A 23-Month Prostate-Cancer Anecdote

BACKGROUND

In May 1994, I learned the value of PSA testing from a Scientific American article [1] and from conversations with friends; and at age 56 I was diagnosed with Prostate Cancer. PSA 9.5, Gleason 7, post-biopsy staging B2. CAT and bone scans were clean then, as was an MRI a year later. The most realistic estimate, accounting for habitual understaging, that the tumor was organ-confined was 70%. I was confident of this estimate.

THERAPY OPTIONS

I accepted all of the following as options for therapy.

1. Immediate Radical Prostatectomy, recommended by two urologists.
2. Immediate cryosurgery, recommended by a third urologist.
3. Combined hormonal therapy for six months to a year, followed by a reevaluation. This option arose in conversations with PCa survivors and in the literature [2, p. 1000]. No physician volunteered this approach.

THERAPY NON-OPTIONS

I rejected all of the following as therapy options for the reasons given.

1. Immediate EXRT, explained by a radiotherapist without recommendation. Irradiation seemed an unwise wager at age 56 [4].
2. Seed implantation, recommended by none. In 1994, this option seemed to me even less suitable than EXRT.
3. Proscar, Hytrin, Casodex: I hadn't heard of these compounds, so couldn't judge.
4. Orchiectomy, which I judged inappropriate at my age.
5. Combined hormonal therapy -- Lupron plus flutamide -- for life. One urologist volunteered this therapy without recommendation. I thought this equivalent to Orchiectomy, and thus unsuitable.

THERAPY CHOSEN

I elected combined hormonal therapy for a finite period -- option 3 -- to begin in September 1994 and to proceed until some indefinite date in the future (it turned out to be August 1995). All three urologists with whom I was speaking went along with this choice, none enthusiastically. My reasoning was that Combined Hormonal Therapy could do no harm (it would halt the tumor's progress); and that it could help (it might shrink the tumor).

In August 1995, I underwent a radical retropubic Prostatectomy.

CHT SIDE EFFECTS

The obvious side effects of Combined Hormonal Therapy were these:

1. Utter and complete loss of libido.
2. Joint pain.
3. General weakness, lethargy, and tiredness with a concomitant 20% loss in work productivity.
4. 10% weight gain from 200 pounds.
5. Hot flashes.
6. Breast enlargement (a cancer-survivor friend very kindly observed that I managed to develop a "pretty good-looking B cup").
7. Perhaps some depression.
8. Some diarrhea.

SUMMARY OF THERAPY OUTCOME

Almost immediately after beginning CHT, my PSA fell to 0.2 or below and stayed there. A digital rectal exam in early 1995 revealed that the tumor seemed no longer palpable and that the gland was smaller than before. With respect to PSA values, one can believe that "PSA becomes an unreliable indicator of disease status after initiating preoperative androgen deprivation therapy." [3]; [5].

After the RP (Radical Prostatectomy), the surgeon confirmed that the gland was very small indeed; and that this had helped to make it easy to save one sphincter, more of the urethra than expected, and the nerves on one side. He could feel the tumor on removing the gland, but thought that the margins would be negative.

The pathologist reported that the gland had atrophied; that no tumor was evident in the gland; and that the margins were negative.

VERBATIM PATHOLOGY REPORT

Final Diagnosis

A,B,C,D. RIGHT AND LEFT LYMPH NODES: LYMPH NODES NEGATIVE FOR TUMOR.

E. PROSTATE: PROSTATE ATROPHY CONSISTENT WITH ESTROGEN THERAPY. NO RESIDUAL TUMOR SEEN.

*** Signed Copy on File ***
[first pathologist's name]
08/10/95/LMM

Clinical History: Prostate CA
Intra-Operative Consultation: No Tumor seen in left and right nodes.
[second pathologist's name]
Gross Description: Received in formalin in five parts.

Specimen A labeled "right nodes nfs" consists of multiple yellow-tan adipose tissue measuring 5.5 x 4.5 x 3.5 cm. in aggregate and serially dissected to reveal multiple lymph nodes. Entirely submitted in A1-2.

Specimen B labeled "right nodes fs" consists of three irregular yellow-tan rubbery tissue fragments measuring 2.1 x 1.9 x 1.1 cm. in aggregate. Entirely submitted in B1.

Specimen C labeled "left nodes fs" consists of three yellow- tan irregular rubbery tissue fragments measuring 2.5 x 2.1 x 0.9 cm. in aggregate. Entirely submitted in C1.

Specimen D labeled "left node nfs" consists of multiple irregular yellow-tan adipose tissue measuring 3.5 x 3.1 x 2.1 cm. in aggregate. The specimen is serially dissected to reveal multiple lymph nodes entirely submitted in D1-2.

Specimen E labeled "prostate" consists of one previously inked and cut prostate measuring 4.1 x 3.7 x 1.9 cm. and weighing 12 grams. The right side of the prostate has been previously inked in red and the left side has been inked in green. The specimen is serially sectioned to reveal multiple white-gray ill demarcated nodules in the left and right lobes with the largest measuring 1.1 cm. in diameter. The right seminal vesicle measures 2.1 x 1.1 x 0.9 cm. The left side measures 2.4 x 1.1 x 0.8 cm. Section codes; E1, apex resection margin; E2, bladder neck resection margin; E3-7, right lobe of prostate; E8-13, left lobe of prostate, entirely submitted.

LMM JXZ/JXZ

CONCLUSIONS

The biggest conclusion, and the most surprising, is that, given the hindsight provided by the pathology report, perhaps no operation was necessary as shown by the state of the gland. However, I would not have been comfortable without some kind of mechanical intervention, even had I known about the state of the gland. I would probably have chosen the RP regardless even of knowledge certain about the tumor.

So, for me in this particular set of circumstances, a year of CHT helped to:

1. ease the subsequent Radical Prostatectomy and enhance its effects;
2. ensure negative margins; and
3. perhaps effect a cure, as I now think possible.

However, I must also conclude that an entire year of CHT was too much; the same effects might have been accomplished in six months or less. But two studies [3,5] show that three or four months of CHT is likely ineffective in reducing tumor mass.

LONG-TERM PSA LEVELS, EVENTS, MORBIDITIES, AND OTHER EFFECTS

Events, Morbidities, and Other Effects

Short-Term Effects

1. Catheter Out: 19 days postRP.
2. Continence: 95% continent one month postRP; 99.9% continent eight months postRP.
3. Urinary Strictures: Some apparent a few weeks postRP, but these proved to be transient.
4. Driving: Driving two weeks postRP; MD OK to drive three weeks postRP.
5. Lifting: No lifting for eight weeks postRP.

Back to Work

I was nearly 58 at RP time and reasonably healthy, though far from fit. They make you walk the day after the RP. I walked all I could -- 3 or 4 times a day. That really helped, I think. Very important for me. So I was comfortable walking when I was discharged. I was driving some two weeks after the RP; the doc said it was OK to drive three weeks after the RP.

I work for myself so really had to work. But I didn't want to go to work with an embedded catheter; I waited the nearly three weeks (postRP) for the catheter to come out. I thought I could go back to work then.

It wasn't so. I actually did show up at work, but couldn't do much. I really hadn't the stamina to do anything. And I couldn't stay awake (well, no surprises here). The incontinence didn't bother me (pads took care of that) and my gut was pretty comfortable (I wore sweatpants to the office). But I just couldn't get and keep going. It really was eight weeks before I was anywhere near normal, and I felt the effects of the RP (diminishingly) for six months. I had to sleep 10 or 12 hours each day. It was a bitch.

I do not know what I could have done to change things. There might be something one can do to restore his stamina quickly, but I've no idea what. Long-Term Effects

1. Libido: Barely noticeable until four months postRP (that is, four months after the cessation of CHT), when it returned as before.
2. Potency: Completely impotent eight months postRP.
3. Orgasms: As strong, pleasurable, frequent, and easily achieved as ever, even in the absence of potency. Impotence has had absolutely nothing to do with orgasms one way or the other. Neither does the absence of ejaculate have any effect; in fact, I'm told this is a plus.

REFERENCES

1. Marc B. Garnick, "The Dilemmas of Prostate Cancer," Scientific American, April 1994, pp. 72-81. A clear, straightforward overview of the disease and strategies to diagnose and combat it. Required reading for the layman age 40+.
2. William J. Catalona, "Management of Cancer of the Prostate," New England Journal of Medicine, Vol. 331, No. 15, 13 Oct. 1994, pp. 996-1004. An overview of treatment strategies. Required reading for the newly-diagnosed patient.
3. Joseph E. Oesterling et al., "Preoperative Androgen Deprivation Therapy: Artificial Lowering of Serum Prostate Specific Antigen Without Downstaging the Tumor," The Journal of Urology, Vol. 149, April 1993, pp. 779-782. The study shows that PSA level is a poor indicator of the state of the tumor after CHT begins; and that very-short-term CHT (one to four months) may reduce the volume of the gland by about 25% but has little or no effect on tumor mass.
4. Thomas A. Stamey et al., "The Value of Serial Prostate Specific Antigen Determinations 5 Years After Radiotherapy: Steeply Increasing Values Characterize 80% of Patients," The Journal of Urology, Vol. 150, Dec. 1993, pp. 1856-1859. The study concludes that external-beam radiotherapy fails within five years in 80% of patients with clinical stages A to D1 prostate cancer.
5. Mark S. Soloway et al., "Androgen Deprivation Prior to Radical Prostatectomy for T2b and T3 Prostate Cancer," Urology (Supplement), Vol. 43, No. 2, Feb. 1994, pp. 52-56. The study concludes that very-short-term CHT may reduce the volume of the gland by as much as 33%, but has little or no effect on the mass of the tumor.