I am writing this at the end of May, 2012, and I am, as of early March, seventy years old.
To go back to the very beginning, in chatting with a slightly older friend six or seven years ago, the topic turned to health matters, and my friend stated that at our age it's essential to have an annual physical check up, and that he certainly did without fail. That started me thinking that I hardly remembered what my G.P. (family physician) looked like, let alone his location. Not having had any health issues for as long as I could remember, and not being reminded of preventive maintenance in the manner of dentists, I had simply not bothered with routine visits. So I took the initiative and lined up an appointment with my doctor, and went through the process of the complete physical. This naturally incorporated the normal prostate checks - the PSA blood test and the DRE (digital rectal exam). My G.P., who was on the verge of retirement, did not like the combination of the elevated PSA and a slight irregularity he felt in the DRE, so he referred me to a urologist. The urologist, who was, in my view, pretty young for a specialist, but seemed very knowledgeable and confident, went through much the same procedure; and upon reaching the same conclusion, ordered a biopsy: a singularly unpleasant experience involving an ultrasound device which scans the prostate rectally and removes eight samples of tissue.
That was in the fall of 2006 and the results of the biopsy were negative. However, I was now on the urologist's watch list, and an annual recall was arranged. When we went through the exam again in the late fall of 2007, he determined that I should have another biopsy. That was scheduled for January 2008, and another meeting was arranged to discuss the results. This time the biopsy was positive in a couple of samples. He then asked me to schedule another appointment which would be at the end of his working day. The timing was set so that we would have no time constraints on the meeting, in which he could go over my options. He asked me to bring my wife to this session and to prepare for it by assembling all possible questions that we might have concerning the situation.
In the intervening period I did some intensive research on the topic of prostate cancer treatment and discussed it in detail with Elaine. We determined that there were three viable options, and a number of others, such as HIFU, which bore little serious consideration. The three were: radical prostatectomy (surgery), brachytherapy (radiation), or wait and watch. Hormone treatment was a possible supplement to the third option, but with significant side effects and not, in our judgment, a viable long term solution. I had determined that although standard open surgery was likely the most common and largely successful treatment, there had been a relatively new system of robotic laparoscopy developed, which looked like a very promising variation on the surgical theme. Although it was readily available in the larger population centers of the U.S., it had not penetrated significantly elsewhere, and was brand new that fall in Vancouver. The da Vinci robot had by this time proved to be very successful in minimizing trauma and recovery time for what are a series of highly invasive procedures, including prostate removal. The more I studied it, the more convinced I became that it was what I wanted, and with a system working at Vancouver General Hospital, it looked like a real possibility.
In any event, the interview with the urologist came and went, and he, being a surgeon, indicated his bias and recommended surgery. However, he insisted that we get a comparably biased opinion from a radiologist, and referred us to the B.C. Cancer Clinic for the radiological consultation. That took place in late March, and answered a lot of our uncertainties and concerns about brachytherapy, which implants tiny radioactive seeds in and around the cancerous tissue. We found the radiologist very open and easy to relate to, and when we suggested that our ultimate preference was for the da Vinci system, his response was to refer us to the principal surgeon associated with the system. We had not dreamed that access to the best of treatments could be so readily attained. What follows is a series of emails I sent out to friends and family on my progress, starting with one immediately after meeting Dr. Larry Goldenberg.
May 2, 2008
When events start taking shape, they can sometimes work faster than we expect.
Elaine and I went to the Prostate Centre this morning (the interview with Dr. Goldenberg had been moved ahead from May 9) with the expectation that we would be told that the robotic laparoscopic surgery as an option was available in a few months, and that we would go home and think about it. I was hoping for this outcome, so that I would then have the option to consider whether I wanted to wait or go ahead with the brachytherapy within the next month. Having been offered the standard open surgical option effectively within 2-3 weeks if I decided to go that route at Lion's Gate Hospital, I had more or less decided that I would prefer to check out the other options and choose open surgery as a fall back if the others were not available or seemed more hazardous.
I had pretty well formulated a game plan that if the wait for the robotic system was more than four months, then I would go for the brachytherapy in order to avoid the increasing chance of the cancer spreading in the meantime. So when I was offered the robotic surgery in July, it was a pleasant surprise, but still offered the chance to think about it. When time came to book it, there was an opening for May 27, but I had to decide on the spot. It took all of a couple of minutes, but it wasn't difficult. So I am booked, and in the meantime I am to participate in a clinical test of a new oral drug - enzastaurin - the efficacy of which will be judged by the effect on the cancerous tissue of my prostate upon removal. Anyway, the really good news is that the da Vinci robotic system is available locally, and getting referred to it was just a matter of asking.
I'm still working on getting used to the accelerated schedule, but it's all to the good.
May 30, 2008
The procedure went better than planned, and I have been home since Wednesday evening (May 28th), with high expectations of being back to normal (minus a prostate) within a month.
My surgeon, Larry Goldenberg, and the da Vinci system lived up to their star billing, and although all I saw was a lot of equipment in the operating theatre before going under, the after effects have been as benign as expected, with some unexpected bonuses. On the day before, I was advised that I had been moved from second place that day to first place, so I had to be at VGH a little before 0600. I was offered a private or semi-private room at extra cost, and I declined - and then I wound up with a room to myself with a fabulous view on the 10th floor (the question should have been not whether I wanted a private room, but whether I wanted to pay for one). Then being in it for barely 24 hours was mind boggling. Even the urology resident prescribing my painkillers turned out to be a gorgeous blonde!
The night in hospital was fitful, but without much pain, and back home I am sleeping normally, only more, and eating like a horse. I am on a catheter for a week while the severed urethra grows back together again, and then it's just a matter of avoiding strenuous activity for a while, which I tend to do anyway (let the young folk do the work!). Other than the five small incisions through which the work was done, there is no visible after effect, and I don't even have any sutures - the incisions are small enough they aren't worth stitching or stapling.
The pathology results should be interesting, since the clinical test of the drug, enzastaurin, in which I participated, may have cured the cancer anyway. But in any event, the surgeon tells me that my prostate was quite large, so its removal is a plus in terms of bladder discomfort.
June 8, 2008
Twelve days post-op, and while not
quite back to normal, recovery is progressing at a rate where I am
confident that within a month it will all be a distant memory. The
catheter came out last Wednesday (8 days post-op) after a cystogram had shown
that the bladder was fully functional. The initial relief was
somewhat tempered by the disappointment of peeing myself on the way
home, but my initial reaction with plastic underlay and towels in bed
proved to be unwarranted. It turns out that bladder control is a
matter of preservation of the nerves controlling the sphincter (they
are intact), and practice and exercise beyond that. In the eight days
with the catheter, the sphincter assumes that the relaxed condition is
normal and has to be coaxed into the reverse attitude. So far it
looks like my determination not to consume more than the original
package of 20 absorbent pads may be vindicated.
The visible impact of the surgery is a 2 centimetre scar above my navel, and the other four incisions are virtually invisible - and certainly hard to find. Imagine the comparison to standard open surgery, where there would be one incision from navel to pubis - at least 15 cm long. It's hardly any wonder that recovery time, blood loss, and pain involved are minimized by the da Vinci system.
The latest word from my surgeon, Dr. Goldenberg, is that the pathology results showed that the cancer had progressed to one edge of the prostate, so the timing of its removal may have been critical. I am scheduled to meet him later this month for an update on the clinical study of Enzastaurin, and again in three months time for further evaluation - including a PSA test. I had thought that removal of the prostate would eliminate any further interest in or presence of prostate specific antigen, but that is apparently not the case.
That seems to be the end of the story - a very positive outcome in a remarkably short time, with minimal discomfort along the way.
The visible impact of the surgery is a 2 centimetre scar above my navel, and the other four incisions are virtually invisible - and certainly hard to find. Imagine the comparison to standard open surgery, where there would be one incision from navel to pubis - at least 15 cm long. It's hardly any wonder that recovery time, blood loss, and pain involved are minimized by the da Vinci system.
The latest word from my surgeon, Dr. Goldenberg, is that the pathology results showed that the cancer had progressed to one edge of the prostate, so the timing of its removal may have been critical. I am scheduled to meet him later this month for an update on the clinical study of Enzastaurin, and again in three months time for further evaluation - including a PSA test. I had thought that removal of the prostate would eliminate any further interest in or presence of prostate specific antigen, but that is apparently not the case.
That seems to be the end of the story - a very positive outcome in a remarkably short time, with minimal discomfort along the way.
July 19, 2008
On the advice of the
surgeon, with whom I shall meet again in September, I made an
appointment with the oncologist to assess the continuing risk of the
cancer having spread beyond the prostate. Prior to the meeting I had
a PSA test - which should have indicated if there was any residual
cancer that would then have to be dealt with by radiation. The PSA
was below the detectable limit, so it appears that I am home free -
at least for the time being. However, PSA will require continual
monitoring, and is not 100% reliable. The oncologist indicated that
some patients opt to have radiation treatment anyway, to reduce the
chance of the cancer persisting. Like all the treatment, it only
reduces the chance of cancer recurring (by about 50%) - there is no
guarantee with any option, and there is likelihood of minor side
effects such as fatigue, minor loss of urinary control, etc. My
response was that I would rather do without it. Having managed to
live without dependence on medication of any sort for this long, I
would prefer to return to avoidance of medical intervention once more
for as long as I can.
Otherwise, I am back to pretty well all normal activity and then some - now if only I could locate that elusive fountain of youth...
A couple of concluding comments may be appropriate. First and foremost, I firmly believe that attitude has a huge influence on all aspects of life, and especially health. A positive attitude is necessary to be able to apply the discipline required in the maintenance of a healthy lifestyle and consequent overall fitness. And of course, physical fitness is a huge factor in overcoming the impact of any trauma, especially surgery. A positive attitude may not save one's life, but it certainly improves the odds.
A number of associated hazards need to be recognized and faced. Two which the physicians certainly stress are the likelihood of incontinence and erectile disfunction. These are of differing and variable importance to each individual, and somewhat age dependent. In my view, when one's life is on the line, they are relatively minor considerations, but others may see it differently. In any event they are somewhat dependent on the extent of the cancer and avoidance of nerve damage during surgery. Again, in my opinion, intuitively, I maintain that the likelihood of nerve damage is substantially reduced with the robotic system where the surgeon is comfortably seated at a console and has perfect control over the motion of surgical instruments. My outcome was positive on both counts in spite of repeated warnings that some nerve damage was likely because of the location of the tumor. I attribute that success to the combined skill of the surgeon and the capability of the robot.
Closure
At my last session with Dr. Goldenberg on June 17, 2013, when we agreed that after five years of monitoring and post surgical consultation I no longer needed his level of expertise, I was passed on to my G.P. for further minimal monitoring with no further specialist input unless there was an unfavorable development. At that time I asked him how intensive the utilization of the da Vinci system was in light of the newly imposed patient levy for robotic laparoscopy. He indicated that it was not heavily used at all, and needed all the promotion it could get: he asked me to write to the Ministry of Health in an effort to lobby for this obviously cost effective system. My email exchange on the matter is in another blog.
Epilogue - May 2018.
In the fall of 2015 I had a call from Dr. Goldenberg's office to arrange an appointment to see him. I was a touch surprised at this initiative, but arranged an appointment in December, preceded by a PSA test for which they sent me a requisition. At our meeting I neglected to ask what the recall was about. I filled in a standard form, which queried my health generally and urinary system specifically, including sexual function. I answered all in a very positive manner, and spent about ten minutes with the doctor who seemed satisfied with my condition, and I thought nothing more of it. About a year later, I went through the same experience, and again I thought nothing of the summons, and had another pleasant chat with Dr. Goldenberg, who seemed pleased with my state. This year, I responded to the same summons, and went to see the doctor a month ago, for a morning appointment after another insignificant PSA test. However this time, I cooled my heels for the best part of an hour in his reception area, having had to go to some exertion to make it on time for the appointment. This provided plenty of time to reflect on why I was here, and whether it was worth the effort. In any event, after three quarters of an hour, I went to the receptionist and asked her to pass on a message to Dr. Goldenberg that I had decided that I should really stick with our agreement of five years ago, and not take up his precious time with pointless visits. She was quite incredulous that a patient should have the temerity to cancel an appointment with a specialist physician, but I pointed out that it was simply in line with a prior agreement, and I did not need his further assurance that all was well.
I must admit that I feel a bit embarrassed about not having queried these appointments all along, and I blame it on having fallen into the trap of putting too much trust in the medical system, and not being sufficiently critical and inquisitive. I submit that if I had been subject to even a minimal fee for any such interaction, I would not have been so passive in accepting the doctor's summons.
Otherwise, I am back to pretty well all normal activity and then some - now if only I could locate that elusive fountain of youth...
A couple of concluding comments may be appropriate. First and foremost, I firmly believe that attitude has a huge influence on all aspects of life, and especially health. A positive attitude is necessary to be able to apply the discipline required in the maintenance of a healthy lifestyle and consequent overall fitness. And of course, physical fitness is a huge factor in overcoming the impact of any trauma, especially surgery. A positive attitude may not save one's life, but it certainly improves the odds.
A number of associated hazards need to be recognized and faced. Two which the physicians certainly stress are the likelihood of incontinence and erectile disfunction. These are of differing and variable importance to each individual, and somewhat age dependent. In my view, when one's life is on the line, they are relatively minor considerations, but others may see it differently. In any event they are somewhat dependent on the extent of the cancer and avoidance of nerve damage during surgery. Again, in my opinion, intuitively, I maintain that the likelihood of nerve damage is substantially reduced with the robotic system where the surgeon is comfortably seated at a console and has perfect control over the motion of surgical instruments. My outcome was positive on both counts in spite of repeated warnings that some nerve damage was likely because of the location of the tumor. I attribute that success to the combined skill of the surgeon and the capability of the robot.
Closure
At my last session with Dr. Goldenberg on June 17, 2013, when we agreed that after five years of monitoring and post surgical consultation I no longer needed his level of expertise, I was passed on to my G.P. for further minimal monitoring with no further specialist input unless there was an unfavorable development. At that time I asked him how intensive the utilization of the da Vinci system was in light of the newly imposed patient levy for robotic laparoscopy. He indicated that it was not heavily used at all, and needed all the promotion it could get: he asked me to write to the Ministry of Health in an effort to lobby for this obviously cost effective system. My email exchange on the matter is in another blog.
Epilogue - May 2018.
In the fall of 2015 I had a call from Dr. Goldenberg's office to arrange an appointment to see him. I was a touch surprised at this initiative, but arranged an appointment in December, preceded by a PSA test for which they sent me a requisition. At our meeting I neglected to ask what the recall was about. I filled in a standard form, which queried my health generally and urinary system specifically, including sexual function. I answered all in a very positive manner, and spent about ten minutes with the doctor who seemed satisfied with my condition, and I thought nothing more of it. About a year later, I went through the same experience, and again I thought nothing of the summons, and had another pleasant chat with Dr. Goldenberg, who seemed pleased with my state. This year, I responded to the same summons, and went to see the doctor a month ago, for a morning appointment after another insignificant PSA test. However this time, I cooled my heels for the best part of an hour in his reception area, having had to go to some exertion to make it on time for the appointment. This provided plenty of time to reflect on why I was here, and whether it was worth the effort. In any event, after three quarters of an hour, I went to the receptionist and asked her to pass on a message to Dr. Goldenberg that I had decided that I should really stick with our agreement of five years ago, and not take up his precious time with pointless visits. She was quite incredulous that a patient should have the temerity to cancel an appointment with a specialist physician, but I pointed out that it was simply in line with a prior agreement, and I did not need his further assurance that all was well.
I must admit that I feel a bit embarrassed about not having queried these appointments all along, and I blame it on having fallen into the trap of putting too much trust in the medical system, and not being sufficiently critical and inquisitive. I submit that if I had been subject to even a minimal fee for any such interaction, I would not have been so passive in accepting the doctor's summons.
