|
DON’T CHOP IT, ZAP IT Dr. Louis J Capozzoli, PE retired This story will address two topics, the first is the importance of periodic medical examinations. The second is my treatment selection for prostate cancer. I started flying airplanes in 1953 and as a private pilot was required by the FAA to pass a medical examination by an aviation medical examiner, AME, every two months. Commercial pilots getting paid for flying had to pass a more stringent medical every year and airline pilots an even more stringent medical every six months. The latter included a stress EKG after the age of 45, now monitored in real time by an FAA flight surgeon in Oklahoma City. Failure as determined by him results in immediate grounding. Regardless, every airline pilot is grounded on his 60th birthday. That is one reason for the safety of airline travel. I went along fat and happy with the simple biannual examinations until 1981 when I obtained an airline pilot’s license to show improved flying proficiency. Then I discovered the airline pilot EKG requirement. Since I was just as important to myself as 400 people in a 747, I started the EKG routine at every bi-annual exam. I also told my AME he had a hot one, give me every test he had in his office. This added chest X rays, blood work, and the DRE. About 1990, the PSA test became available and was added to this test group. Five years ago the fun started! The EKG looked funny and was sent it to a cardiologist for review. The cardiologist required a heart catherization which found three coronary artery blockages. While I was still on the examination table, he stated I needed an operation. The good (?) blockage was 35%, the other two were 95% and 100 %. I could not believe this and asked him how I was able to swim 100 yards the previous morning. He explained collateral arteries, how the body builds bypasses around blockages with time. Fortunately, my activity gave my body time to do so. Only after a review of the exam results by a nephew who is an anesthesiologist in Palm Beach, Florida and has participated in many such operations did I become convinced of the necessity for the operation. Even though I never had chest pain or shortness of breath, I had the operation. Every thing went well and I was out of the hospital in four days, about one day ahead of schedule for the typical case. The only drawback was it took the FAA 17 months to restore my flying privileges thanks to government paperwork. I must take a stress EKG every year to maintain my pilot’s license. I feel somewhat stronger now after that surgery although it may be psychological. With this background, I was prepared for the bad news about my prostate. The periodic DRE showed typical prostate enlargement as I aged and I experienced slowdown of flow in urination. The PSA was still below 4 until June, 2001 when it rose to 5.5. My AME sent me to Dr. Richard Carter who confirmed the DRE examination results but found the PSA as 3.7. With this variation, he recommended a retest in six months. Six months later, on 12 December, the PSA was 5.9 and three months afterward on 13 March it was 6.3, a high velocity. This resulted in a six sample biopsy on 28 March. The samples on the right had 5 % cancer, those on the left 10 to 20 % cancer. The cancer was T1c with a Gleason of 6 (3+3). All these were on the low side, at least some good news. Now decision time!. My wife, a trained hospital dietitian, and I, an engineer, together had half hour each discussions with Dr. Carter and Dr. Sheldon Johnson of Mary Bird Perkins Cancer Center as to treatment choices. I had previously used Dr. Johnson’s services to radiate skin cancer on my left nostril for three weeks the year before. Both doctors provided extensive information and literature as to treatment choices. Neither pushed one treatment over any other. Nelson Boudreau’s web site (boodrow.com) on prostate cancer also provided extensive information since he had prostate cancer a year earlier. (As a humorous side note, I accused Dr. Johnson of not curing my nose skin cancer but merely moving it to my prostate. Possibly I caught prostate cancer from Nelson in his computer class.) We investigated six possible treatment choices. While they all would treat the cancer, the side effects would be the determining factor. These possible choices and our analyses follow: 1. WATCHFUL WAITING: Ridiculous. Why go to all the tests, do nothing, and live on a time bomb with something that will kill you. 2. HORMONES: The side effects of weight gain, less libido, and general energy loss did not make this attractive. I experienced these side effects later. 3. SURGERY: The commonly noted side effects of incontinence and impotence did not make this attractive. Additionally, the extent of the cancer beyond the prostate capsule could not be noted during surgery and the necessary amount of tissue to be removed beyond the prostate was unknown. 4. BRACHYTHERAPY: This iodine seed implant looked the most promising. The radiation source would be placed in the prostate, the location of the cancer, immediately. The treatment would take only one night in the hospital and no follow-up treatment would be required. The radiation would also affect tissue ¼ inch beyond the seeds, giving treatment outside the capsule. The half life of the seeds is 60 days. 5. EXTERNAL BEAM RADIATION: My nose treatment gave me experience with this. Aside from the time required, three other negatives arose: The radiation starts outside the body and the tissues immediately next to the radiation source get a big zap, not good for them. Seven weeks were required to get all the radiation into the prostate. Movement of the organs could impair aiming of the beam possibly radiating organs that should not be radiated. Now intensity modulated beam radiation has reduced the effects of the first and third negatives. 6. BRACHYTHERAPY AND EXTERNAL BEAM: This was the treatment selected by Nelson a year earlier and since he is a fellow engineer, I considered it extensively. Beside requiring the treatment to be done in Atlanta, it had all the negatives of external beam alone. Based on the above analyses, I selected the brachytherapy treatment. The next steps were an ultrasound analysis and a CAT bone scan. The former showed a prostate of 65 cc volume, an equivalent diameter of 2.0 inches, the CAT scan showed no metastasis. The latter was good, the former not. This size prostate placed the prostate slightly behind my pelvis, inaccessible to some of the needles used to place the seeds. Also, the larger the prostate, the more seeds needed with more undesirable side effects on the adjacent organs and nerves. Dr. Johnson recommended hormone treatment to reduce the size of the prostate. In early June, 2002, I received a four week shot of DepoLupron to stop production of testosterone from my testicles. I also started taking Casodex to stop testosterone production from my adrenal glands. After four weeks with only the usual side effects, I received a 12 week shot of DepoLuoron and continued with the Casodex. After these 16 weeks, a new ultrasound test showed the prostate size as 39 cc, an equivalent diameter of 1 5/8 inches, a 40% reduction,. Based on these results, plans were made for the seed implant in two weeks. At this time, an additional four week shot of DepoLupron was recommended along with continued taking of Casodex. Having experienced the usual side effects of these hormones, I asked if the prostate would spring back to it’s original size in two weeks without the hormones. When the answer was no, I declined these treatments. I had enough of the side effects of the hormones. (1) On Monday, 16 September, 2002, 101 iodine pellets were placed in my prostate by Drs. Carter and Johnson. I stayed in the hospital overnight with a catheter in me and was released the next day after the catheter was removed and my bladder functioned. If the original 65 cc prostate volume could have had seeds implanted, the number of seeds required could have been 168 with considerable more of the detrimental side effects noted below and possibly others. Ten days after the seed implant, I was checked by Dr. Carter and complained about lack of urination capability. The volume of retained urine after voiding was 125 cc, about four ounces. He placed me on Flomax, 0.4 mg per day, which helped but was not perfect. About four weeks later, my retained urine was only 75 cc, about 2 1/2 ounces. He doubled my dosage of Flomax and the urinary problems were reduced. At that time, my PSA had dropped to less than 0.1. This was surprising since I still had my prostate. The seeds did a fast job of killing production of PSA. About March, I reduced my Flomax to one capsule per day and in June to one every other day. At the beginning of September I was able to go to one capsule every three days. I tried one every four days but after discomfort on the fourth day twice, I went to one every third day. It is a gradual improvement. The good news: I have more energy then before the seed implants, my libido has increased, and I have no incontinence side effect, just the opposite. My PSA is still below 0.1 and I have lost half of the weight (about 10 pounds) I gained from the hormones. I still do my 100 yard swim almost every day. Unknowns: I have one year’s experience with this treatment. What will be the results in five or ten years (when I will be 80 or 85)? Will long term effects of the seeds bring on other undesirable side effects even though by September 1, they will have only about 1.6 % of their original strength and this amount will decrease by one half every 60 days? When will I be off Flomax completely? Known: I am happy with my choice and would make the same choice again. Thank God for periodic medical examinations! Dr. Louis J Capozzoli, PE retired (1)Side effects of any medication should be carefully monitored by the patient. Chemical warfare in the body is harmful. My cardiologist started me on one aspirin per day in 1999. After gout flare-ups occurred almost bi-weekly, I stopped aspirin on 1 May 2003 and have had no gout attacks since then. I have been on 1000 mg of glucosomine chondroitin daily for the last several years to keep my joints lubricated. One patient at a Man to Man meeting stated chondroitin was suspected to cause prostate cancer??????
|