Examining The Basis For New Prostate Cancer Screening Recommendations

Image from a 3D staged biopsy - the only type that can eliminate false positives.


Many men are confused after the latest shift in advice from the U.S. Preventive Services Task Force's  2012 recommendations against prostate cancer screening.  At that time the advice was less screening, specifically via the PSA test, for men even past the age of 55, noting that the "possibility of the PSA lowering deaths from prostate cancer was very small." .  The reasons were not hard to grasp, mainly that one can get false positives which put the tested person on a track for even more invasive tests including unnecessary biopsies.  These can carry their own risks, including sepsis, impotence.

For example, the standard prostate biopsy consists of an extraction of from 10 to 20 cores of tissue.. Thus, a needle device is inserted into the rectum and each time extracts tissue from the gland after puncturing the rectal wall. The 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.

Even given all this, the biopsy is basically "random" and can miss up to 30 percent of cancerous lesions.  By contrast, the 3D staging biopsy 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 meticulous and exhaustive sampling ensures nothing is missed, hence represents the "gold standard" for prostate biopsies with up to 99 percent confidence of identifying all carcinomas.

The downside is, while vastly more accurate, it entails a far greater medical burden. Thus one must undergo a full surgery prep for general anesthesia, including being asked if you're an organ donor, and to leave an advanced medical directive .  The main risk is for hemorrhage, given the dozens of extractions.

A confirmation of lesion, however, then also is more accurately graded (by Gleason score) and can allow more choices in terms of treatment which one may not have with the standard biopsy. (For example if the standard biopsy reveals a higher Gleason score than the lesion actually merits, as I learned in my own case - after getting the 3D staging biopsy)

Now, in the new advice from the U.S. Preventive Services Task Force for men aged 55- 69, the conclusion is that the benefits of getting the test are marginally enhanced over the risks. This has been ascribed to "additional medical evidence from some clinical studies increasing the certainty about the PSA test reducing the risk of dying from prostate cancer.".   Even so, the panel's qualifying remarks noted the balance between pluses and minuses "was very close", and advised men aged 55-69 to consult their doctors in deciding whether to get the PSA.

Let's note that the statistics show that for every 1,000 men who get screened, an estimated 240 will test positive on the PSA. Some share of these - maybe 10 percent - will show false positives meaning those men will be faced with unnecessary biopsies. Those who decide to get treatment run the risk of developing impotence and incontinence as a result of surgery or radiation.

Owing to these facts,  the Task Force recommendation for those 70 and older stands by its 2012 position that "the benefits of screening do not outweigh the risks". .  The reasoning, again, is that because most prostate cancers are slowly growing, by the time one is diagnosed - say at 70 or 71 - he is still more likely to die from any other cause than cancer. (Up to 50 percent have a form of prostate cancer that doesn't spread or grow rapidly.)

In addition, an older guy getting screened sets him up for even more nasty complications, as well as costly treatments that may not be needed, and in fact are unwarranted. This is assuming such a test is positive with "high PSA" say 5.0 or 6.0.  One is then liable to be trapped in the "rabbit hole" of cancer quandaries summarized by the aspects below:

1) Cancer experts themselves can't agree on which primary treatment is best.

2) The same experts (oncologists) can't agree on which ("salvage") treatment for recurrent disease is best, or when to start it.

3) Most agree that if a guy has recurrent disease and a biopsy shows it has spread to the bones ("bone mets"), his days are basically numbered - though certain treatments (e.g. hormone) will allow some limited life extension.

Now also, once driven into the treatment domain one will have to decide how far to go, i.e. how many and what type of treatments are you willing to get in order to grab maybe ten years of life? Are you even willing to go the medical castration route?

Recall I earlier cited the Prolaris genetic test for the aggressiveness of a prostate cancer tumor,e.g.


I cited my own score of 6.6, corresponding with a 12.5 % specific risk of mortality at ten years. That translated to a 1 in 8  probability of croaking from it if I decided to do nothing.  As my oncologist (Dr. Crawford) pointed out, most guys at age 70 would make that bet.  I'm not doing it because he insists I have a better chance getting rid of the tumor completely using focal cryotherapy. But the point is for many "watchful waiting" might be an equally ok strategy.

Watchful waiting, especially if a guy is younger (say than 55)  - becomes a dicier proposition especially if the Gleason score is 6. By now most everyone has also seen or read of actor Ben Stiller's bout with prostate cancer, e.g.
http://www.cnn.com/2016/10/04/health/ben-stiller-prostate-cancer/

But what they may have ignored is how the treatments and testing can often be worse than anything else - especially if one has a slow growing cancer. The risks of further treatments include sexual impotence and incontinence  The latter means wearing diapers - as in Depends - permanently. This is also why Otis Brawley of the American Cancer Society, has warned that most men need to be very careful before stepping through that testing and treatment door. Nine times out of ten the cancer will be so slowly growing that you can do 'watchful waiting' - especially for Gleason scores of 6 or less.

But ....also nine times out of ten a guy's significant other will insist the cancer come out as in out, out, out. The idea of living with a tumor that can grow - no matter how slowly - is a non-starter.  This is why it's a good idea for men and their spouses to have "the talk" ahead of time, say before the next PSA test. Decide in advance what PSA test value or threshold sets in motion further tests, including the "free PSA" test, MRIs and prostate biopsies (including MRI fusion biopsy.)

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

Biopsy Result Shows Writing On The Wall - Maybe Limited Time To Act

Horizontal -spatial view showing distribution of cancer regions and percentage of cells deemed malignant

The grim-faced urologist entered the patient consultation room late yesterday morning as wifey and I stood up to greet him. Since I already suspected the worst (from an earlier telephone call) I wasn't totally shocked into insensibility when he handed me the summary sheet for the recent MRI fusion biopsy, e.g.

http://brane-space.blogspot.com/2016/09/what-i-got-wrong-about-my-mri-fusion.html

The worst part of the damned pathology report was the Gleason 7 score in one region (3 + 4) with 63 percent of the cells assigned malignant status. My temptation was to try to emphasize the benign regions and the lower (Gleason 6, or 3 + 3) score areas, e.g.

But the urologist wasn't sharing any confidence for non-action. It was clear from these results as well as the associated Partin Table*,


 I had little choice other than to act, or face a possible metastasis of the (currently) confined cancer in as little as 5-6 months. But to establish whether I had even that much time to act, the urologist suggested getting a genetic marker test, made on the biopsy cells - called Prolaris.  This test is designed to indicate whether the cells in that Gleason 7 region are very aggressive, or much less so. If the former, I will have to act much more rapidly.

When I asked how much time I'd have if I did nothing, he hedged, conceding no test could be a crystal ball. However, wifey, who worked for decades in the fields of radiotherapy treatment as well as software testing, warned me the last stages of the disease could be agonizing with bowel and bladder problems, bone fractures and pain that would be enough to make the strongest guy cry unless he was on a diet of opioid pain killers. (Which I hate, since I don't like taking anything more potent than a baby aspirin). So it appeared even Janice was taking the doc's side that I had no choice other than to treat the damned thing.

After fifteen minutes of discussing treatment options, side effects, the choices came down to two: 1) focal cryotherapy, or 2) salvage brachytherapy.  (1) is the "ice ball" treatment that is shown in two videos in the link above. (2) represents a repeat of the treatment I had in San Francisco four years ago but now done in two administrations, at much higher doses (36 Gy a week apart).

The urologist affirmed that he leaned more to (1) given my previous experience with brachy indicated the cancer was resistant to this treatment. That basically meant I might be "nuking" my prostate - including urethra and bowel, for nothing. (But I am still waiting for a full brochure or document discussing the full salvage treatment from UCSF).

I said earlier, with much bravado, I was prepared to do nothing. But that was delivered with the understanding (or assumption) I'd have maybe 7 quality years left. However, if doing nothing means dying in 1-2 years then it becomes a no go, a non option. I might be ready to toss in the towel at some point, but not that early.

If the focal cryotherapy is chosen we have in mind an expert in Denver, Dr. David Crawford, who is also at the forefront of 3D staged biopsy. That will necessitate a meeting with him to see if I qualify and also (likely) another 3D biopsy with full mapping - meaning that he'd take up to 150 core samples while I am knocked out under general anesthesia. Then, a month or so later I'd have the procedure done and stay over in a hotel until the Foley catheter can be removed (hopefully in under a week).

For now it's a watching and waiting game and the pathology slides also have to be reviewed by Dr. Hsu of UCSF. I am hoping on his review he will find that the Gleason 7 region is really a 6 and there are more benign areas than malignant.

But....that may be just wishful thinking.

* Partin Table:

A probability table showing outcomes expected just prior to treatment, assuming it is done in a reasonable time. A table shows the probabilities of the cancer remaining contained in the gland or getting out ("extraprostatic extension") including getting into lymph nodes. Bracketed values shown with it give the 95% confidence values.

See also (for more information on the 3D Staging biopsy and Focal Treatment):

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

Mail Call Brane - Readers Seeking Answers

Could you please complete the solution to the ship problem differential equation in your blog of May 12? I know you started the solution for many of us but I can't seem to finish it! -
Andy K., Omaha NE

Let's pick it up where the partial solution left off.  I.e. you had to integrate:

dv/ (g - av) = dt


To obtain:

ln (g - av) = -at + C



The hint was then provided that you had to obtain the value of  a  to get the integrating factor.

As given in the partial soln.:

(k/m) = a

=   (10, 000 f/s lbs.)/ (4 x 10 ⁶ sl) =  2.5 x 10 ^-3

Now, taking natural logs of both sides of the integrated equation and simplifying::

  v =  g / a    -   B (exp - a t)

But the condition from rest is v= 0 at t = 0,  Þ   B = g / a

So:  v = g / a   - [1 - (exp - a t)]


=  g / a  - [1 - (exp - 0.0025)t]


Then, if  g / a  = 20 f/s, v = 20 [1 - (exp - 0.0025)t]


And from this the terminal velocity can be found.  Remember as v approaches the terminal velocity the second term must approach 0. so effectively the terminal velocity is: v = 20[ 1 - 0] = 20 f/s

Which equals 13.63 mph when converted from  feet/ sec  to miles per hour.


Q. I must have missed something! In your June 4 blog post you explained how the Germans you met at Zugspitze aren't buying Tom Hanks' version of events in what you describe as an up and coming "HBO 13-part series". Could you elaborate a bit because I'm sure I must have missed some back story! - Jake, Oklahoma City, OK

A. This stems from the news last year that Hanks told Truthdig.com in an interview that he intends to "do the American public a service" - because he thinks they "have been snookered into believing that Lee Harvey Oswald was framed."  So, he plans to do a 13-part HBO series to remedy that situation - or so he believes. And he intends to use the mammoth book 'Reclaiming History" by Vince Bugliosi as his "historical" basis. Of course, the book is nothing of the sort, and has numerous problems of fact, history and logic which I already expatiated on at some length, e.g.

http://www.brane-space.blogspot.com/2012/04/vince-bugliosis-magnificent-obsession.html

and:

http://www.brane-space.blogspot.com/2012/04/vince-bugliosis-magnificent-obsession_29.html

and:

http://www.brane-space.blogspot.com/2012/04/vince-bugliosis-magnificent-obsession_30.html

and:

http://www.brane-space.blogspot.com/2012/05/reclaiming-historyor-redacting-it.html

and:

http://www.brane-space.blogspot.com/2012/05/reclaiming-history-or-redacting-it-2.html


Clearly, Hanks' hubris has gone to his head, along with his 3 Oscars and some success in making HBO docu-histories, such as The Pacific. I mean, cripes, the guy actually believes he's chief historian of the country despite the fact he probably can't even pass a basic test on the assassination! See e.g. http://www.brane-space.blogspot.com/2012/05/basic-test-on-kennedy-assassination-can.html

Readers interested in other takes on Vince Bugliosi’s debauchery of history can check out these links:


http://911research.wtc7.net/essays/green/BesmirchingHistory.html


http://realhistoryarchives.blogspot.com/2007/05/reclaiming-history-from-vince-bugliosi.html


Q. I had been on a high T regimen to build more muscle mass, but then last year started to develop pains in my lower back. It got so bad I had to see a doc, and strangely enough, he wanted a PSA test done. Well, I had it done and the result came back at 7.3. He now wants me to get a biopsy but after reading your account of it, and then the treatment options for prostate cancer I'm not sure I want any part of it! I know you will probably say to get it done, including treatments, but do I have any other options here? - Tony M., Sacramento, CA

A. Well, you could try watchful waiting. You don't give your age but that may only be a solution if you're over 65 or so. If you're a young man then I'd say you've got zero options left and you need to get the biopsy. It's the only way to ascertain if you have prostate cancer, where it's located and how aggressive it is.  Readers can see my account of the biopsy I had here: http://www.brane-space.blogspot.com/2012/07/notes-on-prostate-biopsy-dont-fear-and.html

The problem with waiting if the cancer (usually an adenocarcinoma) is aggressive, it that you may run out of options. At least at the early stage, say several cores and no Gleason scores over 3 +3 or 3+4 you have a range of treatment choices. But once the threshold is crossed to Gleason scores 4+3 or 4+4 or higher, you're basically down to the most extreme response which is generally a radical prostatectomy, and often adminstration of androgen suppression hormones afterwards.

My suggestion? Find a urologist or have your physician refer you to one, and get that biopsy! Oh, and leave those gels of T alone!


Q. I want to get your take on some recent responses to Edward Snowden's travels, especially this line that we've heard from Jay Carney, John Kerry and others in the administration:

"Mr Snowden's claim that he is focused on supporting transparency, freedom of the press and protection of individual rights and democracy is belied by the protectors he has potentially chosen: China, Russia, Cuba, Venezuela and Ecuador,"

Margaret S., Cincinnati, OH

A. What you referenced is the usual sort of false analogical rot trotted out by paid lackeys and other servants of the State and other State-System-Big Media actors. Can you take it to the bank? Hardly!  First, Snowden's ultimate and most important objective was preserving his own freedom, as opposed to wasting away in an Army Brig somewhere, being left naked for 24 hrs. a day for weeks (as Bradley Manning was), subjected to intermittent sleep deprivation and fed bread and water (ok, I exaggerate a bit on the last but only a bit). Hence, the choice of where he went must be seen in that light, i.e. with primary goal of avoiding the U.S. 'Gulag 'at all costs - after likely being given justice at the hands of a kangaroo court "grand jury" assembled out of Alexandria, VA (the domain of CIA, NSA, FBI)...

Also, to ensure no intervention he had to select nations that at least had some kind of power or leverage to stand up to a raging Uncle Sam. China and Russia met the criteria, for differing reasons.

The portrayal of both China and Russia as specious destinations for Snowden is absurd: China is now our leading trade partner for Pete's sakes - also our leading lender for all those Social Security, DoD and other monies! Russia assisted us with the apprehension of the Tsarnaev brothers, real terrorists!  Also, keep in mind Hong Kong wanted him out asap. He was a  PR liability and it was only on account of large pro-Snowden protests from thousands of people (and maybe some slight arm twisting from the mainland)  they laid off him, and let him leave HK for Moscow. Let's also bear in mind that China is now the largest capitalist nation in the world, and basically our banker! So, if we are calling down opprobrium on that country,  WTF are we doing taking out loans for military weapons from them etc.? Talk about hypocrisy (but of course, that's our nation's biggest export) - see also: http://www.smirkingchimp.com/thread/greyraven/50300/america-the-land-of-stupendous-raging-hypocrites

As for Russia, Putin also isn't exactly enamored of having Snowden holed up there at Moscow’s Sheremetyevo Airport. Note also: the airport is not on Russian soil, so technically Putin isn't obliged to extradite him, or indeed, pay any attention to a huffing and puffing bunch of Amerikkan hypocrites who seem to forget or ignore their own lawlessness the past 12 years, including starting illegal wars violating Article IV of the Nuremberg laws, see also:  http://www.smirkingchimp.com/thread/robert-scheer/50246/the-good-germans-in-government, not to mention violating the Geneva conventions with rendition and torture (water boarding).

As for Ecuador, I have news for the Amerikkan bigots and hyper-false patriots: Most of Latin America and the Caribbean sees us as a Yanqui gangster state after the  CIA assisted some reactionary Venezuelans (including Luis Posada Carriles, a former CIA agent)to  blow up a Cubana Airlines passenger plane over Barbados on Oct. 6, 1976.

One thing to take away from all of this: the US of A is not as pure as the driven snow as it claims or portrays itself. It also has supported terrorists, as in Honduras and Guatemala in the 80s, and also helped bring bin Laden to fruition by leveraging him against the Russkies when they invaded Afghanistan n 1979. But see, then it was convenient and expedient, to advance U.S. geopolitical objectives. Never mind the geopolitical strategies, a terrorist can be a state actor and hide behind all kinds of excuses, rationales.

Imho, the worst calamity to happen to the world was the collapse of the bi-polar equilibrium that prevented one country from gaining too much hegemony and power in the world. That happened with the collapse of the Soviet Union. Given that one big "superpower" now tries to rule everyone, it's no surprise a lot of smaller players- and even big ones-  would like to jab a finger or two in its hypocrtical "eyes."

Most interesting to me has been who exactly has come out on each side. It's now become much easier to tell the pro-state purveyors of deceit and character assassination from real patriots invested in protecting liberties. Ed Schulz, for example, is now dismissed by me as a bloviating propagandist having called Snowden a "punk" and demanded his return and prosecution. Chris Hayes, meanwhile, has been pro-Snowden - if not as outspoken as some others. But his intelligent take gets kudos from me. Rachel Maddow? I've no idea where she sits because she's presented some segments on her show but hasn't disclosed her position. Nice and coy, and safe!

The media corporo-pundits  like Aaron Ross Sorkin and David Gregory? Blow dried hacks, both of whom ought to be sent to Komodo Island on one way tickets - mainly to provide protein for the giant reptiles there. Oh, and you can toss Dianne Feinstein into that stew too, along with John 'Wuss' Kerry and Dick-head Cheney!

Mail Call Brane - Readers Seeking Answers!

(Note all the following questions were received in 'comment' format but with the askee requesting no special comment space rather the question(s) collated into one blog ....this one!)

Q. President Obama in response to a question yesterday at his news conference stated that one can't be sure if superstorms such as Sandy are really caused by climate change. What is the take of the climate science community on this? - Roger B., Minneapolis, MN

A. This is a tricky question, and Obama can be forgiven for dodging it in a way at his press conference, because let's face it: most of the press corps possesses the attention span of gnats.

The truth is that one aspect of climate change does show a causal relation to the genesis of Superstorm Sandy. That is the phenomenon known as the North Atlantic Oscillation (NAO) and its geographical distribution at particular times of the year. The NAO embodies the atmospheric pressure over a particular region (in this case it was the U.S. northeast) and it can be either 'positive' or 'negative'. In the case of the latter, which was what we observed preparatory to Sandy's arrival, the jet stream displayed a pronounced southward dip. In a positive display the jet stream would have more straddled the higher latitudes (e.g. 45N) and not bent so far south.

Now, here's the kicker: research by Charles Greene at Cornell University and other climate scientists has shown that as more Arctic sea ice melts   e.g. in the summer because of global warming (as I noted before, see my blog of  Sept. 21) then the NAO is more likely to be negative, i.e. jet stream sloping way south. This condition then set the stage for a superstorm in two stages: 1) the warm Atlantic water off the eastern U.S. coast fed energy into the system, and 2) the encounter with the cold air ensconced in the southerly jet stream added the energy equivalent of 5 single megaton nuclear bombs to the system and dramatically expanded its reach - incepting the massive destruction we beheld.

We can predict then, that if northerly moving hurricanes become a more common feature, as does a continued negative NAO, then we will see more superstorms like Sandy. The east coast and its cities will then have to decide whether or not it will spend the money, as the UK has, to construct a massive system of dykes etc. to ward off the storm waters, waves. If not, we better have no more wars, because we're going to need all that money for constant rebuilding!

Q. Reading about your brother ('Fighting Cancer, Fighting Your Brother') I can't believe you had to put up with all his crap while you were recovering from prostate cancer! What gives with the dude? Is he 52 cards short of a full deck or just ornery or what? - Mitch C., Stanford, CA

A. Well, what would you think of a guy that once circulated an idea to put all atheists in the country on a "national registry" like sex offenders?  Granted, he had to be saved from himself (he received over 400 death threats via email from outraged atheists across the world) but all that meant is that he shut down the 'Pastor Mike' blog and started a new one ('Straight Talk with Mister Mike'). The bottom line is I don't know what his main problem is, but as I said in blogs from a few years ago, I suspect IF he has mental issues they arise from believing an insane fundamentalist brand of religion. His 'god' - if you can call it that, is totally batshit insane, since it has no problems allowing a son to be killed for mouthing off against parents - as per Deuteronomy 21;18-21, or adulterers (say like Petraeus and Broadwell) to be stoned to death by Deut. 22:22 or chldren to have wild bears set loose on them if they mock "prophets". (By 2 Kings 2: 23-24). Oh, his god also approves of genocide when it means "cleansing the earth" - as in Gen. with the slaughter of the Canaanites.

As I've said many times before, tell me the concept of god in which you believe, and thence the morality you uphold,  and I will forecast your odds of going nuts. Indeed, I can tell how much of a nut you already are. If you accept or believe in batshit crazy gods you will be a batshit crazy person, and likely end up in a straight jacket on thorazine, if not in some other horrendous end.

Q. I read your blogs on prostate cancer with great interest. My husband, age 43,  recently had a biopsy and it came back with four cores at Gleason 3+4. He's in a dilemma as to the treatment but as in your case, the urologist said watchful waiting wasn't an option. He dreads all the post-operative issues to do with surgery including difficulty with sexual relations, but isn't sure about radiation either, and doesn't want to face the prospect of having the cancer come back after having done the radiation. Any ideas, suggestions?  - Marilyn F., New Orleans, LA

A. In the end the choice of treatment is a highly personal one. Apart from the information already given in the blogs, I can only suggest he obtain the two books cited as well: 'The Invasion of the Prostate Snatchers' and John C. Mulhall's  'Saving Your Sex Life: A Guide for Men with Prostate Cancer". (Note: Dr. Mulhall is the Director of the Sexual & Reproductive Medicine Urology Service based at the Memorial Sloan- Kettering Cancer Center.) Mulhall's focus is also highly on the issue of "penile rehabilitation" : http://brane-space.blogspot.com/2012/10/penile-rehabilitiation-what-most-docs.html .

The aversion to post-op problems following surgery is understandable. Incontinence and erection problems are often mentioned (but the solutions to these were given in the blog link, based on Mulhall's book) but the acute or short term problems are also turn-offs for many men: including risk of infections, having a catheter inserted in the bladder for possibly as long as 3 weeks, coping with the pain, constipation arising from use of pain meds, and risk of rectal injury during bowel movements because the rectal wall becomes much thinner following surgery - after removal of the prostate which originally adjoined the rectum. All this is detailed in the UCSF Patient Guide for Radical Prostatectomy which also includes sections dealing with sexual recuperation, other treatments -meds for incontinence, etc.

I chose the high dose rate brachytherapy because: 1) I didn't wish to be laid up weeks with post-op difficulties or catheters, or bowel problems, 2) I didn't want to be possibly faced with months or years of incontinence limiting my travels, freedom, and 3) I didn't want to go to extraordinary lengths for "penile rehabilitation" including having to have an implant operation, or reduced to continually using Viagra, vacuum pumps or injections. But again, each man has to make his own choices!

Q. I found your blog on solar oblateness fascinating, and wondered if you would be so kind as to provide the oblateness formula for the planets from Earth outwards.to Neptune. Thanks! - Mick, Trenton, NJ

A. The oblateness formula depends on the planet's equatorial diameter, a and its polar diameter, b. Then:

f = (a - b)/ a

The values are as follows for Earth outwards to Neptune:

Earth: 1/ 298.257

Mars:  1/ 154.409

Jupiter: 0.06487

Saturn: 0.09796

Uranus:  0.02293

Neptune:  0.0171


Q. If your Aug. 22 blog on 'the biggest spy center on Earth' is to be believed, Gen. Petraeus had much to worry about churning out all those emails. Should he have known about this spook kingdom and how they can scoop up emails, tweets on a whim? Or was he just dumb? - Andy K.,  Tucson, AZ

A. I don't believe the general was 'dumb' but perhaps in the heat of his affair his brain cells didn't process that anything committed to cyberspace or that gets infused into the 'cloud' - is there for years for any spook to grab, save and see. In the blog you referenced, I specifically mentioned (from the cited WIRED piece, 'The Black Box'):

"The mammoth Bluffdale Center will have another important and far more secret role that until now has gone unrevealed. It is also critical for breaking codes. And code-breaking is crucial because of the data that the center will handle: financial information, stock transactions, business deals, foreign military and diplomatic secrets, confidential personal communications, legal documents and anything else initially heavily encrypted."

I also added:  "Everyone's a target, everybody with communications is a target."


So, it boggles the mind that Gen. Petraeus could have been that careless. Also, virtually anyone that spends any time on the net has to be aware that the FBI's "Carnivore" program - for ferreting out emails- is still in play. Also, the 4th amendment protections against extraordinary searches have essentially vanished since the critical provisions of the Patriot Act (mainly to do with wiretapping without the need for warrants) have been extended twice (by Democrats and Repubs - at least it's one thing they can agree on.)

My advice to anyone is that if you don't want the spooks to be amassing all your (saved) Facebook pages, blogs or tweets, then the best step is not to post them. If you don't care, it's no biggie. Btw, for those who want to learn more about the national security state we've erected (to keep us "safe") since 9/11 be sure to get hold of James Bamford's book: The Shadow Factory: The Ultra-Secret NSA from 9/11 to the Eavesdropping on America.

Confronting the Cancer Demon....Full Speed Ahead!

 Being taken through the ins and outs of a prostate biopsy result, clinical all the way, is a weird experience. Weird because for the first time, in living color, you're coming "face to face" with what is growing - otherwise unseen - inside you. Something that if left to itself, will surely kill you and as totally, painfully and miserably as almost any other cancer.....maybe just short of the misery of pancreatic cancer. But there it was, one photo-micrograph specimen of two 'cores' (in glaring reddish stain, with menacing looking, ragged cell borders)  bearing Gleason scores (3 +4 = 7) . The two most malignant "fragments" occupied the mid lobe and apex, respectively and with 20% extent meaning the tumors in those areas are now 6mm (or a quarter inch wide) and growing.

(Aside: Btw, the nurse gave the Gleason scores incorrectly: There were actually SIX of twelve sample cores with abnormal cell manifestation, and five identified as malignant. Two samples had 3 + 3 = 6 Gleason total, and the other two (noted above) had 3 + 4s. )

When I asked the urologist if there was any option for "watchful waiting" he said that based on his 20 years experience, including at Johns Hopkins and Mayo Clinic, no. The tumor doubling time for a 20% volume wasn't known for certain but he didn't leave out a potential of once every six months in which case the whole prostate might be occupied by tumor in 2 years and might break out to the lymph nodes and bones in three. In other words, discomfiting or not, it was a damned good thing I did get the biopsy done and didn't hesitate any longer.

I was also frankly amazed that when I mentioned my preferred choice of treatment (HDR monotherapy) the urologist didn't express dismay. As he put it: "Unlike some docs who get their noses out of joint because a patient chooses a treatment outside their own specialty, I don't!" That was very satisfying, also when he volunteered his assistance in case any problem arose in the aftermath.

By the way, the use of "seeds" is not where the UC- San Fran. monotherapy is at. They now have a method of HDR treatment planning in which nothing - no seed - is left inside ....for its radiation to decay. Instead, the needles are themselves radioactive - each bearing a designated, pre-computed dose - and are inserted into the affected areas of the gland (through the perineum) then removed daily. The treatment for needle insertion is generally done over 3 sessions, occupying two -three days depending on one's tolerance for the pain, discomfort. (You are also given control of the pain, according to wifey, by being allowed to squeeze a morphine drip to get relief any time needed. I've never taken morphine before but be assured if I need it I will use it! I ain't worried about "addictions" like so many are in this country and why many drs. are pain amelioration averse.)

The urologist will be sending all the biopsy results and slide histology over to SF today or tomorrow, and on calling my Medicare Supplement insurance company - found out they are A-ok with going out of state for treatment. So, depending on how soon the clinical assessment is done, and the availability of seats (using accumulated  free miles), we will be on our way. I always wanted to see the Redwood forests and Golden Gate Bridge....as well as Haight-Ashbury!

More than likely this won't happen before September, maybe the first or second week. We will probably miss the start of the NFL football season for our teams (Ravens and Packers) but hey, that's what DVRs are for.

Am I looking forward to it? Not all of it, but then you gotta do what you gotta do. Guys, here's another object lesson for you: When wifey nags you to go in for that PSA test or biopsy do not fob her off. She has your best interests at heart. Yeah, the biopsy was bloody uncomfortable in parts, but tolerable and no where as bad as the outcome had cancer taken over everything.

Do what you have to do!

Verdict Is: Prostate CANCER......So Now What?

Well, 12 days had elapsed and to be truthful, I had been living in a "fool's paradise". I believed the old saw that no news was good news, and that with almost 2 weeks gone past the prostate biopsy the only reason the urologist hadn't called by now was the result had to be negative. Wrong conclusion! The urologist was actually out of town on an 'emergency' for a week so was incommunicado. But he did call today, actually his nurse, and informed me that 5 of the 12 extracted tissue samples were positive for cancer - with two of the samples displaying high Gleason scores, of 6 and 7. That means the malignant cells are aggressive. The good news is they're contained and relatively localized.

I am scheduled to meet the urologist tomorrow at 10.15 a.m. and he will discuss my options at this point. I do know he is a Da Vinci robotic procedure specialist so will be eager to go that route. However, my reaction will be 'Not so fast'!

After reading the account  ('Hello, Prostate Cancer') of Dr. Steven B. Mason in the latest issue of the Region VII Intertel Newsletter, I definitely do not want to go that way. Not with excruciating pain, with 12 weeks of post-op recovery and being basically hobbled to the point of a cripple. Mason noted that one ("not uncommon") complication he had was a "pelvic abscess" and having to go back into the hospital after 8 weeks "with a drainage tube poking out of my belly a second time".   At the end of his 12 -week ordeal (which he says he'd never have gotten through without a mate) he states he retained urinary control, but many sources suggest rates of incontinence approaching 50% after Da Vinci robotic surgery. It ain't as neat and straightforward as many have been led to believe.

The options? Well, proton beam therapy (which is VERY expensive, averaging $48,000 a treatment) and HDR brachytherapy - for which my wife was an expert treatment planner before retiring. The HDR stands for "High Dose rate' and it entails a procedure in which radioactive seeds (usually of Iodine) are implanted into the prostate by way of hollow needles through the perineum. The implanted seeds then release specified doses of radiation to the affected region and thereby kill the cancer cells. (This is also the method that Warren Buffet has elected to use in treating his own prostate cancer.)

We just talked on the phone to a guy (who used to work with wifey)  and had HDR monotherapy done last year, at the Univ. of California - San Francisco, and he said it entailed just three sessions - each in the hospital - over 5 days total, and there have been no side effects, whether to urinary function, inflamed  rectum or other. He said the only incidental discomfort was from a reaction to the local anesthetic but that this was unusual. The great thing is he was up and about in just a week as opposed to being laid up like an invalid on pain killers for 12 weeks.

Of course, negative nabobs note that if the radiotherapy doesn't work then your pelvic area will possibly be too damaged to then have surgery. But hey! Them's the breaks of the game! Nothing is assured, as I am finding out. Even PBT or proton beam therapy can have its nasty side effects including the need for resection of intestines or even needing evacuation (ostomy) bags worn permanently if the treatment goes awry. Surgery meanwhile invites high rates of infection, including from prolonged use of catheters, as well as possible strokes. Not everyone walks away from it unscathed, or clean as a whistle.

You basically take your pick of treatment, go with it, and (hopefully) live with it without regret. But there are no ironclad guarantees. Anyone who wants such guarantees has no business living. Life is a crap shot each time you wake up in the morning. Ask those people still recovering after going to the Batman midnight movie premiere in Aurora, CO ten days ago.

So I will let blog readers know what the upshot is from the meeting tomorrow. In any case, I also have other medical issues to deal with as well including a possible perforated eardrum. (For which I have to see an ENT specialist on Thursday).

When it rains, it pours!

No Reprieve, No Alternatives! Biopsy Forthcoming!

The appointment at the urologist's this morning  (10.15) lasted at least a half an hour and included a review of family history (no prostate cancer) as well as previous infirmities, afflictions - from bronchitis to high blood pressure. Also a physical exam, which was passed with flying colors (i.e. no unuusal or abnormal growths, or enlargement of gland in question and no other evidence of anything amiss). These were all good signs, but alas, not enough to convince the urologist to leave out a biopsy.

His primary concern was the unrelenting increase in the PSA (doubling from 2.8 to 5.6 in a year, then increasing again to 6.1 in 3 months, and again to 6.5 in 3 weeks - registered in a most recent blood test that also found a low free PSA percent of 5.1. In combination, he said, all the numbers pointed to biopsy. There was only left the matter of scheduling it.

A range of dates, times was available at the front desk, but since the longer the time the longer the build up of anxiety, I decided to arrange it for next Wednesday morning, at 10.30. This would be the day after my last physical therapy session (for a strained lower back muscle) and also leave ample time to finish necessary chores ....like mowing the already overgrown lawn.

Also at the desk I was advised by a nurse of all the things which had to be done prior to the procedure, including filling prescriptions. The key one is for the antibiotic, Levofloxacin (500 mg), one of which is to be taken 1 hour prior to the procedure and the other the next day.

The issue of antibiotics and their potency is an especially critical one for me, as my wife had to be hospitalized twice for c. diff. infection in late 2006, and early 2007, after taking only four days of Augmentin.(Augmented Amoxycilliin) for a sinus infection.  This high potency antibiotic essentially erased nearly all her "good" gut bacteria, leaving her prey to clostridium difficile, which had her running to the toilet 22-25 times a day for over a week, until she had to be hospitalized for treatment....ending with vancomycin - the only thing that would stop it.

On questioning the urologist about the antibiotic prescribed and possible risks of acquiring c. diff. he assured me that its emergence was more an issue of duration of use. And since I am only on it for two days (as opposed to the normal three or four) there was little chance of redux situation, with me now as the 'star'. He didn't rule out, however, adding yogurt and acidophilus to my diet to ramp up the good guys in the gut. Just as an extra precaution and because I also likely have latent c. diff. spores in the gut.

Also emphasized by the RN was the importance of following instructions on administering an "Adult FLEET Enema"  2 hours prior. The accompanying biopsy fact sheet and summary states in loud caps: IF YOU DO NOT USE AN ENEMA YOUR APPOINTMENT WILL BE CANCELLED! Fair enough! It's probably not as bad as the "cleansing" one must undergo before a colonoscopy, drinking all that disgusting pineapple tasting stuff - then having to sit on the can for eight hrs.

Before the actual procedure I have to provide a urine sample to rule out any urinary infections. Immediately before the actual biopsy there will also be an ultrasound examination, in which an ultrasound probe is inserted into where the sun don't shine. Transducers on the end of the probe then will send sound waves into the prostate. When different textures and densities are encountered to those deemed normal, the waves are reflected back to the transducer. A computer then measures the time for the sound waves to travel out and back, dispatching the information to the urologist.

The importance of the ultrasound can't be overemphasized, as it can well reveal conditions (not cancer) that are present and may have incepted high PSA readings. These include: inflammation, cysts, vascularity, and prostate stones. (One must magine they're somewhat like gall stones except maybe a lot smaller!)

Finally, the biopsy is done by insertion of a spring-loaded device (through the ultrasound tube)  which injects ten fine needles, five on each side of the prostate. The end of each needle snatches tissue each time, which is recovered as a sample for the histology. Ultimately, that histology will be scored on what's called a "Gleason score" with 5 being the highest....and also indicating the worst, cancer. Two samples bearing cancer cell histology are then added together to yield  the total score. What you do not want to see is anything like a '10' which basically means your choice of options for treatment is pretty limited.

I am hoping for a 1, 2 or better, 0! Anything to avoid a next round requiring treatment that can leave you in a hospital and with surgical risks, not to mention having to deal with urinary catheters, associated infections!

As for the pain aspect, the urologist was most sympathetic since not all males experience pain, but many do (leading 1 in 3 to never have a biopsy again!) The difference is attributed to whether the injecting needle hits a nerve or not. Contary to some myths, the prostate is not unenervated! It's got nerves all right, it just depends whether the biopsy needle hits 'em or not! If not, the guy brags he felt no pain. If they do, the guy goes into a ball and lets out a primal scream vowing no more tests....ever.

Anyway, I will be allowed to have a light sedative (versed) during the procedure....and yes, my wife can be there too! Perhaps the ideal nerve-calmer of all!