IMRT: The Gift that Keeps on Giving

BY RALPH BLUM

By 2013, I had lived with prostate cancer for almost 25 years without submitting to any form of radical treatment. I was fortunate that my cancer was the non-aggressive, slow moving variety. And over the years I became a strong advocate of a “Die with it not from it” policy.

I learned early on that a “Whatever you say, doc,” attitude can be dangerous, and I knew that the longer I could simply monitor the cancer and use the time to educate myself about the disease, the better off I would be. However, the main reason I resisted radical treatment was the book Mark Scholz and I wrote with the sub-title: “No More Unnecessary Biopsies, Radical Treatment or Loss ofSexual Potency.” I reckoned I’d better practice what I preached.

Then, a little over a year ago, when my PSA suddenly spiked to 26 for no reason I could determine (like BPH or an infection), I figured the cancer was finally on the move. And maybe, after all these years, my immune system was no longer the staunch ally it had been. Mark was reassuring. My cancer hadn’t changed—it was still the non-aggressive type. Which meant the odds of surviving were pretty much in my favor if I decided not to submit to treatment. Still, “To treat or not to treat” remained the question.

After determining that the cancer hadn’t spread to my lymph system or to my bones (big relief there!), I couldn’t help wondering if perhaps I was pushing my luck by sticking to my credo. And to tell the truth, I was getting tired of living with cancer. So as I am no fan of surgery, and anyway at my age (81) it was not an option, I decided to go for a cure with IMRT, Intensity Modulated Radiation Therapy.

It is now almost five months since I completed 45 sessions of IMRT, and I could not be more pleased with the results. At first, I was dismayed to see a rather snail-slow descent of my PSA. Then I learned—and this is the really big news—that cell death, or apoptosis, continues after treatment for another year to a year and a half. According to Lisa Chaiken, MD, an admirable and patient teacher, who is in charge of St. Johns Hospital’s IMRT program, “The cancer cells turn over slowly. More and more die off with the passage of time. There is an immediate impact of the radiation—the damage, is done—but the process takes time."

And get this: the cells only die when the time comes for them to divide! In trying to participate in the creative process of replication, cell death, apoptosis, is the result.  The cancerous cells are actually committing suicide: How’s that for irony?

To confirm with visual evidence what is taking place, I’ve been to see radiologist Duke Bahn, MD and compared his various ultrasound images of my prostate: the multiple red tributaries indicating angiogenesis (the flow of new blood to the tumor), once as thick as a busy river delta, are now reduced to a scattered few!

An unexpected bonus for me from undergoing IMRT is a new understanding of PSA function, about which I was always uncertain in the past. Now that I understand the process, the behavior of my PSA—post-treatment—makes total sense: As the cancerous cells die off, the PSA falls. I am now almost five months post treatment, and my PSA has dropped from 26 to 17 to 7.8 and a week ago, in the most recent PSA, to a gratifying 2.8! A level I haven’t seen in a quarter of a century!

Technically speaking, I still have prostate cancer. But my cancer is terminally feeble, itself waiting for the final cut by the Grim Reaper of cancers.

IMRT is truly the gift that keeps on giving!

The 2013 PCRI Conference, How to Handle So Much New Information

MARK SCHOLZ, MD

Every year, it seems, the enthusiasm and excitement at the conference grows. Why?  Certainly Dr. Mark Moyad who moderates the conference, and the PCRI staff and I, who organize it, have grown from our experiences over the years. We are fine tuning and improving the agenda over time. But this isn’t the primary reason.

The prostate cancer world is changing, and changing quickly.  In the early years of putting a conference agenda together, I used to spend a lot of time “scrounging around the basement” to find content with high enough quality for presentation.  Back then the main treatments for early and advanced prostate cancer were surgery and chemotherapy respectively. Now for these same stages we have active surveillance and immunotherapy.

So the problem now – it is insufficient to do justice to all the new information in a two day conference. Nathan Roundy, one of our helpline volunteers, who recently returned to the PCRI from sabbatical, came up to me after the conference and said, “I can’t believe how much things have changed in just the last six months!”

The introductory comments I wrote in the conference syllabus convey some of these same thoughts about how the PCRI handles the massive overload of new information:

“Knowledge is power. And what you don’t know can indeed hurt you.  However, in this modern information age, the deluge of unfiltered data can be completely overwhelming. How can patients without professional training sort through it all out and distil a sensible plan of action?” 

No one can offer an easy solution.  The prostate cancer world is complex, and there are too many behind-the-scenes conflicts of interest to simply trust the first smiling doctor you encounter.  Although you can’t escape from the responsibility of doing your homework, you can make sure that you are registered ‘in the right classroom.’ 

The field of prostate cancer is vast, so the PCRI breaks the disease down into different categories, which we have termed Shades of Blue.  Failing to recognize the different Shades of prostate cancer is like wandering randomly between classrooms teaching totally different subjects. Is it any wonder there is so much confusion? Patients don’t need more information. They need personalized information—unbiased resources that are tailored to their specific disease category.”

Even though cancer is a serious subject, we had a lot of fun as well.  Ryan O’Neal came and shared his personal experience of having undergone focal cryotherapy with Dr. Duke Bahn. Dr. Mark Moyad and Ryan had a hilarious exchange culminating with Ryan giving Mark a kiss on the cheek.  Jerry Peters, our Grammy Award winning board member, along with his twelve-piece band, hosted a rocking evening at our Gala dinner Saturday night. Dr. David Hung, the CEO of Medivation, the manufacturer of Xtandi, gave a strikingly inspirational presentation concerning the acceleration of new drug development in the pharmaceutical world.

What a wonderful problem to have - with so many brand new treatments it’s hard to do justice to them in a two day conference.  The key is to recognize your shade of prostate cancer, identify the treatment options available based on that shade, and follow up with more research about those options.  The PCRI website is presently going through a major upgrade and will go live in the next week or so.  Check out www.pcri.org when you get a chance.

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.

Third Dispatch from the Front--IMRT

BY RALPH BLUM

In my last blog, I said that after all this time living with prostate cancer the uncertainty was beginning to wear on my nerves.  At this point, and having thoroughly researched all my options, the idea of having my prostate fried by electrons doesn’t seem quite so alarming, and as four-letter words go, “cure” has a sweet ring to it.

I’m talking about IMRT, which is short for Intensity Modulated Radiation Therapy. IMRT is a precisely targeted procedure that allows the physician to control the intensity of the radiation beam within a given field. This means that a much higher dose may be given to a tumor within the prostate without an increase in radiation to the surrounding tissue or organs. And if the cancer has spread through the wall of the prostate gland into the seminal vesicles (as in my case) the target field and dosage can be adjusted as necessary.

The big advantage of IMRT over regular external beam radiation is that the beam can be shaped to the exact dimensions of the area to be radiated. And instead of a solid beam of uniform intensity, it utilizes a variety of small independent beams known as “multileaf collimators” that can be turned on or blocked during treatment, varying the radiation beam intensity across the targeted field.

Because of the complexity of the treatment plan, radiation oncologists employ special high-speed computers, treatment-planning software, diagnostic imaging, and positioning devices molded to fit the precise contours of the individual patient. Typically a patient will be required to have several scans, and a team consisting of a radiation oncologist, a medical physicist, a dosimetrist (who sets the radiation dosage), a technician (who does the set-up session), a therapist and a radiation oncology nurse will oversee the treatment.

As with conventional radiation therapy, multiple treatments are required, but with IMRT, the eight-to-nine weeks of treatments (lasting about twenty minutes each) significantly lower the risk of adverse side effects, and the chance of a cure is substantially higher. When I first saw the twelve-foot tall linear accelerator in the treatment room I have to admit I found the idea of having a mountain of energy shot at my pelvis from this giant ray gun--the muzzle of which would be situated barely two inches from my pecker--extremely daunting. And the matter of “rectal burn” cannot be ignored.  However I have been assured that with IMRT rectal irritation is generally temporary, and can be relieved with medication.

So it’s decision time again. I still wish I could safely stay on Active Surveillance, but with IMRT the odds are favorable for a cure, Dr. Bahn has advised me to go for it, as has Dr. Scholz. Even I, the ultimate “Refusenik,” suspect it is time to act.

I’ll keep you posted!

The Leaders of the PCRI

BY MARK SCHOLZ, MD

Recently a donor to the Prostate Cancer Research Institute (PCRI) asked me about the composition of the board of directors. As I was relating details about board members, I noticed my swelling pride in these wonderful individuals who have been so instrumental guiding the management and development of the PCRI.  What follows is a brief bio of the twelve board members who govern the PCRI.

Chester Swenson (President) is the Chairman/CEO of Marketing and Financial Management Enterprises, Inc., a company that has pioneered the development of corporate cause-related marketing programs designed to access the lifestyle interests and activities of targeted customer segments.  He was formerly CEO of College Enterprises, a premier outsourcing provider of ‘on demand publishing’. He has a BA in political science with a minor in economics from California State University Northridge. He is the author of Selling to a Segmented Market: The Lifestyle Approach, as well as numerous articles in the Journal of Business Strategy, American Demographics, Management Review and the Los Angeles Business Journal.

Jerome Seliger, PhD (Vice President) is a Professor of Health Administration and Public Health in the Department of Health Sciences at California State University with experience in ambulatory care, managed care, community-based health services, community mental health services, behavioral health services and grants management. He has authored numerous scholarly articles on community development, health care and methods for training professionals. He is Co-Founder/CEO, Bienvenidos Children's Center, Co-Founder, Health Compliance Systems PPO and Founding Director, Institute for Communication and Professional Studies.  He has a BA from the University of Minnesota and a PhD from USC.

Barry L. Friedman, Esq. (Secretary) is a family law mediator and former member of panels of arbitrators, American Arbitration Association and Los Angeles County Bar Association. He was formerly a member of  the panel of judges pro tem of the Santa Monica Municipal Court, and family law judge pro tem, Los Angeles Superior Courts. He graduated from the University of Pennsylvania in chemistry and economics as a National Science Scholar and Foundation Fellow. He received his law degree from the University of California with honors.

Kent Graham (Treasurer) is the Founder and Chief Executive Officer of Wellness Ideas Network (“WIN”), a private company specializing in designing, delivering and directing customized health and wellness plans to both organizations and individuals. Prior to WIN, Mr. Graham was a senior executive in the financial services industry for 30+ years. He holds a Bachelor of Arts degree from Dartmouth College and a Master of Business Administration degree from Drexel University.

Mark C. Scholz, MD. (Executive Director) is the Medical Director of Prostate Oncology Specialists in Marina del Rey. He received his medical degree from Creighton University and internal medicine residency and Oncology fellowship from USC.  He is the co-author of Invasion of the Prostate Snatchers and has written and produced extensive educational material on the subject of prostate cancer in various medias which include DVDs, blogs, newsletters and pamphlets. He is also an educational speaker on behalf of Amgen, Dendreon and Sanofi-Aventis. Dr. Scholz has authored or co-authored over 90 scholarly articles and abstracts in his area of expertise.

Duke K. Bahn, MD is the Director of the Prostate Institute of America in Ventura California and is Board Certified by the American Board of Radiology. Dr. Bahn is the preeminent world expert in color Doppler ultrasound imaging of the prostate as well as being one of the original researchers who documented the effectiveness of cryotherapy for prostate cancer, work that ultimately led to Medicare approval for cryotherapy. Dr. Bahn has many academic and professional appointments including Clinical Professor of Urology, Keck School of Medicine, University of Southern California.

Stanley Brosman, MD graduated from Indiana University Medical School. His Urology training was at UCLA where he conducted extensive basic research into the immunology of prostate and bladder cancer. He is a Clinical Professor of Urology at UCLA. He has been involved in numerous studies including the development of the PSA test as well as a variety  of modern therapies currently used in the management of prostate cancer such as Lupron, Firmagon, Casodex, Nilandron, Flutamide, Xgeva, Prolia, Zometa and Zytiga. He is currently practices in Santa Monica and is affiliated with St John's Hospital.

Scott Cohen is CEO of 180 Fusion, a Search Engine Marketing and Search Engine Optimization Company recognized as the leading local SEO Company in North America. Mr. Cohen served in key executive management roles in start-up and high-growth software companies. Most recently, he took PSS Systems from pre-revenue stage to market leader before being acquired by IBM. He currently holds advisory and board member positions at several privately held companies in the technology sector as well as being Co-Founder of TeleHealth America.  He holds a Bachelor of Arts degree from the University of Arizona.

Arthur N. Lurvey MD, FACP, FACE is a board certified internist and endocrinologist, and has been a Medicare Contractor Medical Director for 16 years working for Transamerica Occidental Life Insurance Company, National Heritage Insurance Company and National Government Services; and most recently for Palmetto GBA.  He received his MD from the University of Illinois and had his post doctorate and fellowship training at Los Angeles County-USC Medical Center.  He is a Fellow of the American College of Physicians and the American College of Endocrinology. He is also a CMA surveyor for both the Joint Commission hospital survey program and the CME accreditation program in California.

Jerry Peters is an American songwriter, record producer, multi-instrumentalist, conductor and arranger. He is best known for writing the hit song Going In Circles by The Friends of Distinction. This became his first gold record. Peters also recorded his album, Blueprint For Discovery.  Peters is an in-demand composer, songwriter, arranger and producer. Peters has worked with Earth, Wind & Fire, Aretha Franklin, Quincy Jones, Marvin Gaye, Natalie Cole, The Emotions, The Jacksons, Diana Ross, Deniece Williams, Gladys Knight, Al Green and Lionel Richie.  He won a Grammy for co-writing the “Gospel Song of the Year” with Kirk Whalum, “It’s What I Do.”

Claudia Sangster is an expert in estate, gift, and charitable tax planning having published extensively on topics dealing with ways to prolong family wealth. She speaks extensively at professional conferences and client events, including participation as a panelist at the Milken Institute Global Conference where the discussion focused on philanthropy’s role in improving the lives of global communities.  She has a BA in sociology from Pepperdine University, graduating summa cum laude. She later graduated magna cum laude with a JD from University of Houston Law Center.

Michael L. Steinberg, MD, FASTRO, FACR, FACRO is Professor and Chair of the Department of Radiation Oncology at the David Geffen School of Medicine at UCLA, Director of Clinical Affairs for UCLA’s Jonsson Comprehensive Cancer Center and Chair of the Clinical Chairs of the David Geffen School of Medicine, and also, Chair of the Electronic Health Record Oversight Board (EOB).  He is the founding Chair of the Health Policy Council of American Society for Radiation Oncology (ASTRO) and is currently ASTRO’s Chairman of the Board.   Dr. Steinberg graduated from Occidental College, Phi Beta Kappa, was elected to AOA at University of Southern California School of Medicine, and did his radiation oncology residency and fellowship at UCLA. 

The PCRI board members have wide ranging experience in the healthcare world, charitable endeavors, the arts, as well careers as physician specialists from all the important specialties including oncology, urology, radiation therapy and radiology. Several have had to deal with prostate cancer in their own lives. PCRI is truly fortunate to have such excellent and diverse leadership.

Another Dispatch from the Front

BY RALPH BLUM

In my Blog “Nervous Moments” I wrote about the sinking feeling in my gut—half panic, half “Oh s--t!”—when I learned that my PSA had spiked to 26. Since then I have done a course of Cipro, in order to determine whether the hike was a result of an infection (Jeanne and I had both had the flu). And I made an appointment with Dr. Duke Bahn for a color Doppler MRI.

If I had a significant bout of the flu, it wasn’t severe enough to effect my PSA which, on re-checking after the course of Cipro, was undiminished. The result of Dr. Bahn’s test showed a small but discernible progression of the cancer. Not what I wanted to hear, and as a result of his findings (pointing out on the images the enlarged dark cancer patches) I began to entertain serious thoughts of finally getting treated. But before determining the type of treatment I had to determine that the cancer hadn’t spread to my lymph system, or to my bones.

So it was back into the clickety-clack, thumpa-thumpa-thump of the MRI machine, with Vivaldi’s “The Four Seasons” soothing my ears. I admit, I rather enjoy the contrast: flutes and strings and kettle-drums. Directly following the MRI, I went next door for a bone scan.

The first results were provided by the same dayfollowed  the next afternoon by the results of the bone scan (“No evidence for any spread of cancer.”)  The news was great. Both were clear. Big sigh of relief. Thank you, God! So now the question is: to treat or not to treat? I started this journey back in 1990 when I was 58 years old, and apart from 15 months on hormone blockade (a single drug protocol with Lupron when my PSA last spiked in 2003), I have monitored my cancer with Active Surveillance. And now, at eighty I still have options.

I’m still in the process of decision-making. But I’m getting tired of the uncertainty, and I’m leaning toward placing myself in Dr. Lisa Chaiken’s competent hands. Dr. Chaiken is the chief radiation oncologist at the Santa Monica Treatment Center, a state-of-the-art facility for Intensity Modulated Radiation Therapy (aka IMRT) at St. John’s Hospital in Santa Monica.

So, finding myself at the decision point once again, in my next Blog, I will take a closer look at IMRT.  The odds are that it will become my treatment of choice.

Nervous-Making Moments

BY RALPH BLUM

I’m interrupting my series of Blogs on “Stress” to give you a bulletin from the front. It concerns my latest PSA. It caught me off guard and gave me a bad moment.

I talk about these nervous-making moments often enough with men who contact me after reading “Snatchers.” But that’s them. This is me, my prostate.  And there it is: the sinking feeling in the gut, half-panic, half “Oh s--t!” Not that this toxic cocktail is new to me. But it is never quite something that even my long experience with prostate cancer never lets me to take in my stride.

This time, the moment is triggered by an email from Mark: 

Hi Ralph, 

I have been away on vacation.  Just got back.  Did anyone discuss your elevated PSA with you?  It was elevated to 26.  Can you give me a call today? 

Mark

I realized I had stopped breathing. No, no one has discussed my elevated PSA with me. 26! Ouch! In less than three months—for no reason I can think of—that’s up by more than 40%!

Dialing Mark, I thought what my friend, Harvey, would say: “Well, my PSA is 60—and I don’t even have a prostate! Consider yourself blessed. . . . You’re going to die in your sleep in 20 years after dinner out and a good movie.”  

Yeah, well, I still feel like I’ve eaten rotten fish.

Mark doesn’t sound concerned. He wants to know if I’ve noticed any symptoms of an enlarged prostate. No. Done any heavy lifting? Negative. “Well, let’s put you on an antibiotic for ten days—you tolerate Cipro alright—and then have you see Duke Bahn_for a Doppler MRI. He’s taking Medicare again. Then in about three weeks we’ll do a repeat PSA.”

Makes sense. But the panic is still there; the fear that perhaps I have tempted fate one too many times by not going for a cure.

When I tell my wife, Jeanne, who has a degree in Traditional Oriental Medicine and practices an ancient form of acupressure, her reaction is professional and predictable, but hardly comforting. “You’ve got to stop eating pork. And start eating tomatoes; you’re getting no lycopene. Diet, diet diet.”

And then it occurs to me: There may be an obvious explanation for the PSA spike.  I’ve had the flu for two weeks. Some fever along with the usual symptoms. Was that enough to spike my PSA? It happened once before when we were living in Hawaii. Or is this my body telling me it is finally time to do something?

I remember something Mark wrote in “Snatchers” that is somewhat reassuring: “How the cancer behaves over time is the most important predictor. It supersedes Gleason score, it supersedes stage and PSA. . . In your case, Ralph, we’ve had two decades to observe its behavior, and that behavior has to trump all the stats. 

In Mark’s experience, cancers do not tend to change their stripes after twenty years. “It’s like having new neighbors,” he once said. “With time you learn that they keep their property neat, that their dog won’t poop on your lawn, and that if you want to borrow a cup of sugar, sugar is what you’ll get. Well, the same with prostate cancer.”

Well, maybe prostate cancer has been my closest neighbor for long enough. I am once again in uncharted waters, and ultimately, there is risk in whatever I do. If I do nothing, I risk the cancer progressing. If I chose treatment, I risk unpleasant (or worse) side effects.

What’s the old-time carnival barker’s challenge? “You pays your money and you takes your choice.”

Time for long thoughts.

Introducing Color Doppler Ultrasound

BY RALPH BLUM

Accurate information about the status of your prostate cancer is essential for determining whether you need treatment, or whether you can safely continue with active surveillance. Although some centers of excellence like Memorial Sloan-Kettering and the University of California, San Francisco, use spectrographic MRI, most urology practices still rely on repeated random biopsies as their primary form of monitoring—despite the risks and discomfort involved.

As I have said before, I am no fan of biopsies. As far as I am concerned biopsies are a necessary evil. But under no circumstances should men allow themselves to be rushed into having one before less invasive diagnostic methods have been explored. Having said that, a S-MRI means traveling to a specialized facility, costs a small fortune, and involves having a probe that is called an “endorectal coil” inserted up your butt to improve the image quality.

Fortunately, there is another form of prostate imaging—color Doppler ultrasound—that is considered comparable in quality to S-MRI. It is also easier to perform, takes less time, can be done in the doctor’s office (Prostate Oncology Specialists, Mark Scholz’s office, has color Doppler capability), and requires a much smaller probe than the S-MRI. Big plus! Color Doppler ultrasound provides higher resolution images than the usual gray-scale ultrasound machine, and also “sees” areas of new blood vessel formation (angiogenesis) associated with higher-grade, more aggressive prostate cancers. (I will look more closely at this process in my next Blog.)

Color Doppler ultrasound will, in time, be widely used in clinical practice to evaluate blood flow through organs or tumors. Thanks to its simplicity, ease of use, speed, and safety, ultrasound imaging is being increasingly employed to monitor angiogenesis for diagnosis, treatment assessment, follow-up, and therapy guidance.

All monitoring tools have limitations, including biopsies. Color Doppler is only one of many tools that provide useful information about the status of cancer in the prostate. It was from the color Doppler imaging of Dr. Duke Bahn back in 2008 that I learned the reassuring news of no new blood flow and the stalled growth of my tumor. This accurate feedback, confirming how my cancer was behaving, made it safe for me to continue to watch and wait and avoid radical treatment. A blessing for which I will always be grateful.

Confessions of an Anxious Man

BY RALPH BLUM

Like every man I know who is living with prostate cancer, I’ve had my bad moments. But right at the start, during the phase known as “newly-diagnosed,” I knew the odds were in my favor; knew I could die with it not from it. Now, after more than two decades of successfully and peacefully co-existing with this disease, I am once again feeling anxious and at risk.

I have succeeded in one area: the treatment I have undergone has been minimally invasive: no surgery, zero radiation, no chemo. Only a stint of hormone blockade, aka androgen deprivation therapy, and/or Testosterone Inactivating Pharmaceuticals (TIP). And even then, instead of the conventional triple medication—Proscar, Casodex and Lupron—being a minimalist rather than a fan of saturation bombing, I took only Lupron. Still, since there is no question about prostate cancer being testosterone driven, it was appropriate to choose TIP as the least invasive treatment option and, in my case, reduce my testosterone level to that of a pre-pubescent boy.

           

What else did I do to “fight” the cancer? I confess that my behavior as a prostate cancer patient does not receive high marks:  slovenly attention to weight (I’m 5’9” and weigh 218). Diet? Despite my wife Jeanne’s best efforts, I was only part time successful. Exercise? A stationary bike at my neighborhood YMCA, 20 minutes twice a week; no weights work. I am not proud of my record.

Prostate cancer specialists are now rethinking the validity of PSA monitoring. Still, as it was general practice with the option known as “Watchful Waiting,” I was regular in getting my PSA recorded. And until about six weeks ago, my levels were reasonable for a 79-year-old semi-careful patient of a conscientious, competent oncologist, my writing partner, Mark Scholz.

Then, in what might be called “overnight” after two decades of stability, my PSA doubled, vaulted up to 23 and change. And I confess, my sleep is being riven with anxious thoughts. The all but forgotten  “What  if . . .” assault has begin again earnest, with its companion stomach acidity, staring into the darkness, a renewed sense of urgency and, most upsetting, the writing on the wall has become the mirror image of my mantra: Die with it not from it.

However, since my last PSA test, I did undergo a form of heavy duty stress: two surgical procedures for kidney stones. And since surgery—together with heavy lifting, bike riding and recent sexual activity—is known to drive PSA to unrealistic levels, following any of these stressors, you are advised not to be re-tested for a good month or more.

Furthermore, although I was unaware of it for several months, I have been host to a nasty infection known as Proteus Mirabilis (More about that rabid puppy later!). Remembering a previous scare when my PSA suddenly jumped to an alarming level due to infection, I need to undergo a course of antibiotics—in my case Cipro—and then get another PSA test, and a rectal probe with analysis of prostatic fluid to determine whether the infection was actually the cause of my elevated PSA.

Then I will want two essential consults.

First, I need to see Duke Bahn, MD, radiation oncologist, and for my money, the world grand master of the Transrectal Color Doppler Ultrasound for Diagnosis, monitoring with Active Surveillance, and the management of Recurrent Disease.

           

And finally, I will consult with Lisa Chaiken, MD, radiation oncologist at St. John’s Medical Center in Santa Monica, and herself a grand master in the forefront technique of Intensity Modulated Radiation Therapy (IMRT), the only radiation procedure I would feel even provisionally comfortable undergoing.

So first things first: I just came back from my neighborhood CVS Pharmacy with 39 tablets of 500mg Ciprofloxacin HCL. Took the first tab in the parking lot. I’ll complete the two-a-day course of antibiotics; then redo the PSA and get the opinions of the prostate mavens I trust. But whatever the case, I have decided that it is time for definitive treatment—aka cure. Living with low testosterone is downright debilitating.

Enough is enough.