My own biggest problem initially was fully comprehending that I had cancer, with its possible implications for my life. I felt mortal in a way that I never had before. I noticed it in little things, like a brief hesitation over whether I should renew a medical journal subscription for one year or three years.
By talking to my wife and medical colleagues, I developed a plan of attack. I read two of the most widely used books on prostate cancer and checked a few websites, but was disappointed with what I found. Much of the information seemed biased toward one treatment or another, and some of the websites were openly commercial. In discussing the cancer with my family and friends, I realized that I had a strong support system already in place.
I next assessed the severity of my cancer. Having a Gleason score of 7 was not advantageous, but the fact that it was 3+4 and not 4+3 was helpful. Three of my nine biopsy cores contained cancer cells, which occupied 20 percent of the core in two cases and 5 percent in the third. Gleason grade 4 cells constituted 40 percent of the cancer cells in one core and 20 percent in the second, and there were no grade 4 cells in the third. The fact that all three positive cores were in the right half of my prostate seemed to confirm the impression of my urologist that the cancer was confined to the right lobe but occupied more than half the lobe; thus, the cancer was probably a stage T2b.
The fact that my PSA was only 3.3 seemed promising. My previous PSA had been 2.0 but had been measured almost four years previously; I was deeply embarrassed to realize that I had gone that long without a PSA test and thus could not assess my PSA velocity over the past year. Overall, my assessment of the severity of the cancer produced a mixed outcome: ''intermediate'' was the official term, which translated into ''it could be worse, but it certainly could be better.''
In assessing treatment options, I quickly ruled out watchful waiting and seed radiation therapy as not appropriate for my Gleason 7 cancer. Hormone therapy by itself also seemed inappropriate, since it would not cure the cancer and brought with it serious side effects. That left beam radiation therapy and surgery as the logical options. I calculated my life expectancy to be more than fifteen years. A major factor in my ultimate decision was a distinct unwillingness to live with uncertainty. Surgery for me offered the advantages of finding out the precise severity of the cancer and also being able to use the PSA postoperatively to ascertain possible recurrence.
I thought carefully about the possible side effects of surgery. The odds of urinary incontinence beyond the first few weeks seemed relatively low, and I thought that I could live with pads if necessary.
I did not like the threat of impotence at all, but I had had a long and satisfying sex life and was willing to barter it if necessary for a possible cancer cure and additional years of productive life. Given the apparent size and position of my cancer, I was not optimistic about saving both nerves but was hopeful that one could be saved, thereby providing a reasonable chance of continuing to have a sex life. I discussed the possible outcome extensively with my wife, who was extremely supportive and agreed with my decision. Having been happily married for thirty-seven years seemed a great advantage in this situation.
Once I had decided on surgery, the next questions were ''who'' and ''where.'' My medical colleagues were extremely helpful in this regard, and I quickly ascertained that there were at least three Washington-area urologists who were highly regarded. One of them, Nicholas Constantinople, was the urologist who had performed my biopsy and whom I liked. I also explored the possibility of going to Johns Hopkins Hospital in Baltimore, where I had close research ties and visited regularly. I had a cordial telephone conversation with Patrick Walsh, who was then chief of urology, and investigated clinical aspects of the hospital. I also ascertained that my medical insurance plan would cover the cost of treatment and that I had abundant sick leave available.
After weighing all the options, I decided to have my surgery done by Dr. Constantinople at Sibley Memorial Hospital, a highly regarded community hospital a mile from my home. A medical colleague on staff there had verified its reputation for excellent anesthesiologists and nurses and a fine radiology department with the latest equipment in case I needed follow-up beam radiation after surgery. I liked the idea that my urologist would be assisted in surgery by one of his board-certified urologist partners, not by a resident in training. In my medical training years, I had performed my first biopsy, appendectomy, and Caesarian section under the watchful eyes of an attending surgeon and understood that such supervisory surgery is necessary. When it came to suturing my severed urethra to my bladder in a manner that might determine my lifetime urinary continence, however, I opted for proven experience.
In retrospect, I would make the same decisions again, except that I would probably buy more good red wine to help me with the decision making.
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