If all goes as planned, I will, in fact, be going under the knife on Monday morning. They will come for me here at the National Institutes of Health (NIH) in Bethesda, Maryland at about 7:00 a.m. By 8:00, I will be under anesthesia, and they will be positioning me – head down and feet up – on the operating table. Then, they will make seven small incisions in my abdomen, insert cameras and devices for cutting and sowing, and the fun will begin – as my surgeon, Dr. Peter Pinto, sits down at the Wurlitzer in the corner and begins the process of removing my prostate and the lymph nodes associated with it.
I am already on a clear-liquid diet, and the dread “bowel prep” looms on the horizon. I have had an EKG, an Echo Cardiogram, a chest X-ray, and a pulmonary exam, and I have spent the last couple of days cooling my heels in the hospital, working on my book on Sparta, and contemplating mortality. The odds are excellent that I will emerge from this ordeal incapable of further procreation but otherwise intact and cancer free. There can, of course, be “complications,” and none of them are pretty. Some of them you can die from. Others leave you impotent in the fullest sense of the word or permanently incontinent. It all depends on your health in all of its aspects when you go under the knife, on the effectiveness of the antibiotics, and on the skill of the surgeon. I will not tell you that I am glad that I am here. But a prostatectomy is a bit like old age. It is not so bad when you consider the alternative.
The truth is that I am lucky. One of my cousins, on my mother’s side, died of prostate cancer when he was in his early to mid-60s, as I am now. My brother had his prostate out nearly two decades ago when he was my age, and he is still going strong. If this operation goes well and Dr. Pinto removes all of the cancerous tissue, the odds are good that I, too, will still be alive and kicking in my 80s. Apart from chronic asthmatic bronchitis, for which there is now medical help, there is nothing else wrong with me.
But the real reason that I am lucky is that my condition was diagnosed early on. As longtime Ricochet regulars who read my post Prostate Cancer: New Procedures for Diagnosis – and Cure back in April, 2011 may remember, my Prostate Specific Antigen (PSA) level was quite low (ca. 1.07) but took a jump between December, 2009 and December, 2010 and was on track to double within an eighteen-month period – which can be a sign not only that one has cancer but that it is aggressive. Mindful of my family history and concerned about the welfare of my wife and our four young children, I called a distinguished urologist whom I have known since childhood and asked his advice. He consulted Dr. Pinto, who then invited me to join a study he was directing. Here is what took place in March, 2011:
On day one, the staff at the Molecular Imaging Program subjected me to trans-rectal Magnetic Resource Imaging (MRI) with Gadolinium. This involves the insertion of an endorectal coil into the rectum, the inflation of a balloon to hold it steady, and the introduction of an intravenous contrast material into one’s veins. In the course of the MRI, one is slid into a machine that produces a powerful magnetic field – where, from time to time for about an hour, one is assaulted by radio frequency pulses. With the help of sophisticated software, the technicians who operate the machine can produce a detailed picture of the prostate. And here is the kicker – if you have cancer, it shows up as a splotch in the picture, and those working with these procedures can grade any splotches they see with an eye to the likelihood that they are cancerous.
If nothing suspicious is found in the course of the MRI, that is the end of the story. If, however, there are suspicious splotches, one returns to NIH on day two to have a biopsy, which was my fate. Using sophisticated software, the technicians initially map the picture of the prostate produced by the MRI onto the picture produced by ultrasound. Then, guided by these images, a surgeon, performing the biopsy, samples the precise places where the MRI found suspicious splotches. To supplement this procedure, he then performs an ordinary biopsy, taking samples from the twelve sectors into which the ultrasound divides the prostate.
The first set of procedures is not a joy, but they are considerably less unpleasant than a colonoscopy; the second set involves some discomfort, but, at NIH, they use novocaine to deaden the prostate and reduce the pain. In my case, the MRI team identified five suspicious patches – three of them moderately likely to be cancerous, two of them worrisome but much less likely to be malignant. The biopsy revealed two minuscule patches that were cancerous. Each made up something like 2% of the biological material in the particular sample taken. In neither case was there any indication that the cancer is aggressive.
A year later – which is to say, this past March – I underwent another trans-rectal MRI. To all appearances, nothing had changed. Then, I underwent another targeted biopsy. This time, in a number of the samples, 50% of the biological material taken turned out to be cancerous. A couple of weeks after the biopsy, Dr. Pinto called to inform me of the results and to recommend intervention. Given my age (actually, he thought that I was in my early fifties) and my health, he thought that surgery was the best of the options now available, and he urged me to act soon. “Do it within six to nine months,” he said. “I would not wait a year.” I scheduled surgery with him at the first available opportunity.
There is a debate going on within the medical community concerning the PSA test. It is not an especially accurate indicator of cancer, and some think that too many biopsies are done and too many men have their prostates removed. Others, including people here at NIH, are firmly of the opposite opinion. They contend that, in the last quarter-century, there has been a dramatic drop in the number of deaths from prostate cancer. The reason appears to be that PSA testing, digital rectal testing, and biopsies – when these techniques are all in play – often enough enable physicians to detect aggressive prostate cancer early on. And, when early detection is followed by surgery or radiation, they can usually stop the cancer in its tracks.
The new techniques, being pioneered by Dr. Pinto and his team here at NIH, promise to identify the tissue that is suspect and to enable those conducting biopsies to hone in on the suspect tissue. When these techniques are sanctioned for general use, they should make early diagnosis easy, and they should then even more dramatically reduce the number of deaths resulting from prostate cancer.
Tomorrow, if I do not die under the knife, the odds are good that Dr. Pinto will remove everything that is cancerous and that I will get a new lease on life. I owe the fact that the odds are on my side to vigilance on the part of physicians and on my part. If the powers that be succeed in striking the directive that causes physicians to administer the PSA test on men over the age of fifty as a matter of routine and you are such a man, you should exert yourself and insist on having the test done, and – if there is any indication of danger – you should have a biopsy. In my case, the indications were not strongly indicative. At the time of my first biopsy, my PSA had actually dropped from its mildly but suddenly elevated level. And last December, though it had gone up a little, there was no dramatic change. If I am alive in five years, it will be because I was alarmed when I got the news in December, 2010.
One further word of warning. Genes may not be destiny, but, in these matters, they come pretty close to having that status. Know your family history, and take precautions. My father died of pancreatic cancer at the age of seventy-eight. Perhaps by the time I reach that age, there will be a regimen of treatment for that. If I get past this crisis, I will be alert.