Post radiologist dialog
July 15, 2016

Tracy,

Here are some communications I've had with my urologist following my MRI, biopsy and bone scans.  The quick and dirty is -- it's interesting that  I'm now a cancer patient, but the disease is otherwise unremarkable, and non-threatening at this time. The odds are good that the cancer will grow slowly. If it becomes more active, the odds are very good that it can be eliminated through radiation before it spreads to other organs, with possible discomfort, but otherwise manageable  impact on surrounding tissue. The probabilities are vastly in my favor.

The communication follows:

----- Message -----From: SMITH,ROBERT D
Sent: 7/15/2016 2:07 PM PDT
To: *************************, MD
Subject: RE: Bone scan
Hi, Dr. G*****. It's not clear from your message whether you want a face-to-face, or just an e-mail conversation, so I will start with an e-mail.

Here's my recall from what I learned today:

1. Very little chance that anything more than some "seed cells" have migrated from the prostate, if that. 
2. High PSA could be due to the size of my prostate (no news there); in light of the biopsy, I probably have a low grade cancer -- while at the same time acknowledging that there might be something more aggressive lurking there. 
3. Men over 65 who developed prostate cancer and treated it with radiation had a very good recovery rate, with about a 2 percent chance of fatalities. (I know I'm not being very precise here.) 
4. Radioactive seeding of the prostate is about as effective as radiation from an external source, and both are fairly effective at controlling the disease. My understanding is that that the risk of causing another cancer is limited and the likelihood of terminating growth of the current cancer is very good. 
5. There is not a sense of urgency. Dr. G****** talked about annual biopsies and continuing to watch the cancer.

This obviously isn't all we covered in our consult, but these are the high points as I understand them. 
Based on what he said, my thinking is to rely on PSA, biopsy and MRI for now, with an eye to external radiation treatment if it seems warranted. One model might be 6-month intervals for PSA, a possible MRI if there's a sharp growth spurt in the PSA score, and annual biopsies. 
This is my layman's analysis and I accept it might be flawed, so I'm interested in your thinking, and I'm open to your suggestions. I'm up for a face-to-face if you believe that's appropriate. I'm available 21 July -17 August, except for July 25, if you feel that a meeting is warranted.

Sincerely , 
Robert Smith

==========================

To:
Robert D Smith 
From: ********************, MD Received:7/15/2016  4:31 PM PD 
Hi Robert,
Thanks for the message. You have a good summary of the situation. A phone visit would likely suffice for any follow-up questions.
I scheduled you for a phone visit for Thursday July 21 at 8:00 AM.
Please feel free to contact me with any further questions or concerns. 

Regards, 
**************,
MD Capitol Hill Urology

Results of phone consult: I will have PSA (prostate specific antigen) blood draws every four months to see whether the prostate calms down or continues to generate higher PSA scores. We will respond to what we observe.

Love,
Dad

Bone scan results
July 13, 2016

Hi, Kiddo.
Here's the result of the bone scan I had -- the cancer hasn't spread. Key points are underlined.

Study Result
IMPRESSION: 
No convincing evidence of bone metastases.
Degenerative changes as noted above.
END OF IMPRESSION.
_________________________________________ 
Signed by: *****************
Date: 7/13/2016 4:59 PM

Narrative
[HST]: Prostate cancer with PSA of 19- rule out mets
EXAMINATION: TOTAL BODY BONE SCAN, 11/13/2015
CLINICAL INDICATION: Prostate carcinoma.

COMPARISON: No previous.

RADIOPHARMACEUTICAL: 27 mCi of Tc99m-MDP, I.V.

PROCEDURE: Following intravenous injection Tc99m-MDP, three hour 
delayed images of the total body were obtained in anterior and 
posterior projections. 

FINDINGS: 
In the right acromioclavicular joint, there is asymmetrically 
increased radiotracer uptake. This is typical for degenerative 
changes.

Left first digit carpometacarpal joint with degenerative changes.
Right medial proximal tibia uptake is compatible with degenerative 
changes.

Small joint uptake of the bilateral feet and ankle are compatible 
with degenerative changes.

No abnormally increased radiotracer uptake to suggest bone metastases.

Kidneys are symmetrical and normal.

That's it -- that's the report
Love, Dad.

Prepping for the bone scan  
July 13, 2016

Hi, Kiddo.
I had an infusion this morning, and in a short while I will have a full body bone scan. It's nothing unusual for someone my age. A few weeks ago a doctor explained to me that, at age 70, I had a 50 percent chance of prostate cancer, and that's indeed what my urologist found when he performed the saturation biopsy on June 27. At my age prostate cancer obviously is very common. Usually it is extremely slow growing, presenting virtually no threat. But there are some considerations, the main one being a high PSA (prostate specific antigen) count of 19, when the norm is 2-4. What is especially interesting is that the count has gone from gradual growth over several years to an escalated growth, which has gotten the attention of me and my urologist.

You'll note that I'm writing this somewhat impersonally, because this is more than an e-mail to you -- these messages have become a blog about this process, so that I can track this as a bona fide cancer patient, which I now am. I'm doing this because we are both male, and some day, unless there are dramatic changes in medicine relating to men's health, you have a high probability of developing prostate cancer as well. You are more than my heir from a standpoint of estate. You are my genetic heir as well, and also a social heir. And, as I said, you are male. So, you should have at least a mild interest in the progress of this disease.

While I am not advertising the blog, it's there to be discovered by other men my age who may be curious about what may befall them. My understanding is that it's a virtual certainty that all men who live long enough will eventually develop the disease over time -- and so they might as well have a sense of what to expect. Perhaps they will benefit from what I write here. While it's unusual for me to publish information about my nether regions, I'm comfortable with it, because in a sense this is not my story alone; it is kind of an Everyman morality play.

It's also an opportunity to keep a record for my own use on how this progresses.

The blog is not going to be highly technical. Those who want to know all the minutia can speak to their urologist or oncologist, or they can  perform online research. On the other hand, it provides a foundation for any man to start from.

By now you may have guessed why I asked you to produce the graphic of a man beholding a crab in his outstretched palm, much like the image of Hamlet, contemplating the skull of Yorick. "Cancer", as you may know, is Latin for "crab." Ironically, according to a Google search, 

cancer, is the dimmest of the 13 constellations of the Zodiac, having only two stars above the fourth magnitude. Cancer lies between Leo, the lion, and Gemini, the twins.

Well, my biopsy, which involved probing in the vicinity of my Leo and Gemini, also turned up two stars out of 24 samples, so there's some symmetry there.

And so, in honor of this adventure, which has roots dating back to about 2005, when my heightened PSA first became known, I am calling my newest blog Crabwatch. And I'll be watching my cancer -- as much as I am able, anyway, considering where it's situated.

Love, 
Dad

Biopsy results--carcinoma.
June 27, 2016

Tracy,
Five years ago, 50 samples were plucked from my prostate, probing from one direction. This time the doctor probed from two directions and settled for 24 samples, two of which proved to be cancerous. Here is the specific language, with key words highlighted in bold face:

DIAGNOSIS A,B,C) RIGHT ANTERIOR (APEX, MID, BASE), NEEDLE BIOPSIES: PROSTATIC
PARENCHYMA; NO CARCINOMA IDENTIFIED. 


D) LEFT ANTERIOR APEX: FOCAL PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+3=6
OF 10:Carcinoma length: 0.1 cm.Total biopsy length: 1.8 cm.Cores
involved: 1 of 2.Perineural invasion: Not identified.
E,F) LEFT ANTERIOR (MID, BASE): PROSTATIC PARENCHYMA; NO CARCINOMA
IDENTIFIED. 
H) RIGHT MID: FOCAL PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+3=6 OF
10:Carcinoma length: 0.13 cm.
Total biopsy length: 3.4 cm.Cores involved: 1 of 2.Perineural invasion:
Not identified.
High-grade PIN.


G, I) RIGHT (BASE, APEX): PROSTATIC PARENCHYMA; NO CARCINOMA IDENTIFIED. 

J,K,L) LEFT (BASE, MID, APEX): PROSTATIC PARENCHYMA; NO CARCINOMA
IDENTIFIED. 
High-grade PIN (L, left apex)

I will spare you any further technospeak, such as the meaning of the Gleason Score, because I don't understand them very well to begin with. But the upshot is that out of 24 samples taken (representing less than 1 percent of the volume of the prostate), two incidents of a low-grade cancer were identified.

Considering the facts that 1) I'm going on to 71 years old, with  half the men my age facing a similar outcome and 2) that no aggressive cancers have been found, I'm attentive, but not worried.

Althought the results of the MRI suggested nothing alarming was discovered in my prostate, the fact that carcinomas were found has prompted my urologist to call for a bone scan, to see whether there is any indication of the spread of this disease. So I'll be lying on my back once more, while a machine looks me over. I'll keep you posted.

Love,
Dad

Cancer--The Crab

Notifying the kiddo
June 20, 2016

Hi, Tracy.
It's always a toss-up on how much to tell you about my prostate, because the science is so incomplete. My prostate-specific antigen score has climbed suddenly, so I'm scheduled for my second saturation biopsy (first was five years ago) to determine whether I have prostate cancer, and if I do, whether it's the type of cancer to be concerned about. This is somewhat a fool's errand, because at 70 years old there's a 50 percent chance I have it anyway and that's it's nothing to worry about. This an aggravating issue for the doctor who will be performing the surgery, because the indicators are so ambiguous and the practice of even bothering to watch the PSA is controversial. So I have a biopsy next Monday when many in the medical field would say "don't bother!" But you are my son, and male, so I hope you will find this informative, but I hope not worrisome.

Here's the synopsis: In 2005 I had a PSA score that was about 6, if I recall, while the normal was 2-4. So I had a rather uncomfortable through-your-behind-opening biopsy that jabs a needle through your intestinal wall to pluck out a piece of tissue about 1/8 inch long and thinner than a pencil lead. They took 8 samples, examined them under a microscope, and found nothing. The PSA kept inching up, so I had a couple more biopsies over the years and was operating under the assumption that the odds of having cancer were really low after so many negative biopsies. But having a long life expectancy means I should pay attention, because I won't necessarily have the convenience of dying of something else before prostate cancer can take me down. So in 2011, I had my first  saturation biopsy, when my score was somewhat in the range of 10. The doctor took 50 samples.
Nada. Zip. Nothing.

My doctor told me to just continue to monitor it. It bumped up and down a bit, and then a couple months ago it was at 16, and we did another blood draw a bit later and it was at 19. The PSA score was growing rapidly.
This led to my having an MRI of the pelvic area about a month or so ago, and nothing was found, but just to be on the safe side the saturation biopsy has been scheduled for next Monday. I'm fatalistic about all of this, and not particularly worried. It will be what it will be.

A few years ago I was given the understanding that when the PSA reaches 20 there's a 50 percent chance that you have cancer and it has metastasized.  But now it's my understanding that only if you have an aggressive cancer there's a 50 percent chance it's metasticized at a score of 20. I think that's what the stats are; I'm getting a little fuzzy on this stuff.

I went in for my pre-op interview today and the doctor gave me some sort of 3 percent figure for fatalities from prostate cancer. You'll find it in most males by the time they are 80, or something like that. At this point I have stopped trying to understand and remember all the stats.

The difference between this biopsy and the last one is this: five years ago they probed the prostate through the intestine wall. This angle limits the percentage of the prostate they can sample. This time they approach from the perinea, the area in front of the anus extending to  the scrotum. I may be walking strangely for a few days following the procedure. They will probably take 40-50 samples including parts of the prostate they couldn't reach through the other method.

By the way, the MRI cost just under $400 and was covered by health insurance. I'm sure the surgery will be a lot more expensive.

So, this e-mail is just an F.Y.I. because I think as my son and heir you should at least be aware of what's happening.

OK, I've told you. Now I fully expect life to go on as it always has....

Love,
Dad

Prelude: An MRI*
May 25, 2016 
*Magnetic resonance imaging

Getting an MRI is sort of like taking a nap. They ask you whether you are claustrophobic, and then they give you head phones so you can listen to music while you are lying very still in a white tube getting scanned; but the machine is so noisy and the headphones are so ineffective that you know music is playing someplace, but you have to guess at what the tune is, because the sound is so low. You do have the opportunity when the sound stops from time to time to ask whether you can wiggle a little bit. I think it lasted less than an hour.

Study Result

Impression: No focal signal abnormalities in the peripheral zone of the prostate gland identified.

Here are some of the details:

Narrative
[HST]: PSA* 19 and rising- Please perform multiparametric prostate protocol 
MRI to look for suspicious areas of prostate cancer
(*prostate specific antigen)
Exam: MRI of pelvis without and with Contrast

20 cc of Multihance was injected intravenously without complication.

Findings:
The central gland is enlarged and heterogeneous. The peripheral zone 
is homogeneous with no definite abnormalities on either the ADC map, 
the T2-weighted images, or the enhanced images. No adenopathy.* No 
evidence for abnormality of the pelvic sidewall. The seminal vesicles 
are unremarkable.

*adenopathy = enlargement or disease of the glands

Bottom line: Not enough is going on to get the attention of the MRI analysts.

Love,
Dad

A Birthday Request
July 7, 2016

Tracy,

If you can get your creative juices flowing, I want something very simple for my birthday -- a sketch, which doesn't have to be very finessed. It would be reminiscent of the scene in the Shakespearean play, Hamlet,  in which he and Horatio are in a graveyard and discuss the skull that might have belonged to a courtier named Yorick. "Alas, poor Yorick, I knew him, Horatio," says Hamlet, as he gazes at the skull. I'm enclosing some images to work from, including a photo of me before you were born. What I would like is a sketch of an individual, that might resemble me, holding up an object in contemplation. But the object is not a skull, it is a crab. The graphic should be suitable for placing in a space that is 200 x 1,000 pixels; It can have an entirely blank background, or a black background, depending on what works.

I know you're busy, but that's all I want for my birthday, and it doesn't have to be tremendous art, just recognizable --but with the crab, of course.

Do you have time to do that for me?

Love,

Dad