hypertension.

I had a follow up appointment on January 28, my blood pressure now under control. But a blood test revealed a PSA of 6.7. Prostate Specific Antigen is a substance produced by the prostate gland in men. I'd never given much thought to PSA, nor my prostate either for that matter, as I've never experienced any problems normally associated with an enlarged prostate (urinary or sexual dysfunction). A high PSA means your prostate cells are too active. Under 4.0 is OK; over 4.0 should probably be followed up; it can go as high as 20 or more.

A next follow up appointment with Dr. Preiss on Feb 25, my PSA was again above 4, at 7.0. As far as I recall, he didn't notice a lump. But he did recommend I see a urologist. Oh sure, no problem, I'll humor the doctors. Obviously I'm "in the system" now and ought to play along. Dr. Preiss looked me straight in the eye and said, "Don't postpone scheduling the urologist, it's important."

I'll never forget that look.

Biopsy

I met with a urologist Dr. Bihrle, on March 21. He gave me a rectal exam, 'felt around', and told me I had a lump on the left side of the prostate. Oy. And he recommended I schedule a biopsy so they can see if it's cancerous. Oh shit. And I should do this as soon as possible. Oh shit, oh shit.

I went in for the biopsy on April 21 (soonest they could schedule it). Dr. Seigne, head of urinary oncology, would do the procedure; we met at 9:30a for conversation, do the procedure and be out of there by noon. A simple outpatient thing, or so they say. Yeah, right! I found it to be really fuckin' intense, or at least nerve-wracking. They stick this probe up your butt and fire little hollow needles into your prostate (through the large-intestine wall) to pull out core samples. I had 15 in all, up and down the prostate, on both sides.

The prostate is a gland about the size of a walnut, only in males, located just under the bladder. Its primary function is to produce semen that carries sperm during sexual activity. The prostate often gets enlarged in older men, affecting the ability to urinate and/or get an erection. I've had neither of those symptoms.

It was a very long week waiting for Dr. Seigne to call with the results. He makes 'these calls' once a week, on Monday evenings. The call came in. Lisa and I got on the phone, and he delivered the news: yes, the results are 'positive', there is a malignant cancer, and it's 'early stage' yet 'aggressive'. It's that lump on the left side. The right side appears clear.

One thing about prostate cancer, compared with cancers originating in other parts of the body, it grows fairly slowly so there's time learn about it and decide on a treatment, he says.

NO FUCKING WAY! Get this monster out of me, NOW!

The good doctor instructed us to not panic and contact his assistant to schedule an appointment to discuss the findings in more detail and explore treatment options. I did. And a letter arrived in the mail with the prognosis details, including the bottom line: "I have staged your prostate cancer as T2aN0M0 Gleason score 4+4=8". That means it's quite aggressive but there's a good chance it's still contained within the prostate and has not spread.

A large envelope also arrived with booklets, information fliers, and a DVD. And I was asked to fill out a (confidential) on-line questionnaire before the next visit. Lisa and I met with Dr. Seigne again on May 8th.

Treatment discussions

Basically treatment options fall into one of 3 categories (Disclaimer: this is totally my interpretation as it pertains to my situation, I am not a doctor nor do I play one on television). If the cancer is well contained in the prostate, you can go for radiation therapy where they nuke the gland every day for a couple months and hope to vaporize the bad cells. A side effect is it may/will damage some good cells too, causing other kinds of problems (just think about which basic bodily functions occur in the pelvic region).

If the cancer has a significant lump but is pretty much still contained within the prostate, they can surgically remove the gland, and some surrounding tissue as well. This is more radical but seems much more precise. Actually, statistics show that surgery may not be any more effective in the long run than radiation, depending on the details of the case. But for aggressive cancers, it's going to remove the tumor all at once, that's for sure. A possible side effect is ED (as defined on prime time TV these days), especially if they remove the nerves adjacent to the gland.

If the cancer has spread beyond the prostate, your treatment options are more systemic, like chemo or hormone therapy. And life expectancy is significantly diminished.

Having an early stage, aggressive cancer, I opted for the surgery, scheduled for June 9th (same as my wedding anniversary-- will be our 23nd this year), with the chief surgeon for prostatectomy at DHMC, Dr. Heaney, a leader in the field (with significant web presence as well).

Next up, I was asked to schedule a nuclear bone scan to check for any evidence the cancer had spread to an advanced stage. The test, taken on May 12, as expected, showed no signs. But a suspicious thing was found on my left kidney, probably a common cyst, that should be checked. A follow up ultrasound on May 23 showed no cancer there.

Then we met with Dr. Heaney on May 27 to meet "the man" and get another perspective on all this.

He told a helpful analogy. Consider a fruit gift package from Harry & David. The prostate is like a fruit. Surrounding it is a tissue paper (thin membrane), and that sits inside a foam filled box (fatty tissue). As the cancer becomes more aggressive it can push through the membrane into the fatty tissue. Eventually cells break loose and can spread into lymph nodes and beyond.

The cancer "game" is all about statistics. No one will tell you anything except in terms of probabilities, with lots of caveats. There's also a lot of "controversy" (a word that keeps coming up) about which numbers are significant, which treatments work better than others, and what's correlated with what, or not. And then they quote you the old cancer standby's - the 5-year and 10-year "survival rates".

Lisa has joked that she's going to make me play in the traffic every day, which should lower my chances of dying from prostate cancer...

There are online calculators the doctors use, available to anyone (like www.mskcc.org ) where you punch in specs about your case and it spits back the chances of it spreading, and probabilities of your being free of it after 5 years etc. I won't share my numbers but I will say, they leave me hopeful.

The probabilities become increasingly accurate as more information is collected. The tissues removed during surgery are sent to the lab for a complete new biopsy work up. That will tell exactly where the cancer is (was) and whether (how much) it has spread beyond the gland itself.

In my case the plan is to remove the prostate, some surrounding tissue, including the left nerve, sparing the right side one (Yipee!). They'll also remove a couple lymph nodes (the closest ones to the prostate are near the pelvis) for testing.

A month after surgery they take my PSA again. Pray for zero (under 0.2), which means they got it all (for now). A PSA of 2.0 or higher indicates there's prostate cells elsewhere in the body (presumably cancerous) and further therapy will be recommended. Or, I continue getting my PSA checked regularly looking for any signs of recurrence.

"They" say one out of 6 men get prostate cancer during their lifetime. They say "most men die with prostate cancer, not from it", since it's slow growing they die of other causes. Somehow I'm suspicious whether this idiom applies to someone my age, but only time will tell.

Emotional Response

For whatever reason, I have yet to respond to the news with much negative emotions -- fear, anger, nor depression. I believe everyone should ask themselves from time to time: If I were to learn I'm going to die soon, what would I do differently with my life? Remarkably, my answer is "Nothing".

Seriously, I have been blessed with a great life and freedom and opportunity and circumstances to carve out a lifestyle and environment that makes me happy. There isn't another place on this planet I'd rather be living. There are no other people in the world I'd rather be spending my time with. If anything, there are things I'd like to get done quicker, as time becomes ever more precious, or better, as there's always room for improvement, but these pertain to simple things and projects. No profound regrets or anxiety. Thank God. And God Bless America.

My sister Sue died at age 38 of breast cancer 15 years ago, leaving a husband and two young children. It was a traumatic time in my family, she was the first (and still the only) one to die in my generation among 20 or so first cousins. My father passed away last year at age 90.

My greatest negative response to all of this is a sad fear of possibly getting shortchanged. In ten years my youngest daughter may be entering college. My oldest daughter may be wedding. I fully intend to be there with them, in sound health. I cannot imagine otherwise.

My greatest motivation now is to appreciate every day, to speak a little softer, to love a little more, to be less impatient, to smell the air, gaze the stars, and sow my garden (both literally and figuratively). After all, that's what life is about.

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.