“If ignorant both of your enemy and yourself, you are certain to be in peril.” – Sun Tzu
The physician’s assistant (PA) at my urologist’s office met with us (Vick and I) after the biopsy, another hour and half trip one way, to discuss the biopsy results and options for treatment. If the cancer was confined to my prostate he gave me two options:
- I could have the prostate removed, a prostatectomy.
- I could have radiation therapy.
There were two options to the radiation therapy:
- 44 sessions of getting zapped by radiation or;
- 5 sessions of getting zapped with high intensity radiation referred to as “CyberKnife©.”
I was told that because the radiation would also affect surrounding tissues there would be collateral damage. A strategy to “minimize potential side effects of prostate cancer radiation therapy” is what they call “SpaceOARTM Hydrogel.” Boston Scientific’s marketing tells us, “Make space for life as usual.”
“SpaceOAR Hydrogel is a polyethylene glycol (PEG) based hydrogel clinically shown to minimize urinary, sexual, and bowel side effects and protect quality of life for prostate cancer patients undergoing radiation therapy.”
To protect your colon and rectum from the potential side effects of the radiation therapy they transrectally inject you with hydrogel. The hydrogel moves your rectum 1.3 centimeters further from and shields your rectum from damaging radiation. What a difference a silly millimeter makes if you recall the cigarette ad for 101’s “They taste one better.” I’m still skeptical of 1.3 centimeters making much difference in protecting my precious arse.
I remember back almost a half century ago when I was teamed up with Folks and Higgins one evening in our Fugitive Warrants Unit. We arrested an old guy, probably younger than I am now, and on the drive to jail down Charles Page Boulevard Folks and Higgins were joking with our prisoner. When asked about his sex life his response, “At my age I get more pleasure out of a good dump.” went way over my young mind. What could give you more pleasure than . . . well now I understand our old criminal.
Now I’m faced with how to destroy the enemy within while minimizing the destruction to adjacent organs. If radiation is killing cancer cells but simultaneously destroying healthy tissue how dangerous is this option? How effective is Hydrogel at protecting my rectum and how about all the other stuff in the vicinity? Do I want to put my faith in a wax?[1] I guess it can be multi-purpose much like horse de-wormer.
All options seemed limited, radical, and frankly in the 21st century quite medieval. And remembering the scene from the movie Pulp Fiction I do not want anyone going Medieval on my ass! What I actually wanted was for my response to my cancer is, “I’ma get medieval on your ass.”
Radiation therapy also comes with hormone therapy or “androgen deprivation therapy (ADT)”. This reduces your cancer feeding male hormones (androgens) in your body. This therapy I’m told puts you in “male menopause.” My grandchildren call me “Grumps.” I can’t imagine what they would call me if I subjected them to Grumps during male menopause! That’s not how I want my grandchildren remembering Ole Grumps.
What now?
Now with the cancer diagnosis absolutely determined, knowing its location, numbers, and strength are now the mission. The biopsy determined that it is in the prostate but is it elsewhere? Where is it and what’s it doing? Sun Tzu taught, “When a general, unable to estimate the enemy’s strength, allows an inferior force to engage a larger one, or hurls a weak detachment against a powerful one, and neglects to place picked soldiers in the front rank, the result must be rout.”
I’ll get fingered. I’ll be injected, MRI’d, PET Scanned, and biopsied but my getting routed is not an option. This is total war with a fight to the death. There is no capitulation. Total and absolute annihilation is the only acceptable outcome for my satisfaction. To paraphrase Sun Tzu, we must use spies to know the enemy’s strength and position. I must know the enemy’s strength and engage it with a superior force of the best soldiers to ensure that the rout is mine.
The Positron Emission Tomography (PET) Scan is that spy. You will be injected with a radioactive tracer called a “radiotracer.” The radiotracer will then take approximately forty-five minutes to spread throughout your body. You will then lie on a sliding table that moves you into and out of a tube. In my ignorant opinion this tube equates to an MRI.
For another forty-five minutes you will be required to remain completely still while you are scanned. The scanner is recording the radiotracer throughout your body. According to WebMD.com cancer cells are more active than other cells. “Areas with cancer cells light up as bright spots on the images.” WebMD also says, “A PET scan can often detect cancer before most other tests.” Hmmmmm, why didn’t my urologist suggest a PET scan right off the get go rather than the MRI with contrast and then the invasive perineal biopsy?
Ninety minutes later you’re done. I didn’t feel the tiny needle used to inject the radiotracer into my blood stream. The only preparation required before hand is to avoid intense physical activity, drink only water and lots of it, don’t eat for several hours, and remove all metal from your clothing and body. This was easy but another hour and half trip to the imaging center. When you are fighting cancer, you’ll go to any lengths.
Hallelujah, according to the PET scan my cancer is currently confined to the right side of my prostate. The PA explained that if cancer was outside of my prostate a prostatectomy would not be an option. The only treatment would be radiation.
The biopsy sampled tissue from all around my prostate. Each sample is examined under a microscope and is graded. In the 60’s Dr. Donald Gleason separated cancer cells into five patterns. He then graded these distinct cells into a scale of 1 to 5 with ones being normal prostate cells and five are “high-grade” and do no resemble normal cells. The method of grading prostate cancer is now called the “Gleason Score.”
This image from the Prostate Cancer Foundation https://www.pcf.org shows how cells change when invaded by cancer:
Three samples on the right side of my prostate scored fours and one sample scored a five characterized by my urologist as “aggressive.” No one wants to hear cancer and aggressive used in the same sentence.
Next, another hour and a half trip to speak with the urologist about options. More decisions.
Next – At your age . . .
[1] One of the first commercial products based on polyethylene glycol was CARBOWAX, a water-soluble wax introduced in 1940 by American manufacturer Dow Chemical Company. https://www.britannica.com/science/polyethylene-glycol
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