Apparently The Jury Is Still Out

RALPH BLUM

The  duration of the Intensity Modulated Radiation Therapy was long, and I embarked on it with no guarantees, but from the start I have expected the best. And so far, I am getting a good outcome. Only problem:  It’s far from over.

 

It is more than a month since I completed my 45^th IMRT session. What’s called for now? Another color Doppler ultrasound by Duke Bahn, MD, will show how much the cancer is diminished. Add another PSA and that should be the completion of IMRT.

 

I admit that I am getting kind of excited. Still, it is part of my self-protection policy not to expect miracles. The truth is, Dr. Chaiken never made any promises regarding a number of my concerns: What can I make of the shrinking PSA readings? What can I expect regarding tumor size? Do I dare think in terms of a “cure?”

 

And what about blood flow feeding the cancer cells? We have Bahn’s color Doppler results going back almost two decades. The last set of images showed massive blood flow to the tumors. So my first step will be to start  with the Duke.

 

The drive to Dr. Bahn’s office in Ventura seems longer than ever. Finally, we get to Brent Street, to the Prostate Institute of America.  We get started right away and I am, butt-hole lubricated to receive the ultrasound probe while lying on my left side, facing the Duke’s ultrasound screen.

 

Both Jeanne and he are seated behind me. And there on the screen are the color Doppler pictures revealing the status of Blum’s prostate: the dark shadow which is the tumor, and most telling, the red threads indicating blood flow to the tumor—the cancer’s lifeline and nutrient source.

 

As always, Dr. Bahn is very quiet and meticulous, taking what seems to me like a long time to analyze the images. Jeanne asks about the seminal vesicle, and Duke replies, “It’s not an issue anymore.” He doesn’t explain; we don’t ask. Mostly I keep my eyes closed, but when I open them I catch small adjustments on the screen. It seems to take forever. Then, out slides the probe. He says, “We’re done,” and scurries off to his office while I wipe away the jelly and dress, wondering: Will this be my last color Doppler ultrasound?

 

The Duke does his write-up, and then shows me the last color Doppler. Although he tends to be mild-mannered and unexcitable, I catch a thread of—what? Enthusiasm, perhaps, in his voice? He seems pleased with the results.

 

“Over 80 percent, gone. What we call apoptosis,” he explains, “apoptosis being cell death.” Jesu! I’ve known about apoptosis for years!

 

Then the Duke tells me something I did not know and am not happy to hear: That there is no immediate result. That the out-working of apoptosis [the IMRT effect] will stretch out, continuing for a number of months into the future, often as much as a year,

 

What about continuing Avodart? I have a feeling that I should. And the Duke says, yes, absolutely continue. Why? Important to retard transition of testosterone into dihydrotestoseterone. And, Important to monitor  inflammation to keep it down. So for once, it's a situation where PSA really does count.

 

Back home, Jeanne is totally exited when she tells me, “The reduction in blood flow was amazing. The right side of the last color Doppler image was a rat’s nest of blood flow—so many blood vessels, all criss-crossing and jammed together. And now that entire side showed only a trace of red here and there. The difference was incredible!”

 

Still, we need a final PSA reading. If it follows pattern, it should now be well under five.

 

Two days later I received the Duke’s summary: The volume of the tumors was dramatically reduced: Before treatment, the right lobe tumor was 22 x 17 mm; after treatment it was down to 14 x 11 mm. The shadowy area on the left lobe which was 27 x 23 mm before treatment, had shrunk to 15 x 13 mm. [The lesions were also markedly reduced in size.] Pretty dramatic results, I thought, from such non-invasive treatment.

 

Here’s how the Duke summed up his test findings: “A significant decline of tumor volume involving both the right and left lobes. Significant  reduction of micovascular density (Now 1+ grade, where it was 3+ before) .  Reduced tumor neovascularity .(Another way of saying the same thing). . . Significantly declining trend of his PSA . . .”

 

But then the Duke knocked the wind out of me with this: “I clearly told Mr. Blum that we may not see a full radiation effect soon after finishing the treatment. It may take months, if not a year.” Then he advised monitoring my PSA, adding, “It will be satisfactory if his PSA nadir reaches 1.0 or under.”

 

So it’s far from over! I suppose I had half-expected the damn cancer to shrivel up and disappear. Hardest to accept was the fact that I will probably not know how effective the IMRT has been for an entire year, maybe longer. What I do know for damn sure is that I can’t get additional IMRT. Not to the same tissue. The tissue targeted has received its maximum tolerable lifetime dose.

 

So what to do? Eat good food. Continue with Avodart.  Get regular exercise. Avoid sugar and anger since according to Traditional Oriental Medicine, cancer is an angry disease. And anger and sugar feed cancer.

 

Then this disappointment: Turns out my PSA hasn’t budged. It’s still at 9.5 where it was six weeks ago. And it didn’t reassure me to learn that the Duke doesn’t want to see me for at least six months. A year of living with uncertainty. With the jury still out.

Biting the Bullet

BY RALPH BLUM

The idea of  “biting the bullet”—enduring a painful or otherwise unpleasant situation that is seen as unavoidable—has a lot of history in the folklore of American cowboys, Indian soldiers and other embattled warriors. I found the first literary reference to the phrase in Rudyard Kipling’s 1891 novel, The Light that Failed.” As a call to courage under duress, the Kipling character advises his wavering friend, “'Bite on the bullet, old man, and don't let them think you're afraid.” By 1926, the term had moved from the battlefield to the drawing rooms of upper class England in P.G. Wodehouse’s comic novel The Inimitable Jeeves, with Bertie Wooster advising Jeeves, “Brace up and bite the bullet. I’m afraid I have bad news for you.” 

For me, the “bullet” is the decision (after almost 25 years of living with prostate cancer with only one brief excursion into hormone therapy) to give up active surveillance and undergo some form of more radical treatment. My lurking fear is that whatever treatment I choose could produce significant “collateral damage.” That’s the downside. The upside is the possibility of a cure.

This uncertainty is nothing new. Many years ago, I decided that for me, surgery was not an option. I had interviewed too many men who, after surgery, found themselves living with irreversible side-effects, or worst case scenario, on chemo and miserable when the cancer had returned. (The irony of attacking the cancer with a deadly poison was not lost on me.

Then one day, when I was doing research on the two most effective radiation options—seed implants, and intensity modulated radiation therapy (IMRT)— Mark Scholz said, “You still could go for a knockout with IMRT. It’s the best treatment choice in your case. You might want to check it out.” For “knockout” read “cure.”  And frankly, I am worn down from co-existing with prostate cancer.

So it’s time to move on. The cancer has been in the right seminal vesicle for over five years. Which to many urologists means out of the capsule, and therefore likely to be heading for my bones. Plus even though Combidex testing indicated that the lymph system was clean, that was four years ago!

What is measurably different in my situation? I can think of three things that weigh on my thinking. For a start, I am almost a quarter of a century older than when I was first diagnosed. Second, my 80 year old immune system may no longer be the potent ally it was when I began the “watchful waiting” protocol. And third—and most chilling—for no obvious reason, my PSA has just spiked from 14 to above 34.

Considering Mark’s advice, I realize that my generation is blessed to have Medicare in its undiminished form. Add to that a chunk of backup insurance offered by AARP. So for less than $500 a month, I am covered for almost any situation. Which is hugely lucky, since IMRT, the treatment on which I am about to embark, will cost the taxpayers around of $500 per treatment—of which there will be 44!

I am not looking forward to starting the treatments, but of all the four-letter words in the language, the word “cure” is most appealing one to me right now.

Time to bite the bullet.