To that alphabet soup of grouped letters so important to our lives--IRS, CIA, FBI and NSA--has been added a special selection for seniors--SSA, MRI, CAT and PSA. This last one, PSA, (prostate-specific antigen) has now cast its dark shadow upon you. Your doctor has been insisting for years that you have it checked.
Friends and relatives have related their PSA stories, seemingly all bad, and now it's your turn. In just months it seems, you leaped over the magic level of 4.0 and climbed yet even higher. Even your initial 3.4, comfortably within the upper limit of normal, did not seem to please your doctor. Sure enough, 3.4 became 4.3 and then, in just two years, the value has become 7.7.
Your physical exam is fine, with normal DRE (more alphabet soup) and ultrasound. Of your six biopsy specimens, five are normal but one heralds malignancy, not just focal dysplasia, but definite malignancy.
The lower abdominal CAT scan is free of any evident metastases. The diagnosis is made: Early prostate cancer, moderate grade with no evident spread. From the perspective of preventive medicine your case is a "good catch;" a potentially life-threatening malignancy is identified in the early, pre-invasive phase. Destroy it by one means or another and you're back to normal, aren't you?
Defining normal is not as straightforward as one might think, because the biostatistics of one's prostate gland is a very sobering read. The bottom line is that if you live long enough your chance of prostate malignancy is extremely high. I will not bore you with details for that is not the purpose of this page, but suffice it to say that routine biopsies reveal a rapidly rising incidence of focal prostatic "neoplasia" with age.
This has tempted more than one philosopher to suggest that Mother Nature has thereby engineered a fail-safe against indefinite longevity. By default then, one's normal becomes an ever-increasing risk for prostate cancer--if something else doesn't get you first. This reality makes the option of "why bother" surprisingly appealing when the grade of malignancy is found to be low. There is a tendency toward reserving intervention for those younger individuals who have higher grades of malignancy or longer lives to live. In fact one's state of health and expected longevity become very important factors in determining what course of action to take when the diagnosis has been made.
You can imagine my surprise when the first question asked by Chief of Urology Dr. John Heaney, of the famed Dartmouth Hitchcock Medical Center (DHMC), was "How much longer do you expect to live...?" "Ten to fifteen years," I replied.
I take pride in being physically fit and, barring an accident, fully expect to see my mid-eighties. As a retired, experienced family doctor I had reviewed the therapeutic options prior to my visit with Dr. Heaney, and opted for seeding of my prostate with radioactive pellets in a procedure known as brachytherapy. What could be better than a brachyterapy? Resolution of the prostate malignancy using beta radiation from implanted pellets with no collateral radiation damage to the skin, bladder or bowel.
This was medicine of the future; complete with total eradication of the prostate tissue. I must admit to a slight dampening of enthusiasm however, when I discovered that microscopic analysis of prostate glands treated with brachytherapy did not reveal uniform scar tissue. Rather, the typical histologic picture was one of scar tissue mixed with remnants of prostate glandular tissue--exhibiting varying degrees of radiation damage.
Then, when Dr. Heaney advised that, should I suffer the side effects of radiation burns to my bowel and bladder, they might not be apparent until about eight to ten years after treatment...he had my full attention! I had anticipated no such damage with beta radiation. "The prostate is bounded by the base of the bladder above and by the rectum behind," Dr. Heaney reviewed, using the same manner with me he uses with his flock of residents. "No more than a thin membrane of tissue separates them," he patiently explained. He continued, "It's impossible with these radioactive pellets, no matter how cleverly placed, to irradiate the prostate gland completely without including adjacent margins of these two vital structures. And the symptoms of damage may be delayed some eight to ten years."
Dr. Heaney then announced a possible alternative which is emerging as a new approach to radical prostatectomy, using the laparoscope and robotic technology. Seeing he had my full attention, he added with a smile, "We deliver your prostate through your navel, leaving you with minimal discomfort. We put five band-aids on your abdomen and send you home within 24 hours; then take the catheter out in one week."
Amazed that a procedure of this type existed, the doctor in me told me it was the perfect choice. I immediately nodded my acceptance. "Don't you want to think about it?" Dr. Heaney asked. "No," I responded, "...there is nothing further to think about--set it up!" Two weeks later I awoke in DHMC minus my prostate and, true to his word & with three hours to spare, had already adjusted to the demands of catheter living and was heading home.
One week later the catheter was removed and I was introduced to a strange new world of adult urine protection. But that lasted for only a few weeks and by the time of my National Park trip one month later, I was "dry."
Medical and surgical technology had made impressive gains during my career as a family doctor. Laparoscopic resection of the prostate (LRP) is another of these incredible feats undreamed of only 10 years earlier. Only one dark cloud drifted across my otherwise bright sky of experience with LRP: At my medical school alumni meeting a classmate, good friend and family doctor, confided that he had just had the "seeds." We compared notes briefly: His case was almost identical to mine with slowly rising PSAs of comparable levels. One of the biopsies was positive with no evidence of spread, but he was completely unaware that a laparoscopic option existed. I could see a growing realization in his eyes that perhaps he had taken, or been led down, the wrong path.
I said no more.
Duane Graveline MD MPH
Former USAF Flight Surgeon
Former NASA Astronaut
Retired Family Doctor