My Radiation Therapy: Discovery as well as Watchful Waiting

This is the first part of a guest series written by Dr. Andrew Karam. As I’m writing this I am in the middle of a series of daily radiation exposures that’s beingused to treat prostate cancer; by the time I finish this series my radiation therapy oughtto be finished (or nearly so). The reason for writing this as a series is that, in the sixyears since I was first diagnosed with prostate cancer a lot has happened – diagnosis,biopsies, MRIs, blood tests, two urologists, and more – to try to cover all this ground inone shot would make for a long post or I’d have to leave out a lot. So…a series! This my first time having cancer so all of this has been new to me and I’ve beenconfused, irritated, curious, scared, and much more; and many of my family and friendshave had their own questions and concerns. One thing I’m hoping I can do here is to tryto support others to better understand how the process works, how the devices work, why Idecided to simply watch it for several years, then to go with radiation therapy instead ofsurgery, and so forth. Finally (for this introduction) I’ve got to say that I’ve had it easy compared to people I’veknown who had some of the nasty, aggressive cancers, who had to undergo chemoand/or radiation treatments that left them weak, exhausted, and puking their guts out,and whose hopes of survival were slimmer than mine. Compared to so many, I’ve had iteasy – but I can only write about what I’ve experienced. And with that, let me get startedwriting about how I found that I had prostate cancer, why I decided to go the “watchfulwaiting” route, and the various testing that took place between the first test and thedecision to treat the cancer. My cancer story starts with a trip to the cardiologist – based on family history, heartproblems seem much more likely to be an issue, but at the end of my cardiologyappointment, almost as an afterthought, the good doctor asked when I’d last beentested for my levels of prostate specific antigen (PSA). I told him I’d never had one doneso he added PSA to the list of tests to run. A few days later the results came back withslightly elevated levels. That’s the point at which I realized I had no urologist and noidea how to find a good one; my cardiologist suggested his and I made an appointment. Oh – I might opt to also mention that I live in New York City and there might well be enoughurologists here to populate many small towns – my doctor’s suggestion made it a loteasier to choose one (as did the fact that the urologist accepted my insurance!). About a month later I got in to see the urologist, who did a fairly thorough interview andexam, lubed up for a quick rectal exam to palpate my prostate, and talked about options. With a result of 6 (anything higher than 4 is considered something to keep an eye on) and only one test and exam there wasn’t a lot of data. I used to work in a medical radiation safety program as the Radiation Safety Officer so I wasn’t completely clueless – I knew, for example, that prostate cancer can fatal, but that it’s usually fairly slow-growing. As the Chief of Urology at that hospital put it, “Many more men die with prostate cancer than from it.” Anyhow – all things considered I felt that the top-tier strategy was to simply keep an eye on it with quarterly visits to the urologist, semi-annual PSA tests, and an annual biopsy – the first of which was scheduled a few weeks hence. My first biopsy was my first experience with prep for, well, just about anything involvingimaging, sampling, or treating the prostate. Due to its location, the prostate is close to the rectum and the bladder, getting the most effective results usually calls for adjusting thefullness of both – either full or empty with the bladder with the rectum as empty aspossible. Laxatives, enema, stool softeners – all of them were given as options; the bigthing was to not eat after midnight and to have a bowel movement an hour or so beforewhatever was being done. And since this first biopsy was a quick one, going through thewall of the rectum into the prostate, I needed to take antibiotics the day before, the dayof, and the day after the biopsy. The biopsy itself was pretty anticlimactic. Some local anesthetic kept it from beingpainful, but there’s really no dignified way to let someone put a sampling tool in one’srectum and punch a bunch of holes through the wall of the rectum to retrieve tissuesamples from the prostate. It took about a half hour from the initial numbing injection tothe final sample, and then I was sent on my way. A week or so later the pathologistreport noted that a small part of a single sample contained some cancer cells and a fewother samples showed cells that were part of the way on the path to cancer. An MRIshowed two nodules whose locations coincided with the problematic samples, whichwas sort of nice as it meant there didn’t seem to be anything that was hidden away. So Iwas concerned, but I didn’t see a reason to worry and the urologist agreed. This is the point at which I decided to tell my family and close friends what was goingon. On the one hand, I didn’t want to worry them unduly; on the other hand, I didn’t wantto hide something potentially key from them. Outside of family and close friends,however, I didn’t say much – I figured that, unless there was enough going on tointerfere with my work or my commitments to friends there wasn’t a could use to tell others –and I didn’t want to be treated differently by people just because I had a low-grade formof cancer. And that’s where it stood for the next five years or so…seeing the urologist, takingblood samples, and a biopsy every few years…. although as my PSA continued to rise (peaking at about 22) the biopsies changed to be precisely guided by MRI images and they were done through the perineum rather than through the wall of the rectum. At the same time, genetic sequencing showed that my particular cancer cells had a 28% probability of continuing to expand and that the cancer itself showed a small chance (about 5% or so) of metastasizing over time. But watchful waiting still seemed a goodway to go – my thinking was that it’s hard for something to go wrong if you don’ (forexample, a surgeon can’t make a mistake or cause side effects if they don’t operate).During this time, too, my original urologist (let’s call him U1) retired and I was changedto my current doctor (U2 – and nothing to do with the band), who picked up withscarcely a bobble. That changed a few months ago, when my most recent biopsy showed that the canceritself had grown, it had started to invade some of the nerves of the prostate, and thenature of the cells was starting to change, making them more likely to becomemore…shall we say…interesting. And this is where the general approach changed fromcollecting information to taking action based on what that information was telling me. I’llget to that in the next installment! ******************************************************************************************************** Andrew is a scientist and radiation safety professional who began plying his trade in the early 1980s, as an enlisted man in the US Navy’s Nuclear Power Program, and has worked in a wide variety of radiation-related jobs ever since. His work spans government, consulting, radiation instrumentation, academia, and the characterization and remediation of radiologically contaminated sites; not to mention joining a number of missions for the International Atomic Natural energy Agency and conducting training on a few occasions for Interpol, and for the Tokushukai Medical Assistance Team in the aftermath of the Fukushima reactor accident. Andrew has earned degrees in Geology and Environmental Science and is board-certified in his profession. He is the author of over 20 books and book chapters, dozens of peer-reviewed scientific publications, and thousands of articles and blog posts aimed at both technical and non-technical audiences. Other things to check out: Dr. Eeks’The Causes or Cures Podcast! What does Burnout Do to Your Brain(It isn’t pretty!)