A Midlife Crisis Avoided

BY MARK SCHOLZ, MD

Building up a medical practice and getting a late start with a family, my midlife crisis was delayed past the usual occurrence for men in their early 40s.  However, by the time I hit 50, self-questioning was starting to surface. My life had meaningful pursuits but it was time to take a deep breath and do the traditional life inventory of the “mid-years,” to reassess my goals for the last third of my existence here on planet earth.

After reflection, I realized that I really didn’t have any great ideas to reinvigorate my passion for the last lap. I couldn’t sell my wife on the idea of buying a Lamborghini (I already owned a small boat).  I didn’t have any specific desire to travel.  I had given up on golf due to a terrible and uncorrectable slice.  I have never been successful playing the stock market.  All these considerations were going through my head about ten years ago.  Now ten years later, I turned 60 and I feel revitalized and reinvigorated.  So what turned things around?  

Many of you have come to know Ralph, my coauthor in the Snatchers Blog. He is as a sensible dispenser of advice and knowledge about life and about prostate cancer.  I first met Ralph almost fifteen years ago, first as a patient, subsequently as a writing teacher and now as a writing partner. As I reflect back over the years that we have worked together I am convinced that its Ralph who spared me from my mid-life crisis.  Don’t get me wrong, I have a lovely family.  My wife Juliet is a bulwark of truth.  My children are delightfully sensible, talented and hard-working. I am also blessed with an amazing medical practice with wonderful coworkers and extra-special patients.

Even so, visiting with a dozen men a day, five days a week, year after year, decade after decade can wear you down.  Getting paid less and less every year while the work load steadily increases is hardly inspiring either.  A midlife crisis was in the wings and I had no idea how my passion for the medical profession could be restored.  So back in 2005, I was looking for a new challenge when Ralph first approached me to write a book . I even agreed after he told me the zany title, “Invasion of the Prostate Snatchers.”

Fortunately, when Ralph invited me to be a cowriter, he didn’t give a second thought to the paucity of writing skills.  (Ralph has so much confidence in his own writing skills he believes he could train a monkey to write). Over the next four years we clashed on many occasions. Considering that English was my worst subject in school I have to give myself some credit for having the courage to accept his proposal.

Back then I had little interest I had in developing the craft of writing.  Writing is hard to do.  In addition, with limited free time in a busy medical practice, it’s no surprise that developing writing skills was a low priority to me.  But I was also starting to get upset about the injustice of so many men’s sexual identities being robbed by unnecessary surgery.  The dawning realization, that men, rather than being helped by surgery are actually being tremendously harmed, is what motivated me to finally confront the painful task of developing some writing skills so I could convey my observations to the naïve and unsuspecting patients. Thank God I had Ralph to tutor me along through this long and arduous journey.

Learning to write about topics that matter to me (such as saving men from the loss their sexual identity) has saved me from the “meaningless” philosophical wandering that characterizes a midlife crisis.  And as I get older and further polish my writing skills, I have enjoyed even more satisfaction by helping men to avoid numerous medical pitfalls.  For example, in my next blog I’ll be exposing another incredibly repugnant policy—men on Active Surveillance who have 12 large needles plunged through their rectal wall into the prostate gland every year. Yikes!

In the meantime, let me express my genuine appreciation to Ralph for having the patience and skill to draw me down this totally unexpected pathway.  At this point I am happy to report that I see no hint of an existential crisis looming on the horizon.     

A Closer Look into the Book

MARK SCHOLZ, MD, prostate expert and medical oncologist and Ralph Blum, living with prostate cancer for over 20 years, co-authored "Invasion of the Prostate Snatchers:  Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency."  Written for newly diagnosed men - do research before you take the next step, rather than rushing forward.  They present a closer look into the book with these three videos CLICK HERE

KNOW YOUR OPTIONS

RALPH'S JOURNEY

DOCTOR MEETS PATIENT

Dealing with Unnecessary Worry

BY RALPH BLUM

Two favorable characteristics of IMRT caused me to go for the procedure. First, the fact that the radiation does not interfere with normal tissue it traverses but only affects targeted cancerous cells. Second, the fact that the process of cell death or apoptosis continues for a year-and-a-half to two years after IMRT is completed.

In the just over a year (June 27, 2013) since I finished the 45 sessions treatment, I have watched my PSA fall from around 26 to—at last reading three months ago—a PSA of 2.81, an impressive drop to a level I haven't seen in a quarter of a century.

A week ago I went in to doctor's office for another PSA. I have not heard the result, which is unusual since I usually get the results in a day or two. So when a week had passed, and still no word, I began to worry. Is he holding back because the results were not favorable? By all counts, the PSA ought to have dropped below two. Has it actually gone up?

I found myself growing more and more anxious with each passing day. I remembered what Lisa Chaikin, MD, an admirable and patient teacher, who is in charge of St. Johns Hospital’s IMRT program, had told me: that the cancer cells turn over slowly. More and more die off with the passage of time. The impact of the radiation, the damage, is done. But the process takes time.

In my anxiety, I called Dr. Chaikin and told her about my new concern. She told me, “The cancerous cells try to reproduce, their radiation-damaged DNA blocks their reproduction.  So the rise is expected to slowly decline over a period of a year or two. However, the PSA does not decline in a straight line.  It can bounce up and down a bit before it stabilizes. So even if the PSA has gone up a little there is no reason to worry. It's the long term trend matters."  

So being made aware of the possibility of a PSA bounce relieved my mind.  Took the worry away.  Enabled me to wait without concern.

When the PSA report finally came in: 3.0, a bare rise and no reason for concern.  And I had already given up worrying.  A big step!  Waiting for test results is always a difficult time.  Even if the results are not what you want to hear, knowing in advance what to expect makes the uncertainties easier to deal with.

Combidex the Detective: Where has the Cancer Spread?

MARK SCHOLZ, MD

In our book, Invasion of the Prostate Snatchers, Ralph Blum and I devoted a chapter to the heartbreaking story of how Combidex, a revolutionary way to detect cancerous lymph nodes, was shot down by the FDA.  Detecting cancer in the lymph nodes is the Holy Grail of cancer scanning because the lymph nodes are the first place prostate cancer usually spreads if it leaves the prostate.  Standard CT scans fail to detect cancer until the tumorous nodes are bulging with cancer.

The early detection of lymph node metastases has become a much higher priority now that lymph nodes can be safely targeted with modern radiation.  In the past, with older radiation, side effects were excessive due to collateral damage to the intestines.

 

At Prostate Oncology Specialists we have had reasonably good results imaging lymph nodes with C¹¹ acetate PET scans performed by Dr. Fabio Almeida in Phoenix.  Also, Choline PET scans have been used with success at the Mayo Clinic. However, even with PET scans there needs to be minimum amount of tracer present in the lymph node before it reaches the threshold of detectability. Therefore, PET scans may be unable to detect metastatic nodes until the cancerous nodules are more than 6 mm in diameter.  Studies evaluating intravenous Combidex in conjunction with MRI scanning indicate that normal lymph nodes can be distinguished from metastatic nodes even when the metastases are as small as 3 mm. In one study comparing Combidex with Choline PET scans, Combidex was more accurate at detecting metastatic nodes.

 

I am raising the matter of Combidex in this blog because now, for the first time in years, Combidex has become commercially available again in Europe.  Dr. Jelle Barentsz from the University in Nijmegen has been able to purchase all rights to Combidex along with all the documents and files from the original manufacturer. Unfortunately, as yet there are no sites in the United States that offer Combidex.

 

More than 50,000 men annually develop a cancer relapse after surgery or radiation.  A relapse is indicated by the presence of a rising PSA level in the blood. The rising PSA signals that cancer is present, but offers no indication about the location of the cancer in the body. New scans such as C¹¹ PET and Combidex-enhanced MRI have opened up a whole new realm of treatment possibilities. After all, if the cancer can be located, it creates a possibly for cure by targeting it with radiation.

 

We welcome the renewed availability of Combidex, thanks to the concerted efforts of Dr. Barentsz.

READ MORE ON COMBIDEX

Past Blogs by Ralph Blum
http://prostatesnatchers.blogspot.com/2012/11/life-after-combidex-part-1.html
http://prostatesnatchers.blogspot.com/2012/11/life-after-combidex-part-2.html
http://prostatesnatchers.blogspot.com/2012/12/blog-post.html

Latest PCRI Insights written by Jelle Barentsz, MD
http://prostate-cancer.org/detecting-lymph-node-metastases-combidex/

 

Vasek Polak, The Benefactor: From Porsches to Prostates

BY RALPH BLUM

My IMRT sessions are two-thirds done, and I’m feeling hopeful. After 30 sessions, with only two weeks to go, I got my second PSA reading. To my profound relief, it registered another downward shift—this time from 24 to 17.5. Yeah team!

Yet before I get any further, I need to express my gratitude. In particular, to Vasek Polak, (Pronounced “Vachek”) who funded the state-of-the-art Accelerator with RapidArc technology at St. John’s, in the unit named for him, my every weekday Monday through Friday IMRT destination.

To get from the Emergency Entrance to the IMRT unit, I have to traverse an entire block from Arizona Avenue to Santa Monica Boulevard, take an elevator to the lower level “Garden” level (No basements in this Bel Air crossed with Easthampton part of West LA), then down another long corridor to the electronic doors that close off the Radiation unit.

It is cool and quiet down here: twenty-foot high white and teal colored walls. The lighting is benign (round, inset ceiling bulbs - the kind used to illuminate single paintings) and the only sound a distant faint humming, like you might hear late at night on a giant cruise ship.

Around the last curve and you can see the legend. High on the outside wall, in silver letters—the size of letters I’d seen used to spell Eisenhower’s name on monuments; letters tall enough to cast shadows on the teal blue wall—are listed the Benefactors of this vast medical complex. And there’s my man, albeit given a supporting player credit under John Wayne’s star billing (“The John Wayne Cancer Center”), but there it is and I’d passed under it mindlessly every time I came for IMRT: Vasek Polak Radiation Treatment Center

I’d never heard of Polak, so I started by checking him out with “Dr. Google.” Turns out, he was a Czech immigrant, a genius Porsche mechanic and racing driver with a hair-trigger temper and a knack for making money, a muscular, wavy haired, roughneck wizard who liked to have a flask of Pilzner Czech beer at his side when he worked.

Polak opened the first exclusively Porsche dealership in the United States and built it into a South Bay-based auto empire. From all reports, Polak was overbearing and dictatorial, “A man of strong opinions, which he did not keep to himself,” as one of his mechanic friends told me. “He was an S.O.B. who could also be kind and very generous.” And he used his fortune to fight cancer.

Reading about this cantankerous genius, and interviewing several of his friends and co-workers, I was struck with the fact that Polak was fearless. The size of the challenge didn’t seem to faze him: a faulty ring or piston, an entire transmission to be replaced just hours before a race, grappling with a drunken mechanic—whatever the situation, like a bull-rider, Polak took it by the horns, and dealt with it. All his energy went into problem solving, winning races, and building a Porsche empire. And underwriting state-of-the-art healing facilities.

Polak built major treatment centers in this country as well as in his native Czech Republic. In the Los Angeles area alone, thanks to his generosity, we have the Long Beach Children’s Clinic, the Vasek Polak Health Clinic in Hawthorne (“No appointment or insurance needed.”), Polak’s Breast Diagnostic Center in Torrance, and the St. John’s installation where, thanks to Polak’s over 6 million dollar funding, I am receiving IMRT, each $3,000 session paid for by Medicare and AARP.

IMRT RapidArc technology enables the linear accelerator to deliver precise forms of radiation up to eight times faster than other systems. This allows St. John's patients to receive higher dose radiation precisely targeted to their particular tumor in shorter sessions. As a result, healthy tissue is spared, side effects are held to a minimum, and outcomes are improved.

However, as I pointed out in my last IMRT blog, the continuing availability of IMRT is under siege. Which is why I’m checking in—starting with my gratitude to this amazing dude who thought it was “a hoot” that the slang word for syphilis in the Czech language was “music” (musika). And who is probably saving my life.

I’d like to have gotten to know Vasek Polak, thanked him personally, and had a chance to buy him the best Czech Pilsner.

Fifteen Days and Counting

RALPH BLUM

It’s now been three weeks of IMRT—that’s fifteen radiation treatments. The procedure is simple enough, which is somehow reassuring. I arrive Monday through Friday afternoon at the Arizona Avenue Emergency Entrance of St. John’s Health Care Center. If possible, I find a parking place on the street. Otherwise, it’s Valet Parking, with Fernando smiling broadly, “Don Rafael!” and a five-dollar deduction if I have my parking ticket stamped in the treatment center.

Making my way to the radiation unit was a challenge. On my first visits, I used my cane to hobble down a corridor lined with photographs of previous Directors of St. John’s, and stretching most of the way from Arizona to Santa Monica. Then I took an elevator down to the Garden Floor (No “Basements” here). Then another long trek, passing beneath a Commemorative Tablet honoring Vasek Polak, the prostate cancer patron (his money built the IMRT unit). Finally I arrived at the “PRESS HERE” electronic door into the Radiation wing.

With my bad knees, even using a cane, it was a long haul. And since I’ll be making it for 44 days in all, I reckoned it was time for a change. I remembered seeing a clutch of black canvas-backed, metal-framed wheelchairs just inside the door from Valet Parking. So I appealed to “Transportation.” After only a few minutes, a blue-smocked, gray haired lady volunteer arrived, settled me into a wheel chair, and wheeled me down to Radiation. And so it would continue—someone to wheel me down, someone to wheel me back, for the remaining treatments.

What an improvement! I never thought about wheelchairs before—I was never wheelchair “bound” before IMRT. I learned that the first known “dedicated” wheelchair (called an “invalid’s chair”) was made in 1595 for Phillip II of Spain by an unknown inventor. I bless his unknown memory as the wheels turn and I ride at ease.

The aide parks me just inside the door of the bright comfortable waiting room. There are usually several people sitting in the lounge chairs, reading out of date magazines, waiting for a friend or family member to return from treatment. Or waiting to stretch out and fit into their own treatment mold.

The routine is the same every day. I sit in the waiting room until collected by James or another radiation tech or nurse, who takes me into the changing area and hands me a blue, open–in-the-rear, cotton garment to change into. Then I am escorted through the Ops area (Computer screens frozen on the vast Ion Chamber, charts and graphs, the empty, waiting slide) and into the treatment room with its futuristic cyclorama unit where I am settled into my custom-fitted lower body mold. My three tattoos are aligned with the brilliant green, needle-thin laser beam, followed by my daily MRI. And when all is aligned,  the canned Tchaikovsky starts up, and the whirring of gears announces that the flow of electrons has begun. The zapping itself is surprisingly brief: my prostate is receiving radiation for barely two minutes.

Once a week, Dr. Chaiken and one of the nurses interviewed me: Any pain? Blood in urine? Rectal discomfort? Urinary problems? They each repeat the same questions. Covering the bases twice, just to make sure. I had no unwelcome side-effects. More important, I now believe,  I never felt anxious. Never felt a sliver of doubt. I knew that all would be well.

Only twenty-nine or thirty treatments to go.

Over-Treating Prostate Cancer

BY MARK SCHOLZ, MD

Prostate cancer treatment is out of control, and the U.S. Preventive Services Task Force* has stepped up with the recommendation to stop PSA screening. The recommendation to ban PSA testing surprises patients and doctors alike. After all, in a trial published in the New England Journal of Medicine PSA screening was shown to lower prostate cancer mortality in a trial published in the New England Journal of Medicine in 180,000 men.

Some have questioned the expertise of the Task Force panel because there was no representation by urologists, radiation therapists or medical oncologists, the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel members appear entirely appropriate to comment on screening, an area of medicine usually handled by primary care doctors.  The panel members consisted of 12 MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force has been taking massive criticism for recommending the end of PSA screening.  While conceding that PSA screening may save lives, their judgment was that too few lives are saved to justify the thousands of men getting radical treatment they don’t need. They also point out that at least a hundred thousand men annually are burdened with a diagnosis of CANCER when this particular type of cancer is very rarely life-threatening.  The sad thing is that even though most prostate cancers are harmless, a robust surgical and radiation industry can’t seem to stop treating ill-informed patients who assume that anything called cancer needs immediate treatment.

Invasion of the Prostate Snatchers was written to counter this dangerous ignorance. Throughout the entire book, Ralph Blum and I explained why something termed CANCER, as long as it is preceded by the work PROSTATE, in many cases should be totally harmless.  Ralph himself is a living example, diagnosed more than 20 years ago and still in possession of his prostate. Of course, confusion inevitably arises because certain types of prostate cancer can indeed be dangerous. Not dangerous like lung or pancreas cancer which can kill within months of diagnosis. But, over a decade or two, prostate cancer does indeed kill a minority of men. Demise from cancer certainly qualifies as “dangerous,” even if the death is much postponed.

Because there is so much confusion about the different types of prostate cancer our book pays special attention to the modern methods for distinguishing between the good and bad types.  Suffice to say in this brief blog, as long as there is a modicum of attention to detail, telling the difference between the good and the bad types is usually pretty simple.  Far more difficult is getting the uninitiated to slow down and study the situation before taking irreversible action. In the rushed process leading up to treatment, many fail in their struggle to believe that something termed CANCER really represents no threat at all.  Others, even more sadly, never hear their over-enthusiastic doctors marshal a single argument against immediate treatment.

So the Task Force is shooting PSA, the messenger, when doctors and patients are the real culprits. PSA is not the problem. The real problem is rushing to immediate biopsy at the very first sign of a PSA elevation.  A million men have mindless biopsies every year. I call them mindless because most men undergo biopsy before they have any idea of what they are getting into.  They are not pre-informed that most men over 50 have cancer cells in their prostate, and that a biopsy will be positive 20% of the time.  So when bad news comes, usually via a phone call, emotional hell breaks loose.  After all, isn’t CANCER a call to action?   Unfortunately, the urologists the doctors designated to treat prostate cancer are surgeons, who are by definition, men of action.

The Task Force is correct in their view that too many men are being frightened in unnecessary radical treatment.  The problem is a million men undergoing mindless biopsy, not PSA screening.  PSA elevation should precipitate further testing, prostate imaging and most of all, education.  My next Blog will outline the process of how to handle an elevated PSA.

*Previous blog written about this topic can be found here:  http://prostatesnatchers.blogspot.com/2011/10/discontinue-psa-screening.html