The bad news
My urologist called with the results about three weeks after the biopsy. One of the 12 cores was positive. My Gleason sum was 6 and my clinical stage was T1c. I was now one of some 186,000 men who would be diagnosed with prostate cancer last year in the United States, according to American Cancer Society estimates.
Given my disease characteristics, I met clinical trial criteria for low-risk disease. Had I not been well-informed about the nature of prostate cancer as a consequence of my job, I might have reacted differently. Many men take the news hard. In April 2008, I reported on Swedish studies showing that men recently diagnosed with prostate cancer—especially relatively young men—are at elevated risk of cardiovascular-related death and suicide.
My urologist said my prognosis was excellent, and in a later consultation, he ran down the treatment options, namely active surveillance, radical prostatectomy, external beam radiation, and brachytherapy. He recommended against active surveillance and provided an unbiased description of the other three approaches. He noted that the treatments are associated with similar oncologic outcomes, but they differ in their adverse-effect profile. Following the consult, he asked me to let him know what I decided.
To treat or not to treat?
Again, knowing that prostate cancer usually is slow growing, I held off on treatment for a few months to think about what I wanted to do. Despite prevailing wisdom, I strongly considered active surveillance, figuring the longer I could spare myself the adverse effects of treatment (such as urinary problems and erectile dysfunction) the better. It was a tough decision. Active surveillance usually is considered an option for patients who have low-risk tumors and a life expectancy of less than 10 years. The thinking is that these men are likely to die from other causes before the tumor becomes a problem, and thus it is reasonable to spare them the adverse effects of treatment.
The dilemma for me was my age. I was about 20 years younger than the typical prostate cancer patient and thus had a life expectancy of far more than 10 years. I could live long enough for the tumor to grow and metastasize. Whether this would be the case for me, I had no way of knowing. There are no good clinical trial data on active surveillance outcomes among prostate cancer patients in my age group. I was stuck with this question: Should I suffer the adverse effects of treatment for a tumor that might never cause me problems?
The answer came to me over the next few months. As I weighed the options, it occurred to me that immediate treatment provided my best chance of cure. I did not want to regret missing this window of opportunity. I also remembered that some evidence suggests that prostate cancers in younger men have a greater likelihood of being aggressive, although this is a matter of debate. A jump in my PSA to 7.6 tilted me in favor of treatment. I might well have a tumor that could cause serious problems, I thought.
So which treatment? Early on, I rejected the surgical option. I was leaning toward brachytherapy, but I learned that seeds can cause severe urinary adverse effects and also result in erectile difficulties. My only other conventional option was external beam radiotherapy. This modality has been refined in recent years such that radiation is delivered more precisely to the prostate, producing less collateral damage to rectal and other tissues. Among the advances in technique is image-guided intensity-modulated radiotherapy (IMRT).
I met with a radiation oncologist in August 2008. He gave me another DRE. Again, no palpable tumor. He explained the different radiotherapy options. I left the consult fairly certain about wanting IMRT, but for various reasons, I decided to wait a few months before starting treatment. Mainly, I needed to arrange things with my employer. IMRT would require me to undergo 38 treatments, which generally are administered Monday through Friday for about eight weeks.
My commute to work—which is by bus—is about two hours each way. The earliest I could have treatments was between 7:30 and 8:00 am, meaning that I would arrive about two hours late for work. Fortunately, my supervisors were sympathetic and allowed me to work later and on weekends to make up the time. My publisher suggested that I start treatments in November so that they would span the holiday season (Thanksgiving, Christmas, New Year’s), during which I take a lot of vacation days anyway. And that is what I arranged.