Health

BL Longform: A diagnosis of prostate cancer is not a death sentence

Reporter Robert Eliason's firsthand account of the journey to wellness.

The phone rang and I thought of an old Ogden Nash couplet: “If it’s cancer/don’t answer.” But I did not have a choice that day. My doctor was calling back with the results of my prostate cancer biopsy and I had to take the call.

If people have heard anything about prostate cancer, they tend to dismiss it as “the cancer you want to get if you have to get cancer.” Prostate cancer is usually a slow-growing cancer and, if you are over 70 years old, the doctor might suggest you not get it treated—you are more likely to die of something else before your prostate cancer kills you.

The author in his car awaiting COVID testing. Photo by Robert Eliason.
The author in his car awaiting COVID-19 testing. Photo by Robert Eliason.

That does not mean it can be dismissed, though. One in nine men will be diagnosed with prostate cancer and it is the second-highest cause of death in men among the cancers.

I am 64 years old. I never had any of the symptoms of prostate cancer: dull pain in the lower pelvic area, frequent urinating or trouble urinating, bone pain, or the others. I did, however, have a couple of marks against me: my paternal grandfather and my maternal uncle both had prostate cancer.

Testing

I made sure I got my prostate checked and my Prostate-Specific Antigen (PSA) tests done. The PSA test checks the level of a protein that is produced by the prostate gland and is in your bloodstream.

But the PSA is not a particularly accurate test. A normal test result for the protein would be under 4 nanograms per milliliter. A result between four and 10 indicates a 25% chance of cancer. Over 10 indicates a 50% chance. My last test came back as a six, but it had been steadily rising for the last 18 months.  

“Your PSA can be elevated if you have an enlarged prostate or prostatitis,” said Dr. Laura Stampleman, a medical oncology specialist. “But basically you should be under one and if you are at six that is pretty much a sign that something is wrong. A six is pretty high. What we try to do is see if there is a trend—does it go up, does it go down. So we retest. If it stays high, we proceed under the assumption that there is a problem.”

The only sure way to tell if it is prostate cancer is to have a biopsy, which my doctor scheduled.

“There is some controversy in the medical field as to when a biopsy is appropriate,” Stampleman said. “It is a question as to what you are going to do with the information. With a young healthy person with an elevated PSA, you probably want to know what this is. If you have an 80-year-old with other health conditions, you may not want a biopsy because you will probably have a slow-growing cancer and something else will probably kill them first. The problem is, from a PSA you can’t tell how aggressive the cancer might be. But we retest and look at the PSA velocity—how much it changes over time.”

The biopsy procedure is pretty much what you would expect it to be. The doctor performing it said I would feel like King Kong’s finger made out of stainless steel was being inserted into me to reach the prostate. The probe allows a needle to inject six doses of lidocaine into the prostate to numb it—and I felt all six at about the same discomfort level you feel from injections at a dental appointment.

During my biopsy, the doctor took a total of 14 samples. The doctor used an ultrasound scanner to position the probe, then announced the triggering of the needle—all 14 times. For each one, there would be a loud click and an odd sensation—I definitely felt the needle puncturing the prostate each time but it was more of a sense of something really uncomfortable happening than real pain. By the time he was done, I was weak, sore, and exhausted.

The doctor told me to take a few days to rest. The immediate side effects, because of the position of the prostate and the puncturing of the wall of the rectum, would be bleeding that would show up in my urine and stools. Blood clots are possible, and symptoms need to be watched for and reported.

After a few days, my doctor called with the results. The left half of my prostate was indeed cancerous and registered a seven on the Gleason cancer scale.

In the 1960s, Dr. Donald Gleason created this scale based on degrees of cancer in cells. There are five different grades of cancer cells and the Gleason scale reflects a count of the two most predominant grades present in the biopsy.

“The biopsy is the gold standard for diagnosis because it gives you the Gleason grade,” Stampleman said. “It tells you how aggressive the cancer is and how much cancer there is. The critical thing is knowing how aggressive it is because we want to cure it before it can spread.”

In my case, my grade of seven was made up of three parts of an aggressive cancer and four parts of a less aggressive cancer. According to these standards, I was in Grade Group Two: favorable intermediate risk. The worst classification is Grade Group Five: very high risk.

The next step was to determine if the cancer had spread. I was immediately scheduled for bone and lymph scans to see if the cancer had escaped the prostate. Prostate cancer cells are such that they can enter the system and create other spots of prostate cancer, which would need treatment.  

“The commonest place that prostate cancer spreads is to the bones,” Stampleman said. “Different cancers have different propensities to go to different organs. Another is the lymph nodes, which drain the prostate gland. If your tests come back positive for spread, then you would not have surgery. You would have immediately had other courses of treatment.”

Treatment

In my case, the scans came back with no sign of spread. So the question became what to do about the cancer.  

There are three basic options, with pluses and minuses to each.

The first is doing nothing. This is referred to as “active surveillance” or “watch and wait.” The patient would have regular PSA tests and digital rectal exams. Should the PSA go up, there would be another biopsy. If the cancer was growing more aggressive, treatment would be needed. Choosing this option can be risky. By the time aggressive cancer is identified, it may have already spread.

The second is the removal of the prostate, most commonly through a “robotic prostatectomy.” The surgery is done with a “DaVinci Machine,” a five-armed robot operated remotely by a surgeon. This machine provides greater accuracy, smaller incisions, and less blood loss than traditional prostate surgery. Side effects may include impotence and incontinence. 

The third option is radiation. The prostate is bombarded with radiation five days a week for six to nine weeks. Side effects are similar to surgery, with possible long term bowel problems and fatigue.

“Your biopsy came back smack down the middle,” Stampleman said. “Not so aggressive. But you’re a younger man, you have no condition that is about to take your life. It is reasonable to treat it directly with radiation or surgery just to remove it and not have it get worse. With a Gleason Seven, you could watch and wait—but the danger of watching and waiting is that while you are waiting, it can spread. It really depends on someone’s level of comfort in not doing anything.”

In my case, I consulted four oncologists connected to four different hospitals, including Stampleman. After discussing all the options, all four recommended surgery as the best choice for someone my age.  

I had mentioned to the last doctor I consulted that I had three other opinions saying “surgery” and I asked if I should consult with another doctor.  

He was blunt. “If you keep asking for more doctors,” he said, “it is more likely you are not seeking opinions but looking for someone to tell you that you do not need the surgery. And I think that would be a poor approach to making a decision.”

With radiation and surgery, there is one important thing to understand as a patient: neither procedure is guaranteed to render you cancer-free. Follow-up tests must be done periodically to check PSA levels. With a successful procedure, the PSA level should be close to zero a couple of months after completion of treatment.

“In terms of effectiveness, we judge in terms of survival,” Stampleman said. “Surgery and radiation are roughly equivalent in terms of survivability. But there are people who, after radiation, develop a recurrence of cancer. They have to have what is called a ‘salvage prostatectomy’ which is difficult to do because of all of the scar tissue leftover from the radiation. In the case of surgery, if there is a recurrence then you would go into hormone treatment to fight the cancer. That would tend to be cancers with a higher Gleason scale where cells enter the bloodstream and show up in other places as cancer.”

Hormone treatment depends on blocking testosterone.

“Testosterone feeds prostate cancer,” Stampleman said. “The treatments are various methods of blocking the production of testosterone and possibly chemotherapy. Hormone blockers are not curative—they will keep the cancer into remission and they can keep it into remission for a long time.”

Prepping for surgery

I have chosen surgery, which has been scheduled. In the run-up to the procedure, I have had more tests to check on my health and ability to withstand the lengthy operation, including a series of blood tests and an electrocardiogram. Four days prior to the operation I will have a COVID-19 test.

On the day of the surgery, I will be driven to the hospital. After being prepared, the operation will commence and last for what I was told would be around three hours. Afterward, I will be allowed an hour or two to rest. If I seem able to be discharged, I will be released and sent home.

Prior to the pandemic, the hospital would have kept me there a couple days to monitor my condition. Post-COVID-19, hospital stays for this surgery are no longer an option—there are just too few beds and services to accommodate the current overload.

While not looking forward to the surgery, I accept the reality of it and have prepared for my recovery. I am optimistic but I am also mindful of what comedian Rodney Dangerfield said about his own surgery when asked how long he was going to be in the hospital. “If all goes well, about a week,” he said. “If not, about an hour and a half.”

If things go well for me, I will be following up this article with an account of the aftereffects of the surgery in a couple of months—the expected recovery time.  

See you on the other side.

 

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BenitoLink appreciates the Health Projects Center and Del Mar Caregiver for their interest and support for this important work.

 

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Robert Eliason

I’ve been a freelance photographer since my dad stuck a camera in my hand on the evening of my First Grade Open House. My dad taught me to observe, empathize, then finally compose the shot.   I have had gallery showings and done commercial work but photojournalism is a wonderful challenge in storytelling.   The editors at BenitoLink have encouraged me to write stories about things that interest me, turning me into a reporter as well.  It is a great creative family that cares deeply about the San Benito community.