Tuesday, May 26, 2015

Prostate Cancer Hysteria

If you Google “prostate cancer,” in just .53 seconds, the internet will signal 24,300,000 results.  Most of the results address treatment options.  There would be even more results if women had prostates but they do not. Only men get prostate cancer. 

Junior high school biology taught us that the prostate, is a small almond shaped gland below a man’s bladder that produces seminal fluid “the little river” for sperm.  Anything relating to sperm catches a man’s attention. Women pay attention for cancer’s obvious effect on the mortality of their men but also because, if they are heterosexual and monogamous, their future sex life may depend on the results of treatment.

If you read just a few of the sites you learn:

Prostate cancer is the most common cancer in men, and the second leading cause of cancer death among men in the U.S. About one in six men will be diagnosed with prostate cancer during his lifetime, but only one in 35 will die of it”.

 “Prostate cancer is a malignant tumor that usually begins in the outer part of the prostate. In most men, the cancer grows very slowly. Many men with the disease will never know they had the condition. Early prostate cancer is confined to the prostate gland itself, and the majority of patients with this type of cancer can live for years with no problems”.

 “Prostate cancer is characterized by both “grade” and “stage.” The size and extent of the tumor determine its stage. Early stage prostate cancer, Stages T1 and T2, are limited to the prostate gland. Stage T3 prostate cancer has advanced to tissue immediately outside the gland. Stage T4 prostate cancer has spread to other parts of the body.

 To predict the aggressiveness of the prostate cancer, the physician will look at PSA (a protein excreted by the prostate gland) levels before a biopsy and will calculate the patient’s “Gleason Score.” The Gleason Score ranges from two to 10, with two representing the least aggressive form (confined to the gland) and 10 representing the most aggressive form of cancer (highest risk of spreading outside the gland). From the PSA levels and the Gleason Score, a treatment plan is devised”.

Last month my PSA scored a troubling 14 after a 6 just a year earlier.  I figured it was a mistake and consulted the internet  (my answer book for everything) to sample all other possible reasons the PSA could escalate.

“PSA tests measure a protein in your blood called prostate specific antigen, or PSA. Prostate cancer makes PSA levels go higher, but high PSAs aren't always a sign of prostate cancer. Sometimes, readings may be elevated because of something benign, such as ejaculating within 24 hours of the test. Your “normal” PSA depends on your age, but even if your PSA level is elevated between 4 and 10, you have only about a 25 percent chance of prostate cancer.

Obviously that was it…masturbation.  I was an ejaculator.  

I decided to wait at least a week without any self manipulation to magically bring that number down. 

It did not come down. 

It stayed the same.

Since cancer was out of the question it had to be prostatitis, a condition I had heard about from a friend years ago.  I had a pain below my right testicle. Clearly prostatitis. 

I googled “prostatitis” + “groin pain”.

Common causes of inflammation in the gland, called prostatitis, can cause high PSA levels." Prostatitis caused by bacteria can be treated with antibiotics. Another more common type of prostatitis, called nonbacterial prostatitis, can be harder to treat and last a long time. Prostatitis is the most common prostate problem for men younger than 50.

My urologist was amused but not persuaded by my research or conclusion. He ordered a slightly different type of PSA test called a “PSA free”. 

PSA is a protein produced by prostate gland cells that circulates through the body in two ways: either bound to other proteins or on its own. PSA traveling alone is called “free” PSA. The free-PSA test measures the percentage of unbound PSA. Most of the PSA protein released into the blood becomes attached to other blood proteins. The PSA that does not become attached is known as free PSA and can be measured.

It has been found that the level of free PSA is decreased in men who have prostate cancer compared to those with benign conditions. If your percent of free PSA is less than 10% you have a 56% probability of prostate cancer.  

To completely destroy my prostatitis argument my doctor also ordered a urinalysis to check for infection.

I passed the urinalysis but badly flunked the PSA free. 

The regular PSA test makes you worry about a high number.  The PSA free test allows you to worry about a low number.  Apparently I scored poorly on both. 

What now Doc?

He said the next step is a “transrectal ultrasound-guided biopsy.”

I consulted the Mayo Clinic Web Site:

What to expect during transrectal prostate biopsy

In most cases, the urologist performs a transrectal prostate biopsy. For this procedure, your doctor will start by having you lie on your side, with your knees pulled up to your chest. In some cases, you may be asked to lie on your stomach.After cleaning the area and applying gel, your doctor will gently insert a thin ultrasound probe into your rectum. Transrectal ultrasonography is used to create images of your prostate using sound waves. Your doctor will use the images to identify the area that needs to be numbed with an anesthetic injection, if one is used. The ultrasound images are also used to guide the prostate biopsy needle into place.In most cases, an injection of a numbing medication is used to reduce the discomfort associated with the prostate biopsy. A needle is used to inject the anesthetic at various points near the base of the prostate.Once the biopsy device is situated, your doctor will retrieve thin, cylindrical sections of tissue with a hollow, spring-propelled needle. The procedure typically causes a very brief, uncomfortable sensation each time the spring-loaded needle takes a sample. Your doctor may target a suspicious area to biopsy or may take samples from several places in your prostate. In most cases, doctors will take 10 to 12 tissue samples. The entire procedure usually takes about five to 10 minutes.

That was pretty accurate, but the clicking was more like 12 staple gun firings.  It startles you more than it hurts. 

What is actually happening is 12 thin rods are probing your almond sized prostate to gather possible cancer cells for the pathologist to study and evaluate and generate a Gleason score.

When the doc was finished I asked him “off the record” “since it was also an ultrasound” whether he could see anything that gave him a clue.  Of course, I added, “I won’t hold you to it”. 

His response: “Well there appears to be some calcification in your prostate which could account for the high PSA, but we will have to wait and see”.

Well, of course, that was it: “calcification”. 

I decided not to give my prostate another thought.  I expected favorable results in about a week and dismissed the entire unfortunate subject.

Three days later while sitting in the dentist chair waiting to have my teeth cleaned, my cell phone chimed with my Bach French Suite ringtone.  The dentist remarked: “how pleasant the ring”. 

The ring did not properly foreshadow the call. 

I noticed from the number that I better answer since it was from my doctor’s office.
I did.

I had cancer. 

The doctor explained that he needed to talk to me in person to go over the pathology report and discuss what’s next.  I said I would see him tomorrow. 

He said: “No, come today”.
I brought my partner Barbara for notes and courage.

If your biopsy finds cancer, the first piece of information you’ll want to note is the Gleason score. This numerical value grades prostate tumor cells according to how they look compared with normal cells and how mutated they appear under a microscope, a quality known as differentiation. (Normal cells are well differentiated and cancer cells are not.) Because tumors often consist of multiple cell types, the pathologist assigns two values between 1 and 5: the first to the predominant cell type, and the second to the next-most-prevalent cell type (see Figure 1). The sum, ranging from 2 to 10, is the Gleason score; the higher the number, the more aggressive the cancer. An ideal report also specifies how many samples, or cores, were removed during the biopsy. 

The standard number of cores used to be six: three from the right side of the prostate and three from the left. However, this limited sampling meant that cancerous portions of the prostate, if there were any, might be missed. As a result, as many as one in four patients eventually diagnosed with prostate cancer was told, on the basis of the initial biopsy, that he did not have cancer — meaning that the test provided a false-negative finding. Today, most doctors agree that an initial biopsy should include at least 10 to 12 core samples. In certain situations, some doctors recommend doing a saturation biopsy, which typically removes 12 to 14 cores — and sometimes as many as 20 or more — but less agreement exists about this practice.

Basically I got stabbed 12 times and 6 of the 12 hit “pay dirt”.  On the right side of my prostate 5 of the hits were just small samples of the bad goo.  One of the cores, however, was cancer complete. 

The Gleason score was 3+3. Not that bad.  But the single core that was all cancer was not good.

Now comes the hard part. 

About 10 years ago, I started to get “floaters“ in my left eye.  The floaters resulted in a complete detachment of the retina in that eye.  The detachment happened at a seminar miles from my home. I called my regular eye doctor immediately and was told to go directly to the hospital. She was to make arrangements with her recommended surgeon who I did not know. In less than 6 hours I was in surgery with a doc I had never met who never asked me a single question nor did he explain anything about the necessary surgery before it occurred.  The surgery fortunately was successful.  Without my involvement or consultation.

“Just lay there and we will let you know how it goes”.

This was much different.  I had to make decisions and be involved.

According to the American Cancer Society:

Depending on the situation, the treatment options for men with prostate cancer might include: Expectant management (watchful waiting) or active surveillanceSurgeryRadiation therapyCryosurgery (cryotherapy)Hormone therapyChemotherapyVaccine treatmentBone-directed treatment These treatments are generally used one at a time, although in some cases they may be combined.The treatment you choose for prostate cancer should take into account:

  • Your age and expected life span 
  • Any other serious health conditions you have 
  • The stage and grade of your cancer 
  • Your feelings (and your doctor’s opinion) about the need to treat the cancer right away 
  • The likelihood that each type of treatment will cure your cancer (or help in some other way) 
  • Your feelings about the possible side effects from each treatment. 

Many men find it helpful to get a second opinion about the best treatment options based on their situation, especially if they have several choices. Prostate cancer is a complex disease, and doctors can differ in their opinions regarding the best treatment options. Speaking with doctors who specialize in different kinds of treatment may help you sort through your options.

The main types of doctors who treat prostate cancer include:Urologists: surgeons who treat diseases of the urinary system and male reproductive system (including the prostate)Radiation oncologists: doctors who treat cancer with radiation therapyMedical oncologists: doctors who treat cancer with medicines such as chemotherapy or hormone therapyYour primary care doctor can also be a helpful source of information as you sort through your treatment options. It’s important to discuss all of your treatment options, including goals and possible side effects, with your doctors to help make the decision that best fits your needs.

Are they kidding! 

How was I supposed to decide what treatment was best for me. 

I had no idea. I am 71 years old, in otherwise very good health. Healthy diet.  Very little drinking.  No smoking. Lots of exercise.  How the hell did I get prostate cancer.

My doctor is a surgeon who performs robotic surgery using the Da Vinci robotic system.  The choice was immediately clear.


He told me to slow down and explore other choices.  “Some people do nothing but wait and see if their cancer progresses”.  “Many cancers are indolent.”

And then you hear it for the first time:

“Most people die with cancer not from cancer.”

From Web MD:

Thinking about survival rates for prostate cancer takes a little mental stretching. Keep in mind that most men are around 70 when diagnosed with prostate cancer. Over, say, five years, many of these men will die from other medical problems unrelated to prostate cancer. To determine the prostate cancer survival rate, these men are subtracted out of the calculations. Counting only the men who are left provides what's called the relative survival rate for prostate cancer. Taking that into consideration, the relative survival rates for most kinds of prostate cancer are actually pretty good. Remember, we're not counting men with prostate cancer who die of other causes: 99% of men with the most common types of prostate cancer overall will survive more than five years after diagnosis. For the more than 90% of men whose prostate cancer is localized to the prostate or just nearby, the prognosis is even better. Almost 100% of these men will live at least five years.

Ok, my doctor is younger than both my sons.  I am an old man to him.  Am I reading things into his demeanor? He seems to be saying: “think about the “watchful waiting” option”.  Many prostate cancers are indolent.

Did I hear him say: “Hey you may be dead in five years anyway from something else”? 

My partner Barbara is taking notes.  I see the doctor’s lips moving but the sound and content are no longer registering. 

Am I now an old man suddenly facing his mortality for the first time. 


I have had an amazing interesting life with some satisfying accomplishments.  True, but, I am still active and involved. And but for the occasional glances in the mirror, I feel far younger than my years. But then I am old: five grandkids; core family all deceased, many, far too many, of my best friends now gone. 

Damn…is my run about done? 

If I do nothing, at least prostate cancer probably won’t get me for another five years.

What is my life expectancy anyway.  My mom lived to 90.  My brother 48.  My Dad 86 (five of those years with Alzheimer’s. 

According to the Social Security Retirement Life Expectancy Calculator, from the office of the Chief Actuary, I should live to 85.7. 

Doing nothing about my cancer could erase 10 years of my life. 

So yes I need a treatment plan.

Although prostate cancer is often reported in stages (I II and III), I had been cautioned not to think in terms of these buckets.  There is a continuum that may be more complex.  But since my Gleason score was 6 and PSA 10, for treatment purposes, I considered Stage I treatments.  The main argument supporting Stage 1 treatments is : your cancer is apparently confined to the prostate. 

But can they really know?

Individualized treatment options outlined to me and considered appropriate were basically limited to three bold categories: 

Watchful waiting or active surveillance;
Radical prostatectomy; 
There were subcategories for the last two.  I learned that there were more than one way to perform the surgery (Da Vinci or not) and that there were two types of radiation treatments: either external or internal.  If you choose internal you choose temporary or permanent seeds.  There are also different equipment (and manufacturers) employed to guide external and internal radiation depending on where you go to have the procedure and slight variations in how the procedures are conducted.

Of course the first and primary objective should be to prolong your life by killing the cancer. 

Oddly enough I was only focused on the cost. 

And I don’t mean money. 

Every procedure has “unfortunate” side effects. 

I wanted to know how to pick my poison.

The main type of surgery for prostate cancer is known as a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. A radical prostatectomy can be done in different ways.  The most common today is with the Da Vinci robot.

Robotic-assisted laparoscopic radical prostatectomy 

A newer approach is to do the laparoscopic surgery using a robotic interface (called the da Vinci system), which is known as robotic-assisted laparoscopic radical prostatectomy (RALRP). The surgeon sits at a panel near the operating table and controls robotic arms to do the operation through several small incisions in the patient’s abdomen. Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there seems to be little difference between robotic and direct LRP for the patient. In terms of the side effects men are most concerned about, such as urinary or erection problems (described below), there does not seem to be a difference between robotic-assisted LRP and other approaches to prostatectomy. For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of LRP is the surgeon’s experience and skill. If you are thinking about treatment with either type of LRP, it’s important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that either type of LRP is the treatment for you, be sure to find a surgeon with a lot of experience.

And then, the side effects:

The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). … Urinary incontinence: You may develop urinary incontinence, which means you can’t control your urine or have leakage or dribbling. There are different levels of incontinence. Being incontinent can affect you not only physically but emotionally and socially as well.
 There are 3 major types of incontinence: Stress incontinence is the most common type after prostate surgery. Men with stress incontinence might leak urine when they cough, laugh, sneeze, or exercise. It is usually caused by problems with the muscular valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments can damage the muscles that form this valve or the nerves that keep the muscles working.Men with overflow incontinence have trouble emptying their bladder. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.Men with urge incontinence have a sudden need to pass urine. This problem occurs when the bladder becomes too sensitive to stretching as it fills with urine.Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence. After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs gradually, in stages. Doctors can’t predict for sure how any man will be affected after surgery. In general, older men tend to have more incontinence problems than younger men. Most large cancer centers, where prostate surgery is done more often and surgeons have more experience, report fewer problems with incontinence. Incontinence can be treated. Even if your incontinence can’t be corrected completely, it can still be helped. You can learn how to manage and live with incontinence. See our document Managing Incontinence for Men With Cancer to learn more about this side effect and what can be done about it. Impotence (erectile dysfunction): This means you can’t get an erection sufficient for sexual penetration. 

Erections are controlled by 2 tiny bundles of nerves that run on either side of the prostate. If you are able to have erections before surgery, the surgeon will try not to injure these nerves during the prostatectomy (known as a nerve-sparing approach). But if the cancer is growing into or very close to the nerves, the surgeon will need to remove them. If both nerves are removed, you won’t be able to have spontaneous erections, but you might still be able to have erections using some of the aids described below. If the nerves on only one side are removed, you might still have erections, but the chance is lower than if neither were removed. If neither nerve bundle is removed you might have normal erections again at some point. Other treatments (besides surgery) can also damage these nerves or the blood vessels that supply blood to the penis to cause an erection. Your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were cut. All men can expect some decrease in the ability to have an erection, but the younger you are, the more likely it is that you will keep this ability. A wide range of impotency rates have been reported in the medical literature, from as low as about 1 in 4 men under age 60 to as high as about 3 in 4 men over age 70. Surgeons who do many nerve-sparing radical prostatectomies tend to report lower impotence rates than doctors who do the surgery less often. Each man’s situation is different, so the best way to get an idea of your chances for recovering erections is to ask your doctor about his or her success rates and what the outcome is likely to be in your case. If your ability to have erections does return after surgery, it often occurs slowly. In fact, it can take from a few months up to 2 years. During the first few months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments. If potency comes back after surgery, the sensation of orgasm should still be pleasurable, but there is no ejaculation of semen – the orgasm is “dry.” This is because during the prostatectomy, the glands that made most of the fluid for semen (the seminal vesicles and prostate) were removed, and the pathways used by sperm (the vas deferens) were cut. Most doctors feel that regaining potency is helped along by trying to get an erection as soon as possible once the body has had a chance to heal (usually several weeks after the operation). Some doctors call this penile rehabilitation. Medicines (see below) may be helpful at this time. Be sure to talk to your doctor about your situation.

I read this and said: DAMN.

My oncologist who does Da Vinci is among the best so his competency was not part of the calculus.

It was the side effects.

My doctor has an assistant who was available for questions and help.  He put me in touch with a former patient who described how he was doing.

  “Great except for ED”. 

I didn’t need to talk to any others because three of my friends who had had surgery and were contemporaries also had ED.  That didn’t mean they now needed Viagra or Cialis.  It meant they needed more drastic help.  The details aren’t necessary. 

None had urinary problems. 

The “nerve sparing” advertised was not sparing.

Barbara’s sister had significant “best of the best” contacts in the cancer world.  And since I needed another opinion on treatment options I followed her lead and moved from Palo Alto Medical to Stanford for more information.  But those appointments were two weeks away and suddenly I realized a month had passed since my biopsy.  Shouldn’t I finally figure this out.

While waiting for Stanford, I saw the radiologist at Palo Alto.

Now this seemed more like it.

External radiation means that the radiation has to travel through your body before it hits the target.  Lots of sessions are required since the dose has to be lower not to damage the surrounding tissue on the path to the prostate.  I would be going every day for 52 sessions, with weekends off.  Fiducial markers (gold or carbon fiber) are inserted in your prostate to help the advanced machine track your moving prostate and make sure it gets the radiation.  The amount of radiation you receive is measured in Gray.  I would receive dose escalated IMRT to 81 Gy. This procedure doesn’t require a hospital because there is no cutting and no anesthetic.  Just patience and time.  And it was close to my house.

It was perfect.

Side effects:

Advances in the precision of radiation therapy have lessened the risk of complications. Still, radiation can cause short- and long-term side effects, including incontinence (the involuntary loss of urine), erectile dysfunction, bowel problems, fatigue, and symptoms in other parts of the body (if you receive radiation therapy for disease that has spread outside the prostate).

Sloan Kettering

Overall the side effects appeared less drastic than surgery.  ED problems were more likely to occur down the road when I may not care as much.  Urinary issues generally were short term.  Bowel problems very unlikely.

I was ready to go but I had promised to hear out Stanford.

And then there were “seeds”:  Brachytherapy.  Internal radiation.  “Put the radiation where the cancer lives, directly in the prostate”.

Many of my friends had “permanent” seeds.

I asked my doctor about them and he simply said: “that’s old school now.”

With low-dose-rate (LDR) brachytherapy, we insert tiny titanium seeds containing radiation in or near the tumor while you’re under anesthesia. We use ultrasound imaging to guide the placement of the seeds. In 95 percent of cases, this technique is successful in eliminating the cancer. At MSK, we perform LDR brachytherapy on an outpatient basis. It usually takes a little over an hour. Although the seeds are permanent, they cause little or no discomfort, and their radioactivity lessens after several weeks or a few months. To ensure that the tumor receives high doses of radiation while the surrounding tissue is protected, we developed and use real-time image guidance when the radioactive seeds are implanted into your body. During the procedure, while you’re under anesthesia, a mobile CT scanner (called an O-arm) provides up-to-the-second images of your prostate. A sophisticated computer software system fuses ultrasound images obtained before the procedure with these real-time CT scans. Using this data, the computer analyzes millions of possible seed locations and, in a matter of seconds, selects the ones that will deliver a precise dose of radiation to the tumor while avoiding injury to healthy tissue. Before you leave the operating room, we take a final CT scan to ensure the seeds were placed at the ideal locations. Sloan Kettering

Good enough for Sloan Kettering but at UCLA they abandoned the approach:

The two forms of brachytherapy performed today for the treatment of prostate cancer are low dose rate in the form of permanent seeds and High Dose Rate (HDR) temporary implants or HDR brachytherapy. Our physicians did hundreds of permanent seed implants before switching to HDR in 1991. We feel that HDR temporary implants are superior to permanent seed implants in most circumstances. To date, our center has done over 4,000 HDR brachytherapy implants for prostate cancer.

 I have friends who had seeds years ago and were asked to sleep in another room until the radiation “calmed down.”

Would “permanent” seeds do the trick.   Had they fallen out of favor?

Low-dose-rate brachytherapy has the great advantage of being practically a one-time procedure, and enjoys a long-term follow-up database supporting its excellent outcomes and low morbidity. Low-dose-rate brachytherapy has been a gold standard for prostate brachytherapy in low risk patients since many years. On the other hand, HDR is a fairly invasive procedure requiring several sessions associated with a brief hospital stay. Although lacking in significant long-term data, it possesses the technical advantage of control over its postimplant dosimetry (by modulating the source dwell time and position), which is absent in LDR brachytherapy. This important difference in dosimetric control allows HDR doses to be escalated safely, a flexibility that does not exist for LDR brachytherapy.

Ok so I needed more information.  What was HDR all about.

High-dose (HDR) brachytherapy is most commonly used to treat prostate, cervical and head and neck cancer. During the procedure, the radioactive material, such as iridium, is temporarily placed in the tumor and then removed. The radioactive material travels through small plastic catheters to the targeted area. The precise location is determined with the aid of a specialized computer system. Since the position of the radioactive material can be precisely adjusted, customized dose distributions can be created to meet each patient's needs. Recent technological advances at UCSF have led to breakthroughs in the delivery of HDR brachytherapy. Computerized tomography (CT) and magnetic resonance (MR) image guidance and clinical expertise create the optimal dose distribution.

UCSF offered a comprehensive brachytherapy program in California.  So did UCLA.

HDR Brachytherapy can be used as the only treatment for prostate cancer or it can be used in combination with external beam radiation therapy (EBRT). When used as single treatment it is known as "HDR Monotherapy" and when used it is given with external beam it is known as "combined HDR and EBRT".  Basically, HDR Monotherapy is used for early or localized prostate cancer or in some cases where cancer has recurred after prior radiation therapy.

I knew Palo Alto didn’t offer this.  I heard Stanford offered it but it was in combination with external which seemed silly to me.  If I needed external why not skip the discomfort of the internal.

I talked to UCLA about Mono which skipped the external.

Their response was:

In terms of outcomes (ie PSA control) the data seem to suggest improved PSA control with brachytherapy compared with IGTheirRT to about 80 Gy.
 Here is an abstract below from the recently updated RTOG 0126 trial that compared about 70 Gy to about 80 Gy IGRT and you would have been eligible for this trial. You can see that at 10 years the PSA control in the higher dose arm was 70% (30% of men had a PSA failure).
 If we look at the outcomes with HDR monotherapy from one of the largest studies to date (abstract below) you will see that the PSA control at 96 months is 90% for the entire group (this includes higher risk patients than you).
 In terms of toxicity I think the short term urinary side effects are a more intense than those of just IGRT but these usually subside within about 1-3 months after treatment otherwise I think the risk of long-term ED is about the same between the two (some people think they are less with brachytherapy but I think this is debatable).  The risk of rectal complications is very low with both modalities.
 Hope this helps.

I asked my radiologist at Palo Alto what he thought.  Basically he discouraged me from HDR.  He suggested it was tough and not any more effective.

So onward.

I had my Stanford appointment and I was not going to cancel although I was 99% ready to get on with the external treatment at Palo Alto.   I learned that Stanford did do HDR Mono therapy, but only as a clinical trial.  Frankly I was curious but not really open minded.  I had had enough.

Before my appointment I watched several YouTube videos Stanford had offered on the HDR Brachy procedure.  It did not look pleasant. At least you were asleep.   You were given two procedures a week apart and, if you were accepted for Mono, that was it. You were done.

Something very different happened at Stanford that changed everything.

Every guy dreads the digital exam. When this journey started my urologist gave me one and felt nothing strange. 

The Stanford urologist was less gentle and more effective.  He did not feel a nice smooth prostate.  There was definitely something there.  My cancer was not in nursery school.  It might be ready for junior high.

It’s nice to worry about side effects but you need to kill or control the cancer.  So was surgery back on the table?

No.  But the more grays and the more targeted the radiation, the better the potential results.

So I am in the clinical trial. My next step three weeks away will be HDR.    The procedure is explained here:   https://www.youtube.com/watch?v=Kug_z22Mrn0

I will let you know how it goes.  I’ve read a lot about the actual procedure and guys who have had it but Stanford is slightly different in their approach from UCLA and my body is different from the other guys who have had it and reported.   So Que Sera Sera

Some are comforted by “Give it Up to God.”

I am not one of them.

I fully surrender my prostate to Stanford.

There is a silver lining to a bad prostate cancer diagnosis.  Unlike many cancer appearances, this one slaps you in the face.  It does not hit you with a hammer.  It’s a tossed bucket of ice water on the ego of your immortality. 

I am thankful. It could have been “wrap it up hotshot” “what were you thinking?”

What are we thinking?

Apparently about everything but death and dying.

Maybe that is changing.  Read Being Mortal by Atul Gawande

Like most expert procrastinators, after my procedure, I will probably postpone my promise to great each day with new wonder and appreciation.  There is, however, a new calm, respect and acceptance of my mortality now.

I just replaced my alternator and several other essentials on my 2006 Camry (144,000 miles) in the hope that my great car can hang around a little while longer.  I’m hopeful it will take many years to discover whether the magical repairs to my body functioned as planned.