CONFUSION ABOUNDED

So we thought we were ready to embark on the radiation pathway. Yep, I thought a one time procedure of pellet implantation was very desirable over 40 external beam treatments. This would be much less disruptive to my schedule.

Furthermore, I had a conversation with at least two people who either had external beam or pellets with external beam. But before I committed to any type of treatment, I was still confused about what I had heard at one of my urologist appointments regarding my Gleason 7 score. This was confusing to me. But after doing some research, it seems that even if most of the core specimens are 3+3 and only one is staged at 3+4=7, the person is staged according to the higher number.

So the Gleason system is based on the assumption that the higher number is representative of what’s actually occurring. Here I am thinking that sine most of the core biopsies were a Gleason 6, that’s what was representative of the cancer. Oops, I guess NOT!

Oh well. I had to stay on track. I had to keep moving forward. So next stop on this train was an appointment with the oncologist at the cancer center. I was ready. My wife and I had discussed this and made up our minds on the treatment plan and was ready to go and get this radiation thing scheduled and started. But I could not have been less prepared for what came next.

Continued….

THE RECONNAISSANCE MISSION

After having heard about my treatment options, I was determined to speak to someone who had been through radiation. However, my quest was more specific than just anyone. I was on a mission to hear from someone around my own age who had been through radiation treatment.

So through a friend, I was able to speak to a gentleman who had a history a higher Gleason score and went through both brachytherapy and external beam treatment. And he was doing well with minor side effects. So after this conversation I was encouraged and ready to go forward. So I thought.

After this conversation, my wife and I met a couple who were nutritional vendors promoting a vegan lifestyle. The gentleman had a significant history of prostate cancer, however, his had metastasized. He underwent both surgery, testosterone suppression therapy and radiation. He shared research information about how a diet free of animal products and low in saturated fats, was known to protect against prostate cancer and actually reverse the process.

The name that stuck out the most during our conversation was Dr. Dean Ornish. He authored a study in the Journal of Urology, which detailed the effects of an “intensive lifestyle change” on men with early, low grade prostate cancer. The study showed that the PSA revealed a 4% decrease on the experimental group versus a 6% increase in the control group. Furthermore, there was an decrease in the growth of cancer cells of up to 8 times as much in the control group.

This sounded groundbreaking! But was it truly real science? This may not be mainstream, I thought, but certainly worth some attention. Furthermore, Dr. Ornish may not be a cardiologist or nutritionist, but even the American Cancer Society recommends a reduction of saturated fats and reducing red meats.

Although this gentleman had some side effects, his claim was that they were improved with a vegan diet. Although I was not totally ready to bet the farm on these claims, it was clear that there were at least anecdotal evidence. So we did research on a vegan diet and decided to adopt this practice. I had nothing to lose. And my wife, in a demonstration of love and support, decided to adopt this lifestyle with me. (Mostly because she’d be doing the cooking anyway. LOL)

Our hope and prayer was that God would use this change in diet in conjunction with the upcoming radiation treatments to give me good outcomes. But wasn’t totally sure if this was my treatment option for sure. I still had a consult with the Cancer Center.

THE TREATMENT PLAN

Now that we are well versed on the Gleason system, I’ll continue my story.

So with all the pieces of the puzzle together, now came time to break out the National Comprehensive Cancer Guidelines (NCCN) to develop a treatment plan. The NCCN is a comprehensive set of guidelines developed through extensive review of clinical trials and existing treatment protocol along with expert medical judgment and recommendations by physician panels made up from Member Institutions. These guidelines cover 97 percent of all cancers affecting patients in the United States and are updated on a continual basis.

According to the NCCN flowchart, interventions or treatment protocols are based on age and life expectancy. This means that the younger the patient, the more aggressive the intervention. Conversely, the older the patient, the more conservative the approach. For example, a 75 year old male diagnosed with a Gleason 7 prostate cancer would more than likely undergo radiation rather than surgery.

Well, from what I remembered, my Gleason score was 6. According to the NCCN Guidelines, the recommendation was prostatectomy (removal of the prostate), brachytherapy (radioactive pellets placed into the prostate gland) or external beam radiation. And with the radiation, I would have to decide if I wanted to have androgen deprivation therapy (ADT), which are basically injections to decrease testosterone, which is known to promote prostate cancer growth.

So, again, my Gleason score was repeated as a 6. And now I had to decide on which type of radiation I wanted as treatment and if I wanted to go through with ADT. Well, nothing sounded extremely attractive about pellets being inserted into my prostate or ADT. So I decided against those and surgery and opted for external beam radiation, which I know from others who had it or were having it, that it was 40 treatments.

Of course, as with any discussion of a surgical procedure or medical treatment, came the discussion or “informed consent.” “Everyone is different and not everyone has these effects, but some of the side effects of radiation are urinary incontinence, blood in the urine, painful urination, diarrhea and erectile dysfunction. These are mostly temporary and medications can be given for erectile problems.” (Sorry, I have to keep it real). Just what I wanted to hear- feasible ways in which I could help keep the prescription drug industry viable! (insert sarcasm face). Well, this was starting to sound less attractive

I left that appointment determined to do more research in terms of pros and cons of radiation therapy. I knew I need to find people who had been through this type of treatment and glean from their experiences. To be continued…

As we continue to raise awareness for prostate cancer, please remember: Although there may not be a hard rule for screening, talk to your doctor about a PSA test if you’re between 45 and 55 years old. Screening should be done at 40-45 years of age for African Americans, Latinos or if there’s a strong family history.

THE GLEASON GRADING SYSTEM

Remember the numbers associated with my biopsy specimens? Let’s get back to those. During my phone conversation with the urologist before my vacation, I was told I had a “Gleason 6” staging. Or maybe I understood that in my mind. Remember this, it will be important later in the journey.

Normally the pathology report will list each specimen or “core” (named such because it’s a “core needle biopsy”) separately by a number assigned to it by the pathologist, with each core, having its own diagnosis. The cores are listed separately because If cancer is found, it’s often not in every core, so the each core has to be examined separately to accurately make a diagnosis.

Pathologists grade prostate cancers using numbers 3 or higher based on how much the cells in the specimens look like normal prostate tissue under the microscope. Grades 1 and 2 are not used. Instead, if the core sample present with cells that look normal, it is designated as “benign.” This is called the Gleason System. Most biopsy samples are grade 3 or higher.

Since prostate cancer specimens can often have areas with different grades, a grade is assigned to the two areas that make up most of the cancer. These two grades are then added together to give the Gleason Score. In this system the higher the number, the more likely the probability of spread and thus the higher stage the cancer. The highest a Gleason sum can be is 10. Recall that the numbers are designated as a sum: 3+3, 3+4 or 4+3. The first number assigned is the grade that is most common in the specimen. For example, if the Gleason score is written as 3+4=7, it means most of the tumor is grade 3 and less of it is grade 4, and they are added for a Gleason score of 7. This sum can also be designated as 4+3=7. Although this is the same Gleason score, most of the cancer is grade 4, which is obviously higher. If a tumor is all the same grade (for example, grade 3), then the Gleason score is reported as 3+3=6.

Although most often the Gleason score is based on the two areas that make up most of the specimen, when a core sample has either a lot of high-grade cancer or there are three different grades including high-grade cancer, a higher score is determined to reflect the aggressive nature of the cancer.

The other significant part of the pathology report, besides the Gleason score is the volume of each specimen. This basically refers to the percentage involvement that each specimen is affected by cancer. For instance, one of my specimens, the one graded at 3+4, had 50% volume. And one of the 3 + 3 specimens had 40% volume. These are consistent with a possible greater involvement of the prostate gland and a greater possibility of spread.

This certainly was a cause for concern. However, I already knew from the scans that there was no spread. Next stop: Treatment Plan.

As we continue to raise awareness for prostate cancer, please remember men: Although there may not be a hard rule for screening, talk to your doctor about a PSA test if you’re between 45 and 55 years old. Screening should be done at 40-45 years of age for African Americans, Latinos or if there’s a strong family history.

THE SCANS

So what’s it like to hear you have cancer right before a vacation? Well, let’s just say that it wasn’t in my bucket list.

After our vacation, came the follow up visit. As it had already been related to me, I would need some diagnostic studies to rule out any spread. Oh yeah, I guess this is a good time to say that I’m a doctor and I was very familiar with all these steps. Familiarity, however, didn’t add any level of comfort. It did however, allow me to cut out the middle man and schedule my own tests! In my sense of losing control I needed to feel like I still had some, even if it was in my own head.

As I laid motionless on the hard, cool table for the bone scans, I could see my images on the screen and immediately knew there was no spread. I guess my knowledge was helpful in this case. But I also knew that the next step involved a discussion of treatments. And I knew that I was facing radiation or surgery. However, I thought for a moment how someone in my shoes would feel if they didn’t have the medical knowledge that I did. Would they feel lost, out of control and helpless? I think they would. Because in a way, so did I.

I guess I also have to share at this point the fact that my darling bride of 23 years was with me during these visits. It was very reassuring to know that I had her support. I told her she didn’t have to go with me but in a very assertive way, with a not so nice look she said, “shut up!” That made me happy.

To be continued…

THE BIOPSY

“Next stop, Biopsy,” said the conductor as the train pushed forward. Then the Tran came to an abrupt stop. As I de board, I enter into the urologist’s office for my biopsy appointment. This would be what’s called a core needle biopsy. For this procedure, the doctor uses a probe with a somewhat of a spring-loaded, thin, hollow needle to obtain specimens from the prostate gland. (I won’t go into all details).

When the trigger is pulled, the needle retrieves a small cylinder of prostate tissue called a core. This is repeated about 12 times to get several samples from different areas of the prostate. Yes, there’s local anesthesia involved. Besides some discomfort, it wasn’t horrible. I wouldn’t sign up for it again though!

Well, we were all set to go on vacation in three days and here I am, waiting on biopsy results! I didn’t really know if I wanted my results before or after our vacation. But in a way, I wanted to know what I was up against so that I could have some time away from the hustle and bustle to gather myself and get mentally prepared for what was coming up. After moments of contemplation, I decided to bite the bullet and call for my results two days before our trip. Well, when I called, I was transferred to the doctor’s assistant. “Hi Mr Araujo,” said the nice assistant. Her voice was friendly and chipper. This could only be good news, right? Could this be a sign for optimism? I didn’t find out because I was told the doctor would have to call me in the morning. Ugh!!!!

So I get a call in the morning. Not only was I told the results, but I was also e-mailed the report. In a matter of seconds I felt like had just entered the twilight zone! I don’t remember anything else that was said but I could probably reel off what the pathology report read. What I remember most vividly, was the word “adenocarcinoma.” Adenocarcinoma is the type of cancer that develops in gland cells and is the most common type of cancer found in the prostate gland.

50% of the biopsy specimens were positive for adenocarcinoma. There were numbers

associated with each biopsy specimen that appeared in the following manner: 3+3=6 which were most of the core specimens. One however, had the numbers 3+4=7. The others were labeled with what became my favorite word, “benign.” I was also told, as I would’ve expected, that I would need to have a bone scan and MRI to check for possible spread. Yes, I had now entered into the cancer world. The only question was, how deep?

Wow! This was a lot to take in right before a vacation! But I just needed to know so that I could at least use a few days off to process this information.

To be continued…

The Start Of A Journey

About two months ago we embarked on a new journey. Although, I got ticket for this ride when I was by myself, it became apparent rather quickly that this would be a trip for two. A journey or a trip usually implies something new and exciting. Although we are experiencing something new, it’s not necessarily exciting.

There’s no better place to start other than the beginning. So here it goes:

I just recently had my first physical in at least 13 years! Yeah, yeah I know. This in spite of the fact that there’s a strong history of prostate cancer in my family. Well, the same evening of my physical and blood work, I received a call from the doctor’s office advising me that I would need to call to schedule an appointment “to go over the blood work.” That’s never a good sign.

Well, I called the next day, which happened to be a Saturday, and was told I could walk in. I was told that my PSA was elevated. For those of you that don’t know, the PSA stands for “prostate- specific antigen.” which is a protein produced by both cancerous and non cancerous cells in the prostate. There is normally a small amount of this protein in the blood, so the PSA blood test is a screening tool for possible prostate cancer.

Back to my PSA. It was 16 ng/mL. To put this in perspective, a range of 0-2.5 ng/mL is considered a safe zone. This however, can vary a little by age. Anything over 4-5 ng/mL will most likely be followed by a discussion with a medical provider. So obviously there was cause for concern. Was my father’s history of prostate cancer making its fateful appointment with me? I was told that an appointment would be made for me with a urologist. After an initial visit and a repeat PSA blood test, my value was still high, 14 ng/mL. Now came the moment of truth: “We’ll have to do a biopsy.” Each stop on this ride became a little more serious and a little more surreal.

If you’re a man between the ages of 40-50, please get a physical and a simple PSA blood test.

To be continued…