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Posts Tagged ‘bored to death’

one is too many...ten is not enough...

I have had fun with the character in “Bored to Death” Ted Danson getting prostate cancer. I have learned a lot about the TNM staging system. It is confusing. I initially posted about that it was not “real life” to just tell  a patient that he had Stage  Two prostate cancer. That is a very broad statement. I rarely use the staging system tell patients about their newly diagnosed cancer. To me a patient needs to know-

  • the volume of the disease and it’s importance
  • that the PSA is mildly, moderate, or markedly elevated and the importance
  • is the cancer palpable to my exam
  • the importance of the Gleason’s score and how his score was determined
  • what staging is…is the cancer anywhere else?
  • then of course underlying health and if there are any voiding symptoms (this  helps guide the decision process)

If you know all the stuff up above then you know your stage….good luck putting it into the AJCC system. I asked a radiation colleague about the TNM system thinking that he would understand it and use the system that included grade and volume and PSA and he said he usually did not go beyond the TNM alone. (Staging uses the TNM system and then add other factors to assimilate all the info into a stage. The deal is that if you simply tell a patient “you are Stage Two” he would not know the specifics of his disease. A better way to tell a patient, if you prefer a generalized method, would be to  say you have prostate cancer with favorable parameters (mod PSA, mod volume, and mod Gleason’s) and it is confined (to the best of our knowledge) and you are a candidate for all  of the currently available curative modalities. Whewwwww!

Back to Mr. Danson. You’ll see below that he helped out with prostate cancer awareness  years ago. So he must be an  advocate of prostate cancer awareness and probably had something to do with the script including prostate cancer. Every little bit of awareness  helps. Thanks Ted.

 

ESPN Hosts, Ted Danson & D.L. Hughley Stand Up To Cancer

Updated 1:51 PM PDT, Thu, Dec 4, 2008

College basketball analyst and sports ambassador Dick Vitale and co-host of ESPN’s “Pardon the Interruption” Michael Wilbon have teamed up with ESPN, The V Foundation for Cancer Research® and Stand Up To Cancer in an effort to create a national discussion about the often ignored reality of prostate cancer and to help men start to understand their potential risk for the disease. Prostate cancer is among the biggest men’s health concerns. It currently affects approximately two million American men; more than 186,000 men will be diagnosed with prostate cancer in 2008 alone.

The effort launches with “Life: Interrupted – Stand Up To Prostate Cancer,” a town hall-style program taking place Thursday, December 4, at New York City’s ESPNZone. The event will tackle prostate cancer, which affects 1 out of every 6 American men. This event signals the start of a robust collective fight to defeat prostate cancer by empowering men to take control of their prostate health.

“Last year, I had a prostate health scare. Luckily, I escaped a diagnosis of prostate cancer, but I’ve since realized I need to take control of my health, especially my prostate health,” explained Vitale. ”I’ve joined this cause because I want men to seize control of their health and take the necessary steps to help manage their prostate cancer risk. The disease causes so much of an interruption to men’s life, and the time has come to step up the fight against it.”

Vitale and Wilbon are hosting the town hall, which will follow a sports show style format and will feature various sports and prostate cancer-relevant topics. This format engages men about their health within a dialogue of sports topics. Other panellists include one the nation’s leading urologists, Dr. Steven Kaplan; CEO of The V Foundation, Nick Valvano; Dr. Jonathan Simons from the Prostate Cancer Foundation;

 Dr. Jean Bonhomme from the Men’s Health Network as well as celebs Ted Danson, Mary Steenburgen, DL Hughley and Joe Theismann.

“If the first time you think about prostate cancer is when you’re diagnosed, it might be too late. Men over the age of 40, especially those with other risk factors, should be proactive in managing their prostate health,” said Kaplan, M.D., F.A.C.S., Vice Chairman of the Department of Urology at Columbia University.

“The PSA, which is a simple blood test, is an excellent tool to help manage your risk of prostate health. ew studies now point to higher-than-average PSAs as correlating with a higher likelihood of being diagnosed with prostate cancer in the future. One marker is 1.5 or higher in men over the age of 50. This is significant because we now potentially have a new way to closely monitor men who may be at increased risk for developing prostate cancer.”

Dr. Kaplan, among the other panellists, will paint the picture of prostate cancer in America, showing why prostate cancer is such an interruption in men’s lives. Indeed, every 2.5 minutes, a man is diagnosed with prostate cancer. And, every 19 minutes, a man dies from it.

“Dick and I wish that every guy out there can hear the message we are trying to spread,” commented Wilbon. “The good news is that the show will be available as a podcast on www.JimmyV.org.”

GlaxoSmithKline (GSK) proudly provided funding and support for the ‘Life: Interrupted’ initiative. GSK is closing in on cancer from all sides with a new generation of patient-focused cancer treatments in prevention, supportive care, chemotherapy and targeted therapies. Just one example of this commitment: GSK has invested significant resources in prostate cancer prevention research. GSK also is a major supporter of Stand Up To Cancer, and its innovative research-support efforts.

Additional supporters and in attendance at the “Life: Interrupted” town hall event include the American Urological Association Foundation, CancerCare, Men’s Health Network, Prevent Cancer Foundation, Prostate Cancer Education Council, Prostate Cancer Foundation, UsTOO International Prostate Cancer Education & Support Network, Women Against Prostate Cancer, and ZERO – The Project to End Prostate Cancer.

About The V Foundation
The V Foundation for Cancer Research was founded in 1993 by ESPN and the late Jim Valvano, legendary North Carolina State basketball coach and ESPN commentator. Since 1993, The Foundation has raised more than $80 million to fund cancer research grants nationwide. It awards 100 percent of all new direct cash donations and net proceeds of events directly to cancer research and related programs.The Foundation, which has received five consecutive top 4-star ratings from Charity Navigator, awards grants through a competitive awards process strictly supervised by a Scientific Advisory Board.

About Stand Up to Cancer (SU2C)
Stand Up To Cancer is a program of the Entertainment Industry Foundation (EIF), a 501(c)(3) charitable organization, and was established by a group of media, entertainment and philanthropic leaders, whose lives have all been affected by cancer in significant ways.

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I saw a patient recently as a second opinion regarding what to do about his newly diagnosed prostate cancer.
“What is most important to you?” I asked.
He said, ” I want my very best chance of cure regardless of the side effects. I also want to be able to do something curative if the first treatment fails.”
In my mind what this describes is a patient that wants the prostate removed and then if the PSA rises after treatment then curative doses of radiation is still an option. Certainly there are caveats in this scenario i.e. the parameters of the biopsy and the patient’s underlying health.
So this person helped me. He told me what is important to him. That, many ways, helped me advise him what to do. In other words, to me as the doctor, I need to know “who are you.”
Today, a patient told me after my having told him that his prostate biopsy showed small amounts of cancer, told me this.
“I have to work. I cannot risk something happening to me that will preclude me providing for my family or keeping my business going.”
That helped me. To me that took a prostatectomy off the table. I don’t feel there is enough of a difference in cure to push surgery in this patients situation. I told him he might have aggravating symptoms of radiation but that he probably would not have a major complication that would keep him from working. I mentioned that active surveillance, or seed therapy would have minimal impact on what was important to him i.e. his job. Customized care….that’s what I try to give my patients. It’s not about me, it’s about them.

So back to Ted Danson and his cancer on the show “Bored to Death.” Watch the trailer.
“Fiscally responsible, sexually out of control.”

Here is a patient that puts his sexual function to the forefront in the decision. You might think this odd. But prostate cancer is unique that way. Patients often put other issues ahead of cure. The reason is that in prostate cancer, if the parameters are favorable and we don’t know Ted’s, you can balance quality of life with chances of cure. So what to do with Mr. Danson and his cancer.

McHugh “Who are you ” factors and why they are important.

Let’s assume he has favorable parameters…low PSA, low volume and a Gleason’s of 6….what would I recommend if I am asked to be the second opinion on the show. (By the way I am available and would readily fly to the show free of charge and be on that particular episode.)

Favorable parameters: “Mr. Danson, your promiscuous lifestyle and the importance of sexual activity makes you an excellent candidate for active surveillance.” You would need a PSA twice a year and a prostate biopsy once a year. We would abandon this if any of your parameters progressed. If you can accept the small risk of “doing nothing” you are an excellent candidate for this.”
“If you are not comfortable with surveillance then I’d recommend external beam radiation. The reason I would not recommend surgery is that no surgeon in the world can promise you that after surgery you will regain your potency. With radiation you may experience a deterioration in your function but in most cases this can be corrected with medications. Seed therapy, I feel, has a slight higher chance of negatively affecting your sexual function so that might not be best for you.”

Here’s the caveat here….one can have perfect sexual function after prostatectomy, but you can’t promise that. There is risk with that from a purely sexual consideration. I feel I am very good at a Walsh Nerve Sparing Prostatectomy and my patients do well on all fronts as rule…but I cannot promise continence, cure, or in this case potency. No one can, I don’t care who tells you that.

If the advisors of the show consider all…Mr. Danson will not be having a prostatectomy. The only thing that will trump his concerns about sex, would be if he freaks out about cure. If a patient does this, in most cases they will choose to have the prostate removed.(Of course by the “robotic” method. If he chooses radiation it will be “Proton.” He’ll need to be trendy for sure. A thought just crossed my mind. He may be advised to have HIFU, and fly to Bermuda for the treatment. So very Hollywood like.) It could happen. Funny things happen to a man and his mind and the people who love him when he is told, “you have cancer. ”

Trust me. I’ve been there.

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Bored to Death Recap: The Bubble Bursts

Bored to Death Recap: The Bubble BurstsPhoto: Barry Wetcher/HBO

Bored to Death

SEASON

The Gowanas Canal Has Gonorrhea!
The third episode of Bored to Death’s second season gets off to a pretty sober start, as Sexy Urologist of a Certain Age tells George that he’s STD-free (yay!), but, alas, not stage-two-prostate-cancer-free (boo!). The good doctor comforts him with an ethically dubious make-out session, but this much is clear: For all its gags centered around pot vaporizers, and this episode is essentially one long one, the show isn’t afraid to throw a little mortality into the mirth-making. (Maybe Oliver Platt has it in his contract to only appear in premium-cable comedies with cancer-related plotlines?)
  • Patients and the public have trouble with differentiating a cancer’s grade with the stage. As it pertains to prostate cancer, grade is described as it’s Gleason score. The higher the grade, the less the cancer cell looks like a normal cell and the more aggressive and more unpredictable the cancer will behave. The grade describes the cancer itself, its personality for abnormal behavior so to speak.
  • The grade of a prostate cancer often can predict how well a patient will do long-term and the potential for spread of the disease beyond the prostate (metastasis).
  • The stage of prostate cancer is determined by three factors: the characteristics of the tumor, whether there is nodal metastasis, and whether there is distant metastasis (for prostate cancer this often times bone).
So here is what we know about Mr. Danson’s prostate cancer and it being “Stage II” and what  we don’t know.
  • First, if it is Stage II, we know that the doctor was able to feel an abnormality at the time of the rectal exam. So the doctor in the episode has done a rectal and that an abnormality was felt, usually a nodule or an area of asymmetry.
  • We don’t know the volume of the disease or the Gleason’s score. In other words we don’t know if it is small volume, unilateral (the prostate has two lobes, a right and left), and we don’t know if cancer was found on both sides (bilateral).
  • We know he has had a PSA and that it was probably elevated and that he had a prostate biopsy and all the sequelae of a biopsy. That is an episode in and of itself. The could use my book for several episodes of this series.
  • We know that because it is Stage II that there is no spread to the lymph nodes nor is there any metastasis to bones.
  • We know that to the best of the knowledge of his doctors the cancer is confined to the prostate and that he is a candidate for all forms of therapy, including active surveillance.
  • We know he had to have a CT scan and a bone scan to prove that the cancer was nowhere else. (Where is this in all the episodes?)
So….right now we don’t much about Mr. Danson’s cancer other than we think it is confined to the prostate. We don’t know PSA, Gleason’s grade, or the volume of his disease on the biopsy he supposedly had.
My wife and I love the show. We as you will be anxiously awaiting how the writers will handle this and also if the politics of prostate cancer and all the “debilitating” things that happen to a prostate cancer patient will be handled. Watch for the politics….it will be there.

Stage II prostate cancer can be detected with a digital rectal exam (physical exam). In stage II, there is no evidence of spread of cancer outside the prostate to other organs. Stage II disease may also be further be sub-categorized as follows, depending on how much tissue in the biopsy harbors prostate cancer:

  • T2a – The tumor involves half or less of one lobe (section) of the prostate.
  • T2b – The tumor involves half or more of one lobe of the prostate, but not the other lobe.
  • T2c – The tumor involves both lobes of the prostate.

 

The aggressiveness of prostate cancer is best shown by the Gleason’s score.  Did you notice that this score is not included in this  “Staging system?” The Gleason’s and PSA are included in the AJCC system but see if you can comprehend it. (Skip down to the Stage Two scenarios and see if you can follow it or place your self in a particular stage and then ask youself if it will help you or your doctor decide how to treat your cancer.) I have trouble with it and don’t quite see the clinical usefulness of it.

So…are all Stage II’s alike?  Will all Stage II’s behave the same? Should all Stage II patients be treated the same?

Should you make your decision the way your brother, neighbor, or Ted Danson (an actor) does? That is why the book, “The Decision” is more about working out what is best for you based on the particulars of you, rather than touting a particular treatment. The word “beat”, “cure”, “survive”, is not in the title to entice you to purchase. It is a system to arrive at a decision best for you. And that is why the book is different from the others and a necessary arrow in your decision tree quiver.

Apples to apples-Prostates to prostates my friend.

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