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ANDY GROVE
REPORTER ASSOCIATE BETHANY MCLEAN
My secretary's face appeared in the conference room window. I could
see from her look that it was the call I was expecting. I excused myself
and bolted out of the room. When I stepped outside, she confirmed that
my urologist was on the phone. I ran back to my office.
He came to the point immediately: Andy, you have a tumor. It's mainly
on the right side; there's a tiny bit on the left. It's a moderately
aggressive one." Then, a bit of good news: "There are only
slim odds that it has spread." The whole conversation was matter-of-fact,
not a whole lot different than if we had been discussing lab results
determining whether I had strep throat.
But what we were talking about was not strep throat. We were talking
about prostate cancer.
Let me start at the beginning...
MY FIRST PSA. It all started about a year earlier when my
family doctor of 20 years retired. In the fall of 1994, my new doctor
gave me a physical exam to establish a new baseline. The physical involved
an assortment of blood tests, all of which were in the normal range,
with one exception. The test called PSA came back with a result of
5. The acceptable range, according to the lab computer, was 0 to 4.
I didn't know what this test was. In fact, I don't think I'd ever
had one before. My doctor's comment was, "It's slightly elevated.
It's probably nothing to worry about, but I think you should see a
urologist."
He did not seem too concerned, so I didn't get anxious, either. I
put off the whole issue without much thought. I did, however, happen
to tell one of my daughters, who is a health-care professional. She
told a doctor friend of hers, who, it so happens, was just publishing
a long article on the pros and cons of screening people with this very
same PSA test. Would I want to talk to him about it? I would. I did.
Oh, my God.
With that conversation, I parachuted into the middle of one of the
raging controversies of contemporary medicine. Briefly, the issue,
as I understood it, seemed to be this: A PSA test (PSA stands for prostate
specific antigen) measures a substance emitted both by the normal prostate
gland and by cancerous tissue in the prostate gland. Very little escapes
from a healthy gland, so elevated PSA readings can be telltale signs
of prostate cancer. But just because they can be doesn't mean that
they always are.
Telling a person with an elevated PSA that he might have cancer leads
him into a system of increasingly complex and uncomfortable diagnostic
tests to ascertain whether it is so. If it is, the patient has to make
some choices about what, if anything, to do. None of the choices, the
friendly voice matter-of-factly explained to me on the phone, are good.
None of the treatments work all the time, and all of them have side
effects that are unpleasant or worse, like incontinence and impotence.
Anyway, according to my daughter's doctor friend, prostate cancer
isn't necessarily fatal. Autopsies show that about half of all men
who die of other causes have some cancerous tissue in their prostate.
So, my new acquaintance said, why submit unsuspecting men indiscriminately
to this test, which only leads to more tests, which then lead to a
series of choices, none of which are very good?
He sent me a preprint of his article. It was a scientific medical
paper with charts, filled with learned discussion. But I picked up
enough of the subtext so that my eagerness to visit a urologist, not
very high to start with, waned some more.
It so happened that I was due to leave town on sabbatical in early
1995. I was planning to spend a month in the mountains skiing and writing
a book. After a while, the PSA issue worked its way back to my consciousness.
Having a computer with me and some time on my hands, I started looking
for information on CompuServe. It wasn't hard to find. I found a prostate
cancer forum where patients and relatives of patients swapped stories,
asked questions of each other, and gave answers. The term PSA was mentioned
in every message.
I also found a long review paper in the forum that was written by
the head of the urology department at Stanford University, Dr. Thomas
A. Stamey. I downloaded it, and I read it from beginning to end.
I found out some basic facts, such as: Some 200,000 men were diagnosed
with prostate cancer in 1994, and 38,000 men were expected to die of
it, making it the No. 2 cause of cancer deaths among men (after lung
cancer). The paper discussed the seeming paradox of why such a small
proportion of the people who have prostate cancer die of it, and speculated
that most prostate cancer isn't very aggressive. I wondered, Is it
not simply because most prostate cancer is diagnosed in older men who
die of other diseases before the prostate cancer has a chance to get
them? (This was not encouraging for me. I was only 58 and otherwise
in perfect health. I couldn't wave the threat away with such an argument.)
Then the paper went through the treatment options. My daughter's
friend was right. They were all lousy. The most prominent is surgical
removal of the tumor. This is done by removing the whole prostate gland,
then rebuilding the related internal organs. It's major surgery, with
a long recovery and pretty bad side effects. Dr. Stamey's article only
hinted at how unpleasant they are. I read a posting on the forum by
an airline pilot who had undergone this surgery and was bitter beyond
words. He claimed that it cost him his health, his job, and his marriage,
and that it ruined his life. It was all very depressing.
But the important thing I took away from this essay was the concept
that PSA is a tumor marker. It seemed that the larger the tumor, the
higher the PSA. My own result of 5 seemed to correspond to a tumor
the size of a sugar cube. I visualized a sugar-cube-sized tumor inside
me, and I shuddered.
I came across a mention of a book on prostate cancer, jointly written
by a patient and his doctor. I ordered it and when I returned home
after my sabbatical, I picked it up. It was quite readable, a thorough
and organized review of different treatments, but it was noncommittal.
The book itself reflected the contradictions of the literature, without
providing guidance as to what course of treatment is best.
I went back and had a repeat PSA test done. As in my case we were
looking at a difference in PSA readings of 4 (the upper range of acceptable)
and 5, I wondered if the tests were precise enough. So I also decided
to test the tests. I had my blood sent to two different labs. Unfortunately,
what I hoped for--widely varying results--did not materialize. One
test came back at 6.0, the other at 6.1. It appeared that the sugar
cube was growing.
These tests ended my procrastination. I made an appointment with
a urologist. He first checked my prostate with his finger (this test
is called a digital rectal exam, or DRE), and he didn't feel anything.
But given my PSA, he did a biopsy a week or so later (not a pleasant
experience but not a terrible one either). The biopsy turned out to
be positive. Hence the conversation that started with "Andy, you
have a tumor."
R&D. I went back to see the urologist. He sat me down
and told me my options: surgery, radiation, cryosurgery (in which the
tumor is destroyed by freezing it), and, finally, doing nothing and
playing the odds. This is euphemistically called "watchful waiting."
He told me that in my case "surgery would have a reasonably good
chance of getting rid of the tumor." He gave me the impression
that the other treatments would have a lower probability of curing
me.
He walked me through the complications of surgery, but reassured
me: "Don't worry, we can do something about each of those." The
examining room walls were covered with posters of contraptions like
penile implants and vacuum pumps. I knew that they were devices meant
to restore potency, but they evoked images of medieval torture.
I was sent to the hospital to undergo two complex tests. In the first,
a bone scan, an instrument scanned my body looking for signs of metastasis--advanced
prostate cancer tends to spread to the bones. The second was an MRI,
a long and mildly uncomfortable procedure, which looks for evidence
of spread into the abdomen. Both were negative, but I got the impression
that neither test was all that sensitive, so there might very well
be disease that they wouldn't pick up.
I wanted to know more. I called a number of friends who are doctors,
who came back with names and phone numbers of prominent practitioners
of the different types of treatment. I also decided to dust off my
research background and go directly to the original literature. I wrote
out the first batch of titles from the bibliography in the prostate
cancer book I'd bought, and my wife got copies of these articles from
Stanford. My life entered a new routine.
By day, I set up appointments. This was a royal pain. The doctors
were hard to get hold of, and when they called back, I was often in
meetings, so making one appointment required half a dozen phone calls.
By night, I read scientific papers, plotting and cross-plotting the
data from one paper with the results from another. As I noted other
interesting references from these papers, I would ask my wife to get
them on her next trip to the library. This whole exercise reminded
me of my younger days, when I did the same thing in the field of semiconductor
devices.
Meanwhile, life went on. I had to concentrate on work, which turned
out to be a good thing, because it meant I could think about cancer
only while I was actually doing my R&D. What suffered was time
for sleep. Fortunately, prostate cancer is completely asymptomatic
for a long time; my energy level was as good as ever and I was able
to keep up with the extra load.
At first, the papers were overwhelmingly confusing. But the more
I read, the clearer they got, just as had been the case when I was
studying silicon device physics 30 years ago. That added a strange
element of enjoyment to a process that was, overall, very scary. I
remember how creepy it felt the first time I walked through a hospital
door labeled RADIATION ONCOLOGY.
The appointments led to more appointments, the papers led to more
papers. A doctor friend ran a computerized search on a number of researchers'
names I gave him. From this search I got a bunch of papers that were
written in the last six to nine months--written after my reference
book was published, in other words. Some of these turned out to be
the most significant ones in this whole exercise. The field was hopping,
not just with new work and discoveries but with controversy.
Each medical specialty--surgery, cryosurgery, different branches
of radiology--favored its own approach. I listened to the audiotape
of a long interdisciplinary medical meeting called, appropriately enough,
"Prostate Cancer Shootout." I could sense the undercurrents
of strong disagreement, couched in polite, faux-respectful terms. I
had the impression that the people whose comments I heard had made
the exact same comments in meetings before this one and would make
them again in the future. The tenors always sang tenor, the baritones,
baritone, and the basses, bass. As a patient whose life and well-being
depended on a meeting of minds, I realized I would have to do some
cross-disciplinary work on my own.
WHAT I LEARNED. The most important thing I learned was that
the use of the PSA test reset the entire field of prostate cancer studies.
PSA tests went into use only about ten years ago. Their use moved everything
forward in time. Typically, a PSA test can indicate the presence of
prostate cancer as much as five years earlier than diagnosis by other
means, like digital rectal exam.
Not only does this allow for earlier treatment, but it also has an
important consequence from a scientific standpoint: We can now learn
a lot more about the effectiveness of various treatments by using the
PSA test to look for recurrence of the disease. It used to take ten
years or more for recurrences to be discovered by DRE and other clinical
means. But since PSA can detect recurrence much earlier, the learning
process about the effectiveness of treatment is accelerated.
Since the PSA test accelerates the discovery of the tumor in the
first place, you have the chance to treat tumors earlier than ever
before. One doctor I met told me that all the treatments basically
work quite well if you embark on them when your PSA is still relatively
low. By contrast, none of them work well if it's high. Being a marker
of tumor size, a high PSA suggests that the tumor is large, and a large
tumor often extends outside the prostate gland to other parts of the
body and can begin the process of metastasizing.
At this point I got a shock. I had an ultrasound imaging test done
on my prostate to look for the shape and extent of the tumor. Most
ultrasound machines give very ambiguous results, so much so that they
are pretty much disregarded as diagnostic tools. But I had this done
at a university hospital, where they have a very elaborate, newfangled
machine that, in the hands of expert interpreters, supposedly gives
more definitive results. In my case, the test suggested that there
was a 60% chance that I had extracapsular extension, that is, the tumor
extended outside of the prostate gland. I got depressed. Yet I soon
found out that this should not have been a surprise at all.
Perhaps the most important paper I came across was a recent study
by a group of doctors at Johns Hopkins looking at ten-year results
after surgery on some 700 patients. In this study, they correlated
the clinical findings--the medical findings on each patient before
surgery, such as his PSA, the size of his tumor as established by digital
rectal exam, and the biopsy results--with what the pathologists found
during surgery. These results were then tabulated. The tables were
extremely useful. They allowed me to look up any set of clinical findings
and assess the statistical probability of the nature of the cancer
in a minute. I had a PSA of 6, with the tumor largely contained in
one half of the prostate and found by the biopsy to be moderately aggressive.
When I looked up this set of clinical findings in the table, it showed
that the chance of my having extracapsular extension was, in fact,
about 60%.
The significance of this was contained in a companion paper, which
correlated the chance of recurrence of the cancer with the medical
observations before surgery. It found that even though the population
of patients was carefully selected in terms of being good candidates
for surgery, and even though all the operations were performed by one
of the best prostate surgeons in the country, many of the patients
experienced a recurrence of prostate cancer as indicated by their PSAs
starting to rise again. When these patients were classified, the data
showed that patients whose cancer was completely contained in the prostate
gland experienced the lowest rate of recurrence, patients who had extracapsular
extension experienced more frequent recurrence, and patients whose
tumor had penetrated other organs near the prostate had an even greater
chance of recurrence. I could see in these data what I had been told
earlier: Surgery (like everything else) seems to work better at a low
PSA.
In my case, if I didn't have any extracapsular extension, the data
suggested that if I had a leading surgeon operate on me, I would have
only a 15% chance of recurrence in ten years. If I did have extracapsular
extension, I would have a 60% chance of recurrence at that time. And
I had about a 60% chance of being in the latter class. Computing the
odds based on these numbers suggested that my recurrence rate in ten
years worked out to about 40%. I wasn't crazy about those odds. Clearly,
surgery did not cure everyone, even under the best conditions.
Then there was the question of side effects. As indicated by the
CompuServe posting from the airline pilot, these could be pretty bad
after surgery. How bad depended on whose data I looked at. According
to the surgeons who write papers, the side effects are not so bad.
But I also read a study that questioned a large group of patients directly,
and those results were alarming: The reports of incontinence and impotence
were dramatically worse in the second study, leaving me to wonder whether
patients described these things to a third party more pessimistically
than to their doctors, or whether patients in the second study were
more representative of the work and results of urologists all over
the United States, as compared with leading practitioners. In any case,
these certainly motivated me to examine other types of treatment.
Prime among these was external radiation. While surgery works by
cutting out the tumor along with the rest of the prostate, radiation
works by bombarding the area of the prostate, selectively causing more
destruction of the cancerous cells than of the healthy ones. There's
a lot of controversy about how well this works. Although there seems
to be agreement that the side effects associated with radiation treatment
are substantially less than with surgery, the effectiveness of the
treatment is another issue.
It was especially difficult to get a good handle on the effectiveness
of radiation because of the presumption by most urologists that surgery
works best. Consequently, younger and healthier patients, particularly
patients considered to be good candidates for surgery on account of
their tumors being smaller, are selected for surgery, leaving the older,
less healthy patients with more advanced tumors to make up the bulk
of the patient population that undergoes radiation therapy. The results
in the latter class are, of course, worse--reinforcing the spiral that
sends the early-stage patients to surgery and the later-stage patients
to radiation.
Yet in recent years, as enough patients with lower PSAs have overcome
this selection bias and chosen radiation, data have emerged to show
that results with radiation are also a lot better when the tumor is
treated at an early stage. I came across a study that showed radiation
therapy results and related them to the patient's initial PSA. When
I took the radiation treatment data and compared them with the surgical
data, matching the initial PSAs of the patient populations as best
I could, the outcomes were not that different, at least at five years
after treatment. (See chart on "recurrence rates.")
When I was doing semiconductor device research, it was expected that
I would compare my results with other people's previously published
results and that I would comment on any differences. But it seemed
to be different in medicine. Medical practitioners primarily tended
to publish their own data; they often didn't compare their data with
the data of other practitioners, even in their own field, let alone
with the results of other types of treatments for the same condition.
So I kept on doing cross-comparisons as best I could.
I read about another radiation technique. Radiation can also be delivered
to the prostate by implanting radioactive seeds directly into the gland.
This was not a new idea. It was tried decades ago and discarded because
the results were poor; it seems that the placement of the seeds wasn't
uniform enough, leaving "cold spots" between them, and consequently
the tumor wasn't completely eradicated.
More recently, however, this technique was being refined. Using ultrasound
machines, the doctors could place the seeds far more uniformly and
minimize the chances of cold spots. The seeds were left in the body,
emitting radiation for six to nine months. The radiation would eventually
decay, even though the seeds would stay in place indefinitely. Often
the seed therapy (formally called brachytherapy) was combined with
external radiation just to ensure that the coverage was complete; even
if the seeds should migrate around within the prostate, all parts of
the tissue would get some radiation.
While I found references to brachytherapy in my reference book, I
could not find any good recent papers on it. I called the technical
support department of the manufacturer of the radioactive seeds, and
got quite a bit of information from them. The results, at least at
five years, looked very good. The technical people also gave me the
names of some of the practitioners of this technique. Then, in the
middle of my search for information on this subject, a full paper was
published that contained ten-year data on hundreds of patients who
had been treated by a combination of seeds and external radiation.
Unlike most, this paper actually compared the results with the best
published surgical results. Basically, the two were very, very similar.
To make matters even more complicated, a doctor friend faxed me an
abstract of a presentation describing yet another procedure, a variant
of the seed technique called high-dose-rate radiation. In this technique,
a highly radioactive seed is attached to a wire that is momentarily
inserted into the patient's prostate through a number of hollow tubes,
one after the other. The procedure is performed with the patient under
local anesthesia. The results in this abstract seemed even better than
with regular seed therapy, especially when it came to side effects.
What particularly impressed me about both sets of data was that it
seemed few of the recurrences were local, meaning that in the cases
in which prostate cancer recurred, it usually didn't appear in the
prostate but rather in some distant place in the body. This suggested
that these combination radiation therapies are very effective in eradicating
the tumor that's in the prostate. If the tumor had already escaped
by the time the treatment was given, none of the therapies--not surgery,
not any kind of radiation--could be expected to be effective.
The results looked good enough to warrant visits to two practitioners,
both in Seattle. One practices seed therapy with the seeds left in;
the other one practices high-dose-rate radiation with the seeds inserted
for a short time and then removed. There was a logic to the high-dose-rate
radiation therapy that really appealed to me. Evidently, one can compute
how long the radioactive seed should stay in the prostate. The aim
is to achieve a radiation exposure that is matched quite precisely
to the size, shape, and location of the tumor. For instance, since
the bulk of my tumor was on the right side of the prostate, the therapy
could direct more radiation to the probable location of the tumor without
having to expose the entire prostate to the higher levels of radiation.
It's a programmable technique, customizable to an individual case.
The doctor described high-dose-rate radiation as "smart bombs," while
external radiation or even the implanted seeds were more like carpet
bombing. This was important because the side effects in the case of
radiation come from exposing the neighboring organs, like the urethra
and the rectum, to radiation. If one could irradiate the tumor heavily
while minimizing the exposure of the other organs, theoretically one
should get good results with minimal side effects. In fact, this was
consistent with this doctor's results. I sat in his office absorbing
the elegance of this technique, and then I turned to him. "If
you had what I have, what would you do?" He hesitated. Then he
said, "I would probably have surgery." I left, utterly confused--but
with some more unpublished data from the two seed doctors that I could
add to my charts.
There was one more treatment to consider: cryosurgery. In this technique,
instead of cutting the tumor out or blasting it with radiation, doctors
freeze the tumor with little coils filled with liquid nitrogen that
are inserted in the prostate under anesthesia. I couldn't find any
hard data on the results of this technique, and it seemed that the
side effects are almost as bad as they are with surgery. I took it
out of the running.
I also found that a recent school of thought suggests that both radiation
and surgical results can be improved by taking certain testosterone-suppressing
hormones that cause the tumor to shrink. The shrunken tumor, I understand,
is easier to cut out or to blast away. Since hormones seemed to help
both surgery and radiation, I started taking them under the "smart
bomb" doctor's suggestion. The hormones had their own side effects,
supposedly temporary. I had mild diarrhea and lost all interest in
sex.
Meanwhile, I continued with visits to three more well-known surgeons.
All were ferociously opposed to the combination radiation therapy,
or any radiation therapy whatsoever. One, for instance, suggested the
likelihood of a need for a colostomy (this scared me enormously). Another
argued that none of these therapies result in zero PSA after treatment,
as successful surgery does. This puzzled me. Since some PSA is generated
by the prostate tissue itself and radiation does not destroy the prostate
tissue, why shouldn't the patient end up with some PSA after treatment?
The conversation got so heated that my question was never answered.
Looking for counterarguments, I called up the "smart bomb" radiation
oncologist. To my surprise, he took a very evenhanded and unexcited
position on the controversy, even as he debunked the specific issues
raised. He had never seen a single case of colostomy, for example;
he speculated that it may have happened in the very early cases when
the rectum was overradiated. With the modern technique, he assured
me, in all likelihood that can be avoided.
It sounded good, but I had one last question. "Why," I
asked, "would you have surgery done to yourself then?" He
thought about it. Finally, he said, "You know, all through medical
training, they drummed into us that the gold standard for prostate
cancer is surgery. I guess that still shapes my thinking."
I continued with my investigations. I talked to people who had gone
through various procedures, including two who had undergone the "smart
bomb" procedure. When it was all said and done, I had talked with
more than 15 doctors and half a dozen patients. I began to get the
same information. I plotted all the relevant data I could find (see
"how the treatments compare" chart). It was clear that some
cancers recur with the passage of time after all the treatments and
that the range of variations for each treatment can be quite broad.
It also appeared that whatever recurrences take place come on gradually
and that the better the results were at five years, the better they
would be at ten.
In any case, it was time for a decision.
DECISION. In July 1995, I went on a weeklong bike trip with
my wife and some friends. Hours of biking are good to let your mind
roam and put a helpful distance between all the mind-numbing data and
yourself. I prepared a "balance sheet," first in my mind,
then on paper. It looked like this:
Pro: surgery:
- It's the gold standard: All these people believe it's the better
answer. Can they all be wrong?
- If the tumor is truly contained inside the prostate, it seems to
work well.
Pro: seeds plus radiation:
- Looks like fewer complications, such as impotence and incontinence.
By most accounts it is also easier to go through.
- If my tumor has spread outside the prostate, the radiation can
perhaps still get it, as the external radiation covers an area that's
larger than the prostate gland.
I looked at the sheet and concluded that if I knew that my tumor
was entirely contained, I would go with surgery. On the other hand,
if I knew that it wasn't, I would go with the combination radiation.
The data said I had about an even chance. I kept riding my bike.
One of the arguments that surgeons tended to make against radiation
was that the long-term results--that is, anything longer than ten years--were
not as good as in surgery. This wasn't obvious from the data. PSA has
only been around for ten years, so as far as I was concerned, both
surgery and radiation had relevant data only for ten years or less,
and not very much even at ten years. But it occurred to me that if
combination radiation, which looked better to me than external radiation
by itself, only gave me ten years of freedom from disease, I could
buy myself a ten-year reprieve relatively inexpensively, considering
that it's a lot less onerous treatment. I have a rule in my business:
To see what can happen in the next ten years, look at what has happened
in the last ten years. PSA happened in the last ten years, and it is
transforming the diagnosis and treatment of prostate cancer. Big things,
I reasoned, could happen in the next ten years.
But this argument only worked if the combination radiation treatment
gave results comparable to surgery in the first place. All the surgeons
said it didn't. The radiologists shyly suggested that it did. I fell
back on my data. I looked at my plots. The data said that the treatment
results were the same--maybe even better for seeds.
I decided to bet on my own charts. Midway through the week, I confirmed
my appointment for high-dose-rate radiation treatment a few weeks later.
TREATMENT. The "smart bomb" doctor said it would
help him target his weapons if I had a special MRI procedure done that
was more sensitive than the one I had earlier. I lucked out. The university
hospital that has this capability was also experimenting with a new
technique, in which chemicals injected into the patient's blood interact
with the magnetic field of the MRI machine to produce an image of the
tumor as a group of red dots superimposed on the image of the prostate.
I was awestruck by this technique. I could actually see where the tumor
was and, to my relief, I saw no evidence of it being outside the capsule.
It was about the size of a sugar cube. I made sure this film arrived
at the Seattle doctor's office before me.
Then I headed up to Seattle. I had to check into the hospital at
5:30 in the morning on a Tuesday. Monday was a very hectic day at work,
which was wonderful: I didn't have a chance to think about Tuesday
at all. But when I settled in on the late-evening flight, the workday
behind me, no computers, no phones, the anxiety hit. Although my wife
was with me, I didn't feel like talking.
The next morning, I got on the conveyer belt. It was no different
than any outpatient procedure: questionnaires and a seemingly unending
series of nurses asking very similar questions, taking my temperature,
taking blood, on and on. Then, anesthesia. Although it was local anesthesia,
it made me zonk out. By the end of the procedure, during which they
inserted 16 hollow needles through my crotch into my prostate, I remembered
very little of what happened. One incident that stood out involved
the attending urologist (the procedure was jointly done by a radiation
oncologist and a urologist, who was responsible for placing the hollow
needles in the right positions). As I was coming out of my daze, the
urologist showed me how he had watched the needle insertion through
a fiber-optic cable threaded in my urethra. He described how he could
see the needles advancing one after another toward his eyes, as it
were. It was very strange.
I was wheeled into a CAT scanner, where they checked the placement
of the needles one more time. I later saw the film of my body with
the parallel needles in it; it reminded me of a porcupine. They proceeded
to do the radiation analysis. Given the shape and size of my prostate,
the tumor, and the placement of the needles, they needed to figure
out how long the radioactive seed should take traversing in and out
of each of the hollow needles. The special MRI came in handy here.
The radiation planners were able to use the shape of my tumor as shown
by the MRI as the basis for their calculations.
Two youngish guys did the calculations. They didn't look like doctors.
They looked as if they could be designing chips at Intel. The calculations
went on forever. Tongue in cheek, I asked, "What kind of computer
are you using?" I was told, seriously, that they were using a
286, a product that we introduced 13 years earlier and stopped producing
four years ago.
Over the next 48 hours, I was wheeled into the radiation room four
different times. Each time, a robotic-looking contraption drove the
radioactive seed through each of the tubes, one after the other. Then
it was all over. They took the needles out. My delighted doctor gave
me a high-five and discharged me. The next day I flew home, and the
following day I was back at work.
Altogether, I was out of work for three days. After that, for a couple
of weeks, things were back to normal. Then the external radiation phase
started. This follow-up radiation was done in 28 daily doses, each
of which took no more than a few minutes but was a bit of a nuisance.
I showed up at a local hospital every workday morning at 7:30 A.M.
I would undress, get radiated, put my clothes back on, and go to work.
A week or so into this phase, just as they predicted, I started to
get tired in the afternoon. I solved the problem by going home at 4
o'clock, instead of my usual 6:30 or 7 o'clock. I'd take a nap for
an hour, wake up, turn on my home computer, and complete my workday
at home.
Sometimes I would have a late-afternoon meeting. On those days I
checked into a nearby hotel, took my hour's nap, and went back to work
as good as new, albeit a bit sheepish about what people might think
about my checking into a local hotel in the middle of the afternoon.
If they only knew how harmless I was.
To my great annoyance, I gained weight, probably because I had to
change my diet. I couldn't eat roughage because of all the bombarding
my bowels were getting, so I ate more rich stuff. I gained three or
four pounds in five weeks, quite a bit for me.
Then the 28 days were over. I was done. No more hormones, no more
radiation, no more naps. In a week or two, I started eating vegetables
again, started losing the weight I'd gained, and regained my normal
energy. The latter was most important. Three weeks after the end of
radiation, I was scheduled to give the keynote speech at Telecom 95
in Geneva, Switzerland. The preparations for the speech were demanding,
and the speech itself was the most high-profile of my career. Between
Telecom 95 and other activities, I spent two weeks traveling in Europe.
All systems functioned just fine. Everything seemed to be back to normal.
Except not quite. Right after radiation ended, I had my PSA checked,
the first in a lifelong series of such tests in which they look for
recurrence. Even though the results were good, it was a reminder that
at least emotionally, things would never be altogether "normal" again.
Half a year and three PSA tests have since passed. My life has been
the same as before: my energy, well-being, physical functions (including
sex). Still, periodically I have to face the dread of a PSA test. And
although the results of the first three tests were very good, I know
I will be stuck with this fear for the rest of my life.
SOME CONCLUSIONS. As a result of my progression through the
experience of prostate cancer, I arrived at a few conclusions:
First, tumors grow. Sometimes they grow quickly, sometimes very slowly,
but they do grow. I think you should hit a tumor with what you believe
is your best shot, early and hard. In my case, it was a combination
of hormones, high-dose-rate implant radiation and external radiation.
For others, like Senator Dole and General Schwarzkopf, it was surgery.
If my best friend had this disease, my advice to him would be, "Investigate,
choose, and do--and do it quickly. Be aggressive now. Don't save the
best for later."
All the debates notwithstanding, PSA tests are a godsend. They give
you the next best thing to not having cancer: They give you time. I
cannot comprehend the arguments reflected by my daughter's doctor friend
that we shouldn't do them because the treatment options aren't perfect.
Using that same argument, should we not eliminate digital rectal exams?
After all, both of them do the same thing: They signal the presence
of prostate cancer. PSA just does it earlier.
I feel very strongly that if you are a middle-aged man, you should
have this test done regularly; given the rapid rate at which some prostate
cancers grow, I would opt for a frequency of once a year. You should
know your PSA number just as you know your cholesterol count. Remember,
it's a marker. What PSA gives you is the chance to act early. Don't
blow it.
I shared what had happened to me and what I'd learned with a handful
of friends and close associates. I learned that three of them had elevated
PSAs. They were riddled with anxiety but hadn't done anything about
it. I ran into another friend who had two relatives with prostate cancer,
which greatly increases the likelihood of his getting it himself. Yet
he hadn't had a PSA test. When I sit in meetings at work and look at
groups of men who are my contemporaries, I want to shout at them, "Do
you guys know what your PSA is?"
There is no good gatekeeper in this business. Your general internist
is not; the field of prostate cancer is a complex and changing specialty.
Neither is a urologist; urologists have a natural preference toward
surgery, perhaps because urologists are surgeons and surgery is what
they know best. Any other treatment is deemed experimental even if
it has just as much data associated with it. My review of the data
led me to conclude that there are viable alternatives.
The whole thing reminds me of the uncomfortable feeling I experienced
when I first sought out investment advice. After a while, it dawned
on me that financial advisers, well intentioned and competent as they
might have been, were all favoring their own financial instruments.
I concluded that I had to undertake the generalist's job myself; I
had to take the high-level management of my investments into my own
hands. Similarly, given the structure of the medical practice associated
with prostate cancer, that's the only viable choice any patient has.
If you look after your investments, I think you should look after your
life as well. Investigate things, come to your own conclusions, don't
take any one recommendation as gospel. For starters, know where your
case fits in the Johns Hopkins tables--this tells you volumes about
your condition. In fact, I think these tables ought to be posted on
the walls of every urologist's office. They should be viewed as the
point of departure for a prostate cancer patient's bill of rights.
The right answer, in my view, can be arrived at only by comparing
the results achieved by the practitioners of all the different treatment
forms. This would best be done by cross-disciplinary work. Frankly,
I am not impressed by what I encountered of this.
In the paper by Dr. Stamey, the one I downloaded from CompuServe
at the outset of my odyssey, he says,"...when faced with a serious
illness beyond our comprehension, [each of us] becomes childlike, afraid,
and looking for someone to tell us what to do. It is an awesome responsibility
for the surgeon to present the options to a patient with prostate cancer
in such a way that he does not impose his prejudices which may or may
not be based on the best objective information." I think we have
a long way to go to reach this ideal.
--In the course of surgery, doctors studied the actual nature of
prostate tumors and correlated their findings to what urologists had
observed during examinations before surgery. The results are tabulated
in what I refer to as the Johns Hopkins tables.
This particular one shows the probability--expressed as a percentage--that
the tumor penetrated the prostate capsule. The horizontal heading shows
the size of the tumor (size increases left to right); the vertical
numbers on the left, called the Gleason rate, indicate how aggressive
the cancer cells are (the larger the number, the more aggressive the
tumor).
In my case, some urologists said I had a T2a tumor; others characterized
it as a T2b. My cancer cells had a Gleason score of 7. These numbers
placed me in the green area, pointing to a 49% to 68% probability that
my tumor went through the prostate capsule. I averaged those numbers
and put my odds at 60%.
From A.W. Partin and others, Johns Hopkins, Journal of Urology, Vol.
150, pp. 110-14, July 1993.
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