From “The Decision”
On one particular occasion (however it has happened countless times) I had just told a patient that his biopsy showed cancer. I began to lay out an overview of the options and happened to start with surgery. Before I could continue, the patient told me, “My brother has a friend who has prostate cancer, and he did radiation because a doctor told him that if he had surgery he’d be impotent and that surgery lets air get to the prostate and will make it spread. My brother and his friend told me to steer clear of surgery.” Now, normally I will take a deep breath and slowly explain the pros and cons of both radiation and surgery and the concept of apples to apples, but sometimes I have a little fun showcasing the folly of how some patients will place so much credence on something someone has told them. On this occasion I said, “Mr. Jones, thank you for sharing that with me. What type of work does your brother do?” “He sells insurance.” “Thank you. And what type of work does your brother’s friend do?” “I think he builds houses.” I then said,” Okay. Based on what you have told me, this is what I’d recommend for your cancer. My advice to you would be for you to do what your brother said his friend was told by his doctor about your brother’s friend’s cancer. Do you have any other questions for me?”
There was a story that was in the news several years ago regarding claims made by several people that the Arkansas State Patrol would secretly bring women to Bill Clinton when he was governor there. One lady in particular said that Clinton undressed in front of her in a hotel room and that she saw something about him that could prove that he did what she claimed he did. The thing she noticed was never publicized or reported but it was something that she said was “proof positive” that she had seen Clinton without clothes one.
I know what it was. It is a urologic condition that is only noticable if the male is erect. (Follow me here….everything always goes back to urology, prostate cancer, dogs or fish.) I also am a student of politics but try to leave that out on this site…most of the time….the doctors in white coats at the White House supporting Obama’s Health Plan was too much to not to comment on or make fun of….but I digress.
So here’s the quiz question for today: What urologic condition can only be noted by an observer of a male in the erect state ? This condition cannot be detected by an observer in the flaccid state.
I know this is very interesting to all of you and that the anticipation of the answer is killing you. Don’t get bent out of shape….here’s the answer.
Peyronie’s disease. In this disease there is a fibrous “plague” on the expandable tissues of the penis that in the erect state prevents that portion of the tissue to expand. This in turn curves the penis in the direction of the plague and only detectable when the penis is erect. I would bet that this is the “characteristic finding peculiar to Clinton” to which the lady claimed she saw.
What’s neat about this claim and why it could be used in a novel or detective story is that not only would the person have to be naked, which you can’t prove happened, but there would have been a condition that the accuser, would only know or could testify to, if the defendant was both naked and erect. Brilliant. As you know nothing came of the law suit however we do not know if there was a settlement…. I bet there was because I could have been an expert witness to confirm the lady’s claims from purely a urologic perspective.
So what does this have to do with the link above to the year journey of the gentleman’s prostate cancer.
Just like the Lockerbie bomber and the lady’s claims about Clinton, as you learn more about prostate cancer and the nuances you can piece together the unsaid or unwritten part of a person’s journey with prostate cancer. Apples to apples, prostates to prostates is how I describe this in my book.
Here are some salient points to get you started. You then read this man’s story…(I haven’t but I don’t need to) and see if you can pick out favorable stuff or unfavorable stuff. Knowledge is power, past is prologue. This actually brings up an interesting point. Do you want to know your prognosis if you have recently been diagnosed with prostate cancer? Do you want to know if your parameters or favorable or not? Well…you do need to know the difference between favorable and unfavorable factors because that might help you decide to value cure over ease of treatment. Knowledge of good signs or bad signs may or may not determine how aggressively you view your cancer and subsequent treatment decisions. Just because uncle Bob did good with his cancer doesn’t mean you will do with yours. It is prostate cancer, but ” ain’t all prostate cancers the same” my frin.
See if you know which of the following are good or bad, favorable or unfavorable and how each would affect a patients course or ones decision:
- a treatment that results in a low PSA that stays there and there is no other treatment given….ever.
- additional treatment is necessary…whatever it is
- the PSA changes upward after the initial treatment
- there’s evidence prostate cancer in the bone or lymph nodes
- the path report of a removed prostate reveals perineural invasion
- the path report reveals seminal vesicle involvement
- a Gleason’s 6 versus a Gleason’s 8
- the path report of the biopsy has only one of 12 positive for prostate cancer
- the biopsy path report has 10 of 12 positive cores
- you are young when diagnosed
- you are old when you are diagnosed
- the radiation therapist wants you to be on hormone therapy before he begins radiation treatment
- hormone therapy corrects the elevated PSA and then the PSA comes back up on hormonal therapy
- you are on casodex, your PSA rises, you stop the casodex, and your PSA goes back down
- you have had radiation with pellets (brachytherapy) and at about 18 months the PSA begins to rise…reason to worry?
- PSA bounce after radiotherapy
- the path report of the prostate removed has extra-prostatic extension
- the path report of the prostate removed shows capsular penetration
- the prostatic acid phosphatase is elevated (bet you don’t know this one)
- Gleason’s 6, small biopsy volume, path without seminal invasion,no capsular invasion, in the center of the gland away from the apex, urethra margin and away from seminal vesicles, small volume on final prostate path report
This is just the start of it…. and the reason the “Decision” is so hard…the above doesn’t even consider all the potential affronts to the male ego as it relates to continence and potency. That is a whole “nother” chestnut.
So when it comes to prostate cancer and you read about it or hear about it from others….read between the lines and consider everything.