Life After Radical Prostatectomy: 96 Months Later

So it’s been 96 months since my radical prostatectomy on 4 January 2011. How am I doing?

Status

My PSA resumed its upward climb last month after a brief hiatus between April and August. It certainly wasn’t unexpected, yet I was holding out hope that I could have had three consecutive PSA readings at the same level. It just wasn’t meant to be. That means that I’m one step closer to having to make a decision about what’s next.

Emotions

At this point, I’m at peace with where I’m at regarding the cancer returning. What’s actually been gnawing at me since my last post like this six months ago is something completely different—relationships.

Relationships require effort and commitment by both parties and lately, I’ve been asking myself the question, “At what point does one stop investing in a relationship when you get little or no return?” I don’t know that I have the answer to that question. I don’t want to burn bridges, but time is the most precious thing we as cancer patients have, and we want to invest our time as wisely as possible.

The sad thing is that I’m beginning to ask that question of the people who are the ones that I’ll  need to turn when the cancer advances to the point where I’ll need assistance. (Remember, I’m single and the thought of facing this alone scares the piss out of me.)

Incontinence

Speaking of piss out of me, let’s talk incontinence. (Sorry, I couldn’t resist.) I have noticed a slight increase in stress incontinence episodes and, if I’m perfectly honest with myself, I would attribute that to the fact that I have gained weight again. I really think there’s a correlation there, so I’m going to work on losing some weight and see what happens.

I’m still 90+% dry, but when I sneeze, cough, or lift something of even moderate weight, the likelihood of a few drops leaking out has gone up slightly.

The other time that I have issues is immediately after emptying my bladder. (I don’t know why I haven’t talked about this before, but it’s been an issue for quite a while.) If I don’t go through a little routine at the urinal to “milk” any residual urine from my urethra after emptying my bladder, the chances are good that I may have a squirt of urine as I’m putting everything away.

Sexual Function

My ability to achieve decent erections has remained pretty constant through the last six months. I’m in the 70%-85% range now. Good enough to achieve an orgasm, but questionable for much more than that. Some days I can get lucky and get in the 90% erection stage, but those days aren’t common. Of course, all of that is without any chemical assistance.

Summary

I’ve got a lot on my plate in the months ahead. I’ll continue to research imaging trials and salvage radiation in anticipation of my next PSA test in April. I’ll also evaluate my relationships, looking inward first to see how much of this may be my problem, to see where I should invest my precious time. I have no doubt that 2019 will prove to be an interesting year.

Season’s Greetings from San Diego

I just wanted to wish everyone a Merry Christmas and all the best for 2019 with a few photos and a video that I took on Christmas Eve at the iconic Hotel del Coronado across the bay from San Diego.

You can go ice skating under the palm trees about 100 feet/30 meters from the beach. (I know better than to strap a pair of ice skates onto my feet. No Christmas Eve trip to the hospital emergency room for me!)

Day 2,960 – Meeting with the Urologist

One thing that I’ve learned along this journey is that every doctor has his or her own take on the situation and what should be done, and very few of those opinions match. They can’t even agree on standard definitions.

This afternoon’s meeting with yet another urologist proved to be interesting at best and a tad frustrating at worst.

He was a younger doctor but the interesting thing was that he held to the belief that I haven’t had a biochemical recurrence yet and won’t until I hit the magical 0.2 ng/ml. I was a bit taken aback by that given what everyone else has been telling me for the last two years. He also talked about the newer ultra-sensitive PSA tests, but hung on to the definition that anything less than 0.1 ng/ml was “undetectable.” In his mind, my PSA at 0.13 was “very low.”

We talked at length about my PSA doubling time, and that was one area that we came to consensus on. That having a PSADT of more than two years was a good thing. He seemed quite interested in seeing the results of the Memorial Sloan Kettering PSADT calculator, which had my doubling time at 35 months (based on only four data points because their calculator accepts only those values >= 0.1 ng/ml). (I also had my PSA tracking chart printed out and sitting on his desk when he walked in.)

I asked him about what his experience was with dealing with the long-term side effects of salvage radiation therapy as a urologist—how frequently they occurred and what severity they were. He went through the list of things that I had already known, and said in his “whole career” he had seen only three or four cases that were significant. (Note: His “whole career” spanned all of six years. I’ve had cancer 8 years.)

Lastly, we talked about the Ga68 PSMA imaging trial going on at UCLA. It was clear he was aware of the research, but wasn’t at all familiar with the details or requirements of the trial. I didn’t expect him to be well-versed on the topic, but it was clear that I knew a bit more about it than he did, especially when it came to the requirements to participate, (I didn’t tell him that I had actually contacted UCLA.)

He did ask me if I had a PSA threshold in mind where I would want to take action when it comes to salvage radiation therapy. In my mind, if we get into the 0.15 or above range and the PSADT starts to shorten, I’ll have to strongly consider the next steps. But I did bring up the Freedland study that shows, with my numbers, I can do nothing and have a 94% chance of being around in 15 years.

Normally, I don’t mind seeing younger doctors because sometimes they’re more familiar with the latest research and current treatment philosophies than their older counterparts. I’ll take his input with a grain of salt considering how he’s not in line with the thinking of some of the others that I’ve seen in the last year or two.

In the end, we agreed to kick the can down the road and do another PSA test in four months in April 2019.

I’m still interested in speaking with a radiation oncologist about this again. I may try emailing the one I saw in May or just ask for another referral after the beginning of the new year.

It was a bit of an odd consult. I’ll just forge my own path forward and we’ll see where that leads. In the meantime….

Wishing you all a very Merry Christmas and the healthiest, happiest New Year possible!

—Dan

IMG_20171207_140153690
We have to improvise here in San Diego!

Month 97 – Researching and Evaluating What’s Next

Last week’s bump up in my PSA level certainly knocked me from my blissful state of denial back into reality. I was surprised by how emotional I got about the results. On the good side, however, the emotions lasted only a few hours and were pushed aside by the demands of work.

After work, I wrote the study coordinator at UCLA about the gallium 68 (Ga 68) PSMA-11 PET/CT trial. I was pleasantly surprised when I received a reply within 18 hours.

In a nutshell, they’re still accepting participants to be randomized into two arms of the trial. In one arm, they will use the Ga 68 PSMA PET/CT imaging to attempt to detect the cancer in patients about to undergo salvage radiation therapy; the other arm just begins salvage radiation therapy without the benefit of the imaging. Of course, UCLA covers the cost of the imaging for those in the first arm of the trial.

Interestingly, they do have another related trial where the patients “pay around $2,800 USD, but everyone gets the scan and there are no obligations about what treatment patients should do next.” That has tremendous appeal to me, but I did send some follow-up questions on Friday.

Specifically, I wanted to know if they had any preliminary results that showed the rate of a positive scan result with a PSA of 0.13 ng/ml. If you look at the information in my previous post about imaging, you’ll see that the detection rates for a PSA of less than 1.0 ng/ml ran from 29% to 67% (median 51.5%). I suspect that the further one’s PSA is from 1.0 ng/ml, the less likely it is that you’ll detect the cancer cells.

Now I’m not trying to be penny-wise and pound-foolish, but $2,800 is a decent chunk of change to shell out for something that may have very little chance of doing what it’s supposed to given my PSA level. I mean, really—that’s the equivalent of a sweet Gitzo carbon fiber tripod with ball head and a new lens for my landscape photography. 🙂

Of course, I could wait for my PSA to get closer to 1.0 ng/ml, but that’s pretty scary.1 The longer you wait, the more the cancer cells replicate and spread and, by then, it may be too late to just zap the cells in the prostate bed (assuming that’s where they’re still at right now).

Because Ga 68 PSMA PET/CT is not yet approved by the U.S. Food and Drug Administration, I did ask the coordinator if there were any adverse events or side effects that have been identified with the imaging trial so far. That would be nice to know before injecting some unapproved glow-in-the-dark juice into my system.


I’ll get my urologist’s take on all this when I have my next appointment on 18 December. I’ll ask for another referral back to the radiation oncologist but, while that’s happening, I’ll likely email the radiation oncologist that I met with in May and ask for his thoughts on the Ga 68 PSMA trial.

While salvage radiation therapy has certainly moved higher on my list of things to consider, I’m still concerned about the potential long-term side effects impacting daily quality of life as a result. That will definitely factor into my decision-making process.

More to come…

Footnote:

1 – I ran the trend function in my spiffy PSA tracking spreadsheet and, using a linear trend based on my historical increases, it predicts I wouldn’t hit 1.0 ng/ml until December 2045. I’ll be just shy of my 88th birthday—or dead—by then. Perhaps I don’t need to sweat this after all… 🙂 (Yes, I realize that the trend won’t remain linear over time.)

A review of PET Imaging for Recurrent Prostate Cancer

This is a quite informative paper from Practical Radiation Oncology, giving a good overview of the newer imaging technologies being developed to identify the location of recurrent prostate cancer before beginning salvage radiation therapy.

Prostate cancer–specific PET radiotracers: A review on the clinical utility in recurrent disease

I’ll comment in a separate post on where my head is at after receiving my latest PSA results.

Day 2,948 – PSA Results

My slight sense of optimism that I gained after my last consistent PSA result was shattered at four o’clock this morning when I hopped online in a fit of insomnia to check my PSA test results from this week. I’m back on the upward climb again with a PSA of 0.13 ng/ml.

PSA 20181203 clean

My spiffy spreadsheet predicted a value of 0.129 ng/ml, so it wasn’t unexpected. Just my hope for a more stable PSA went out the window.

Obviously, I’ve got some serious thinking to do in the weeks ahead.

The predictive part of my spreadsheet shows the increase will continue at a rate of about 0.011 ng/ml every four months. In April, I would be at 0.140 and in August at 0.151. Is that rate slow enough to delay any decision about salvage radiation therapy a while longer? I don’t know.

Do I get involved with the imaging trial at UCLA to see if we can determine where the cancer is before undergoing salvage radiation therapy? I don’t know.

Or do I just say screw it and start the salvage radiation therapy in early 2019? I don’t know.

Stay tuned for the answers. That, or for pictures of ostriches with their heads buried in the sand.

Dr. Thomas Hope: New Directions in Prostate Cancer Imaging

Here’s an interesting article about the current state of imaging that can be used in the detection and treatment of recurrent prostate cancer:

https://wp.me/p4yQj7-yk

Eight Years

It was eight years ago today that I learned that I had prostate cancer. I had no idea then what would transpire in the days and weeks ahead, and I certainly had no idea that I’d still be dealing with it—and writing about it—eight years later.

You’ve heard me say multiple times that, once you introduce the word cancer into your vocabulary, it never goes away, even if the disease does. There will always be that little cloud called “fear of recurrence” that will follow you around for the rest of your days.

You’ve also seen me throw around the phrase cancer-free with each successive undetectable post-surgery PSA test. It’s hard not to. With each undetectable test result over time, you become more confident that you have this beat. You get lulled into a sense of routine and PSA tests become less scary. But because cancer is so insidious, there’s a danger in using words like cancer-free and cured.

My first indication of biochemical recurrence 54 months after surgery was an utterly unexpected slap upside the head. “Not so fast, fool!”

Ever since then, I’ve become a big fan of NED—No Evidence of Disease—as a better descriptor of how successful a treatment option has been because it accounts for that little recurrence cloud. Saying cancer-free or cure implies a finality. You’re done. It’s behind you. A decade later, you may find out that no, in fact, you’re not done with cancer.

Some may say that’s a rather dismal outlook on things and that we need to be optimistic. Perhaps. I prefer to be more realistic, obviously as a result of my own recurrence experience. And, just because I had recurrence, it doesn’t mean that others will as well. You may live the rest of your days with no evidence of disease and, if you do, more power to you.

There is good news. It’s eight years later and I’m still here, still pretty much fully functioning, and still writing.

After eight years, I’ve learned:

  • Be optimistic but understand that, with cancer, there are no guarantees.
  • Research, research, and research some more, but step away and take time for your mental health.
  • We may think that we’re fighting a battle, but the reality is that the cancer is in control and we’re simply reacting to the next treatment or test result.

My next PSA test will be on 6 December 2018 if all goes to plan. Will it remain stable at 0.11 ng/ml, or will it return to an upward movement? Stay tuned.

Work life and my travels over the last three months or so have been so busy that I haven’t thought, read, or researched about prostate cancer much at all. It’s been a pleasant break. But the one thing that has been lingering in the back of my mind is the trial of 68Ga-PSMA-11 PET/CT Molecular Imaging for Prostate Cancer Salvage Radiotherapy Planning [PSMA-SRT] at the University of California Los Angeles (UCLA).

I’m not sure that I would want to enroll in the full-blown trial itself, but I would like to learn whether or not I could get the scan outside of the trial, even if it’s at my own expense. I’d really like to know that we’re zapping where the cancer is located instead of blindly, based on statistics, if I do choose salvage radiation therapy. It’s something I’ll discuss with the urologist on 18 December 2018.

Month 95 – Road Trip

I had an idea for the topic of this month’s post but I really never fully developed it because I was off gallivanting up and down California, Oregon, and Washington over the last week or so on an overly ambitious road trip. I’ll work on fully baking my idea for a future post but, in the meantime, I’ll leave you with a link to my travel blog where you can check out autumn in the Eastern Sierra Nevada mountains and the Olympic Peninsula of Washington. It was a great escape from all things work and cancer.

Enjoy! I sure did.

Chaotic and revolutionary progress in the diagnosis and management of prostate cancer

Here is a good summary of where we’re at in diagnosing and treating prostate cancer.

https://wp.me/pdkiw-6Sf