The Log of Moira

Prostate Cancer (November 2008 – April 2009 et seq.)

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These are mostly Larry’s remarks. Susan’s notes are indicated thus <Susan: blah blah blah.>.


In our last installment (December, 2008), we were visiting Antigua Guatemala, and the Mayan ruins at Tikal and Yaxhá. It was our intention to leave Guatemala on Moira in early 2009, work our way through the offshore reefs of Belize, the Yucatán of México, up the East Coast of the US, and spend the summer in Maine.


A funny thing happened on the way to Belize.


This installment of our website will feature no pretty pictures (the staff photographer was preoccupied), and will discuss subjects not suitable for conversation at the dinner table. Those with weak stomachs will want to wait for our next installment.

PSA: Fair Warning

In November of 2008, Susan and I visited Southern California for, among other things, our annual checkups with our physician, Dr. Michele Ryan. During that exam (November 3rd of 2008), I had the usual Digital Rectal Exam (DRE) test that is one of the indignities of being an Older Male, and the Prostate-Specific Antigen (PSA) blood test, both of which are used to find evidence of prostate cancer (PC). The DRE was negative (seemed normal), and I was back in Guatemala on November 13th, before the results of the PSA test caught up with me. Then Dr. Ryan called me with the PSA results, and they weren’t reassuring.


The prostate is a walnut-sized gland that lies in the male pelvis, just in front of the rectum. The urethra (coming from the bladder) leads through and is enveloped by the prostate, rather the way the core of an orange is enveloped by the orange.


Prostate cancer is the 2nd most common cancer in American men (after skin cancer), and age and genetics are the most significant known risk factors for PC.


Prostate cancer is the most common non-skin cancer in America, affecting 1 in 6 men… Although only 1 in 10,000 under age 40 will be diagnosed, the rate shoots up to 1 in 39 for ages 40 to 59, and 1 in 14 for ages 60 to 69. (Prostate Cancer Foundation)


Prostate cancer… “is the second leading cause of male cancer deaths (after lung cancer)…throughout the Western world. …The risk of the disease is greater than that of breast cancer in women.” (Scardino and Kelman, Dr. Peter Scardino’s Prostate Book, p.93)


“20 percent” of “men whose biopsy results lead to a diagnosis of clinical cancers”… “will eventually die of the disease.” (Scardino and Kelman, p.102) “If you are an American man, your lifetime risk of being diagnosed with the disease is 1 in 6, and the chance that you’ll subsequently die of it is 1 in 28.” (op. cit., p.113)


The PSA test has come under fire for its high rate of false-positive errors (where the test indicates that there is cancer, but there isn’t).


Most men with an elevated PSA test result turn out not to have cancer; only 25 to 35 percent of men who have a biopsy due to an elevated PSA level actually have prostate cancer. (National Cancer Institute).


My PSA score had been hovering in the range of 3-3.34ng/ml for some time, but my test in November came back at 4.19. That number by itself was not alarming. The normal threshold for concern for a 60+ male is about 4.0, and a 4.19 was still likely to be a false positive. But the jump in the PSA level was cause for concern (anything more than about 0.75ng/ml/year is a red flag: Scardino & Kelman, p.146). In the spirit of “better safe,” we began looking for an opportunity to make sure, which would require a prostate biopsy.

Biopsy: Confirmation

PC usually proceeds slowly. Most men who are diagnosed with PC eventually die of something else (heart disease, etc.). It has been argued that after some age, perhaps 70 or 75, there’s no life-extending value to a new diagnosis of PC, and that at some point, the PSA test does more harm than good. If, for example, on some date a man has an actuarial life expectancy of 10 years from that date, and is diagnosed with PC that if untreated is likely to take 15 years to kill him, what has been gained by the diagnosis, and what is to be gained by treatment? Those are not rhetorical questions. When analysts say that universal PSA screening has resulted in PC being “overdiagnosed” and “overtreated,” this seems to be what they mean—if something else is going to kill the guy, why treat the PC, with the attendant expense, anxiety, medical risk, and probable quality-of-life issues? The same arguments are being applied to breast cancer screening.


Because PC usually proceeds slowly, there was no great urgency to get the biopsy. Dr. Ryan indicated that she “could live with” a delay in getting the biopsy done until April, when we planned to be back in the States. As it turned out, through the American Embassy in Guatemala City, we were able to find an excellent urologist in Guatemala City, Dr. Victor Sandoval Shannon, who had very good English, and who was able to accommodate us in early January.


As part of the work-up to the biopsy, the lab in Guatemala City repeated the PSA test. Their test reported that my PSA level was in the 4.4 range. There is a related blood test, called “free PSA,” which is not commonly used in the USA (in my experience), and which reduces the percentage of false positive PSA tests. For the free PSA test, the results of which are expressed as a percentage, higher is better. My free PSA was 9%, which is quite low. Things were not looking up. I try to live without hope in such matters—if one does not hope, one does not suffer disappointment.


After putting myself through a revolting regimen of enemas and laxatives, plus some prophylactic antibiotics, we took a cab from our hotel in Guatemala City at a grim, dark hour of the morning to the admitting lobby of the hospital Sanatorio Nuestra Señora del Pilar. We learned to no surprise that they wouldn’t accept our US-based insurance (we put the charges on our credit card, and eventually got reimbursed by submitting the paperwork to the insurers ourselves).


<Susan: We have talked before of the importance of Spanish skills in Central America. The hospital experience was typical of that. The staff of the hospital spoke only Spanish; the occasional doctor or resident spoke some English but not much. The nun who came to pray with each patient spoke only Spanish, and was not reassured when we did not answer back in Spanish. Larry’s Spanish is very good but we both had to discuss some of the nun’s questions before we could come up with an appropriate response. Something about hearing Spanish in a hospital that was treating us was disconcerting to our normally-faster responses. Larry shared the pre-op room with another man whose wife was there as much as I was. She would pitch in occasionally, translating the question for us, much to everyone’s relief.


The hospital facility was one of the best in Guatemala City. It looked and felt like a small American hospital. However, there were some differences which Mr. Obama’s health team may want to consider. Take thermometers for instance. This hospital used disposable mercury thermometers. Larry’s temperature was taken quickly and correctly. In the City of Hope hospital, an electronic thermometer was used that was brushed across the front of the head and face. It did not enter the body at all. Very neat, even like “star wars”. What I question is the probable $1000 difference in the cost of the equipment. It’s time to consider whether this difference makes any sense in treatment and experience. There are dozens of other examples.>


After some predictable institutional hurry-up-and-wait, I was wheeled into a small operating room, where I chatted with the anesthesiologist (who also had excellent English). When Dr. Sandoval Shannon arrived, they stuck a needle into my IV and put me out.


The prostate biopsy is done by using some hollow needles, one to two dozen, to withdraw tiny tissue samples from the prostate (the typical biopsy removes something like 1/500th of the prostate). The procedure consists of dilating the anus and inserting the needles through the forward wall of the rectum into the prostate, which lies just in front of the rectum. I’m glad I was asleep! Some doctors use only a local anesthetic. One of the urologists we spoke to about the procedure indicated that with a local anesthetic the process would be “uncomfortable.” I can well believe.


I was released from the hospital the same evening, and we headed back to Moira (a six-hour bus ride) the next day. Recovery was relatively quick, though my bowels took some time to re-establish regularity: the antibiotics had killed off all of the normal, beneficial bacteria, and things took a while to regroup. It was a little disconcerting when my first ejaculation after the biopsy was coffee-colored.


Three days after the biopsy, Dr. Sandoval Shannon called with the pathology report: microscopic examination of the tissue samples had found abnormal cells. I had prostate cancer. This was no false positive.


I suppose that at that instant I became a “prostate cancer survivor.”

Options: Surgery, Radiation, etc.

The results of a prostate biopsy are graded in what’s called the “Gleason score,” which attempts to quantify how aggressive the cancer is. Cancer cells are examined under a microscope to determine how aggressive the cancer is: more aggressive cancers have cells more irregularly shaped. The cells are graded on a scale from 1 to 5, 5 being the most aggressive cancer. Generally, there are several types of cancer cell present, and the final Gleason score is the sum of the grades of the primary (predominant) and secondary patterns, so the Gleason score can vary from 2 to 10, with higher being more aggressive. My cancer was a Gleason 7 (3 + 4), which is sort of on the border between “bad” and “really bad.” In addition, the fraction of samples that show cancer is gives an initial estimate of how far the disease has spread within the prostate. In my case, about half of the samples showed cancer.


Update, 12/2014: Via the “New” Prostate Cancer Infolink: “The NCCN <National Comprehensive Cancer Network>  intermediate risk group is currently defined as including patients with any of the following characteristics:



(If multiple risk factors are present in a specific patient, the clinician may optionally deem such a patient to be high risk.)


<Dr. Anthony> D’Amico advocates for the intermediate-risk subgrouping proposed last year by Zumsteg et al. (from the Memorial Sloan-Kettering Cancer Center):


Unfavorable Intermediate Risk

Favorable Intermediate Risk:


Based on this updated scheme, my cancer would have been classified in the ‘Unfavorable Intermediate Risk’ category, due to 50% positive biopsy cores and ‘multiple NCCN intermediate risk factors.’


Because my cancer was detectable by DRE, but the tumor seemed (by feel) to be within rather than on the surface of the organ, it was described as a “Stage 2” (T2 stage). That staging (which attempts to quantify how far the cancer has advanced), combined with the relatively low absolute PSA number, meant that the cancer was probably confined to the prostate (had not metastasized) and that either surgery or radiation would likely get it all. When a prostate cancer is detectable by a DRE, the odds of metastasis go up, and once the tumor appears on the surface of the prostate, the odds of metastasis go way up; radiation therapy can become the preferred treatment, and other treatment options such as hormonal therapy become more appropriate.


A calculator called the Partin Tables is available to predict (before treatment) the odds that the cancer has progressed beyond the organ itself, given the Gleason score, PSA levels, and staging numbers. Those odds are used to inform the decision on the course of treatment.


We sent the report on the biopsy to Dr. Ryan, our physician in Southern California, along with a request for guidance. She responded with the names of several surgeons and radiologists in the Southern California area. There are many tradeoffs involved in the choice of a PC treatment strategy, and she wisely left us to make our own choices.


A conventional analysis of my case would focus on the following elements:


After a lot of internet-based homework, we felt that at least part of the question was resolved: I chose to go with complete surgical removal of the prostate (radical prostatectomy, or RP) over radiation treatment. There were two elements to our decision. First, the rate of complications and side effects for RP seemed to be somewhat lower than for radiation treatment. Second, and more importantly, radiation treatment is a decent backup if there is a recurrence after surgery, but surgery is a poor backup if there is a recurrence after radiation treatment. Always be thinking about Plan B.


Disclaimer: the technology of PC treatment is in constant flux, with new tactics and new technologies frequently being introduced. Each new technique needs time to prove itself, work the bugs out, and build a track record. Most importantly, practitioners need time to develop experience with how to bring out the best in each technique. We chose as we did based on the information we had at the time.

Quack, Quack

“News gets around, when it’s bad.” –Eileen Quinn


So I was chatting with someone who asked why we were flying back to the States, and I told her. Her response was “Oh, you don’t want surgery! I know a man who was cured of prostate cancer through prostate massage!” Hmm, OK.


One of the problems with assessing new, alternative treatments is that virtually every man diagnosed with PC lives at least five years after diagnosis. It’s when one approaches the decade mark that one begins to separate the quick from the dead. If someone studied eating spaghetti as a cure for PC, and followed such patients for five years, spaghetti would have a pretty good survival record.


90 percent of men diagnosed with the disease survive for ten years regardless of what they do. Demonstrating that watchful waiting confers the same survival advantage as surgery or radiation at eight years after diagnosis is not meaningful. You could show a similar survival rate for men who played poker, watched football, or read People magazine. (Scardino & Kelman, p.233)

Surgery: City of Hope

Radical prostatectomy is mostly divided into “open” or traditional RP, and “laparoscopic” (LRP) surgery. In open surgery, a vertical cut is made from the navel to the pubis. In laparoscopic surgery, four or five 1” incisions are made in a rough arc from hip to navel to hip, and a longer incision (3-4”) is made horizontally at the pubis. Laparoscopic surgery may be manual or robotic-assisted (RALP or RLRP).


In early March, we flew from Guatemala to Los Angeles. We interviewed the two surgeons whose names Dr. Ryan had given us. She considered them to be the top practitioners of their respective (open and laparoscopic) techniques in Southern California. We came away from the interviews with a deep respect for both men. I’m sure that either of them would have done a fine job. I would encourage men who are going through the same decision process to consider that the experience, skill, and track record of the surgeon are more important than the specific technique. Find a surgeon who has done hundreds of prostatectomies with the technique you’re talking about. The learning curve for open RP seems to flatten out after about 500 surgeries, the learning curve for laparoscopic (non-robotic) surgery after about 700 or so, and the learning curve for robotic RP (and here) at maybe 250 surgeries, though these numbers are not strictly comparable, and estimates vary widely. Do you really want to be some surgeon’s training cadaver? (Note: quantity is no guarantee of quality—some surgeons don’t learn from their mistakes, so check your surgeon’s outcomes with the technique you’re considering. But inexperience with a technique definitely raises the odds of problems.)


We chose to go with Dr. Mark Kawachi at the City of Hope (COH), in Duarte, California, the leading practitioner in the Los Angeles area of robotic-assisted (“Da Vinci”) laparoscopic prostatectomy (RALP/RLRP). Since we were from out of town, Dr. Kawachi was kind enough to rearrange his schedule to accommodate us, and scheduled surgery for me about two weeks after our interview. <Susan: Dr. Kawachi argued that the tools he used resulted in less blood in the “field of vision” than the open surgical approach, giving the surgeon the benefit of a clear “field of vision” for the surgery. It sounded good to us but the articles we read on the supposed differences lead us to the conclusion that the real determiner of the outcome was the skill and experience of the surgeon involved. More time may lead to stronger data supporting one approach over the other. For now RALP/RLRP appears too new (less than ten years) for reliable statistical comparison of outcomes with open RP.>


The City of Hope is a huge campus in Duarte, California, at the north end of the Los Angeles basin. Although they treat other diseases, the largest part of their work is the treatment of cancer. The complex is large enough that, at least for the first visit, a volunteer is assigned to steer one through the maze, else one might be lost forever in the warren of hallways and buildings.


The size of the operation leads to an odd inconsistency in the patient’s experience. On the one hand, COH is a factory. Get in the queue, take your turn, endless labyrinthine corridors, wait without it being quite clear what one is waiting for or when it is likely to arrive. On the other hand, every COH employee we spoke to was an attentive caregiver, asking first whether I was in pain, alert for signs of the patient’s discomfort, asking for how things could be made better, explaining the process, offering options. Dr. Kawachi was an example of this dichotomy: when we interviewed him, he was reading and marking up another patient’s chart while chatting with us, but when it came time to do the job for me, he made damned sure to do it right, and made sure I was comfortable with how the process was going to go. I’ll take that tradeoff. <Susan: COH had a process for everything done during our stay and well-written patient’s handbooks with information on the procedures and the probable results. The flow of information was very helpful to us. As part of the pre-op process a nurse led us both through what to expect of the entire procedure, from the time Larry was to be admitted to the wheel chair out of the hospital. The actual process followed the briefing. Such a briefing may now be part of the process in every major hospital but I was impressed at the thoughtful briefing that we received. It lowered the anxiety level for me.>


Surgery was scheduled for mid-afternoon on March 23rd. I was scheduled to be at COH about 24 hours. After I got the gown on, the anesthesiologist came in to the staging cubicle to ensure that I was ready. Susan was shooed out to the waiting room, and I was wheeled down the hall, across an enclosed bridge to another building, and in to the operating room. I barely had time to notice the hydra-like surgery robot in the corner before they put me under.


<Susan: In the pre-op briefing we had been given, the nurse promised that the medical staff would keep me informed of the progress before, during (if the operation took more than two hours, they would give me an update), and after the operation, and they did. Prior to the operation starting, one of the nurses called my cell phone from the operating room to tell me that Larry was fine, comfortable and that they were ready to start the anesthesia. After the operation was concluded Dr. Kawachi called me to advise that all had gone well and that his staff would be at the hospital in the morning to further brief us. The staff nurse called me when Larry was in recovery to tell me that he was fine and that he would be transferred to his room in about 75 minutes. I was to meet him there at that time. She gave me directions and I was able to find the room and be there when Larry was brought in to the room.>


When I woke up in my private room after the surgery, in the early evening, I had a small amount of abdominal pain (thank God I didn’t need to cough!), not enough to ask for more painkillers. Pneumatic leggings covered my legs from the knees down, alternately squeezing and relaxing a couple of times a minute to encourage circulation and reduce clotting, which actually felt rather nice.


Somewhere down there was a catheter. The urethra runs from the bladder through the center of the prostate. The urethra is cut away from the bladder during the removal of the prostate, then stitched back to the bladder afterward. In order to keep pressure off of the junction as it heals, a catheter is run from the bladder, through the urethra, and out the end of the penis to a collection bag. It looked pretty revolting, but it mostly looked worse than it felt.


On a whiteboard in my room were posted the name of my nurse and my patient care assistant (orderly), updated with each shift change. Every hour during the night, the patient care assistant came in to check on my condition. I did sleep, though not deeply. About 5am, he came in to lead me on my first post-op walk, up and down the halls towing the IV (intravenous) trolley. It took me several minutes to assume the vertical position, slowly stretching the incisions and swollen abdomen, but I don’t recall any real pain. I think the first walk lasted maybe 20 minutes.


I was encouraged to walk as much as I comfortably could. The only difficulties with walking were the IV trolley, which I was afraid of knocking over, and the afore-mentioned maze of hallways at COH, which are not laid out in a grid. To be frank, I was afraid of getting lost! I made sure to memorize my room number. After my initial walk, with my patient care assistant as my guide, I was on my own, so I stuck with one route and did laps, up and back. The most painful part of the walk was getting into and out of bed, because of the abdominal incisions. The trick they taught me was to roll on my side facing the edge of the bed, put my lower legs over the side of the bed, and use my bottom-side arm to lever myself to the vertical, thus minimizing the use of the abdominal muscles. <Susan: I was invited to stay in the room with Larry for the night if I wished. The hospital provides an elongated chair that turns into a bed for spouse of the patient. But by the time Larry was out of surgery and back in his room I was exhausted and needed a real bed to rest. I visited my aunt, who lived close by, and came back to COH the next morning to find Larry wandering the hallways. I joined in the walks until his lunch came, and then I went to find some lunch as well. I was made to feel a part of the team, and I appreciated that kindness.>


After a final round of lab tests, the staff determined that I could be set free on schedule. Just before I got dressed, a couple of nurses came in to instruct me on the care of the catheter. I never would have thought that I could have a couple of pretty women fussing with my penis and not have it cause a disturbance, but that’s the way it went.


(One of my patient care assistants at COH was originally from Colombia. He had walked from Colombia to the USA a number of years ago, making it in 105 days on a dollar a day. Why would we turn away people with that kind of guts and drive?)


Susan drove me home to the apartment we had rented in Long Beach. After abdominal surgery the bowel goes into shock and refuses to operate, only releasing from its seizure after several days. In that condition, it would be unwise to challenge the bowel with, say, prime rib, and I commenced a period of “clear liquid” diet (consommé, jello, cup ‘a noodles, etc.). After several days, things unclenched and I was able to return to a more interesting diet.


In the first days after surgery, the color of the urine in the catheter tube was an index to my healing: cran-apple became pink-lemonade became peach became sauvignon blanc became pinot grigio. The catheter stayed in place until my post-op appointment one week later. The catheter was never really uncomfortable, but the collection bag and tubing were a damned nuisance, in the way and needing to be emptied every few hours, including the middle of the night. If I got up from a sitting or lying position, I had to make sure I picked the bag up before I took a step.


The greatest pain was, surprisingly, in the shoulders. I was later told that the pain was somehow due to inflation of the abdomen during surgery. I took two Extra-Strength Tylenol at bedtime the first two nights I was home from the hospital, and that was the only painkiller I wanted for the whole post-op process, though COH had provided much stronger stuff in case it was needed. (The stronger stuff will go into Moira’s medical kit—you never know.) The abdominal incisions bothered me only when I needed to change position from sitting to standing to lying down, and bothered me less each day.


Every day I walked a mile or two along the beachfront sidewalk in Long Beach.


A week after the surgery, we returned to COH for a post-operative checkup. Susan drove (I can now say that the last time I allowed her to drive me anywhere, I ended up in the hospital!). We got there quite early, a chronic failing of mine. The post-op began with the obligatory blood test, after which we were free to go to one of the deli’s at COH and grab a bite. After lunch they shot a series of X-rays to check that the urethra was knitting as it should.


Gemmalin Endriga, Dr. Kawachi’s Nurse Practitioner, did the post-op and gave us the “what to expect.” Part of the post-op was a review of the analysis of the removed prostate by the pathology lab, as an indication of whether the cancer was contained in the organ, or whether it might have spread. In my case, the pathology was very positive, all indications being that the cancer had not reached the edge of the organ or the seminal vesicles (see below).


Because a biopsy takes a semi-random sample of tissues from the prostate, it may under- or over-estimate the extent and aggressiveness of the cancer, or miss cancer entirely. For example, my biopsy detected cancer in only one half of the prostate, whereas the actual gland had cancer in both halves. However, the pathologist at COH agreed with the Guatemalan pathologist on the overall Gleason score of 7 (3+4).


The last element of the post-op was the removal of the catheter, which was painless and very quick, much to my relief. I was very happy to be rid of the damned thing. One of the frequent complications of prostatectomy is incontinence: it can take days to months to re-establish bladder control. A male is born with two sphincters in the urethra, and prostate surgery removes one of them. The surgery also involved a lot of cutting very close to the nerves that control the remaining sphincter. I was very glad to discover that I had immediate, full bladder control and continence from the start. Post-surgery incontinence has not been a problem, perhaps in part because I’ve been religious about doing my Kegel exercises as prescribed. Of course, it didn’t hurt that the guy who was controlling the knives knew what he was doing.


The other frequent complication of prostatectomy is impotence: as with incontinence, it can take days to months after surgery to get the hydraulics going, and again, knives had been in use very close to the relevant nerves. Dr. Kawachi prescribes a daily half-dose of one of the drugs from the Viagra/Cialis/Levitra constellation, not only for its widely-advertised “on label” purpose, but also as a vasodilator, increasing the size of the blood vessels to promote healing of the incisions. About four days after the post-op, I was pleased to note initial indications that impotence was not going to be a problem.


That day I easily walked four miles.

Follow-Up and Prognosis

And now, we wait.


It is very difficult, maybe impossible, to remove every last cell of the prostate during prostatectomy, especially if the surgeon is also trying to avoid damage to the nerves in the vicinity. Even if the remaining few prostate cells are not now cancerous, given the individual’s history of PC, there’s some likelihood that the remaining cells will imitate the propensity of their departed brethren and become cancerous, eventually.


Historically, about 1/3 of men who have had a prostatectomy have a recurrence of PC in the 10 years after surgery, though this number has come down somewhat in recent years due to earlier detection, i.e., PSA testing. But:


…”10 percent of radical prostatectomy patients whose cancer appears to be confined actually have microscopic metastases that were not detected…” (Scardino & Kelman, p. 265, emphasis added)


The difference in outcomes between the “10 percent” and the “1/3” above it is the post-surgical discovery that the “cancer appears to be confined” (to the prostate capsule). That laboratory determination by the pathologist distinctly improves one’s odds if one qualifies, as I appear to. It’s not perfect, but 90% odds of success beats 66% odds.


 A calculator called the Han Tables is available to predict (after surgery) the likelihood of recurrence based upon the data of a specific case. The key determiners of whether there will be a recurrence are:


Once again, the PSA test comes to the fore. It takes about four to six weeks after a prostatectomy for the body to purge itself of the pre-surgery PSA in the bloodstream. After that time, ideally, the PSA level should be “undetectable,” in any case less than 0.1ng/ml. The expectation is that the post-surgery PSA level will bottom out at some number, called the “nadir.” Several studies (Sakai-2006, Shen-2005, Doherty-2000) have shown that if the nadir is less than 0.01ng/ml (note the extra “0”) using the so-called “ultrasensitive assays,” the odds of avoiding “biochemical recurrence” (rising PSA) after 5 years are in the range of 90-95%.


A level greater than “undetectable” (conventionally, > 0.1 ng/ml, alternatively expressed as 0.2 ng/ml or greater) indicates that some amount of prostate tissue remains in the body. The PSA level is watched carefully: an increase in the PSA level indicates a return of the cancer.


Approximately half of the patients with a rising PSA level after RP will develop clinical recurrence during their lifetime and die of prostate cancer. (Stephenson, Scardino, et al.)


It is well to remember that this is an imprecise test. A rising PSA after surgery can be yet another false positive.


With “recurrence defined as single PSA of at least 0.2 … an estimated one third [of patients] was followed for 4 years without evidence of a continued rise in the serum PSA level …[and] an estimated 55% of patients were free of secondary therapy at 7 years.” (Stephenson-2006)


After the nadir, the number of months that the PSA level takes to double (“doubling time”) is a common indicator of the health of the region, and of the need to take remedial action. Roughly 1/3 of men who have a recurrence of PC have a very short PSA doubling time (less than one year), indicating an urgent, life-threatening problem. At the opposite extreme, roughly 1/3 have a high PSA doubling time (greater than 10 years), slow enough to indicate that no action beyond continued vigilance is called for.


Patients with a doubling time of three to 12 months are at a significant risk for the development of systematic disease and cancer-specific death. Patients with PSA doubling times of one to 10 years are more likely to have a local rather than systematic recurrence, and patients with a PSA doubling time of greater than 10 years are at a low risk of recurrence. (Mayo Clinic)


<Update 1/2015: In a study by Pound et al, after surgery, 15% of the men developed biochemical PSA level elevation.The median actuarial time to metastases” within their study population “was 8 years from the time of PSA level elevation… Once men developed metastatic disease, the median actuarial time to death was 5 years… Factors that predicted the time course to the development of metastatic disease included the timing of initial PSA elevation, Gleason score, and PSADT.”  In this study, for example, a man with pre-surgery Gleason score of 5-7 who avoided PSA recurrence for at least 2 years after surgery had an 82% chance of remaining free of metastasis for 7 years after PSA elevation if his PSA doubling time was greater than 10 months, but only a 60% chance of remaining free of metastasis for 7 years if his PSA doubling time was 10 months or less. Of the group of men in the study who met these criteria for PSA recurrence time and Gleason score, about 85% had a PSA doubling time greater than 10 months.>


The schedule I’ve been given requires a PSA test every three months for the first year, then—assuming no significant rise in the PSA level—every six months for the next four years, then (I should be so lucky) annually. If my numbers start to climb, then it will be time for radiation treatment, hormone treatment, or some other “salvage” (that’s what they call it!) treatment.


There’s a certain irony here. Because recurrence can happen so long after treatment, even more than a decade, a guy who has been through the PC mill is in a sense constantly looking over his shoulder. They call it “PSA anxiety.” You only know that the PC treatment succeeded—really succeeded—when you get the news that you’re about to die of something else. Sort of an odd signal for a celebration, wouldn’t you say?

By the Numbers

09/07:  PSA 3.32

11/08:  PSA 4.19

01/09:  (biopsy) PSA 4.4

03/09:  (prostatectomy) Pathology of the removed prostate

Gleason: 7 (3+4, mostly low-grade, but with some high-grade)

Total involved by tumor: 10%

Staging: pT2c (organ confined, palpable, bilateral)

Margins: uninvolved

Seminal vesicle/venous (large vessel)/lymphatic (small vessel) invasion: absent

Perineural invasion: present


Han Table (Johns Hopkins version) calculations based upon the above (based on immediate post-surgery timeframe):

Probability of Biochemical Recurrence
(detectable PSA level) at

3 years after surgery:     4% (1-10)
5 years after surgery:     6% (2-17)
7 years after surgery:     9% (3-24)
10 years after surgery:   12% (4-29)
All Han Table numbers represent predictive probabilities, with a 95 percent confidence interval in parentheses


(Sloan-Kettering version) calculations based upon the above (based on immediate post-surgery timeframe):

Progression-Free Probability After Surgery

2 Year:             99%

5 Year:             98%

7 Year:             97%

10 Year:           96%


Follow-up PSA:

            05/09, 08/09 <0.01

12/09 <0.07

3/10 0.011

9/10, 3/11, 10/11, 4/12, 4/13 “undetectable”

9/13 0.02

12/14 “undetectable”


An Equivocal Toast: To Persistence!

I would like to offer a toast: To Persistence!


Persistence is a characteristic shown by those who keep trying in the face of failure.


Persistence can be a good thing, even in support of a hopeless cause. Let us not forget that death is also persistent, and eternally so. Life must succeed every time, and death needs to succeed only once.


This spring, a very nice, small, oriental fellow used some very sharp knives to remove some stuff from my abdomen. At the moment, there’s every indication that he got it all.


Winston Churchill is reported to have said that "There is nothing more exhilarating than to be shot at without result," and it’s true. For now, the wine is a little sweeter, and for now, I persist.


But “that which does not kill me” will reload, and eventually, it will win. And so for the moment, in the moment, an equivocal toast:


To Persistence!


Do your part for Prostate Cancer Awareness: Get the word out—Early detection saves lives!











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