Facing disease makes you re-examine life
B.C. Cancer issued a news release about a study in the Journal of Urology based on the agency’s brachytherapy radiation program. It found that in 1,006 men treated from 1998 to 2003, 95 per cent of patients didn’t have a recurrence following brachytherapy. That led to the claim that brachytherapy can be seen as a “likely cure of prostate cancer.”
Gleave countered that B.C. Cancer minimized brachytherapy’s potential side-effects and effects on quality of life, and that the study involved men at low risk of developing aggressive cancer in the near future. The study was based on a median followup of five years, so it’s premature to call the treatment a likely cure, he said.
Goldenberg said that brachytherapy “is not at this time a cure or a likely cure until there is more experience with it and longer-term studies.”
Dr. Mira Keyes, B.C. Cancer’s head of brachytherapy in Vancouver, told the Province: “We anticipated surgeons might be critical of what we said. We discussed and chuckled that some might not like it, so we were very careful about how to word it.”
These days the two sides adopt a more conciliatory tone.
“There are two curative options for men, both with excellent outcomes,” Gleave said.
Is the deck stacked in favour of surgery?
What I’ve learned from my journey as patient and reporter is that the odds are stacked in favour of removal of the prostate.
The Ministry of Health crunched the numbers at my request, and found that during the fiscal year 2016-2017, 180 brachytherapy procedures were conducted on B.C. residents in this province compared with 969 radical prostatectomies. That’s a ratio of more than 5-to-1 in favour of surgical removal.
If physicians agree the two procedures both yield good results, then why such a discrepancy?
The desire to have the cancerous organ removed is one factor. Says Goldenberg: “Quite often the wife is sitting there going, ‘I want it out.’ And he’s saying, ‘What do you mean you want it out?’”
Because urologist surgeons are the ones who diagnose the prostate cancer and inform the patient, their prejudices must also be factored in.
“There’s an innate bias,” Goldenberg said. “We all are professional and we all believe in what we do. As honest health care providers, we have to take a step back.
“There are situations where I will twist an arm, and say I really think surgery is better for you. Most of the time, I’ll say they’re both good.”
Surgeons also employ a variety of methods: traditional open surgery, laparoscopic surgery with smaller incisions or — in hospitals equipped with the technology — robotic-assisted laparoscopic surgery.
Arguments in favour of robotics include: better magnification; reduced bleeding, pain and risk of infection; faster recovery; closer monitoring of the surgeon’s skills; and better ergonomics for the surgeon. Sixteen per cent of 658 prostate surgeries performed last year at Vancouver General Hospital/UBC Health Sciences involved robotic technology.
“The nurses call it my boy toy,” said Goldenberg, whose father has prostate cancer. “It’s a big video game, a wonderful instrument.”
Gleave sticks by the open method, arguing: “My outcomes are as good, for half the price.”
Said Goldenberg: “When I need my prostate out, I’m going to find an experienced robotic surgeon. Full stop.
“I think not enough (patients) are referred for radiation,” he said. “Every one of my patients is asked if they’d like to see a radiation doctor, and I’d say 50 per cent of them say yes.”
Oppal opted for surgery in March 2007 without consulting a radiation oncologist.
“Larry (Goldenberg) ... said — and I bought into this — that once you have the surgery you get rid of it (the cancer), provided they get it all, whereas if you had the beads and all the alternatives you’re shrinking the tumours so it could come back at any time.” Patients need to know that surgery and brachytherapy have different side effects.
Oppal’s PSA readings ever since his surgery have been negligible, but he’s had to deal with issues surrounding incontinence and impotence. “I was leaking for a long time. I had a sling put in ... and that helped me a lot.”
As for sexuality, if the nerves surrounding the prostate can be spared during surgery, the chances of continued sex are improved.
The Vancouver Prostate Centre offers a Prostate Cancer Supportive Care Program (prostatecentre.com/ PCSC), with educational courses for men, including one labelled “primary treatment decision-making” that allows attendees private time with a urologist and an oncologist. Program manager Monita Sundar said that in 2015, 389 men participated in the program in Vancouver. That’s just 15 per cent of the 2,675 men diagnosed with prostate cancer that year.
The province in 2017 provided $6 million to help expand the program, which, Sundar says, is now running in Victoria and Kelowna, with Surrey and Prince George next in line — in addition to Telehealth programs planned for remote communities.
Other courses address diet and exercise, which should be important to men regardless of whether they have prostate cancer. There are also tips on how to maintain sexuality, and how to survive the considerable side effects of hormone therapy, which can include hot flushes, weight gain, fatigue, enlarged breasts, shrinking penis, loss of bone density and muscle mass, mood swings, and failure to achieve an erection or, if you can, achieve an orgasm.
In short, treatment can seem almost as devastating as cancer itself.
Canadian-born researcher Charles Huggins won the Nobel Prize in 1966 for his research into the relationship between hormones and prostate cancer, including the use of castration as a way to stop the production of testosterone upon which the cancer feeds.
Today, hormone therapy achieves the same results.
Every three months, a contracted nurse comes to my home, where I lay on the living room couch as she or he injects Zoladex, a drug that releases slowly, into my abdomen. This week, I received the fifth and last needle in my series of treatments.
Helping men make the right choice
Often the treatment decision is obvious, but sometimes it can go either way. Factors typically include the nature of the cancer, how far it has spread, and the physical and psychological characteristics of the patient, including age.
Keyes said surgery is a better option for men already suffering from urinary problems or with large prostates.
Brachytherapy is a good option for patients whose medical conditions are perhaps compromised by other medical ailments that preclude surgery.
“The majority of patients could actually have either,” she said.
The benefits of brachytherapy, she argues, are that fewer men have incontinence issues (so no wearing of pads), sexual function is better preserved, and the recovery time is reduced.
Gleave points out that if the cancer returns, men have more options after surgery. “If the PSA comes back, you can come in with hormone therapy and radiation … two potential cracks at a cure.” He added: “The advantage of surgery is you get pathology, you know much more precisely what the extent of the cancer is. Your PSA load is zero right away.”
Low-dose brachytherapy involves the permanent placement of radioactive seeds into the prostate.
An alternative form is high-doserate brachytherapy, practised in B.C. only in Kelowna. The procedure involves temporarily placing a super-radioactive seed in a series of needles, typically 16, in the prostate. Men walk out of the hospital without being radioactive.
In my case, I had limited options because my cancer was detected late in the game.
I had a PSA reading of 3.0 in January 2014, which jumped to 8.8 almost two years later in December 2015 — a missed opportunity to be referred to a urologist for further investigation.
By the time I saw Poon at age 61 in November 2016, my PSA had reached 10.
Gleave subsequently told me that as a guideline men in their 60s should have a score under 4.5.
The Gleason score is a grading system used to estimate the aggressiveness of a cancer, and is based on analysis of multiple prostate tissue samples obtained through a biopsy. It is an uncomfortable procedure, to say the least. You are awake, flinching repeatedly as a needle — which sounds like a stapler — extracts one piece of your prostate after another.
In hindsight, the psychological effects are worse than the physical pain.
My Gleason score was 3+4 or 7/10, which put me in a high-intermediate category.
Poon suggested I go the private route for an MRI, to avoid waits in the public system.
But my family doctor put out an emergency request and I got an appointment in a week at Peace Arch Hospital in White Rock. The results showed the cancer had spread beyond my prostate into the surrounding tissue, but, fortunately, a bone scan determined it had not metastasized in the bones.
Because the cancer had moved beyond my prostate, surgery was no longer an option.
After consulting with her colleagues, Keyes recommended I choose high-dose-rate brachytherapy, which offered a better chance of targeting the area where the cancer had spread.
Dr. Juanita Crook conducted the procedure in May 2017, followed by more than four weeks of external-beam radiation at B.C. Cancer in Vancouver, in addition to the hormone treatments.
In short, the medical system tossed everything it could at it, given my “high risk” category.
With any luck, I’ll return to some sense of normalcy late this year as the hormone treatments wear off and my body begins to produce testosterone again. Then it’s a waiting game, regular PSA checkups to see who wins the battle — me or the cancer.
If such a disease can have a silver lining, it is the fact that it causes you to re-examine your life, how you can be a better person, how you can improve your lifestyle, how to give your body a fighting chance.
As I go forward, I try not to look over my shoulder for the silent killer, and instead focus on the future. The path ahead may not be clear, but I accept it with a renewed sense of purpose and passion for life — for however long that might be.