A personal view of prostate cancer
A number of correspondents have asked generously about my health. It isn’t something that I have been anxious to broadcast, in part because it is a private matter, and in part because I am sure others have more to complain about than me. But I have decided to talk about it now in the hope that it will serve both as a warning and as an aide to others. This was prompted by a couple of regular correspondents who seemed to be tracking down the same diagnosis pathway as I did, but were ignorant of the process.
The warning is that you don’t need to get into my situation if you are sensible. The aide is that the diagnosis and treatment of cancer can be a confusing and overwhelming experience, and any explanation of what they both involve should reduce the anxiety. Having worked in the cancer field for 30 years, I guess that I was better equipped than most to face the situation, and yet the process of being caught up in the medical tide was daunting.
I was diagnosed with prostate cancer in July 2008. It was classified as Grade T3 and with a Gleason score of 9. That meant that it was an aggressive cancer that had extended through the gland capsule. I was told that I was going to die from the cancer and that my 5-year survival outlook with treatment was 30-50%.
The cause. The first question that went through my mind was where had this thing come from? Most men if they live long enough will probably get prostate cancer, so we shouldn’t be too surprised. But in the majority of cases it will be a mild form, where the PSA doubling time is measured in years. In my case it was in weeks, indicating a highly aggressive form. So what had pushed me towards the aggressive end of the spectrum?
I was fit, didn’t smoke, wasn’t overweight, was just a moderate drinker, ate healthily, and took (admittedly only irregularly) my Trinovin. My father had lived to the ripe old age of 88 without any prostate problems and cancer was not a disease that featured large in my family. The scientist in me went looking for reasons and I mention them here for no other reason than I believe that they are relevant questions that the community needs to ask.
The first one that came to mind was the years spent on planes and trains and in airports and hotel rooms with a laptop computer on my lap. There was this piece of equipment, emitting God-only-knows what, perched just millimetres away from my prostate gland. Mobile phones have been linked to brain cancer, so why not laptops to cancer of the lap? I have no idea how much of a causal link there is there and I couldn’t find any information about it. I suspect it probably is a low risk, but I would be willing to bet that computer manufacturers haven’t asked the question in any depth. Does anyone out there have any idea?
The second reason that came to mind concerned a spring spent working in Germany in 1986. I was working at the Deutsches Krebsforshungszentrum (German Cancer Research Institute) in Heidelberg. This institute had a major research interest in human papillomavirus and its relationship to cancer, under the directorship of Professor Harald zur Hausen who just last month was awarded the 2009 Nobel Prize in Medicine for his studies. I was there to study the role of papillomavirus in virulent squamous cell carcinomas of the skin. That meant working with highly radioactive material that was used to probe cancer specimens for the presence of HPV DNA. Virtually everyone in the place was working with radioactivity, and to help contain accidents, the main corridor was armed with huge radiation detectors that set off an alarm if anyone walking down that corridor happened to have any radioactivity on their clothes or skin. On a late April morning in 1986, I sent that alarm off in no uncertain manner, as did a number of others staff.
The answer soon became apparent. A nuclear plant at Chernobyl in the Ukraine had blown up a day or two earlier and a nuclear cloud was drifting westwards across Europe. Heidelberg was directly in its path.
I rode a bicycle to work and like anyone else who spent any time outside that day, I was exposed to radioactive fall-out and particles of iodine, caesium and strontium were what set off the corridor alarm. Millions of people across Western Europe and as far away as Canada were similarly exposed. The only difference between them and people like me working at centres likes the Heidelberg institute was that we had hard evidence of the extent of the problem. I knew I had been exposed and I knew just how much radiation had landed on me…everyone else had no idea. A housewife in Brussels, a train driver in London, a jogger in Dublin……they would have heard about the nuclear cloud on the news, but they would have had no idea about their level of risk. Anyone who spent any time outside at that time would have been exposed. Food growing in fields would have been exposed, and the food-chain for the next 12 months at the very least would have been contaminated.
Anyone in the immediate vicinity of Chernobyl suffered a high risk of cancer, especially leukaemias and especially children. Outside of the immediate vicinity, however, the story is less clear. I would be interested to learn if anyone has mapped the incidence of different cancers across Western Europe in relation to the pattern of movement of the Chernobyl cloud. Perhaps it is all too late and having that information is not going to deliver anything useful in terms of community health. I even remember thinking at the time, what could health authorities do? The scale of the problem was so vast, and the remediation measures so enormous, that action was almost inconceivable. What was to be done? Tell several hundred million people to go and have a radioactivity test? And even if they had done so, it was far too late to take preventative iodine tablets. And are you going to tell several hundred people to only eat canned food for the next few years? I am far from being a conspiracy theorist, but I remember thinking at the time that the only way to handle the problem and to avoid mass panic and community disruption was to pretend there wasn’t a problem.
That event was 23 years ago, a long time to wait for any after-effects, and plus there is no biological basis to link radioactivity to an increased risk of prostate cancer. But let’s say that an individual does not have a particular genetic susceptibility to cancer, except for the fact that being a male, he is likely in later life to develop prostate cancer, just because he is a male. Then any event that predisposes to cancer will be likely to increase his risk to the one cancer that he is likely to get. And being a very slow-growing cancer that probably develops over decades, an event that occurred 23 years ago that left him with radioactive particles with half-lives of about 30 years (cesium-137 and strontium-90) might well be enough to trigger carcinogenesis over that time.
It’s just a thought, that’s all. And it is something that middle-aged men across Western Europe might just want to think about and cause them to be a little bit more judicious when it comes to having regular prostate checks.
The third causative factor that came to mind was stress. Stress is an accepted risk factor for degenerative diseases in general, cancer included. Everyone has stress in their lives, so I am not going to elaborate on my private stressors, other than to say that I am satisfied that this was the dominant factor that shifted an underlying mild form of slow-growing prostate cancer into an aggressive tumour. Being in Heidelberg at the wrong time and using a laptop in an unguarded manner may have contributed, but I have no doubt that stress was the major player.
The message?
Don’t ignore stress as a major risk factor for cancer. Most stress is temporary, even the big ones like the loss of a loved one or divorce. The grieving process usually is finite and so the biological outcomes will be limited. But the kind of stress that is relentless and goes on for years and leaves you feeling disempowered, I can say from personal experience is infinitely worse in terms of its effects on the body. The problem with being in that state is that you are less inclined to look after yourself….either because your energies are going elsewhere or you simply don’t care. But that is the very time that you should be making an even bigger effort to monitor your health. That’s the message for what it is worth.
The symptoms. I agree with women. Men are idiots when it comes to health.
I’ve spoken to thousands of people about prostate health and I thought that I knew my own body and its nuances. And yet I managed to overlook the obvious and even when it was dangled in front of my eyes, I didn’t want to believe it. That alone shifts me from the simpleton into the village idiot category.
I had stopped travelling and fighting a board of directors and dealing with disgruntled shareholders and was working on my farm. I was doing the usual heavy, physical sorts of things that farmers do, all day every day. Then early in 2008 I started to get tired. Suddenly I couldn’t do an hour’s work without needing a rest. Also, whenever I lifted anything, I got this discomfort in my pelvic region. Being male, I ignored it. But three months later it was bad enough to warrant seeing a doctor. My blood pressure was through the roof and anti-hypertensive medication failed to lower it. [In 2008, a study was published showing that high blood pressure is an associated symptom of early prostate cancer]. It was only when I developed urinary obstruction that the finger was pointed, so to speak, at my prostate. A blood test showed that I had a PSA level of 25 ng/mL. But being bullet-proof, I still didn’t think I could get prostate cancer. It must have been prostatitis due to a bacterial infection. I managed to convince myself that is what it was, and I even managed to convince my doctor of the same. Six weeks of antibiotics did nothing to relieve the symptoms, and a follow-up PSA test showed that it had risen to 35. Off to a urologist who only had to check my prostate with his finger to pronounce me a cancer statistic.
The message?
(i) If you are over 50 and feel a slight discomfort in your pelvic floor whenever you exert yourself (so raising your abdominal pressure), get yourself off to a doctor.
(ii) If you suddenly develop increased blood pressure, make sure your doctor checks your PSA level.
(iii) If you are over 50, don’t wait for the above symptoms. Have a PSA test done anyway every year or so. My doctor (a lovely man who I would still trust with my life) missed the problem initially because he conducted a digital examination and felt that all was OK. It wasn’t, and a PSA test would have shown that.
The diagnosis. Fine needle biopsy provides the ultimate diagnosis. This involves a device being inserted into the rectum that takes a series of biopsies through the bowel wall. Gentlemen, it is not painful, just mildly uncomfortable, although it carries a very low risk of complications such as infection.
A pathologist then looks at the biopsies under the microscope in the same manner that PAP smears are examined for the presence of cancer cells. The extent of cancer presence within each biopsy specimen is noted, along with the mitotic index (indicating rate of growth) within the cancer cells. A scale of 0-5 is applied to each specimen (with 5 being the most cancerous). The two highest graded specimens are taken to given a score known as the Gleason Score.
The treatment. In my case treatment was high-dose brachytherapy. The term derives from the Greek word brachios, meaning short. It involves the temporary insertion of a device in and around the tumour to enable the delivery of a relatively high dose of radioactivity to a confined area, thus sparing surrounding tissues.
High-dose brachytherapy involves the insertion of a plastic device containing a number (usually 18) of catheters into the prostate through the perineum. A computer-controlled machine then pushes a single highly radioactive iridium seed into the catheters one by one.
This is done on 3 separate occasions over 48 hours. The plastic device then is removed.
After a break of several weeks to allow healing of the surgical site, external beam radiotherapy then is applied to the pelvic region on a daily basis (Mon – Fri) for 6 weeks.
The biology of this process is interesting. The field of damage involves the entire prostate and surrounding tissues to a radius of about 3-4 cm, taking in the bladder, urethra, rectum, anus and penis. Some of the effect is immediate, with necrosis of those tissues. But part of the effect of the radiation on DNA ensures that the damage can go on for the next 12 months, as cells with damaged DNA progressively die over that time.
The after-effects of this damage can be severe. Most are temporary, but some can be permanent.
The second approach is androgen ablation therapy. This involves taking medication that results in castration blood levels of testosterone. This makes brachytherapy look easy. Severe mood swings, hot flushes, loss of muscle mass, loss of libido, osteoporosis and gynecomastia are the result.
The outcome. For me, this treatment put me into remission for 12 months. The PSA reading was 64 immediately prior to treatment, falling to a nadir of 0.3 after treatment.
The PSA level has risen over the past 6 months, and has now resumed its previous aggressive doubling time. The cancer has been confirmed as having metastasised.