It did not matter that Paul Schellhammer, MD, founded the Virginia Prostate Center at Eastern Virginia Medical School in Norfolk some 18 years ago, or that he remains the center’s medical director, or that he chaired the school’s urology department, or that his expertise would eventually land him the position of president of the American Urological Association (2007-2008). His vast experience did little to soothe him when he received his own diagnosis of prostate cancer (PCa) in 2000 at age 60.
“Some people think that because I know the playing field and because I’m familiar with the options, it would be very much easier to digest the news and make appropriate decisions,” he tells Renal & Urology News. “True, [as a urologic oncologist] I did not have to do a lot of homework to sort out the pros and cons, but digesting the news is equally as disturbing even though the knowledge base is present. I’ve confirmed this with other urologists and physicians: The news that you have a disease puts you on a similar emotional plane as any patient getting the word.”
Two years before the cancer finding, Dr. Schellhammer suffered a myocardial infarction. That event had the potential to be immediately lethal and was much more dangerous overall. However, he says, “While that worried me, it still didn’t grab the strings of emotion as powerfully as hearing that I had cancer. You intellectually know the data about cancer being survivable, but the way you react is not necessarily in harmony and in step with the intellectual data set that you have in your head.”
In 1990, when PSA testing was new, a 50-year-old Dr. Schellhammer had a reading of 3.0 ng/mL. “At that time 3 was well within the limits, but we now know it is very inappropriate for someone that age,” he points out. “Our knowledge of PSA testing was so crude back then, but I was happy with a 3 because all we knew then was that 4 was this magical number. Four is still a reasonably good cut-off point, but not for someone who’s 50.”
Today, Dr. Schellhammer says, he would have gotten a biopsy “straightaway,” but to uncertain consequences. “True, I might have found the cancer sooner,” he acknowledges, “but it all could have turned out the same way and I would have had 10 more years of problems.”
As it was, over the next decade Dr. Schellhammer’s PSA level rose past 4 to 4.5 and 5; once it hit 6, he underwent a sextant biopsy, the protocol at that time. “If you had a negative outcome you’d go back and have another biopsy, so this is one area where it was certainly of benefit to be a urologist,” he says. “I knew clearly that prostate cancer was there based on the PSA rises and I didn’t want to go through repetitive biopsies, so I asked my partner to triple the number of biopsies (18-20) so as to find cancer the first time around.”
For his radical prostatectomy, Dr. Schellhammer chose to travel cross-country to be operated on by Paul H. Lange, MD, of the University of Washington Medical Center, Seattle. He and Dr. Lange had become close when Dr. Schellhammer treated Dr. Lange’s father-in-law for PCa. Dr. Lange himself had already been operated upon for PCa, making for an even stronger bond between the two physicians.
In 2006, they published an honest and thorough monograph on their experiences, filled with treatment and management advice: Views From the “Other Side”: Personal Reflections About Prostate Cancer From Two Urological Oncologists. (accessed February 2, 2011; adapted from: Kirby RS, Partin AW, Feneley M, Parsons JK, eds. Reflections on PCa: personal experiences of two urologic oncologists: PCa: Principles and Practice. New York, NY: Informa Healthcare; 2006:617-624).
Following surgery, Dr. Schellhammer had a PSA failure, which was treated with hormone therapy and radiation. “And then again, like so many men, yet another PSA failure after salvage radiation,” he recalls.
He then enrolled in a clinical trial, experienced yet another PSA failure, and went on more hormone therapy, including ketoconazole and transdermal estradiol patches for his castrate- resistant nonmetastatic PCa. “I have been able thus far to avoid chemotherapy,” he remarks.
“But I point out to folks that here I am 10 years later doing—by all appearances and in actuality—quite well. I still work part-time, and I can tell patients, ‘This happened to me 10 years ago and you’re seeing me here now, even though I’ve been through these iterations of so-called failed treatment, so there’s plenty of optimism on the horizon.’ It’s not a choice that anyone would make in regard to their health status, but certainly in the big picture of being able to control the process and making prostate cancer a chronic disease like arthritis or diabetes, it falls into that spectrum.”
The emotional toll
As Dr. Schellhammer has told himself and his patients, the news of a PSA failure is devastating the first time and very upsetting the second time, “But after hearing it three or four or five times, like most things in life you begin to accommodate and say, ‘Let’s not crumble; let’s just suck it up and move on.’”
But unlike many of the men he has treated, Dr. Schellhammer did not have to struggle with the overwhelming question of, “What should I do?”
“It was a bit easier in the sense that I had, at biopsy, high-grade, Gleason 4 plus 5 so surveillance or watchful waiting certainly wasn’t a wise thing to think about,” he recounts. “I was still young at 60, I was familiar with the surgery, I was interested in learning more about the exact pathological findings—which I tell patients is one of the advantages of the surgical procedure.” Lymph nodes can be removed and examined to learn about extension beyond the prostate and maybe the need for hormone therapy or radiation to supplement the surgery.
However, he tries hard not to influence his patients. “If they know I’ve had the surgery, they click off and won’t even review the other options. They say, ‘Well, if that’s what he had, that must be the best,’” he affirms. “I want them to work through the decision in as unbiased a way as possible.”
Interestingly, despite his professional training, Dr. Schellhammer can relate well to the confusion his patients feel. “I can honestly tell them that with all my background, the treatment options weren’t crystal-clear to me just as they are not to them. I don’t find it the least bit unusual that they can’t make up their mind about what to do, and they shouldn’t feel uncomfortable about their uncertainty either. I was surgically inclined, but that didn’t mean that I was confident surgery would cure the disease.”
He advises men to devote a few weeks to the research and decision-making process. “You’re going to live with the side effects of therapy almost certainly for 10 or more years, so don’t go rushing straightaway to a treatment decision,” he cautions.