The Preliminary Battle Plan
I decided to go to Africa and to put this subject out of my mind until I returned. As I traveled through South Africa, Zimbabwe, Tanzania, Kenya, and Zambia I marveled at many wonderful sights, seeking a diversion from the overpowering reality and overwhelming thought "I had cancer!". Still, I knew that I would soon have to face my problem directly and that the decisions I made would affect the rest of my life.
It was while bouncing along in a Land Rover, over the African Savannahs and Maras that my soul finally absorbed the "Acceptance" phase and I felt myself recharged for the next phase "A Battle Plan". One I felt confident I would win, but first I must select the best plan of attack and the most competent allies to victory.
Upon my return from Africa, four weeks later, I returned to discuss the options with my Urologist, whom I now respected. The possibility of surgery was discussed with my doctor who did not consider it necessary but who would perform it if I desired. "Many men just want it cut out" he said! My cancer was quantified as PSA 14.7, Gleason #6, and TNM T2B. The possibility of radiation was discussed.
I had read about and studied the new procedure of Intensity Modulated Radiation Therapy (IMRT) and it sounded like an ideal solution to the problem - high rates of cure - minimal adverse side effects - virtually no interruption of life style - a procedure involving 8 to 9 weeks, 5 days per week, plus the initial work up procedures. Still, this seemed preferable to the potential side effects of surgery.
I opted to have the work done at a major cancer center which is one of the finest cancer research and treatment center in the U.S. based on five consecutive annual awards of this honor by U.S. News and World reports.(1992 - 1997 incl)
Of the 26 nationwide such centers to merit the National Cancer Institute's highest designation - Comprehensive Cancer Center - two are located in New York City: . To earn the title, both hospitals met a series of rigid requirements set forth by the NCI, including strong laboratory and clinical research, the ability to put these results into practice, and high priority trials for promising treatments. Because an array of specialists are housed under one roof, patients benefit from the medical equivalent of one stop shopping.
The hospital I had chosen had been using 3 D-CRT (Three Dimensional Radiation Therapy) since 1990 and had amassed a great wealth of experience in its use. They had been using the knowledge gained here to develop and perfect IMRT, which is a technical progression from 3D-CRT. I realize that commuting to treatment for 45 daily sessions would involve four hours cumulative travel of 200 miles per day times 45 days or 9000 miles by train, while I lived in a suburb of N.Y. The entire daily regimen, including treatment, would require about 7 hours.
The difficulties or inconvenience of the daily journey were of little consideration when I could have the finest treatment available administered by superlative and dedicated cancer specialists who see more cancer patients in a year than most doctors see in a lifetime.
While waiting for my appointment in New York I had some the preliminary work done at local hospitals or health care centers. These included: Bone Scan, MRI, more blood testing. A diagnostic CT scan can be performed outside of the cancer treatment facility. However, a CT Scan, for treatment planning purposes MUST be performed in the same facility which will perform the ultimate IMRT procedure.
I had my appointment with my radiation oncologist in late November 1996. Additional testing during that session downgraded my PSA from 14.5 to 10.45. It is important to note the range possible in PSA testing from different labs or even the same lab on different dates in a short time span. The test is accurate to +/- 30%. My Gleason number was upgraded to 7.0 from 6.0. My radiologist indicated that both his hospital and some others tend to give sightly higher Gleason Scores than regional labs. So with this final and expert result in I could then quantify my cancer as: PSA = 10.45, Gleason = 7.0 and TNM = T2B. My cancer cells finally had a first, last and middle name!!
The personnel in New York recommended the IMRT procedure. I was pleased at this because this recommendation agreed exactly with my own thoughts after a highly intensive study of all the appropriate literature I could find.
The procedure would begin with three months of Androgen Ablation Therapy. Then the IMRT therapy would begin concurrent with an additional three months of androgen ablation. At the conclusion of 42 treatment sessions both the androgen ablation and the radiation would cease at 7,560 RADS. I could expect a 60% - 70% chance of a cure - about as good as any other form of treatment.
It is important to understand that cure rates referenced in this narrative are rough estimates based on the experience at the treatment center I had chosen. They are based on radiation treatment when the cancer cells are confined within the prostate gland.
Example: With 8100 rads of radiation the odds of having a positive biopsy, after conformal radiotherapy is less than 10% or is reported as a 90% chance of cure.
Prior to my meeting with my radiation oncologist I studied the potential side effects of the proposed treatment. . However I was not privy to much of the details of the technology at that time.
My radiation oncologist would measurably expand my education over the time we spent together in the coming months. I had arrived at the decision that the IMRT therapy was best suited for my case.
My radiation oncologist agreed with me and then added the Total Androgen Ablation protocol and submitted this entire program to a multidisiplinary prostate conference consisting of Radiation Oncologists, Medical Oncologists, Pathologists, and Urologists. This conference concurred that this was the proper treatment for my case. Baseline tests were done on liver function to monitor the Casodex side effects and testosterone levels.