Tuesday, March 07, 2006


My Prostate Adventure

I’ll bet you think you’re hearing a lot about prostate cancer and PSAs these days. That’s because prostate cancer is the most common cancer in American men. It’s expected that the number of men diagnosed with it will triple over the next twenty years and the deaths from it will double.

Perhaps many of you reading this have already dealt with prostate cancer. So what I’m about to discuss may be old news for you. This column is, therefore, aimed at those lucky Baby Boomers and Seniors who haven’t. You’re next.

I didn’t say it like that to scare you. Well, maybe I did because prostate cancer is nothing to sneeze at. It’s vitally important that guys our age take it seriously enough to start being checked for it regularly. I’m speaking from experience, folks. I recently went through my diagnosis and treatment of choice and I learned a lot. Perhaps I can pass some of that knowledge on to you and yours in the hope that it will help. Let’s start with some basics.

What is the prostate and what does it do?

It’s a walnut sized gland that sits beneath the bladder and surrounds the urethra. It produces the fluid that makes up part of the semen that carries sperm out of the penis. That makes it a pretty important part to us studs and one of our most prized possessions. Unfortunately, it comes with a price.

For most men, the prostate will become cancerous if you live long enough. Many men will die of other causes while they have prostate cancer. That’s because prostate cancer is usually very slow growing. But don’t count on it. It’s no reason not to be concerned.

How do you know if you have it? What do you do?

Like all cancers, the best way to beat it is by early detection. The “gold standard” for this is a simple blood test that measures the amount of Prostate Specific Antigen (PSA) in your blood. The higher the number the greater your risk for having prostate cancer. If you’ve never had your PSA checked and you are over fifty years of age, its time for you to do so. Many doctors are even saying if you’re in your forties you should start checking it to establish a baseline. I know that some doctors pooh pooh the PSA as unreliable. If those doctors are over fifty, I wonder if they’ve ever checked their own PSA. I bet they have but won’t tell you.

If you question the reliability of the PSA test, consider this. The James Buchanan Brady Urological Institute (named for Diamond Jim Brady) at Johns Hopkins Hospital in Baltimore is ranked as the best place in the country by U.S. News and World Report for dealing with urology issues. Kings, princes, presidents and prime ministers come from all around the world to have their prostate cancer treated there. Hopkins uses the PSA for aiding in early detection. If the best place in the country (maybe the world) uses it then that’s what I want for me. I don’t want my urologist steering me in another direction, away from the industry standard, for whatever his reasons. It’s my life he’s messing with!

OK, you got your PSA test done. Now what?

If your PSA is over 4.0 and you’re in our age group, you need to have a biopsy. That’s the rule of thumb but there may be reasons to have the biopsy even if your PSA is lower. Has it jumped over a point in the last year? Do you have a family history of prostate cancer? If the answer is yes to these questions then you should have a biopsy.

I know many of you are getting squeamish just thinking about a biopsy. I understand. Boy, do I understand. I’ve had a three of them and I admit they are no fun. But they are vitally important because the only way you can really know if you have prostate cancer is through pathology. The PSA and a family history and your age are all indicators of risk, but having actual tissue taken from your prostate and studied under a microscope by a trained and experienced pathologist is the only way to know conclusively if you have cancer. Will you like having a biopsy? Heck, no! It’s literally a pain in the ass! But it can save your life.

Here’s another way of looking at it. If you don’t like the idea of a biopsy, how are you going to like being treated for prostate cancer if it has spread (metastasized) beyond the prostate? You won’t like it at all and neither will your loved ones. Think of them, too, whenever you hear discussions about prostate cancer.

What to do if your biopsy is positive?

As you progress up the prostate cancer chain the decisions become more difficult. To help you, I recommend that you read the book “Guide to Surviving Prostate Cancer,” by Dr. Patrick Walsh, M.D. of Johns Hopkins and Janet Farrar Worthington. Dr. Walsh is considered the world’s leading figure in prostate cancer research and treatment. He pioneered the techniques in the 1980s that are common practice today at Johns Hopkins that result in less bleeding, shorter recovery time, better pain management, less incontinence, sparing the nerve bundle that contributes to erectile function and, most importantly, saving lives.

You need to learn about the various factors to consider when deciding on a course of treatment. This will include your age and overall health. These contribute to your life expectancy before your diagnosis and that will influence your course of treatment. Your biopsy will yield what is called the Gleason Score, developed by Donald F. Gleason, reference pathologist for the Veterans Administration Cooperative Group. This score illustrates the relative aggressiveness of the cancer and, although it is derived from your actual prostate tissue, it is not fully conclusive. The biopsy does not cover the entire gland, only those specimens that are extracted. So a specimen can reveal a Gleason 6 cancer but the actual tumor, which is larger than the specimen taken, can have cells that rate a higher Gleason score. This was true with me. My biopsy showed a Gleason 6 but the final lab report after surgery showed three tumors, two of which were Gleason 7 and 9. These are more aggressive than a Gleason 6. Your Gleason score will suggest the speed with which you need to make a decision. It is one of three factors (along with PSA and clinical stage; T1, T2, T3 etc.) in a tool that Johns Hopkins uses called the Partin Tables. This was devised by Dr. Alan Partin and it is an important guide for your decision making. It’s actually very complex, involving a series of questions fed to a computer with a neural network. I think they used to call them expert systems.

I believe that the primary decision you will make is whether or not to have surgery. There are reasons why you should have it and reasons why you may choose otherwise. You need to make an informed decision. Remember, it’s your life and that life is shared by your loved ones. As I said earlier, take them into account throughout this process. You want to be cured and live a “normal” life. The Partin Tables can help. The tables helped me understand that my cancer was most likely confined to the prostate (about a 75% chance). Although not a guarantee, it was not likely that the cancer had spread beyond the prostate capsule.

Radiation is another form of treatment that you will consider. There are two ways to receive this: one is through external beam radiation and the other is by having radioactive pellets (called seeds) implanted directly into the prostate. Once again, your age and overall health will influence your decision here. The seeds are becoming very popular today because it is a one time procedure and performed as out patient surgery. There is also less risk to other body organs and some data suggest the same result as surgery. Dr. Walsh at Johns Hopkins contests these data, however, and says that more studies are needed to show the results of treatments focused on men who are diagnosed under the age of sixty. He states that surgery is beginning to show better results. If, however, your Gleason score is high your cancer may have spread making surgery a non-option.

Even if your decision is surgery there are further decisions to be made. One is whether to have the “open surgery,” as performed at the Brady Institute or to go with the newer surgery called laparoscopic surgery. Either one will get the job done but there are differences. An important one concerns “positive margins.” To the layman this means what is the likelihood that they removed all the cancer when they removed the prostate. Open surgery has a much lower percentage of cases with positive margins. Although laparoscopic surgery shows many appealing points, such as quicker recovery time, the positive margin issue and the great track record of the Brady Institute helped me decide to go with open surgery. I’ve recently met a man who has undergone computer aided laparoscopic surgery in Detroit, who, despite having positive margins, has the same desired result as I do – an undetectable PSA. That’s where you want to be.

Learn about these procedures and make an educated decision.

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