With treatment, I am not very likely going to die as a result of my prostate cancer, as my father before me did. The scoring and grading complete, I am among those with a 90% chance of being prostate-cancer-free through at least the next ten years (10 years is pretty much the extent of the data), and can look forward to being a cancer survivor. Thanks be to God that such mercy has been given to me.
While my prognosis is just about the best that one could hope for, I am at somewhat of a loss before a buffet of good treatment options. Advancements in medicine offer those with prostate cancer a plethora of choices of excellent treatments: da Vince, brachytherapy, IMRT, IGRT, clinical trials, active surveillance, proton beams, HIFU, laparoscopic robotic radical prostatectomy, cryotherapy. While the biopsy was certainly uncomfortable and nerve-wracking, and the news that I had cancer invoked rage and fear, having to pick my own treatment may yet be the most agonizing part of this journey through prostate cancer so far.
Dr. de la Paz told us that either surgery or radiation therapy will offer cure rates of about 90% or better, that is that after 10 years there is less than 10% chance of recurrence of prostate cancer. Hardly before I truly had the opportunity to rejoice in the prognosis, my mind was spinning at the idea that I will have to make such a momentous choice. It’s hard to confess this. Shouldn’t I be celebrating? I sure wouldn’t have wanted him to say the only thing to do was go home and pray! While today’s prognosis means that virtually any treatment is available to me, today’s prognosis means that I will eventually have to choose my treatment from all the treatments available to me.
Pulling out the cross-section model of the male torso, the doctor carefully started at the beginning and showed us the position of the prostate in the body and its relationship to other important organs and structures. In his view, I have five reasonable choices: active surveillance, surgery done one of two ways, or one of two radiation treatments. Using his pen he points to what else besides the prostate is effected by each of these choices. By my own research I have already decided that active surveillance, sometime called watchful waiting, has no place in our consideration: once the “C” word is on the table, we beyond the point of waiting. De la Paz agrees that at age 50 with a history of PC in the family, we would only be exchanging handling the cancer now or handling it later.
The surgery, called a radical prostatectomy, completely removes the offensive gland, and the urethra is then reattached to the bladder. Done the tried and true way, Dr. de la Paz would make about an 8″ incision for down from the belly button to my pubic bone. Alternatively, one of his colleagues could use the daVinci robot to assist him in completing the surgery laproscopically through five small holes. The daVinci surgery promises a better chance at preserving the precious nerves around prostate and shorter recovery time. Either way, surgery means I will be peeing through a catheter for two weeks after surgery.
While a surgeon himself, de la Paz acknowledges that radiation therapies have about the same effectiveness in curing prostate cancer as a radical prostatectomy. The choices for radiation are either image guided radiotherapy or brachytherapy, which involves driving tiny radioactive “seeds” directly into the prostate.
But what of the morbidity, the side effects, the dreaded “I” words: incontinence and impotence? My own research along with conversations with prostate cancer survivors I have come to know have convinced me that the risk of prolonged or bad incontinence from either surgery or radiation is not great–in the range of 90 percent are free of any serious incontinence issues a year after surgery. Impotence is a whole other story. Impotence was an accepted cost of all prostate surgery until relatively recently. But in the ’80s, surgeons found the nerves that control erections and perfected “nerve-sparing surgery” to save them. Research seems to support that three-quarters of patients my age or younger who have surgery regain satisfactory erections within a couple years. The reversal of the two “I”s isn’t an easy road, and satisfactory rarely means a man regains all of what he had before the cancer. Impotency is an immediate reality after surgery. With radiation it can take two to three years after radiation treatment with nearly half of all radiation patients eventually becoming impotent.
My wife and I left Dr. de la Paz’ office nowhere near ready to make a choice. We live out lives shaped by the choices we make. I am afraid of making a wrong decision. More reading. more conversation. more prayer.
Other posts in the Prostate Cancer Journal can be found under Categories in the sidebar of this blog.
At least one person has contacted me and was wondering what are my “numbers.” Well here they are for those keeping score: age 50, PSA 4.8, Gleason score (3+3)+6, Stage T1c.