Yesterday the urologist who made my prostate cancer diagnosis laid out his view of what steps I needed to take as we evaluated the extent of my illness. He had been objective, clear and direct. But at one point he admitted to being puzzled that I didn't have either a more worrisome picture, or a less worrisome picture. “With PSA levels as high as you’ve had,” he said, “I’d expected maybe to find no cancer at all, and would have had to believe that the high PSA was caused by the large size of your prostate. The other situation I thought possible,” he continued, “would have been to find even more aggressive cancer in even more of the samples.” My PSA levels had been nearly 50 recently, and over 30 nearly a year earlier. “As it is,” he said, “I’m anxious to get as much information as possible to find out the extent of spread, if any, outside the prostate gland, and make recommendations on how to proceed. Soon.” He wanted to proceed aggressively with the in-between picture he did see. I appreciated his science and his enthusiasm, and I hoped it would work to my advantage. The critical issue was going to be how much treatment would be useful, and what benefit it would bring me. Those items remain unknown, so far.
I have been a military service member, and I’m eligible for care at the network of Veterans Administration (VA) hospitals across the country. There’s one about six miles from my home. Last year I had talked over my prostate enlargement and my high PSA values with one of the urologists there. Looking at my history, he told me that getting a biopsy was an option but not an urgent necessity. He pointed out that as many as one third of patients who have their prostates removed for cancer really didn’t need that surgery done. Those who don’t actually need the surgery are likely to die with their cancer, but not of it. Unfortunately, you can’t tell which patient is which, and which ones will need the surgery to avoid a cancer death, until after the operation. When I visited, we had set up a return appointment in about a year. As it happened, the return visit that had been set up so long ago with that doctor was scheduled for today. It was an opportunity for a second opinion, but I was not sure I’d be assigned the same man, and I did not know if the bureaucratic hospital would even look at the biopsy report my urologist had given me. Someone on the hospital staff had warned me that they might want to do to a completely independent evaluation. Nevertheless, I looked forward to the chance of visiting with him again, to get his take on the recent developments.
I was lucky. I was shown into the same urologist’s office, and he remembered my name from the one prior visit nearly a year ago. This urologist at the VA is a different sort of guy altogether from the young guy I’ve been seeing. He's been in practice forever. I think he may be in his 70’s. When he speaks, his recommendations are in terms of a great depth of experience. He does not get excited. He seems pretty comfortable with his advice. He seems to give a lot of consideration to the implications of treatment for the patient. And, he’s very approachable and easy to like. When I was taken into his office there were two medical students there, a guy and a gal, who were getting a little orientation to urology from this man who had tons of experience. They both seems to enjoy listening to him deal with a case. I wondered if they thought he was so old as to be irrelevant. My view, however, was that his age, and associated experience, were prized assets.
I told this urologist about the biopsy results, and mentioned the name of the urologist who had done my biopsy. I was quite surprised to learn that this doc I was seeing now had once been one of my other urologist's instructors! He was very complementary of my urologist, and related that he and the other teachers had felt it would be a good idea to send my urologist off for training in robotic surgery. They had been impressed with his skill and with him as a physician. Great to hear this unsolicited praise. Talk about small world. I can’t wait to tell the younger guy that I met one of his teachers. And that the teacher gave me a good report!
The VA urologist turned to the issue at hand, and looked seriously at my medical history and at the laboratory report of the biopsy. He was not in a hurry, not agitated. He turned to me and he strongly urged I seek treatment. He would not recommend making the bet that my cancer was a slow growing cancer that would be with me until I died, but would not be the cause of my death. He was much less urgent and much less definite about the likely outcome of the scheduled diagnostic tests. He pointed out that the VA center did robotic prostate surgery and had most of the up to date therapy options. He was genuinely and warmly interested in me and answered questions an unhurried way. We parted with his invitation to keep him informed about the results of the bone scan and the CAT scan that I had just scheduled, and suggested, without pushing it, that I might consider the VA as a treatment option.
I was sorry my wife was not along. I had gone to the VA mostly with the expectation that I could drop off the results of the biopsy and make an appointment for a later date. I had not expected the interview that happened. I had not expected to see the same physician a second time. For these reasons, she remained at work while I took time off to go to the appointment. I wish she had had the opportunity to see the approach that this doc taken and the experience he brought to bear. He was very measured and supportive in a totally different way than the younger urologist we had seen together.
The effect of the interview on me, however, was profound. I left the visit feeling like I was walking on a cloud. I had just made the discovery that there were options. Here was a guy whom I could consult who seemed to understand my fears and looked at the problem in much the same way I would. His advice was based not only on knowing, and teaching, urology, but on many years of experience. He was clear and direct in his recommendations, but not at all directive. And he made me feel comfortable and cared for. Funny. Now I have two urologists whom I respect who are offering very similar advice, and coming at it from different bodies of experience. I really appreciated the second opinion, and I am very happy to know that I can have some say in who does what to me. It felt nice.
Walking toward the lobby I felt like a huge burden had lifted from my shoulders. I walked out of the hospital as light as air. Riding back on the city bus I felt the day was sunny and clear, despite the need for an umbrella. I have not made any decisions, but feeling that I now have two reliable advisors was an unexpected pleasure.
Even before I got home I called my wife at work to tell her how great I felt. When I got home, I found she was a little worried and also wished she had been there. Her concern was that this older guy may not have the skills or the up to date knowledge of the younger guy. She very much wants me to get the best treatment possible, and to live forever. I have to agree with her that it will be very important to get some objective advice about various paths forward, and the risks and benefits of each. But just knowing that there is more than one person to talk to makes everything a bit easier.
The next step is the diagnostic tests. My (younger) urologist recommended three: a bone scan, looking for cancer that had already spread to bones, a favorite place for prostate cancer, it seems. A CAT scan, looking for lymph nodes that are enlarged and may have cancer in them. And an MRI, with the specific purpose of trying to see whether the cancer has extended through the wall of the prostate and into any nearby structures. The information from these tests will help the doctors make recommendations.
After the bone scan and the CAT scan , I will have one more evaluation. This one will be at the National Institutes of Health. They have recommended that the MRI be delayed for 6 weeks or so to give the prostate a chance to heal from the biopsy. I’m not unhappy at the delay. I’ve read that the MRI takes about 40 minutes to complete, involves lying still on your back for all that time, and that a probe that is part of the procedures is inserted into the rectum, inflated a bit to keep it in position, and remains there for the entire procedure. That’s got to be a little weird.
So the bone scan and CAT scan are next Wednesday. Nothing much to do until then. My wife and I are hoping they come out alright. But the younger urologist seems kind of worried that that will be unlikely. Or maybe I’m reading into his sense of urgency. I really don’t know. For me, I just want it done as quickly as possible, and, of course, I want the tests to show no cancer spread. Just a matter of waiting…
I have been a military service member, and I’m eligible for care at the network of Veterans Administration (VA) hospitals across the country. There’s one about six miles from my home. Last year I had talked over my prostate enlargement and my high PSA values with one of the urologists there. Looking at my history, he told me that getting a biopsy was an option but not an urgent necessity. He pointed out that as many as one third of patients who have their prostates removed for cancer really didn’t need that surgery done. Those who don’t actually need the surgery are likely to die with their cancer, but not of it. Unfortunately, you can’t tell which patient is which, and which ones will need the surgery to avoid a cancer death, until after the operation. When I visited, we had set up a return appointment in about a year. As it happened, the return visit that had been set up so long ago with that doctor was scheduled for today. It was an opportunity for a second opinion, but I was not sure I’d be assigned the same man, and I did not know if the bureaucratic hospital would even look at the biopsy report my urologist had given me. Someone on the hospital staff had warned me that they might want to do to a completely independent evaluation. Nevertheless, I looked forward to the chance of visiting with him again, to get his take on the recent developments.
I was lucky. I was shown into the same urologist’s office, and he remembered my name from the one prior visit nearly a year ago. This urologist at the VA is a different sort of guy altogether from the young guy I’ve been seeing. He's been in practice forever. I think he may be in his 70’s. When he speaks, his recommendations are in terms of a great depth of experience. He does not get excited. He seems pretty comfortable with his advice. He seems to give a lot of consideration to the implications of treatment for the patient. And, he’s very approachable and easy to like. When I was taken into his office there were two medical students there, a guy and a gal, who were getting a little orientation to urology from this man who had tons of experience. They both seems to enjoy listening to him deal with a case. I wondered if they thought he was so old as to be irrelevant. My view, however, was that his age, and associated experience, were prized assets.
I told this urologist about the biopsy results, and mentioned the name of the urologist who had done my biopsy. I was quite surprised to learn that this doc I was seeing now had once been one of my other urologist's instructors! He was very complementary of my urologist, and related that he and the other teachers had felt it would be a good idea to send my urologist off for training in robotic surgery. They had been impressed with his skill and with him as a physician. Great to hear this unsolicited praise. Talk about small world. I can’t wait to tell the younger guy that I met one of his teachers. And that the teacher gave me a good report!
The VA urologist turned to the issue at hand, and looked seriously at my medical history and at the laboratory report of the biopsy. He was not in a hurry, not agitated. He turned to me and he strongly urged I seek treatment. He would not recommend making the bet that my cancer was a slow growing cancer that would be with me until I died, but would not be the cause of my death. He was much less urgent and much less definite about the likely outcome of the scheduled diagnostic tests. He pointed out that the VA center did robotic prostate surgery and had most of the up to date therapy options. He was genuinely and warmly interested in me and answered questions an unhurried way. We parted with his invitation to keep him informed about the results of the bone scan and the CAT scan that I had just scheduled, and suggested, without pushing it, that I might consider the VA as a treatment option.
I was sorry my wife was not along. I had gone to the VA mostly with the expectation that I could drop off the results of the biopsy and make an appointment for a later date. I had not expected the interview that happened. I had not expected to see the same physician a second time. For these reasons, she remained at work while I took time off to go to the appointment. I wish she had had the opportunity to see the approach that this doc taken and the experience he brought to bear. He was very measured and supportive in a totally different way than the younger urologist we had seen together.
The effect of the interview on me, however, was profound. I left the visit feeling like I was walking on a cloud. I had just made the discovery that there were options. Here was a guy whom I could consult who seemed to understand my fears and looked at the problem in much the same way I would. His advice was based not only on knowing, and teaching, urology, but on many years of experience. He was clear and direct in his recommendations, but not at all directive. And he made me feel comfortable and cared for. Funny. Now I have two urologists whom I respect who are offering very similar advice, and coming at it from different bodies of experience. I really appreciated the second opinion, and I am very happy to know that I can have some say in who does what to me. It felt nice.
Walking toward the lobby I felt like a huge burden had lifted from my shoulders. I walked out of the hospital as light as air. Riding back on the city bus I felt the day was sunny and clear, despite the need for an umbrella. I have not made any decisions, but feeling that I now have two reliable advisors was an unexpected pleasure.
Even before I got home I called my wife at work to tell her how great I felt. When I got home, I found she was a little worried and also wished she had been there. Her concern was that this older guy may not have the skills or the up to date knowledge of the younger guy. She very much wants me to get the best treatment possible, and to live forever. I have to agree with her that it will be very important to get some objective advice about various paths forward, and the risks and benefits of each. But just knowing that there is more than one person to talk to makes everything a bit easier.
The next step is the diagnostic tests. My (younger) urologist recommended three: a bone scan, looking for cancer that had already spread to bones, a favorite place for prostate cancer, it seems. A CAT scan, looking for lymph nodes that are enlarged and may have cancer in them. And an MRI, with the specific purpose of trying to see whether the cancer has extended through the wall of the prostate and into any nearby structures. The information from these tests will help the doctors make recommendations.
After the bone scan and the CAT scan , I will have one more evaluation. This one will be at the National Institutes of Health. They have recommended that the MRI be delayed for 6 weeks or so to give the prostate a chance to heal from the biopsy. I’m not unhappy at the delay. I’ve read that the MRI takes about 40 minutes to complete, involves lying still on your back for all that time, and that a probe that is part of the procedures is inserted into the rectum, inflated a bit to keep it in position, and remains there for the entire procedure. That’s got to be a little weird.
So the bone scan and CAT scan are next Wednesday. Nothing much to do until then. My wife and I are hoping they come out alright. But the younger urologist seems kind of worried that that will be unlikely. Or maybe I’m reading into his sense of urgency. I really don’t know. For me, I just want it done as quickly as possible, and, of course, I want the tests to show no cancer spread. Just a matter of waiting…
