Fighting Prostate Cancer At -90 C: My Cryo-therapy Experience At UC Health

3D image shows tumor which was subjected to  three freezing cycles, with temperatures as low as 90 degrees below zero, centigrade.


Almost five years to the day after being diagnosed with stage 1 prostate cancer I found myself Tuesday at the University  Of Colorado  Anschutz Medical  Campus  - Inpatient Bldg. to check in for focal cryotherapy surgery under Dr.  E. David Crawford.  After the requisite  initial processing of insurance  cards, ID and answering prelim questions (Would you like to see a pastor?, Do you have an advanced directive?)  I was checked in to the Urology pre-op station,  and met by a perky  RN I will call 'Greta'.   She took my vitals, then  had me change into  the standard issue gown and yellow  happy socks,  after which  my  belongings were  bagged  (taken away by Janice).  I was then connected  by Greta to an IV after some initial difficulty finding a vein.

As with my earlier experience with the 3D staging biopsy in January, I was first met by rounds of specialists, to  answer   further questions, i.e. What  is the name of the procedure you're having?, When did you last eat and drink?  Do  you have an advanced directive or living will?  Will you accept a blood transfusion if one is needed?  Do you have any allergies?  Do you suffer from sleep  apnea?  Have you had general anesthesia before?

The sole remaining formality was to sign an acknowledgement of risks form, always being told these risks (e.g. fistula) are "relatively low". But, of course, they have to disclose every possible permutation or possible outcome - much like the horrific (possible) side effects of Pharma drugs. Oh, there is also an acknowledgement that no guarantee is made that the treatment will eliminate the cancer. Well, that one's fairly straightforward and no sensible person would expect some magic cure! At least for prostate cancer.

By 7.25 a.m. Dr. Crawford and a  urological resident appeared and asked if I had any last minute questions (I had a few, e.g. 'How long does the catheter stay in?') and then I was wheeled into the OR by an anesthesiology resident. Once there I had to move myself to an adjacent table where an oxygen mask was  affixed to my face and the anesthesiologist (Dr. Erin Tracy) instructed me to breathe deeply.   Within about a minute the slight stinging sensation of fentanyl was noted and then.....lights  out.

When I came to it was nearly 10.30 a.m. in the recovery room, and the attending  nurse - Shannon - asked how  I was feeling.  As in January,  I noted the burning sensation in  the urethra - now the pain arising not only from the insertion of the indwelling (Foley) catheter. - but also  a  cystoscope to locate the bladder position as the freezing needles (cryoprobes) were inserted into the prostate.

Each cryoprobe from 1-3mm in diameter  inserted through the perineum,  used Argon for super cooling to sub-zero temperatures. The effect was to freeze the cells of the tumor creating an "iceball" with colder temperature at the center and warmer at the periphery. However, this difference is eliminated by repeated freezing and thawing cycles.  To protect the urethra a warming catheter remains in place during all the cycles.

To relieve the post -op urethral pain,  Shannon gave me two hydrocodone pills (which UCH calls  "narco)' and the pain subsided but the feeling of grogginess increased.  This was somewhat  different from the  3D biopsy when I came rather quickly out of general anesthesia with little or no hangover.  By contrast, this time I had to ask for a barf bag whereupon I did one or two dry heaves.

By 11.30  when Janice arrived, I was able to eat:  a couple of saltines with some ginger  ale. Janice told me that Dr. Crawford met with her in the main conference room and informed her the procedure went "very well" and  a total of three freezing cycles (at different temperatures) were done, including one at -90 Celsius or - 130 F.  (Cell death occurs at -40 C which is also - 40 F).  This sequence of freezing was why the procedure took longer, and hence the need for more anesthesia.

Only later, once I was dressed, did I realize another source of discomfort was a "scrotal support" that had been appended to me after the procedure. I asked the RN why this had been put on and she explained it was to prevent or inhibit "scrotal edema" - a swelling of the testicles to potential football size that sometimes accompanies insertion of the cryo-probes.  I asked how long I needed to have it on and she replied: "Maybe two to three days". Well, after 2 days I cut if off with a jack knife I brought with me to the hotel.

This morning, barely two hours ago, Janice used a saline syringe given to us by the UC staff to change the pressure inside the catheter to release the bulb and the connection. "Liberation" arrived with immense relief but also lots of blood and clots, much of which was probably associated with the dead cancer tissue that had morphed into the "ice ball".  After drinking quarts of water the urine has gradually begun to return to the usual (straw)  color. The pain has also subsided enough to sit down and write this post - to bring interested readers up to date-  also indicate why no posts appeared the past three days.

Anyway, the takeaway is that now I will have to get PSA tests done at 6 month intervals, and then hopefully, see it dive down to negligible levels in about 12-18 months. Otherwise, another biopsy may be needed. But in any case, I've made it clear no further treatments after this.

The prognosis, however, is very good and by all accounts from Dr. Crawford the tumor ought to be literally terminated as an ice ball that subsequently turns to dead cell slush.

Fortunately, I've not had to pay for any of the treatments, tests, biopsies I've had over the past five years. Ok, I take that back, I had to cough up about $1200 for the HDR Brachytherapy treatment I had at UCSF in 2012. But the total I would have had to pay for all cancer treatments, had I not had Medicare, is estimated to be around $115,000 when the cryo-ablation is factored in. In fact, without Medicare, we'd likely have had to declare bankruptcy.

That brings up the question as to what millions of Americans will now do that this misnamed Senate health care bill ("Better Care Reconciliation Act Of 2017") is ready to pass.   And by the way, let's also cut the crap this is a health care bill. It  is not. It is a revival of the zombie tax cut paradigm that the GOP has turned into an abiding fetish. This despite the fact that NO evidence exists that cutting taxes for the rich or corporations increases economic growth..  That canard was last exposed during the Gee Dumbya Bush reign, but now has been revived by Paul Ryan and Co. Never mind, the Repukes are salivating to cut the critical medical access for tens  of millions to give the richest more gold-lined tubs, yachts, 20,000 sq. ft. vacay homes and blood diamonds that they don't need.

So this vile tax cut bill  - in the words of one commentator - "takes a meat axe to their health care.". That is, to Medicaid, through which $800b would be cut, lowering the bottom on 75 million Americans. What if the males  in that population get a cancer like I have, what can they do? Well, the Repuke bill will ramp up their deductibles, increase co-pays (by an average of 20%)  and limit access, while offering only measly tax credits - if they pass an income test. End result? Most would either have to go bankrupt accessing the treatments needed, or allow the cancer to progress.

For people with disabilities, Medicaid is the primary benefit that allows them to stay in their own homes.  Without it they will be homeless on the streets, hence the reason for their plaintive cries yesterday (in front of Bitch McConnell's office)  to "Save our liberties!"

For lower income folks, the bill amounts to the most massive transfer of resources in history from them to the wealthy for $600b in tax cuts. The low income people will be left with virtually nothing by 2025, or be at the mercy of private insurers. Here in Colorado, Medicaid access will revert back to what it was before the ACA arrived, with draconian qualification measures applied - given the extirpation of Medicaid expansion will leave us with a $750 m. plus deficit. That means a low income mother of 2 kids in 2025 will have to earn no more than $300/ month to qualify to receive Medicaid benefits after this god -awful plan allows only limited block grants to the states. The worst hit will be the underclass disabled and seniors barely making ends meet living in high premium states. Seniors alone will have to cough up 5 times more in premiums thanks to this misbegotten atrocity.

And for a take on the for profit health insurance industry we have these words from  William Rivers Pitt - who wrote in a recent Blog post (on 'smirkingchimp.com')- on how they compare to a Mob protection racket:

"The health insurance industry, for the most part, is the Mob painted over with a veneer of legitimacy. They're a protection racket. The Mob got people to pay by offering "protection" for your restaurant or store, and would burn it down if you didn't pay up. With the insurance industry, your body is the store, and as all flesh is inevitably weak, your store will eventually burn down, taking your financial stability with it unless you pay the insurance middleman in full. Nice health you got there, be a shame if something happened to it. That's only if they don't turn down your claim because of a typo on your claim form, which is hardly rare. I had ICU nurses telling me insurance horror stories that made one wistful for the ringing sound of guillotines in the town square.

The problem is the fact that health care in the United States is a for-profit industry, like petroleum speculation or automobile manufacture. It's a few people making a lot of money off of sick people, and after so many years of this being the status quo, they have the political system wired to keep it that way."

Question: If the health insurance lot are analogous to the Mob in a protection racket, what does that make Bitch McConnell, Paul Ryan and the GOP?

Answers?  Inquiring minds want to know.

See also:


http://www.edavidcrawford.com/targeted-prostate-cancer-treatment

And:

https://www.youtube.com/watch?v=Hoi0872F3Cg

The Good News: I'm A "Perfect Candidate" For Focal Cryo Treatment

The meeting with Dr. E. David Crawford earlier this week was concerned with the outcome of the 3D staging biopsy done some two plus weeks ago. To say it went well would be an understatement, especially after he displayed the 3D grid of the mapped prostate on his computer.

He pointed to one localized region, roughly 5-6 mm in diameter, where all the cancer was confined. There were no other lesions or regions, and that assurance is the primary benefit of having the much more invasive 3D biopsy. No such assurances exist for those who get regular prostate biopsies, including the highly touted MRI fusion form (which I also had).

Recall that biopsy mistakenly identified separate cores, e.g.


And the pathology report showed a Gleason 7 score in one region (3 + 4) with 63 percent of the cells assigned malignant status and also with "perineural invasion". Thus, I beheld the summary of diagnostic information as shown:



However, none of that was confirmed in the 3D staging biopsy. Indeed, there was no evidence of any perineural invasion, as the localized lesion was situated not only apart from the rectal wall but also from the urethra. In addition, the maximum Gleason score pair for the sole cancerous region was 3 + 3, not 3 + 4.  

When Janice asked what could account for the difference in Gleason score, as well as the reduction of multiple lesions to just one, Dr. Crawford said "the radiation treatment he had four years earlier". Basically, that high dose brachytherapy treatment - leaving loads of "scar tissue" - left the histology analysis a mess, and unreliable. That pathology report was basically useless, at least in terms of moving forward. Had I therefore not had the 3D biopsy I likely would have opted for a follow-up treatment that was inappropriate.

Dr. Crawford assured me there was no rush to get the treatment done, and in that case I've postponed it until later in the year, after we take a holiday in Barbados.  In any case, as I told him, I was still contending with residual urinary burning as well as urgency, which he agreed was because of the Foley catheter. Again, it had been in barely two days. 

When I asked him how long it would need to be inserted after the focal cryo, he said it "varied" but steered clear of his original claim of "one day" (which his RN vigorously disputed when I spoke with her after the biopsy)  He agreed the most likely interval was 2-4 days, which pretty well conforms with the 3-5 days cited on the UC site. But I am hoping given the localized tumor and placement, it can maybe come out in 2-3 days. 

We will see.   For now, I am simply enjoying the good vibes of being the "perfect candidate" for this focal cryotherapy treatment.  I have asked for the copy of the 3D grid map with the lesion identified, and when I receive it from UC Health I will post it as an update on this post.


See also:


https://www.youtube.com/watch?v=-OnqA-mJDWg


And:


http://www.edavidcrawford.com/targeted-prostate-cancer-treatment

3D Staging Prostate Biopsy Unlikely To Come Into General Use - My Account

Image of a 3D reconstruction- with grids superimposed-- after 3D Staging Biopsy. Note the prostate (in red), urethra (in green) and the exact location of areas of cancer (in mud yellow). 


The advantages of the 3D staging biopsy for prostate cancer which I just had two days ago, are well known and explicated wonderfully on Dr. E. David Crawford's University of Colorado site. We are informed, for example, that with this 3D rendition many more lesions, prostate cancer tumors can now be identified because the technique is much more thorough. As Dr. Crawford has noted, from 10-30 percent of prostate cancers are missed even in the MRI fusion biopsy.

In other words, given the much higher accuracy the 3D Prostate biopsy is now the "gold standard" for PCa diagnosis. But that standard doesn't mean many more men will choose it.  We need to look at why this is so.

The standard prostate biopsy is more or less an "in and out" procedure, done rectally with the accompaniment of an ultrasound to provide location data for the prostate sampling. This may be from 10 to 20 cores. Thus, a needle sample device is inserted into the rectum and each time extracts tissue from the gland after puncturing the rectal wall. Primary risk is for sepsis, which is why antibiotics like ciproflaxin must be administered in advance.

The procedure is usually done in the urologist's office without even a sedative and takes from 20 minutes to 45 minutes, depending on the number of sample cores taken. The chief side effects include: swelling and pain in prostate, possible problem urinating, and blood in urine, stools and semen. In the former two body fluids it can remain 1-2 days and in the last up to 3 months.

The 3D staging biopsy by contrast is an entirely different animal. While described as an "outpatient" procedure, you are actually administered general anesthesia because the technique is much more invasive and entails up to 100 needle sampling insertions through the perineum to extract prostate tissue. The locations are again confirmed via trans rectal ultrasound for later mapping of all the samples to a 3D grid. The samplings are taken approximately 5mm apart. In my case a total of 45 were taken, fewer than originally projected (60).

Of course, before getting it done you are undergoing a full surgery prep, including being asked if you're an organ donor, and to leave an advanced medical directive (or living will) in case the surgery or anesthesia goes awry - or you hemorrhage. Also Janice had to be there to provide durable power of attorney and medical power of attorney in the event I was left unable to render decisions, directions for my own care.

In the pre-op setting you also discuss with the anesthesiologist any allergies, and note if you are sensitive to meds (as I am.) By the time you are being wheeled into the OR you are already half out of it from the mix of sedatives, painkillers including fentanyl.

Once in the OR you must move yourself from the gurney to the operating table where the sampling is done. I don't believe I'd completed the transition more than a minute before I was knocked out.   (Just before I was asked by a urology resident if I wanted a transfusion in case of hemorrhage, and I gave my blood type).

I awakened in the PACU or Post-Anesthesia Care Unit, to the soft voice of a beautiful nursing grad student, "Rachel", who asked the usual questions: Where are you? What is your name? What is your date of birth? What year is it? Etc. All this is done to ensure you are all there.

She then questioned me about the pain, where it hurt and the nature. I told her the worst aspect was a burning sensation all through the urethra, from the catheter. (I ended up opting for a Foley catheter, as opposed to supra-pubic on the advice of a urology resident, "Tim".).

She immediately brought me three meds to take with water, one of which was specifically to reduce the burning sensation that had become almost unbearable.

After giving me the meds, she brought me a few light Jello snacks. This time (unlike my gall bladder removal in May) there was no nausea at all so the anesthesiologist hit just the right mix.

Janice by now had also come up, after tracking my various locations using a "patient tracker" - coded by color to follow my progress. Once she arrived, Rachel and another student RN ("Callie")  showed her how to change the catheter bags, and also go from the usual (day time) leg bag to the much larger night bag.

Let me say right off the bat that having a Foley catheter in place is no ball of fun, and ranks maybe up there with a root canal - or two.  I had to wear the damned thing for two days before Dr. Crawford's RN gave the ok to take it out.   She emphasized it was foolhardy to do so too early because then "you could be in a real world of hurt". That refers to all the ancillary tissues swelling up preventing urination, which earns you a trip to the ER. 

So now, with it out I am still recovering and will get the results of the biopsy in 5 days or so.

Having had the normal biopsies and this one I can agree right now with what a paper dealing with it noted, that in general most men would not opt for it given the greater "medical burden" - that entails more invasive procedure - as I described - as well as more side effects, bleeding from rectum, penis, etc. and pain as well as having to wear a urinary catheter.

Most men, despite the touted accuracy of results (which isn't in dispute),  will simply not opt for this advanced biopsy unless they are looking for a specific treatment option (e.g. focal cryo-ablation) for which it is required.

Anyway, recovering now, and thankfully with no catheter. I am just waiting for further word on whether I am a candidate for the focal cryo. I will have to meet with Dr. Crawford again in 2 weeks.

See also:


http://www.edavidcrawford.com/video-gallery

Update:

Yesterday (1/24) I received word from UC Health that the biopsy came results came out favorably for further treatment. 5 of 45 cores showed cancer but no scores higher than Gleason 3 + 3. So I am cleared to schedule treatment in about two months.

Bone Scan Scare Passes - And Cryo-Ablation Treatment Is Next

Two and a half weeks ago, as technetium 99m, a radioactive tracer. coursed through my veins, I had little inkling of what would be found some two hours later by the gamma camera, given the Tc-99m emitted 140 keV gamma rays..  After a longish wait, perhaps, ten days, the Urological Associates Nurse phoned me and said the bone scan results came back "mixed" with two suspicious areas identified.

She asked about a possible rib fracture that seemed to appear as a thin dense line in one right rib. I responded that I believed it occurred some 13 years ago when I tripped on a hump in the road while jogging and fell flat on my face. I managed to get up and walk back home but the pain was excruciating, and I had to get flexeril from our then primary care doc. But I never suspected a rib fracture and the doc herself diagnosed it just as a rib "bruise" - meaning the cartilage was bruised.

Anyway, having dismissed that, the Urological RN then pointed to an area in the pelvis which showed "unusual cellular activity". She said it was necessary to now get an x-ray of the pelvic area in order to rule out a bone "met" that escaped. Recall these "mets" are actual prostate cancer cells that have  escaped from the gland and taken up residence in other organs, regions. If indeed a met, as I pointed out in my earlier post (Nov. 21) it would have meant  there was no point doing the focal cryotherapy treatment- or the 3D staging biopsy, see e.g.

http://www.edavidcrawford.com/video-gallery


So now the stage is set to first get the 3D biopsy done next month, and then the month after do the actual focal cryotherapy.

The 3D biopsy will necessitate taking a total of some 62 cores of the prostate while I am under general anesthesia - because you can't be moving at all.  The number of cores taken, as Dr. E. David Crawford told me in our Nov. 16 meeting, is generally twice the mass of the prostate. Given mine,  at the last (MRI fusion) biopsy,  was 31.3 g that means at least 62 cores.

Since the entire gland then swells up in the wake of this "assault" (the usual biopsy is 10-15 sticks) it also means you have to have a catheter in for at least two days. Since I don't handle urinary catheters very well, Dr. Crawford suggest a supra-pubic catheter, which is effected by creating a hole below the navel so the catheter can be placed into the bladder. Unlike the urinary type, this one would have to be removed by medical personnel -so we plan to stay over at least two nights in the neighborhood close to the  university hospital.

It takes about a month for the perineum to heal (the biopsy is done by inserting the needles directly through the perineum, not the rectum) then I return to have the actual focal cryotherapy done.  That will require only one day having a catheter in, so again we will stay at least one night so the same type of catheter can be removed before we depart for home.

It was a relief to receive the follow-up phone call from the RN yesterday saying the x-rays also came out negative, but I am not exactly looking forward to the 3D biopsy and cryo -ablation with two general anesthesia administrations in a row. But as Janice said, the alternative of just letting the cancer be is not much of an option either, and invites metastases that can end up anywhere.

So, it's game on!  I will post after the 3D biopsy to let interested readers know how it went, since there are very few personal accounts of such medical procedures. (In contrast to regular prostate biopsies). In particular, it will be interesting to see the exact extent of any complications - of which I will certainly make others aware.