[PDF] Download the silent battle within - Free Download PDF (2024)

Download Download the silent battle within...

THE SILENT BATTLE WITHIN A PATIENT’S VIEW OF PROSTATE CANCER (PC) BY

DALE HOLLENBECK

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER (PC) BY DALE HOLLENBECK

Reproduction, sharing, translation, or transmission of this work, in whole or in part, without the expressed permission of the copyright owner is unlawful. Requests for permission or further information should be addressed to owner of the copyright. Third party illustration contributions herein are reused with permission. As such; permission to reuse any third party content should be directed to the associated copyright owner of the work. Released in pdf format, last updated December 2012. Library and Archives Canada Cataloguing in Publication Data is available on request. ISBN:

978-1-927768-03-7

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Table of Contents Title

Page

Cover

Front matter

Table of Contents Preface The Eye opener

Chapter 1 Terrain and the Enemy Prostate Organs, Musculature and Nerves of the male Pelvic Area Lymphatic System Cytology The Genome Normal Cell Life Cycle and the Phases of Cell Division Abnormal condition of the Prostate Benign Growth, Condition and Presentation Dysplasia and the Cancer Cell Malignant Growth, Condition and Presentation

3 6 13

17 16 20 23 27 28 31 37 38 39 39

Chapter 2 Symptoms, Examinations & Opinions

Symptoms Prostate Self-Examination (PSE) Clinical Prostate Examination (CPE) Ultrasound Imaging CT Scan Molecular Imaging (PET/CT Scan) MRI Near Infrared Scanning Biopsy Pathology

43 46 50 52 53 54 56 61 61 62

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Invasiveness and Staging Survivability Statistics Relative Survival Rates for Prostate Cancer ECG (Electrocardiograph) Second Opinion Archives

Chapter 3 Surgical Treatment and Therapy Surgeons and Surgical Teams Preparation for Surgery Prostate Surgical Procedure Prostatectomy Orchiectomy Prostate Conserving Surgery Laparoscopic Procedure Robotic Surgery Surgical Options for Advanced Metastasis Surgical Risk After the Surgery Infection and Antibiotics Post-Operative Condition and Rehabilitation Post-Operative Pathology Report Lymphedema Long-term surgical outcome Spousal and family reaction to hard times

Chapter 4 Non-Surgical Treatment and Therapy Oncologists and Oncology Staff Clinical Testing Chemotherapy Non-Conventional Chemotherapy Radiation Therapy Recurrence following Treatment Quality of Life High Intensity Focused Ultrasound Therapy

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

64 70 71 73 73 75

76 80 81 82 82 84 85 85 89 91 93 95 98 103 106 107 108 108

110 113 116 119 129 136 139 141 141

Chapter 5 Alternative Strategy & Prevention Diet Sugar, Starch and other things Sweet Toxic Contamination and Organic Produce Metronomics Attitude and Environnent Exercise Acupuncture Early Recognition and Screening Prevention Follow Up Miscellaneous and Promising Research Patient Support Praying and Belief Cancer Foundations

142 147 150 153 155 160 164 168 172 174 175 176 177 179 179

Glossary of Terms

181

References and Notes

189

Index

209

Third party Illustration Permission & Agreements

213

Acknowledgements

215

Disclaimer

216

Synopsis

217

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Preface

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

It was about twenty years ago that I recall my Uncle Wellington made one of his rare visits to my parent’s place out in the country. He didn’t usually travel or visit much and lived in the city about an hour and a half away. So when I wandered in to my parent’s kitchen about a month later and saw Uncle Wellington again I made a “note to self” to ask Mom if everything was Okay. It was then I found out that Uncle Wellington had cancer. At the time I chalked it up to yet another relative with cancer, but this time it was not someone who was a heavy smoker. In fact, Uncle Wellington did not smoke at all as far as I knew. Nor did he have any wild or uncontrolled habits. He didn’t drink and I never thought of him being anything but peaceful. It all made no sense. Here was a lean, strapping, quiet man who always looked fifteen years younger than his age. A man that was as pleasant as one could ever be. In my whole life I never heard him so much a raise his voice or say anything stronger than “gese”, “by golly” or “son of a gun”. He always seemed to have a smile on his face and loved to listen to music. I always thought Uncle Wellington strangely articulate for someone who had only high school education and drove a delivery truck. I assumed he must have spent his time reading and listening. He had a small house in the suburbs, raised two children and put them through university, and worked his “blue collar” job until he took early retirement at the company’s request. The only “out of the ordinary” thing that I knew about him was that he had divorced, which was unusual for the times. Prostate Cancer (PC), sometimes there is no pain and no dire symptoms just invasive metastasis silently making its way from tumor and into everything else even after it has been diagnosed. A disease that respected the serene surface of a man like Uncle Wellington while reeking complete havoc with his insides. Oh, Uncle Wellington seemed optimistic enough at the beginning about the possible success of surgery and treatment; but, as much as I gather, his condition was too far along and nothing at that time was successful in halting the migration of his disease. Over the course of about three years Uncle Wellington fought his “silent battle within” and lost. Every year hundreds of thousands of men worldwide are diagnosed with Prostate Cancer. To me, Uncle Wellington’s battle was the one that really brought home the message that this disease can strike any man no matter what their apparent physical wellbeing or habits and become fatal. In the year 2008, according to the World Health Organization (WHO) Prostate Cancer (PC) was the number one cancer diagnosed of men in developed countries. Accompanying this fact is a marked increase in the number of reported instances of PC; however, mortality from PC is generally decreasing.1 Overall, PC is the most prevalent cancer for males in 111 countries worldwide. 2 In the United States based on rates for 2007-2009 SEER (Surveillance, Epidemiology, and End Results) data it is estimated that roughly 16% of men born today

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

will be diagnosed with cancer of the prostate during their lifetime. This is like saying that if six random men stand in a room together from that country, one of them will be diagnosed with Prostate Cancer during the course of their life.3 In the United States the National Cancer Institute reports that as of January 1, 2009 there were 2,496,784 men alive with a history of Prostate Cancer! Further consideration of the patients and their profiles, it is obvious that Prostate Cancer incidence is most common in older men. The statistics indicate that 67.1% of all diagnosis occurs in the age group between 55 to 74 years. In addition, it has been reported that men of Black descent have a rate of incidence 52% higher than all other races; and a death rate that is more than double the rate for all other races in that country. Also be aware that death rate due to PC in all races begins to rise after 45 years of age.4 These are all facts to consider and cater to when you have your annual physicals. Since the early 1990’s PC awareness has become much more prevalent. This is in no small way due to the efforts of private research, as well as, the intervention of major world and governmental health organizations, foundations, and cancer societies. Adding to this list are those individuals who have stood in the celebrity limelight who graciously share their personal experience with this disease. As I sit here poised in front of my keyboard I suppose I should qualify just who I am to be writing what some would regard as a quick reference handbook on Prostate Cancer (PC). I am not a health worker or a medical researcher. I do not pretend to know all the answers in order to prevent, recover from or cope with the disease. I, like many of you, have had what seems an unending line of relatives afflicted by cancer of one sort or another. Beyond this, my interest in cancer is one that was spurred as a cancer patient. Mine was a different cancer than what is discussed in this book and by the time it was discovered I was at Stage III. For those of you not yet “in the know” of the jargon of oncology (the study of cancer) I will let you know that for my cancer Stage III is considered an advanced cancer. Stage IV is the final or end stage of any cancer. I underwent surgery and adjuvant (post-surgical) treatment and am presently in remission. Being able to recover to a state of remission is my good luck. I get my inspiration to write this from the actor and philanthropist Paul Newman who lost his battle to lung cancer several years ago. This was a man who, in a very low key and gracious way, touched the lives of many through charity from what he called his “good luck”. He made the point that he, in his life, was lucky and that there are a lot of people out there that are not; and, that those who are lucky should help those that are not. I agree. In my experience with cancer one of the things I found about being a patient was just how difficult it was to make any sense out of the mountain of information on my disease. So I did my research and took notes which eventually became a book on colorectal cancer. That book was the first in this “series” that I am writing which deals with cancer information that caters more to a patient’s perspective. In this book I will also recount some of the recollections and view of my friend and colleague, Tony, who is a Prostate Cancer survivor. I believe it is important to have the benefit of a patient’s

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

perspective on the disease. It adds to the clarity of interpreting the literature, as well as events and outcome of treatment. The literature surrounding the cause and effect of Prostate Cancer is extensive and spans more than a half of century in modern medicine in research, diagnostic pathology, surgery and treatment. The variables that go in the progression of such a disease are numerous and are hypothesized to carry over in everything from host “genetic make-up”, to habit, to environmental exposures, diet, exercise and attitude. No one has the same combination of the variables that conspire to cause disease. As such; how one arrives in the line of being diagnosed and treated for Prostate Cancer is different for each patient. Prostate Cancer is a man’s disease. This is because women in their anatomical development have an equivalent structure often referred to as the Skene’s glands that is rarely affected by this cancer. Socially the prostate is not one of those areas of the anatomy that surfaces over light discussion at the dinner table. Of course, there may be a “haw- haw and a tee-hee” when one refers to the snap of a rubber glove at an annual physical, but that is usually the extent of the conversation. In this way it can be said that PC is not a “popular” cancer, in as much as there is no general and obvious awareness of it especially if you are relatively young. This is a disease that can run its course with no more than a “burble” or two until it is too late for the host to do anything about it if you don’t make a point of having yourself checked as you get older. My point is that you must be aware and take measures that will both harden your resistance to Prostate Cancer, and, afford early detection, diagnosis and treatment. Three of the simplest things you can do to raise your guard against PC is to: 1) Be aware of the anatomy involved; 2) Know the symptoms of PC and get checked if you have any of those symptoms; 3) Know your lifetime risk category for PC and begin screening in accordance with your risk category; which involves a blood sample for a PSA (ProstateSpecific Antigen) test and a DRE (Digital Rectal Exam) annually. The symptoms of Prostate Cancer when they do occur are not easy to ignore; however, it is easy to think that they are related to some other “not so serious” affliction such as prostatitis. Prostatitis is a disease that causes the prostate to inflame. Pain in the area of the urinary system, abnormal frequency or difficulty urinating, or upset sexual function are some of the symptoms for both afflictions. Since the prostate is basically encased in the pelvic area it is possible to have referred pain in areas that do not seem related. Places like the rectum, penis, hips, groin, back, thighs and even the head. Some of this is because there are a number of nerves that radiate to and around the prostate. When these nerves are impinged upon by abnormal growth they can cause considerable pain in areas that one would not normally associate with the prostate. It is the predominant theory that Prostate Cancer generally proliferates

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

(grows) slowly and takes years to develop. Along with this slow proliferation of the cancer can be an equally gradual build-up of symptoms and discomfort. Even advanced Prostate Cancer, like most cancer, may be asymptomatic (without symptoms). Advanced stage Prostate Cancer may only present with one or two of the symptoms listed below. In short, it is important to have regular medicals and report any of the following symptoms if they are persisting. It is also important to start paying attention to how your “plumbing” and health are doing. It is important to start taking care of yourself. The following are signs and symptoms that are can be brought on by Prostate Cancer: • • • • • • • • •

need to urinate often (especially at night); intense need to urinate (urgency); difficulty in starting or stopping the urine flow; inability to urinate; weak, decreased or interrupted urine stream; a sense of incompletely emptying the bladder; burning or pain during urination; blood in the urine or sem*n; painful ejacul*tion 5

This list is not all of the symptoms, but it does have some of the most common ones. Having symptoms does not mean that you have Prostate Cancer. It could be something else that is the cause. If; however, you have any of these, GO SEE A DOCTOR and find out the cause. Also, it is time to start exercising if you don’t already; stay away from tobacco smoke, and eat better. Eating better will be discussed later in the discussion so you will know what that means in terms of a Prostate Cancer strategy. A person’s lifetime risk of Prostate Cancer can be assessed by a medical evaluation, so have this done. The risks that make someone more susceptible to developing Prostate Cancer are as follows: o Middle or Advanced Age (PC is unusual in young men); o Family (first degree male relatives) history of PC; o Race (Men of Black descent have a much higher risk of PC incidence and mortality); o Consuming a diet high in animal fat; o Having a high intake of dairy products and calcium; o Excessive use of multivitamins; o Exposure to cadmium which is one of the cancer causing agents in tobacco smoke; o Topical exposure to dioxin such as agent orange.6 A quick prostate cancer risk calculator is available on line at the link: http://sunnybrook.ca/content/?page=OCC_prostateCalc To use this risk calculator you will have had to undergone a clinical prostate exam because this risk calculator requires the following basic prostate information:

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

- the presence of urinary symptoms as measured by the eight question International Prostate Symptom Score (for the questionnaire see ww.urospec.com/uro/Forms/ipss.pdf); - your total PSA value; - your Free (PSA not bound to other proteins) to total PSA ratio value; and, - your DRE of prostate results from your physician. Provide this information to the risk calculator when prompted and select the “Evaluate Prostate Cancer Risks” push button for the risk result. Screening is the testing for a disease before symptoms are present. Screening, when done correctly, affords early detection of any cancer. The debate is ongoing in the mainstream medical community as to the value of early detection of Prostate Cancer. As is the case with other cancers there is no harmonized approach to PC screening. Conflicting reports continue to allow medical policy makers to circumvent the common sense need to have men checked. For example, a recently published study involving 76,693 men reported that after 7 to 10 years of follow up, the death rate from Prostate Cancer was very low and that there was no significant difference between the group who had undergone screening with annual PSA testing and DRE (Digital Rectal Examination) versus the group who had not.7 The results of this study are in sharp contrast to those reported in another study involving 182,000 men. Researchers in that study reported that PSA based screening reduced the death rate from Prostate Cancer by 20% but was associated with a high risk of over diagnosis and overtreatment.8 In any case, there are basically two common ways that Prostate Cancer is screened for. One involves the testing for the level of PSA (Prostate-Specific Antigen) which is a simple blood test; the other involves a clinical exam (CE) where the attending physician checks the prostate via the rectum using a finger. This is called a DRE (Digital Rectal Examination). General practitioners, as well as, urologists will be able to conduct such an exam. My personal view is that a urologist should be involved since this is their area of expertise. The facts of PC are that incidence and mortality are predominant with men in their later years. The National Cancer Institute has summarized Prostate Cancer screening generally practiced in the mainstream medical community and point out that screening advisory groups are saying that there are pros and cons of PSA testing; and, that a detailed discussion between patient and doctor should occur before using the test. The concern revolves around PSA results that could prompt “unnecessary” biopsy resulting in complications including incontinence (unable to control bladder); bowel disruption; erectile dysfunction; and, infection.9 These concerns coupled with a relative high survival rate among those diagnosed with PC have seen recommendations to begin screening of men beginning at 50 years old being “backed away from”.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Cancer research, screening and treatment costs money. In countries where there is no social medical coverage the repercussion of paying for healthcare can be devastating to those trying fight the disease. In a place like Canada, where there is a relatively comprehensive social medical system, there are nevertheless inconsistencies in provision for cancer screening. For example, in the provinces of Ontario, Quebec and British Columbia, the medical system does not cover the cost of routine PSA testing. To make things more difficult, one cannot even get a PSA test at an independent laboratory without a doctor’s referral! It’s bad enough to try to get a man into a doctor to get his “plumbing checked”; but, the principle of having to pay for a what seems an essential medical service; the cost of having to pick up the bill when there may not be funds to do so, especially if living solely on a senior citizen’s pension; and, the fact that a lot of men do not even have a family practitioner available to write them a referral are all completely inconsistent with what should be basic medical coverage and early PC detection. Nevertheless, my attitude is, if you can afford it, stay on top of your health with regular examination, immediate diagnosis and timely treatment. Much as agencies, such as the U.S. Preventative Services Task Force, call attention to the statistics that PSA testing does not save lives,10 someone should point out that early detection of PC is not just about saving lives. It is about finding better ways to address a disease that can emasculate even before advanced stage. Having interviewed Tony, I found his experience an “eye opener” in terms of expectation, consideration, processing, resource, and relief. In addition, it is obvious that there are mistakes that should be and could be avoided if only we were all made a bit more aware. This discussion is a layman’s interpretation and overview of the literature that is available for anyone’s review on the topic. The diagrams and tables in this document may not be the most definitive or current and are referenced only as example to support the discussion. They are the better part of what I found to become informed of this cancer and the medical jargon belonging to it. Most of the information herein is found on the internet in a number of sources that are openly available to the public. It is where I went in order to make sense out of my own cancer condition so I could have an idea of the key issues and questions to ask of my physicians. The remainder is derived from a patient’s first-hand experience in addressing this disease from within. To be clear, this discussion is not intended as a solution to replace qualified medical professionals or their opinion. It is meant to give you a footing in the topic so you can have an informed dialogue with your medical team. This way you are better able to understand the issues and options so as to be more comfortable making decisions relating to your condition. These are my words in hopes of spurring a bit of awareness. If you find that when you are reading the description of PC symptoms they seem oddly familiar to what you or

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

someone you know are experiencing, I strongly suggest immediate follow up with the appropriate medical visits and referrals. No one wants the CANCER sign hung around their neck, but burying ones head in the sand and counting on PC progressing slowly is not going to improve on your situation.

The Eye Opener I interviewed my friend Tony while having coffee at Tim Horton’s on a cold day in January. He told the story of how he was diagnosed with PC at the age of 61. Tony was a corporate pilot then and since the age of forty had to pass a Transport Canada aeromedical twice a year to stay current in his licencing and be able to fly. Tony’s employer made allowances to include PSA testing for their pilot staff; and so, he did this at the same time as his aeromedical. After one aeromedical in the winter, Tony’s doctor did not say what the results were in the post-medical debrief. Tony really did not pay much attention to this until he showed up for his next medical in the summer. After questioning the lack of results on a PSA test it was discovered that his results had somehow been “misplaced”. When they were eventually found, a review of those PSA results detailed levels that were alarmingly higher than the results on his previous PSA done the summer before. Tony immediately followed up and his urologist who conducted a DRE, as well as, biopsies. The pathology report stated that three of the tissue samples showed malignancy and Tony was given the choice of three courses of action. These were: 1) Do nothing [known as the “Watchful Waiting” approach]; or, 2) Undergo hormone treatment (Androgen Deprivation Therapy); or, 3) Undergo a surgical procedure called radical prostatectomy. After a bit of consideration he elected to have the radical which also involved a possible lymph node dissection. Tony seemed to recall that his lymph nodes were sampled in the same session as the radical prostatectomy (RP) and the results came back negative (no lymph node involvement) while the RP was still being performed. This would have been unusual surgical undertaking for the times. In any case, he was certain that a complete lymph node dissection was not done. The post-surgical pathology report was something that Tony did not see. In fact, neither did he see the preliminary pathology report before surgery. He thinks his condition was diagnosed at Stage III although he was not sure. Five days after surgery Tony was sent home with a catheter still installed. His recovery involved some physiotherapy with exercise including “Kegles” to strengthen his pelvic floor muscles. As for follow up Tony had no adjuvant (post-surgical) treatment; for the first year he had PSA testing every 3 months; then, PSA testing every six months

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

up to five years; and, no imaging of any kind. It has been 13 years since initial diagnosis and Tony is still in remission. Had it not been for his career choice (which made mandatory medicals every six months a part of Tony’s normal life) along with the relative frequency of PSA testing that he had arranged, the PC probably would not have been discovered until it had spread to other parts of his body. Had it not been for Tony’s insistence on knowing his missing PSA results from his winter 1998 testing, his condition could have been allowed to progress even further than it had. Tony reflected on a colleague he knew at the time who was as well diagnosed with PC. He recalled that they discussed each other’s choice of treatment. The other man elected to not have the radical surgery and instead opted for Androgen Deprivation Therapy. Within a couple of years, that man ended up contributing to the mortality figures of PC. All to say, do not assume that you can just fall into a hospital or doctor’s office and trust that your best interests are being taken care of. You have to become informed. You have to ask the right questions and know the reasonable response. You have the right to see your file and have apt explanation. You have to understand the facts and your options. If you can’t understand or remember what is being said, have someone with you that can. When it comes to your own cancer condition, YOU are your best manager of your own case and health. Remember, in the course of a day the doctor(s) and administrators that you are relying on see dozens of patients. It doesn’t matter how smart you believe them to be OR that their procedures and protocols should be able to make sure you are handled correctly and in a timely manner; it is an easy thing to miss something important when you are faced with the patient load that these medical professionals have to contend with. In the grand scheme of things forgetting or failing to properly diagnose a condition doesn’t have much of an effect on their overall patient outcome, but for you it could be devastating. For those of you who want to do nothing and deny a high lifetime risk or the signs of a cancerous prostate condition, I will tell you right now that your inaction is exactly what this disease needs to become advanced to the point that it can have grave repercussions on your quality of life. It can even kill. For the others who are diagnosed with PC and are fortunate enough to find a state of remission, know that cancer is not a bruise or cut or a broken bone that repairs and is all better. The conditions for cancer have already proven to be hospitable in your body. You would do well to consider what you can do to make those conditions less likely to cause a relapse. Relapse in Prostate Cancer can revisit your prostate (if it was not removed in whole); tissues in the vicinity of where your prostate used to be; seminal vesicles; nearby muscles and organs such as the rectum, bladder or pelvic wall; or, other distant organs including the bones.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

You may find some parts of the following chapters as either too much or not enough information. They reflect the scope I think would be needed to lend a better understanding for most of your questions. Time now to begin your fight, and it starts with information on the enemy, the occupied terrain and mechanisms involved.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Chapter 1

Terrain and the Enemy

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

I assume most of you have not studied biology, physiology or anatomy at all, so I will review the pertinent details of the prostate as the area hosting cancer. Be aware that in stage IV the cancer has traveled and resides in distant parts of the body not necessarily covered by this discussion. Prostate Common understanding is that the prostate gland is an organ exclusive to males. In terms of human anatomy the notion that females and males all have the same fundamental anatomical parts makes sense because both genders actually start out as female in the womb. It is only as foetus develops in the womb that the genetic instructions cause some aspects of the human anatomical blueprint to be more or less emphasized. The result of this developmental emphasis is the departure from a strictly female outcome into one that is male. There are other obvious examples of this kind of gender related “emphasis”; however, what it all amounts to, in simplistic terms, is that the prostate has a female equivalent occupying roughly the same place that features differences in size, shape and role. Nevertheless, this organ exists and it is with this understanding more recent study and research supports the contemporary view that the female urogenital anatomy has a smaller variant of the prostate organ typical to males and that has, in the past, been referred to by a number of names including the Skene’s glands; lesser vestibular; periurethral; or, the paraurtheral glands. In 2002 the Federative International Committee on Anatomical Terminology officially renamed the Skene’s gland the female prostate. In reviewing the literature it is clear that PC is a man’s disease as is duly reflected in the data; however, there exist very rare cases reported in females. A simplified illustration of the male urogenital anatomy and the organs and structure that surround it is at Figure 1. In it you see the prostate located in close association with the bladder and the seminal vesicle. Androgens are hormones and include, for example, testosterone and 5alphadihydrotestosterone. In males testosterone is produced in the testes. In females it is produced in the ovaries. Both sexes, as well, have lesser production of testosterone in the adrenal glands. The balance between androgens and other hormones in a man’s body is fundamental to the health of his prostate. The prostate size varies but is generally about the size of a chestnut. It weighs in at anywhere between 10 to 20 grams (near or less than a half an ounce). It is made up of several types of tissue including: - glandular which forms the pouch-like structures where a liquid component of sem*n is made; - epithelial which lines the canals, terminal vesicles and ducts of the glands that open into the prostatic portion of the urethra; - muscle and connective tissues forming the body of the organ; - venous providing veins and arties supplying the prostate; and, - nervous composing the nerves that radiate from the pelvic plexus.11

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

The prostate’s role in men is to produce, store and release a clear alkaline somewhat viscous fluid that contributes to sem*n. Alkaline means that it has a pH closer to a base (like baking soda) than to an acid (like vinegar). The prostate fluid comprises the largest part of the volume released during ejacul*tion. The remainder of the male mixture comes from secretions made by the Cowper’s gland and the seminal vesicles. In terms of fertilization, the characteristic alkaline pH of the prostate fluid serves to help lower acidity levels that are naturally found in the man’s urethra (urinary tract) and the receiving vagin*. Without the contribution of this prostate excretion, the sperm would have much lower survival rate and fertilization would become much less likely.

Figure 1. The male pelvic area including the prostate source: http://en.wikipedia.org/wiki/File:Male_anatomy.png [modified] Originator: http://www.luckymojo.com/faqs/altsex/penis.html

Figure 2 is an illustration detailing the anatomy of a woman’s pelvic area and location of the female prostate or Skene’s glands. Like the male counterpart, this gland releases a clear fluid when stimulated. It is in the area commonly referred to as the “gspot” and, is in close association with the base of bladder above it. These would be the glands involved in a female case of Prostate Cancer.

Figure 2. The female pelvic area detailing Skene’s glands. source: http://en.wikipedia.org/wiki/File:Female_anatomy.svg [modified] originator: Tsaitgaist

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

In pathology reports the prostate will most be referred to in terms of zones. There are four zones that are based on distinct glandular regions of the organ namely the: -

Peripheral zone (PZ) which is the largest of the four zones and includes the posterior aspect of the prostate gland that surrounds the distal urethra;

Central zone (CZ) which is the zone that surrounds the ejacul*tory ducts;

Transition zone (TZ) which surrounds the proximal urethra. This is the region that grows throughout life; and, the

Anterior fibro-muscular zone which is usually devoid of glandular components and composed of muscle and fibrous tissues.

Figure 3 is a cross-section of the male prostate illustrating the zones with the approximate percentage that each zone occupies in the gland. The magenta (pink) portion in the middle represents the urethra and is the major duct that goes through the middle of the prostate from the bladder to exit from the penis.

Figure 3. Lateral cross -section of the male prostate detailing the prostate zones. Pink center is the urethra. source: http://en.wikipedia.org/wiki/File:Illu_prostate_zones.jpg originator: http://training.seer.cancer.gov/ss_module02_prostate/unit02_sec03_anatomy.html

In a pathology report you may encounter the notion of exceeding the prostate “capsule” when detailing cancer spread. Prostate capsule in this case refers to what is known as the prostate parenchyma or the glandular tissue that makes up the majority of the prostate.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Organs , Musculature and Nerves of the male Pelvic area The next few illustrations are to ensure a more comprehensive understanding of the location of the prostate and its surrounding anatomy. This will allow you to better understand the issues involved in any surgical procedures that may be used to address a prostate condition. Figure 4 illustrates the muscles in the male pelvic floor.

Figure 4. The male pelvic floor musculature. source: http://en.wikipedia.org/wiki/File:Gray406.png originator: Henry Gray (1825–1861). Anatomy of the Human Body. 1918

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 5 illustrates the location of the prostate in a male beneath the pelvic floor musculature. The prostate is shown here with the base of the bladder behind it. When considering the jargon used to describe the orientation of the prostate the part closest to the bladder is called the base; and, the part further downstream towards the penis is called the apex.

Figure 5. The prostate and associated organs of the male [pelvic floor view]. source: http://en.wikipedia.org/wiki/File:Gray543.png originator: Henry Gray (1825–1861). Anatomy of the Human Body. 1918

Figure 6 more clearly illustrates the prostate and the associated urogenital structures that converge on it. In pathology this organ is often referred to by lobes (left and right sides) and the diagram shows the prostate split down the middle into left and right lobes to make this point and also shows the canals that run through the surrounding lobes.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 6. The prostate and its component parts with cutaway views of 1- vas deferens; 2- Seminal vesicle; 3- Base of prostate; 4- Apex of the prostate; 5- Prostatic urethra (leading to the penis) . source: http://en.wikipedia.org/wiki/File:Illu_quiz_prostate01.jpg originator: http://training.seer.cancer.gov/ss_module02_prostate/unit02_sec05_quiz_match01.html

Figure 7 illustrates the major nerves associated with the male urogenital area. Disruption of area nervous tissue by abnormal growth or by surgical procedure can result in chronic pain or erectile dysfunction, for example.

Figure 7. Nerves serving the male urogenital area. source: http://en.wikipedia.org/w/index.php?title=File:Pudendal_nerve.svg&page=1 originator: Mikael Häggström

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Lymphatic System The lymphatic system is a network of vessels or conduits that stem from head to toe throughout the body. Associated with these lymphatic vessels are nodes. A node is a “bean shaped” filter in a lymphatic vessel. There are approximately 500 to 600 lymph nodes in the human body and they are clustered in areas such as the neck, armpits, abdomen and groin. At Figure 8, the diagram details some of the major components of the lymphatic system. This diagram is a simplified view of the very complex lymphatic network.

Figure 8. The Lymphatic System source: http://humanphysiology2011.wikispaces.com/06.+Cardiology

The lymphatic system has three major roles: Firstly, consider that the average adult human is composed of 55 to 60% water. Some of this water circulates in the form of blood. Some of this water resides in cells. Some of

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

water lies in the fluid between the cells. The fluid between the cells is called interstitial fluid. The lymphatic system is responsible for the filtration of this interstitial fluid. The filtered fluid is called lymph and is eventually returned to the circulatory system (blood). As such the lymphatic system is a player in the distribution and balancing of fluid in the body; Secondly, the lymphatic system absorbs lipids, for example fat, from the intestine. So the lymph also transports lipids to the blood stream; and, Thirdly, in the lymph nodes there are a number of cells that respond in the event of disease or injury. These cells are the “workers” that make up the body’s repair and defence or immune response. Their purpose is to recognize, trap and absorb infection called immunogens. Among such cells are the B cells, T cells and Natural Killer (NK cells). B and T cells are specialized white blood cells called lymphocytes. These lymphocytes make their way from the circulatory system to the lymphatic system in response to a signal released when there is infection or injury. To do this the white blood cells actually excrete an enzyme that allows them to escape through the wall of their closed circulatory system into the surrounding interstitial fluid. Then they are picked up by the lymphatic system and migrate along specific paths that direct them to the point of injury or infection. Typically when a lymph node encounters an immunogen (invading foreign body that is not supposed to be there) it becomes enlarged. This is primarily because of B cell migration occurring in that node in response to the infection. When nodes are infected with cancer they usually become inflamed. Sometimes; however, they do not. This is one of the reasons why it is so difficult for the surgeon and pathologist to determine exactly how far the cancer may have traveled within the lymphatic system.12 The lymph is not pumped through the body like blood. In fact, the lymphatic system has no recognized pump at all. Throughout the lymphatic system there exists the equivalent of “one way” valves so that lymph does not tend to flow backwards. Cancer cells can make their way to other parts of the body through the lymphatic system if they manage to get picked up by the lymphatic system then somehow survive its defenses and get dumped into the bloodstream with the returning lymph.13 The rate and extent of flow of lymph through the lymphatic system is a matter that is not completely understood and is still under investigation by researchers. The lymph fluid is picked up and generally moves slowly through the lymphatic network by the action of local skeletal muscle movement, local arterial expansion and contraction, and, by peristalsis in the case of the larger lymphatic vessels. It is thought that sometimes the movement of the lymph fluid actually “skips” at a much faster rate than the described slow progression. As such; this becomes a problem in the certainty of just how far any surviving cancer cells have moved towards the circulatory system once in the lymphatic network. 14

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

As the lymph from the prostate area is drained it is transported through an array of lymphatic vessels and ducts and eventually makes its way to the blood stream. The blood stream then distributes the lymph all over the body. Sentinel nodes is a term used to describe the lymph nodes that are first in line to receive the draining lymph of the prostate on its way to being returned to the blood. These nodes are often sampled (biopsied) to determine if the cancer has spread from the prostate via the lymphatic system. Classic anatomical theory for the drainage of the prostate gland lymph is basically that the vessels of the prostate have drainage to the periprostatic node; internal iliac nodes; sacral nodes; and, external iliac node. These are considered the regional lymph nodes for the prostate. 15 Pathology reports often refer to regional lymph nodes as a way to determine metastasis (spread) of the cancer. Figure 9 is a side view of some of the prostate regional lymph nodes and how they are situated with respect to each other. In this illustration the intestinal tract has been “left out” so that the prostate lymph system structures are more obvious. The lymph tissue is detailed in blue. The bean-like structures are nodes and are referred to as glands in the diagram.

Figure 9. Lymphatics of the prostate (sagittal view). source: http://en.wikipedia.org/wiki/File:Gray619.png originator: Henry Gray (1825–1861). Anatomy of the Human Body. 1918

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

The collected lymph then passes into the lateral aortic nodes and eventually makes its way to the thoracic duct via the abdominal confluence of lymph ducts or the cisterna chyli (see Figure 8). Figure 10 is a front view illustration as though facing someone and looking down into their pelvic area lymph node distribution. This shows the left and right lateral aortic nodes.

Figure 10- Lymphatics of the pelvis. (frontal view). source: http://en.wikipedia.org/wiki/File:Gray611.png originator: Henry Gray (1825–1861). Anatomy of the Human Body. 1918

Recent investigation involving whole body scans using a form of imaging called SPECT/CT (Single Photon Emission Computed Tomography/CT) has shown that patients can exhibit variable prostate drainage patterns and that those patterns can be mapped using SPECT/CT imaging techniques to better identify sentinel and secondary lymph nodes that may be harboring microscopic metastasis (cancer spread). This may be a way to assist in addressing the estimates that speak of 50% relapse for those patients with high risk PC following definitive treatment.16 THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

The SPECT/CT is basically a “doubled up” approach to traditional CT imaging involving a gamma camera combined with an inline CT scanner (which will be discussed later). Such imaging greatly improves capture of detail that allows the technicians and physicians a more accurate understanding of disease spread. Definitive treatment is what is regarded as the best way to address a patient’s disease after all of the options have been considered. When cancer goes undetected and is allowed to develop it eventually exceeds the bounds of its originating site and then passes beyond the prostate. When this happens the cancer cells can find their way into the surrounding interstitial fluid where they are moved into the lymphatic system. When they arrive at a node in the lymphatic system they are attacked by body’s immune system. If the immune response is successful then the “migrating” cancer cells are destroyed. If the response is unsuccessful then the cancer cells will, in time, proceed through the lymphatic system to other lymph nodes and eventually into the circulatory system and other organs. This process of cancer spread from its original site to other parts of the body is called metastasis.17 The lymphatic system is not the only way through which metastasis occurs. Prostate Cancer, like any other cancer, may spread through a number of ways. To summarize, spread occurs: 1) Directly [Direct extension] - this means the cancer spreads and grows in more than one place within the organ of origin; 2) Trans-coelomically - Once the cancer exits through its originating organ it gains access to the fluid between cells. This means it may migrate in the body cavity through the fluid there; 3) Via Blood circulation - Tumors are a group of cells and cells need blood to live. Tumors build their own circulatory networks that are connected to the rest of the body’s blood circulation. When this happens blood that is circulating through cancer cells is moved throughout the rest of the body as well; and, 4) Via Implantation - What implantation most commonly refers to is “tumor spillage” that occurs due to unintentional contamination of the surrounding area with cancer cells during the process of surgery.18

Cytology For those of you not familiar, cytology is the study of cells. In order to understand the process of cancer, as well as the “why and how” of the way it is treated, one has to have a bit of an understanding of cell division and structure. A cell is the building block of life. It is the smallest unit that can be considered living. Although you

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

may not have been aware, an example of a single cell is a chicken egg. Of course, not all cells are this large. In fact, most cells can only be viewed under a microscope. Some organisms are made up of only one cell. Humans are made up of many cells and so we are a multi-cellular organism. In a human there are approximately 60 to 100 trillion cells. These cells do not all look or behave the same. They as well have complex signalling and communication processes that, for the most part, defy our present scope of medical understanding. Some cells can repair or regenerate. Some cannot. Some last the life of the person, for example, brain and nervous tissue cells. Others last only a few days and are replaced.

The Genome The location, structure and function of any cell are coded in the organism’s genome. The genome is the complete package of genetic material that each of us contain. This genetic material is our entire blueprint of life. The genome is made up of individual genes. There are approximately 50,000 to 100,000 genes in the human genome. Genes are made from large molecules called DNA and RNA. There are two types of genetic material. One is called DNA (deoxyribonucleic acid). The other is RNA (ribonucleic acid). This genetic material is arranged in long “spaghetti-like” complex molecules and these molecules are located in the cells. DNA is packed in a double helix molecule format (see Figure 11). RNA is transcribed from the DNA and does not feature the double helix packing.

Figure 11. Segments of DNA molecule packed in three helical formats. From left to right A, B and Z variants respectively source: http://en.wikipedia.org/wiki/File:A-DNA,_B-DNA_and_Z-DNA.png originator - Richard Wheeler (Zephyris) at en.wikipedia

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

DNA’s main role is the long term storage of an organism’s genetic information. RNA, on the other hand, is involved in carrying information and translating it into proteins. DNA and RNA are made up of smaller parts called nucleotides. Nucleotides are the small building blocks that make up DNA and RNA. To simplify, there are five primary nucleotide bases. Each of the nucleotides can attract its matching group of nucleotide. For example, the nucleotide Thymine attracts Adenine; and, Guanine attracts Cytosine. After bonding with each other the order that nucleotide pairs are arranged and replicated is unique and specific to each life form. The packing and storage of this genetic material is contained in the form of chromosomes. Humans have 46 chromosomes. A human made by normal sexual reproduction receives half of their genetic material from the mother which is stored in her egg, and, the other half from the father which is stored in each individual sperm. Upon fertilization the genetic material in the egg and sperm combine and form chromosomes. As stated, in a healthy human genome there are 46 distinct chromosomes. The genetic material of the mother and father combine to make 23 pairs of chromosomes. Figure 12 is an example of a full complement of 23 chromosome pairs for a human male. The only difference between the male genome and the female is at the final pair there is an X/Y for males and X/X for females. That means an additional X (female) half is in place of the shorter Y half to form the X/X pair.

Figure 12. The 23 paired chromosome compliment of a normal human male source: http://commons.wikimedia.org/wiki/File:DNA_human_male_chromosomes.gif originator: National Human Genome Research Institute http://www.genome.gov/Images/EdKit/bio1c_large.gif

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Somewhere embedded in our 46 chromosomes are the instructions that allow cancer cells to be made and multiply. So you can say that we all have the built in capacity to “self-destruct”. Similarly, instructions to turn off the cancer are as well embedded in this genetic material. Where exactly any of these instructions are in the genetic code is a matter of ongoing research. How and when this cancer code becomes active is, as well, under investigation. The study of genetics and unravelling the secrets of this genetic code will result in being able to better understand and control cell behaviour. This understanding will eventually give us the ability to address disease, deformation, mutation and even aging. The hopes are that there are actual strands of genetic code that can be identified then removed or modified so as to affect a cure for a disease such as Prostate Cancer (PC). In 2011 a collaborative effort involving two teams of researchers managed to sequence the entire genome of a prostate tumor. In comparing this sequencing to healthy prostate sequencing they discovered that the prostate tumors had entire “chunks” of their DNA sequencing that appeared to be cut out and inserted to another location in the genome. These chunks of DNA that had been relocated contained genes that help drive cancer progression; and, they were moved to areas in the genome where they may be most active.19 How this exactly takes place is still a matter of investigation; however, being able to identify these changes may soon afford a clinical method to better diagnose and treat prostate malignancy. In May 2012 the same researchers have identified what appear to be at least two distinct sub-types of Prostate Cancer based on those that have ETS fusion genes and another subtype that has mutations to a protein called SPOP. Apparently ETS fusion genes such as TMPRSS2-ERG occur in approximately 50% of Prostate Cancer and have so far not be found in tumors featuring the SPOP mutation. Prostate Cancer with SPOP mutations were observed in approximately 6-15% of the study’s Prostate Cancer. 20 In any case, the mechanisms involved are so far not understood and a matter of promising ongoing research. In the literature it is suggested that certain inherited gene mutations may increase the risk of familial PC which is also referred to as HPC (Heredity Prostate Cancer). Some of these mutations are found on chromosome 1; and others are located on chromosomes 8; 17; 20; and, X.21 None of these mutations have been reported to reliably signal the inheritance of PC. With the exception of PC in a family with evidence of heredity breast /ovarian cancer syndrome (HBOC) a clinical test to determine genetic predisposition to PC is so far unavailable.22 HCOC is a syndrome associated with mutations on the BRCA1 and BRCA2 genes. BRCA stands for BReast CAncer. Everyone has the genes in question. Usually the genes are in a normal unchanged state; however, some people have inherited genes in a mutated or variant state. Carrying any one of these genes in a mutated or variant state does not necessarily mean that you will get Prostate Cancer. It only means that you may be more at risk to get Prostate Cancer.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Identifying those more likely to inherit PC is looking at the family history of Prostate Cancer combined with genetic analysis. Criteria detailed by the researcher B. Isaac and his team at the James Buchanan Brady Urological Institute consider certain characteristics that suggest which mutation a family may have. HPC can be also be passed through either the father’s or mother’s side of the family and can involve mutated genes on different chromosomes.23 For the present we are still bound by a relatively poor understanding of how cancer cells are directed due to the complexity, variability and microscopic nature of the processes and genetics involved. While the research continues, medical treatment of cancer in terms of chemotherapy and radiotherapy, is aimed more at interrupting or disrupting the cycle and processes of quickly replicating cancer cells. To do this the strategy is to take advantage of key weaknesses of cancer cell cycle.

Normal Cell Life Cycle and the Phases of Cell Division From conception onwards a human is one big bundle of cellular and chemical activity. The cells in a body are in a constant state of dynamic process. Such dynamic process includes the “making of cells” referred to as cell Replication; the exchange and use of energy called metabolic process; and, programmed cell death (PCD). This cell activity is all arranged to support our specific design, function and needs as a biological organism. These cell processes are the essence of life and death. Replication is part of the “cell cycle”. When a normal cell replicates it divides into two halves called daughter cells. When daughter cells are formed, each daughter cell takes half of the sequenced genetic information of the normal parent cell. Figure 13 shows a normal cell dividing into daughter cells. Notice the “shared” genetic information being pulled to opposite poles in each daughter cell on strands called microtubules.

Figure 13. A cell dividing into two daughter cells during M or Mitotic phase. source: http://en.wikipedia.org/wiki/File:Anaphase_IF.jpg originator- Delta Vision Roy van Heesbeend

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Daughter cells are formed in a phase of the cell cycle called the Mitotic phase. The Mitotic phase is only a small part of a cells life cycle. The other phase is called Interphase and represents the remainder of the cells life. To visualize this sharing of genetic information, think of a common garment zipper. When the zipper is “zipped up” both sides are joined together. If you hold the zipper at both ends and twist in opposite directions you now have made a helix. This is basically how the DNA is packaged as complete strands in a normal cell. During daughter cell formation the complete DNA strands or helix is “unzipped” into halves. Each half is now called a template. The “unzipping’ occurs at each bond between two joined nucleotides. Remember the nucleotides are the building blocks that are paired and arranged in sequence in a DNA molecule. They are like the teeth on a zipper except, unlike the teeth on a conventional zipper, there are different types of nucleotides that are designed to bond only with nucleotides from a matching group. Rebuilding and preserving the order of the DNA sequence in the daughter cells is a matter of respecting the order of nucleotides on the template and joining template nucleotides with the correct free nucleotide they are normally attracted to. Figure 14 demonstrates the unzipping of nucleotide pairs in a DNA strand into two separate templates. Notice that each side of the strand keeps its nucleotide sequence intact so it can later attract free floating nucleotides of the correct type to complete (replicate) two new DNA strands with exactly the same order of nucleotides.

Figure 14. DNA unzipping into two templates during Mitotic (M) phase source: http://commons.wikimedia.org/wiki/File:DNA_replication_split.svg originator – Madprime

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 15 demonstrates how each unzipped template becomes a blueprint in assisting the replication of a complete DNA strand bound for each daughter cell.

Figure 15. DNA rebuilding during Interphase. source: http://commons.wikimedia.org/wiki/File:DNA_replication_split.svg originator - Madprime

The sequence of the genetic information is specific to the form and function of a human. Mistakes in the copying of DNA, if made, may occasionally go undetected and so get passed on to the next generation of cells. These are called mutations.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Mutations are not supposed to occur. If DNA copying mistakes occur, the cell has internal mechanisms that recognize most of these errors. If the error cannot be corrected, it usually results in the cell “self-destructing”. This way the genetic sequence or code is preserved and errors are not passed on through replication. Unfortunately, cellular mechanisms to recognize mistakes in the genetic code are not perfect and sometimes mistakes go undetected. A cell’s life follows a set of phases. As stated, Mitotic phase is when the cell splits into two daughter cells. After this the daughter cells must rebuild the shared genetic information into complete DNA strands and go on to reproduce, or, live out their cycle as mature cells. This is done in the next stage that is called Interphase. Interphase can be divided into four distinct sub-phases and these sub-phases must follow in order, otherwise, the cell cycle is interrupted and the cell will likely die. The sub-phases are: G1 or Gap 1 occurs immediately after the Mitotic phase. In G1 one of the important things to occur is the production of enzymes involved in DNA synthesis. Without these enzymes the cell will not be able to rebuild DNA and so will not proceed to the next cell sub-phase; S or Synthesis phase is the next sub-phase. This is when the DNA is actually rebuilt or replicated. During S phase the templates provide the nucleotide sites that attract and bind to matching “loose” nucleotides within the daughter cell. The result is complete DNA strands or helices. When DNA synthesis is complete the S phase is done; G2 or Gap 2 is the next sub-phase. During G2 the cell manufactures proteins used to build the microtubules that act like cables and draw the shared DNA to opposite daughter cells in the M phase. If protein synthesis is interrupted in G2, the cell will not proceed to the Mitotic phase and so the replication process stops. For cancer cells, which tend to replicate quickly, upsetting G2 protein synthesis is a tactic used by some types of chemotherapy to halt or slow down replicating cancer cells. When the cell does not replicate and instead proceeds to its normal duties directly from G1 it enters into the sub-phase called G0. Cells that go into this sub-phase can stay in this sub-phase for the remainder of their life or, at some later date, re-join the cycle of cell replication. Depending on the cell type and condition, the age of a cell varies. Red blood cells last only a very short amount of time (days) then are removed and replaced by new red blood cells. Comparatively brain and nervous tissue cells, if treated nicely, last the life of the person they belong to. Figure 16 shows a simple schematic of the cell cycle. In reality, the length of each phase or sub-phase varies. So the duration of each phase is not accurately reflected in the diagram. The order of each phase; however, is accurate and the diagram should be considered in a clockwise sequence. This means that a cell will not skip, back up or

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

proceed to any other phase out of sequence. The circle of the schematic shows the phases of Mitosis (M) and Interphase (I) with its sub-phases G1, G0, S and G2. Although this pie diagram implies timeframe you should know that time frame varies substantially between different cell types. So this diagram only represents the rough notion of cell phase duration to example the element of accumulating timeframe to the reader.

Figure 16. Schematic of Cell cycle involving mitotic division. source: http://en.wikipedia.org/wiki/File:Cell_Cycle_2-2.svg Originator- Zephyris

The initiation, pace, and, duration of cell replication is regulated by instructions that are guided by proteins within a cell’s genetic material. In adults, there are two rules that define the way a normal cell behaves. These rules are: 1) Normal cells should not reproduce unless they are trying to repair or replace damaged cells; and, 2) A normal cell is not allowed to stay alive if the damage to it is too extensive, it is replaced. Further, damage does not just mean trauma, it can also mean mistakes in the cells genetic code. As stated; should the mistake go undetected then it becomes part of the DNA sequence that can be passed on and replicated. A mutation is a permanent change in a

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

gene’s code resulting from a mistake in the original DNA sequence. Such mutations can change the end result of what is being replicated, as well as its functional ability. It is theorized that such mutation opens the door for changes that can eventually progress into cancer cells. Generally speaking, cancer is caused by mistakes or mutations in protein production and particularly, mutations in enzyme production.24 Mutations can be caused by copying errors, breakages or overlaps in the DNA, and exposure to agents called mutagens. CIGARETTE SMOKE, either first or second hand, is an example of a mutagen. So is radiation. Mutations also occur when precancerous cells lose their identity as differentiated cells. When a cell loses its identity as a differentiated cell this means the cell loses its capacity and structure to behave, resemble and integrate with normal cells that reside in the same area. Figure 17A illustrates this notion of normal cell division and how mutations that give rise to a cancer cell typically results in the death of the mutant cell. Figure 17B shows what happens when the mutation resulting in cancer is not handled correctly by the body’s defenses and the cell is allowed to replicate.

Figure 17. A - A cell division Mutation giving rise to a cancer cell that dies; B- Surviving Cancer cell division. Source: http://en.wikipedia.org/wiki/File:Normal_cancer_cell_division_from_NIH-2.svg originator - Normal_cancer_cell_division_from_NIH.png

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

When one considers cancer cells, the initiation, pace and the extent of this replication is not like normal cells. Cancer cells do not abide by the two rules of normal cells. This lends to a signature that is common, either in whole or in part, to all cancer. The cancer signature includes: a) The ability of the cancer cell to function independent of the chemical signals (in the form of proteins) that tell the surrounding normal, healthy cells how to behave; b) The resistance or refusal of the cancer cell to self-destruct, also known as a resistance to apoptosis. This allows the cancer cells, which are basically non-standard or damaged cells, to thrive and proliferate with apparent immortality; c) The ability of cancer cells to form their own network of blood vessels; and, d) The ability to reproduce without any normal reason resulting in the proliferation of the cancer cells and the subsequent invasion of surrounding tissue and body systems.25 Active cancer cells generally multiply quickly. They can overgrow surrounding cells and can migrate. If left untreated the cancer cells will continue to develop until their host is overgrown to the point where normal biological function and process are so burdened or interrupted that it is inconsistent with life.

Abnormal condition of the Prostate Occasionally the prostate becomes host to growth resulting in feature or condition not normally associated with a pristine organ. Cysts; 26 inflammation (prostatitis); painful condition resulting from abnormal nerves or muscles in the region (prostatodynia); benign prostate enlargement (prostatomegaly); as well as, PC are examples of conditions that a prostate may host. Unfortunately, when such condition or growth occurs there is often not much by way of symptoms that indicate any change or problem until these abnormalities become quite advanced. These conditions are either benign or malignant (cancerous). Sometimes abnormal structure can harbour what is called pre-cancerous cells. It is thought that if pre-cancerous cells are left unattended for a substantial period of time they can eventually develop into cancer. As much as I gather, the mechanism of how or when such a change happens is not understood. Neither is how long it actually takes for PC to develop. Abnormality should, at the very least, be monitored closely especially if it is regarded to be in a precancerous state or if you are moderate to high life time risk based on your history and profile.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Benign (Non-Cancerous) Growth, Condition and Presentation Prostatomegaly (enlarged prostate) is a common occurrence especially as men grow older. This can be due to a number of conditions which include: 1) Benign prostatic hyperplasia (BHP) is enlargement of the prostate due to the increase the number of cells of the prostate.28 Another name that finds its way under the title of BHP in the literature is adenofibromyomatous hyperplasia; 2) Benign prostatic hypertrophy (BPH) is enlargement of the prostate due to the increased size of the prostate cells. This condition is common in elderly men and occurs usually in the peripheral zone of the prostate. Its cause is not known; however, there is evidence to suggest it is hormonally mandated; 29 3) Benign cystic hyperplasia involves irregular and abnormal prostate enlargement caused by an increase in the reproduction rate of cells related to benign cyst development. A cyst is basically a fluid filled sac. Paraprostatic cysts are an example of a type of cyst found connected to the prostate by thin stalks; 4) Squamous metaplasia is a benign condition where prostate cells start changing into a squamous (plate-like) form. It also mimics a cancerous condition called squamous carcinoma although no there is no clear understanding that this benign condition leads to a malignant condition; 5) Prostatitis is a group of prostate disorders that are sub-divided into four categories. - Bacterial prostatitis is usually caused by urinary tract pathogens (foreign bacteria) and can be either acute or chronic. Prostate abscess is a complication associated with acute bacterial prostatitis; - Non-bacterial prostatitis can be inflammatory or non-inflammatory the cause of which is not really known. It is thought that it could be related to elevated urinary pressure triggering an inflammatory response in the prostate OR increased pelvic autonomic (immune system) activity leading to chronic pain (prostatodynia).30 6) Prostatodynia is a term for pain that emanates from the prostate. Described as a deep burning or aching pain, it often radiates to the rectum; which sometimes causes it to be misdiagnosed as proctalgia, a more generalized term referring to pain in the rectum. Prostatodynia can be formative to a syndrome called PPOD (pelvic pain and organic dysfunction) which can manifest into a wide range of bladder, bowel and sexual dysfunctions.31 Prostatomegaly, if left unchecked, will likely advance and create more pronounced problems as the prostate enlarges. It must not be ignored and requires medical attention.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Dysplasia and the Cancer Cell Sometimes in a pathology report you may encounter the word dysplasia. As I have been told, dysplasia is the earliest form of pre-cancerous lesion that a pathologist can recognize. Dysplasia can be low grade or high grade. It is thought that the risk of low grade dysplasia transforming into high grade dysplasia and then into cancer is low simply because the process of cells changing to feature cancer-like behavior can take a very long time if it happens at all. It is proposed that for the cells of the low grade dysplasia to turn into cancer a series of undetected random mutations have to occur. However unlikely it may be, when a lesion is typed as low grade dysplasia the cells therein could be in the beginning Initiation phase of cancer. Following this Initiation phase is the phase of Promotion. The Promotion phase is when the cancer becomes robust through successive mutations. In theory this phase can last for many years before the cancer transitions to the next phase called Progression. High grade dysplasia represents a more advanced trend towards malignant or cancerous transformation. Carcinoma in situ, (CIS) means the cancer is restricted to the surface on which it resides. Lesions of this type essentially have cells that undergo no maturation. They are said to have lost their ability to differentiate into a recognizable healthy cell. As such; these CIS cells have lost their tissue identity and have assumed what is considered a primitive cell form that grows rapidly and without regulation. Further to this, it is thought that the lack of maturation generally results in associated changes in the genome since irregular cell growth generally results in incorrect replication and/or mutation of the genetic code. This is the essence of cancer-like cell behavior. Progression is the phase when the cancer invades the local tissue (in this case the prostate elements) and eventually moves throughout the rest of the body. Invasive carcinoma is the final step in this sequence. It is cancer which has metastasized or invaded beyond the original tissue layers and has spread. Invasive cancer can usually be treated but not always successfully; however, if it is left untreated it is certain to be fatal with time.

Malignant Growth, Condition and Presentation Generally the longer cancer goes undetected and untreated the more chance of it exceeding the membranes of its original site and becoming invasive. It is important to catch any cancer before it has become invasive. The timeframes involved in the development and progression of the different types of Prostate Cancer in humans remain unclear. The staging of Prostate Cancer will be discussed more thoroughly in a later chapter.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

As stated, the prostate requires androgens to function and the balance between androgens and other hormones is fundamental to the health of the organ. Considerable research is ongoing to investigate the impact of this balance and its role in activating and promoting PC. It has long since been reported that Prostate Cancer development is initially steroid hormone dependent. Androgen receptors (ARs), Estrogen receptors (ERs), and, Progesterone receptors (PRs) with their matching hormones are all participants in normal and malignant prostate cell activity and growth. Research is focused on the processes of how these assorted receptors of hormones change; and in so doing, activate and promote PC. It has been reported that PC cells have marked differences from normal prostate cells in that two of the three Estrogen α receptors (types ERα-A and ERα-B) are often found to be deactivated.32 It is not clear when exactly this deactivation of ERα receptors occurs. Nor is it clear if this deactivation is in fact causative to PC initiation or simply a feature of PC promotion. In the past one of the strategies in addressing PC was castration (removal of the testes). As stated, the testes produce most of an adult male’s hormone called testosterone. Testosterone is one of the androgens that contribute to male hormone levels. It is also made at much lower levels in the adrenal glands. As well, adult women produce testosterone but also much lower levels than in an adult male. Prostate cells need androgen; the idea was that by removing the testes the associated reduction in a man’s ability to produce androgen hormones would either stop or significantly slow the PC. This worked on some PCs; however, it has since been known that there is “castrate resistant” PC (CRPC) that can grow despite medical interventions [surgical and therapeutic] aimed at reducing androgen hormone levels. CRPC continues to challenge and confound treatment regimens. It is reported that 90% of men with CRPC develop bone metastases which can lead to significant pain fractures, spinal cord compression and bone marrow failure.33 Overall, it can be said that there is much more to discover as to how and why hormones affect PC cells. At times the term neo-plastic will be used to describe a tumor. Neo-plasticity means that an abnormal tissue mass has developed as a result of uncontrolled cell growth occurring usually after a genetic mutation. Neo-plastic tumors do not always progress (get worse), but sometimes they do. Neo-plastic tumors can be benign, pre-cancerous or cancerous. High Grade prostatic intraepithelial neoplasia (HGPIN) is believed to precede the development of prostate adenocarcinoma. Figure 18 shows a microscopic view of HGPIN. Grading will be discussed in a later chapter.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 18. Micrograph of High Grade prostatic intraepithelial neoplasia (HGPIN). Lesion (HPIN at left of image) progressively changes to a solid cord of tumor cells (pointed to by arrows). N (top right) is used in the photograph to mark a normal prostate cell. source: http://openi.nlm.nih.gov/detailedresult.php?img=3177701_PC2011-249290.002&query=human Prostate carcinoma &fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=42&prt= originator – R.B Nagle and Cress, A.E.

The following is a brief overview of the types of Prostate Cancer and tumors: Acinar Adenocarcinoma (also known as glandular Prostate Cancer) – this disease accounts for more than 90% of all newly diagnosed Prostate Cancer.34 It begins when normal sem*n secreting gland cells mutate into cancer cells most commonly in the prostate’s peripheral tissues. Figure 19 shows a microscopic view of prostate acinar adenocarcinoma;

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 19. Micrograph of prostate acinar adenocarcinoma with Gleason pattern 4. source: http://en.wikipedia.org/wiki/File:Prostate_cancer_with_Gleason_pattern_4_low_mag.jpg originator - Nephron

The remaining 10% of those diagnosed have a number of different types of PC including: Adenoid cystic carcinomas (AdCC) – can be associated with distant metastasis; Basal cell carcinomas (BCC) and carcinoid tumors – are rare prostatic neoplasms with unfavorable clinical outcomes; Carcinosarcomas and sarcomatoid carcinomas - are biphasic tumors that progress (grow) rapidly; Lymphoepithelioma-like carcinomas - are poorly differentiated carcinomas with a syncytial growth pattern and adverse clinical behavior; Mucinous carcinomas – rarely respond to hormonal therapy and often cause bone metastases; Prostatic duct carcinomas- originate in the larger dilated central ducts of the prostate gland and typically are low to intermediate aggressiveness. -

Endometrioid adenocarcinomas are included in this ductile PC group;

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Prostatic transitional cell carcinomas – arise from the periurethral glandular epithelium OR from metaplastic prostatic epithelium; and, often develop aggressive tumors that are not responsive to hormonal therapy; Signet-ring cell carcinoma – is a clinically aggressive PC; Small cell and neuroendocrine carcinomas – are associated with poor prognosis; Squamous and adenosquamous carcinomas - may develop following radiation therapy or after conventional adenocarcinoma has been treated with estrogens; 35 and, Transitional cell carcinoma (TCC) – rarely develops as a primary cancer in the prostate instead is derived from primary tumors present in the bladder. As a primary cancer of the prostate it difficult to detect until it is advanced. In advanced condition its prognosis is unfavorable.36 Notes to clarify the jargon used in the above PC descriptions [in order of appearance]: - Carcinoma means cancer of the epithelial tissue (in this case, thin tissue that covers the outside or lines the insides of the prostate);

either

- Sarcoma means cancer of connective tissue such as bone, cartilage and fat; - Basal cell is one of two types of cells that make up the epithelial tissue of the prostate. The other type of cell in the epithelial tissue is called luminal cells; - Biphasic means it occurs in two different phases; - Syncytial refers to cytoplasm (the contents normally inside a cell where metabolic activity and cell division occurs) that is not separated into cells; -Mucinous means it is related to or covered with mucous; -Metaplastic means the transformation of cells from a normal to abnormal state; - Signet ring cell is an unusually malignant cell containing clear cytoplasm that into a signet (flat cookie) shape;

flattens

- Neuroendocrine means relating to or involving both nervous system stimulation and endocrine system secretion; - Squamous means characterized or covered with scales.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Chapter 2

Symptoms, Examination & Opinions

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Diagnosis is the medical determination of disease or syndrome performed by a physician. The focus is on the disease process and the physical, genetic, or environmental cause of that process.37

Symptoms As outlined in the previous chapter, the symptoms associated with the range of prostate related condition and ailments have striking similarity. These symptoms can be obvious, missing or masked by other condition or disease. In the end, correct diagnosis of normal, benign or malignant prostate condition must rely on proper medical examination and testing. It is important to be aware of what the symptoms of PC are. A doctor should be consulted and follow up should be done with the appropriate tests if any of the following symptoms are observed. To reiterate, some of the common symptoms are: •

need to urinate often (especially at night);

•

intense need to urinate (urgency);

•

difficulty in starting or stopping the urine flow;

•

inability to urinate;

•

weak, decreased or interrupted urine stream;

•

a sense of incompletely emptying the bladder;

•

burning or pain during urination;

•

blood in the urine or sem*n;

•

painful ejacul*tion.

Additionally, symptoms of more advanced PC can be any one or combination of the following: •

Bone pain (back, hips, thighs and neck);

•

Weight loss;

•

Fatigue;

•

Anemia (low red blood cell count);

•

Weakness or numbness in the legs or feet;

•

Loss of bladder or bowel control. 38

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

These symptoms are all obvious aspects that can be detected by any one hosting them then brought to the attention of medical staff. All that is required is to apply your knowledge.

See Also

Form 8-K - Current report

Prostate Self-Examination (PSE) It has long since been known that those who conduct breast self-examination (BSE) and are proficient in their technique may reduce the risk of death from breast cancer through earlier detection.39 Since I only recently finished writing a book on Breast Cancer, by logical extension I went about in search of reputable reference for proficient Prostate Self Examination (PSE) technique and studies reporting on the impact of such technique with respect to the incidence or mortality of Prostate Cancer. Unbelievably, I found nothing in this regard in the literature. I did find a number of opinions on why PSE is not even considered. Most of which I consider invalid since DRE (digital rectal exam) used to be the gold standard for PC detection and remains an integral part of prostate Clinical Examination and is often used to give context to a patient’s screening PSA test results.40 So it is not like the DRE has been abandoned by the mainstream medical community. In fact, the American Cancer Society recommends that for those who have had an informed discussion with their physician and elect to participate in prostate screening; a DRE in conjunction with PSA testing should be done for men of: o average lifetime risk beginning at the age of 50; o high lifetime risk beginning at the age of 45 which includes AfricanAmerican men and those with first degree relatives (father, brother or son) already diagnosed with PC at an early age; o highest lifetime risk beginning at the age of 40 which includes those with more than one first degree relative diagnosed with PC at an early age. All of this as part of a strategy promoting early detection of PC.41 Given the ongoing use of DRE, it is my view that if a Clinician can be taught to perform DRE in a way that promotes earlier detection of PC; then similarly, so can a patient. So then what aspects have to be overcome in order to have proficient PSE technique? First, it must be understood that any such technique would not be a substitute for clinical examination where DRE is performed by a trained medical clinician in accordance with a patient’s risk and proposed screening regimen. PSE could be used like BSE (breast self- exam) to maintain a regular check on the status of an area that is within reach and amenable to a patient’s palpable review. Palpable review means

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

figuring out the health or status of something by feeling it; in this case, with a finger. Those that have been properly trained and regularly practice PSE would know the palpable areas of their prostate better than anyone. With this, any palpable abnormality could then be brought to the attention of the patient’s physician or urologist in a more timely way. Second, most people are really uncomfortable with the notion of having what amounts to a total stranger stick a finger up their butt and probe around; even if it is only for a few seconds. Several years ago I recall hearing the former Surgeon General of the United States, Antonia Novello, M.D. speak on pressing health issues in her country. Addressing a room filled mostly with men, she raised eyebrows by stating that men are afraid of losing their “anal virginity”. After a great silence in the room along with a couple of solitary coughs she clarified by making the recommendation that everyone should consider the statistics on colon cancer and go get a colonoscopy as they get older. Her comments spoke volumes on the psyche that leads to advanced cancer in those parts of the body that folks consider private or otherwise “off limits”. I know having gone through surgery and treatment for advanced colon cancer the notion of “off limits” is a non-issue as soon as you show up to a medical facility with cancer. Everyone can do themselves a great favor by being sensible about their body when it comes to keeping track of abnormality and possible cancer. In terms of PSE, I think it may be a way to begin being aware of your prostate status while respecting your need for a bit of privacy without any “surprises”. After all, I am sure most men never have a clinical prostate exam. Those that do go for a clinical exam probably do so once every five years and start late when they are in their fifties, for example. What about all of that time in between check-ups? The lack of monitoring is precisely what PC needs to develop into invasive condition. Third, PSE is basically self-practiced DRE after one has been properly trained. It is a way to increase the chances of early detection which can be a valuable addition to screening for those with moderate to high lifetime risk of developing PC. Training can be found by asking your urologist or physician. They should be able to accommodate your request. If not, then go find another who will. Fourth, there are those who say that self-practiced DRE can’t be done because of the difficultly of correct hand placement. This is absolute nonsense if you have appendages (arms, hands and legs) that are developed and function within the norm of our species. If one bends one’s knees so as to crouch to the floor in a full squat resting on your feet then slide the preferred hand between the onside hamstring and lower calf, not only can you position your hand in exactly the correct position over the anus; but as well, your leg has a firm grip on your forearm and provides a rock steady platform from which your hand can be leveraged and maneuvered without physical exhaustion during PSE. I would suggest holding onto something solid with the other hand to maintain your balance. Fifth, the technique for DRE is not rocket science. In fact, it is considered an easy technique to learn given a sound understanding of the prostate’s anatomy, the knowledge

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

of what to feel for, and, a bit of practice. Medical students learn the technique in a number of ways. Some these ways involve prostate examination simulators; others involve practicing on other students or volunteer patients.42 The bottom line is that real proficiency comes with training and practice. So the question is what is involved in a DRE that would make it amenable to selfexamination? To reply, the following is a brief description of some of the practical considerations in clinical DRE: - The patient usually assumes a knees bent position on the examination table. This is the equivalent of the full squat position discussed above; - Preparation for the examination is simply that the patient evacuates the bowel (i.e. has a bowel movement) before doing the exam and then washing the area. This will normally afford a sufficient void in the colorectal complex to conduct the exam; - Using a hand dressed in a latex glove to avoid the transfer of bacteria, the physician or urologist applies lubrication (like KY jelly) and gently accesses the prostate via the rectum using a finger. The same can be done by a patient. General rule, don’t put anything up your anus that you would not put in your mouth (for example baby oil or Vaseline are made for external application only); - Finger palpation will not allow the entire prostate to be examined. In fact, only about 40% to 50% of the prostate is accessible using a finger because of the anatomy of the prostate and the length of a finger.43 This shortcoming is the same for a clinician as it is if the patient is conducting a self-DRE; -

When a clinician conducts this examination they are feeling and looking for any irregularities that may be symptomatic of PC. These include abnormal prostate size, shape, nodules (bumps); ulcers; bleeding; unusual hardness or sponginess; and, pain for example. As well, the prostate is being felt through the colon wall so there has to be a regard so as not to injure either organ during the examination. In addition, one must be aware that any discovery could be the related to the colorectal tissue harboring abnormal condition instead of the prostate; - The prostate is small and a DRE done by a seasoned clinician usually takes less than ten seconds. The clinician uses their experience with other patients as a basis of comparison. A patient conducting self-DRE on the other hand knows their own prostate; so any changes may be more immediately obvious. As well, the examination can be conducted more slowly in a relaxed atmosphere so that a more thorough understanding of abnormality can be had. Patients can also monitor any changes over much shorter intervals; - DRE technique involves using an index finger to sweep from the top of the prostate laterally back and forth over each lobe while being vigilant for any palpable

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

abnormality.44 This can be done by anyone who is properly versed in the technique, including the patient; - According to J.M. White et al, “the clinical significance of careful examination of the prostate gland is highlighted by the observation that approximately one-third of those above age 60 will have some symptoms or findings that can be referable to the prostate”;45 - The risks of DRE are minimal in terms of causing injury or infection so long as the examination involves accustomed DRE technique and protocol. For the patient this means get some training; cut your fingernails so that there is less risk of causing injury during the DRE; wash; wear a latex glove on the examining hand; be gentle; use common sense as to the interval between self-DRE; don’t use “accessories” to extend reach, even if they are from what is advertised as an approved kit; and, bring any concerns to the attention of your clinician. Overall I see no reason why proficient self-practice DRE cannot be done given training, common sense, and, some open communication with your physician or urologist. Some prostate patients have pointed out that DRE can similarly be conducted by a willing “significant other”. In my view, whatever you are comfortable with; as long as they have proper training and exercise the same considerations as discussed. Figure 20 is an illustration of the area the DRE accesses.

Figure 20. The DRE (Digital Rectal Exam). source: http://visuals.nci.nih.gov/details.cfm?imageid=4351 originator: National Cancer Institute, Alan Hoofring (illustrator)

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Clinical Prostate Examination (CPE) Clinical Prostate Exam (CPE) is an examination of your prostate by a medical professional usually done as part of a screening regimen. Unfortunately, even with the obvious recognition of the need for better screening techniques; there remains a complete lack of harmonization of screening recommendation using the present technology within the mainstream medical community. The American Cancer Society, the Canadian Urological Association, and, the American Urological Association all have prostate screening recommendation.46 In contrast; the US Preventative Service Task Force unbelievably has issued statement in 2008 saying that for men younger than 75 years the balance of harms and benefits of prostate screening cannot be determined. Effectively, they have no recommendation except to say that for men over 75 they do not recommend prostate screening.47 Nevertheless, CPE can be done as part of your annual physical examination; or, in accordance with a specific schedule associated with your PC lifetime risk; or, in response to concern brought to your physician as a patient. CPE can include a number of tests and examination; however, more commonly, it involves a DRE; a PSA test; and a thorough review of your profile including family history of PC. In the case of high levels of prostate specific antigen (PSA) a trans-rectal ultrasound (TRUS) may as well be done. The findings of the CPE are not conclusive to any diagnosis. Further testing involving more blood work, imaging and biopsy may be required if the physician feels it is merited. In short, CPE is very much a preliminary examination that assists the physician in determining the merit and need for further investigation of suspected abnormal prostate condition, as well as the emphasis and direction of that investigation. One of the problems of examinations, tests and imaging is that sometimes the results are interpreted “incorrectly”. This could involve failing to find or report abnormal growth resulting in the patient being sent home with the condition untreated. This is called false negative results. It can also involve calling some types of imaging artifact “abnormal” growth when it is not. This can result in unnecessary follow up and/or surgical procedure such as biopsy. This is called false positive results. Ideally, it is best if results from tests or imaging are reviewed twice. This way the reviewing specialists can compare their findings. A second review lowers the risk of review error. Unfortunately, this is costly and health facilities in North America do not necessarily provide this service as commonly as those in Europe. To address this, a number of technologies are now used. One such technology is called Computer Aided Detection (CAD). It is another way to have a more thorough review of your images. CAD is a program that analyses the images for high probability areas of abnormal growth. The program then “marks” the high probability area so that it can be looked at by the radiologist. CAD programs can be found on X-ray, CT and MRI imaging, for example. Figure 21 shows an example of TRUS image with CAD markings and Color

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Doppler enhancements to point out areas where the blood flow pattern is suspicious and may be the result of malignancy. Consider how difficult it would be to identify suspicious tissue in this type of ultrasound imaging without the benefit of CAD.

Figure 21. TRUS images of a prostate lesion in a 45 year old man. A – band like lesion (arrows) with regular outline at outer peripheral zone; B- CAD enhanced Color Doppler US shows prominent hypervascularity (arrows) indicating likelihood of malignancy; source: http://openi.nlm.nih.gov/detailedresult.php?img=2672179_kjr-10-244-g001&query= Prostate Cancer tumor &fields=all&favor=none&it=u&sub=none&uniq=0&sp=none&req=4&simResults=f0a0c121 f0a1c6 f0a2c133 f0a3c60 f0a4c9 f1a0c347 f1a1c244 f1a2c3 f2a0c146 f3a0c141 f3a1c134 f3a2c138 f3a3c3 f3a4c3 f3a5c6 f4a0c94&npos=12&prt=2 originator: H.Y. Lee et al.

One of the larger problems is trying to address the processing of the 5-10 million cores from the 1,000,000 or so prostate biopsy procedures that occur annually just in the United States. The traditional efficiency of reviewing these cores on micrograph slides and finding cancer is only about 20%. HistoCAD is a CAD program able to review such micrograph slides and provide analysis and grading of Prostate Cancer with near 100% reproducibility.48 The biggest problem with this technology, apart from it not being available in most medical facilities, is having sufficient storage to bank all of the additional information that is processed in reviewing biopsy tissue at a microscopic level with CAD. Still, it is a tool that would greatly improve a pathology clinician’s ability to identify PC and render accurate PC prognosis. After your clinical prostate exam, protocol and process is such that in most facilities the results take time before being released to you. If you have not received your results and it has been two weeks since the exam, follow up with a call to either the facility or to your overseeing physician. Find out why. This is important to do because sometimes results get misplaced. Delaying disclosure of the results makes for unnecessary anxiety; and in the case of disease, can ultimately delay diagnosis of any abnormality you may have. This is unacceptable. You must be aware that a clinical exam will not necessarily provide a solid diagnosis of your prostate condition. In the case of abnormality that has been confirmed by imaging, you can expect to undergo a biopsy before diagnosis.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Ultra Sound Imaging Ultrasound or sonography (USG) is a technology that sends high frequency sound waves through tissues and captures the signature of those sound waves. Tissues all have different reflective qualities because of structure and their physical properties and it is this sound reflection and absorption that is captured and compiled to create an image of the area and organ(s) being scanned. The prostate trans-rectal ultrasound is a procedure that involves the patient lying on their back on an examination table with their knees bent and legs open. The examination table may or may not have stirrups to assist in maintaining the patient’s station during the examination. The technician conducts the examination using ½” diameter wand-like probe (called a transducer) that is inserted via the anus to the prostate area. Several adjustments to the probe’s angle and position may be required to ensure adequate “sounding coverage” allowing the capture and imaging of the area of interest. Apart from some slight discomfort, the examination is totally painless. It takes about 15 to 20 minutes to perform. Sometimes the TRUS may be used as “real time” guidance of a core biopsy of the prostate. In this case, a sedative and anti-biotic are administered to the patient before the biopsy needle is inserted into the prostate and core samples taken. Figure 22 shows TRUS image with CAD markings and color Doppler enhancement. As stated, the Doppler enhancement is able to detect the movement of blood. A cancer tumor typically has a congested network of veins serving its needs of circulation. This type of congestion is obvious when the ultrasound has Doppler enhancement.

Figure 22. TRUS images of a prostate lesion. E – lesion (arrows) mostly located in peripheral zone; F- Color Doppler shows vascularity (arrows) in lesion. source: http://openi.nlm.nih.gov/detailedresult.php?img=2672179_kjr-10-244-g001&query= Prostate Cancer tumor &fields=all&favor=none&it=u&sub=none&uniq=0&sp=none&req=4&simResults=f0a0c121 f0a1c6 f0a2c133 f0a3c60 f0a4c9 f1a0c347 f1a1c244 f1a2c3 f2a0c146 f3a0c141 f3a1c134 f3a2c138 f3a3c3 f3a4c3 f3a5c6 f4a0c94&npos=12&prt=2 originator: H.Y. Lee et al.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

CT Scan Advancement to X-ray or radiographic technology has seen the arrival and use of the CT (computed tomography) scan. The CT scan uses the same ionizing radiation as an X-ray to make an image. The CT is the modern version of the old CAT scan which could only take images in an axial plane (2D). So the CT is essentially an X-ray that is taken over multiple cross sections and then be recompiled into a 3D image by computer. Again like the X-ray, this type of imaging is best suited to tissue or structure composed of calcium or carbon; so, in the case of the prostate, it is not as useful an imaging solution as for example an MRI; and, therefore it is not so commonly used for imaging the prostate. Nevertheless, CT is used for imaging organs and vessels. Figure 23 is a picture of a spiral CT scanner. For the scan the patient lies down on the platform and they are then passed through the opening of the scanner. While the scanner is taking the image the patient will be asked to remain still. The beam emitter inside the scanner then “spirals” the patient while taking numerous images that are collected and to later render a 3D projection. Other than a little discomfort in having to lie still on a platform, the whole procedure is totally painless. The time frame varies according to the extent of the condition being imaged. Generally, the imaging session only takes a few minutes to complete once begun; however, the preparation for the CT if contrast agents are involved will take about an hour since the contrast agent has to be delivered to the patient they adequately absorbed by the tissues before the CT is began.

Figure 23. Spiral CT Scanner. source: http://commons.wikimedia.org/wiki/File:Ct-scan.jpg Originator: NithinRao

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Contrast agents are used to enhance the CT image allowing for structure to be more easily determined. These agents are delivered to the patient either orally or by intravenous injection. IV injection of contrast agents will likely cause you to feel tingly and warm shortly after the IV is started as was my experience with IV contrast agents. CT imaging is less likely to have artefacts caused by patient movement. Molecular Imaging (PET/CT scan) It is known that cancer cells generally multiply quickly. To do this cancer needs fuel. The fuel that it uses to drive its energy needs is a basic sugar, which I will discuss in Chapter 5. As the cancer cells grow the tissue that is formed requires a circulation network to supply oxygen and fuel, and remove waste. Fortunately, because cancer tissue grows without any “plan” the associated circulation network generally becomes congested and “choked” much like a bowl of spaghetti. This makes for circulation that is typically not very good or dependable in delivering oxygen to the cancer tissues. In short, the cancer basically resides in an oxygen deprived (anaerobic) environment and adopts a way of processing fuel, called glycolysis, which is inefficient and requires much more sugar than normal cells do in order to satisfy the energy requirements. Uptake and processing of fuel by a cell is called metabolism or metabolic activity. When cancer cells exist they are typically associated with areas of high metabolism or hypermetabolism. With these facts, imaging specialists have developed techniques that attach a “label” to molecules that are introduced to the bloodstream by IV then consumed and concentrated in cancer cells. The technology then “sees” the label and a better picture of the malignant area of activity is the result. This approach to viewing cancer is called molecular imaging. A common label used during molecular imaging in oncology is fluorine-18. Fluorine-18 is combined with glucose (sugar) molecules then introduced to the patient by IV for the purpose of the scan. The labeled molecule is called 18F-floro-2-deoxy-Dglucose which is abbreviated as FDG in the literature. Most cancer cells have increased uptake of FDG compared to normal cell tissue. The imaging that can see these labeled molecules is called Positron Emission Tomography or PET. FDG-PET scans show the distribution of tumor deposits based on their metabolic activity. The relative intensity of FDG uptake gives an idea of cancer cell activity. If a patient is being treated for cancer, the effectiveness of the treatment can be monitored using FDG-PET. Decreases in FDG uptake, for example, indicate that the patient is responding to the selected therapy.49 PET is combined with computed tomography (PET/CT) and used as a diagnostic tool for determining aspects such as the stage, response and recurrence of cancer. Recent data is indicating that there are possible advantages of using FDG-PET in whole body imaging in order to earlier detect cancer spread or recurrence.50

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 24 shows a PET/CT scan with areas of concern throughout the thorax and pelvic area from a cancer that originated in the colon. Crosshairs on the image clearly point out a tumor in the right lung in front, sagittal and plan views of the patient. With this type of imaging used in a screening capacity, early detection of prostate metastasis to distant parts of the body is made much more likely. As such; proposed treatment can be more accurately tailored to address the patient’s actual condition.

Figure 24. PET/CT of a staging exam of colon carcinoma - Tumor in the crosshairs on right side of body is a lung nodule. Numerous other tumors are visible in thorax and pelvic area. source: http://commons.wikimedia.org/wiki/File:RectalCancerStagingInPETCT%2Barrow.jpg originator: Hg6996

In 2006 it was reported that the contrast agent 11C-Choline combined with PET/CT accumulates preferentially within Prostate Cancer tissue. As such; PC can be located and imaged precisely. In addition, this type of imaging can differentiate

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

between malignant and benign tissue within the prostate. 51 In 2011 these findings were supported by investigators reviewing this type of imaging and who also encouraged training of technical readers in the specifics of 11C-Choline uptake and its distribution in the body as a way to minimize false positive and false negative occurrence in the interpretation of 11C-Choline PET/CT scans.52 This type of imaging has significant clinical implications both in the screening and diagnosis of PC.

MRI Magnetic resonance imaging is another totally painless procedure that takes between 20 to 45 minutes to do for the pelvic area. As the patient lies flat on the platform they are passed through what looks like a big donut (see Figure 25). The MRI machine creates a very strong magnetic field that induces mini magnetic emissions in the body’s hydrogen nuclei which can be captured and stored by the MRI system. Successive pictures or “slices” of these emissions are made at different angles and planes. These are then compiled by computer to make the 3D image of the area scanned. Since every tissue and structure has a distinct magnetic imprint, the reviewing surgeon can clearly see the abnormal outline and growth in the pelvic area before they ever operate. This allows the surgeon to operate with more confidence that they are addressing the problem area(s).

Figure 25. Example of an MRI scanner. source: http://commons.wikimedia.org/wiki/File:MRI-Philips.JPG originator : Jan Ainali

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

MRI is well suited for cases when a patient is to undergo the exam several times successively in the short term because, unlike X-ray and CT scan, it does not expose the patient to the hazards of ionizing photon radiation. A small inconvenience of the MRI is that the patient must be still during image capture. If they are not, the image becomes unclear. This is called motion artifact. As a result, MRI scanners are equipped with speakers that tell the patient when to hold their breath as they are being scanned and when they can breathe after. This again only happens for a few seconds at a time. During the pelvic imaging, the patient is positioned on the platform and can be administered a sedative to keep them from moving excessively from discomfort or pain during the scan. There are some risks in using MRI that have to be considered. As I have been told the magnetic pulse generated by this machine is about 60,000 times the pull of earth’s gravity. As a result, patients are briefed not to wear any ferrous (steel or iron) type jewellery. The problem is twofold. First, the ferrous object can be attracted to the center of the magnetic field (not good). In addition, severe thermal burns can occur as the metal heats in response to the magnetic pulse. If the patient has any kind of steel prosthetic implant it becomes problematic. As well, vagus nerve stimulators, implantable cardioverter-defibrillators, loop recorders, insulin pumps, cochlear implants, deep brain stimulators all may be susceptible to thermal heating or failure if exposed to MRI pulse. Patients with integrated hardware of this nature should always give complete information (manufacturer, model, serial number and date of implantation) about all implants to both the referring physician and to the radiologist or technologist before entering the room for the MRI scan. The ability of MRI to detect PC metasis is well documented in the literature; however, sometimes the MRI scan produces image where the abnormal growth is not so obvious. Techniques using organic complexes of metals like Gadolinium or Manganese can be introduced intravenously to patients to enhance image contrast while the magnetic pulse is being applied. When the MRI pulse ends these metals do not retain any magnetic field. These organic compounds then deteriorate and leave the patient’s system via the urinary tract. It is important to take in a lot of fluids following this type of scan to ensure quick purging of the enhancement compound. Figure 26 a, b and c is a series of side-by-side images taken over the period of 6 months on a patient with Castration Resistant Prostate Cancer (CRPC) comparing full body MRI to sagittal (side) view imaging of the vertebrae of the same patient using 11CCholine PET/CT. The accuracy and ability of MRI and PET/CT imaging to detect metastasis well in advance of traditional radiological methods such as bone scan (BS) involving the non-specific uptake of the nuclear enhancement agent 99mTC with plain Xray raises the question of whether the era of traditional method of bone scanning is over.53

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 26a. Initiation scan of patient with Castrate Resistant PC (CRPC) with full body MRI image on left and sagittal view 11C-Choline PET/CT on right. source: http://openi.nlm.nih.gov/detailedresult.php?img=3195676_AU2012-893193.002&query= 11CCholine PET/CT&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=3&prt= originators – B. Tombal and F. Levouvert

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 26b. Scan of patient with Castrate Resistant PC (CRPC) with full body MRI image on left and sagittal view 11C-Choline PET/CT on right at three months. Arrow on right image points to obvious metastasis in vertebrae. Similar metasis can be seen in the MRI. source: http://openi.nlm.nih.gov/detailedresult.php?img=3195676_AU2012-893193.002&query= 11CCholine PET/CT&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=3&prt= originators – B. Tombal and F. Levouvert

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 26c. Scan of patient with Castrate Resistant PC (CRPC) with full body MRI image on left and sagittal view 11C-Choline PET/CT on right at six months. Arrows on right image points to progressive metastasis in vertebrae. Similar metasis can be seen in the MRI. source: http://openi.nlm.nih.gov/detailedresult.php?img=3195676_AU2012-893193.002&query= 11CCholine PET/CT&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=3&prt= originators – B. Tombal and F. Levouvert

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Near Infrared Scanning Advancements in imagery have given rise to the development of other technologies in search of more economical ways to better screen for Prostate Cancer. Near Infrared Scanning is one such technology that is in development. The technology involves a portable rectal scanner that is able to detect emission from a bio-dye that has been delivered and absorbed by the PC. The scanner records differences and patterns of laser absorption by the prostate tissue then displays it in a 3D image.54

Biopsy After prostate abnormality has been discovered, there remains a question as to whether or not it is benign or malignant. The common procedure used to determine this is a biopsy. The tissue taken during a biopsy is sent to the laboratory for analysis. At this point, imaging and biopsy are considered clinical evidence of malignant growth. There are several types of biopsy procedure used on the prostate. The one used depends largely on the location of the growth, its properties and the availability of technology. These days, the “gold standard” for prostate biopsy is the use of real time (see it as it is happening) TRUS radiographic guidance of the surgical tool to perform multiple sampling of suspect prostate tissue. The actual sampling of the prostate tissue, in this strategy, is done with a spring loaded coring needle. In preparation the patient is usually given a local anesthetic, as well as, an antibiotic. The coring needle is part of the TRUS probe and the clinician positions the point of the transducer wand then takes a sample. This is repeated between 8 and 18 times! The procedure lasts about 10 minutes. Blood in the sem*n and urine as well as light bleeding from the rectum may occur for several weeks following the procedure. One of the comments that will come back from the pathologist’s report after analysis of the cores is the percentage of cores that actually have cancer in them. 55 Manual needle placement is a major limitation of the accuracy with which a prostate biopsy can be taken using conventional methods. As well, the relatively poor imaging associated with traditional use of TRUS guidance is problematic. To compensate for this “less than ideal” combination, multi-samples of the prostate tissues using needle coring is done during biopsy. This method is inaccurate; traumatic to benign tissues that are erroneously sampled; and, imposes an extraordinary burden on pathology lab resources in having to process millions of unnecessary samples annually. To improve on the conventional “the gold standard” for prostate biopsy, a team of researchers at Brigham and Women’s Hospital developed an MRI-guided transperineal prostate biopsy approach that allows for targeted sampling of suspected abnormalities. 56

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

The use of MRI significantly improves image quality allowing the clinician to guide 3D slicing tools of the robotic surgical system with pinpoint precision to sample suspicious tissue. Nevertheless, TRUS imaging, manual positioning and manipulation of coring biopsy needle, and multiple coring of the prostate remains the pre-dominant method in use to date. Figure 27 illustrates the TRUS core needle biopsy.

Pathology Pathology is the laboratory based study of disease. It is a discipline that uses microscopic techniques to determine the state of disease in tissue, organs and bodily fluids. Diagnosis of Prostate Cancer is only as good as the technique and resource available. In a modern and well equipped laboratory the tests and techniques available are substantial. Nevertheless, new techniques and diagnostic machines are constantly developing and the burden of acquiring and being trained with the “latest and greatest” is a constant financial and medical concern for every institution. The personnel performing the analysis in pathology labs are trained technicians and medical doctors. Their backgrounds include such disciplines as microbiology,

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

biochemistry and genetics, to name a few. The physician will perform the clinical examination and take note of the patient’s physical symptoms. If merited, usually due to elevated levels of PSA, biopsy of the suspect tissue will be performed and forwarded to the laboratory for analysis. The laboratory then takes these samples and processes them to determine the state of the sample tissue or fluids. The results of this analysis can take a few days to a few weeks to receive, depending on the efficiency of your health system or chosen institution. During this analysis of the sample tissue if cancer cells are discovered the report reflects where in the tissue these cells were located. As well, the grading of the cancer and percentage of the biopsy cores involved will be detailed. Recommendations are also made as to the prudent follow up that should occur in order to address the malignancy with sufficient margin and possible invasiveness (metastasis). Margin is the distance between the healthy and infected tissue. When tissue is removed during surgical procedure it, as well, is analyzed in the pathology lab to determine the margin. Negative margin means there is a comfortable “buffer zone” of healthy cells between where the cancer ends and the edge of the removed tissue. Positive margin means that the cancer cells extend right out to the very edge of the tissue taken. Close margins means there are healthy cells between where the cancer ends and the edge of the removed tissue BUT the distance is not substantial. Generally, if positive or close margins are found further treatment may be required. Bodily fluids of the patient, such as the blood and urine are also analysed for other possible signs of tumor and immune response to cancer. Tumor markers are specific proteins in the blood and urine that may occur as a result of different types of cancer. So far, the levels of these specific proteins in bodily fluids are not a reliable way to diagnose any cancer. This is because most patients can have low levels of tumor marker in their fluids even if they do not have cancer. As well, some patients do not necessarily have elevated levels of the tumor marker even if their cancer is advanced.57 The use of PSA (prostate specific antigen) testing is widespread and clinically recommended and accepted as one of the most useful indicators of the presence and outcome of Prostate Cancer. It is also useful in monitoring patients with a Prostate Cancer diagnosis and evaluating their response to therapeutic interventions; and, detecting tumor relapse. This is despite the fact that PSA it is not a cancer specific marker. In other words, elevated PSA levels can be the result of benign prostate condition as well as PC. 58 PSA is made within the prostate epithelial tissues. If the prostate is completely removed there should be no PSA in the blood. Pre-diagnosis PSA testing is done by taking a sample of the blood before DRE or any procedure that could disrupt the prostate. The test results are detailed in terms of total PSA, as well as, Free PSA (fPSA) in a pathology report. Free PSA is the portion of the

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

total PSA that is not bound to its usual carrier molecule and is expressed as a percentage of the total PSA. Total PSA is expressed in micrograms (millionth of a gram) per liter. The symbol for a microgram per liter is µg/l. Total PSA is the sum of circulating fPSA and that part of the PSA bound as a stable complex called PSA-ACT. 59 In the reviewing the literature on PSA testing an ongoing debate exists as to when total PSA levels should merit further testing and biopsy of a patient. Again there is no consensus between major health organizations as to the level that would best detect PC in early stage while keeping the number of unnecessary biopsies to a minimum. Metaanalysis suggests that when total PSA is < (less than) 10 µg/l the % fPSA and DRE results should also be considered to make a decision on whether to proceed with biopsy.60 On a pathology report a PSA value of “X” may be remarked. This means that the PSA value cannot be determined. The next generation of Prostate Cancer markers are undergoing evaluation. In the meantime PSA testing remains the predominant and preferred marker used by clinicians.

Invasiveness and Staging Invasiveness describes the way that cancer cells of a tumor or lesion make their way beyond the organ of origin to other parts of the body as the disease progresses. The factors that influence the rate and extent of invasiveness are numerous and not well understood. Invasiveness remains a matter of continuing research and redefinition. The extent of invasiveness is measured by staging conventions that describe the degree and extent the cancer is considered to have advanced in a patient. Clinical staging is based on information available to the physician before any treatment and is used to define treatment options. Pathological staging is based on clinical information AND surgery whereby a more comprehensive analysis of the suspect tissue has been done and is detailed in a post-surgical pathology report. There are several standard staging conventions used by physicians for PC. These are the TNM; and, the Whitmore-Jewett conventions. Please note, interpretation of your pathology report must be done with your attending physician as classification is sometimes applied differently between medical facilities. From what I have reviewed in the literature, the TNM system seems the most precise and descriptive of the staging conventions. It was the one used on my pathology reports for Colorectal Cancer. It is the system accepted by the American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer (UICC). The following is my understanding of the alpha-numeric combinations commonly found in the pathology reports describing the stage of Prostate Cancer with TNM. In places I have simplified the text and use different language so that it can be more easily understood. For the comprehensive and exact wording of TNM definition based on the

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

latest 7th Edition of TNM staging go to this site and click on the Prostate large poster: http://www.cancerstaging.org/staging/index.html The latest Prostate Cancer TNM convention is detailed in AJCC TNM 7th edition which came into effect January 2010. For those diagnosed before then, the alphanumeric combinations found in your earlier pathology report(s) is based on previous AJCC TNM convention that is similar but not exactly the same. The TNM convention covers 3 key factors of Prostate Cancer staging as detailed below. On any pathology report each of the three factors will be commented on in this alpha-numeric expression. The convention makes further distinction of how the factor was arrived at by clinical or pathological means. To simplify, clinical assignment basically means the factor is based on imaging or non-excisional biopsy; and, pathological assignment involves excision or biopsy sometimes beyond the prostate such as the lymph nodes, for example. The T factor describes the tumor. It notes the size and extent of spread within the prostate and nearby tissues. Clinically detected T factor will be designated as cT or T and pathologically detected T factor will be designated as pT. By progressive order the following is what the assorted T factors mean in edition seven: ClinicalTx: the primary tumor cannot be assessed; T0: there is no evidence of primary tumor; T1: Clinically unapparent tumor neither palpable nor visible by imaging: T1a: the tumor is incidental (small) in less than 5% of the tissue resected (removed by surgery); T1b: the tumor is incidental (small) in more than 5% of the tissue resected; T1c: the tumor identified by needle biopsy. T2: the tumor is confined within the prostate: T2a: the tumor involves one half of one lobe or less; T2b: the tumor involves more than one half of one lobe but not both lobes; T2c: the tumor involves both lobes.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

T3: the tumor extends through the prostate capsule: T3a: the tumor has extra-capsular extension (unilateral or bilateral); T3b: the tumor has invaded the seminal vesicle(s). T4: a tumor is fixed or invades adjacent structure other than the seminal vesicles. Pathological – There is no pT0 or pT1 designation. pT2: the tumor is confined to the prostate: pT2a; the tumor is confined to one half of one side of the prostate or less; pT2b: the tumor is confined to one side of the prostate and involves more than half of that side; pT2c: the tumor is on both sides of the prostate. pT3: the tumor has extended beyond the prostate: pT3a: the tumor has microscopic invasion of the bladder neck; pT3b: the tumor has invaded the seminal vesicle (s). pT4: the tumor has invaded parts of the body other than the seminal vesicle(s). The N factor describes whether or not the cancer has spread (metastasized) to nearby lymph nodes and, if so, how many lymph nodes are involved. Clinically detected N factor will be designated as cN or N and pathologically detected N factor will be designated as pN. By progressive order the following is what the assorted pathological N factors mean in edition seven: Clinical Nx: the regional lymph nodes were not assessed; N0: there is no evidence of regional lymph node metastasis; N1: there is metastasis in the regional lymph nodes. Pathological pNx: the regional lymph nodes were not sampled. pN0: No regional lymph node involvement was found.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

pN1: Metastases in the regional lymph nodes was found.

M factor stands for Metastasis and indicates whether or not the cancer has spread to distant organs such as the bone, liver, lungs, or brain. By progressive order the following is what the assorted M factors mean in edition seven: M0: No evidence of distant spread. M1: Distant spread is present: M1a: spread involves the non-regional lymph nodes; M1b: spread involves the bone; M1c: spread involves other site(s) with or without bone disease; pM1c: when more than one site of distant metastasis is present. This is the M factor describing the most advanced condition of spread. In addition to factors of the TNM nomenclature being preceded by the small case letters c or p; you may encounter y or r (for example rTNM). In such cases the letter y identifies a factor after the patient has undergone neoadjuvant (before surgery) pretreatment; and, the r refers to factor that has occurred after relapse from a disease free period. Although it is not reflected as a prognostic stage in this 7th edition of Prostate Cancer TNM; Stage 0 is cancer in the earliest stage. This stage is also known as Carcinoma In Situ (CIS). CIS cells have already lost their tissue identity and have reverted back to a primitive cell form (less or poorly differentiated) that grows rapidly and without regulation. Further to this lack of maturation generally results in associated changes in the genome since irregular cell growth inevitably results in incorrect replication of the genetic code. After the T, N, and M factors are determined. The three factors are combined and the patient‘s samples are taken in context of total PSA and Gleason grade (as available) then staged. The stage is expressed in Roman numerals from stage 0 (the earliest and least advanced form) to stage IV (the most advanced). Some stages are further subdivided with letters, for example IIA and IIB. Table 1 is an overview of how the TNM factors are combined and anatomic stage/prognostic groups are arrived at derived from the latest 7th Edition of AJCC TNM. It has some simplification and change in language so that it can be more clearly understood. For the original wording go to the following link and click on the Prostate large poster – http://www.cancerstaging.org/staging/index.html.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Note- the following signs are used in the next table: < (less than); to); > (greater than); ≥ (greater than or equal to).

M Total PSA Stage/Prognostic T N Group factor factor factor µg/l

≤ (less than or equal

Gleason

< 10

≤6

< 10

≤6

T1-2a

Any T1

< 20

Any T1

≥ 10 ≤ 20

≤6

T2a

≥ 10 ≤ 20

≤6

T2a

< 20

T2b

< 20

≤7

T2b

T2c

≥2

T1-2

≥ 20

≥2

T1-2

≥8

III

Any T3

≥2

Any T

≥2

Any T

Any N

≥2

Any T1

T2a

IIA

IIB

Table 1. TNM Prostate Cancer Autonomic Stage/Prognostic group derived from AJCC 7th Edition. source: http://www.cancerstaging.org/staging/index.html

The longer cancer cells are allowed to duplicate, the farther away they become in appearance and structure from the cells of the surrounding healthy prostate tissue. This is

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

the aspect of the cancer cells becoming “less or poorly differentiated” than their surrounding normal tissue cells. The departure from any recognizable healthy cell type of cell is graded. Grading gives an indication of how closely the cancer cells resemble normal surrounding prostate tissue when looked at under a microscope. It is also used as an indicator of prognosis. Generally speaking; higher grade Prostate Cancer means a worse prognosis for the patient. Grading of Prostate Cancer is usually done with a system called Gleason grading. Gleason grading provides a score between 2 and 10 which is the result of adding the two most prominent tissue patterns seen by the pathologist when examining the prostate tissue samples from biopsy or surgery under a microscope. A Gleason score of “X” means that the score cannot be determined. Tissue patterns are rated between 1 and 5. For example, pattern 1 means the cancerous cells closely resemble normal prostate tissue. In the most advanced pattern 5 the tissue does not have recognizable glands and, there are often sheets of cells throughout the surrounding tissue. Figure 28 illustrates the cell patterns referred to in the Gleason grading.

Figure 28. Prostate Cancer cell patterns according to Gleason grading system. source: http://en.wikipedia.org/wiki/File:Gleasonscore.jpg

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Survivability Statistics One of the facts that Prostate Cancer patients have to address is that the disease does have an impact on a patient’s survivability. Intervention with treatment is effective for most Prostate Cancer and greatly improves overall patient survivability statistics. Care must be taken when reviewing the statistics associated with survivability. To set things into perspective you should consider the following when looking at any study’s statistics on patient survivability for Prostate Cancer. First, make sure that the statistics you are looking at come from a reputable source. Reputable sources are usually those that publish in refereed medical and biological journals or government sites. Refereed means that there are a panel of experts, associated with the journal, that review the researcher’s submission and makes sure it is scientifically valid before allowing it to be published. If you have doubt as to whether or not you are viewing a reputable source, the easiest thing to do is to call or go to any University or Hospital library and ask their reference desk for an opinion on that source. The size of the sample or actual number of patients that were involved in the study is a significant aspect of the validity of the statistics. Beware of study statistics that have small sample sizes. The idea of statistics is to draw conclusions that would be valid and apply to the Prostate Cancer population as a whole. If you look at the number of patients involved in the data of the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) statistics you see that the number is in the thousands. Generally, the larger the sample size of patients, the more likely the data gives a reliable picture of what to expect overall. Watch out for studies that are conducted over a relatively short period of time. The best studies on any biological or medical related theme are those that last years not weeks. This way the weight of the results can be better seen over the long term. It is the long term that one must consider in survivability. As well, consider that diagnostic method and treatment schemes for PC evolve all the time. Data for long terms studies take a bit of time to gather and compile into a meaningful analysis. Sometimes this takes years. If so, the methods and treatments used 5 or 10 years ago are quite likely improved upon or no longer used at all. So the survivability statistics for present treatment regimens are likely even better than statistics based on timeframes from a half to full decade before the present date. Next, it is important to know what kinds of patients were used in the study. This is called patient profile. If you are 40 years old, athletic, fit, non-smoker and have been operated on for a Stage III Prostate Cancer, it is difficult to have a meaningful comparison to your case if the study you are looking at has an average age was 75, are generally inactive, and 50% of the sample size are smokers. As well, remember the numbers of environmental and genetic variables that usher each patient to the point of being affected by Prostate Cancer are numerous. No one really knows the exact impact of these variables on each patient or how to weigh these differences. So there will always be unaccountable differences between individuals in a study. In short, if you are looking

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

for survivability statistics that are meaningful in your case ideally the closer those study’s patients are to your profile the better and more meaningful the results. Be aware of who paid or funded the study. It is sad to say, but, studies can have a tendency of “propping up” the desired result in favour of the funding body. The funding body justifies spending money on such studies because they are great marketing tools. The researchers skew their research in a way that is supporting to the funding body so that they can be sure to receive continued funding. The bottom line is that independent studies are a rare thing. Almost every researcher has to contend with finding and maintaining continued funding for their work even if they are an academic conducting research under the flag of a university. Studies put out by the government generally have less concern with funding so the published results tend to be less biased in that regard. At the end of most reputable studies is a commentary or column that denotes any “conflict of interest”. In this column the ideal is to see the word “none”. Finally, look at the results of many studies and get a general feel for survivability as it pertains to your profile. This way you get around bias introduced by the wrong patient profile, the influence of funding bodies, evolving treatment schemes and researchers who have ran their statistical analysis using inappropriate statistical method. Remember one thing; statistics of any sort are a tool to give someone a rough idea of probability to support theory, policy and decision making. They likely do not define exactly how your individual response is going to be or what your “chances” are.

Relative Survival Rates for Prostate Cancer The focus on survival rates is done to be able to help answer, among other things, the question of prognosis of a patient. Some say that prognosis is just a fancy word that means the “best guess” as to how a patient will do given their profile, the state of the disease and the proposed treatment regimen. Statistics is the science of probability. Probability of an event happening involves collecting data from a defined population then analyzing the trends in the data with mathematical method. It is not a certainty; but rather a probability that events will play out according to the statistics. Prognosis considers the statistics but is not that simple. Ultimately it is the doctor’s experience, understanding of the facts of your particular case, disease and profile that result in the prognosis. As well, it should be understood that five year survival rates do not address what happens after the five year period. Living for 5 years following diagnosis does not necessarily mean a patient is cured and will never experience PC relapse. A standard 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Sometimes a study will include people with PC who died of other causes, such as heart disease, during the timeframe of the study. The conclusions from a study carry more weight if such mortality (death) is excluded from the end figures on five year survival. This brings us to relative survival rates.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Relative survival rates are quoted because patients that participate in the study sometimes expire due to causes that do not have anything to do with PC. So the researchers take this into consideration and produce what is called a relative survivability quotient so as to remove this unrelated mortality from the data. The statistics below come from a study of the SEER database, looking at United States patients diagnosed with Prostate Cancer between 1975 and 2009. Note that the study involves hundreds of thousands of men with Prostate Cancer; and, the period over which the data was collected is in excess of 30 years. PC mortality (death) has been on a steady, small percentage decline since the early 1990s. The incidence of PC has as well been on a small percentage decrease of approximately 1.9% between 2000 and 2009.61 In review of the SEER results between 2002 and 2008, we find that the average 5 year relative survivability for Prostate Cancer that is local [confined to primary site] is 100%; Regional [spread to regional lymph nodes] is as well 100%; and, Distant [spread to the body] is only 27.8%.62 Table 2 summarizes the 5 year Relative Survival between 2002- 2008 and details the distribution of stages for Prostate Cancer during that period.

Stage

Stage Distribution (%)

Local [confined to primary site ]

Regional [spread to regional lymph nodes]

Distant [spread to the body]

Relative 5-year Survival Rate 100.0% 100.0% 27.8%

Table 2. Relative 5 year survival rate SEER Prostate Cancer All races, Males by stage 2002-2008. source: http://seer.cancer.gov/statfacts/html/prost.html

As you can see, the 5 year relative survival for local and regional PC is as good as it gets. As soon as the PC invades parts of the body other than the regional lymph nodes the 5 year relative survival tumbles significantly to where roughly only 1 in 4 men make it to 5 years. These figures speak to the importance of making sure that Prostate Cancer is caught early and not allowed to progress to advanced stage. After the initial pathology results from biopsy are received a course of action is formed to address the condition either by monitoring or by treatment. In the event of cancer, a number of considerations go into the next step including the PC type; the size of the mass; location of the tumor(s); progression of the disease, your overall state of health, age, preferences, and the medical institution’s resource.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

If surgery is required and the growth is substantial, treatment to reduce the growth may be proposed before surgery. In which case, your next appointment will be with an oncologist. An oncologist is the specialist who deals with treatment specific to your cancer. This may delay the surgery for several months. Alternatively, surgery may be appropriate immediately. In any event, your specialist will discuss the matter with you and if surgery is the next step then the surgeon will request a standard pre-operative work up which usually includes blood and urine analysis, chest X-ray (if not already done), ECG (electro-cardiograph) and an MRI or CT (if not already done or sufficiently current).

ECG (Electrocardiograph) The electrocardiograph (ECG) is given to a patient prior to surgery as a precautionary measure to determine the state and relative health of the patient’s heart. Surgery imposes stresses on the body and if the patient proceeds to surgery with an unknown heart condition it could result in complications and even death. Identifying hidden heart problems in advance allows the surgeon and anaesthesiologist to make the appropriate modifications to their procedure and so avoid any related complications during surgery. If you have not already experienced an ECG it is a totally painless procedure that takes a technician or nurse about 15 minutes to do. You simply lie flat on an examination table and the probes of the ECG are attached to your chest, wrist and ankles with a light adhesive. Some of the new generation machines only require attachment of probes to the chest. Then a recording of your heart beat is sampled and graphed for the cardio specialist to review. That’s it, unless a problem is discovered. In which case, a better understanding of your cardiac condition will have to be had. If a problem is discovered you may have to go through a stress test. The stress test is a cardiac examination designed to assess heart performance during exercise. To do this, probes are connected to the patient and the patient is put through a monitored routine to make the heart “work” harder. Then the results are reviewed by a cardiologist and a determination of your suitability for surgery is made. Occasionally, if a patient’s heart is too weak, the risk of surgery may be too great. If so, then alternative treatment and strategy to address the prostate condition may be made.

Second opinion Sometimes what is being told to you in terms of explanation of your symptoms and condition may seem to not make any sense. Sometimes you may not trust the individual who is delivering the initial opinion because you may not know them or they may not be that experienced or they just don’t seem to be behaving as expected. Maybe you are not comfortable with the methods or equipment being used at a particular facility. Sometimes you may just be grappling with the idea that you are sick and can’t believe it.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Your option is to get a second opinion. Seeking out the opinion of other urological experts can be a valuable exercise, even if you end up staying with the medical staff that you started with. The biggest problem most patients encounter when seeking a second opinion is that they do not know who to ask or how to ask it. Medical specialists are usually referred to by another physician. If you are not happy with the specialist that you have been “directed to” then you can always go back to your referring physician and ask he find someone else for you. Doctors understand the concept of a second opinion and they do understand that it is important that you are comfortable with those who are going to treat you. Be aware that referring doctors tend to use specialists they know of. It is their way of sending you off to where they think your treatment will be satisfactory. Saying you want a second opinion is asking them to rethink their initial recommendation. Nevertheless, do not be shaken from getting a second or third or fourth opinion if that is what is required to satisfy your concerns and make you comfortable. Sometimes the referring physician will ask if you have a particular specialist you would like to be referred to. As such; ask around. You may be surprised the specialists who are in some way linked to network of acquaintances. Know that the medical profession has a tendency to respect the “insight” of their colleagues. One of the first things I was asked when I sought a second opinion was who was the specialist handling my file and what did they say. What followed, however, was a careful review of the imaging and reports in my file and a very calm and professional discussion to support the opinion that the results were inconclusive and that a laparoscopic procedure was appropriate. Also know that most physicians and specialists in a social health system are already having difficulty dealing with their own case load. In short, they simply do not have enough hours in the day. So their administrators have to prioritize the workload. From this, getting an appointment for a second opinion may not be so easy because the administrator may consider that providing second opinions to some other specialist’s patient may not merit disrupting pressing schedule and case load. In a system where you pay for the medical service, those specialists renowned for their work in the field are as well highly in demand. They too usually have a very heavy case load and getting to them for a second opinion in a timely way can be near impossible unless you are in some way connected. All I can say is you must politely insist that you need their insight and assistance. Lastly, in speaking to friends and relatives, I have found that most people uphold the premise that they have to unquestionably trust the health system when it comes to disease and treatment. Patients are not usually in the habit of questioning their doctors. I have heard stories of old school doctors who actually discourage patients from asking questions. This is not acceptable. Sometimes patients are not so well informed as to be asking the right questions. Those patients that have good questions sometimes get a bit

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

intimidated by the fact that they do not necessarily have sufficient command of the medical jargon and techniques to understand the response. My solution to this is to “read on” and get acquainted. Then start believing and insisting that you are the user of a service and, in the case of PC, your life and quality of life depends on timely, well directed and executed medical attention. If that means you have to go to a facility out of your district then seriously consider that option. It could mean the difference between a favorable outcome of treatment or not. One of the things that you must do before you arrange a second opinion is to get your hands on the results of what has been done and diagnosed to date in your file. Make sure these are as complete as possible and include the preliminary pathology reports, CDs or DVDs of any scans or imaging. When you contact the doctor that you are going to use for a second opinion they will often ask that they be faxed your file in advance of any appointment. Make sure that the doctor of second opinion clearly understands the timings of what is being proposed by the medical staff presently handling your case. This way the appointment can hopefully be scheduled in such a way as to afford to you the option of resorting to alternative staff and treatment. After you have discussed your file and received a second opinion the decision now becomes yours to make a choice as to how best to proceed. I suggest that you choose the one that you have the most confidence in and are comfortable with. Consider the treatment, your recovery, and, the impact to your quality of life during and after treatment.

Archives If you have not realized it by now I will tell you that you should be keeping a personal record on your condition. The progress of your condition, schedule and details of treatment can become quite involved over a period of time. It is easy to lose track of what and when things were done, and, what progress was made. If you keep a running record on things you will be able to avoid or minimize the fog that typically blankets a lengthy monitoring or treatment regimen. Prostate Cancer can have lengthy monitoring or treatment regimens that span over many years particularly if recurrency occurs. Even if your treatment regimen is relatively short, you will be monitored for the rest of your life. So it is good to have something to refer to and refresh your memory ten years after surgery if, for example, new medical staff takes over the role of monitoring you. To get a copy of your records you can either ask your doctor’s administrative assistant or, if you are in a hospital or clinic, go to the department of archives and make the request. Both may charge a small administrative fee for the copies. So have some cash on you when you do this. I found it best to make a phone call first and let the administrator know what you need. Then ask for the best time for you to pick it up. If possible, go in person. Otherwise, the request may get “lost in the shuffle” and not be forwarded to you for a long time.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Chapter 3

Surgical Treatment and Therapy

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Surgical prostate procedures are done to address benign and malignant growth. If there is doubt as to the state of disease, the general tact for any kind of mass in the prostate is to biopsy. Then, an analysis of the extracted tissue can be done to determine whether or not cancer cells exist within those tissues. Biopsy procedures are most times scheduled for “Out Patient” surgery. This means that you arrive at the hospital on the day of your surgery, have the procedure done then leave that same day. Local or general anaesthetic will be administered for the procedure and most medical institutions will not release you unless someone is with you to ensure that you are “Okay”. For more complex surgery you will be admitted. Whether or not surgery is appropriate for a particular Prostate Cancer condition is a matter to be discussed between the patient and their doctors. There are times when the cancer is not operable. For these conditions the options may involve Radiotherapy (RT), chemotherapy or combination approaches instead. Treatment facilities have protocols (guidelines) to help determine when a condition in operable or not. This coupled with the specialist’s experience, and, the patient’s or family’s wishes are normally the determinant factors of proceeding with certain surgery or not. Once the surgery has begun the surgeon will use their discretion as to exactly what tissues ought to be removed to achieve the best prognosis for the patient. When surgery is appropriate lymphatic node dissection, resection surgery on the prostate and other organs infected by metastatic PC may be performed. Such surgical procedures may be done as “stand alone” or in combination with regimens of chemotherapy and/or radiotherapy depending on the state of invasiveness. Sometimes the initial surgery has not been done with sufficient margin so additional surgery has to be done at the primary site. Sometimes surgery may be delayed pending shrinkage of tumor tissue by chemotherapy or radiotherapy. If the metastasis is extensive, several surgical sessions may be required. Distant metastasis may require the involvement of other surgical teams who specialize in organs such as the liver, lungs, brain or bone for example. Prostate Cancer is addressed by resectioning (removing) the prostate. This is called a Prostatectomy. There are two types of prostatectomy. One is called the Radical Perineal Prostatectomy (RPP); and, the other is called the Radical Retropubic Prostatectomy (RRP). The RPP was first described in 1905 and does not involve resection of the pelvic lymph nodes. The RRP was first described in 1947 and involves PLND (Pelvic Lymph Node Dissection). This procedure addressed local disease that had made its way to the regional lymph nodes. These days if Prostate Cancer is diagnosed at early stage while it is still localized, the PLND is not mandatory. Instead, there is a better understanding of the risk of lymph node involvement based on a “probability” of Prostate Cancer spread given specific prognostic indicators.63 Such probability is formatted into tables for easy reference and interpretation by the surgeon. These are called Partin tables and depending on the type of treatment (surgical or radiographic) the probable risk from these tables is used to determine whether or not to proceed with the PLND. For example, for an open

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

(large incision) RRP any Partin probability above 3% and the surgeon will typically proceed with a PNLD. For the RPP any Partin probability above 10% and the surgeon typically schedules another operation to perform the PNLD instead of proceeding with that procedure at the same time as the RPP.64 It should be understood that now a days imaging has arrived to the point where we have good understanding of what lymph nodes are first in line to receive the drainage from the prostate (called sentinel lymph nodes) and can sample those to determine the stage of cancer involvement instead of relying on probability tables and procedurally removing pelvic lymphatic tissue based on probability charts. Unfortunately, although sentinel node sample is common surgical practice for breast cancer, colorectal cancer and lung cancer, sentinel node sampling for Prostate Cancer is still in the investigative stage with mainstream medicine withholding approval until more conclusive evidence of its effectiveness is reported. 65 The idea of a surgeon having to still rely on probability charts to make a decision as to whether or not to proceed with a PNLD is, in my view, something less than optimal and follows the same blind approach as does the ongoing use of TRUS guided manually executed multiple core needle biopsy and the prognostic staging that relies on that. Hopefully, known imaging techniques involving 11C-Choline enhancement able to exactly pinpoint Prostate Cancer activity will be considered along with available robotics and non-invasive means to arrive at a more reasonable and effective clinical solution to determine and address lymphatic involvement in the pelvic area using sentinel node sampling. In 1982 better understanding of the neural and venous anatomy in the prostate and pelvic area gave rise to the nerve-sparing technique that yielded better post-operative results for urinary continence (ability to control bladder) and erectile function while limiting the possibility of positive margin. 66 This nerve-sparing technique greatly improves the quality of life aspects for the patient following prostatectomy. Surgical cure only occurs if all of the tumor can be removed. It is reported that approximately 20-30% of men with one or more positive margins following treatment experience relapse of their Prostate Cancer. To improve on the long term disease-free survival for those men considered high risk (i.e. men with very large prostates due to tumor; high Gleason grade; or, high PSA) Neoadjuvant Androgen Deprivation (NAD) therapy is an available option. NAD shrinks hormone dependent tumor which increases confinement of the cancer to the prostate. It also decreases the incidence of positive margins and is theorized to address occult (stealthy/hidden) regional and systemic micrometastasis. It does; however, remain debatable as to the long term success of NAD in being able to improve on overall survivability of those treated for PC. 67 It used to be that the only hormonal treatment for PC was for the patient to undergo orchiectomy (surgical castration or removal of the testicl*s) as part of a strategy to slow PC progression by reducing androgen output. This surgical solution is not reversible. As stated, even with the testicl*s removed the body will still produce

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

testosterone but at a much lower level via the adrenal glands. With that, the PC will eventually continue to grow. These days other options are available for hormone treatment such as chemical castration. These other types of “castration” involve the prolonged prescription of drugs or agents. For chemical castration, testicular production of testosterone restarts when the medication is halted. Also consider that these treatments are expensive. When unavailable or when the failure of alternative hormonal treatment has occurred with advanced hormone sensitive PC, surgical castration is still used. Sometimes surgical castration is as well combined with the other types of hormonal treatment. In any case, beyond the immediate impact to hormone production and the associated effect on slowing Prostate Cancer the result of surgical castration has an enormous impact on the male post-orchiectomy physiology, physical attributes and psyche. Testosterone is the main androgen affected by surgical castration. The largest contribution of it is made by a man’s testes and the loss of normal testosterone levels associated with surgical castration in an adult male affects a number of physiological aspects including but not limited to: - Cognitive (which includes male aggressiveness and libido); - Physical energy; - Characteristic male increased muscle mass and strength; - Bone density; as well as, - Body hair. 68 Note to clarify – cognitive means relating to thought process; physical energy levels can diminish; muscle mass and strength will be reduced and the possibility of gynecomastia (male development of breasts) becomes higher; bone density will diminish and can become problematic with a much higher risk of fractures and osteoporosis; and, body hair will reduce.

It is recognized that cosmetic procedures to restore the testicular area following surgical castration improves a patient’s post-orchiectomy psychosocial adjustment and long term quality of life. In 2004 a five year clinical study released its results regarding the trial of a saline filled testicular implant. The principle investigator P. Turek, M.D. stated that, “The implant can provide improved sense of well-being for patients who receive this prosthesis that is beyond cosmetic surgery.” Testicular implants have been available and performed since 1973; however, complications related to the use of silicone implants resulted in the development and trial of saline filled testicular implants. 69 Testicular prosthetics or implants can sometimes be done immediately and as part of the same session as the orchiectomy or it can be delayed. Delaying will allow more time for the cancer diagnosis and treatment to be carried out before the area has to accommodate cosmetic procedure. From my own experience undergoing chemotherapy following CRC surgery I found that my ability to heal incisions became difficult during that part of treatment. Good ability to heal is necessary to have a successful result from cosmetic procedures. Although the desire to get all of the surgery “over with” as soon as

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

possible is understandable, that will not happen if you are not healing well; or, if ongoing aspects of cancer treatment compromise the cosmetic procedures by requiring more surgery, for example. This is certainly something to consider. Overall, the pros and cons of such reconstructive surgery, its timing and its applicability to your particular case have to be discussed with your surgeon(s).

Surgeon and Surgical Teams Genito-urinary surgeons contending with Prostate Cancer have the particularly difficult task of operating in an area that is buried deep in the pelvis and in close association with bladder, bowel and sexual structure and function. The prostate’s small size; location; architecture; and, how it is knitted to the surrounding lymphatic, urinary, circulatory, reproductive and nervous tissues makes for a complex and easily compromised surgical environment. Even exploratory procedure such as core biopsy can carry real risk in terms of inflicting collateral damage to the area’s structure that can result in substantial and lasting impact on a patient’s quality of life. Clinical experience, precision, thoroughness and finesse can make an enormous difference to the success of your diagnosis, recovery and fight. If they proceed with the wrong surgical option, if their technique is flawed, if they act hastily or without the necessary considerations it can have disastrous effects on your constitution and physical abilities. Do remember; however, that operating on the prostate and pelvic areas does have unavoidable risks, despite the best of present day clinical technique and consideration. All to say make sure your genito-urinary surgeon is very experienced in the techniques being used; make sure they have an excellent record and reputation; and, make sure you are properly assessed and prepared going into the surgery. This will minimize any associated surgical risk. Again, remember that when you are seeking out a surgeon it has to be someone that you are comfortable with. The more experienced the surgeon, the better able they are to perform the procedure properly, and, foresee and address any complications. You can ask them when you have your initial appointment just how many of the procedures being proposed have they done. Ideally, the answer should be hundreds or more. From the first appointment onwards you should expect that your surgeon has a completely professional and calm approach to patient care. Their manner should be methodical and to the point. They should be experienced, organized, and considerate. They should not discourage your questions. Their explanations should be well presented, patiently delivered and understood. They should brief you on the options for your condition, the proposed procedure, the risks, and how the surgery will be modified in the event that complication occurs. If you have been admitted, the morning after surgery you should expect to be visited by one of the surgical team members as they pass by “on rounds”. Doing the rounds is something doctors do to check on their patients’ status. Sometimes the rounds will be done by another member of the surgical team instead of the lead surgeon. This will probably be a junior member of the surgical team such as the chief resident surgeon.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

The chief resident surgeon is a qualified medical doctor who is finishing off their residency (apprenticeship) as a surgeon. The chances are that you will not have met this doctor before your surgery. Apart from checking on how you are doing you can expect that they will give you a thorough brief on what to expect in the period of surgical recovery. It is not unusual for the team anaesthesiologist to stop by to ensure that any pain is being adequately managed as well after the surgery. Barring any complications such as infection, release from the hospital after surgery usually depends on few things. Firstly, the patient has to be able to “get around by their self”. In addition, adequate physiological function that may be disrupted by the surgery has to be regained. As well, the patient has to be able to manage any post-surgical pain. If the patient has not arrived at this minimum state of self-sufficiency, then chances are pretty good they will not be released from the medical facility until they have. Exact length of stay in the hospital after surgery can be clarified when you speak to your surgeon(s) before you have your procedure. Depending on the surgical procedure undergone, patients can be encouraged to start moving around within a day after surgery. The idea is to keep as much strength and mobility as possible by making your muscles and joints move through their range. Expect some pain and discomfort doing this. Generally, the more regularly you exercise the quicker you will recover, and the stronger you will be to commence any additional treatment if required. You will be given instructions on what activity and exercise you can do by the medical staff. Be mindful of these instructions.

Preparation for Surgery A week or two before surgery the patient usually undergoes a standard series of pre-operative work up tests. For outpatient surgery the patient usually arrives two or three hours before the scheduled procedure. If being admitted, then the patient is usually expected to arrive 12 to 24 hours before surgery depending on the medical facility. During this time they will settle into their room, are briefed on the surgery, and then, be physically prepared. If you are only admitted on the morning of your surgery, you will probably be instructed to limit the type of food you take in within 12 hours prior to surgery to juices and broths. General anaesthetic often causes nausea as a short term side effect so having a stomach full of food going into surgery is probably not a good idea. Deep vein thrombosis (DVT) is the formation of blood clots in veins when one remains inactive (usually sitting) for extended periods of time. It is something that can happen even to passengers on long range airline flights if they sit still for too long. Such clots can cause all sorts of complications and even death if they wander through the circulatory system and make their way to the brain or heart. If the proposed procedure is forecasted to last several hours, to minimize the risk of DVT you may be required to put a pair of compression stockings on hours before your surgery. These are basically a pair of really tight nylons without toes called Thromboembolitic Deterrent Sockings (TEDS). The idea is to squeeze your lower limbs to help prevent blood clots from forming in the

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

veins of your legs during and after surgery. These “support hose on steroids” may seem like one more thing to make you feel really silly. Never mind, it is better to feel a bit silly than to contend with clots.

Prostate Surgical Procedure So now it is time for the procedure that will address the abnormal growth in your prostate. This round of surgery is the first and it will determine the stage of your Prostate Cancer and attempt, as much as possible, to remove the bulk of the malignant growth from you. It is normal to be apprehensive as to how all of this will go. The only thing that I can suggest is think positive. The more positive you are, the easier this and anything else to follow will be. Let us discuss with a bit more depth the more common procedures associated with surgery for PC.

Prostatectomy A common treatment option available to low risk and high risk PC patients remains to completely resection the prostate.70 As stated, there are two types of traditional open type prostatectomy. Open procedure means that the surgeon has “hands on” direct access to the prostate through an incision. The Radical Perineal Prostatectomy (RPP) is the first one that we will discuss. The RPP involves removal of the prostate through an incision between the scrotum and the anus. This area is known as the perineum. As much as the patient’s condition will allow, nerve sparing technique is used. If merited by Partin probability above 10%, for example, the surgeon will also access and remove regional lymph nodes via an incision in the lower abdomen (see Figure 29 at left). As you can see the abdominal incision is large resulting in major disruption to abdominal musculature and long recuperation times. If lymphatic dissection is not required the only incision will be that in the perineum for the RPP. The operation takes on average between 2 - 3 1/2 hours and the patient is typically discharged in 2 days with no more complication than any other type of prostatectomy.71 Figure 29 illustrates the traditional abdominal incision and the perineal incision. Length of the abdominal incision may not always be as diagramed. The Radical Retropubic Prostatectomy (RRP) is the same as the RPP in that it removes the prostate in its entirety; however, there is the additional performance of a PLND (Pelvic Lymph Node Dissection) if merited by Partin probability above 3%, for example. As such; it is the more “radical” of the two prostatectomies. Instead of removing the prostate through a perineal incision, the prostate is removed through the abdominal incision that is detailed at the left in Figure 29. The perineal incision is not required.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 29. Incisions for the Radical Perineal Prostatectomy. Left - Abdominal retropubic incision; Right - perineal incision. source: http://www.cancer.gov/dictionary?cdrid=373938 Illustration: ©2005 Terese Winslow, U.S. Govt. has certain rights

The Transurethral Resection of the Prostate (TURP) is used to remove all or part of the tissue from the prostate using a resectoscope. The resectoscope is a surgical instrument that has a viewing scope and a cutting tool. It is inserted via the urethra of the penis to access the prostate. This procedure is sometimes used to address tumor blockage of the urethra before other treatment is done. The prostate is not removed en bloc (in whole) with this procedure. The TURP can be done under either general anesthetic or spinal anesthesia. With the spinal anesthesia the patient remains awake during the procedure and typically feels paralyzed in the lower half of the body when the anesthesia is in effect. The patient stays in the hospital 1-3 days after the procedure and typically is asked to get up and move around after the first day. A catheter will be installed following surgery to allow urine to drain from the bladder. This device will also allow the medical team to prevent clogging by residual bleeding with flushing liquid. The catheter is usually removed 1-3 days after the surgery. 72 One of the post-operative effects of prostatectomy is that about one in five patients experience shortening of the penis by as much as 15%. The reason for this is theorized to involve two factors. Firstly, there is the element of permanent nerve damage that may have occurred during surgery; secondly, it is known that temporary erectile dysfunction can occur for several months after the surgery reported to affect anywhere between 26% – 100% of those who have undergone prostatectomy. This temporary condition basically prevents the penis going through its full range of muscular activity and just like any other muscle not being exercised it will get smaller. Meticulous nerve sparring procedures coupled with penile rehabilitation regimen are the best ways to THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

minimize this effect. In terms of penile rehabilitation options, the Vacuum Erectile Device (VED) seems to be one of the most effective of the solutions according to the literature.73 Figure 30 is an illustration of the transurethral resection of the prostate.

Orchiectomy There are two types of orchiectomy. One is performed via a 4” incision made in the lower abdominal inguinal (just above the groin) area. This takes approximately 45 minutes to perform, usually involves a general anesthetic and an overnight stay at the hospital.74 The other procedure is via an incision in the scrotum. The orchiectomy via scrotal incision can be performed under either local or general anesthesia. Orchiectomy can be unilateral (involving one testes) or bilateral (both testes). Whether done by inguinal or scrotal incision the testes are removed en bloc (in whole)

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

through the access incision. The remaining ducts that were connected to the testes are clamped and sutured. Then the incision is closed. As stated, reconstructive surgery to a restore cosmetic appearance of testes is an option that can be discussed with your surgeon.

Prostate Conserving Surgery (PCS) The details of the anatomical aspects of the prostate including its circulatory, nervous and lymphatic systems are well documented. As well, recent advances in imaging have rendered the ability to specifically view malignant prostate cells.75 In addition, the ability to use real time MRI guidance of precision surgical systems is available and used in prostate surgery. Nerve conserving technique for prostatectomy is also a well-practiced technique; so it can be said that there is an awareness and acceptance of the value of aspects of prostate conserving technique. As such; it would seem that all of the technical ingredients necessary to conduct Prostate Conserving Surgery have arrived. The idea of conserving surgery is to address early stage disease with negative margin so as not to compromise the patient’s survivability while preserving as much as possible the organ and its function. Conservation procedures are commonplace for cancer involving the colorectal complex; the lungs; and, the breast, for example. In the literature, I see techniques that use radiation, cryoablation and High Frequency Ultra Sound in what appears to be prostate conserving approaches; however, it is not clear from the literature if present methods involve the surgical removal of only the tumor portion (with sufficient margin) of organ contained disease and so leaving the better part of the prostate intact. These approaches have varied side effects and some techniques have better outcomes than others which will be discussed.

Laparoscopic Procedure Advancements in manipulable endoscopic optics; miniaturization of surgical tools; computer assisted imaging; radiographic positioning; and, surgical training have all contributed to the use of techniques that provide sound and proven non-invasive surgical procedure in a number of fields addressing cancer. These days, endoscopic technique is at the point where radical prostatectomy is safe and feasible through small, hidden incisions in the area of the lower abdomen. This procedure is known as Laparoscopic Prostatectomy (LP). Just as was the case when endoscopic technique was applied to the treatment of other cancer, the mainstream medical community remains embroiled in debate as to the value of laparoscopic over open procedures. Those in favor of open procedure argue that laparoscopic procedure is costly with prolonged operation times; offers no significant clinical benefit to the patient

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

despite much smaller incisions; has similar profiles for post-operative quality of life result; and, seems to result in more complication and positive margins.76 On the side of laparoscopic technique consider that in the lower abdomen the musculature is multilayered and multidirectional. Figure 31 is a side view illustration of what the abdominal muscles looks like.

Figure 31. Abdominal musculature side view with body on its back. source: http://en.wikipedia.org/wiki/File:Grays_Anatomy_image392.png originator: Henry Gray (1825–1861). Anatomy of the Human Body. 1918

The abdominal muscles contribute substantially to counterbalance exertions on the back; and, they are the focal point for lower and upper body strength and mobility. When the abdomen is breached by large incisions it is severely compromised until it heals; and, it never heals the same as it was before the surgery. As a colorectal cancer patient I underwent laparoscopic surgery instead of the open abdominal procedure. My colon resection involved four fingertip sized incisions with a fifth slightly longer extraction incision all in the lower abdomen. This is a similar laparoscopic strategy to that used to address prostate resection. I can say that these types of incisions not only result in substantially less pain, less discomfort, less blood loss and faster incisional recovery; but also, minimizes the possibility of later abdominal hernias because the 1015 cm (4 - 6”) incision associated with open procedures has been avoided. Figure 32 illustrates the size and positioning of the incisions used for a laparoscopic prostatectomy.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 32. Schematic of port placements during prostatectomy (circles at position 1, 2, 3, and 8). source - http://openi.nlm.nih.gov/detailedresult.php?img=3250319_ymj-53-236-g003&query=pelvic laparoscopy &fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=691&prt= originator: J.H. Jung et al.

Laparoscopic Pelvic Lymph Node Dissection (LPLND) has been performed extensively particularly in the field of gynecology so it is, in fact, quite a common and standardized laparoscopic procedure.77 In terms of Prostate Cancer it is used to exclude high risk patients from non-curative therapy, as well as, to stage high risk patients at the time of laparoscopic prostatectomy.78 LPLND avoids the lengthy incision associated with open PLND by port access incisions that are illustrated in Figure 33.

Figure 33. Laparoscopic Pelvic Lymph Node Dissection port placements. source http://openi.nlm.nih.gov/detailedresult.php?img=2917550_11701_2010_189_Fig1_HTML&query=pelvic laparoscopy &fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=207&prt=

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 34 shows a laparoscopic surgical team at work on a patient.

Figure 34. Surgical team viewing image monitors during laparoscope procedure. source: http://upload.wikimedia.org/wikipedia/commons/c/c3/Laparoscopic_stomach_surgery.jpg originator : http://www.defenselink.mil; VIRIN: 050131-F-1936B-008

Notice that the laparoscopic operation is being done manually with the surgical instrumentation brought through placement port incisions. The lower abdomen is inflated during surgery using carbon dioxide to assist in creating a positive space allowing the surgical team to better view and work on the area of interest. Several large screens display the magnified image being transmitted from the endoscope which is positioned via a navel access. This gives the surgical team an enhanced ability to see minute detail which is critical to nerve preserving procedures and the minimization of post-operative urinary incontinence, bowel incontinence, and erectile dysfunction. As is the case with any kind of surgical procedure, you must ensure your surgeon is familiar with and “well exercised” in any procedure that is going to be done with laparoscopic technique. This way you can ensure the best result and minimize risk of complication. If that means going to a different facility or changing surgeons then do that. I did this when the first surgeon handling my colorectal cancer proposed open procedures. I ended up getting a second opinion and having a laparoscopic procedure done instead by a specialist at another facility. I was in and walked out of that hospital in less than two days having received a colon resection. I had almost no pain; several small incisions in my lower abdomen; and, I healed very fast. Compared to open procedures, it was marvelous!

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Robotic Surgery Surgery is hard work and not only requires expertise but also focus, finesse, precision, physical strength and a set of steady hands. With the successes and regular use of laparoscopic techniques the medical industry has taken the next step in endoscopic surgery by introducing robotic systems to assist the surgical team. The use of robots with hydraulic arms, enhanced optics and integrated computerized control allows the operating surgeons to perform minimally invasive procedure from remote locations (away from the patient) with precision and tirelessness that would otherwise not be attainable. If needed, the surgeons that commence the operation can now be replaced by other surgeons mid-operation with seamless results. This is particularly useful when dealing with lengthy procedures or advanced cancers in other parts of the body perhaps requiring different surgical teams. Figure 35 shows one of these robotic systems. During an operation attending staff stay with the patient to assist the surgeon(s) who perform the procedure(s) at control stations away from the robot.

Figure 35. da Vinci® Robotic surgical system with patient in position under the hydraulic arms equipped with surgical instruments. source : http://openi.nlm.nih.gov/detailedresult.php?img=2628019_ymj-49-891-g002&query=pelvic laparoscopy &fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=559&prt= originator : S.H. Baik

The surgeon’s control station has a comfortable seat; a viewing port to allow the surgeon see the area being operated on; and, controls to manipulate the assorted surgical

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

tools that the robot is configured with. The operating surgeon may be at a control station located near the operating room with the patient or on the other side of the world. Figure 36 shows such a station with the surgeon at work.

Figure 36. da Vinci® robotic surgeon’s console with surgeon at work. source : http://openi.nlm.nih.gov/detailedresult.php?img=2628037_ymj-49-886-g001&query=da vinci&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=8&prt=

originator : Y.T. Kim et al.

Telesurgical technology now allows for experts to conduct or assist in surgery from remote locations. The same applies for the traditional non-robotic laparoscopic surgery. In short, having benefit of high levels of surgical expertise from other facilities to oversee or assist in procedures is now a reality. Techniques to more accurately biopsy the prostate are now being evaluated. So far it would seem that manual manipulation of surgical instrumentation is more efficient in addressing the issues of accurate prostate biopsy than are robotic sampling solutions. The results of MRI guided biopsy were comparable in time and accuracy between manual and robotic biopsy; however, manual set up is considerably less “technically involved” than that of the robotic solution. 79 Figure 37 shows a patient positioned for MRI guided biopsy and the robotic surgical extension that has been designed for biopsy. Restraining straps are used to ensure that the patient’s position remains stable. The time and complexity of the set up imposes obvious discomfort to the patient.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Figure 37. Robotic prostate biopsy with patient and robotic extension in position for MRI guidance. source http://openi.nlm.nih.gov/detailedresult.php?img=2628037_ymj-49-886-g001&query=da vinci&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=8&prt= originator : M.G. Schouten et al.

Surgical Options for Advanced Metastasis In 1889 Stephen Piaget conducted autopsies on 700 women who had died from metastatic breast cancer and formulated the “seed and the soil” hypothesis of cancer metastasis. Essentially this hypothesis states that the seed (cancer cells) has an affinity for specific soil (organs). This theory still stands to the present. Generally, cancer cells migrate to areas where blood and energy supplies are abundant (such as the bones, lungs and liver) OR to places where they are separated from the immune system by physical barrier (such as in the brain). 80 When Prostate Cancer cells migrate or metastasize to other parts of the body they maintain their particular type of microscopic character. So, in the case of PC, no matter where the cancer infects next it still can be identified as Prostate Cancer. As such; it is still referred to as Prostate Cancer even though it may be occupying another organ. This is the same with other cancers as well.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Depending on the type of primary treatment, Prostate Cancer recurrency can occur locally, regionally or distantly. Advanced prostate almost always develops bone metastasis. Metastasis in the bones is usually accompanied with severe bone pain and in many patients the skeleton carries the most significant tumor burden.81 Strategy to address metastasis in the bones or other organs such as the liver depends on a number of factors including patient condition, treatment history to date, tumor size and location, and state of the metastasis in other parts of the body to name a few. The variables, options and risks will be discussed with you by your oncology and surgical team leads. If PC metastasis is found on the liver the cancer may be such that the liver can be surgically resectioned or not, depending on the location and number of lesions or tumors on the liver. The more advanced the cancer in the liver the more painful it becomes. Surgical removal of a part of the liver is called a hepatic resection. RFA or radiofrequency thermal ablation is a non-invasive image guided therapy used to address liver cancer that would otherwise not be amenable to conventional resection. The idea is to guide a RFA probe into the affected tumor using imaging technology to the suspect areas of the cancer. The probe is then energized with alternating current and manipulated in and around the area being treated. This causes necrosis (death of tissue) and thermal desiccation (drying out) of the treated area. The RFA energy effectively “cooks” the tumor.82 Figure 38 below shows the working end of an RFA probe. Notice the ablation “tines” that spread out at the end of the probe. These are retractable to facilitate positioning into the tumor. There is also a center electrode that extends (not shown) when the probe is in use through which an electrical current travels.

Figure 38. Example of an RFA probe. source: http://openi.nlm.nih.gov/detailedresult.php?img=2840607_TOBEJ-4-3_F1&query=Radio Frequency thermal ablation&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=112&prt= originator: I.A. Chang

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

Another treatment that is presently under review is Isolated Liver Perfusion (ILP). This is also referred to as Isolated Hepatic Perfusion and is a highly invasive surgery involving the complete isolation of the liver’s vascular system so as to enable point specific delivery of high drug doses (typically melphalan) to the tumor(s), without a subsequent toxic impact on the rest of the liver. It is reported that this type of treatment is responsible for high response and survival rates.83 Figure 39 shows a simplified diagram of the liver divided into segments based on its circulatory system.

Figure 39. Anterior view of the liver. Hepatic segments (I- VII) with portal venous (PV) branches separated by the hepatic veins (HV). HA is the hepatic artery. source: http://openi.nlm.nih.gov/detailedresult.php?img=2627163_kjr-8-302-g001&query=liver segments&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=5&prt=0 originator : H.Y. Lee et al.

As you can see the extent and complexity of the liver’s circulatory network is formidable and this organ continues to challenge the best efforts of surgeons and oncologists who treat metastasized cancers.

Surgical Risk By professional code of ethics your surgeon has to brief you on the risks and possible side effects of the procedure before the surgery and the patient has to sign a document of consent which states the patient understands the risks and the procedure that

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

they are giving consent to. The list of risks, possible side effects complications vary with the specific procedures being done. Depending on the type of prostate surgery the list may include abscess; sepsis; severe infection; seroma; lymphedema; injury to nearby nerves and muscle structure resulting in erectile dysfunction; bowl or urinary incontinence; bleeding; heart attack; blood clots; and, death. Your surgeon will make it clear that most of these have a very small chance of happening; but, because they can occur, they have to be discussed. General anaesthetic as well has its risks. The longer a patient remains under the influence of a general anaesthetic the greater the risks. This is one of the reasons why surgeons concern themselves with the amount of time a particular operation takes. The risks associated with anaesthetics related to specific prostate procedures can be answered by your anaesthesiologist. You will have an opportunity to speak to this specialist before your surgery. The exact type of anaesthetic you are given depends on the procedure you are having. For operations requiring general anaesthesia, the sedation may be initiated with a drug injected through the cannula. A cannula is a small device that can accept needles that is usually installed on the vein in your wrist, or fore arm or bend of your elbow. Before going into the operating room you will know how long the procedure should take. Typically you will be retrieved in your room by an orderly and wheeled on a gurney up to the operating wing. There you will meet the assisting nurse and anesthesiologist. They will help transfer you to the operating table. Shortly thereafter the anesthesiologist will access the cannula on your wrist and within about ten seconds (or less) you will be “asleep”. I found an overview on the following website that basically answered most of my questions about general anesthesia: http://www.surgeryencyclopedia.com/A-Ce/Anesthesia-General.html The following is my understanding of the practical aspects of general anesthesia in a nutshell. Starting the anaesthetic is known as the "induction". When I was operated on for colorectal cancer I was “induced” through a cannula but it is also possible to induce sleep with anaesthetic gases breathed through a mask. After you are asleep you will be given a mixture of oxygen and anaesthetic gases through a flexible tube put into your windpipe. This part of anaesthetic is known as "maintenance". To control pain during and the first 24 hours after surgery, your anesthetist will inject you with strong painkiller. This is usually done through the cannula while you are still in surgery. During the operation, you will be connected to monitoring systems that give ongoing information to the anesthesiologist. Most countries have the same or similar

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

standards and guidelines for this monitoring. These standards typically address patient oxygenation, ventilation, circulation and body temperature.84 As such; the monitors that are commonly in place during surgery and what they do are: An ECG (electrocardiogram) monitor - Three sticky pads on your chest connect to a monitor which shows the electrical activity of your heart on a TV screen. This shows how fast your heart is beating, and allows the anesthetist to pick up problems such as an irregular heartbeat or signs that the heart is not getting enough oxygen; A BP (Blood Pressure) cuff - This cuff goes round your upper arm. From time to time it will squeeze your arm tight, to find out the pressure of the blood in your arteries. It is important that this is neither too high nor too low. An automatic blood pressure machine usually shows four numbers, the high, average, and low pressures with each heartbeat, and the heart rate; A pulse oximeter - This is a device which goes on a fingertip or earlobe, and measures the amount of oxygen in your blood. It works by detecting a slight change in the blood color from the usual bright pink to blue as the blood oxygen level decreases, long before this change is visible to the naked eye; A temperature monitor - This is an electrical thermometer which checks that you are neither too hot nor too cold; and A carbon dioxide monitor - This measures the amount of carbon dioxide in your breath, which shows that you are breathing adequately. It is connected to the breathing tubes coming from the anaesthetic machine. These days the monitoring machines have integrated alarm systems to signal the anesthesiologist in the event of a patient distress. As well, the anesthesiologist remains with the patient from the time the patient goes to sleep until they are stable in the recovery room.

After the Surgery When the procedure is complete the anaesthetic gases are stopped and the patient begins to wake up. A drug to reverse the effects of any muscle relaxant is administered and the patient is moved to the recovery room where a nurse will provide one-to-one care. The nurse is there to monitor the patient’s heart rate, blood pressure and other vital body functions and make sure the recovery from the anaesthetic goes well. It is possible that you will not recall anything of this time. The anaesthetic “maintenance” tube that was in your throat will usually be removed shortly after you wake up before you are returned to your room. You may not even recall it being removed. I didn’t remember this being removed after my CRC

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

resection. Your throat may feel a bit dry and perhaps a bit sore from having experienced this tube. It is routine to be given oxygen to breathe through a face mask. Instead of a mask you may be given oxygen by a non-invasive assisted pressure (NIV) oxygen line fitted in your nostrils. This looks a bit like a clear tube with a couple of small prongs. The prongs are positioned one in each nostril. Some patients feel nausea after the general anaesthetic but medication is usually given to control the nausea. Once the anesthesiologist is satisfied with the patient progress, the patient is disconnected from the monitors and taken back to their room. After the surgery if you have not had “day surgery”, you will have a time to rest in your room. You will likely not feel too much pain at this point because of the ongoing sedation. It is now that you will see the dressings of your operation, and a number of “lines” leading from an IV (intravenous) rig to you. As well, you can expect to have a catheter for the next week, so as not to disrupt healing and allow for unhindered bladder relief. For those of you who do not know, a catheter is a tube that is inserted via the urethra (plumbing where the urine usually comes out) into the bladder for drainage. It is usually inserted while under the general anaesthetic in preparation for the operation. Don’t even think of pulling it out by yourself because there is a special technique that has to be performed by a trained staff to remove it. Trying to remove it without this medical technique will cause substantial damage to your “parts”, to say nothing of the pain that would ensue. While sedated and in surgery usually not a lot of emphasis is given to the exchange of patient status and progress of the operation to those “in waiting”. This lack of update can make the operation a long and worrisome period, especially if the patient is overdue. It is understandable how the surgical team has its hands full with the operation. Nevertheless, spouses and “significant others” waiting should know that they can ask to be brought up to the recovery room as soon as you are stable. As well, if you ask the nursing staff on the operating floor for an update you are more likely to get one. The very next thing that will happen will probably be a visit by a senior surgical resident, who participated as part of your surgical team. They will be able to tell you how the surgery went and what was discovered. Shortly thereafter the anaesthologist will likely arrive and reconfirm what has already been told to you by the other surgical team member. The anaesthologist is an experienced doctor who has seen many surgeries. They will explain what to expect in terms of function and recovery in the next week or two. You may find that you are attached to a PCA or Patient Controlled Analgesia pump. The anaesthologist will explained was how this pump is configured to administer morphine at your command. If you know anything about opiates, the bag of morphine hanging above your head in the confusion of bags of saline, electrolytes, anti-biotics and vitamins, is probably enough morphine to put the entire ward and staff down for 12 hours or maybe even kill an

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

elephant. Morphine is a) highly addictive, and, b) lethal if too much is taken all at once. The anaesthologist will explain that the PCA Patient Controlled Analgesia pump has a safety mechanism that restricts the delivery of any dosage of morphine that is commanded during a predefined time period. This is called a “lock out” period. In effect, it is not possible to over medicate or overdose. Of course, the lock out period has to be correctly programmed according to the anaesthetic and dosage prescribed, AND, the pump has to actually behave as expected. Despite any concern about having such a thing tapped directly into your circulatory system; and, even you are not experiencing much pain, the chances of you convincing the anaesthologist to disconnect the PCA so soon after surgery are probably very remote. Anaesthologists have a way of being very “pro” sedation when it comes to managing pain. The United States Pharmacopeia (USP) is a body in that country that oversees patient safety. They have a mandate to review anything that has to do with patient care and safety and make recommendations through Quality Reviews to alert patients and practitioners. Quality review #81 details the high rate of medication errors associated with the PCAs. The USP has found that there are some advantages to self-delivery of pain killer for non-critically ill patients. Generally, these pumps have been shown to improve pain management with less sedation and fewer adverse effects. Despite these advantages however, the USP has reported the chance of patient harm increased more than 3½ times over the normal staff assisted delivery of painkiller. According to MEDMARXsm, the United States national database for medication error, the error rate affects approximately 2% of all patients, that’s 1 out of every 50. The most common types of error reported are improper dosage (38.9%) and the incorrect drug being delivered by the PCA (18.4%).85 One of the things about surgery and treatment is that you are going to be exposed to drugs and agents for the first time. One of the standard things for the medical staff to do is to ask you and keep track of those known allergies that have already been discovered. Be aware, morphine does not always produce a “euphoric high” to all patients. There are those who will instead present an immediate allergic reaction. Such a reaction could involve a strong sensation of “tingling” all over the body. Extremities may go numb. Hands and feet may turn blue (cyanic). Vomiting may occur within a minute or two after being administered a dose.86 If you have never experienced a certain agent or drug and you are self-administering via something like a PCA, it is probably not a bad idea to wait until medical staff is nearby before you initiate your first dose. This way, if you have an allergic reaction there is someone there who knows exactly what has happened and so will be able to promptly respond to your reaction. Again, for those patients who have known allergies, it is important that the medical staff is reminded of the allergy anytime new medication is being administered. Before discharge, patients are given the details of their next appointments with the surgeon and laboratory for follow up. The patient’s incision(s) will have been closed with either stitches (which are often dissolvable and do not need to be removed) or staples (metal clips) that are normally removed after 10-14 days. The nurses on the ward can do this, or district nurses if you have already returned home.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

When a patient undergoes an operation it is normal for some blood and fluid to exude from the surgical incision(s), therefore, a drain or tubes may be installed to remove this fluid. This flow will be monitored and the tube will be removed when the flow decreases. The nurse will remove the drain on the ward. These procedures are not painful but can be a little uncomfortable. Patients are made to get up and walk remarkably soon these days. Often, you can expect the day after surgery to be encouraged to do this. Generally, discharge from the hospital occurs after they manage to tolerate an oral diet, when their postoperative discomfort can be controlled with oral pain medication, and when they can get up and move around “reasonably well” on their own.

Infection and Antibiotics The prevention, treatment and control of infection for any surgery are of the utmost importance. Bacteria can infect the patient through sources either internal to the body or externally. Steps to minimize the risk of any infection are a consideration of any surgical option. The following is some information so that you can better understand familiar terms associated with infection. A septic abscess is a pocket or capsule of pus formed by the body’s immune system in response to invading foreign organism or material. Pus occurs when white blood cells called neutrophils attack foreign organisms or material. The neutrophils are phagocytic, meaning that they “eat” or ingest foreign cells. Unfortunately, when neutrophils ingest foreign cells or material they do not survive the meal. The main component of pus is dead neutrophils, but it also consists of live white blood cells, as well as, the invading foreign material or organism(s) and enzymes. As the neutrophils respond in defense, the invading organism or material continues to kill the local cells. As this occurs there is a release of toxins. These toxins trigger an inflammatory response in the tissue giving rise to a swollen, red, sore area that feels unusually warm. Healthy cells near the site of infection eventually form a wall around concentrated areas of pus. This separates the pus and infected area from the healthy tissue, but such encapsulation tends to trick the incoming immune cells and prevents them from attacking any foreign organisms or objects still in the pus. The lancing of an abscess is a procedure used to drain the concentrated area of pus and any remaining foreign organism or material therein. Surgical Site Infections (SSI) for those undergoing open versus laparoscopic robotic surgery is significantly lower for robotic procedures. According to a study in 2011 SSI rates following retropubic radical prostatectomy (RRP) was 4.5% compared to a robotic prostatectomy SSI occurrence of only 0.6%. In addition it was reported that those SSIs associated with robotic prostatectomy involved much less severe infection. 87

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

The use of prophylactic antibiotics in Prostate Cancer surgery has yet to be standardized even though this is a common approach for many other types of surgery. Prophylactic means a measure that is done before something has happened. In a report analysing the effectiveness of prophylactic antibiotics in urological surgeries it was found that shorter durations of prophylactic antibiotics yield lower incidences of SSIs. It is theorized that is due to bacteria developing resistant strains with longer exposure to the same antibiotic.88 Nevertheless, the incidence of urinary post-surgery SSIs is reduced by prophylactic anti-biotics. Since most infections occur well after the Prostate Cancer patient has been discharged from the hospital a discussion regarding the use of prophylactic antibiotics has merit and should be had with your surgeon. Septicaemia is a rare but potentially life-threatening infection in which large amounts of bacteria are present in the blood. It is the result of bacteria spilling over from a known primary infection site, such as an abscess, into the blood and is commonly referred to as “blood poisoning”. The infecting bacteria are carried throughout the body via the circulatory system and Systemic Inflammatory Response Syndrome (SIRS) can result. SIRS is a condition whereby the entire body becomes inflamed. The bacteria strains most commonly responsible for septicaemia include Escherichia coli (E. coli), Pneumococcus, Klebsiella, Pseudomonas, Staphylococcus and Streptococcus. 89 For the patient, the onset of septicemia usually begins with fever and chills. Profuse sweating may occur. As the fever becomes more intense the patient’s heart rate and respiratory rate may increase. At this point, the patient will likely feel very ill and weak. The skin can become very pale and the person may exhibit petechiae. Petechiae are tiny (1-2 mm in size) red or purple spots on the skin. These are the result of minor hemorrhaging. As the condition worsens the patient’s blood pressure starts to fall and they may lapse into unconsciousness. If the blood pressure is allowed to fall sufficiently it could cause organ failure. This is called “septic shock” and can be fatal. Septicaemia is treated with intravenous (IV) antibiotics. Quick treatment is essential if the patient is to survive. Typically the attending physician will start antibiotic treatment before the test results that identify the bacteria strain come back from the laboratory. In this case, topical (broad spectrum) anti-biotics are normally used until the lab has identified the particular bacteria causing the septicaemia. Then the antibiotic treatment is altered to eradicate those particular bacteria. Additional infection management options depend on the cause of the infection and the presence of complications. These may include the introduction of IV fluids and drugs to maintain or boost blood pressure; surgical removal or drainage of the primary infection site; and/or removal of the foreign material or objects such as a catheter.90 Infection following surgery can be related to a number of factors. These can be specific to the patient, the surgical environment, an institution’s standard operating procedures (SOPs) pertaining to prophylactic infection management, or, the administering of drugs and radiotherapy for continued cancer treatment. In the patient list of factors, old age, malignancy, malnutrition, obesity and the harbouring of other disease such as diabetes have all been implicated in higher susceptibility to infection. In

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

terms of the surgical environment, contamination, the management of the wound after contamination, prolonged surgery in excess of 2 hours, blood loss requiring transfusion, and the use of “open” drains to remove fluids have, as well, been linked to higher infection rates. Researchers have also found that if a patient has surgery towards the end of the day’s surgical list, as opposed to early on in the day, it makes them substantially more susceptible to infection.91 In this regard it seems better to be scheduled in the operating room in an early morning slot. One of the side effects of chemotherapy, in a conventional sense, is that it impacts on the production of blood components. This reduction in the white and red cells and platelet production compromises the body’s immuno-response, ability to transport oxygen, and ability to heal. The result is that the patient is substantially more susceptible to infection from any invading bacteria, fungus or virus. The more extended the regimen of chemotherapy, the greater its impact on the blood components. Normal white cell count in humans is between 4300 to 10,800 cells per mm3.92 It is not unusual to see a white cell count below 4000 cells per mm3 half way through a 12 session regimen of chemotherapy. As stated, neutrophils are white blood cells that defend against foreign organism and material invasion. Normally they comprise approximately 60 to 70% of all your white blood cells. With this substantial reduction in white blood cell count, there is a corresponding reduction in the body’s immuno-response. The range of Absolute Neutrophil Count (ANC) is roughly between 1,500 and 7,500 cells per mm3. If the patient’s neutrophil count drops below 1500 cells per mm3 they are considered neutropenic.93 Your hospital will have “protocols” or guidelines of policy stating when treatments can proceed or not. In the case of low neutrophil count, for example, chemotherapy may be delayed until the count recovers to above 1500 cells/mm3. This is what happened to me when I was undergoing chemotherapy for CRC. The scientific name for red blood cells is erythrocytes. The bone marrow produces about 4 -5 billion red cells every hour in an adult human. Red blood cells are involved in the transportation of oxygen from the lungs to the muscles, tissues and organs. They do this with the help of a protein called haemoglobin. The haemoglobin can bind with a number of gases including oxygen and carbon dioxide. After the red blood cells have delivered oxygen they transport carbon dioxide waste from that same area and deliver it back to the lungs through the veins. The carbon dioxide is then released or expelled through the lungs. A red cell only lasts about 120 days and then it is removed from service by the spleen.94 During chemotherapy the production of red blood cells usually diminishes too. The result is that the patient may experience general fatigue. I found that the further into my chemotherapy regimen I was, the more tired I became. If the patient is tired and feeling without energy it makes them susceptible to invasion from foreign organisms. I know that when I am tired it affects morale as well. Morale is critical to the patient’s “will to fight”. The solution is to rest and intake more foods rich in iron such as red meat and dark green vegetables. This will provide additional material to build red blood cells

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

100

during the time between chemotherapy sessions. I found that, in my case, maintaining an exercise regimen helped a lot in alleviating the feeling of fatigue. Platelets play a major role in the body’s ability to stop bleeding and heal. They are capable of “filling in” small gaps that develop in the circulatory system. Platelets can also form “plugs” in response to vessel injury. In addition, they secrete growth factors to stimulate healing after injury.95 Normal platelet count in adult humans generally range between 150 000 to 450 000 platelets per mm3. Thrombocytopenia is a condition where the patient has a reduced platelet count. 96 Determining the exact count of platelets is not so straight forward. Platelets in a blood sample have a tendency of decreasing rapidly with time. In effect, delays in analysis of the blood sample can result in a report of low platelet count when, in fact, the platelet count is much higher. What I noticed was that during my chemotherapy treatment my usual ability to heal from cuts and abrasions in a couple of days turned into weeks as my platelet count fell below the lower bounds of normal limit. Open sores and prolonged periods without healing make the body vulnerable to infection from any source. Radiotherapy (RT) will impact any cell in its delivery path. A week long course of RT may not produce any obvious side effects in terms of infection; however, if the RT course is sustained over a four week period for example, or, coupled with chemotherapy, it can have an impact on the patient’s ability to fight off infection for the same reasons as does sustained chemotherapy. As stated, one of the problems with infection is that it often strikes a patient after they have left the hospital. Normally patients who have had surgery feel a bit better every day. If suddenly you start feeling worse it could mean that you are harboring infection. As such; it is important for the patient to recognize the signs of infection. Be aware that you may only have one of the symptoms listed below. If you suspect infection take immediate action by calling your contact nurse or overseeing physician. Be prepared to be able to tell them a description of your symptoms, your temperature and pulse rate. Do this before you have taken any aspirin or “over the counter” medication that would reduce the fever. The signs of infection include but are not restricted to:     

Feeling of being tired and without energy (Malaise); Fever in excess of 38 degrees Celsius (101 Fahrenheit); Increased pain around the incision; Redness around an incision; Swelling/hardening on or near the incision or post-surgical port or drainage tube(s);  Foul smelling pus or discharge from the incision.97

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

101

Treatment of infection varies depending on the area of the body and the degree of infection. The more common medications to treat infection include penicillin, cephalosporin, tetracycline, aminoglycosides, macrolides, chloramphenicol, ivermectin, rifamycins, polymyxin, and bacitracin, for example.98 Antibiotics have varied delivery strategies and depending on the medical protocol may be given by mouth, injection or IV. In more severe cases the patient may have to be admitted to the hospital. If the patient is undergoing chemotherapy or RT the oncologist may order that the regimen be delayed until white blood levels have returned to normal and the infection is gone. Prevention is “key” and there are a number of things that a post-surgery patient can do to minimize the risk of infection. Common sense and good personal hygiene must prevail. The number one behavior that must occur is that the patient must wash their hands more frequently and keep them away from the face and mouth or the incision(s). This is especially important after having been out in public areas or using the bathroom, and before eating. Keeping the assorted incisions clean until healed with regular changes to dressing is a must. This can be arranged with the patient’s nurse or physician. Be aware, washing if not done correctly, can actually “stir up” bacteria under surface skin plates and increase the number of bacteria on the washed surface. This is one of the reasons why surgeons wear gloves during surgery. Additionally, stay away from crowds or individuals where colds and flu are an issue. Clinics and hospitals are full of runny noses and coughing, so it is best to arrange a set time to see the doctor rather than just showing up and sitting for hours in a waiting room. Do not receive any vaccination (including flu shot) unless it has been approved by your physician or oncologist. 99 Finally, if you are neutropenic you have to be especially vigilant and consider not eating things that are uncooked or unpasteurized until the count recovers into the normal range.100 On the topic of spillage, healthy tissue can become contaminated with cancer cells if the malignant tissue is not properly handled and contained during surgical removal. Telltale signs of spillage can be a line or grouping of small “wart–like” recurrent tumors on the skin surface around the extraction incision scar or in the underlying tissue depending where the contamination occurred. In the case of recurrent tumors on the skin, they may be visible within several weeks after the initial surgery. A vigilant eye should be kept on the healing process and incisions for the first several months and any irregularities reported to your doctor immediately. I had a couple of small bumps appear near my extraction incision after about a month. It turns out they were the result of a buried suture that had somehow not been removed. After it was removed everything was fine. So don’t jump to conclusions if you see a couple of small bumps. One of the effects of surgery is the fact that the tissues surrounding the incision will be swollen for days or several weeks after. This is in part a result of fluids and blood leaking from capillaries and damaged tissues in the area. Swelling can restrict

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

102

movement, slow recovery and aggravate or cause pain. One solution is the use of ice to reduce swelling. Sports physiotherapy often makes use of icing as a way to treat inflammation and pain associated with acute and chronic injury. Typically very large bags of ice cubes are applied on the affected area, held loosely into position by wrapped elastic bandage or towel, and left for approximately 20 minutes or until the area feels somewhat numb. Then the ice is removed. Repeating this procedure four times a day during the healing period can help with recovery. Care must be taken not to wet or contaminate the incision or the dressing during icing. Ice “double wrapped” in plastic bags should keep any leakage contained. Ice cubes are used because they afford a degree of flexibility between the cooling agent (ice) and the injured surface that may be tender. Hard plastic “ice packs” designed for cooling food and beverage usually fail to make adequate contact with the affected surface, and they hurt so they are really not that useful. Icing may be started shortly after surgery with your physician’s permission. Just ask your floor nurse to prepare a bag of ice for you and to bring a couple of towels along with it. Be aware that icing can reduce blood flow by temporarily “shrinking” vessels in the iced area. As such; it is especially important that you consult your physician and/or physiotherapist to ensure the appropriateness of icing for your post-surgical condition and use correct technique.

Post-Operative Condition and Rehabilitation Exercise can be a valuable assistance in recuperating lost range of motion, regaining strength and reducing pain after the trauma of any surgery. Apart from the patient having to regain abdominal and/or perineal integrity from open procedures, the prostatectomy is associated with a number of other upsets that can last for years the likes of which may respond to a well-directed and followed exercise regimen. Erectile dysfunction; urinary incontinence; and, bowel incontinence are some of the afflictions that exercise regimen have been tailored to address following prostatectomy. Initially exercise should be done under supervision. One of the members of your treatment team will be a physiotherapist. They are typically assigned to you before your surgery and will brief you on post-surgical breathing exercises to assist in your recovery. After the surgery they will be involved in the regimen to assist you in regaining strength; range of motion and functionality. It has been reported that those who undergo prostatectomy seem unaware of its repercussions and so have false expectations of how much of their former functionality will be regained. The known shortcomings from prostatectomy will be the inability to ejacul*te or produce sperm. org*sm dysfunction is possible. For those capable of org*sm, a number of men may experience pain and urinary incontinence with org*sm. As well, Peyronie’s disease may develop within 3 years of the operation.101 In addition; it may take upwards of two years to regain ability to experience a normal erection. 102

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

103

Note to clarify - Peryonie’s disease is a connective tissue disorder where scar tissue forms in the thick sheath of tissue surrounding the corpora cavernosus (see Figure 5) causing pain, erectile dysfunction, indentation, loss of penile girth and shortening.

In any event, the key is patience, consistency in doing the regimen, and persistence. Sometimes pain and embarrassment will have to be “worked” thorough in order to have improvement. So you can expect to be guided into routine that is not always comfortable. According to an overview presented in the 2012 Annual Meeting of the Urological Association of Physicians Assistants, the largest complaint from those who have undergone radical prostatectomy is “sexual bother” which includes urinary incontinence (especially during org*sm); erectile dysfunction; and bowel incontinence. The data indicates that the overall rates of these afflictions are not affected by rehabilitation regimens; however, the timeframe for those who will be restored to postoperative maximum functionality is much shorter if rehabilitation is followed. Additionally, it has been reported that penile rehabilitation minimizes long term penile shrinkage. The secondary benefits are that sexual relations are improved; which in turn, eases the burden of sexual related upset and stress on significant relationships. 103 The following are some considerations and examples of what you can expect to encounter in post-operative Prostate Cancer rehabilitation program: There are several types of Pelvic Floor Muscle Training (PFMT) programs. The idea is to consciously contract the pelvic muscles, and, in so doing develop awareness, strength and control over traumatized or unexercised pelvic, rectal and urinary muscles. Such training includes: - Exercises to strengthen pelvic floor muscles [Kegels]; - Physiotherapy with biofeedback; and, - Physiotherapy with rectal electrical stimulation.104 Notes to clarifyKegels are an exercise that is used to promote urinary sphincter control similar to how someone would arrest urinary stream mid-flow. There are two sphincters associated with the urinary tract. One is at the base of the bladder; the other is at the apex of the prostate (i.e. just after the prostate on the way to the penis); Biofeedback involves the uses of small devices (sometimes handheld) to cue on and signal subtle body changes (like skin conductivity, for example) allowing a person to become aware of their ability to control what are normally automatic body mechanisms and response; Rectal electrical stimulation is used to train and develop the rectal muscles using a low energy electrical current. The device emits an adjustable electro-pulse which is sustained for several seconds and causes the rectal muscles to contract and release.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

104

Regarding Penal rehabilitation the goals are to promote early return of erection; improve cavernous muscle oxygenation (muscles have to have oxygen to function); help reduce fibrosis (formation of excessive connective tissue) and apoptosis (cell death); and, minimize loss of penile size (length and girth). 105 Regimens and rehabilitation strategy vary greatly between medical facilities since there is really no standard as to the content or timings. In addition, individual patients have different profiles and conditions so regimens have to be flexible enough to get results. The following is an example of a proposed rehabilitation strategy: 2 - 4 weeks prior to surgery - Assessment questionnaires; - ED risk Assessment; - Patient/Partner counselling; - Commencement of prophylactic therapy with PDE5s. Note to clarify – PDE5s stands for phosphodiesterase-5 inhibitor therapy. PDE5 therapy involves taking oral agents such as sildenafil citrate (Viagra®) which is one of a number of sildenafil citrate agents used to treat post-prostatectomy nerve sparing ED.

10 - 14 days after surgery -Foley catheter is removed; - Medical therapy involving oral medication of 2g/day L-Arginine; nightly PDE5; IUA; and, vacuum erection device (VED) therapy 20 minutes/day. Notes to clarify – L-Arginine is one of the most common amino acids. It is a precursor to the formation of nitric monoxide, which is a chemical made in our body that, among other things, is involved in erection response; IUA stands for Intra-Urethral Alprostadil. Medicated Urethral System for Erection (Muse®) is a term sometimes used as well. This is an “erection on demand” drug that involves the insertion of a suppository into the urethral opening of the penis. When the drug is absorbed it promotes the production of a chemical called cAMP which can affect better blood flow for an erection. It is reported that this prescription increases risk of penile or urethral burning for those who have had radical prostatectomy.

One month after surgery - Continued medical therapy as directed; - Start using PDE5s prior to intercourse; - IUA titration; - Combination therapy prior to intercourse (PDE + IUA, PDE +VED).

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

105

Note to clarify – IUA titration means increasing the dose.

Three months after surgery - possible penile injection therapy 2-3 tmes per week if previous meds not effective - re-challenge with PDE5s.106 Notes to clarify – Penile injection therapy involves the direct injection via a needle of either a single or combination of erectile enhancement drugs into the side of the penis. Re-challenge with PDE5s means to try the oral medication again.

Post-Operative Pathology Report After surgery your pathology report will be delivered to your surgeon. When this happens you can expect to be contacted by that surgeon and they will tell you the results. It is probably a good idea to take a tape recorder because this can be a time of upset and it may be difficult to maintain focus and really understand or remember what is being said. Make it clear to your surgeon that you want to have detailed explanation of everything on the report. They, as well, will usually give an overview with the bottom line options for any further treatment and prognosis. Most often a copy of the report will not be given to the patient unless it is specifically requested. It is a good idea for you to keep a copy of this report with your personal records. You many not completely understand the report at the time of receiving it, but a little research will usually make things more clear as to exactly what your condition is. The report will detail exactly what was removed, where the tissues were located, and, the state of those tissues. It will also describe in plain language the abnormal tissue and in which part of the abnormal tissue the cancer was. Also in plain language will be a comment as to whether or not the cancer had developed or metastasized beyond the prostate and the location of invasiveness if discovered during the surgery. If you have cancer the stage of the disease can be extrapolated with your specialist from the pathological details in the report. Don’t expect your surgeon to “sugar coat” the findings. They are usually straight forward as to what the next step is and that may be a referral to the oncologist depending on the stage of your condition. The pace of this referral and initial appointment is usually fast. You can expect to be set up for an appointment within 7 to 10 days or sooner, if not then find out why.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

106

Lymphedema Secondary lymphedema is a condition that causes tissue to swell because the fluid balancing aspect of the lymphatic system has been disrupted, in the case of PC treatment due to PLND (Pelvic Lymph Node Dissection) OR damage to the lymphatic tissues as a result of radiotherapy. Swelling occurs because the drainage of lymph cannot keep up with the demand. There is no cure for lymphedema; however, it can be managed. Figure 40 shows a picture of a man who has developed lymphedema in the lower extremities. It is an example of what can occur if the condition is not properly managed.

Figure 40 – Lymphedema in lower extremities. source: http://openi.nlm.nih.gov/detailedresult.php?img=2962263_ijmsv07p0353g02&query=Lymphedema&fields =all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos=33&prt= originator - E.K. Symvoulakis et al

Treatment for lymphedema seeks ways to help the drainage of the accumulated lymphatic fluids. Keeping one’s weight more to the ideal, compression devices, bandaging, special drainage techniques using massage therapy, exercise, elevated resting positions, and, physical therapy are all strategies used to help move the excess lymphatic fluid into the circulatory system where they can be naturally excreted from the body. When the pelvic lymphatics undergo dissection or damage the risk is that lymphedema will occur in the trunk, pelvic area or lower extremities over time. This condition can be quite painful and involve substantial swelling and complication. As

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

107

such; it is important to keep a close eye on swelling and report this immediately to your physician. Long-term Surgical Outcome Data was analyzed on 844 Prostate Cancer patients diagnosed with early Prostate Cancer from 1989 through 1998 in Geneva, Switzerland. Majority treatments included prostatectomy; radiotherapy; watchful waiting; and, hormone therapy. It was reported that, for the period in question, surgery offered the best chance of long term survival (10 year relative survival) in particular for patients younger than 70 years old and patients with poorly differentiated tumors. It was found that men who opted for Prostate Cancer treatment with EBRT (External Beam Radio Therapy) instead of surgery were 2.3 times more likely to die of Prostate Cancer in the ten year period following treatment. Men who opted for “watchful waiting” were 2.0 times more likely to die of Prostate Cancer in the period up to ten years after diagnosis than those who had surgery. 107 According to interviews with the overseeing researchers of a follow up 2007 study, it is proposed that this increased survivability for those who had surgery is related to more thoroughly addressing the bulk of the localized disease; and/or, the fact that patients who had undergone surgery had more treatment options to address recurrency than the others who did not have surgery.108

Spousal and family reaction to Hard Times So by now you have gone through what feels like a gauntlet of diagnostic test and procedure for Prostate Cancer. By the time I was ready for chemotherapy with my cancer I felt like I had been pricked, probed, squeezed, stabbed, scanned, cut, snipped, sutured, stapled, magnetized and irradiated all over a part of my body that I really preferred not to have “poised to the breeze and attentions” of a plethora of medical staff and stranger. I felt like my dignity was considered completely irrelevant. Then I started considering the facts of my advanced condition along with the eerie realization that I was headed for even more vast “uncharted waters”. At that point I started looking back and thinking about wrong turns and all the “if onlys” that contributed to my condition. I thought, if only the detection technology could have been better; if only I was a little better informed; if only I had exercised more or ate better or knew about the relative whose same condition predated mine. But all of that did not matter. Of course, you don’t want to repeat the known mistakes that put you where you are, but what matters is to look forward to what can be done to help fight. At this point one of the things you should consider is making sure you have the support of those that matter around you. Cancer, in any form, is a battle that you must win. To win a battle you have to first know your enemy. Then you must fight with focus, resolve and what resource you have. I will tell you that it is a lot easier if you have someone to talk to “now and then” that matters. Making sense out of what you are going through and coming to terms with it may not be so easy initially, but you will. THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

108

If you have a spouse or a mate, bring them close. Hold them and let them know that you intend on bouncing through the battle. They may want to drift, because it is a natural thing to do in order to cope, but don’t let them. Tell them you need their energy when yours is waning. Tell them you need them to hold your hand. Tell them you need something to look forward to every day; but understand, watching someone you love and care for go through such a fight is not easy. Neither is coming to terms with it. So stand your ground and make the effort to address the issues instead of withdrawing. We all fight in different ways. How, when and who in your circle you inform will be yours to decide. At least consider informing the ones that make you feel good and laugh a little. If you speak to any floor nurse in oncology they will tell you that attitude and will are major factors in how successfully a patient fights. It is important to keep the most positive of attitudes. It is important to want to make your way back to good health. One more thing, if you still smoke, STOP NOW! Other than the common sense aspect of improving the overall climate for your recuperation, it has long since been reported from a study involving 47,781 men that smoking seems unrelated to the incidence of Prostate Cancer; however, actively smoking does have a significant impact on the occurrence of fatal Prostate Cancer. 109

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

109

Chapter 4

Non-Surgical Treatment and Therapy

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

110

At any point following diagnosis of Prostate Cancer a patient has options. Initial treatments do not always involve surgery. The same can be said for treatment of advanced disease. Let us examine some of the non-surgical options for PC treatment. As stated, surgical option is used for low, medium, high risk and advanced disease given the appropriate patient profile and condition. Clinically approved alternative management options include Active Surveillance; External Beam Radiotherapy (EBRT); Branchytherapy; Cryosurgery; High Intensity Focused Ultrasound (HIFU); and, Chemotherapy. Active Surveillance is used for those patients who have low risk disease that is considered to be indolent (lazy) PC. This is basically a “wait and see” approach that favors Quality of Life without treatment over immediate intervention. Repeat biopsies (every one or two years); annual DREs; and, PSA testing (every 3-6 months) make up the bulk of the surveillance protocol. The understanding is that if surveillance shows unacceptable progression then intervention options are available such as prostatectomy, radiation therapy or hormonal therapy, for example. 110 One of the problems of this approach is mistakenly categorizing PC that actually poses higher risk or is more aggressive than expected. External Beam Radiotherapy (EBRT) is used for low, intermediate and high risk disease, as well as, advanced condition.111 The idea is to use directed beams of radiation to kill the cancer cells. The problem with this therapy involves collateral damage to all cells through which the radiation beams pass; long term side effects of radiation treatment; and, not being able to confirm what degree of margin was actually attained following the therapy. Branchytherapy can be used to address low, intermediate and high risk patients. This strategy involves the delivery of radiation either near or in the PC tumor using a segment of radioactive wire (typically Iridium) inserted through a guidance needle that is positioned in the desired area. Such delivery “seeds” are usually permanently implanted with low dose radiation emission. Alternatively they can be temporarily implanted then removed after several minutes having delivered a high dosage of radiation to the area. Guidance of the needle/wire complex is usually done using IMRT. Protocols can call for either stand-alone or combination therapies used in conjunction with branchytherapy. 112 Cryosurgery is the solution that involves killing cancer cells using extreme cold. This is not a common treatment and its relative non-use in the urological field makes it difficult to know exactly how effective it is or not. The technique is to position one or more probes in the suspect area via perineal access using radio-guidance such as TRUS. These days argon gas delivery is possible so the probe is sharp enough for direct insertion to the area. The argon gas delivers temperatures of -187 degrees Celsius (- 304 degrees Fahrenheit) to the tumor. This cryo-albilation is then followed by warming helium to neutralize the freezing. 113 Focused Ultrasound (HIFU) is a trans-rectal procedure used to treat localized disease on patients that are not suitable candidates for radical surgery. This is a

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

111

treatment option that is repeatable. It delivers a brief (less than one second) high energy heat charge to the suspect area causing rapid coagulation necrosis (death by thickening of the liquid components) of the targeted tissues without causing damage to surrounding tissue.114 According to one of the formative researchers of HIFU, H. Ahmed, this is a treatment that occupies the middle ground between active surveillance and radical surgery offering non-invasive day case treatment while substantially reducing the side effects associated with traditional PC treatment options.115 In a study involving 172 patients with local PC treated by HIFU, no evidence of disease was reported for 159 of the 172 patients after one treatment.116 The following is an example of the management options for the assorted categories of PC. The specifics of your facility’s management options may vary from this as there is no common set of PC management options. Low risk disease management options Active surveillance; External beam radiotherapy (EBRT); Low does rate (LDR) brachytherapy; Cryosurgery; High Intensity Focused Ultrasound (HIFU). Intermediate Risk disease management options EBRT; Brachytherapy - LDR (low dose radiation) - HDR (high dose radiation); Cryosurgery. High Risk disease management options EBRT + Androgen Deprivation Therapy (ADT); Androgen Deprivation Therapy (ADT). Advanced disease management options Radiation therapy. Stage T1-4, N1-3, M+ Hormone Sensitive Disease management options Castration is the preferred treatment. Non-surgical castration strategies include: Medical castration with LHRH analogue; or Single agent anti-androgens.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

112

Stage M+ Castrate Resistant disease management options Palliative radiotherapy; Strontium 89; Palliative chemotherapy 1st line Docetaxel ; 2nd line Mitoxantrone; and, Bisphosphonate therapy.117 To oversee and implement your PC treatment you will be assigned members from the Department of Oncology. Here is where your cancer will be reviewed and addressed by the specialists in the field of cancer. Their intent will be to either cure, if possible, or manage the cancer so that it progresses more slowly and you live longer with a reasonable quality of life. In any case, to do this your team will be a concert of specialists in oncology, pharmacology, surgery, radiology, nutrition, physiology and psychology. They will tailor a treatment regimen depending on your age, size, stage, affected organs, the success of your initial surgery or previous treatment(s), your overall mental and physical condition, and, their institution’s resource and programs. If you reside in a country where there is no social health system, your ability to pay will also impact on the measure and availability of treatment options. PC treatment can be very expensive. What most impressed me as a patient when I entered my hospital’s Oncology ward was the overwhelming sense of calmness and respect that prevailed over the entire area. The waiting room was not crowded with patients who had to wait for hours before being seen. There were no loud speaker announcements calling patients into examination rooms. The staff dealt with me “one to one” in a kind and informative way. My mate came with me, and we looked around during our brief wait and saw patients afflicted with cancer. Some were alone, most were not. There were those who looked frail and ill and, there were others like myself, who seemed oddly out of place and in apparent good health. Everything was very ordered. The patients, old, young and in between, came and went “with minimal delay”, without event.

Oncologists and Oncology Staff An oncologist is a physician who studies and treats cancer. Their field is a bombardment of information, research, practical application, and, an endless line of patients hosting disease that can reach into and confound every conceivable aspect and functionality of the human body. Oncologists witness the “known and unknowns” of cancer every day and are there to address these in the best and most effective way possible. In your first appointment with the oncologist you can expect to be briefed on your condition. This doctor will discuss your pathology report and the options of treatment for your Prostate Cancer. They will also answer any questions you have. If you are unsure as to how best to proceed after this, you can ask them for another appointment before you

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

113

make a commitment to further treatment. In the interim, you will have time to absorb the information that you have just been given, research further if necessary, and, decide what you would like to do. As well, a second or third opinion on the options of treatment can be sought from oncologists in other institutions. After my first appointment I was really not at all sure of the options. I had already gone through surgery and was told I required adjuvant (post-surgical) chemotherapy. I was not in any way familiar with the proposed drugs to be used in chemotherapy, methods of delivery and side effects. I was not even so sure as to whether or not a different approach to treatment was in order. So I asked for a second appointment and a brief delay so I could research the options of treatment that were given to me by my oncologist. I came back for next appointment about a week later better informed and with more precise concerns. After that I went ahead with chemotherapy. Although your surgical team may be optimistic that they had managed to remove all the infected tissues, there remains the nagging fact that, at a cellular level, it is impossible with present technology to say exactly if any cancer cells escaped into the body, or where or how many of those cancer cells remain. Adjuvant chemotherapy or radiation is a way to address any cancer that is either known or has a high probability of having exceeded the bounds of the prostate. This way the chances of “recurrency” are minimized. Adjuvant therapy is usually started within 6 weeks after surgery. This is because the effectiveness of treatment to prevent recurrency has been founded on clinical trials where treatment was started it during that period. Any later and no one is really sure of how effective it will be. The timeframe for adjuvant treatments varies with the patient profile and the treatment type and regimen. For example, in metastic, hormone sensitive PC patients will undergo Androgen Deprivation Therapy (ADT) as part of standard management. In some cases continuous and intermittent ADT are both considered viable options.118 This means that ADT can go on for years. For those Prostate Cancer patients that are considering Prostate Cancer at a microscopic level [and everyone should] you should be aware that the general trend for mainstream medicine in the treatment of Prostate Cancer thus far does not seem to recognize or apply measures that address Prostate Cancer on a microscopic level until there is clear indication of primary treatment failure. This indication is usually in the form of rising PSA following surgery or radiation therapy. Further, it has been pointed out that cueing on rising PSA after primary treatment inevitably allows metastic PC recurrence at a very high rate (as high as 70% at the 10 year mark) with certain mortality from that recurrence if the patient does not expire from other unrelated cause first.119 These facts are some of the most compelling reasons to screen for early stage disease and intervene in a timely way so that the patient has the best possible chance of cure given the shortcomings that present treatment protocols have in addressing the obvious aspects of microscopic invasion and spread of PC.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

114

So that you know, there are basically two types of cancer therapy. These are neoadjuvant and adjuvant. Neoadjuvant therapy is given before surgery to make the cancer tumor or diffuse spread more amenable to surgery by reducing its size. Radiation therapy or combinations of radiation therapy and chemotherapy can be used to do this. Adjuvant therapy is given after surgery and is used to increase survivability and reduce the risk or recurrency. Primary treatment refers to what was first used to address known cancer. Cancer treatment is either curative or palliative. Curative means that the treatment intention is to cure. Palliative means the treatment is being given to slow the progression of the cancer or improve the patient’s quality of life as the cancer proceeds. There are a number of different strategies of how to treat Prostate Cancer. The treatment regimens are always evolving, as are the drugs and techniques themselves. As a result, patients with Prostate Cancer have better support in their fight today than was the case ten years ago. Still, cancer represents complex dynamic and self–organizing biosystems.120 It is considered adaptable and often develops resistance to assorted treatment regimens.121 Your oncologist has the difficult task of finding the recipe that is effective treatment. Sometimes this may involve combinations of drugs and schedule that are different from what is prescribed for others undergoing treatment for the same type of cancer. Be advised, due to the pace of research and the scope of treatment for Prostate Cancer, it is a full time job to keep up with what is has been developed, its state of regulatory approval, its clinical status, and, availability for treatment. Your oncology specialists are the best ones to consult in this regard. If they do not know of something you have heard of, then they will likely research it or refer you to someone who does. As well, because incidence and survivability statistics take years and large samples of patients to yield meaningful results, the newer treatments simply will not have this kind of statistics available to support their effectiveness. In short, the “cutting edge” of new drugs and treatment development, for the most part, proceeds with relatively little statistical support as to exactly how effective they truly are. So don’t expect any questions regarding chances of survival or effectiveness to be answered with clear percentages for these types of treatment. Some hospitals have the additional aspect of Naturopathic medicine. Naturopathic strategy can as well be incorporated into cancer treatment regimens and be beneficial to the fight and recovery. To do this; however, the Naturopathic staff must be working in communication and concert with your oncologist. In terms of self-administered naturopathic treatment, consult your oncologist before you supplement the treatment course they have prescribed with anything else such as vitamins or holistic remedy or agent. This is especially important because even the most seemingly innocuous and common of supplements, for example, vitamin C, may have an adverse impact on the effectiveness of drugs used in your treatment, for example.122 Patients who have undergone primary treatment and are experiencing recurrency may be candidates for either salvage chemotherapy or salvage radiotherapy. Salvage means it is not preventative, but, instead is addressing certain recurrency. If one has

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

115

castrate resistant disease that has metastasized, palliative chemotherapy or palliative radiotherapy are both included in the PC management protocols.123 To assist and deliver the chemotherapy agents are the Floor Nurses in the Department of Oncology. These are the staff with the greatest empirical exposure to the patients and treatments of cancer. They administer the chemotherapy treatment for all types of cancer. As such; they have a broad understanding of the drugs, current trends of research and development, treatment regimens, delivery strategy, problems with clinical applications and technique, side effects, and each patient’s response to treatment. Normally, you will be introduced to the floor staff when you arrive for your initial consultation with the oncologist. These nurses are a select few that specialize in oncology. Their focus is to care for and assist cancer patients with dedication and compassion. Usually the number of oncology floor staff is such that every time you come back for treatment you will see a familiar face. Further to the floor staff, you will usually be assigned a Case Nurse. This nurse will review the details of the proposed treatment with you, ensure that your questions and concerns are properly addressed, and will likely be your “point of contact and resource” for anything that pertains to your condition, treatment, recovery and follow up. Another specialist associated with the Department of Oncology is the Pharmacologist. This specialist is the expert in preparing and managing the chemotherapy drugs that are being administered for treatment, as well as the drugs used to mitigate (soften) the side effects, and any required painkiller. If you have any questions about your treatment drugs this is the person to ask. Usually, on your first treatment, you will meet the pharmacologist and they will give you an overview of the drugs that are going to be administered to you, as well as, answer any of your questions. For those of you who are prescribed radiation therapy, you will meet the radiation oncologist and their technical staff to discuss your treatment. These are the experts on cancer treatment using radiation.

Clinical Testing Before any agent or technique can be approved for human use in anything more widespread than research treatment or trials, studies on humans must be conducted that support the reactive process associated with the introduction of the agent or technique in treatment. As well, statistical proof has to be made to confirm that the treatment is effective, and, has benefits that outweigh the side effects. To do this various regulatory bodies, for example the FDA (Federal Drug Administration) in the United States, oversee phases of trial or studies whereby agents and regimens are tested. These are called clinical trials.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

116

Leading up to any clinical trial is laboratory research and testing on the proposed agent or treatment. This usually means that some testing has been done using animal models to ensure that the effects are reasonably predicted, understood and in all likelihood “safe” prior to exposing humans to it. Common animal models involve mice, for example. Studies using mice as subjects are called murine studies. Clinical trials are conducted on humans when the exact effects of the agent or treatment in trial, as observed on a large number of individuals, has not been proven. As a result, there can be grave and serious risks involved with participating in such studies. The agent or regimen or treatment may have no effect at all; or, may have unforcasted side effects or results. One of the things you should be aware of is that in some clinical studies comparisons are done on subjects that have had benefit of the treatment, as well as, subjects that have not. The researchers try to keep “all things equal” between subjects except the reception of the active agent or experimental treatment. The bottom line is that you may participate in such clinical studies thinking you are receiving the agent, when you are in fact not. In the case where you are not given the trial agent, you are unknowingly participating in the study as part of a “control group” and instead are given what is known as a placebo. A placebo is something that gives the impression of the real aspect but is not. The classic placebo for example is a sugar pill that has the same appearance as the active drug. The idea of giving the placebo is to account for the psychosomatic aspect of patient response. In short, control groups rule out the notion that any benefit is “all in the head”. Generally, the research is conducted by medical institutions or pharmacological establishments that have an interest in seeing the agent come to market for wide scale use. The people that participate are called subjects. The subjects for such studies are “solicited” by these institutions or establishments. Sometimes the study may call for healthy subjects or subjects that are already afflicted with disease at a certain stage. An example of how this solicitation is done can be found on the web page for the Mayo Clinic, whereby interested persons are provided with a contact name and number of the individual overseeing recruitment of subjects. Subjects are as well usually “compensated”. Compensation may be in the form of some small amount of participation bursary or, hopefully by benefiting from treatment with the new agent or regimen. Clinical trials in North America are conducted in four phases. The timeframe involved can be years. The essence of what occurs in each phase of clinical trial is as follows: Phase I tests a new drug or treatment in a small group. This involves the initial studies to determine the metabolism and pharmacologic actions of drugs in humans, the side effects associated with increasing doses, and to gain early evidence of effectiveness. The subjects of such studies may include healthy participants in addition to patients; Phase II expands the study to a larger group or sample of people. Controlled clinical studies are conducted to evaluate the effectiveness of the drug for a

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

117

particular indication or indications in patients with the disease or condition under study and to determine the common short-term side effects and risks; Phase III expands the study to an even larger sample size. Expanded controlled and uncontrolled trials are allowed after preliminary evidence suggesting effectiveness of the drug has been obtained. The intention is to gather additional information to evaluate the overall benefit-risk relationship of the drug and provide an adequate basis for the physician labeling; and, Phase IV takes place after the drug or treatment has been licensed and marketed. Post-marketing studies are used to detail additional information including the drug's risks, benefits, and optimal use.124 For information regarding clinical trials in Australia/New Zealand consult the site at: http://www.anzctr.org.au/default.aspx For information regarding clinical trials in China consult the site at: http://www.chictr.org/en/ For information regarding clinical trials in the European Community consult the site at: https://www.clinicaltrialsregister.eu/ For information regarding clinical trials in India consult the site at: http://ctri.nic.in/Clinicaltrials/login.php ` For information regarding clinical trials in Russia, former Soviet Republics and Eastern Europe consult the site at: http://gctrials.com/ In the course of reviewing the literature on the effectiveness of various agents and treatment regimens one may encounter the expression of a hazard ratio (HR). A hazard ratio compares the death rate for patients receiving a given treatment, to the death rate for those receiving no treatment. A hazard ratio of 1.0 means the treatment is ineffective and gives no apparent boost to assist in fighting the cancer. A hazard ratio of greater than 1.0 means that the treatment is actually making matters worse. Ratios of less than 1.0 mean the patient’s survival is extended due to the regimen. In short, the lower the HR value is below 1.0 the greater the regimen’s effectiveness. Since the 1990’s the treatment of breast cancer with adjuvant chemotherapy has resulted in substantial improvement of breast cancer survivability. 125 Encouraged by these results and others, researchers continue to investigate agents and regimen that can be applied to the adjuvant treatment of Prostate Cancer. In a review of adjuvant treatment in clinical trial registered in the United States it is obvious that the greatest research interest is focused on combination adjuvant solution for those at high risk of recurrency and those with advanced PC disease. 126 Combination

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

118

adjuvant solution is the use of an agent in combination with another or several other agents or other therapy or procedure; such as, radiotherapy or stem cell transplantation.

Chemotherapy There are a number of books written that deal exclusively with chemotherapy. For the purpose of this section, chemotherapy will be considered in more general terms to lend an overview of the drugs in clinical use for treating PC as well as the more common treatment regimens. I found the website http://www.chemocare.com, whose content is provided by the Cleveland Cancer Care Center as part of the Scott Hamilton CARES initiative, particularly helpful in addressing my questions regarding the details of specific chemotherapy drugs. My intention here is to provide you with enough information so you can to have a solid discussion regarding these type treatments with your Oncologist. Typically, chemotherapy is not prescribed in PC therapy unless someone is at high risk of recurrency and demonstrating rising PSA; or, is already in a state of advanced disease.127 It has been suggested that the definition of advanced PC be modified to a more contemporary definition which would include patients with lower-grade disease and with an increased risk of progression and/or death from Prostate Cancer; along with those with widely disseminated metastatic disease.128 Presently, the definition of advanced PC basically dictates the type and timing of its associated therapy. Sometimes advanced disease can progress quickly; or, be resistant to hormone therapy; or, develop resistance to ongoing treatment. These factors along with the overall benefit in prescribing a chemotherapy regimen to support curative or palliative intent are all considered by your oncologist. Chemotherapy can involve one or several drugs depending on each patient’s disease and profile, as well as, any previous treatment. Sometimes these drugs are combined with other agents (like Hormonal Therapy) or strategies (like Radiation Therapy) to enhance effectiveness. Hormonal therapy is designed to target PC that is known as non-castrate resistant. In other words if one had that type of PC and were to be castrated, the disease would slow from the immediate reduction in available androgen hormone. Generally, conventional chemotherapy drugs are designed to target cells that exhibit quick growth and development throughout the body. In effect, they not only target cancer cells but also every other kind of cell that grows rapidly. Amongst these are normal, healthy, rapidly growing cells such as bone marrow (the producer of blood cells), mouth and gastro-intestinal membrane linings, hair follicles, and, skin. Side effects are directly related to healthy cells and systems being impacted by the chemotherapy. The good news is that the damage to healthy tissue usually begins to repair itself as soon as the chemotherapy is stopped. Unfortunately, damage to Peripheral Nervous Tissue due to

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

119

platinum based chemo regimens (such as Cisplatin which is now under trial) may take a couple of years to regain normal functionality. In the interim, you can find yourself dealing with loss of dexterity, “prickly” sensations or numbness in the hands and feet, and, subsequent difficulties with balance and foot placement as did I, for example. Chemo delivery method is varied. These include for example, intravenous injection (IV), intra-arterial injection, pump or pressurized dispenser, intraperitoneal catheter or oral methods. Each drug has a preferred method of delivery, so it really is not so much about what delivery mode you would prefer. Instead it is more about if a specific drug is used for a particular strategy or regimen, then the necessary mode of delivery is going to be whatever is most effective. A session of chemotherapy with a rest period is called the cycle. In order to ensure sufficient functionality and recovery of the impacted bodily systems, a period of time between treatment sessions is set. In my case, treatment was initially scheduled to occur every 14 days over a period of 6 months. A course of treatment is made up of a series of cycles. Time frame between sessions and the dosage can be adjusted to accommodate patient response and mitigate the severity of side effects. Length of the course is variable, and dependant on the extent and location of the metastasis. Sometimes treatment can last for many months or years in an effort to slow the progress of cancer or shrink invasive tumor. Chemotherapy drugs usually have a generic name and one or more registered trademark names. The generic name is the one that cannot be registered as a trademark. The trademark name is followed by an ® if officially registered or ™ if not. This name is specific to a particular pharmaceutical manufacturer. Sometimes the trademark was the first version of the drug so it is more widely used and recognized. Otherwise the generic name is used. For Prostate Cancer, some common chemotherapy agents and combined chemotherapy agents and applications include: High Risk disease management options Androgen Deprivation Therapy (ADT) either with or without EBRT Stage T1-4, N1-3, M+ Hormone Sensitive Disease management options Medical castration with: - LHRH analogue (luteinizing hormone-releasing hormone agonist used to disrupt the release of testosterone); or - Single agent anti-androgens Stage M+ Castrate Resistant disease management options Palliative chemotherapy - 1st line docetaxel (Taxotere®) - 2nd line Mitoxantrone; and,

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

120

- Bisphosphonate therapy.129 In terms of vaccine therapy used to boost the immune system there is only one FDA approved drug called Sipuleucel-T (Provenge®) that is a custom made drug for each specific patient.130 It is costly and reported to extend survival in advanced PC by approximately 4 months over a two year period. There is a number of chemotherapy drugs registered in the United States Trial database undergoing evaluation as to their benefit in treating PC either as stand alone or in combination regimen. The list covers a wide spectrum PC type and stage. The following are some examples: High risk Local disease docetaxel (Taxotere®) for neoadjuvant and adjuvant treatment; docetaxel (Taxotere®), Estramustine Phosphate combination; docetaxel (Taxotere®) , Zoledronic Acid combination ; Prednisone; Mitoxantrone hydrochloride; docetaxel (Taxotere®), goserelin acetate, leuprolide acetate combination; docetaxel (Taxotere®), Casodex, and Zoladex or Lupron combination with RT;

Advanced disease Ixabepilone; docetaxel (Taxotere®) with 3DCRT; stem cell transplantation with filgastrim; camustine; cisplatin; melphalan; vinorelbine tartrate combination; monoclonal antibody therapy plus chemotherapy then stem cell transplantation; bryostatin 1, pacl*taxel (Taxol®) combination;

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

121

Castrate resistant interferon alfa; docetaxel and Estramustine; and, filgrastim, carboplatin docetaxel, Estramustine phosphate sodium.131 Regimens for chemotherapy vary and are not the same from one country or region or facility to another. For this reason the agents and combinations listed are not in any way to be considered a complete list. In terms of delivery method, measures to reduce the trauma of multiple injections are used when patients are involved in lengthy chemotherapy treatment regimens. Instead of having to endure the unsavoury aspect of being pricked in the arm repeatedly, patients are typically given the option of having a “port” or catheter installed. The advantage of these types of devices is that they stay with the patient throughout treatment and usually for several months afterward. Any intravenous needles can then be plugged into mechanical leads serving the port or catheter, which substantially minimizes effect of the patient feeling like a big pin cushion. Arm catheters are typically installed in the veins either in the fold of the arm or under the arm below the armpit. I have seen these installations on other patients and quite frankly I cringe at the idea of having a catheter planted “long term” in a place that is constantly moving, such as an arm. As well, I am informed that care must be constantly given to ensure that the arm installation, if not buried beneath the skin, is not made wet during bath or shower. The dressings for these kinds of installations are also quite obvious, not so easy to conceal and require constant maintenance. This may be a consideration for those patients who are still carrying on with their day to day routine while undergoing treatment. Figure 41 shows examples of port-a-cath installation on the right side of the chest.

Figure 41. Example of subcutaneous installation of a port-a cath. source: http://commons.wikimedia.org/wiki/File:Port-catheter.jpg originator: RecurrentbreastCA.gif

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

122

In my case I elected to have a chest port-a-cath. It was installed underneath the skin (subcutaneously) by surgical procedure. The port-a-cath typically accesses the subclavian artery feeding the heart, and, once installed and healed into position, it is relatively easy to forget about. This device is easy to conceal; has no associated dressings or considerations that preclude the patient from taking baths or showers when it is not in use; minimizes the possibility of IV infection and thrombosis, and it is relatively painless. For chest installations, even when being plugging into and out of the port-acath is a relative “non-event” because it is so well anchored that it really does not move. The only thing a patient feels is a pin prick when being plugged in. As I understand, such installations can as well be done on the left side of the chest, as well as, the underarm. The “bulky round thing” that protrudes under the skin is the port disc where the delivery needle can be poked into to administer drugs. The line or tube leading upwards from the port ties into an artery near the base of the neck in this installation and remains attached for as long as the device is in the patient. It has been my experience that when the patient is scheduled for their first session of chemotherapy they undergo the installation of a port or catheter. Installing the port-acath is a surgical procedure done in the Department of Radiology with local anaesthetic. This is because the surgeons use radiographic imagery to connect the port-a-cath to the artery. Imaging minimizes the size of the incision necessary for the procedure. As soon as the surgical procedure for installation was complete, I walked down the hallway to start my chemotherapy. One thing though, the first “plug in” is not really felt because it is done while the anaesthetic for the surgical procedure is still very much effective. This is not the case for the first “unplug”. Expect that the first unplug will be a bit “tender” because it will be only days after the installation of the port-a-cath and the area still has stitches or staples and has yet to heal and the needle for the portable bottle of chemo drugs is really well anchored in the port-a cath disc and so requires it a bit of a tug to unplug. Other devices that are commonly used in chemotherapy are PICCs (Peripherally Inserted Central Catheters) or central venous catheters. These are also known by manufacturer names like the Groshong® or Hickman® catheters. Figure 42 shows an arm installation of a central venous catheter.

Figure 42. Example of a central venous catheter installed in the arm. source: http://visuals.nci.nih.gov/retrieve.cfm?imageid=4489&dpi=300&fileformat=jpg originator : National Cancer Institute, Rhoda Baer (photographer)

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

123

The main disadvantage with this type of access device is that it is not buried under the skin. This makes the opening into the body around the catheter much more susceptible to infection. This type of catheter is typically used as a shorter term access installation to support treatment such as a 5 week RT/Chemo course. It can be installed in the arm as well. Shorter term regimens lasting approximately a month typically do not require any port installations. Chemotherapy is not given in dosages that “kill” all the rapidly growing cells at once. Instead, dosage is balanced in such a way as to ensure the cancer cells are destroyed over a period of time, while minimizing the “nasty” side effects associated with chemotherapy impact on normal, healthy cells. As I found out, the patient can expect that the side effects become progressively worse the further along the course of treatment is. The reason for this is two-fold. First, it takes a while for the body to process some of the drugs. If processing time is longer than the time between treatment sessions then there can be a cumulative effect that results in more severe side effects. Second, depending on the drugs used, the extent of healthy cells being impacted can be substantial if the course of treatment is prolonged. In simple terms, there is not enough time between cycles to regain 100% functionality for the healthy cells that have been impacted. The side effects for Prostate Cancer chemotherapy regimens are varied. Each drug has its own set of side effects. Side effects can be further compounded when combination strategies are used. The nursing staff is constantly being challenged to keep ahead of the onslaught of new drugs and each drug’s specific “alert signs” for patient distress during treatment. One of the things you will be asked at each treatment is what side effects did you experience from the previous session. It is therefore important for you to keep a record of this. Write down the date, what you experienced in terms of the side effect, and how long it lasted. Bring this with you every session. This will assist the medical staff in making suggestions to minimize the side effect(s). At the beginning of my course, one floor nurse who happened to be on her last day before retirement smiled at me and said, “We have a recipe for every side effect.” Side effects for the common PC chemotherapeutic regimens depend upon the agent(s) involved, their combinations with other types of treatment, patient profile, as well as, patient response that can change throughout the course of treatment. Some patients may only experience one or a few of the listed side effects associated with a particular agent. Other patients may experience more. For those who have gone through conventional prostate chemotherapy, fluid retention with weight gain; swelling of the ankles or abdominal area; peripheral neuropathy (diminished dexterity from numbness or prickling in finger and toes); nausea; vomiting; diarrhea; loss of appetite; mouth and lip ulcers; anemia related fatigue and weakness; infection; hair loss; muscle/bone joint pain; increased risk of bruising and bleeding (from low platelet count); finger and toenail aberrations (purple coloration, ridges and weakness);132 and, heart rhythm abnormalities133 are all reported occurrences. Your oncology pharmacologist can give you a more precise and comprehensive list of the side effects associated with each agent involved in your proposed treatment regimen. THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

124

My adjuvant chemotherapy for CRC was platinum based and I had a number of these side effects. I see that Cisplatin is being investigated in trial for possible benefit in treating PC. Cisplatin is one of the platinum based drugs. In my case, some of the effects, like diminished dexterity; purple digits; and, prickling in the extremities, lasted more than a year after my treatment had ended. Nausea is something that occurs naturally when the body “believes” it has been poisoned. Some say this is one of our “preservation” behaviours. The idea being that a quick response rejecting the contents of the stomach should remove the source of poison if it was something “bad” that was swallowed. As some of us have no doubt experienced, this usually accompanies excessive alcohol intake when “throwing up” makes most people begin to feel better. Nausea, however, is not very effective solution to poisonous stings, snake bites and chemotherapy. When certain agents of chemotherapy are introduced, the body responds by producing higher levels of a neurotransmitter called serotonin. Serotonin is responsible for stimulating vomiting. In any event, the thing about most side effects is that they don’t last. So you can expect improvement and gradual return to normal as soon as the chemotherapy is arrested and you have had a little time to recuperate. Besides, the oncology pharmacist knows about this nausea and usually has effective anti-nausea countermeasures. When you proceed to chemotherapy with an IV delivery you will usually arrive on the day of each new cycle at the oncology department where you will receive the cycle. Delivery usually involves sitting down in a room in a comfortable chair alongside of others who are being treated that day. The nurse assigned to you will verify your prescription and then properly “Plug you in” for delivery. Beside you will be an IV rig with several liquid filled bags dripping into their respective line “feeds”. Some of these will be the chemo agents, and others will be the “carrier” solutions for the chemo agents. I suggest that you bring something to do because the time there passes slowly. Carrier solutions, for example 5% Dextrose (a solution of distilled water and dextrose sugar) or 0.9% NaCl saline (a solution of distilled water and the salt called sodium chloride), are fed by IV at the same time as the chemo agents. Each chemo agent has its preferred carrier solution. The carrier solution is designed to assist in the circulation and absorption of the chemotherapy. To control nausea and vomiting usually an antiemetic (anti-nausea) such as Granisetron (Kytril®) and a corticosteroid will be administered to you before the chemo drip is started. Granisetron is in a group of medications called 5-HT3 receptor antagonists. It works by reducing the levels of serotonin.134 When chemo agents are delivered by IV, sometimes it may involve, for example a two hour “drip” in the hospital. After this, more chemo agent may be delivered via a small pressure dispenser over the next 46 hours. The agent, in the small pressure dispenser, is generally taken home and worn in a pouch until empty. At that time, a nurse at a local clinic with a prearranged appointment can remove and dispose of the bottle with the appropriate medical considerations. It is important that trained medical staff is

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

125

involved in the unplugging and removal of such a chemo pressure dispenser. The reasons for this are as follows: 1) Depending on the drug used there may be a potential to cause irritant reactions at the injection site or vesicant reactions if leaked onto either the patient or the caregiver’s skin. An irritant reaction is usually short lived and involves patient symptoms such as redness along a vein or at the injection site, warmth, and, soreness. Vesicant reaction is the more severe and can be delayed for 6 to 12 hours after the leakage onto the skin. Symptoms include redness, blistering, itching, pain and severe skin damage if the appropriate immediate action is not taken; 2) The agents introduced to your body during chemotherapy make your bodily fluids “cytotoxic”. What this means is that they are toxic to normal cells so anyone that is not being treated must not be exposed to them; and, 3) In unplugging the port- a-cath the nurse has to properly irrigate the port-a-cath site and line with the anticoagulant heparin, as per the directions of your attending oncologist. It is important to ensure that they see visible blood backflow in the irrigation syringe to minimize risk of embolism (a wandering mass) or the introduction of air bubbles via the port-a-cath into your bloodstream. An embolism, depending where it migrates to, can cause all sorts of complications including death. The effectiveness of the chemotherapy and its impact on the blood components, electrolytes, and tumor markers are monitored with blood work (usually performed the day before each chemotherapy session). You will likely find that your oncologist is not too concerned with the ups and downs of tumor markers. The fact is that such markers can have erratic counts throughout the course of treatment. What is important is the end result. So do not get overly fixated or concerned about such things. Do, however, consider what you can do to keep your white (neutrophil) and red blood cell counts up. During the course of treatment, expect that platelets are going to be “hit hard” and decrease in count. In the blood, platelets last 7-10 days when they are effective in their blood clotting role before they are removed by the liver or spleen. Normal platelet count is 150,000 – 450,000 per microliter.135 If the platelet count goes below 20,000 per microliter there is a potential risk of spontaneous bleeding. This condition is called severe thrombocytopenia.136 The options, in this case, are either a platelet transfusion or stopping treatment for a period to allow the bone marrow to recover and replenish the platelet count. The platelet transfusion is delivered by IV either through a vein in the patient’s arm or, if a catheter or port-a-cath is installed, via these. A unit or bag of platelet serum takes 15-30 minutes to receive. One bag may be enough depending on the patient’s initial platelet count.137

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

126

The conventional drugs of cancer chemotherapy can basically be categorized into five groups based on how they work and their chemical structure. These groups are alkylating agents, anti-metabolites, anthracyclines, topoisomerase inhibitors, and mitotic inhibitors. These are not all of the groups of chemotherapy agents but they do comprise what is known better as the conventional groups. Some of the agents actually fall into two or more categories. In any case, the following is a summary of each group of conventional chemotherapy agents: Alkylating agents are a group of drugs that work by damaging DNA, and, so they inhibit cell reproduction. These drugs are called non-specific in that they affect the cell no matter what phase the cell is in its cycle. This group of agents or drugs are used to treat many types of cancer including breast, lung, leukemia and colorectal. One of the facts of alkylating agents is that their action on DNA can cause long term damage to the bone marrow. With this there is a risk of inducing a secondary cancer called leukemia that increases with the strength of dosage received. The appearance of leukemia is highest 5 to 10 years after having received chemotherapy involving alkylating agents. Grouped in with alkylating agents (because they kill cells in a similar way) are the platinum based drugs such as Cisplatin (Platinol®). These drugs are less likely than the alkylating agents to cause leukemia.138 Estramustine (Emcyt®) in combination with estradiol is an example of an alkylating agent used in treating advanced Prostate Cancer.139 Among its side effects of Cisplatin is the short term impact on the peripheral nervous system. This is known as peripheral neuropathy. When I went through chemotherapy for CRC I experienced this peripheral neuropathy as a result of the drug Oxaliplatin (Eloxatin®). What this meant for me is that I experienced symptoms like tingling in the fingers and toes that was further aggravated by a greatly increased sensitivity to cold. As well, the ends of my fingers and toes where the tingling was most severe turned a purple hew and remained that way for a good long while after the course of treatment had ended. It has taken the better part of three years to regain my normal coloration. I also had a “metallic” taste in the mouth and prickly feeling in the throat which was made worse by drinking any cold liquid especially if it was sweet. The surface of my tongue would feel like it had been burnt by hot liquid. My hands would become unsteady and I experienced reduced manual dexterity. Also, my calves would ache as though it was the day after I had done a hard work out on that muscle group in the gym. When first started chemo all of these symptoms would begin during session and initially last a week or so after. As the treatment went on such side effects intensified and never left between sessions. During that time I would lose complete interest in drinking anything cold or remotely sweet (such as orange or sugared cranberry juice). This was a problem because one of the things about the recovery period in between sessions is that you have to keep your fluids up. The solution was to drink warm soups and green tea instead. Anti-metabolites are a group of drugs that interfere with the production of cell DNA and RNA by occupying sites on the unzipped replicating template reserved for the nucleotide building blocks. The agents act during the synthesis or S phase of the cell

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

127

cycle (see Figure 16).140 They are commonly used to treat breast cancer, as well as, leukemias, colorectal and ovarian cancers. Examples of such gents used in Prostate Cancer treatment include Capecitabine (Xeloda®) and, 5-Fluorouracil (5-FU).141 Capecitabine (Xeloda®) is a pill form of 5-fluorouracil which is usually administered intravenously. One of the side effects of capecitabine involves a hand and foot syndrome which causes pain, redness, dryness and swelling to the point where the patient has difficulty with everyday normal activity. Anthracyclines are another group of chemotherapy drugs that are used on a wide variety of cancers. These are effective during all phases of the cell cycle except G0 (the sub-phase where the cell does not replicate). They work by interfering with enzyme production that is essential for DNA replication. One consideration in the use of drugs from this group is that they can cause permanent damage to the heart if given in high dosage. Consequently, lifetime dose limits are placed on these drugs. 142 Mitoxantrone (Novantrone®), also known as DHAD, is an example of an anti-tumor antibiotic anthracycline. Its delivery is by IV.143 The next group of drugs is called Topoisomerase inhibitors.144 In order to replicate the DNA strands have to “unzip” and separate into two daughter cells. Topoisomerase I and II are enzymes that assist in this unzipping. In simple terms, Topoisomerase inhibitors work by interfering with the topoisomerase enzymes so that the DNA strands cannot unzip and make copies. 145 This group of drugs is commonly used to treat some leukemias, lung, ovarian, and gastrointestinal cancers. 146 There is a suggested benefit reported by a study investigating use of the Topoisomerase I inhibitor Irinotecan (CPT-11 or Camptosar®) in combination therapy with cisplatin for small cell carcinoma of the prostate. 147 A common and major concern with the use of Irinotecan is the side effect of severe diarrhea that can occur a few hours or days after drug reception. If left unchecked the subsequent severity of the diarrhea can cause serious chemical imbalance and/or dehydration to the point of being life threatening. 148 To let you know how quickly dehydration becomes fatal I had a colleague who went into remission for stage III CRC at the same time as me. Three years later he had a relapse and so left work the first week of December to be treated for a stage IV condition. Within a couple of weeks after starting chemotherapy he experience severe diarrhea that for some reason was left unchecked. I corresponded with him two days before Christmas and he said everything was going well. This was before the diarrhea. Sadly, he passed five days later from dehydration. In short, dehydration is to be taken very seriously. Mitotic inhibitors are a group of drugs derived from natural products such as plant alkaloids. These drugs typically are most effective in the Mitotic (M) phase of the cell cycle (see Figure 16); however, they can damage cells in all phases. They work by inhibiting the production of a protein called tubulin which is involved in a number of the cell’s structural components and in mitosis. As such; these drugs can stop mitosis from occurring. This group of drugs is used to treat a number of cancers including breast, myelomas, lymphomas, leukemia and lung cancer.149 Included in this group of drugs are

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

128

the taxanes for example docetaxel (Taxotere®) which is a common PC chemotherapeutic agent used in advanced disease treatment. Something you should be aware of is that Mitotic inhibitors are known for their potential peripheral nerve damage as a side effect. Such side effect has to be managed by limiting the dosage of this type of drugs. 150 When I was undergoing chemotherapy my oncologist prescribed Prochlorperazine to reduce any short term effects of nausea. When I researched it I found that prochlorperazine is as well prescribed as an anti-psychotic drug in much higher dosages than those used for the treatment of chemotherapy related nausea. Among the list of serious side effects for this drug I found that it could cause irregular heartbeat and seizures.151 I decided not to take any of this anti-nausea/anti-psychotic medication as I reckoned “the fewer drugs I had floating around in me the better”. Neither did I like the idea that I could be launched into a seizure at times when I was for the most part alone. Instead, I found that the nausea would typically diminish if I ate something. In the event that the nausea became “more than a nuisance”, I would take a couple of over the counter Philips Milk of Magnesia tablets and everything settled right down. It is likely that what I did will not work for everyone, but it may be worth a try. As far as the other side effects go, the mouth sores I addressed with a drop of over the counter methlyn blue touched to the ulcer at night, and, salt water rising 3 to 6 times during the day. The gritty feeling of the eyes improved with the more liquids I took in. Cold water splashed in the eyes provided relief if I woke with this gritty feeling. The other side effects just ran their course.

Non-Conventional Chemotherapy Hormone therapy, also called Hormonal Therapy or Androgen Deprivation Therapy or Androgen Suppression Therapy. This therapy uses several strategies to slow or stop the growth of hormone sensitive PC cancer by either blocking the body’s ability to produce the androgen hormones (more specifically testosterone; and/or. dihydrotestosterone) OR by interfering with the hormone’s action that is necessary for prostate tissue (healthy or cancerous) to grow. It only works on PC that is hormone sensitive. This means that the PC is not castrate resistant (also known as refractory). Such treatment is used for androgen sensitive high risk; metastic; recurrent; or, progressive PC. Some doctors recommend intermittent ADT. Intermittent therapy means the treatment is periodically stopped then restarted. This practice presumably improves patient quality of life in terms of sexual function. Prostate Cancer response to a testosterone suppressing serum was first reported in 1941 by two researchers Huggins and Hodges. Beginning in 1971 and over the next three decades a number of LHRH agonists were developed and put into clinical use. These drugs work by blocking the pituitary gland from producing the precursor hormone that cues the production of testosterone. Leuprolide; Goserelin; Triptorelin; and, Histerlin are

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

129

all commercially available LHRH agonists in clinical use today and are typically used to treat metastic and advanced PC.152 When LHRH agonists are first used the immediate result is called a “flare” response where testosterone levels in the patient actually balloon. This not only aggravates the symptoms in advanced disease but can also be fatal if somehow prescribed for voluminous metastic PC. Voluminous metastic PC just means the disease is quite advanced and affects a lot of the body. After the flare the testosterone levels diminish to near zero which is the intent of the therapy. These days the flare response is preempted by prescribing an anti-androgen agent before starting LHRH therapy. Other concerns in the use of LHRH agonists in therapy are side effects which include hot flashes; erectile dysfunction; lack of libido; musculoskeletal impact (reduced strength and osteoporosis), hematologic impact (anemia) and cardiovascular impact leading to assorted related event and affliction. Men who are being treated with LHRH therapy are advised to make lifestyle changes to compensate and minimize these side effects. This means stop smoking; decrease alcohol intake; and, perform resistance exercise while taking calcium supplement to keep bone density levels up.153 Caffeine intake should as well be decreased because it too has been reported to cause bone loss.154 Consider having a close look at the contents list on the bottle of any calcium supplement. Calcium is an element which is marketed in several forms in supplements. Calcium carbonate and calcium citrate are the most common forms. Other forms found in supplements are calcium gluconate, calcium lactate, bone meal and hydroxyapatite. Coral calcium is simply calcium carbonate. Hydroxyapatite is a second generation bovine (cow) “bone meal” supplement that presumably has managed to exclude contaminants that were associated with plain bone meal supplements. Vitamin D level is an important player in calcium absorption. Vitamin D deficiency substantially impacts the ability to absorb calcium. Calcium carbonate requires an acidic environment to be absorbed and optimal absorption occurs if taken at mealtime. Calcium citrate does not require this acidic environment; so, it is the best supplement option for those who are supplementing outside of mealtime or those who have suspected achlorhdydria, inflammatory bowel disease or absorption disorders. Calcium citrate may also be a way around gastro-intestinal supplementing effects of calcium carbonate such as gassiness and constipation. Total daily intake of calcium for adult men and women (don’t forget that calcium is derived from food intake as well) should be no less than 1000-1200 mg/day and not exceed 2500 mg/day. 155 Inappropriate calcium supplementation with or without vitamin D is associated with elevated incidence of irregular cardiovascular behavior such as myocardial infarction and heart attack.156, 157 As well, calcium has the potential to interact with other medications that are being taken.158 In short, your physician has to know what you are supplementing with and follow up with the appropriate tests to ensure that your blood calcium levels, heart and bone density are responding in an acceptable way. Depending on the origin of the supplement, manufacturers of dietary supplements may or may not be required to comply with any government standard. It is important to

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

130

look for a seal which indicates an independent overseeing body has verified that the supplement product is in fact what is labeled. Examples of such overseeing organizations in the United States are the USP (U.S. Pharmacopeial) and ConsumerLab (CL); and, in Europe it would be EP (European Pharmacopoeia). Another type of hormone therapy involves the prescription of Anti-androgens. There are two types of anti-androgen agents. One type inhibits androgen production in the adrenal glands. These include ketoconazole; assorted corticosteroids and aminoglutethimide. Anti-androgens are typically administered at the time of biochemical disease progression. 159 This means that biomarker levels, such as PSA, begin to increase indicating a relapse of PC following primary treatment. Examples of anti-androgen drugs are flutamide (Eulexin®, Drogenil®); nilutamide (Nalandron®); and, bicultamide (Casodex®). Common side effects of androgen suppression drugs include: - Hot flashes; - Loss of bone density - decreased levels of HDL (good cholesterol); - Loss of muscle mass; - Weight gain; - Decreased mental alertness; - Fatigue and depression; - Gynecomastia (breast development); - Anemia; - Sexual dysfunction and loss of libido. 160 Estrogen therapy used to be a mainstay of hormonal therapy; however, they have been associated with inducing significant cardiovascular toxicity and so have fallen out of favor. 161 Ultimately advanced disease PC finds its way around hormonal treatment in all patients and progresses to end stage. In short, the benefit of hormonal therapy is in prolonged survival not cure. 162 Castrate resistant PC (CRPC) is defined as progressive disease that persists with less than 50 ng/dL testosterone detected. Post-castration levels of testosterone are usually somewhere below 20 ng/dL. A number of targeted and immunotherapeutic options are being assessed in clinical trial for survival benefit for CRPC patients in terms of secondary therapy and perhaps even tertiary therapy scenarios.163 Targeted therapy uses a group of drugs that attack cancer cells more specifically than conventional chemotherapy drugs can. Such research and the development of effective PC specific drugs are footed in the better understanding the internal processes and genome of the targeted cancer cells. “Target specific drugs” attack by recognizing

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

131

mutant or modified versions of specific genes; or, cells that are expressing too many copies of a particular gene. Two examples of target therapy drugs in trial for CRPC are Abiraterone which is delivered orally and is a targeted androgen inhibitor; and, MDV 3000 which is a drug that targets androgen receptor function.164 Most recently is the reported effectiveness of a targeted drug conjugate (PSMA ADC) involving a protein that binds to the surface of Prostate Cancer cells as a way to deliver the drug monomethylauristatin E (MMAE) to the PC. This conjugate targeted therapy has just completed its phase I clinical trial. Once the conjugate binds to the surface of the cancer cell the MMAE is absorbed by the PC cell causing its death. Antitumor effects occurred in approximately 50% of the trials patients who had previously undergone up to 2 prior failures in chemotherapy and hormone therapy. Phase II clinical trial involving 75 patients is underway and being overseen by researcher, D. Petrylak M.D. of Yale University Medical Center. 165 Anti-tumor antibiotics are another group of chemotherapy drugs that are derived from a “strain” of microorganism called Streptomyces. These drugs act in a number of ways. For example, such action includes causing breakages in a cell’s DNA; or, blocking the synthesis of DNA and RNA. These drugs work in all phases of the cell cycle. Unfortunately, they again also affect healthy cells and so have a range of side effects. As stated, Mitoxantrone is an example of an anthracycline anti-tumor anti-biotic that has clinical approval and is typically used as a second line palliative treatment in advanced PC.166 Mitoxantrone plus prednisone is reported to reduce pain and improve the quality of life in men with advanced CRPC; however, it does not improve survival. 167 Corticosteroids are a group of drugs that are used in chemotherapy, and, in the treatment of nausea side effects as a result of chemotherapy, among other uses. These compounds are produced naturally in the outer layers of the adrenal glands called the adrenal cortex. Humans have two adrenal glands. They are attached to the top part of each kidney. Cholesterol is a necessary component in the synthesis of corticosteroids. The quantity of corticosteroids required for medical purpose requires that these drugs are manufactured artificially outside of the human body by pharmaceutical companies. Prednisone is a specific type of corticosteroid that is used in the treatment of advanced PC.168 It has anti-inflammatory properties and can be used to decrease the swelling around tumors in the spine, brain or bone. The way corticosteroids work in this capacity is by inhibiting infection fighting white cells from making their way to infected areas in the body. This decreases the pressure on tumor aggravated nerve endings and in so doing gives relief from pain in advanced disease, for example; however, it also makes someone more susceptible to infection. 169 Another group of chemotherapy drugs are those called differentiating agents. Remember the higher grade the cancer cell the less “differentiated” it is. When there is a lack of differentiation, the cell from a specific area or organ loses its mature, healthy

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

132

distinctness and functionality. Differentiating agents cause cancer cells to mature into normal cells.170 As an example of differentiating agents presently under investigation for Prostate Cancer, researchers have reported that a combination of isoflavone and 3,3′diindolylmethane (DR-DIM) substantially inhibits the signaling that promotes cell differentiation in PC bone metastasis. 171 In an effort to minimize the impact of non-specific chemotherapy drugs on healthy tissues, two strategies for drug delivery have been developed. Intra-Arterial Chemotherapy (IAC) is considered a regional chemotherapy technique that allows chemotherapy drugs to be concentrated directly in the area of a tumor. If the Prostate Cancer has metastasized to the liver, IAC delivers anti-cancer drugs directly to the liver through the hepatic artery. Chemoembolization is a more enhanced form of intra-arterial chemotherapy also uses microspheres to temporarily block the flow of blood to the tumor. A microsphere is a very small (2 one millionths of a meter or 2 microns) globule made up of long repeating chains of proteins or polypeptides and formed into a biological membrane that contains no genetic material. The result traps chemotherapy drugs in the area of the tumor and so helps to target the treatment area.172 An antigen is a substance or foreign substance that causes the body’s immune system to produce antibodies. Antibodies are produced in the blood and made in response to antigen invasion. When made by the body, antibodies are specifically designed to attack the particular antigen that caused the antibody to be made. Antibodies are capable of functional interference of the enemy’s essential biological pathways; they can signal cellular toxic response; they can signal or activate other systems in the body to assist in the battle; and, improve the uptake efficiency of other cells (phagocytes) designed to “consume” the invading substance. The production of antibodies is our immune system’s custom response to address specific invasion. They are the “hands-on” Field Marshals of your body’s natural defense system. Immunotherapy drugs are given to stimulate a patient’s natural immune systems so as to more effectively recognize and attack cancer cells OR boost an immune system with immune system components. These drugs focus on cancer vaccines, targeted immunotherapy, and non-specific immunotherapy.173 One of the biggest challenges with immunotherapy drugs is to identify a common or set of common antigens specific only to PC or PC tumor surface molecules that can serve as targets. 174 Knowing this would allow researchers to develop antigens that specifically attack PC cells. To date, a number of antigens and “overexpressions” have been identified that are related to PC; however, almost all of these are found either in healthy prostate tissue and/or tissues from other parts of the body, as well as, PC cells. 175 As such; antibodies cueing on these are not efficient and can impact healthy tissue.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

133

Even so, the development and approval of immunotherapy drugs that provide some survival benefit is ongoing. For example, the immunotherapy drug Sipuleucel-T gained FDA approval for treatment of asymptomatic or minimally symptomatic CRPC.176 Promising research is investigating the possibility of developing immunotherapy that cues on a substance called Survivin. Survivin is an inhibitor of cell death (apoptosis) and promotes proliferation (cell growth). Both of these qualities are essential to any cancer. Survivin is widely expressed in a number of cancer’s including PC. As well, it is something that is almost completely absent in well- differentiated adult tissues. 177 As stated, there are approximately 50,000 to 100,000 genes in the human genome. Decoding the genome and understanding the effects and impact of changes to the content and order of specific genes relating to a beneficial cancer therapeutic response is a colossal task. Recently advances in decoding the complex genomes associated with breast cancer are becoming more successful in identifying changes in genes and the genetic signatures of cancers. As well, technology is approaching methods that can safely deliver genetic solution with specific results and no side effects. Still the results have yet to make their way into the clinical applications of main stream medicine with widespread impact on any cancer. In the meantime, the suitability of targeting cancer with gene therapy remains a challenge since the consensus is that cancer is a culmination of a multi-step process that involves a variety of somatic gene alterations or mutations.178 In short, it is not just a simple matter of finding “the cancer gene” and sorting it out. As such; gene therapy strategy is investigating several approaches in research and clinical trial with varying degrees of success. These approaches generally fall into five groups. The following is a brief summary on each approach: Enzyme/ prodrug systems (Suicide Gene Therapy) – involves lacing a tumor with an agent that can either inhibit or destroy the tumor when in the presence of activation enzymes. This agent is called a prodrug. The activation enzymes are supplied by non-human genes that are introduced to cause the short term activation of the prodrug and subsequent tumor arrest; Gene correction therapy – are those strategies aimed at correcting imbalances between tumor suppressor genes and genes that give rise to tumors called protooncogenes. This is done by introducing a tumor suppressor gene OR by deactivating the proto-oncogene; Note to clarify: a proto-oncogene is a normal gene that when mutated contributes to cancer.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

134

Immune-gene therapy - seeks ways to genetically promote a better immune system response in the body either by making cancer cells more “visible” to the normal mechanisms that typically act on and destroy them is a healthy human OR by introducing non-human genes that result in boosting cancer specific immune response; Drug resistance gene therapy - the use of non-specific chemotherapy drugs is highly toxic to the body. The impact of such treatments on healthy cells limits dosage and effectiveness of the drugs used to combat cancer. The idea behind drug resistance gene therapy is to introduce genes that will make the healthy cell population more resilient to non-specific chemotherapy drugs; and, Chemo-gene therapy - is the approach that attempts to enhance the effectiveness of chemotherapy agents by introducing genes that modify specific cellular expressions or productions.179 Gene therapy trials have been underway since the early 1990’s for PC. In spite of encouraging results, an effective gene therapy strategy for PC has yet to be realized. Recently, an immune gene therapy approach involving the use of a thyroid gland gene NIS as a vehicle that can be transplanted in PC cancer cells is proceeding to Phase I clinical trial. The NIS gene gives the thyroid the ability to uptake and concentrate iodine. When the NIS gene is transplanted into PC cells and exposed to radiation laced iodine PC cell death occurs resulting in prolonged survival benefit. 180This could have curative implications for PC and other cancers as well. Advances in understanding the genetic makeup of breast cancer are ongoing and have yielded some interesting results that may eventually apply to PC research. Recently a team, co-led by Dr. M. Ellis, genetically analyzed 348 tumors from women with breast cancer. From this analysis, four distinct subtypes of breast cancer based on common genetic disruptions were reported. These are luminal A; luminal B; HER2; and, basallike. In light of this discovery, Dr. Ellis suggests that tumors should be classified and treated by the genes that are disrupted instead of by where they are located in the body.181 In other words, it doesn’t matter where in the body the cancer starts, what matters is what genetic changes have occurred that makes the cancer occur, and allows it to defeat immunoresponse and progress. This suggestion, if correct, could have enormous impact in the study and treatment of all cancer. A current theory suggests that most, if not all malignancies, are the result of a sub-population of “stem cell like” tumor cells. To simplify, the theory is that cancer cells are produced from their own set of stem cells. The development of therapies specifically targeting cancer stem cells represents a strategy to completely eradicate tumors and potentially lead to cure, even in advanced-stage disease. As well, the identification of cancer stem cell markers have potential for use in early detection and in being able to provide valuable predictive and prognostic information.182

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

135

For those of you not acquainted with the notion of a stem cell, normal stem cells can be found in embryos or in adult humans. In the human embryo these cells have the ability to change into any kind of specialized embryonic tissue. Embryonic stem cells can give rise to the full spectrum of organs and tissues found in a mature adult. Adult stem cells are not as “capable” as the embryonic ones. Adult stem cells act as the body’s repair system and allow for cell replenishment in tissues that have cell turnover such as blood and skin.183 In May 2012 researchers at the University of Texas Anderson Cancer Center have identified Prostate Cancer Stem Cells. These PC stem cells feature low PSA level expression. As well, the PC stem cells thrive in an androgen low environment; divide slowly and so have an ability to resist chemotherapy; and, when they divide they make a copy of themselves, as well as, a PSA positive cell. The PSA positive PC cells divide rapidly (making them vulnerable to chemotherapy); divide making only one copy of themselves; and, require androgen to progress. This research outlines a need to develop therapy that will target PC stem cells. 184

Radiation therapy Radiation therapy or radiotherapy is used as a way to control malignant cells using ionizing radiation. Radiation therapy can be tailored for therapeutic or palliative treatment. Therapeutic treatment means that there is a survival benefit to the patient and the treatment may well be curative. Palliative treatment means that cure is not possible and the aim is to control or slow the disease or reduce symptoms. The intent of the therapy, as well as the “how” and “when” it is delivered depends on a number of variables including tumor location, type and stage of the cancer, patient age and general health, the patient’s treatment history and whether or not additional or other treatment will be required, for example. Radiation therapy has a number of different strategies and can be delivered before (neoadjuvant), during (intraoperative) or after surgery (adjuvant). 185 Radiation works by damaging the DNA of the cells that absorbs it. The idea is to so damage the cancer cells that they either cannot reproduce or simply die. The problem, however, is that radiation damages non-cancer cells too. Therefore, a number of different delivery strategies and techniques are used to minimize this “collateral damage” to healthy normal cells that are in the path of the radiation and surrounding area of the targeted cancer.186 The actual irradiation is totally painless. Tumor cells typically have an inability to maintain higher levels of oxygen. As a tumor grows its vascular system typically becomes choked and unable to develop at a rate to keep up with the rest of the rapid tumor growth. This poor vascular development equates to low oxygen levels in the cancer cells. Low oxygen levels in tumor cells actually give them a resistance to radiotherapy. This is because the DNA damage caused

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

136

by the radiotherapy is most likely to become permanent only when cellular oxygen levels are high.187 The radiation used in conventional radiation therapy involves photon particles and is measured in and unit called a “gray” or Gy. Radiation is delivered either by external beam or some kind of injected radioisotope. Medical radioisotopes are short term radioactive materials can be introduced into the patient for treatment which then decay rapidly (within a few weeks or months) to low emission levels.188 Figure 43 shows an example of an external beam radiation delivery system.

Figure 43. External Beam Radiation Delivery system with patient in position. source: http://en.wikipedia.org/wiki/File:Radiation_therapy.jpg [modified] originator : D. Wakulchik

Over the years, radiation therapy has branched into specialized modes of delivery to minimize damage to healthy tissue. For external beam delivery, there is 3Dimensional Conformal Radiotherapy (3-DCRT). 3-DCRT involves photon radiotherapy delivery in which several radiation beams are adjusted and shaped to fit the profile of the targeted tumor. This reduces the relative toxicity of radiation to the surrounding normal tissues, and also allows a higher dose of radiation to be delivered to the tumor than conventional techniques could allow.189

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

137

Intensity-Modulated Radiation Therapy (IMRT) is the next generation of photon radiation delivery and features improved calculation of beam numbers, angles and dosage compared to 3-DCRT. 190 The goal is to be able to address tumors with more accuracy and minimize the exposure of healthy cells to the radiation. Further to the new equipment and technique developed to minimize the amount of collateral tissue damage associated with “poor aim” is the use of real-time imaging combined with real-time adjustment of the therapeutic beams to enhance photon beam accuracy and focal point. This new technology is called Image-guided radiation therapy (IGRT). This is also referred to as “four-dimensional radiotherapy”.191 Proton Therapy (PT) involves a different kind of radiation that does not use photon beams. Instead it uses proton beams. A proton is still ionizing radiation; however, the beams used in proton therapy have different emission characteristics that are presumed to allow for a more pin point delivery with lower exposure levels for the collateral tissues enroute to the target; less spread at the target; and, less penetration beyond the target than would be the case with conventional photon delivery.192 In a comparison of the effectiveness of IMRT, 3DCRT and PT in the treatment of localized PC the researchers Sheet et al. have reported that those treated with IMRT compared to 3DCRT have less associated gastro-intestinal problems; less post-therapy incidence of hip fracture; and, less need for additional cancer therapy; however, IMRT resulted in more erectile dysfunction. As well, Proton Therapy outcome was not significantly improved over IMRT; and, proton therapy had a greater incidence of associated gastro-intestinal problems compared to IMRT patients.193 Sometimes, instead of using external radiation an “internal” delivery is used. One method uses unsealed radiation introduced in the body by IV to target tumor. An example of this is the use of Selective Internal Radiation Therapy (SIRT) to address inoperable liver tumor. SIRT strategy involves the use of SIR-Spheres®. These small vehicles called microspheres are laced with radioactive yttrium-90. A catheter is emplaced through the groin into the hepatic artery of the patient and then millions of microspheres are injected and delivered directly to the tumor site. The irradiated microspheres emit Beta radiation and target the liver tumor with radiation that is approximately 40 times stronger than conventional radiotherapy while sparing healthy liver tissue.194 Branchytherapy, as already has been discussed, is another form of internal radiotherapy where a radiation source is placed inside or next to the area requiring treatment either permanently or temporarily.195 During radiation therapy the total dose is usually fractionated, which means it is spread out over time. This is done in order to minimize damage to normal cells OR to act on cancer cells during the most vulnerable parts of their cell cycle.196 Fractionation regimens are highly individualized between different countries, radiotherapy centers, and even between individual doctors. Sessions continue until a total cumulative dosage has THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

138

been received by the patient. If the radiation is delivered in smaller dosages several times a day it is known as hyperfractionation. When the radiation is delivered in several large dosages less than once a day it is called hypofractionation.197 Common short term radiation therapy side effects are expected and are usually most prevalent in the area that has been irradiated. The skin through which the radiation is aimed tends to change and may exhibit dryness, itching, peeling or blistering. Depending on the area of your body being treated nausea, diarrhea, fatigue, swelling and hair loss and trouble swallowing may also be experienced. For the most part, these are short term side-effects and usually go away a couple of months after the radiotherapy is halted.198 There are also long term side effects associated with radiotherapy that typically present 6 months or more after treatment. Any tissue that has been irradiated generally becomes less elastic over time due to diffuse scarring. This is called fibrosis. Sweat and the mucosa linings in the irradiated area can become dry. Hair loss on skin in the irradiated field can become permanent with single doses of generally 10 Gy or greater. Lymphedema or localized tissue swelling due to damaged lymphatic tissues can occur. In addition, there is a small risk of inducing secondary malignancies due to radiation therapy anywhere between 5 and 30 years after treatment.199 Further to the different types and strategy using RT are the clinical and trial combinations of RT with surgery, chemotherapy; non-conventional chemotherapy; and, even other types of RT, for example branchytherapy with IMRT. In 2010 a Phase III trial reported a substantial overall survival and disease specific survival benefit for the combined approach of Androgen Deprivation Therapy +RT in the management of patients with locally advanced Prostate Cancer with no significant increase in late treatment toxicity. In view of this data, the researchers suggested that combined ADT+RT should be the standard treatment approach for these patients. 200 In any case, the type of combination regimen and if and when they are applied is constantly evolving, particularly when it comes to advanced disease that has failed previous treatment. The intent is to improve on survival benefit. The appropriateness of combination RT therapy to your case is a matter to discuss with your oncologist.

Recurrence following treatment Cancer, when exceeding the bounds of the primary organ containment, invariably presents more difficult challenges in terms of cure. Any remaindered tissue still infected with disease following primary treatment is as well problematic. When I had my resection for colorectal cancer my surgeon was confident that his team had managed to remove all the infected areas. Nevertheless, he still referred me to the department of oncology for chemotherapy treatment. When I looked at the literature involving the clinical use of adjuvant chemotherapy I found something like a 16% better chance of 5

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

139

year relative survival for those who elected to undergo that adjuvant treatment at my stage disease. In a discussion with my oncologist it became clear that cancer was a microscopic disease that migrated and that fact was better not ignored. I figured that I could use the improved chances on survival so I proceeded with treatment. I had a colleague that had nearly the same condition as me and underwent resection without chemo. Less than three years later he was in relapse at stage IV with tumors in the lung and liver. He did not make it. I am glad I did what I could at the time to improve my chances. Anyone being treated for cancer should have a hard look at what the treatment options are and what habit can be changed or modified to improve the chances of remaining disease free. Despite best clinical or trial efforts to address the disease, sometimes there is failure of primary treatment. This means relapse from a “disease free” state and usually more treatment to address recurrency. Recurrency rates vary and depend on a number of factors including patient profile; previous treatment regimens; stage of disease; attitude; lifestyle habits; diet; and, exercise to name a few. For instance, in a study published in 2011, it was reported that current smokers have a 61% higher risk of dying from PC and a 61% higher risk of relapse compared to men who never smoked. Smoking was associated with more aggressive disease at diagnosis; and, current smokers diagnosed with non-metastatic disease had an 80% increased risk of dying from PC. Men who had quit smoking 10 years or more before had risks similar to those who had never smoked. Also, men who were current smokers had poorer outcomes in treatment with Emission Bream Radiation Therapy (EBRT); Androgen Deprivation therapy (ADT); and, radical prostatectomy. 201 To assist in diagnosis of relapse, biomarkers such as PSA are monitored. Often it is obvious from PSA values that the PC was not eradicated during primary treatment well before any physical symptoms of recurrency are obvious to the patient. PSA doubling is a concept used by clinicians to determine the rate of disease progression. This along with imaging such as FDG PET/CT scans, for example, assists in providing disease status upon which the need for further treatment is decided. Sometimes PC relapse will involve local recurrence, other times the disease may have migrated to other parts of the body and this as well can depend on the type of primary treatment involved. For example, in terms of primary treatment with radiation therapy it was recently reported that local recurrency usually occurs at the same site as the dominant primary tumor at baseline. 202 Relapse can occur then be arrested then reoccur. In 2011 a study involving 122 men who had undergone RT primary treatment failure then underwent salvage cryoablation to address local recurrency. As stated, salvage treatment just means the next round of treatment to address the relapse or remaining disease. In any case, of these patients 28% experienced a 5-year disease-free survival following salvage cryoablation.203 This means the remainder experienced more relapse in the 5 year period that resulted in death.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

140

Quality of Life (QOL) In hand with considerations involving relative survival for those afflicted with PC are the considerations for Quality of Life (QOL) and how it is impacted by PC treatment. In a review of current research in PC treatment between the years of 1999 and 2005, it was reported that those treated with prostatectomy; or, radiation including brachytherapy; or, cryotherapy; or, androgen deprivation therapy all experienced significant impact on QOL for men with local or advance disease whether in the short or long term. Alterations in sexual functioning cause the most pronounced reduction in QOL. 204 A review of measures to improve on the sexual function of those who have undergone nerve sparing radical retro-pubic prostatectomy (RRP) has reported that sildenafil citrate (Viagra®) has demonstrated efficacy as a PDE-5 inhibitor able to address post-RRP erectile dysfunction. 205

High Intensity Focused Ultrasound Therapy Before we leave this chapter I would like to point out the recent trial efforts, and, findings of high intensity focused ultrasound (HIFU) therapy which now seems able to address localized Prostate Cancer tumor using what amounts to be a “prostate sparring strategy”. According to the Prostate Cancer clinical guideline 58 released by Europe’s National Institute for Health and Clinical Excellence in 2008, High Intensity Focused Ultrasound (HIFU) therapy was then under trial for treatment of men with low, intermediate, and, high risk Prostate Cancer.206 In a study involving 41 men (aged between 45-80 years old with low risk to high risk localized PC and no previous treatment), it has been reported this year (2012) that 39 of 41 participants had no evidence of disease on multi-parametric MRI at 12 months following focal therapy. As well, there is a low rate of genitourinary side effects. The patients received focal therapy using high-intensity focused ultrasound (HIFU), delivered to all known cancer lesions, with a margin of normal tissue, identified on multiparametric MRI, template prostate-mapping biopsies, or both. 207 One wonders if this treatment may even be improved upon using imaging involving 11C-Choline PET/CT. Although the report must be taken in context of benefit after only one year following treatment, the success of this type of therapy would seem to me more than encouraging especially when considering the clinical treatment options for localized disease. Even more so that it reports a procedure that does not target and disable the entire prostate. How civilized. Let’s keep our fingers crossed that the 5 year disease free relative survival of these patients is even more encouraging.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

141

Chapter 5

Alternative Strategy & Prevention

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

142

I sometimes run into anecdotes by those in denial of their marginal or poor health who cite the longevity of a grandparent or a parent who apparently ate all the wrong things, smoked, never exercised, never saw a doctor and still lived to a ripe old age. To these comments I reply, we can only speculate how long they may have lived and how their quality of life would have been had they practiced a few good habits. The question is what is their example of habit doing for you? Dominant theory is that everyone harbors the ability to produce cancer cells. Fortunately, not everyone has cancer cells that progress and develop in a way that is beyond their immune system’s capability to defend against. The medical community is slowly coming to realize that each individual likely has a distinct immunological response that is either capable of keeping the cancer “seed” under control or not. The robustness and effectiveness of this immunological response is therefore becoming a focal point in cancer research aimed at both prevention and treatment. From all the clinical and trial treatments thus far used to address Prostate Cancer, it is clear that there are many varied approaches to treating the disease. One treatment may yield satisfactory results on one patient and on another be completely unsuccessful. This fact is because Prostate Cancer, like any other cancer, is a multi-dimensional disease and grows as a result of a wide range of influencing factors. These influencing factors combine to eventually compromise or overwhelm the host’s immune system. The trend these days in the mainstream medical community is to explore and use combined methods of treatment in an attempt to defeat poorly understood and robust cancer mechanisms that apparently have an ability to evolve resistance to some treatment regimens. These treatments involve combining changes to certain aspects of a patient’s diet, environment, and habit along with other more commonly practiced treatments such as surgery, chemotherapy and radiotherapy. The advantage to such treatment is that there is often a reported synergistic effect by doing this. A synergistic effect is one where the total effect of the combined treatment is greater than the result of each part if applied alone. Figuratively speaking, it is kind of like finding out that 1 +1 can equal 3. There are numerous legitimate studies that have been published in reputable and refereed scientific journals reporting results clearly in support of the benefits of these alternative strategies in helping to deal with cancer. Nevertheless, they stand in the wings and are not necessarily recommended or used. Generally, if you ask what else you can do to improve on your survivability beyond the recommended surgery, chemotherapy or radiation therapy, don’t be surprised if your physician responds by saying “nothing in particular”. I have an opinion as to why such a response is given. That opinion is based on what I have seen and heard in my own experience with our medical system and those who work in it. Firstly, the medical staff that handle you are at the “pointy end of the stick”. To be aware of all of the research while handing an unending patient load is a difficult combination of tasks.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

143

Secondly, cancer treatment has historically been shaped by the emphasis and rules of the medical community and regulating agencies overseeing it. With the exception of clinical trials, these rules and emphasis are such that only those regimens and drugs that are “scientifically and clinically” proven to be effective on humans are used and accepted. This means that “common sense” strategies, which should be a foregone conclusion, receive little emphasis. Modern medicine traditionally involves intervention with surgery, drugs and/or radiation. These methods are great for addressing trauma and isolated affliction. Except, Prostate Cancer is not trauma, and, when it is invasive, it is not isolated either. Thirdly, the medical community and the pharmaceutical industry feed off of each other. Both are big business. Funding availability and research direction align so that huge profits can eventually be realized with the development of drugs and strategies that can be “patented” and used for treatment. As such; directing effort to find a cure is not always the same as directing effort to make profit. In the meantime, patients are left to stumble onto these alternative strategies on their own because the larger part of medical community adhere to convention and are either not so versed or disposed to make the recommendations beyond that convention. Any physician going against convention potentially exposes themselves to the disapproval of their colleagues, funding bodies and their insurance underwriters. So they take care not to step too far away from convention. A prime example of this reluctance is demonstrated in the history involving direct and second hand exposure to tobacco smoke. Despite the obvious “common sense” association between tobacco smoke and lung cancer, it took the better part of twenty years before the majority of government health agencies and medical institutions were prepared to publish recommendations and warnings against the use of tobacco. Even then, tobacco is still government sanctioned, it is a legal product and remains a constant source of government funding through tobacco taxation. As well, you can go to any hospital and see the continued tolerance of patients in poor health pushing their IV rigs outside to have a smoke. The whole makes no sense when you consider the loss of life, and the economic cost of treating and maintaining those afflicted by the host of tobacco related disease. Such is the influence of big business on the delivery of healthcare. Nevertheless, occasionally there are those researchers, medical staff and institutions that boldly depart from conventional opinion and practice. In so doing, they produce the “unglamorous” studies and strategies that support “common sense” solutions that can be added to treatment and prevention regimens. Such strategies touch on the benefits of diet, environment, exercise and attitude. In addition to the common sense of said strategies, is the well-researched science that supports it. It is an unfortunate fact that it seems these alternate strategies are often left on the wayside until conventional treatment of cancer reaches the point of being ineffective or unavailable. This usually means that the disease has progressed to the point of extensive invasiveness or has fallen out of remission into a difficult relapse. It also means that

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

144

likely the patient already has damaged or missing organs, tissue, and immune system response due to the disease and its conventional treatment. In point of fact, alternate strategy can be adopted by anyone at any time to help boost or repair compromised immunological response. There are basically three ways to defeat cancer cells. Introduce an agent or procedure that can identify and kill or remove them outright; promote conditions of cancer cell apoptosis (cell death) whereby the cancer cells self-destruct; or, promote conditions that inhibit cancer cell angiogenesis so that they cannot grow a system of blood vessels. Your body’s immune system, when given the proper conditions and the right food, can do all of these things. Now, let us assume that the foundation of a patient’s immunological system is still relatively intact and responsive. Then apply a strategy designed to promote the recovery of the patient’s immunological response with the intent to revive the patient’s inherent immunological defenses. These defenses are what we have to address not only cancer, but, virtually all manner and type of disease. Existing and widely practiced conventional cancer treatment regimens are crude and inefficient replacement for the precision and effectiveness of our internal immunological defenses when they are working properly. So what would such a strategy involve in terms of the tangible and how is this to be applied? Well, the first thing to understand is that there is no silver bullet or magic snake oil to completely avoid or rid us of Prostate Cancer or any other cancer for that matter. The studies suggest; however, that there is a way to improve on our immunological responses by following some common sense habit and diet. Unfortunately, human nature being the way it is, change and following “common sense” habit and diet is, for most of us, a very difficult thing to do. Can you imagine the alarm and outcry of the general public if 40% to 45% of all commercial flights ended with a crash? Passenger service would be halted over night from public outrage and panic. Now consider that the probability of having cancer during their lifetime for the average Canadian is 40% - 45%. On the basis of current mortality rates one of every four Canadians will die from cancer.208 The World Health Organization’s International Agency for Research on Cancer (IARC) has released its 2008 report on cancer. In this report the IARC expects that by the year 2030 there will be approximately 27 million new cases of cancer annually; another 75 million people will be within 5 years of having been diagnosed with cancer; and 17 million cancer deaths will occur every year.209 Even with such blatant fact and projection everyone seems blissfully content to pay no attention and continue with habits and diet that are totally inconsistent with the high risk involved. IT MAKES NO SENSE!!!! We all like the food that we grew up on, it gives comfort and a sense of home. To abandon our accustomed dietary habit is, like abandoning our heritage and identity. Further, we are all slaves to the stresses imposed by residing where we do at this point in time. The practical rigors of making work and home function can be formidable and not

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

145

at all conducive to good health or healing, especially if there are chronic problems with work or home. In any case, if your immunological system is to be restored or boosted, a more hospitable balance must be found and this will involve change. Be advised, of those that do manage to accommodate such change, it may be a long slow road to repairing and regaining the health of your immunological system. It can take years and there are no guarantees. So patience, tenacity, resolve, and faith are all required ingredients. My suggestion is to adopt the changes early on, ideally, well before you are ever afflicted with a disease like PC. For those who are already with the disease, the sooner one starts the sooner one will see results. Your motivation must be to improve on your baseline health so you can enjoy a better quality of life and live longer. For me this motivation is made easy because I have a mate that has gone through the loss of her mother to terminal breast cancer; and, experienced her own treatment and recovery from an auto-immune disease as a teenager. In response my mate tailored her own “stay healthy” routine, which was a pretty good example of how I should proceed with the issue in terms of diet and exercise. In considering my mate’s informal guidelines, I find striking commonality with the suggestions in Dr. David Servan-Schreiber’s recent book, Anti-Cancer A New Way of Life. For those of you who do not know, Dr. Servan-Schreiber is a physician, researcher, author, public speaker, and, a survivor of brain cancer. In his fight with cancer he has been through surgery, chemotherapy, radiation therapy, remission, relapse and more treatment. At some point in all of this fight, he made a comprehensive review of the scientific literature on the subjects of diet, environment and habit to understand their effect on the immune response. This review is reflected in his book. It is encouraging to have a prominent member of the medical community open the curtain to all the research that has been going on with alternative cancer strategy. I hope that it promotes a more receptive attitude to the value of such strategies within the medical community. Predating Dr. Servan-Schreiber’s book are the efforts and work by Dr. Richard Béliveau and Dr. Denis Gingras, who have done a phenomenal job researching the content and chemistry of foods that fight cancer and relaying that research in accessible books such as Foods that Fight Cancer: Preventing Cancer Through Diet. When I speak of change I am a realist. I understand that the average person is bound by circ*mstance and is not usually in a position economically or otherwise to adopt and nurture grossly different routine. Living alone may make change even more difficult. Nevertheless, the idea is to review your daily habits and see what small changes can be made to help improve your immune response. Small changes that can be maintained are better than sweeping changes that are abandoned out of frustration from apparent lack of result or resource. Further, small changes that occur 2 or 3 or 4 times a week regularly, are better than no changes at all. These represent a beginning to more changes that can be accommodated after you

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

146

become accustomed to and encouraged by the result of the changes that came before. I say again, sustained small changes are better than no changes at all.

Diet My intent with this section is to give an overview of what the considerations in diet should be if one is concerned with enhancing the immunological response over the long term. It is a “short list” of what is affordable and easy to implement. It is not intended to be a replacement for consultation with qualified medical nutritionists in combination with your treatment. It is intended to get you started on the right track and explain a few basics. Modern agriculture and food production introduces a host of pesticides, preservatives, plastics, and other synthetic compounds into our food, both directly and indirectly. “Processing methods” used on our food further alters and reduces the content of the chemical molecules naturally found in different foods that can have a beneficial effect on our immunological response. Guidelines are dictated by government bodies regulating farmers and producers to adhere to “acceptable” levels of certain compounds. As well, governments publish daily recommended dietary intakes of food types. Unfortunately, there is little consideration paid to the notion that the average consumer has no regard or understanding of what the daily requirements are for most aspects of their diets. Nor do they have an understanding of even how to assess them. Nor do they care, for the most part. It has been my experience that the average person who is eating meals and snacks every day, several times a day or more, does so simply because they are feeling “hungry”. They have no regard for any possible health benefits or daily allowances. Policies that publish daily recommended allowances are doomed to failure simply because they ignore this fundamental lack of regard. Further, although the health benefits of factors such as higher ratios of Omega-3 have been clearly identified and publicized, the majority of food production still avoids methods that could enhance the compliment of such factors in our food. All to say, the food industry is an enormous industrial complex intertwined with local, regional and federal government policy and consumer habit. It is not going to change in the immediate future. For the moment, the only concern should be to identify and find suitable produce and product so that we may satisfy our immediate need for immunological repair or boost. When it comes to diet a familiar saying resounds in my head “You are what you eat”. Of course, this is nonsense in the literal sense because none of us is going to turn into a piece of corn, a chunk of a beef or a head of lettuce. What is more the case is that we humans are at the top of the food chain. When we eat anything we generally absorb all of the elements that particular “tasty” has eaten or been exposed to. The same is true for drink.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

147

In our ignorance or denial we typically plod along eating foods that undermine our immunological system. Of course, due to the fantastic resilience of the human body, we get away with it for a while. Later on though, it does catch up to us and compromises both quality and length of life. Much attention and publicity has been given to the beneficial results of antioxidants as a way to minimize or undo damage in our bodies that occurs because of “free radical” reactions. It is widely theorized that this free radical interaction contributes to cancers and that anti-oxidant intake in humans has clinical benefits. Research to that regard is ongoing but has yet to provide conclusive evidence.210 For those who don’t know, anti-oxidant theory considers the following: We humans are basically one big bundle of ongoing chemical reactions. Many of these chemical reactions release molecules or atoms in an unstable (free radical) state as byproduct. This instability allows free radicals to easily react with other molecules that they should not be reacting with. The result can cause chain reactions that confound all kinds of cellular processes and structure to the point of even killing cells. Long term or substantial free radical reactions either exhaust or overwhelm the body’s ability to repair lost and damaged cells. This can lead to disease and is the essence of aging. Anti-oxidants are molecules that have an ability of neutralizing free radical molecules without becoming free radicals themselves. This idea is that intake of antioxidants through dietary sources, for example, protects cells from damage due to free radicals.211 Dietary sources of anti-oxidants include vegetables, fruits, nuts, grains, some meats, poultry, fish and green tea. The list below details some common antioxidants and some of their dietary food sources. Type of anti-oxidant nutrient and dietary sources are: Beta-carotene- sweet potatoes, carrots, cantaloupe, and squash, apricots, pumpkin, mangos, collard greens, spinach, and kale; Lutein – egg yolk, corn, kiwi, grapes, spinach, zucchini, and orange peppers; Lycopene - tomatoes, watermelon, guava, papaya, apricots, pink grapefruit, and blood oranges; Vitamin A – liver, kidney, carrots and carrot juice, sweet potatoes, pumpkin, spinach, collards, and kale; Vitamin C (ascorbic acid) – citrus fruits their juices, green peppers, strawberries, tomatoes, broccoli, sweet potatoes, cantaloupe, papaya, mango,

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

148

watermelon, brussel sprouts, cauliflower, cabbage, winter squash, red peppers, raspberries, blueberries, cranberries, and pineapples; Vitamin E – wheat germ oil, almonds, sunflower oil, safflower oil, hazelnuts, peanut butter; and, Selenium – is a mineral not an antioxidant nutrient; however, this mineral is a component of anti-oxidant enzymes. Produce grown in soil rich in selenium, as well as, stock reared in selenium rich regions will have higher levels of selenium in their tissues that will be passed on to you when you consume them. 212 Now let us briefly examine the foods that we eat being mindful of what promotes good health or not. It is not my intention to be exhaustive in this regard. There are numerous books by reputable nutritionists that are far better in detailing a comprehensive list. I simply want to point out some obvious and common food sources that should be avoided or at least reduced and those that should be given priority in your diet. General rule: Food that is processed, or fried, or smoked should not be regarded as a suitable main meal. As well, red meat and alcohol taken in excess is not a good thing to do. This does not mean that these foods are totally taboo. What you have to do is change the way you regard these types of food. If you want to eat food of this type then do so only occasionally and in moderation. In short, they are to be regarded as a rare “treat” instead of a regular staple.213 When I was a child the only time I could count on having a hamburger was in the fall at a local county fair. That happened once a year. French fries were something that occurred a couple of times in the summer when the seasonal “chip stand” opened up in my home town. I didn’t even taste a pizza until I was 12 years old. You have probably gathered by now that I did not grow up in a large urban center. Nevertheless, the point is still valid. I used to thoroughly enjoy these small treats now and then, but, they were not part of my regular diet. Metabolic process is the way we take in fuel (food) and turn it into useable energy. This “useable energy” is called ATP (adenosine triphosphate) in a human. It is derived mostly from metabolic pathways in the body that convert food into simple sugars. These days a Western diet is largely composed of starch, sugar and meat. The proportions of these foods have evolved since the 1940’s to the point now where most of us consume a staggering amount of refined sugar and starch originating from cane, sugar beets, corn and wheat. What this means, in terms of human biochemistry, is that in digesting this pile of sugar and starch, our metabolic processes produce very large amounts of simple sugar in the form of glucose and fructose. Glucose and fructose are then further processed or

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

149

metabolized in our bodies to meet our cells’ energy needs. When there is too much for our bodies to use, much of the excess is converted and stored in the body. Excess sugar and starch consumption contributes to obesity, cancer and a host of other sugar induced illness.214 This excess consumption is easily controlled if you simply start eating more vegetables or fruits during the course of the day when you feel hungry and use a bit of moderation as to the amount of food intake during a day.

Sugar, Starch and other things Sweet In reviewing a bit of sugar information let us consider the following: 1) There are a number of sugars; however, our bodies can convert the simple sugars glucose and fructose into energy. Glucose and fructose are both monosaccharides. A monosaccharide means “single sugar” and refers to the chemical structure of these sugars. Galactose is also a monosaccharide but does not contribute to our cells energy needs to the extent that fructose and glucose does. Glucose, fructose and galactose have chemical structures that are best referred to as simple sugar “units”; 2) A disaccharide means that two simple sugar units are married together. Sucrose, maltose and lactose are examples of disaccharides. The composition of the two simple sugar units determines which disaccharide is formed. For example, sucrose is made up of a unit of glucose and a unit of fructose; and, 3) Starch is what is known as a polysaccharide. Poly means “many”, saccharide means “sugar”. A polysaccharide is basically a very long chain of simple sugar units joined together by either Alpha or Beta linkages. Starch is a polysaccharide that is formed with Alpha linkages and it is broken down into simple sugar units that are further metabolized into the fuel used by our cells. Humans have the necessary enzymes to easily break down the Alpha linkages, but not so effectively the Beta linkages. An example of a polysaccharide with Beta linkages is cellulose. Cellulose is “roughage”. We don’t digest roughage so well. In short, roughage moves along our digestive tract and exits without much contribution to our metabolic needs; starch and sugars, on the other hand, are main dietary contributors to our metabolic needs. Consumption of roughage is necessary. Roughage serves to normalize bowel movements; helps maintain bowel integrity and health; lowers blood cholesterol levels; helps control blood sugar levels; and, aids in weight loss. 215 As you have probably heard a thousand times, eating more whole grains (like spelt, bran and flax) and a range of vegetables will satisfy your requirement for roughage. Other sources of the “sugar fuel” used by our cells can be derived from the consumption of synthetic sugars like HFCS (High Fructose Corn Syrup). HFCS is a sweetener used in a whole bunch of processed foods, drinks and candy. Although it is often labeled as “natural” on the ingredient lists of many products it is not natural. It is

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

150

the synthetic result of an enzymatic refining process whereby the amount of fructose is controlled. This idea is to produce a sugar that approaches the sweetness levels of regular white sugar (sucrose). There are three types of HFCS. These are HFCS -42, -55 and,-90. HFCS is composed of the following ratios of fructose and glucose: HFCS-42 is 42% Fructose and 53% Glucose; HFCS-55 is 55% Fructose and 42% Glucose; and HFCS-90 is 90% Fructose and 5% Glucose.216 There has been a lot of discussion over the years as to the benefits of natural sugars versus refined sugars versus artificial sweeteners. To clarify the differences; all natural sweeteners that find their way onto our tables as syrup, a tablet, a powder or granules have been extracted and refined. In simple terms, there are basically six naturally derived sugars. These are fructose, glucose, galactose, lactose, maltose, and sucrose. Fructose is the sweetest of the natural sugars and occurs in fruit and plant extractions such as maple syrup, honey, corn syrup, sugar cane, and sugar beets.217 Agave nectar is composed of fructose and glucose. Depending on how it is processed, agave nectar has been reported to have up to 92% fructose in it.218 Fructose and sucrose are the two natural sugars commonly found on our tables. Lactose is the sugar that is naturally in milk. Maltose is the sugar found in germinating cereals like barley. It is used commercially in the brewing of beer. I found that there can be substantial differences in the reported ratios or percentage of natural sweeteners. In in rough approximation the sugar composition of some natural sweeteners is as follows: Agave nectar HoneyMaple sugarMolasses-

92% fructose, 8% glucose; 48% fructose, 39% glucose, 9% maltose, 2% sucrose; 2% other 95% sucrose, 4% glucose, 1% fructose; and, 54% sucrose, 24% fructose, 22% glucose.

Healthy cells generally rely on energy released from a chemical reaction that combines glucose with oxygen in the body. This reaction is called aerobic respiration. This is a very efficient chemical reaction, which means it does not require a lot of energy to make it happen and it gives off a lot of energy in return. According to the Nobel Prize recipient Otto Warburg, glucose is essential to the metabolism of malignant tumors, as well as, normal tissue growth and maintenance. From his work it was discovered that malignant tumors, unlike healthy cells, reside often in an anaerobic state.219 An anaerobic state is one where oxygen is in relatively short supply. This is probably because of the confused spaghetti-like strategy of angiogenesis that cancer cells typically exhibit. In this anaerobic state, the cancer cells rely on the fermentation of glucose to produce energy and grow. This fermentation process is called glycolysis which is also known as anaerobic respiration.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

151

Unlike aerobic respiration, glycolysis is a very inefficient chemical reaction. Aerobic respiration produces a net release of approximately sixteen times more energy than glycolysis for the same amount of glucose processed.220 This means that cancer cells need a lot more glucose fuel to support cellular activity compared to normal cells. Glucose actually has two forms. The one that occurs naturally in higher living organisms like us is called D-glucose. It is also known as Dextrose. This form of basic sugar is what our internal processes can make out of the food we put into our bodies. It is fundamental to the way we make energy. For the most part, this conversion of food into energy is generally done through two common metabolic pathways. One is called aerobic respiration, and the other is called glycolysis or anaerobic respiration.221 There are other metabolic pathways that are in play as well; however, these other pathways are generally not as significant as aerobic respiration and glycolysis. Healthy cells relying on aerobic respiration can “make due” with substantially less D-glucose compared to cancer cells relying mostly on the process of glycolysis. Malignant tumor cells need an abundance of D-glucose to develop and spread. Anyone taking in large amounts of refined sugar and starch is providing a convenient stockpile of raw material that cancer cells use to satisfy their energy needs. So, as cancer fighting strategy #1 take control of their fuel lines by cutting down on your intake of dietary sugar and starch. The healthy cells will not suffer because they can do just fine with less than the average Westerner eats in the course of a day. This means lay off the desserts, sweets (especially soft drinks), and excessive amounts of wheat based food like breads, pizzas and pastas. To continue, many processed foods that are advertised as “sugar free” actually list what is described as “sugar alcohols” as sweeteners. These are in fact not sugars or alcohols. Instead they are carbohydrates that have chemical compositions that are similar to either sugar or alcohol. Typically their sweetness is less than or equal to sucrose. They as well have caloric value. Falling into this category of sweeteners are sorbitol, mannitol, xylitol, erythritol, isomalt, lactitol, and maltitol.222 Although digestible, the long term effects of consuming these sweeteners is not really understood. As such; I personally avoid them since I don’t know what they can do to me. The reason why I am so dubious of any unnatural sweetener over the long term is founded in the history behind the sweetener called saccharin. Saccharin is a nonnutritive sweetener that has been around for about 100 years. A non-nutritive sweetener is one that has little or no caloric value. This sweetener was discovered by researchers working on coal tar derivatives. About thirty years ago it was reported to be causing cancer in animal studies. The food and drug administration (FDA) “black listed” it but since then some 30 human studies have reported it fit for human consumption and so saccharin is back on the shelf again.223 As far as I am concerned, I would prefer not to take the chance. In this category of “non-nutritive” sweeteners are a number of compounds that range between 160 and 13,000 times sweeter than white sugar. They have been

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

152

popularized by those seeking to lose weight by reducing the number of calories in their diet. The long term effects of all of these are poorly understood in a large scale human population. All of these “non-nutritive” sweeteners carry recommended daily amounts not to be exceeded. Some of them are either correlated in studies or associated by anecdote with side effects such as nausea, hair loss, abdominal pain, dizziness, induction of lupus, depression, dementia, confusion, and even cancer. Among these “non-nutritive” sweeteners are saccharin, aspartame, sucralose (which is trichlorogalactosucrose, yes, that means it has chlorine in it), acesulfame K (contains the carcinogen methylene chloride), and neotame.224 Again, I would rather simply reduce the amount of sugar I eat and get used to the lack of sweetness rather than take the chance.

Toxic Contamination and Organic Produce Modern farming and food production methods can introduce a variety of toxins into our food and water supply. In my view, some consideration should be given to consume food and drink that will minimize your intake of toxins so as to reduce the overall stress on your immune system. Later in this chapter there is a discussion on the foods that are best to eat in terms of fighting cancer. As an aside, be aware of “where” the produce comes from. Some countries have vastly different ways of policing their producers in terms of contamination rules. If you intend on eating cultured fish regularly ensure that your supply of fish is not being reared on contaminated feed. There is an ongoing local study in Montreal right now reviewing the frequency of consumers with high levels of mercury due to cultured fish consumption. This most likely is the result of rearing cultured fish on feed containing high levels of mercury. Mercury poisoning damages the central nervous system, can result in all sorts of nasty side effects and can even cause death. It is something we can certainly do without. Organically farmed produce is a new trend making its way into most major supermarkets. Although not strictly regulated, those who advertise organically farmed produce generally are using techniques that stay away from heavy reliance on pesticides, hormone augmentation to promote quick growth, genetically altered feeds, and forced rearing strategies. In so doing, these farmers should be bringing stock and produce to market that are comparatively much lower in contaminants and unaccustomed alteration. As well, in using a strategy of “grass feeding” their stock and fowl, the ratios of Omega-3 fatty acids to Omega-6 fatty acids in the meat, dairy and eggs of that livestock and fowl is much higher. Higher Omega-3 to Omega-6 ratios reduces inflammation, fat storage, and, growth of cancer cells.225 More specifically, Omega-3’s are needed for synthesis of anti-inflammatory molecules and are linked to reduced risk of breast, prostate and colorectal cancer. Excess Omega-6 fatty acid in the body is linked to chronic illness like cancer and cardiovascular disease.226

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

153

Do not misunderstand to think that we do not need either of these fats. They are both essential. Omega-6 competes with Omega-3 for the same rate limiting enzymes; and, higher ratios of Omega-6 to Omega-3 shifts the body’s tissues toward pathogenesis (the generation of disease).227 The problem is that modern Western diets typically have high amounts of Omega6 polyunsaturated fatty acids. These diets have high Omega−6 to Omega−3 ratios reported to fall at or slightly above 15:1. Optimal ratio of Omega-6 to Omega-3 fatty acid is reported to be much lower. For example, in the case of CRC it was reported that a ratio of 2 ½:1 reduced rectal cell proliferation. 228 On a practical note, one drawback to organic product that I have found is that it typically costs more than non-organic. Unfortunately, this is probably a major reason why people do not buy the food labelled “organic”. If you have been avoiding organic food simply on the principle that it should not cost so much, you must understand that organic methods have lower yields than conventional farming techniques. So if the farmer is to exist they have to charge more. If you cannot afford organic food, then at least make sure you properly wash your fruits and vegetables with soap and water. Peeling off the skin can also help reduce intake of toxins. Eating wild game is an effective alternative to non-organic meats and fowl. As well, replacing a large part of your meat and fowl with more ocean caught fish will help. Your Omega-6 to Omega-3 ratio can be lowered by boosting the intake of Omega-3 fatty acids. Eating fish, whole grains, fresh fruit, vegetables, cold pressed olive oil (virgin), garlic, and having a daily glass of wine (red) at mealtime will do this.229 For those who don’t know, “cold pressed” means the oil is extracted without the use of heat. Oil extraction using high heat levels usually alters the oil’s chemical structure. The result is that the oil is changed into a hydrogenated fat. Generally speaking, hydrogenated fats are bad for you. Reducing the amount of hydrogenated sunflower oil, corn oil, soybean oil, margarine and any other hydrogenated fats in your diet will also lower your ratio of Omega-6 to Omega-3 fatty acids, and again, is exactly what you want to do. Be aware, Omega-3 fatty acids are not stable and break down into elements that do not have the same anti- cancer and anti- inflammatory benefits when they are left on a shelf for a period of time as is the case with store bought Omega-3 supplements. It is therefore important to seek out dietary food sources of Omega-3s to ensure that your Omega- 3 intake is beneficial.230 One last thing before we leave this bit of discussion on Omega fats; don’t get lulled into paying more for food at the grocery store because it has a sticker on it saying that it has a higher content of certain Omegas. In short, an egg is an egg is an egg. Stickers and advertising does not make it have any more Omega content than the ones without the advertising that cost less. As far as drink goes, measures to reduce toxin can include running your tap water with a good carbon filter at home. If you drink tap water from a treated municipal supply THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

154

without any home filtration, pouring the water into a container that is openly exposed to air for approximately 24 hours will reduce the chlorine levels in your water. Although the levels in your municipal drinking water are considered safe, chlorine is a known mutagen or agent that causes mutations. As well, it was used quite effectively in WWI as a weapon. The less intake of chlorine you have the better.

Metronomics A metronomic regimen is a treatment that calls for relatively low grade amounts of drugs or compounds to be administered under a continuous schedule to combat disease. Unlike conventional regimens of chemotherapy, for example, metronomic regimens are better suited to long term strategy to prevent, suppress or keep disease from recurring. It is with this strategy in mind that doctors Béliveau and Gingras, both prominent researchers in the effects of foods on cancer at the Université de Montréal, have investigated the use of food as a natural way to continually deliver anti-cancer compounds to the body. This is known as nutratherapy.231 Foremost in their research is the notion of depriving the cancer cells of food and oxygen. This can be done most effectively by limiting or preventing the formation of blood vessels specifically made to supply cancerous growth. Compared to Western society, there are those cultures that typically have lower incident of certain cancers. Research into the diets of these cultures reveals the intake of foods and spices whose chemistry has been found to have anti-cancer properties when consumed in quantities that are similar to those of their related cultural diet. These foods feature a wide range of natural chemicals that can act either independently or in combination to substantially reduce the ability of cancer to develop. Such chemicals are known as phytochemicals and include polyphenols, terpenes, sulfides, and saponins. Phytochemicals are also what is used by plants to defend themselves against microorganisms, insects and animals.232 According to Béliveau and Gingras, there are a few foods and drink that are reported to have a specific inhibiting effect on the growth of Prostate Cancer. These are green tea, garlic, soy, tomatoes, onions, leeks, shallots, cabbage, cauliflower, broccoli, brussel sprouts, turnip, kale, watercress, and collard greens. In addition to these there are a number of other foods (some of which are from related food family to what has already been mentioned), spice and drink that have known cancer inhibiting properties. For example, citrus fruit, grapes, raspberries, cranberries, turmeric combined with pepper, and red wine.233 As you can see these foods, spice and drink are easily found at most grocery stores. What is important is that you alter your diet to incorporate some of these foods in your meals every day. Eventually, when you and your family become more used to eating these types of vegetables, you can gradually evolve your meal content so that the bulk of the meal is made up of vegetables and fruit instead of the meat, fowl or fish. You

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

155

can also evolve your diet so that over time it is mostly made up of the foods mentioned above. When I refer to you and your family I do so intentionally. The following are my reasons for including family in this effort. First, it is much easier to make changes to diet or lifestyle if you have the support of those around you. Being constantly faced with temptation and opposition by members of an entire household, who are neither interested nor participating, makes the task of change really difficult. Second, if you or someone in your family has been diagnosed with cancer, this is the proof that your present conditions can conspire to cause illness. It is time to do something for those already afflicted, and those who could become afflicted if allowed to proceed on the same path without change. Do keep in mind that the recommendations of this type of diet are outlined to lend a stronger hand to those who are either fighting PC or in remission. For these persons, it is important that larger changes are made sooner than later. It is important that such change becomes a way of life. For those who do not have the disease of cancer but are concerned, adopting these changes in your diet and habit gradually will help to make you that much more the resistant to any disease and is certainly a healthy way for you and your family to proceed. To continue, the research suggests that additional cancer slowing benefits are found by using spices from the Terpene family in your meals. Terpene family spices include mint, thyme, marjoram, oregano, basil and rosemary.234 Ideally, the fresher these spices are the better they are for you. This means have a look in the vegetable section of the grocery store for small bundles of fresh herb. These can be used in meals and, in the case of mint, can be decanted as herbal tea. Rosemary has also been found to have a synergistic effect when combined with chemotherapy. The spice that has been found to be a powerful anti-inflammatory and cancer inhibitor is turmeric. Commonly found in Far and Middle Eastern food, its active ingredient is curcumin. Anyone who has eaten chicken noodle soup out of a can is familiar with the yellow color and taste of turmeric. These days you can find this in the spice section of any grocery store and it is inexpensive. Turmeric is one of the main spices in curries. Research has also found that combining turmeric with pepper increases absorption of turmeric by two thousand times.235 So don’t forget the turmeric and pepper next time you make a curry or Cajun shrimp! So far we have discussed food that basically addresses the main course of a meal. Now let’s look at what can be used in terms of snacks, desserts and drink. Reducing sugar and starch intake effectively rules out most of the “goodies” that we typically indulge in between and after meals. Unfortunately, this is something that must be done. So what is a suitable substitute for these goodies? Thankfully there is the berry. According to research, strawberries, raspberries, blackberries, cranberries and blueberries are strong detoxifiers and inhibitors of cancer cell angiogenesis. Their

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

156

active ingredients include polyphenols and ellagic acid. Berries can be fresh or frozen without diminishing the effectiveness of the active ingredients.236 In addition, 70% (or higher) dark chocolate contains polyphenols to the extent that a very small amount (a couple of small squares a day) has an effect in slowing the development and spread of cancer cells. Of course, 70% dark chocolate has some sugar in it, so eat it sparingly! As well, you should know that mixing milk with dark chocolate cancels is cancer slowing effects.237 The logical extension of this is to stay away from milk chocolate. So between the fruit, a bit of dark chocolate and your imagination, you should be covered for dessert and snacks. Next is drink. The most obvious of drinks that will assist in your fight against cancer are those blended from the list of berries above. They can be mixed with ice, water, or other juices. If you are going to use commercial juice be mindful of the amount of sugar in the juice. Remember, you are trying to keep the sugar content down. Pomegranate juice is a detoxifier, anti-inflammatory and slows the spread of cancer.238 It has been one of the staple drinks in the Middle East for centuries. Unfortunately, it has been my experience that in most grocery stores, the available pomegranate juice is filled with sugar, to the point where the juice is almost undrinkable. The alternative to this is to go to a health food store and pick up pomegranate juice that is usually not sweetened at all. I like to mix it with sparkling water at the dinner table. One of the side effects of my platinum based chemotherapy was that the throat became really uncomfortable with exposure to anything even remotely cold. The effect felt like you were drinking jagged ¼ inch particles of slush ice (without the brain freeze). Beverages and food had to be room temperature or warmer to avoid the effect. I also found that anything sweet, in terms of a beverage, made me feel even more nauseous than I already was. Still I had to keep my liquids up and so I struggled to find something I could drink. It was then that my mate introduced me to green tea. After I did a bit of reading I found that apparently most of the world knew about green tea except me. Even more surprising was the reported property of green tea to inhibit cancer cell angiogenesis in the literature. The active cancer inhibiting ingredient in green tea is a chemical called epigallocatechin gallate (EGCG). 239 The green tea has to be allowed to steep for about 10 minutes before drinking and must be drank within a couple of hours of steeping or it begins to lose its cancer inhibiting properties.240 I also found that green tea comes in an assortment of flavours, which makes it easy to substitute if you are already accustomed to drinking Tisane. Further, no sugar is required. Also, you can just buy plain green tea then flavor it yourself by adding herbs like mint leaves or citrus peel or berries to the steep in with the tea. If you are considering drinking black teas instead, be aware that black tea is green tea that has undergone a fermentation process. The unfortunate result of this fermentation is that the tea loses its cancer inhibiting property. So black tea is not beneficial to drink in terms of a cancer inhibitor. Another drink that is full of cancer

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

157

inhibiting chemicals is citrus juice. The zest (peel) and juice of orange, lemon, grapefruit, and lime are all good for you in this regard.241 The last drink I will discuss it one which has enjoyed a considerable amount of recent publicity as to its health benefits. This drink is red wine. Red wine typically has about 12% alcohol content. Alcohol is something that is very easily converted into fat in humans. Alcohol is also a poison, so it does impose stresses on the body in order to process it through the liver. Red wine contains substantial levels of polyphenols that slow the development and spread of cancer.242 All to say, if taken in moderation with a meal, red wine can be a pleasant and effective addition to your anti-cancer diet. The next big question is HOW MUCH of this stuff should one be eating and drinking every day? The answer is that it amounts to about a total of 2 – 2½ cups of “core” fruit and vegetable matter per adult every day. When you think of this in terms of 3 meals, it really is not that much. There is nothing to prevent you from adding other vegetables, fruits and nuts to this list to round things out. As well, small portions of protein in the form of red meat, fowl, and fish can be included. Just keep the portions small. May I suggest around 200 grams (3-4 oz.) per serving, so forget about the 28 oz. steaks even if it is barbeque season!!! I know you think that you are going to starve; but you won’t. The following is what I try to take in (along with a daily serving of a protein like fish or a small portion of foul or meat) during an average day: Garlic

2 cloves

Onions, shallots

½ cup

Cauliflower, broccoli, cabbage

½ cup

Spinach, watercress

½ cup

Flax seeds (finely ground)

1 tablespoon

Turmeric

1 teaspoon

Black pepper

½ teaspoon

Raspberries, black berries or blueberries

½ cup

Citrus fruit Juice

½ cup

Green Tea (steep for 8-10 minutes)

3 cups

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

158

Red Wine

1 glass

Dark Chocolate (70%)

40 grams

In addition, tomatoes, asparagus, fiddleheads, red chicory (radicchio), turnips, beets, and eggplant are all vegetables with anti-cancer properties that can be substituted now than then to lend some variability to the core of your diet.243 This list is for the most part derived from the pocket guide detailed in Béliveau and Gingras’ book Foods That Fight Cancer. It is not exactly the same but I think it is a good start. The differences are because there are foods in their list that: a) I simply do not like (so call me fussy); or, b) I don’t want regularly in my diet (for instance soya). In any case, be sure to take your time and chew your food well. This allows a better release of the chemicals you seek to introduce to your diet. If you don’t already do it, it is time to get used to not overcooking these core foods. Overcooking alters their chemical effectiveness. This should be easy since the above vegetables are typically served up in salads as well as braised, boiled, broiled, pureed into soup or stir fried to name a few ways. There are two controversies that seem to persist in terms of what to omit or add to this anti-cancer core diet. The first involves Soya. Although soya has known polyphenol content, it has been reported that Soya is linked to the increased frequency of breast cancer in animal models. On the other hand, there are studies that point out the benefit of Soya intake to inhibit both prostate and colorectal cancer (CRC).244 Again, I prefer to be more conservative and not take the chance of introducing something that can actually promote another cancer. The second controversy is in the use of dietary supplements. During one of my chemotherapy sessions I sat in the oncology ward while hooked up to my port-a-cath and listened to a very ill old man undergoing treatment himself. In his impatience he asked the floor nurse why they did not have a bottle of liquid or a pill that could be taken and be done with all this fuss of treatment. His comment made everyone in the room smile, as we all thought “what a great idea”. Unfortunately, as I have already stated, there is no magic pill. When it comes to phytochemicals the facts and research do not support the use of phytochemical supplements as a substitute for dietary sources of phytochemicals. The reason for this is that phytochemicals are notoriously unstable and they deteriorate quickly and lose effectiveness when outside of the protective cell walls of the plants from which they come. As a result, by the time the supplement has been shipped and sat on a shelf then consumed the remaining content of an active phytochemical in the supplement tablet can be absurdly low.245

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

159

Secondly, the research has only identified a small part of all the phytochemicals in each plant. It is entirely likely that there are complex chemical mechanisms that act in the dietary intake of phytochemicals that are either fundamental or contributory to the overall anti-cancer effect. It cannot be assumed that any one phytochemical, taken in the form of a supplement, will have beneficial results.246 Thirdly, in the case where the supplement is very fresh, higher doses of chemicals do not necessarily give greater benefits. In fact, over supplementing can confound your absorption system, making it less effective in recognizing and taking in natural molecules that actually have a beneficial result.247 In summary the dietary recommendations are to: 1) Relegate processed, smoked and fried food to the category of “rare treat” instead of regular staple; 2) Drastically cut back on your consumption of starch and sugar; 3) Cut down on your intake of red meat and alcohol. Drink one glass of red wine with your evening meal as a normal habit; 4) Evolve your meals and snacks around more fruits and vegetables, and whole grain items as well, don’t forget to keep the roughage levels up; 5) Introduce foods that are less contaminated by modern farming and lower your Omega-6 to Omega-3 intake ratio. This includes substituting ocean caught fish for non-organically raised meat and fowl. Be aware, the larger the fish caught in the ocean, the higher it is on the food chain and the more contaminants it carries. So eat the smaller ones; and, 6) Rely on natural intake of phytochemical through your diet (instead of supplements).

Attitude and Environment In my first two sessions of chemotherapy I spoke to several of the floor nurses in the oncology ward about treatment and survivability. They were all quick to volunteer their anecdotes and opinion on the value of maintaining a positive attitude and having the support of someone who cares. As I tried to piece together the causes of my cancer in the literature it became obvious as to just how effective the body’s immune response is in fighting disease. It also became clear to me that the effectiveness of those defenses can be impacted both negatively and positively by external influences. Then I started thinking about all the negative influences that may have played a part in the development of my disease. One

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

160

of the undeniable factors that had been consistently there throughout the last ten years prior to my diagnosis was the element of psychological stress. Stress can be divided into two types and are either short-term (acute) or longterm (chronic). The reactions to acute or chronic stressors cue behavioral and biological responses in humans which can manifest themselves physically, psychologically and physiologically.248 Acute stress is the reaction to a perceived immediate threat. The presence of an actual threat is not necessarily required to cause the response. Instead, it is the perception of a threat that is important. Such acute stressors typically elicit what is known as a “fight or flight” response. This response is typically deactivated when the perception of the immediate threat is gone and this is called the relaxation response. Examples of acute stressors are noise (which can illicit response even during sleep), competitive endeavor, trauma, exposure to dangerous event, or the recollection of exposure to dangerous events.249 Chronic Stress is the reaction to stressful situations that are persistent and not short-lived. “Fight or flight” response is generally not appropriate to chronic stressors because the chronic stressor carries an element of omnipresence (being everywhere). This means that they are part of the fiber and weave of the individual’s environment. With this omnipresence is the perception or reality that the stressor cannot be defeated or escaped from, and, therefore, such stressors continually act on the individual with little solution or resolution.250 Chronic stressors include ongoing high pressure work, problems with significant domestic relationships, loneliness, persistent financial worries and disease like cancer (even if it is in remission). The common sense inference from this is that any set of life circ*mstance that seats an individual in the path of such stressors for a prolonged period makes that individual potentially vulnerable to the effects of chronic stress. With this, I made my way through the definitive review of the scientific literature regarding psychological stress and its effect on the human immune system. In a study reviewing thirty years of scientific inquiry, Segerstrom and Miller, define chronic stress to be consistently and reliably associated with decreases in almost all functionally measured immune system response. They summarized chronic stressors with the most detrimental effects to the individual’s immune response as those that: 1) Act on the individual over an extended period; 2) Are persistent rather than intermittent; 3) Act in such a way as to alter the individual’s identity or social role; and, 4) Are less controllable and afford less hope that they will be controllable in the future. 251 The same researchers also noted that men are more biologically vulnerable to stressors impacting on the immune system than women. Acute stressors, on the other

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

161

hand, seem not to have a detrimental impact on the immune response at all. In fact, it has been noted that acute stressors of short duration may actually boost the immune response.252 There are a number of books on stress management and how to best cope with stress. The techniques vary and include solutions involving biofeedback, meditation, philosophy, religion, psychological therapy, and, prescription of drugs to name but a few. Their detail, appropriateness and effectiveness are beyond the scope of my discussion. I will say that, in my view, solutions to chronic stress should rely on a bit of common sense and change. The first thing is to do is to recognize and admit your chronic stressors. This seems like a very straight forward and obvious point, but, it has been my experience that those confronted with problems with no apparent solution tend to cope by “burying their head in the sand” or trying to forget about them. No matter how good your ability to compartmentalize problems, the unattended significant problems will eat away at you, fester and resurface. I have come to realize that most problems have a dynamic aspect about them, so the problem or the initial conditions around it change with time. This means if you have chronic stressors, perhaps you should review them every once in a while to see if there is something that can be done to mitigate (soften) them. Of course, every individual’s specific problems have their own particulars and unique solutions. All problems have solutions and it usually just boils down to a question of cost, timing and ability to apply the appropriate measure. I understand that to find acceptable solution is “easier said than done”, especially when I consider my own case. For years I had worked in a demanding field. This was coupled with a miserable marriage, and an absolute nightmare of a divorce that I had to defend against while still raising a family. The ensuing litigation and subsequent orders put me in a place of financial turmoil carrying a large burden of a prolonged spousal support. When reviewing my chronic stressors against the list noted by Segerstrom and Miller, it would seem that all four qualities had been realized, time and time again. At this juncture, I am still in the process of addressing my chronic stressors. This became even more problematic when I had to contend with cancer as a patient. To explain, consider that there is no such thing as a “bout” of cancer. Cancer is not like a cold or flu that runs its course and never revisits. Instead, it is a disease that, even with “cure”, always looms overhead and is to be constantly monitored and guarded against for the rest of your life. To think that softening a handful of chronic stressors for a few months then reverting back to your “old ways” will satisfy all of your immediate and future immune requirements is absurd. In this case, you must resign yourself to the fact that the changes necessary to repair are the same ones that will probably keep you alive. If you cannot soften a chronic stressor, consider trying to simply “off load” it instead. The easiest chronic stressor to deal with is loneliness. Humans are a gregarious

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

162

species. Gregarious means that we need the company of others. For some, only a small amount of company is enough. If family and friends are not an option, social clubs, hobbies, taking a course, volunteer work, and support groups are all places to meet and speak with others. Now is the time to start becoming involved so that you have someone to “look forward to” or be around that can lend a sense of companionship. In this day and age it is obvious how often people seek out company and connection. Just look at the popularity of cell phones, as well as, on line chat rooms, dating and social networking sites. Studies have also reported that even a pet can satisfy a large portion of this basic human need to have company.253 On the work front, we usually stay with an occupation for any one of a number of reasons. Convenience; limited career choice; a sense of owed loyalty; fulfilling the needs of a desired lifestyle; harsh economic times; or, just plain “target fixation” all come to mind. If your occupation carries unrelenting levels of pressure to perform or succeed, then changes must be made. There is seldom an occupation that is so binding and inflexible that redefinition or replacement is not an option. Changing occupation may mean that your financial situation will be impacted, but creating a more positive environment for yourself has to take priority. When I speak of a “positive environment” I am referring to surroundings that make you feel good. These are aspects that can be counted on to promote laughter, light heartedness, affection, a sense of comfort, accomplishment and calmness. In my case, one of the facts about my work is that it took me away from home a lot. Except for the occasional phone contact, my “away from home environment” was almost completely devoid of those things that reliably make me feel good. So this is an example of something that I had to change. In terms of your domestic situation, it is time to deal with the negative aspects that continually frustrate and over burden you. Marriages or long term relationships that are “bad” have to be improved. Although anger, frustration or apathy may stand in the way, try to address the source of the problem together with your mate. If this does not work then get help with counseling. Religious institutions, clinics, and the courts all have counseling services, some of which are free. The idea is to get to the source of the problem and find solutions. If this does not work then consider separating. As a defendant in a divorce process, I experienced one of the most nasty and unrelenting of separations and divorces. The resulting acts of bad faith, committed by my ex-spouse, were only compounded by the subsequent nonsensical orders that came from the Court. The result imposed a totally unnecessary burden of stress that, in all likelihood, was one of the major contributors to my cancer. Knowing what I do now I would have changed a few things, but, in retrospect, it is easy to see the flaws in a situation. Nevertheless, the end result of divorce was an enormous improvement in lending and promoting positive aspects in my day to day life. It has been my experience with any fight that it is important to maintain a calm and positive attitude. If you go into a fight “scrambled” and with the notion that you are

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

163

going to lose, you probably will. Scrambled causes you to lose focus. Without focus it is difficult to determine or apply what is important. A positive attitude will allow you to continue the fight the cancer with what you have. Do not underestimate the impact of your resource and effort, no matter how meager or inconsequential it may seem. All said I will leave this section on environment and attitude with some words of mine to ponder regarding the effect of even the smallest of things on the overall outcome of enemy and fight: A few grains of sand acting on a soldiers foot is enough to ruin his will and ability to march. Sand, if allowed to infiltrate a column of soldiers, can bring an advance to a standstill. Sand can confound even the most well trained and technically advanced army. So never let it be said that “It is only sand”.

Next, I would like to consider the element of exercise as a way to make you stronger and more able to fight and endure the regimens that will be imposed on you by cancer and its treatment.

Exercise The benefit of exercise in helping fight cancer is an issue that has passed well beyond any doubt. There are reports on how it lowers the risk of assorted cancer and that it is able to benefit those diagnosed with cancer. Exercise can be a valuable assistance in cancer prevention, recuperating lost range of motion following treatment, regaining strength and reducing pain after the trauma of surgery. In a study involving 2,705 men diagnosed with non-metastatic PC observed between the years 1990 to 2008, it has been reported that physical activity was associated with lower overall mortality and PC related mortality in these men. Vigorous activity such as biking, tennis, jogging, or swimming for 3 hours or more a week may substantially improve PC specific survival. 254 In my view, the stronger you are, the easier it is to maintain and endure mental and physical hardship. No one can say how much exercise is “enough” to improve on the effects of Prostate Cancer treatment or to harden you against cancer in general. No one can say what type of exercise is the best. This is because we are all different and all respond in different ways. As has already been said, the medical community is accustomed to basing its recommendations and treatment on research with reproducible results and causative link. The best combination of frequency and type of exercise to address any cancer can only be speculated because there are simply too many uncontrolled variables in the lives, disease and response of those willing to participate in such a study. In any case, fighting cancer requires you to deal with mental and physical hardship. So I suggest you proceed with the idea that any natural thing to make you stronger is going to help. Of course, it is strongly advised that any exercise routine is discussed and approved by your overseeing medical staff before you begin.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

164

Again, it is not my intent to exhaustively discuss the “universe” of exercise. This is a topic that has and will continue to spawn an unending array of books and comment. I will say that generally any exercise, even the smallest amount, is better than doing no exercise at all. Like dietary change, exercise is likely going to require a change in your habit and does not call for drastic change all at once! A few years ago, I heard an interview of Robert Greene who is an author of several exercise and nutrition books, the first of which was co-authored with one of his clients Oprah Winfrey. In this interview, he drew attention to the fact that his books related to diet sell much better than those related to exercise. I found this odd, since he is renowned as THE “Trainer to the Stars”. Mr. Greene’s contention is that people, in general, seem to prefer to address elements of their health and physique with diet instead of exercise. When I listened to this interview I remembered, as a teenager, how difficult it was to get my Dad to do a bit of exercise. It was as though there was absolutely no place or provision for this in his day. My Dad went on to endure several heart attacks, bypass surgery, diabetes and several strokes before he passed. I believe that the greater part of his poor health was directly related to smoking for nearly four decades, coupled with an unfaltering pact to avoid even a small amount of dedicated exercise. Sadly, I never understood the mentality or the lack of motivation contributing to such deterioration. I suppose the argument can be made that exercise didn’t help me avoid cancer. To this I reply, I am still alive and it may be so only because I luckily kept myself strong with exercise and activity. I look at today’s busy world where everything is processed and compressed from the time we wake to the time we “drop” in the evening with exhaustion. I see parents frantically ferrying their children from one tightly scheduled activity to the next, as though on a mission to completely extinguish both child’s and parents’ will to do any activity by sheer overexposure. I see people clearly out of shape and overweight waddling to yet another “line up” for buffet or fast food. I see unreleased frustration in the flexing mandibles and fidgeting eyelids of women and men who have nothing to look forward to except to eat, sleep, work or watch television. In all of this I ask myself: Where is the common sense? Where is the connection with self? Where is the understanding that you must take care of yourself? One needs only to look at a group of small children playing to realize the benefit of activity. Cheeks become rosy, lungs expand, laughter prevails, calories are burnt, sleep is sound, illness is deflected, and friendships are made when we exercise. All of these things are an essential part of living a healthy life and having a good immune response. Why then is there so much resistance to exercise as we grow older? The following are the lines I have heard over the years from friends, family, and associates regarding the reasons not to exercise. Do any of them sound familiar to you?

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

165

I’m too tired. I’m too lazy. I’m too sick. I don’t want to get injured or sore. I’m too sore. I’m injured. I don’t want to look like a body builder. I look like “@hit” and don’t want to be “seen” like this. I don’t like to sweat. It’ll ruin my hair. I’m not comfortable. It’s too nasty outside. I don’t have time. I just need to rest. I already did some a few days ago. I don’t know how to exercise. I don’t like to exercise. Exercise really doesn’t do anything for me. I’m embarrassed. I’ll go next time. I don’t need to. It seems that there is always a way to defer exercise activity in the face of diversion, affliction or lack of motivation. All of this has to be overcome. For those of you already diagnosed with cancer your motivation is simple. Do what you can to stay alive and have a good quality of life. Starting any exercise regimen from scratch is not an easy thing to do, even if you are healthy and not afflicted by cancer. I believe that what stands mostly in the way of exercise is your frame of mind. Almost anyone can exercise regardless of their physical state. You do not need a gym membership. You do not need elaborate equipment. You don’t need a lot of free time. You do not need to be concerned about being injured or getting sore. You do not need to make a fashion statement. What you do need is the will to start exercising for a few minutes every day and stick with it. Time and time again I hear the media report that walking is a good place to start if you do not exercise. Guess what? Walking is good exercise! You can walk on a treadmill, but, exercise indoors and in isolation does not have the same effect as being outside where you can come in contact with the change in scenery, fresh air, your community and others. Of course, there are those who may reside in places where there is just nowhere to go for a neighborhood jaunt. I expect that you will use your judgment in this regard and stay safe. Swimming, spinning (riding a static cycle), and bicycling are all excellent for the cardio-vascular system and easy on the bones, back, and joints. I compare these to running or jogging which can wreak havoc on the body of even the most seasoned

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

166

athlete. Most Decembers I spend a week in South Beach Miami where each morning I witness the arrival of those trying desperately to get back in shape. I can only describe what I see as misguided effort involving running or jogging in the sand for really long distances in the heat of the day. Too much, too soon! At any given time I expected to see any one of these out of shape individuals collapse in “sunbathed” cardiac arrest. Meanwhile, the water has practically no one in it, and I only see a handful of cyclists the whole time I’m there. I know that there is an entire generation out there who harbor irrational fears of going in the water; thank you very much Mr. Peter Benchley. I believe it is time we got over the sensationalism of shark tales and start taking advantage of the recreational and exercise value associated with water activity. I suggest for those who want to do more, to just get in the water and walk against its resistance. If you find this too easy then make an effort to move through the water column quicker by walking faster or walk in a little deeper water. Rest assured that you will soon feel the effects of the water’s resistance. That resistance will produce result in the way you look and feel. Again, use common sense, don’t overdo it, be consistent and be patient. Results take time. If you don’t relish the idea of going into ocean, lake or river find a pool and exercise there. For those who have no way to exercise in water and have no gym, consider your surrounding work or domestic area as a place to conduct calisthenics, isometrics and stretching. The routine does not have to be done all at one time. It can be adapted to fit into small segments that are available throughout your entire day. Isometrics is a type of strength training that involves exerting a force on something that is immovable, like a wall or heavy object. The force (pushing, squeezing or pulling) is exerted for ten to thirty seconds against the immovable surface in the same way as you normally do the full range exercise, but without the movement through the range when exerting the force. The advantage of such exercise is that it may be better suited to the needs of someone who has been substantially weakened by surgery. Exertion, either isometric or the full motion calisthenics such as dips, pull ups, push-ups, squats, calf raises, sit ups, back arches and lunges are exercises that can be done without a gym and only a couple of minutes “here and there” with relatively painless and effective result. To do these exercises all you need for “equipment” is a couple of sturdy chairs, a bit of floor, and a doorway. If you have never been taught the proper technique for these exercises then I suggest you ask your physiotherapist or go to your local gym and consult a certified trainer. Say that you need to adapt a routine, with the above exercises, to the space, equipment, time and physical constraints of your condition. The same can be done for stretching. Ten minutes of stretching should be lots. Be careful not to over extend or bounce when stretching. The idea is to increase your range of motion and elongate your muscles, not tear them. Make sure you are warmed up first. A hot soak in the bath or a bit of exercise helps to do this. If you are relying on a warm up from exercise, plan to do your stretching at the end of your routine. A twenty to forty minute routine of exercise and stretching every day is plenty. As I said, it does not take much to have result but you have to be consistent about doing it regularly.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

167

For those who are already diagnosed and athletically inclined, or otherwise quite active, consider the rigors of surgery and treatment will require you to “ease off” for a few weeks. Let the incisions heal. Don’t become overtired from too rigorous an exercise routine either. Use common sense, keep your physician informed, and keep active. I started my chemotherapy and continued exercising. By the end of a six month regimen of chemotherapy I had lost at least half of my strength. It took the better part of two years thereafter to regain the lost levels, but I persevered and I am pretty much back to my accustomed self. It is known fact that the act of sex is a great exercise with many physical, physiological and psychological benefits. Sexuality in the face of illness is a topic that has a broad scope of considerations as discussed by the authors Schover and Jensen in the book Sexuality and Chronic Illness, a Comprehensive Approach. Men who undergo most currently prescribed clinical treatment for Prostate Cancer will likely have to contend with substantially impacted sexual function. In addition, to prostate trauma or removal from initial treatment there is the possibility of continued therapy regimen that may further impact on recovery of sexual function, self-esteem, physical ability and sexual appetite. Whether you do or do not participate in regular sexual activity during and after Prostate Cancer treatment is a matter of personal choice. You should be aware that the acts of intimacy (not just intercourse) and the chemistry involved has a number of reported benefits including positive effect on longevity; reducing risk of heart disease and cancer; increasing immune response; improving ability to fall asleep; promoting youthfulness; improving fitness; improving sexual and reproductive health; increasing ability to manage pain; reducing stress; and, improving self-esteem, among other things.255 Sounds like a magic pill to me. Of course, all of this is contingent on you and your lover’s success in coming to terms with your actual or perceived condition. The only thing I can suggest is to keep talking and touching. Don’t assume anything is understood unless it is said and say it well in advance if you can. This way both of you have time to find a way. Love, like life, will find a way.

Acupuncture Cancer is an old disease and the medical techniques that are conventionally used to treat it are comparatively new. Traditional medicines such as those developed by the Chinese have been practiced for roughly two thousand years of recorded history.256 Acupuncture is one of the branches of Traditional Chinese Medicine (TCM). In the ongoing quest for solution, conventional consideration is now being directed at dissecting traditional medicine and using portions of it to assist mainstream cancer treatment and care. Although one is hopeful that this is opening the door to the greater use and understanding of such “alternative” medicine, I question the value of any study that passes judgment on the effectiveness of traditional techniques when those elements

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

168

of medicine have been far removed from the forum or expert practice in which they are normally found. The largest barrier for those of us that are not from culture that relies on traditional medicine is our lack of familiarity and understanding of it. Nevertheless, its effectiveness in providing relief for aspects of human affliction and disease is known and accepted by a staggering large part of the world’s present population. Since the 1970’s in the United States, acupuncture began to be brought under the umbrella of recognized government standards for training curriculum content and practice. The United States presently has some 41 states with either Acupuncture Practice Acts or Statues; or, laws governing education and qualification to practice acupuncture.257 In 1996 the FDA approved acupuncture needles as a medical device.258 In the UK, there are some 7,000 nurses, physiotherapists and doctors who have training in acupuncture.259 In Canada the regulation of traditional acupuncture is established in four provinces namely, Alberta, British Columbia, Quebec, and Ontario.260 In Australia the Chinese medicine profession (which includes acupuncture and Chinese herbal medicine practitioners) has been approved for inclusion in that country’s National Registration and Accreditation Scheme for Health Professions as of July 1, 2012. 261 In the eyes of the western medical community there are two types of acupuncturists, those that are trained and practicing according to a set of accredited governmental standards, and those that are not. What goes along with those practicing in accordance with the government standards are baseline protocols in procedure; minimum conversancy with the material; and, safety. Arguably, it would seem to me that mainstream physicians from western medical communities who have studied acupuncture in some brief way are bound by their medical training to apply it in a way that denies the other elements of TCM that in all likelihood makes acupuncture effective. Not to belittle the need for regulation and standards in the practice of acupuncture; however, to me it makes sense that those who have had an extended period of study under a master; have practiced TCM for decades; and, are in good standing with the medical community in their country offer treatment that is effective because they are using acupuncture in a way that it was trained and intended over thousands of years. In terms of how acupuncture works the scientific explanation is that the needles used for treatment are positioned in specific locations on the body to stimulate the body’s neurophysiological chemical process.262 In reality; however, acupuncture technique and process is not well understood by the medical community as a whole. This understanding can be likened to the field of anaesthology in conventional medicine. In short, real understanding of its application is reserved for those who are experienced and wellpracticed in the techniques.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

169

Traditional explanation of how acupuncture works is rooted in Chinese philosophy and science and the concept of Qi (pronounced as Chee) and Xue. Qi is the body’s vital energy. Xue is the body’s blood. It is said that the flow Qi is affected by the balance of Yin and the Yang. Yin is the female side of universal energy and is dark. Yang is the male side and is light. All energy is a combination of the Yin and the Yang. They do not exist separately. Good health involves a balance between the Yin and Yang. If the balance is good, Qi “flows” freely along the energy lines or meridians of the body. Specific imbalances lead to specific health problems. Poor health is treated by manipulation and revitalization of the body’s meridians with a combination therapy of needles, herbs, massage, counseling and exercise. This combination therapy is the how TCM (Traditional Chinese Medicine) is practiced.263, 264 Figure 44 shows a simplified diagram of the body’s acupuncture meridians. There are approximately 2000 acupressure points on the body. The head, hands, feet and sides all have meridians and points. Most of these are not depicted in this diagram.

Figure 44. Simplified illustration of acupuncture meridians and points on the body. source: http://en.wikipedia.org/wiki/File:Chinese_meridians.JPG originator : Phil Perez

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

170

The needles that are used in acupuncture are very fine and when inserted are not really “felt” by the patient as would be a needle used for taking blood, for example. The depth of insertion is shallow and penetrates to just below the patient’s skin. Once positioned these needles are left in for as much as a half an hour. Sometimes practitioners use the needles as conductors for laser, microwave, tactile, and mild electro pulse stimulation OR not. Acupressure is another variation and uses the same meridian pressure points without the needles. In Acupuncture, the number of needles and their placement varies with the affliction and a host of other considerations. The number of sessions required to have results also varies. Reports of effectiveness focus mainly on the sedative aspects of acupuncture.265 For example; there are numerous reports where acupuncture is being used quite successfully instead of anaesthetic during surgical procedures in China. Unfortunately much of this ongoing treatment seems not to be published in what is considered recognized scientific journals. As such; the scientific proof needs to be made available so that questions on acupuncture effectiveness can be properly weighed. In 1997 the United States National Institute of Health began studies on the effectiveness of acupuncture. So far, the results reported are that acupuncture can be effective in: boosting the body’s immune response in cancer patients; and, relieving symptoms of pain and nausea associated with cancer and the side effects of conventional treatment. Ongoing Clinical trials studying the effects of acupuncture on side effects caused by conventional cancer treatments including weight loss, cough, chest pain, fever, anxiety, depression, night sweats, hot flashes, dry mouth, speech problems, and fluid pooling in the arms or legs. The results are indicating that for many patients treatment with acupuncture either relieves symptoms or prevents them from getting worse.266 One unexpected aspect of the “piecemeal” application of acupuncture with regards to tumor treatment is the thought that treating a tumor with acupuncture would “unbind” the energy that caused the formation of the tumor in the first place. Consequently, there are non-TCM acupuncture practitioners who refuse to treat tumors because of concern that the tumor will be dispersed throughout the body leading to more complication. It is questionable whether or not this is sound logic or whether this is in fact the way that the body would respond to acupuncture tumor treatment.267 One of the certainties of acupuncture is that it has application and effectiveness for a number of afflictions. As well, given the spectrum of those practicing this science, it makes sense to seek out practitioners who are experienced and specialize in cancer treatment or prevention if that is what they are going to be required to do. Some hospitals have practicing acupuncture MDs that work in concert with the oncology department and treatment regimens. Alternatively, almost every country has acupuncture associations that can be contacted to find a reputable acupuncture specialist that best fits your needs. In reviewing the literature regarding the applicability and effectiveness of acupuncture, I find that this field of medicine is prominent in the United States Clinical

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

171

Trials (see http://clinicaltrials.gov/ct2/results?term=acupuncture) and there are now some trials regarding acupuncture that are registered in the recently available on line European Community Clinical Trial site (see https://www.clinicaltrialsregister.eu/ctrsearch/search?query=acupuncture). In addition, similar activity is registered on the Australian Clinical Trial Registry (see http://www.anzctr.org.au/trialSearch.aspx). As such, it is clear that acupuncture has been received and is becoming an integral part of the mainstream medical community’s theatre of available service.

Early Recognition and Screening The mainstream medical community is torn between those who recommend Prostate Cancer screening for early detection; and, those who unconvinced of the value of such procedure given the current clinical treatment options in the event early stage PC is discovered.268 On one side of the debate are organizations such as the American Urological Association and the Urology Care Foundation who believe that early detection and risk assessment for PC should be offered to asymptomatic men 40 years of age or older who have a life expectancy of at least 10 more years. They also state that men being screened should have PSA testing and a DRE.269 So let us examine some of the more prominent studies on Prostate Cancer screening. In a study initiated in the early 1990’s involving 182,000 men between the ages of 50 and 74 years of age from seven European countries the results of this “colossal undertaking” found that PSA based screening reduced the rate of death from Prostate Cancer by 20%; but, was associated with a high risk of over-diagnosis. 270 In another study began in 1994 involving 20,000 men that started out between the ages of 50 and 64 it was reported that over a period that extended to the year 2008 (14 years) Prostate Cancer screening (involving mostly PSA testing) reduced mortality by almost half. Similarly, this study states that the risk of over-diagnosis was substantial. 271 So here we have two large studies involving 200,000 men over a couple of decades where there is clear and significant mortality benefit for those who participated in PC screening. On the other side of the fence, for example, is the U.S. Preventative Services Task Force whose current recommendation for Prostate Cancer screening before diagnosis concludes “that many men are harmed as a result of Prostate Cancer screening and few, if any, benefit. A better test and better treatment options are needed. Until these are available, the USPSTF has recommended against screening for Prostate Cancer.” 272 USPSTF co-Chair M. LeFevre, M.D, MS.P.H. goes on to say that, “The members of the USPSTF face the same concerns and fears about health challenges as other people. This decision was reached only after extensive consideration and thoughtful debate. It is based on science and rooted in the knowledge that, while everyone wants to help prevent deaths from Prostate Cancer, current methods of PSA screening and treatment of screendetected cancer are not the answer.” 273

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

172

To justify their position the USPSTF have published what they call a review of the evidence. In this document they state their screening recommendations were based on the results from four questions they answered, those being: - Does PSA based screening decrease Prostate Cancer–specific or all-cause mortality? - What are the harms of PSA-based screening for Prostate Cancer? - What are the benefits of treatment of early-stage or screening-detected Prostate Cancer? - What are the harms of treatment of early-stage or screening-detected Prostate Cancer?274 Having looked at the USPSTF review myself, I have concerns with the USPSTF conclusions and any medical entity that embraces them. To clarify: Firstly, there is no doubt that PSA based screening (that usually involves a DRE) has benefit both in early detection of PC, as well as, impact on PC related mortality as reported by the European studies involving 200,000 men; Secondly, PSA-based screening is not harmful. The harm lies in the current protocols that are in place to address elevated PSA levels discovered from the testing. Percentage based core needle biopsy and biomarker probability charts are the predominant methods used to press on with diagnosis. In my view, reliance on such method to arrive at a diagnosis is what has been resulting in the false positive results and damaging diagnostic procedure; and, Thirdly, the questions of harms and benefits; and more specifically, what to do when one is diagnosed with early stage PC remains a heated debate within the mainstream medical community. I think the question of “what to do?’ is not for the mainstream medical community to address. This question should be addressed by the patient who should be better informed. The mainstream medical community should be more concerned and focused on better ways to diagnose and treat early stage PC so as not to be so blatantly rooted in radical procedures or procedures that are so ineffective and damaging to quality of life that a “WAIT, WATCH AND SEE” option is actually condoned and offered as a legitimate way to address poorly understood disease that can progress to the point of being terminal in timeframe that no one, to date, can be certain of. One example of screening advancement that could result in a reliable, noninvasive, and, affordable clinical screening application as soon as 2014, involves diagnostic nanotechnology featuring a computer chip able to detect prostate specific biomarkers.275

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

173

In any case, awareness, informed screening and taking advantage of more advanced clinically approved methods are all helpful in catching this disease early on and more precisely identifying the extent of the PC. As has already been discussed, such clinically approved methods involve for example, FDG PET/ CT imaging; PET/CT combined with the contrast agent precisely;

C-Choline to image PC more

SPET/CT to determine an individual’s specific prostate lymphatic drainage patterns; and, MRI guided biopsy. Catching the disease early on means that you know where you stand. Early diagnosis means you can take advantage of much less radical options, like HIFU, that may be arranged and actioned early enough to prevent not only advanced stage disease along with its confounding ability to cure; but, also the enormous quality of life impact associated with more invasive treatment regimens. This is just common sense. Overall and in my view, there is no disadvantage with seeing your physician as a young adult to have a Lifetime Risk Assessment of Prostate Cancer done. Know and advise your physician of your family history relating to Prostate Cancer so they can factor that into their assessment. At the same time ask for baseline PSA testing and DRE. The results from this can provide useful data that later screening results may be compared with. Finally, consider asking for a practical demonstration on the correct way to perform self-DRE. If it turns out you have a moderate to high lifetime risk I suggest you make a reasonable plan for screening that involves a specialist and some good imaging like a FDG PET/ CT scan.

Prevention So apart from quitting smoking, adopting a “cancer unfriendly” diet, exercising and having a lifestyle with less chronic stress what else can be done to prevent you from being one of the six men in a room diagnosed with Prostate Cancer? According to a study involving 47,843 men from the United States between the years 1986 and 1998, alcohol does not appear to be a strong contributor to Prostate Cancer risk, except possibly in men who consume large amounts infrequently and in men with type II diabetes mellitus.276 Similarly, in a European study involving 142,607 male participants between the years 1992 and 2000, it was concluded that the use of alcohol has little or no association with the risk for Prostate Cancer. 277

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

174

In a study involving 69,991 men from the United States it was concluded that obesity increases the risk of more aggressive Prostate Cancer and may decrease either the occurrence or the likelihood of diagnosis of less-aggressive tumors. Men who lose weight may reduce their risk of Prostate Cancer. 278 Along the lines of specifically exercising the prostate and it sexual functions, research has reported that that a reduced ejacul*tory output in otherwise normal males is associated with an increased risk of Prostate Cancer, especially if this commences early in adulthood.279 Another study involving predominately white males suggests that ejacul*tion frequency is not related to increased risk of Prostate Cancer; although high ejacul*tion frequency may possibly be associated with a lower risk of total and organconfined Prostate Cancer.280 In perusing the literature on this topic, it seems to me that more data with larger numbers of participants and more accurate reporting on sexual frequency has to be analyzed before any accurate conclusions on the relation of sexual activity and risk of Prostate Cancer can be made.

Follow Up One thing you must keep in mind after you have been diagnosed with Prostate Cancer with or without treatment is the Follow up. Follow-up is not standardized and is in fact quite variable. Your clinician will discuss the exact details as they pertain to your case so that you are aware of what protocol your facility uses and what to expect. As stated, you are your own best manager of your health file. If you have not received appointments when expected then make the appropriate calls to ensure the follow up process is scheduled and done. Follow up has to be done to monitor your condition. It determines if the measures that are in place are adequate; and, affords clinicians the information necessary to make decisions on whether or not additional treatment is recommended. The following are some commonly used types and timings of follow-up: •

For those diagnosed with PC opting for Watchful Waiting - PSA testing (with DRE) every 3-12 months. For those with asymptomatic metastic PC, bone scans once a year OR alternatively, when the total PSA level arrives at 40 ng/ml as an indicator as to whether or not ADT is merited;

•

For those who have undergone Radical Prostatectomy – PSA testing every 3 to 4 months for the first 2 years; PSA testing every 6 months thereafter up to year five; at year five once a year every year;

•

For those treated with EBRT – PSA testing (with DRE) every 3-6 months for 5 years. Annual PSA testing (with DRE) thereafter. Some practitioners recommend biopsy 18-24 months following treatment;

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

175

•

For those treated with Brachytherapy- PSA testing (with DRE) every 3-6 months for a year. Thereafter, annual PSA testing (with DRE) should be done. Some practitioners recommend biopsy 18-24 months following treatment; and,

•

For those exhibiting signs of biochemical recurrence (PSA levels rising) - Closer follow up than what is detailed above with consideration of alternative therapy. If PSA levels double every 10-12 months OR if PSA level reaches 20 ng/ml then imaging is recommended.281

In terms of follow up that I do on my colorectal cancer, I supplement my follow up with an annual “neck to toe” FDG PET/CT scan. I do this because I know the imaging is thorough, comfortable, fast, safe, does not involve a lot of unpleasant preparations, and it covers parts of my body that are beyond the initial area of the cancer. It is the way I address the chronic stressors associated with being in CRC remission. It is also the way I can look at those around me and honestly say that everything is fine. Take note that the cost of a PET scan is not cheap in the area of $2,500.00. So it really helps if you have health insurance coverage.

Miscellaneous and Promising Research There was a news release in 2010 reporting on the meta-analysis led by P. Rothwell from the University of Oxford finding that participants who took one regular pill of Acetacylic acid (Aspirin®) for an average of 4 years had a 44% reduced risk of dying from cancer compared to those in the study who did not take aspirin. From this analysis it was further pointed out that in follow up it was found that 20 years later a subset of those participants who took the aspirin still experienced a 20% reduction in the risk of dying from cancer.282 The whole seemed too good to be true, one cheap little pill that has been around for over a hundred years substantially reducing the risk of dying from cancer; but those are the reported results. On the down side of this reported miracle pill is the predominant concern in the medical community that low dose acetacylic acid use can cause severe gastrointestinal bleeding. As such; the benefits and risk of low dose acetacylic acid use over a period 4 years or more must be weighed against lifetime risk of cancer.283 Certainly such preventative strategy merits discussion with your physician. On another note, there has been substantial interest on the use and effect of Vitamin D both in the mainstream medical community and the naturopathic health community. To clarify, 1) Vitamin D is really not a vitamin at all, instead it is a fat-soluble prohormone involved in the production of hormones; 2) There are two majority sources of this prohormone. One is from plants called D2. The other is called D3 and is made by the body when exposed to sunlight. Both are turned into the active form in the body called 1,25-dihydroxyvitamin D also known as calcitriol. Calcitriol is involved in the body’s uptake of calcium among other things;

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

176

3) There are recommended daily minimums on Vitamin D intake that are age dependent and range from 5 μg (=200 IU) up to 50 years of age to as much as 15 μg (=600 IU) when one is 71 years or older. This daily minimum can be arrived at by dietary intake, by absorption of the sun or by taking supplements. Excessive intake of vitamin D can cause some very undesirable effects including: - calcinosis (the deposit of calcium salts in soft tissues such as the kidneys, heart, and lungs) and/or - hypercalcemia (high blood levels of calcium); and, 4) Associated symptoms of excessive vitamin D intake may include heart rhythm abnormalities; confusion; pain; conjunctivitis; anorexia; fever; chills; thirst; vomiting; and weight loss. 284 There are some 481 clinical trials registered in the USA involving vitamin D and its role in aspects of a number of cancers. The benefits of vitamin D intake for breast, colorectal, Prostate Cancers and leukemia, as well as, chemotherapy treatment side effects such as peripheral neuropathy (common to platinum based regimens) and reduction of bone loss during ADT is certainly a strong interest of the trials.285 Overall; however, there is nothing that I see in the literature indicating that the minimum daily intake level of vitamin D is consistently correlated to lowering the topical risk of cancer. In any case, vitamin D minimum daily intake should be adhered to for all of the normal bodily functions it supports. On the side of promising new developments we find researcher M.Q. Wei of the University of Queensland who’s research is focused on using clostridial spores found in grey kangaroos to arrive at a ‘Trojan horse” vector for cancer gene therapy. Apparently the genetically modified clostridial spores have intrinsic properties allowing them to colonize and destroy tumors, as well as, having a seemingly unlimited capacity to carry exogenous genes when acting in the role of a genetic vector. The curative potential, in my view, is mind boggling. Thus far; however, this promising discovery has not made its way through clinical development.286 So with hope and patience we wait.

Patient Support When I was diagnosed with cancer there was a string of repercussions that went along with diagnosis and treatment that touched virtually every facet of my life. How I was received by friends and family; how I was perceived by colleagues; ability to work; ability to travel; ability to be insured; financial situation; diet; and, considerations for the future were all impacted. “When it rains it pours.” The whole thing can be more than overwhelming at a time when you should be focusing on your fight instead of all these other challenges.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

177

One of the things that will happen when you first arrive at your oncology unit for consultation and treatment is that you will be briefed on what support and help is available. This information details local discussion groups, possible financial assistance, psychological counselling, local clinics, an overview of Prostate Cancer as a disease and its treatment, as well as, a point of contact at the oncology department. Take this information as a start point and don’t be afraid to ask for more help if you need it. Prostate Cancer surgery and treatment can be harsh and the effects more than “bothersome” to self-esteem and significant relationships. There are a number of programs associated with treatment facilities that serve to help patients adjust and come to terms with these effects and changes. Your medical facility will be able to direct you to your local initiative in this regard. In terms of finances, there are a few things you can to do to make sure any transition away from a regular pay check during a period of disability is uneventful. My suggestion is to take out insurance for critical illness or being unemployed before you are diagnosed. Insurance companies always ask for the date of diagnosis when you make a claim. Once you are diagnosed it is too late to apply for such coverage. All major credit cards have this available, and it can usually be made active with a simple call to customer service. Make sure you do this for every active credit card you have. If it becomes necessary to have the insurance cover your credit card debt then you will probably have to fill out a couple of insurance forms supplied by each credit card company’s insurer to describe and verify the details of your condition. This is no problem if you have been keeping a file of you case history. Critical illness and unemployment coverage is also available for mortgages and loans. Unfortunately you typically only have one opportunity to apply for this coverage, and it is when you initially apply for the loan or mortgage. In any case, sometimes policy is different between lending institutions, so if you are not covered at least ask. If you are faced with a monthly payment of income on a short or long term disability scheme, call your creditors and let them know what is going on. This way they can adjust your bill payment time to a date when your disability money arrives. If your employer makes your payments on your life and disability insurance when you are on short term disability, make sure your payments for both will still be made when you are moved over to long term disability. Sometimes this is not the case, and suddenly you find yourself without any life insurance coverage, for example. Also make sure these things are in writing. When I was diagnosed I thought I was pretty well insured. After 6 months into treatment I transitioned from short term to long term disability income which only gave me 45% of what I was accustomed to in terms of gross income. Suddenly, I found myself unable to make ends meet financially. In short, make sure that you are adequately insured and do this well before you ever have to face diagnosis. When you are young and

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

178

healthy insurance of this nature is easy to get and does not cost much to maintain from one year to the next. Sometimes despite the best efforts of fight and medical technology there will be those patients whose Prostate Cancer condition evolves in such a way that it is not curable. In hand with palliative treatment is palliative care. Family members or close friends may often be the only recourse to seeing such patients through. Full time, “around the clock” attendance to the needs of a terminally ill patient is daunting task even for someone who has background in chronic or palliative care. This is further compounded by emotional attachment of watching a loved one deteriorate; and, possible poor health of the caregiver themselves. To assist patient and caregiver there is an assortment of network, information, programs and support that can be called upon. Details of such support are usually available at your local health care centers and hospitals.

Praying and Belief Man’s world is a complicated weave of differences in belief and faith that has historically been at the root of both war and peace, and, will probably always continue to be. Medical intervention is a developing part of man’s ability to “help oneself”. For the most part, it is consistent with the majority of religious and atheistic (non- religious) beliefs. Still, when the best efforts of man-made solutions fall short, critical illness has a way of moving people towards any means that can help them or those they care for. How belief and faith works for any one individual is a personal matter that defies words. It has to be respected that belief and faith can have a profound effect in terms of fight, recovery, or coming to terms with loss.

Cancer Foundations If you go to the internet and type in Prostate Cancer Foundation on a search page like Google it results in approximately 4,150,000 possible results to review. If you type in Cancer Foundation this number expands to a whopping 112,000,000!! This is clear indication of the attention and energy being allocated to disease like Prostate Cancer disease through foundations. Most of these foundations are small and tailored to a scope emphasising support and assistance at regional and local levels. There are, however, foundations that function at national and international levels. Regardless of whether they are local, regional, national or international, the emphasis of these foundations vary and provide support through fundraising dedicated to assorted cancer awareness, acquisition of needed equipment, prevention through screening initiatives, research, specialized training, and, medical facility upgrade. In spite of this, cancer prevails and confounds lives every day, everywhere. Still there is progress towards awareness, prevention, better treatment and cure. The rate of

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

179

progress is directly proportional to the amount of funding available. Every little bit helps. Together we can find a way to drastically reduce the number of lives affected by this silent killer. In the meantime, take care of yourself and don’t give up the fight.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

180

Glossary of terms abscess - a pocket or capsule of pus formed by the body’s immune system in response to invading foreign organism or material. acupuncture - one facet of traditional Chinese medicine using pressure or needles to restore body energy. adenoma - a benign abnormal growth of glandular origin. adenocarcinoma - a cancer that originates in glandular tissue. adjuvant therapy – post surgical treatment used to extend survivability or prevent recurrency. ADT – androgen deprivation therapy. aerobic respiration – efficient chemical reaction occurring in healthy cells that releases energy when glucose is combined with oxygen in the body. AJCC – American Joint Committee on Cancer. anaerobic respiration - (glycolysis) inefficient chemical reaction that occurs in cells in the absence of oxygen resulting in the fermentation of glucose to produce energy. anaesthetic – a drug or combination of drugs used to control pain or discomfort. anaesthesiologist – a physician that specializes in the study and administration of drugs to allow surgery or control pain and discomfort. ANC – absolute neutrophil count. anemia – a condition where there is inadequate transfer of oxygen to the tissues and organs of the body. This can be the result of excessive blood loss, excessive blood cell destruction or deficient red blood cell production. angiogenesis - the formation of blood vessels in cells and tissues. antibodies- immune system component produced in response to invasion by a foreign substance. Designed to combat infection. antigen - a substance or foreign substance that causes the body’s immune system to produce antibodies. anus - the opening at the end of the digestive system from which feces (waste) exits the body. apoptosis - cells self-destructing. arterial – related to the arteries. ATP - adenosine triphosphate is a useable energy source that drives human metabolic processes. axillary - pertaining to the armpit. benign - being without cancer. biopsy – the sampling of a small portion of tissue.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

181

branchytherapy – radiotherapy involving the implantation of a radioactive material either temporarily or permanently. CAD – computer aided detection. cannula - a small device that can accept needles usually installed on a vein in the wrist, fore arm or bend of an elbow. carcinoma – a malignant growth that arises from the epithelium (the covering of internal and external surfaces of the body, including the lining of vessels and other small cavities). This includes the skin and lining of the organs such as breast, prostate, lung, stomach or bowel. catheter – a device inserted into the bladder via the urethra to assist drainage of urine. cellulose – (roughage) a polysaccharide formed of simple sugar units joined by beta linkages and virtually indigestible by humans. chemotherapy – treatment involving chemicals to target and eradicate, reduce or slow cancer cell growth . chromosome – a “package” of genetic material. In humans there are 46 distinct chromosomes, which together contain all the information required for making a living person. CIS – (Carcinoma in situ), the cancer is restricted to the mucosa or surface on which it resides. This is the earliest stage of cancer. coelomic – pertaining to the body cavity also known as the coelome. Corpora cavernosus – muscles involved in penile erection CRC- colorectal cancer. cryoabilation – removal by freezing. CRPC – castrate resistant Prostate Cancer. CT - (computed tomography) scan that uses radiation to make an image of body structure. curative - designed to cure. cyanic – blue tinge of tissue associated with deprivation of oxygen or excessive levels of carbon dioxide in the body. cytokine - is a group of small proteins that stimulate and regulate the immune response. cytology – the study of cells. cytotoxic – poisonous or toxic to cells. desiccation – to dry out or remove liquid from an area or structure. dextrose- a sugar in the form of D-glucose often used as a carrier solution during chemotherapy. diagnosis - medical determination of disease or syndrome performed by a physician. differentiate – a cell’s ability to develop into recognizable shape, structure and function specific to normal cell types associated with organs or systems of the body.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

182

disaccharide – sugar made up of two simple sugar units together. Sucrose, lactose and maltose are each examples of disaccharides. DNA – deoxyribonucleic acid. One of two types of complex chemicals that make genes. DRE – Digital Rectal Exam DVT – (deep vein thrombosis) the formation of blood clots in veins when one remain inactive (usually sitting) for extended periods of time. dysplasia - the earliest form of pre-cancerous lesion that a pathologist can recognize. EBRT – external beam radio therapy. ECG - (electro-cardiograph) an assessment of heart performance and condition using externally attached probes that receives and records the electric transmissions of the heart as it beats. ED – erectile dysfunction. edema – swelling due to fluid accumulation under the skin. EGCG - (epigallocatechin gallate) active cancer inhibiting ingredient found, for example, in green tea. embolism – blocked blood flow as a result of migrating foreign object or air bubble. En Bloc - surgical method of removing a growth as one entire intact piece. erythrocytes – red blood cells FDG - 18F-floro-2-deoxy-D-glucose. Compound used in PET scans to detail possible cancer activity. fibrosis – formation of excessive connective tissue. fractionated – specifically used to describe radiotherapy that is spread out over time to give normal cells a chance to recover. fructose – monosaccharide or simple single sugar unit used to fuel energy to cells found in fruit for example. ganglia - minute tentacles that can radiate from an area such as a tumor or lesion. genome - the full genetic material of an organism. glucose – monosaccharide or simple single sugar unit used to fuel energy to cells. glycolosis – anaerobic respiration. G.P - general practitioner. One who practices general medicine. grade – how closely cancer cells resemble normal tissue when looked at under a microscope. gynecomastia - male condition of developing breasts. hazard ratio - compares the death rate for patients receiving a given chemotherapy, to the death rate for those receiving no chemotherapy.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

183

HIFU – high intensity focused ultrasound. Kegel - exercise that is used to promote urinary sphincter control similar to how someone would arrest urinary stream mid-flow. hematopoiesis – the development of blood cells. hemolysis - blood cell destruction. hemorrhage – excessive blood loss. helix - a twisting structure that resembles a long, partially stretched strand curly hair. hepatic resection - the surgical resection of liver. HFCS - (High Fructose Corn Syrup) a synthetic sweetener used in processed foods. immunogens – foreign bodies that have invaded. immunological response - the body’s defence response to inflammation and infection. immunotherapy – treatment that involves drugs that stimulate a patient’s natural immune system response. IMRT – intensity modulated radiation therapy. induction – the commencement of the delivery of the anaesthetic during surgery. interferon - (IFN) is a cytokine that is used in immunotherapy. Interphase – a stage of cell replication. interstitial fluid – fluid between the cells of the body. intra-arterial – within an artery. intravenous - (IV) within a vein. IUA - Intra-Urethral Alprostadil . Erection on demand drug. laparoscopy – surgical procedure using optic scopes, monitor screens and minimally invasive surgical tools and technique. leukopenic – condition where white cell count drops below 4000 cells per mm3. LHRH - luteinizing hormone-releasing hormone agonist used to disrupt the release of testosterone. liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins. lymph – fluid that is picked up from the body and eventually moved into the blood . lymphandenectomy - removal of a part of the lymphatic system. lymphatic system – bodily system responsible for the movement of lymph and supporting a defence response to inflammation and infection.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

184

lymphedema - swelling that occurs due to insufficient lymph drainage. MRI – (magnetic resonance imaging) examination of body structure using a machine that induces mini magnetic emissions in the body’s hydrogen nuclei which can be captured and stored by a scanner. malignancy – being with cancer. margin – a surgical term used to describe the distance between identified cancer cells and healthy tissue. metabolism – the processes related to the exchange, conversion, storage and use of energy in cells. metastasis - the invasion of cancer beyond its initial site of development into the circulatory system and other organs of the body. metronomic - treatment that calls for relatively low grade amounts of drugs or compounds to be administered under a continuous schedule to combat disease. mitosis – process of cell replication. monoclonal – meaning all the same or “cloned”. monosaccharide – a simple sugar such as galactose, glucose or fructose. NCI – United States National Cancer Institute. necrosis – death of living tissue neoadjuvant - treatment given before surgery in order to shrink tumor(s) that are too extensive or complicated to be removed by surgery alone. neo-plastic – a benign abnormal tissue mass that has developed as a result of uncontrolled cell growth occurring usually after a genetic mutation and if allowed to persist could eventually become malignant. neurons - responsive cell in the nervous system that process and transmit information by electrochemical signaling. neurotransmitter - chemicals that are involved in the relay, amplification and modulation of signals between a neuron and another cell. neutropenic – condition where neutrophil count drops below 1000 cells per mm3. NIV feed - (non-invasive assisted pressure) oxygen line fitted in a patient’s nostrils. non-nutritive sweetener - synthetic compounds that can range from 160 to 13,000 times sweeter than sucrose (white sugar). Saccharin, aspartame, neotame, acesulfame K, sucralase, trichlorogalactosucrose are examples of these compounds. nutratherapy – use of food as a natural way to deliver dietary origin anti-cancer compounds, on a continual basis, to the body. Omega-3 – unsaturated essential fatty acid that can be derived only from intake of food or supplements in humans. Omega-6 - unsaturated essential fatty acid that can be derived only from intake of food or supplements in humans. Reported to be linked to ailments such as heart attack, thrombotic stroke, arrhythmia, arthritis, osteoporosis, inflammation, mood disorders and cancer if its ratio to Omega-3 fatty acids is excessive.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

185

oncologist - a physician who specializes in the study and treatment of cancer. oncology – the study of cancer. occult - hidden or otherwise not obvious. orchiectomy – surgical castration or removal of the testes. palpation – using the hands or fingers to feel something in an examination. palliative – care or treatment that focuses on reducing the severity of disease when cure is not possible. pathology - the laboratory based study of disease. PC – Prostate Cancer PCA pump – (Patient Controlled Analgesia) pump that delivers attached drug on command of the patient. PCD – programmed cell death. perineal – the space in the pelvic floor between the anus and the base of the scrotal sac in males. In females, the space between the anus that the vagin*l opening. peritonitis - abscess or inflammation of the abdominal wall. PET – Positron Emission Tomography. peryonie’s disease – connective tissue disorder where scar tissue forms a thick sheath of tissue surrounding the corpora cavernosus. phagocytic – cells that have the ability to “eat” or ingest foreign cells such as neutrophils. piecemeal – surgical method of removing an abnormal growth in small sections. placebo – substitute agent that is given in place of the active agent or drug. For example, sugar pills. platelet – a group of blood cells responsible for blood clotting and stimulation of healing after injury. PLND – pelvic lymph node dissection. polysaccharide - a long string of simple sugars joined by Alpha or Beta linkages. Port-a-cath – a small receptacle installed surgically under the skin and accessing the circulatory system used to minimize the trauma of successive intra venous injections associated with treatment such as chemotherapy. prophylactic – a measure that is done to prevent something from happening. progesterone – C-21 steroid hormone involved in menstrual cycle, pregnancy and embryogenesis. progestin – synthetic steroid that has similar effect to progesterone. prognosis - outlook or “best guess” as to what a patient will do given their profile, the state of the disease and the proposed treatment regimen.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

186

prostatomegaly – benign prostate enlargement. prosthetics – implant or artificial aspect designed to replace or augment parts of the anatomy. PSA – Prostate Specific Antigen QOL – quality of life. replication – the making of cells. resection – the surgical removal of a part of an organ. red blood cell – a group of cells responsible for the delivery of oxygen to tissues and the transport of waste, such as carbon dioxide, for removal. RFA – (radiofrequency thermal ablation) procedure using electrodes surgically inserted in the affected liver tissue and inducing an alternating current that causes necrosis (death of tissue) and thermal desiccation (drying out) of the treated area. relative survival – survivability quotient that excludes unrelated mortality. RNA – ribonucleic acid. One of two types of complex chemicals that make genes. RPP – radical perineal prostatectomy. RRP – radical retropubic prostatectomy. RT – (radiotherapy) treatment using x –ray waves to target, reduce or slow cancer cell growth. saline – a salt water solution. salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules. SEER – Surveillance Epidemiology and End Result. sentinel lymph nodes – lymph nodes first in line to receive lymph drained from the prostate. septic – the state of being infected. septicaemia - (“blood poisoning”) is a potentially life-threatening infection in which large amounts of bacteria are present in the blood seroma – yellowish pocket of fluid that occurs under the skin as a result of surgery. serotonin – a neurotransmitter responsible for stimulating vomiting. SIRS - (systemic inflammatory response syndrome) syndrome where bacteria in the bloodstream cause the entire body to become inflamed. SIRT – selective internal radiation therapy. SPECT/CT - Single Photon Emission Computed Tomography/ CT Skene’s gland – female prostate gland. starch – a digestible polysaccharide that is formed by simple sugar units joined by alpha linkages.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

187

subcutaneous – underneath the skin. sugar alcohol - carbohydrate sweetener that is neither sugar or alcohol and has caloric value. Examples are sorbitol, mannitol, xylitol, erythritol, isomalt, lactitol, and maltitol. target therapy – treatment involving the use of a group of drugs that attack cancer cells more specifically than conventional chemotherapy drugs can. telesurgery – surgery conducted at a distance from the patient using closed circuit television (CCTV). Terpene- a family of spices including mint, thyme, marjoram, oregano, basil and rosemary. thrombocytopenia – condition where platelet count is reduced and falls below 150 000 per mm3. topoisomerase – a group of enzymes involved in the unzipping of a DNA strand. transcoelomically - within the coelome (body cavity). TNM convention – method to stage or arrive at a prognostic group for cancer. TRUP – transurethral resection of the prostate. TRUS – trans rectal ultra sound. tumor – a neo-plastic swelling or lesion that can be benign, pre-malignant or malignant, tumor spillage – the unintentional contamination of an organ or area by cancerous cells during the surgical removal of malignant growth. Also known as implantation. UICC - Union Internationale Contre Cancer. USP – United States Pharmacopeia. ultrasound – imaging of internal bodily organ and structure using sound waves. Urethra – duct leading from bladder through which urine travels when exiting body. USG – ultrasound. USPSTF - U.S. Preventative Services Task Force. ultrasound – imaging of internal bodily organ and structure using sound waves. VED - vacuum

erection device

venous – related to the veins vesicant - a substance that causes tissue blistering. white blood cell – A group of blood cells that include neutrophils, B, T and NK cells and are involved in the body’s immunological response. WHO – World Health Organization. 3DCRT – 3D conformal radio therapy

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

188

REFERENCES and NOTES

1. World Cancer Report 2008 , International Agency for Research on Cancer, P.Boyle and B. Levin editors, ISBN 978 92 832 0423 7, 2008 www.iarc.fr/en/publications/pdfs-online/wcr/2008/ 2. World cancer burden (2008), World Cancer Fact Sheet, International Agency for Research on Cancer, World Health Organization, August 2012. gicr.iarc.fr/files/resources/20120906-WorldCancerFactSheet.pdf 3, 4, 61, 62. SEER (Surveillance Epidemiology and End Results) Fact Sheets: Prostate, National Cancer Institute, November 2011 SEER data information, posted 2012. http://seer.cancer.gov/statfacts/html/prost.html 5. Signs and Symptoms of Prostate Cancer, Canadian Cancer Society, August, 2010. http://www.cancer.ca/Canadawide/About%20cancer/Types%20of%20cancer/Signs%20and%20symptoms%20of%20p rostate%20cancer.aspx?sc_lang=en 6. Risk Factors for Prostate Cancer Development, Prostate Cancer Prevention (PDQ®), National Cancer Institute, last modified March 2012. http://www.cancer.gov/cancertopics/pdq/prevention/prostate/healthprofessional/page3 7. Seven year mortality results and related findings from the prostate component of the PLCO randomized cancer screening trial. G. Andriole , E. Crawford , R. Grubb et al. New England Journal of Medicine. March 2009, Volume 360, number 13, ppgs 13101319. http://content.nejm.org/cgi/content/full/NEJMoa0810696 8. Screening and prostate-cancer mortality in a randomized European study, F.H. Schröder, J. Hugosson M.J. Roobol et al. New England Journal of Medicine 2009; 360(13):1320–1328. http://content.nejm.org/cgi/content/full/NEJMoa0810084 9. Prostate Specific Antigen Test, National Cancer Institute Fact Sheet, July, 2012. http://www.cancer.gov/cancertopics/factsheet/detection/PSA 10. Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendations Statement, V.A. Moyer et al. , Annals of Internal Medicing, vol 157: (2) July 2012. http://annals.org/article.aspx?articleid=1216568 11. Chapter XI. Spianchnology, The Prostate, Gray’s Anatomy of the Human Body, Henry Gray, Bartleby.com, 2008. http://education.yahoo.com/reference/gray/subjects/subject/263

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

189

12, 13, 14, 17, 18. Surgery of the Anus, Rectum and Colon, 3rd ed. Vol I, 2008, Michael R.B. Keighley, Williams N.S. et al., Saunders pgs 1262 15, 28, 29. Self Instructional Manual for Cancer Registrars, Human Anatomy as Related to Tumor Formation, Book Four, Second Edition, SEER Program, National Institutes of Health & National Cancer Institute, pgs 542. seer.cancer.gov/training/manuals/Book4.pdf 16. Mapping of Lymphatic Drainage from the Prostate Using Filtered 99mTc-Sulfur Nanocolloid and SPECT/CT, Youngho Seo et al., Journal of Nuclear Medicine, vol 52 (7)pp. 1068- 1072, July 2011. http://jnm.snmjournals.org/content/52/7/1068.full 19. The genomic complexity of primary human Prostate Cancer, M.F. Berger et al. Nature vol 470, pps 214-220, February 2011. http://www.nature.com/nature/journal/v470/n7333/full/nature09744.html 20. Exome sequencing identifies recurrent SPOP, FOXA1 and MED12 mutations in Prostate Cancer, Rubin, M.A., Garraway, L.A. et al., Nature Genetics, vol 44(6) pps 685- 689. May http://www.ncbi.nlm.nih.gov/pubmed/22610119 21. Genetics of Prostate Cancer: Role of Family History, Genetics and Louisiana Families, D. M. Mandal PhD., LSU Health New Orleans, November 2012. http://www.medschool.lsuhsc.edu/genetics_center/louisiana/article_prostatecancer2.htm 22. Prostate Cancer risk assessment, Genetics of Prostate Cancer (PDQ ®), , National Cancer Institute, last modified November, 2012. http://www.cancer.gov/cancertopics/pdq/genetics/prostate/HealthProfessional/page14 23. Prostate Cancer Update, Johns Hopkins Medicine, Vol R, Winter , 2000. http://urology.jhu.edu/newsletter/prostate_cancer513.php 24, 25. Preventing Cancer through Diet, Foods that Fight Cancer R. Beliveau,. Gingras D., McClelland and Stewart Publishers, 2006, pgs 213. 26. Cystic lesions of the prostate gland: an ultrasound classification with pathological correlation, Galosi A.B. et al., Montironi R, Fabiani A, Lacetera V, Galle G, Muzzonigro G. Journal of Urology, vol 181(2) pps:647- 657, February, 2009. http://www.ncbi.nlm.nih.gov/pubmed/19091354

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

190

30. Prostatitis, The Merck Manual for HealthCare Professions, last reviewd by G.L. Andriole, M.D., October 2008. http://www.merckmanuals.com/professional/genitourinary_disorders/benign_prostate_dis ease/prostatitis.html?qt=Prostatitis&alt=sh 31, 38. Prostatodynia – Prostate Pain, The Browning Pelvic Pain & Organic Dysfunction Treatment Center, June 2010. http://ppodsyndrome.com/436/prostatodynia-prostate-pain/ 32. Methylation and Inactivation of Estrogen, Progesterone, and Androgen Receptors in Prostate Cancer, Sasaki et al., Journal of the National Cancer Institute vol 94 (5) pp 384390, 2002. http://jnci.oxfordjournals.org/content/94/5/384.long# 33. Guidelines for the management of castrate-resistant Prostate Cancer, F. Saad, M.D. et al., Canadian Urological Association Journal, vol. 4(6), pp 380-384, 2010. www.prostatecancer.ca/files/7-cuaj-guideline-crpc-dec-10 34, 35. Prognostic Factors in Prostate Cancer, J.S. Ross, M.D. et al., American Journal of Clinical Pathology, vol 120 (Supplement) pps S85 – S100, 2003. [pdf full] http://www.ncbi.nlm.nih.gov/pubmed/15298146 [abstract] 36. Primary transitional cell carcinoma of the prostate: a male disease with dismal prognosis despite cisplatin-based systemic chemotherapy, J.C. Angulo et al. , Journal of Men’s Health, Vol 7(1) pps 64-72 March 2010. http://www.jmhjournal.org/article/S1875-6867(09)00373-X/abstract 37. Nursing Diagnosis, J. L. Losey, R.N., Encyclopedia of Nursing and Allied Health, enotes 2012. http://www.enotes.com/nursing-encyclopedia/nursing-diagnosis 38. Signs and symptoms of Prostate Cancer, Canadian Cancer Encyclopedia, Canadian Cancer Society, 2012. http://info.cancer.ca/cce-ecc/default.aspx?cceid=1173&toc=41&Lang=E 39. The effects of breast self examination techniques on the risk of death from breast cancer , B.J. Harvey, MD, Miller, A.B., et al., Canadian Medical Association Journal, 1997, 157: 1205- 1212. http://www.cmaj.ca/cgi/reprint/157/9/1205.pdf 40, 42. Characterizing the range of simulated prostate abnormalities palpable by digital rectal examination, L.A. Baumgart et al., Cancer Epidemiology vol 34 pp 79-84, 2010. 41, 55. Prostate Cancer, Early Detection, Diagnosis and Staging Topics, staff submission, American Cancer Society, Last revised September, 2012. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-diagnosis

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

191

43, 46. Chapter 67, Screening for Prostate Cancer, J.W. Feightner M.D., MSc, FCFP, publication title unspecified. www.phac-aspc.gc.ca/publicat/clinic-clinique/pdf/s10c67e.pdf 44, 45. Chapter 190 Prostate Examination, M.J White et al., National Center for Biotechnology Information Bookshelf, NBK301, Buttertworth Publishers , 1990. http://www.ncbi.nlm.nih.gov/books/NBK301/ 47. Screening for Prostate Cancer, Recommendation Statement, U. S. Preventative Service Task Force, August, 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/prostate/prostaters.htm 48. HistoCAD: Machine Facilitated Histoimaging with Computer Assisted Diagnosis, J.E. Tomaszewski, Prostate Cancer Imaging. Computer-Aided Diagnosis, Prognosis and Intervention, International Workshop proceedings held in conjunction with MICCAI 2010, Bejing, China, pp 63-65, September, 2010. http://www.springerlink.com/content/978-3-642-159886#section=781377&page=1&locus=30 49. Seeing into Cells: The promise of in vivo molecular imaging in oncology, D.C. Sullivan and G. Kellof, EMBO reports 6, 4, 292–296 (2005) http://www.nature.com/embor/journal/v6/n4/full/7400382.html 50. 18FDG PET/CT as a useful prechemotherapeutic tool in carcinoma breast evaluation, N. Raizada, K. Kallur, M. Govindrajan, G. Prashanth, K. Nagaraj, S. Bhattacharjee, B. Ajai Kumar, American Society of Clinical Oncololgy, 2008 Breast Cancer Symposium. http://www.asco.org/ascov2/Meetings/Abstracts?&vmview=abst_detail_view&confID=5 8&abstractID=40400 51, 75. Imaging Prostate Cancer with 11C-Choline PET/CT, S.N Reske et al., Journal of Nuclear Medicine, vol 47 (8) pp 1245-1254, 2006. http://jnm.snmjournals.org/content/47/8/1249.full 52. The utility of 11C-choline PET/CT for imaging Prostate Cancer: a pictorial guide., R.C. Murphy et al., American Journal of Roentgenology, vol 196(6) pp 1390-1398, June, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21606304 (abstract) http://www.ajronline.org/content/196/6/1390/F4.expansion.html (power point presentation)

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

192

53. Modern Detection of Prostate Cancer’s Bone Metastasis: Is the Bone Scan Era Over? , B. Tombal and F. Lecouvert, Advances in Urology, 2011. http://openi.nlm.nih.gov/detailedresult.php?img=3195676_AU2012-893193.002&query= 11C-Choline PET/CT&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&npos= 3&prt= 54. Screening Prostate Cancer using a portable near infrared scanning imaging unit with an optical fiber –based rectal probe, P. Yang et al., Optical Biopsy X SPIE Proceedings, vol 8220, Scanning Diffuse Reflectance and Hyper-Spectral Imaging, 9 February, 2012. http://proceedings.spiedigitallibrary.org/proceeding.aspx?articleid=1275694 (abstract) 56. Integrated System for Robot-Assisted in Prostate Biopsy in Closed MRI Scanner, P.W. Mewes et al., Proceedings 2008 IEEE international Conference on Robotics and Automation, May 19-23, 2008. www.cisst.org/~gfischer/cisweb1_files/Mewes_ICRA2008.pdf 57. What are tumor markers?, American Cancer Society, last revised March 2011. http://www.cancer.org/Treatment/UnderstandingYourDiagnosis/ExamsandTestDescriptio ns/TumorMarkers/tumor-markers-what-are-t-m 58, 59, 60. Laboratory Medicine Practice Guidelines, Use of Tumor markers in testicular, prostate, colorectal, breast and ovarian cancers, C. M. Sturgeon and E. P. Diamandis editors, National Academy of Clinical Biochemistry, pgs. 91, 2009. http://www.google.ca/url?sa=t&rct=j&q=tumor+markers+for+prostate+cancer&source= web&cd=5&cad=rja&ved=0CEAQFjAE&url=http%3A%2F%2Fwww.aacc.org%2Fmem bers%2Fnacb%2FLMPG%2FOnlineGuide%2FPublishedGuidelines%2Fmajor%2FDocu ments%2FTumorMarkersMajor10.pdf&ei=cqrUKSJE6u20AGznIDgCg&usg=AFQjCNFGEeDOPh3rBpXwb2z3Nk6kZimZnw 63, 66. Radical Perineal Prostatectomy for Prostate Cancer, H.J. Korman, M.D. FACS, Medscape Reference, 2012. http://emedicine.medscape.com/article/447239-overview 64. Pelvic Lymph Node Dissection, F. Papanikolaou, M.D., Medscape Reference, 2012. http://emedicine.medscape.com/article/446463-overview 65. The sentinel node concept in Prostate Cancer: Present reality and future prospects, M. Egawa et al. Indian Journal of Urology, vol 24 (4) pp 451- 456. Oct-Dec 2008. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684382/ 67. Neoadjuvant Androgen Deprivation therapy in Prostate Cancer, V.R. Patel, M.D., Medscape Reference, 2012. http://emedicine.medscape.com/article/455994-overview#aw2aab6b3

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

193

68. Androgen, Wikipedia, November, 2012. http://en.wikipedia.org/wiki/Androgen 69. Study Results Show New Testicular Implant ot be Safe and to Improve Self Esteem in Boys and Men, ScienceDaily, October 29, 2004. http://www.sciencedaily.com/releases/2004/10/041029102259.htm 70, 110, 111, 117, 118, 123, 127, 129. Prostate Cancer, Clinical Practice Guideline GU004, Alberta Health Services, last Revised: January, 2011. www.albertahealthservices.ca/hp/if-hp-cancer-guide-gu004-prostate.pdf 71. Radical Perineal Prostatectomy: A More Optimal Treatment Approach Than Laparoscopic Radical Prostatectomy in Obese Patients? , A.C. Leung, M.D. and A. Melman, M.D., reviews in Urology, Winter 2005. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477559/ 72. Transurethral resection of the prostate, MedlinePlus, A service of the U.S. National Library of Medicine and National Institutes of Health, last updated October, 2012. http://www.nlm.nih.gov/medlineplus/ency/article/002996.htm 73. Overview of Contemporary Penile Rehabilitation Therapies, P. Hinh and R. Wang, Advances in Urology 2008, 2008 481218. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2531200/ 74. Testicular Cancer Treatments: The Inguinal Orchiectomy, The Testicular Cancer Resource Center, Doug Bank Editor, last updated 1997. http://tcrc.acor.org/orch.html 76. Open Versus Laparoscopic Radical Prostatectomy, H. Lepor, M.D., Reviews in Urology, 2005 Summer, vol 7(3) pp. 115-127. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477579/ 77. Laparoscopic Pelvic Lymphadenectomy: Standard Technique, A. Wattiez et al., WebSurg, October, 2011. http://www.websurg.com/doi-vd01en3401.htm 78. Laparoscopic Pelvic Lymph Node Dissection, J.T. Bishoff, M.D., Medscape Overview, updated March 2011. http://emedicine.medscape.com/article/445610-overview 79. Evaluation of a robotic technique for transrectal MRI guided prostate biopsies, M.G. Schouten et al., European Radiology, vol 22(2) pp. 476-483, February 2012. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249030/

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

194

80. World Cancer Report 2008 , section 3.5 , International Agency for Research on Cancer publisher, 2008. www.iarc.fr/en/publications/pdfs-online/wcr/2008/ 81. Metastasis to Bone: Causes, Consequences and Therapeutic Opportunities, G.R. Mundy, Nature Reviews, vol 2 pp 687- 693, August 2002. helsenet.info/pdf/metastasis/1.pdf 82.. Radiofrequency Thermal Albilation as Tumor Therapy, Radiology and Imaging Services, National Institute of Health Clinical Center, March, 2009. http://clinicalcenter.nih.gov/drd/tumortherapy.html 83. Recent trends and future perspectives in isolated hepatic perfusion in the treatment of liver tumors, J. Rothbarth, Tollenaar, RAEM, van de Velde, CJH, Expert Review of Anticancer Therapy, Volume 6, Number 4, April 2006, pp. 553-565(13) http://www.expert-reviews.com/doi/abs/10.1586/14737140.6.4.553 84. Standards for Basic Anesthetic Monitoring, Committee of Origin: Standards and Practice Parameters (Approved by the ASA House of Deligates on October 21, 1986, and last amended on October 20, 2010 with an effective date of July 1, 2011).pdf http://www.google.ca/#hl=en&sclient=psyab&q=american+society+of+anesthesiologists+standards+for+basic+anesthetic+monitori ng&oq=american+society+of+anesthesiologists+standsrds+for+basic+&gs_l=serp.1.0.0i 13i30.9906.14179.0.16805.20.20.0.0.0.0.226.3341.0j16j3.19.0.les%3B..0.0...1c.1.agtY6n QFdlk&pbx=1&bav=on.2,or.r_gc.r_pw.r_qf.&fp=77a9610d9993fe05&biw=1366&bih=5 87 85. Errors involving PCA Pumps (USP Drug Safety Review), J.P. Santell, Cousins, DD., Hicks, R., Drug Topics Health System Editions, October 25, 2004. http://business.highbeam.com/62489/article-1G1-127157300/errors-involving-pca-pumps 86. The Silent Battle Within, A Patient’s View of Colon Cancer, D. Hollenbeck, KnowingHelps Corp, 2008, pgs 190. pdf, last updated July 2012. http://www.knowinghelps.com 87. Robotic-assisted radical prostatectomy decreases the incidence and morbidity of surgical site infections, M.K. Tollefson et al., Urology, vol 78(4) pp 827- 831, October 2011 Epub Jul 2011. http://www.ncbi.nlm.nih.gov/pubmed/21802119 88. Surgical Site Infections May Be Reduced by Shorter Duration of Prophylactic Antibiotic Medication in Urological Surgeries, K. Shigemura et al. , Japan Journal of Infectious Disease, vol 62 pp 440 -443, 2009. www0.nih.go.jp/JJID/62/440.pdf

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

195

89, 90. Septicaemia , Better health Channel, Victorian Department of Human Services, Australia, 2007. http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Septicaemia?Open 91. Factors influencing wound infection (a prospective study of 280 cases). L.A. deSa, Sathe, M.J., Bapat, R.D., Journal of Post graduate medicine Vol 30 issue 4 pgs 232-6. 1984 http://www.jpgmonline.com/article.asp?issn=00223859;year=1984;volume=30;issue=4;spage=232;epage=6;aulast=deSa 92. Neutrpenia, M. C. Stoppler, MD, MedicineNet.com, Medical Editor , M.D. Nettleman, MD, MS, MACP. 2012. http://www.medicinenet.com/neutropenia/article.htm 93. Neutrophil Count, FamilyPracticeNotebook, Scott Moses, M.D. Minnesota, MN. USA, July, 2012. http://www.fpnotebook.com/Hemeonc/Lab/NtrphlCnt.htm 94. Red Blood Cells, My Blood Your Blood, America’s Blood Centers, 2002. http://www.mybloodyourblood.org/biology_red.htm 95. The Platelet Role in Haemostasis, R. Klykarni MD, U.M. Reddy MD, and B. Evatt MD , Reddy Medical Commumicatons, LLC 2003. http://www.reddymed.com/hdbc_platelet_rinhemo.htm 96. Platelet Count, FamilyPracticeNotebook.com, Scott Moses, M.D. Minnesota, MN. USA, July, 2012. http://www.fpnotebook.com/Hemeonc/Lab/PltltCnt.htm 97. Signs and Symptoms of an Infection, How to Identify an Infection after Surgery, J.Heisler, RN, About.com Guide, Updated January 22, 2012. http://surgery.about.com/od/aftersurgery/qt/SignsInfections.htm 98. The Microbial World, Lectures in Microbiology, K Todar PhD, Unversity of Wisconsin-Madison, Department of Bacteriology. 2009. http://textbookofbacteriology.net/themicrobialworld/antimicrobial.html 99, 100. Low White Blood Cell Count (Neutropena), OncoLink, P. Cobb, MD, Abramson Cancer Center, University of Pennsylvania, 2001 http://www.oncolink.com/treatment/article.cfm?c=2&s=13&id=68

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

196

101, 103, 104, 105, 106. Best Practices for Post Prestatectomy Penile Rehabilitation/ED Treatment and Urinary Incontinence, A.B. Balchumans, M.S. , PA-C, FAAPA, Urological Association of Physician Assistants, First Annual Meeting, Las Vegas, Nevada. January, 2012. https://wjweis.sslcert19.com/securesite/uapa/meetings/2012/2012%20UAPA%201st%20 Annual%20Meeting%2001.20.1201.22.12/Friday/pdfs/Anthony%20Balchunas%20Best%20Practices%20for%20PostProstatectomy%20Penile%20Rehabilitation.UAPA1.pdf 102. Penile Rehabilitation after Radical Prostatectomy: Important Therapy or Wishful Thinking? J.E. Fall’Era, M.D. et al., Reveiws in Urology, Vol 8(4) pp 209-215. Fall 2006. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1751036/ 107. Short- and long-term mortality with localized Prostate Cancer, E.Rapiti, M.D. and C. Bouchardy M.D. et al., Archives of Internal Medicine, vol 167 (18) pp 1944-1950 October 2007. http://archinte.jamanetwork.com/article.aspx?articleid=413179 108. Prostate Cancer Surgery Best Option?, Study Shows 10 year Prostate Cancer Survival Best When Patients Choose Surgery, D.J. DeNoon, Prostate Cancer Health Center, WebMD, October 2007. http://www.webmd.com/prostate-cancer/news/20071008/prostate-cancer-surgery-bestoption 109. Smoking and risk of total and fatal Prostate Cancer in United States health professionals, E. Giovannucci et al., Cancer Epidemiol Biomarkers Prev. 1999 Apr: pps 277- 282. http://www.ncbi.nlm.nih.gov/pubmed/10207628 112, 195. Brachytherapy (Radioactive Seed Implantation Therapy in Prostate Cancer, D. Theodoresca, M.D, PhD., Medscape Reference, March 2012. http://emedicine.medscape.com/article/453349-overview 113. Cryotherapy in Prostate Cancer, M.R. Cooperberg, M.D., March, 2012. http://emedicine.medscape.com/article/458187-overview 114. High-intensity focused untrasound for the treatment of localized Prostate Cancer: 5 year experience, A. Blana et al., Urology vol 63(2) pp 297- 300, 2004. http://europepmc.org/abstract/MED/14972475/reload=0;jsessionid=H0bqp1YCtKi5mTd HfSrH.2 115. Minimally invasive technologies in uro-oncology: The role of cryotherapy, HIFU and photodynamic therapy in whole gland and focal therapy of localised Prostate Cancer, H. U. Ahmed et al., Surgical Oncology vol 18(3) pp 219-232 September 2009. www.ncbi.nlm.nih.gov/pubmed/19268572

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

197

116. Focal therapy for Prostate Cancer: Fact or fiction?, E. Lecornet, M.D., E.A.U. et al Urologic Oncology: Seminare and Original Investigations vol 28 pp. 550-556. rodriguez-rubio.com/documentos/Focal_Lecornet_Uro_Onc_10.pdf 119. Prognostic Factors ffor Failure after Prostatectomy, G.P. Swanson and Basler, J.W., Journal of Cancer Vol 2 pp 1-19, 2011. http://www.jcancer.org/v02p0001.htm 120. Collective behavior in cancer cell populations, T.S. Deisboeck and I.D. Couzin, BioEssays 31:190-197, February 2009, Wiley Periodicals, Inc. http://www.ncbi.nlm.nih.gov/pubmed/19204991 121. Resistance to chemotherapy: new treatments and novel insights into an old problem, S. Raguz and E. Yagüe. British Journal of Cancer (2008) 99, 387-391 published on line 29 July 2008. http://www.nature.com/bjc/journal/v99/n3/full/6604510a.html 122. Vitamin C Antagonizes the Cytotoxic Effects of Antineoplastic Drugs , M. L. Heaney et al. Experimental Therapeutics, Molecular Targets and Chemical Biology, Cancer Res. October 1: 68 (19): 8031-8. http://cancerres.aacrjournals.org/content/68/19/8031.short 124. Clinical Trials, National Institute of Health (United States of America) , last revised August, 2012. http://clinicaltrials.gov/ct2/info/glossary#institutional 125. Effect of Screening and Adjuvant Therapy on Mortality from Breast Cancer, D.A Berry, KA. Cronin et al. The New England Journal of Medicine, Vol 353:1784-1792 October 27, 2005 Number 17 http://content.nejm.org/cgi/content/full/353/17/1784 126, 131. Clinical Trials for adjuvant therapy Prostate Cancer, National Institute of Health (United States of America) , December, 2012. http://www.clinicaltrials.gov/ct2/results?term=adjuvant+therapy+prostate+cancer&Searc h=Search 128. The Evolving Definition of Advanced Prostate Cancer, J.U. Moul, M.D., Reviews in Urology vol 6 (supplement 8) pp S10-S17, 2004. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472896/ 130. Vaccine Treatment for Prostate Cancer, American Cancer Society, last revised September 2012. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treatingvaccine-treatment 132. Docetaxel, The Scott Hamilton CARES Initiative, 2012. http://www.chemocare.com/chemotherapy/drug-info/docetaxel.aspx

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

198

133, 143, 166. Mitoxantrone, The Scott Hamilton CARES Initiative, 2012. http://www.chemocare.com/chemotherapy/drug-info/Mitoxantrone.aspx 134. Update on Chemotherapeutic Agents Utilized for Perioperative Intraperitoneal Chemotherapy, Table 1. Chemotherapy agents used for perioperative intraperitoneal chemotherapy, Paul H. Sugarbaker et al. , The Oncologist, Vol. 10, No. 2, 112-122, February 2005 http://theoncologist.alphamedpress.org/content/10/2/112.full 135. Platelet Count Reference Range, Lab Tests on Line, American Accociation for Clinical Chemistry, June 2012. http://labtestsonline.org/understanding/analytes/platelet/tab/test 136. Thrombobytopenia (low platelet count), S.T. Nabili, MD, MPH, MedicineNet.com, 2012 http://www.medicinenet.com/thrombocytopenia_low_platelet_count/page3.htm 137. Adverse Reactions to Platelet Transfusion, Risks and Probable Causes, J.H. Angelbeck, Ph.D. Pall Corporation. http://www.pall.com/main/Medical/Literature-Library-Details.page?id=6494 138, 140, 142, 144, 146, 150, 170. What are the different types of Chemotherapy Drugs? American Cancer Society, Making Treatment Decisions, last updated October, 2011. http://www.cancer.org/Treatment/TreatmentsandSideEffects/TreatmentTypes/Chemother apy/ChemotherapyPrinciplesAnIndepthDiscussionoftheTechniquesanditsRoleinTreatment/chemotherapy-principles-typesof-chemo-drugs 139. Estramustine, American Cancer Society, Last revised January 2010. http://www.cancer.org/treatment/treatmentsandsideeffects/guidetocancerdrugs/Estramusti ne 141. Efficacy of Oral Fluorouracil Pro-drug Capecitabine in Cancer Treatment: a Review, G.V. Koukourakis et al., Molecules, vol 13 pp 1897-1922, 2008. www.mdpi.com/1420-3049/13/8/1897/pdf 145. Topoisomerase inhibitor, Wikipedia, April, 2012. http://en.wikipedia.org/wiki/Topoisomerase_inhibitor 147. Use of Irinotecan for treatment of small cell carcinoma of the prostate, W.I. Tung, et al., Prostate, vol 71 (7) pp. 675- 681, May 2011. 148. Irinotecan, Find Support and Treatment, American Cancer Society, last revised December 2009. http://www.cancer.org/Treatment/TreatmentsandSideEffects/GuidetoCancerDrugs/irinote can

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

199

149. Mitotic Inhibitor, Wilkipedia, June, 2012. http://en.wikipedia.org/wiki/Mitotic_inhibitor 151. Prochlorperazine, Medline Plus, U.S. National Library of Medicine & National Institutes of Health, last updated September 2012. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682116.html 152, 153, 159, 161, 162. Androgen Deprivation Therapy in the Treatment of Advanced Prostate Cancer, M.A. Perlmutter, M.D. and H. Lepor, M.D. Reviews in Urology, vol 9 Supplement 1) pp S3-S8, 2007. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831539/ 154, 155. Calcium Supplementation in Clinical Practice: A review of Forms, Doses, and indications, D.A. Straub, M.S. R.D., Nutrition in Clinical Practice, pps. 1- 12, 2007. intl-ncp.sagepub.com/content/22/3/286.full 156. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis, M.J. Bollard et al., BMJ 2010 341 c3691, May 2010; http://www.bmj.com/content/341/bmj.c3691.full and, correction BMJ 2010 341: c6923 http://www.bmj.com/content/341/bmj.c6923 157. Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis, M.J. Bollard et al, BMJ 2011 vol 19: pp 342, April 2011. http://www.bmj.com/content/342/bmj.d2040 158. Dietary Supplement Fact Sheet: Calcium, Office of Dietary Supplements, National Institutes of Health, November, 2012. http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ 160. Prostate Cancer – Hormone Therapy and Chemotherapy , University of Maryland Medical Center, H. Simon Editor in Chief, last reviewed August 2009. http://www.umm.edu/patiented/articles/what_guidelines_treating_localized_prostate_can cer_000033_11.htm#ixzz2EYiDLFHO 163, 164. Castration-Resistant Prostate Cancer; The Emerging Roles of Targeted Therapies and Immunotherapy, E.D. Crawford, M.D and D.P. Petrylak, M.D., MedScape, Faculty and Disclosures, 2011. http://www.medscape.org/viewarticle/736991 165. Antibody-Drug Conjugate Has Antitumor Activity in Metastatic Castration-Resistant Prostate Cancer, D. Huges, M.S. Chemotherapy Advisor, November, 2012. http://www.chemotherapyadvisor.com/antibody-drug-conjugate-has-antitumor-activityin-metastatic-castration-resistant-prostate-cancer/article/267856/

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

200

167, 168. Docetaxel plus Prednisone or Mitoxantrone plus Prednisone for Advance Prostate Cancer, I.F. Tannock, M.D. Ph.D. et al. New England Journal of Medicine, vol 351(15), pp. 1502 – 1512, October, 2004. http://www.nejm.org/doi/full/10.1056/NEJMoa040720 169. Prednisone, The Scott Hamilton CARES Initiative, 2012. http://www.chemocare.com/chemotherapy/drug-info/Mitoxantrone.aspx 171. Targeting bone remodeling by isoflavone and 3,3′-diindolylmethane in the context of Prostate Cancer bone metastasis., Li Y et al., PLoS One, vol 7(3):e33011, March 2012. http://www.ncbi.nlm.nih.gov/pubmed?term=22412975 172. Colorectal Cancer Chemotherapy, Cancer Treatment Centers of America, 2012. http://www.cancercenter.com/colorectal-cancer/chemotherapy.cfm 173. What is Immunotherapy?, American Cancer Society, May, 2012. http://www.cancer.org/Treatment/TreatmentsandSideEffects/TreatmentTypes/Immunothe rapy/immunotherapy-what-is-immunotherapy 174. Monoclonal Antibody Therapy for Prostate Cancer: Finally a Reality?, E.J. Small, Journal of Clinical Oncology, vol 22(13), pp. 2515-2516, July 2004. http://jco.ascopubs.org/content/22/13/2515.full 175, 176, 177. Tumor-Associated Antigens for Specific Immunnotherapy of Prostate Cancer, Review, A. Kiessling et al., Cancers vol 4, pp. 193-217, February 2012. www.mdpi.com/2072-6694/4/1/193/pdf 178. Gene therapy for cancer: what have we done and where are we going? J. A. Roth, R.J. Chistiano, Department of Thoracic and Cardiovascular Surgery, Journal of the National Cancer Institute 89(1):21-39, 1997. http://jnci.oxfordjournals.org/content/89/1/21.full 179. Principles and applications of Gene Therapy in colorectal cancer, R. Durai, et al., Journal of Gasterointestin Liver Dis, vol 17(1) pp. 59- 67, March 2008. http://www.jgld.ro/2008/1/10.pdf 180. Progress in gene therapy for Prostate Cancer, K.A. Ahmed et al., Frontiers in Oncology, 2012; 2:172, November 2012. www.frontiersin.org/Journal/DownloadFile/1/.../fonc-02-00172_pdf 181. Gene Study Yields New Clues to Breast Cancer, MedlinePlus, U.S. National Library of Medicine & National Institutes of Health, September, 2012. http://www.nlm.nih.gov/medlineplus/news/fullstory_129556.html

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

201

182. New Molecularity Targeted Therapies for Lung Cancer ,S. Sun et al. , Journal of Clinical Investigation, 117 (10): 2740- 2750, 2007. http://www.jci.org/articles/view/31809 183. Stem cell, Wikipedia, October, 2012. http://en.wikipedia.org/wiki/Stem_cell 184. Scientists Identify Prostate Cancer Stem Cells Among Low-PSA Cells, MD Anderson NewsRelease [disclosing recent Prostate Cancer stem cell discovery by Tang et al.], May 4, 2012. http://www.mdanderson.org/newsroom/news-releases/2012/stem-cells-among-low-psacells.html 185, 186, 188, 189, 196. Radiation Therapy for Cancer, National Cancer Institute Fact Sheet, June, 2010. http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation 187. Impact of Tumor Hypoxia and Anemia on Radiation Therapy Outcomes, L.B. Harrison et al., The Oncologist Vol 7, No. 6, 492 508, December 2002. http://theoncologist.alphamedpress.org/content/7/6/492.abstract 190, 191, 197, 199. Radiation Therapy, Wikipedia, last updated September, 2012. http://en.wikipedia.org/wiki/Radiation_therapy 192. Proton therapy, Wikipedia, last modified November 2012. http://en.wikipedia.org/wiki/Proton_therapy 193. Comparative effectiveness of intensity modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy (CRT) in the treatment of localized Prostate Cancer, N.C. Sheets, et al., Journal of Clinical Oncology vol 30 (supplement 5 abstract 3), 2012. http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID =116&abstractID=89265 194. Selective Internal Radiation Therapy (SIRT) Targeted treatment for inoperable liver cancer, University of Maryland Marlene and Stewart Greenebaum Cancer Center, April 2008. http://www.umgcc.org/sir-spheres/ 198. Radiation Therapy and You: Support for People with Cancer, National Cancer Institute, April, 2007. http://www.cancer.gov/cancertopics/coping/radiation-therapy-and-you/page6 200. Intergroup randomized phase III study of androgen deprivation therapy (ADT) plus radiation therapy (RT) in locally advanced Prostate Cancer (CaP) (NCIC-CTG, SWOG, MRC-UK, INT: T94-0110; NCT00002633), P.R. Ward et al., Journal of Clinical Oncology vol 28: 18s, 2010.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

202

http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID =74&abstractID=49170 201. Smoking and Prostate Cancer Survival and Recurrence, S. Kenfield et al., Journal of the American Medical Association vol 305(24) pp 2548-2555, June 2011. http://jama.jamanetwork.com/article.aspx?articleid=646754 202. Does local recurrence of Prostate Cancer after radiation therapy occur at the site of primary tumor? Results of a longitudinal MRI and MRSI study. , Arrayeh E et al., International Journal of Radiation Oncology, Biology and Physics, vol 82(5), pp787-93. April 2012 Epub February 2012. http://www.ncbi.nlm.nih.gov/pubmed/22331003 203. The pattern of Prostate Cancer local recurrence after radiation and salvage cryoablation, Chee Kwan Ng et al., Canadian Urological Association Journal, 2011. DOI:10.5489/cuaj.09116, www.cuaj.ca/cuaj-jauc/vol5-no1-early-releases/09116.pdf 204. Quality of life for men with Prostate Cancer. A. Katz MN, PhD, Cancer Nursing, July-August, vol30(4), pp302-8, 2007. http://www.ncbi.nlm.nih.gov/pubmed/17666980 205. PDE-5 Inhibitor Therapy for Erectile Dysfunction Secondary to Nerve-Sparing Radical Retropubic Prostatectomy, H. Padman-Natan, M.D., Reviews in Urology, vol 7 (Suppliment 2) pp s33-s38, 2005. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477594/ 206. Prostate Cancer, Diagnosis and treatment, NICE clinical guideline 58, National Institute for Health and Clinical Exellence, pps 1-58, February, 2008. http://www.nice.org.uk/nicemedia/pdf/CG58NICEGuideline.pdf 207. Focal therapy for localised unifocal and multifocal Prostate Cancer: a prospective development study, H.U. Ahmed MRCS et al., The Lancet Oncology, vol 13(6) pp 622632, June, 2012. http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(12)70121-3/abstract# 208. Canadian Cancer Statistics 2008, Canadian Cancer Society; National Cancer Institute; Canada Statistics; and, Territorial and Provincial Cancer Registries publishers, 2009. http://www.google.ca/url?sa=t&rct=j&q=canadian%20cancer%20statistics%202008&sou rce=web&cd=1&sqi=2&ved=0CF8QFjAA&url=http%3A%2F%2Fwww.cancer.ca%2F~ %2Fmedia%2FCCS%2FCanada%2520wide%2FFiles%2520List%2FEnglish%2520files %2520heading%2Fpdf%2520not%2520in%2520publications%2520section%2FCanadian %2520Cancer%2520Society%2520Statistics%2520PDF%25202008_614137951.ashx&e i=gcfYT-jNA6yy0AWuvMGsBA&usg=AFQjCNHTvutRQDUzx3IHPVsiUmdqTm3OA

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

203

209. World Cancer Report 2008 , International Agency for Research on Cancer, P.Boyle and B. Levin editors, ISBN 978 92 832 0423 7, 2008 http://www.iarc.fr/en/publications/pdfs-online/wcr/2008/index.php 210. Clinical trials of antioxidants as cancer prevention agentss: Past, present, and future, M. Goodman et al., Free Radical Biology & Medicine 51 (2011) 1068-1084. http://www.google.ca/url?sa=t&rct=j&q=clinical%20trials%20of%20antioxidants%20as %20cancer%20prevention%20agents%3A%20past%2C%20present%2C%20and%20futu re&source=web&cd=2&ved=0CF8QFjAB&url=http%3A%2F%2Fwww.grupogales.com %2Fadmin_upload%2Fdocumentos%2Fpagina_medicina%2F2011antioxidants.pdf&ei=Ns_ZT5rXLaXx6AGk_ezLAg&usg=AFQjCNGbypkZBY5L28uurP xFiGr8q2XW2w 211, 212. Antioxidants and Cancer Prevention: Fact Sheet, National Cancer Institute, July 2004. http://www.cancer.gov/cancertopics/factsheet/antioxidantsprevention 213, 214, 226, 230, 231, 232, 233, 234, 236, 237, 240, 241, 242, 243, 244 245, 246, 247. Foods that Fight Cancer: Preventing Cancer Through Diet, R. Béliveau and D. Gingras, (English version) McClelland and Stewart publishers, Toronto, Canada, 2006, pgs 213. 215. Nutrition and healthy eating, Dietary fiber: Essential for a healthy diet, Mayo Clinic staff, November, 2009. http://www.mayoclinic.com/health/fiber/NU00033 216. High-fructose corn syrup, Wikipedia, June, 2012. http://en.wikipedia.org/wiki/High-fructose_corn_syrup 217. Sugar, Wikipedia, June, 2012. http://en.wikipedia.org/wiki/Sugar 218. Agave Nectar, Wikipedia, May, 2012. http://en.wikipedia.org/wiki/Agave_sweetener 219. The Prime Cause and Prevention of Cancer - Part 1 with two prefaces on prevention, Otto Warburg, [Revised lecture at the meeting of the Nobel-Laureates, June 30, 1966 at Lindau, Lake Constance, Germany], English Edition by Dean Burk National Cancer Institute, Bethesda, Maryland, USA, Rev 2 Konrad Triltsch Publishers, Würzburg, Germany, 1969. http://healingtools.tripod.com/primecause1.html/ 220. Medical Biochemistry at a Glance, J.G. Salway, Blackwell Publishers, 2005, pgs. 144. ISBN 9781405107167

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

204

221. Glucose, Wikipedia, June, 2012 http://en.wikipedia.org/wiki/Glucose 222, 223, 224. Artificial Sweeteners, B.Kovacs, MS.RD, W. C. Shiel MD FACP FACR editor, Medicine Net Inc. 2012. http://www.medicinenet.com/artificial_sweeteners/article.htm 225, 238. ANTI-CANCER A NEW WAY OF LIFE, Dr David Servan-Schreiber , Harper Collins publishers, 2007, pgs 258. 227. Omega-6 fatty acid, Wikipedia, May 2012 http://en.wikipedia.org/wiki/Omega-6_fatty_acid 228. The importance of the ratio of omega-6/omega-3 essential fatty acids. A.P. Simopoulos, Center for Genetics, Nutrition and Health, Washington, D. C. USA, Food Reviews International 20 (1): 77-90, 2004. http://www.csuchico.edu/grassfedbeef/research/health-lit.shtml 229. Omega-3 fatty acids, University of Maryland Medical Center, staff, 2011. http://www.umm.edu/altmed/articles/omega-3-000316.htm 235. Influence of Peperine on Pharmokinetics of curcumin in Animals and Human Volunteers, G. D. Shoba, T.J. Joy et al., Planta Medica 64 no.4 (1998) 353-56. http://www.ncbi.nlm.nih.gov/pubmed/9619120 239. Angiogenesis Inhibited by Drinking Tea, Y.Cao. and R. Cao, Nature 398 no 6726 (1999): 381. www.lamtreatmentalliance.com/lta.../cao_1999_angiogenesis.pdf 248. Stress, University of Maryland Medical Center, H.Simon, M.D., Editor-in-Chief, 2011. www.umm.edu/patiented/articles/what_stress_000031_1.htm 249, 250, 251, 252. Psychological Stress and the Human Immune System: A MetaAnalytic Study of 30 Years of Inquiry, S.C., Segerstrom, G.E.Miller, Psychological Bulletin, 2004, Vol. 130, No.4 601-630. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361287/ 253. Promoting Positive Ageing through the Theraputic use of animals, Theoretical Underpinnings and Practical Possibilities, H.A. Reel and D.A. Kleiber, Annual in Therapeutic Recreation, No. XVI, pgs 147-157, 2008. 254. Physical Activity and Survival after Prostate Cancer Diagnosis in the Health Professionals Follow-up Study, S. A. Kenfield et al., Journal of Clinical Oncology, vol 29 (6) pp. 726-732, February 2011. http://jco.ascopubs.org/content/29/6/726.full?sid=e91de6f8-2f71-44d6-9a2bdd2e75eea112

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

205

255. The Health Benefits of Sexual Expression, White Paper, Planned Parenthood Federation of America, Inc, New York, NY, 2003. http://www.hawaii.edu/search/?cx=008945998903415758105%3A4nrwh926ni&cof=FORID%3A11&q=The+Health+Benefits+of+Sexual+Expression%2C+White +Paper&sa=Search&siteurl=http%3A%2F%2Fwww.hawaii.edu%2F 256. How old is acupuncture? Challenging the Neolithic origins theory. Xinghua, Bai; Baron, R.B. The Journal of Chinese Medicine , February 1, 2008. http://ezinearticles.com/?How-Old-is-Acupuncture?-Challenging-the-Neolithic-OriginsTheory&id=3067317 257. State Laws, Acupuncture.com, 2012. http://www.acupuncture.com/statelaws/stelaws.htm 258, 264, 265, 266. Questions and Answers about Acupuncture, National Cancer Institute, U.S. National Institutes of Health. http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/patient/Page2 259, 262. Acupuncture, Cancer Research UK, September, 2011 http://www.cancerhelp.org.uk/help/default.asp?page=246 260. The practice of acupuncture and TCM in Canada and Quebec, Regulatory and educational frameworks, R Bourret, Ac, M.A. Chair Ordre des acupuncteurs du Quebec, Canada. October, 2009 www.o-a-q.org/import/English_Entry_level_competencies.pdf 261. Media Release: Chinese Medicine and National Registration,. Austrailian Acupuncture & Chinese Medicine Association Ltd., April 16, 2012 http://www.acupuncture.org.au/ 263. Acupuncture, An Introduction, National Center for Complementary and Alternative Medicine, Bethesda, Maryland, USA, August, 2011. http://nccam.nih.gov/health/acupuncture/introduction.htm 267. Acupuncture for cancer patients: why not?, N. Samuels, Shoresh Medical Center, Jerusalem, Israel. Harefuah. Jul; 141(7):608-10, 2002. [Abstract] http://www.ncbi.nlm.nih.gov/pubmed/12187559 268. Prostate Cancer Screening, Centers for Disease Control and Prevention, Atlanta, GA. USA, May 2012. http://www.cdc.gov/cancer/prostate/basic_info/screening.htm 269. Early Detection of Prostate Cancer, Policy Title , American Urological Association, 2012. http://www.auanet.org/content/aua-policies/policy-statements/e/early-detection-ofprostate-cancer.cfm

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

206

270. Screening and Prostate-Cancer Mortality in a Randomized European Study, F.H. Schröder, M.D. et al, New England Journal of Medicine, vol 360: pp. 1320-1328, 2009 http://www.nejm.org/doi/full/10.1056/NEJMoa0810084 271. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial, J. Hugosson et al., Lancet Oncolology vol 11(8): pp. 725-32, 2010. [abstract] http://www.ncbi.nlm.nih.gov/pubmed/20598634?dopt=Abstract 272, 273. Screening for Prostate Cancer Current Recommendation, U.S. Preventative Services Task Force, May 2012. http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm 274. Screening for Prostate Cancer, A Review of the evidence for the U.S. Preventative Services Task Force, October, 2011. http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostateart.htm 275. Programming the detection limits of biosensors through controlled nanostructuring, S. O. Kelly et al. , Nature Nanotechnology, Vol 4 pp 844-848 September, 2009. http://www.nature.com/nnano/journal/v4/n12/abs/nnano.2009.276.html 276. Alcohol intake, drinking patterns, and risk of Prostate Cancer in a large prospective cohort study. E.A. Platz et al., American Journal of Epidemiology vol 159 (5): pp. 444-453, 2004. http://aje.oxfordjournals.org/content/159/5/444.long 277. Alcohol Consumption and the Risk for Prostate Cancer in Erupoean Prosptective Investigation into Cancer and Nutrition, S. Rohrmann et al., Cancer Epidemiology, Biomarkers & Prevention, vol 17: pp 1282, May 2008. http://cebp.aacrjournals.org/content/17/5/1282.full 278. Body Mass Index, Weight Change, and Risk of Prostate Cancer in the Cancer Prevention Study II Nutrition Cohort, C.Rodriguez et al. , Cancer Epidemiology Biomarkers & Prevention, 2007; 16 (1) : pp 63-69. http://cebp.aacrjournals.org/content/16/1/63.full 279. Sexual factors and Prostate Cancer, G.G. Giles et al., British Journal of Urology International, vol 92: pp. 211-216, July, 2003. http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.2003.04319.x/full 280. ejacul*tion Frequency and Subsequent Risk of Prostate Cancer, M. F. Leitzmann, M.D. et al., Journal of the American Medical Association vol 291(13): pp. 1578-1586, April,2004. http://jama.jamanetwork.com/article.aspx?articleid=198487

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

207

281. Prostate Cancer Treatment & Management, Long Term Monitoring, , G.W. Chodak, M.D., Medscape, December, 2012. http://emedicine.medscape.com/article/1967731-treatment#aw2aab6b6c12aa 282. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials, P.M. Rothwell et al. Lancet 2011 Jan 1;377(9759):31-41. Epub 2010 Dec 6. http://www.ncbi.nlm.nih.gov/pubmed/21144578 283. Can Aspirin Reduce Cancer Risk and Mortality?, National Cancer Institute, 30 March, 2011. http://www.cancer.gov/clinicaltrials/results/summary/2011/aspirin-prevention2011 284. Vitamin D and Cancer Prevention: Strengths and Limits of the Evidence, National Cancer Institute, June, 2010. http://www.cancer.gov/cancertopics/factsheet/prevention/vitamin-D 285. Search of: Vitamin D Cancer, ClinicalTrials.gov, A Service of the U.S. Institutes of Health, July, 2012 http://clinicaltrials.gov/ct2/results?term=vitamin+D+cancer 286. Clostridial spores as live 'Trojan horse' vectors for cancer gene therapy: comparison with viral delivery systems, Ming Q Wei et al., Genetic Vaccines and Therapy, vol 6:8, 2008. http://www.gvt-journal.com/content/6/1/8

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

208

INDEX abscess – 38, 94, 98 acupuncture – 168 acinar adenocarcinoma – 41, 42 adenoid cystic carcinomas - 42 adenocarcinoma – 41, 42, 43 adjuvant therapy – 114, 115 alcohol – 125, 130, 149, 158, 174 alkylating agents – 127 alternative strategy - 142 anaerobic respiration (glycolysis)- 54, 151, 152 anaesthetic – 77, 81, 94, 95, 96, 97, 123 171 anaesthesiologist – 73, 81 anemia – 45, 124 aerobic respiration- 54, 151, 152 androgen – 13, 14, 17, 40, 78, 79, 112, 114, 119, 120, 129, 130, 131, 132, 136, 139, 140, 141 androgen deprivation therapy – 112, 114, 120, 129, 139, 140, 141 androgen receptors - 40 angiogenesis – 145, 151, 156, 157 anti-metabolites – 127 anti-tumor antibiotics - 132 anthracyclines – 128 anti-tumor antibiotics – 132 apoptosis – 37, 105, 134, 145 archives – 75 arterial – 24, 120, 133 attitude – 160 basal cell carcinomas - 42 benign – 37, 38, 40, 45, 56, 61, 63, 77 Béliveau & Gingras – 146, 155, 159 biopsy – 11, 50, 51, 52, 61, 62, 63, 64, 65, 69, 72, 77, 78, 80, 90, 91, 173, 175, 176 CAD (computer aided detection)- 50, 51, 52 cannula - 94 carcinoma – 38, 39, 40, 41, 42, 43, 55, 67, 128 carcinosarcomas – 42 castration – 40, 57, 78, 79, 112, 120, 131 catheter – 13, 83, 96, 105, 118, 120, 122, 123, 124, 126, 138 CPE (clinical prostate examination) – 10, 50 cell cycle – 32, 34, 35, 127, 128 cellulose (roughage) – 150 central venous catheter - 123 chemotherapy – 119, 129 chromosome – 29, 30 CIS (Carcinoma in situ) – 39, 67 Clinical testing – 116 CT (computed tomography) – 26, 53, 54 cyst – 38 cytology – 27 desiccation – 92 dextrose (D-glucose) – 125 diagnosis - 8, 9, 11, 12, 14, 45, 50, 51, 56, 62, 63, 71, 79, 80, 108, 111, 140, 161, 172, 173, 174, 175, 175, 177, 178 diet – 147 differentiate – 39, 55

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

209

differentiating agents - 133 disaccharide – 150 DNA (deoxyribonucleic acid) – 28, 29, 30, 32, 33, 34, 35, 36, 127, 128, 132, 136 DVT (deep vein thrombosis) – 81 dysplasia – 39 ECG (electro-cardiograph) – 73, 95 EGCG (epigallocatechin gallate) - 157 embolism – 126 En Bloc – 83, 84 erectile dysfunction - 83 erythrocytes – 100 estrogen receptors- 40 exercise – 164 EBRT (external beam radiotherapy) – 111, 112 FDG (18F-floro-2-deoxy-D-glucose )- 54, 140, 174, 176 follow up – 13, 45, 50, 63, 108, 130, 177, 178 foundations - 179 fractionated – 139 fructose – 149, 150, 151 gene therapy – 134, 135 genome – 28 glucose – 54, 149, 150 glycolysis – 149, 150, 151, 152 gynecomastia – 79 hazard ratio - 118 helix – 28, 32 HFCS – 150, 151 HIFU (High Intensity Focused Ultrasound) – 111, 112, 141, 174 Hormone therapy – 131 hyperplasia – 38 hypertrophy - 38 immunological response – 143, 145, 147 immunotherapy – 133, 134 IMRT (intensity modulated radiation therapy) – 111, 138, 139 induction – 94, 153 infection – 98 initiation – 35, 37, 39, 40, 58 interphase – 32, 33, 34, 35 interstitial fluid – 27 intra-arterial – 120, 133 intravenous (IV) – 54, 57, 96, 99, 120, 122, 128 invasiveness – 64 laparoscopy – 87, 89 lesion –39, 41, 51, 52, 64, 92, 141 liver – 92, 93, 126,133, 138 lymph node – 13, 24, 26, 66, 77, 82, 87, 107 lymphatic system – 23, 24, 27, 107 lymphedema – 107 MRI (magnetic resonance imaging) – 50, 56, 57, 58, 59, 60, 62, 73, 85, 90, 91, 141, 174 malignancy – 13, 30, 51, 63, 99 metabolism – 54, 117, 151 metaplasia - 38 metastasis – 7, 25, 26, 27, 55, 57, 59, 60, 66, 67, 77, 92 metronomics - 155 mitosis – 35, 128 mitotic inhibitors -128, 129

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

210

mitotic phase – 32, 34 molecular imaging - 54 monoclonal anti-bodies– 121 monosaccharide – 150 musculature – 20, 21, 82, 86 mutagens – 36, 155 nausea – 81, 96, 125, 129, 132, 171 NCI (National Cancer Institute) – 49, 70, 123 necrosis – 92, 111 neoadjuvant – 67, 78, 115 neo-plastic – 40 nerves – 9, 17, 20, 22, 37, 94 neurotransmitter - 125 neutropenic – 100, 102 NIV feed (non- invasive assisted pressure) – 96 nutratherapy - 155 non-nutritive sweetener – 152 Omega-3 – 147, 153, 154, 160 Omega-6 – 147, 153, 154, 160 oncologist - 113 oncology – 8, 54, 92, 109, 113, 115, 116, 122, 124, 125, 139, 159, 160, 171, 178 orchiectomy – 78, 79, 84 Otto Warburg – 151 palliative treatment – 132, 136, 179 pathology - 62 PCA pump (Patient Controlled Analgesia Pump) – 96, 97 PCD (programmed cell death) – 31 PCS (prostate conserving surgery) – 40, 85 Pelvic floor – 13, 20, 21, 104 PET (positron emission tomography) – 54, 176, 183 PLND (pelvic lymph node dissection)- 77, 82, 87, 107 phagocytic – 98 platelet – 100, 101, 124, 126 polysaccharide - 150 port-a-cath – 122, 123, 126, 159 praying - 179 prevention – 174 primary treatment – 114, 115, 139, 140 progesterone – 40 prognosis – 43, 51, 69, 71, 77, 106 progression – 9, 24, 30, 39, 72, 78, 111, 119, 131, 140 promotion – 39 prostate- 17 prostate self-examination - 46 prostate zones – 19 prostatitis – 9, 37, 38 prostatodynia – 36, 37 prostatomegaly – 38 PSA (prostate specific antigen) – 9, 11, 12, 13, 14, 46, 50, 63, 64, 67, 68, 78, 111, 114, 119, 131, 136, 140, 172, 173, 174, 175, 176 PSA doubling – 140 QOL (quality of life) - 141 Radical Perineal Prostatectomy (RPP) – 77, 82 radical prostatectomy- 13, 85, 98, 104, 105, 140, 175 Radical Retropubic Prostatectomy (RRP)- 77, 82 reconstruction – 80, 85

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

211

recurrence – 54, 114, 139, 140, 176 red blood cell – 45, 126 rehabilitation – 83, 84, 103, 104, 105 relative survival – 71, 72, 140, 141 resection – 77, 82, 83, 84, 86, 139, 140 RFA (radiofrequency thermal ablation) – 92 RNA (ribonucleic acid) – 28 robotic surgery - 98 RT (radiotherapy) – 31, 77, 99, 101, 107, 108, 111, 115, 116, 119, 136, 137, 138, 139, 143 saline – 77, 94, 123 screening – 9, 11, 12, 46, 47, 50, 55, 56, 172 second opinion – 74, 75, 88 SEER – 7, 19, 22, 70, 72 septic – 98, 99 septicaemia (blood poisoning) - 99 Servan- Schreiber - 146 serotonin – 125 skene’s gland -9, 17, 18 SIRS (systemic inflammatory response syndrome) – 99 SIRT (selective internal radiation therapy) - 138 SPECT/CT – 26, 27 spillage – 27, 102 staging – 39, 55, 64, 65, 78 starch – 149, 150, 152, 156, 160 stress – 145, 153, 158, 161, 162, 163, 168, 174, 176 subcutaneous – 122 support –160, 163, 178, 179 surgical treatment and therapy – 76 survivability – 70 symptoms of PC – 45 symptoms of infection – 101 target therapy – 132 Terpene- 155, 156 thrombocytopenia – 101 topoisomerase – 127, 128 TNM convention – 65 TRUS (trans-rectal ultrasound)- 50, 51, 52, 61, 62, 73, 74, 78, 111 tumor – 7, 27, 41, 51, 52, 54, 55, 63, 64, 65, 66, 77, 78, 83, 85, 92, 111, 115, 126, 128, 132, 133, 134, 135, 136, 137, 138, 140, 141, 152, 171 ultrasound – 50, 51, 52, 111, 112, 141 vesicant -126 vitamin D – 130, 176, 177 watchful waiting- 13, 108, 175 white blood cell – 100

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

212

Third Party Illustration Permission & Agreements Figure 1. Creative Commons Attribution-Share Alike 3.0 Unported 2. Creative Commons Attribution-Share Alike 3.0 Unported 3. public domain in the United States because it is a work prepared by an officer or employee of the United States Government as part of that person’s official duties under the terms of Title 17, Chapter 1, Section 105 of the US Code. See Copyright. 4. public domain 5. public domain 6. public domain in the United States because it is a work prepared by an officer or employee of the United States Government as part of that person’s official duties under the terms of Title 17, Chapter 1, Section 105 of the US Code. See Copyright. 7. public domain 8. Creative Commons Attribution Share-Alike 3.0 license 9. public domain 10. public domain 11. Creative Commons Attribution-Share Alike 3.0 Unported license. 12. public domain in the United States because it is a work prepared by an officer or employee of the United States Government as part of that person’s official duties under the terms of Title 17, Chapter 1, Section 105 of the US Code. See Copyright 13. public domain. 14. Creative Commons Attribution-Share Alike 3.0 Unported license. 15. Creative Commons Attribution-Share Alike 3.0 Unported license. 16. public domain 17. public domain 18. public domain 19. Creative Commons Attribution-Share Alike 3.0 Unported license 20. public domain 21. public domain 22. public domain 23. public domain 24. public domain 25. public domain 26. a, b, and c public domain 27. Knowinghelps Corp. has been granted permission to reuse by agreement with the copyright owner. 28. public domain 29. Knowinghelps Corp. has been granted permission to reuse by agreement with the copyright owner. 30. Knowinghelps Corp. has been granted permission to reuse by agreement with the copyright owner.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

213

31. public domain 32. public domain 33. public domain 34. public domain in the United States because it is a work prepared by an officer or employee of the United States Government as part of that person’s official duties under the terms of Title 17, Chapter 1, Section 105 of the US Code. See Copyright 35. public domain 36. public domain 37. public domain 38. public domain 39. public domain 40. public domain 41. The copyright holder of this work allows anyone to use it for any purpose including unrestricted redistribution, commercial use, and modification 42. public domain 43. Creative Commons Attribution 2.0 Generic license. 44. public domain

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

214

ACKNOWLEDGEMENTS

I would like to thank my friend Tony, who is a long term Prostate Cancer survivor and fighter, for sharing his insight and perspective. As well, I would like to thank those who contributed their time and knowledge as reviewers. Finally, I would like to thank those who have graciously contributed to the clarity of this this discussion by lending their permission to display their illustrations and images as examples.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

215

DISCLAIMER

This publication is intended for educational and informational purpose only. The content of this discussion relays the author’s overview of the disease of Prostate Cancer. It is a way to consolidate the subject matter of Prostate Cancer that is largely, but not exclusively, available on internet sites. The figures herein are used as examples only and are not necessarily the most definitive or current associated with their associated aspect in discussion. The comments and discussion herein are the author’s layperson understanding and interpretation of aspects of fact and consideration of that disease as it pertains to a patient perspective and emphasis up to the date of publication release. The author is not offering a medical opinion either in whole or in part in this book, nor is this book and the discussion herein designed to substitute or in any way replace expert medical advice provided by a professional practicing in the associated fields of medicine. Those who use this book should make their own determinations with expert medical advice regarding specific prevention, diagnosis, prognosis, treatment and follow up options. Neither the author, nor the publisher KnowingHelps Corp nor any third party contributor can be held responsible for any damage or liability incurred as a consequence from the use or application of any of the contents of this book.

The figures herein are used as examples only to support the discussion. Image and illustrations from the third party contributors are reused under the provision of permissions and their copyrights are to be respected accordingly. If anyone is aware of any violation of copyright in this publication please send notice to [emailprotected] so that the appropriate adjustments can be made.

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

216

SYNOPSIS In the new year of 2008 the author was diagnosed with a tumor. At the time no emphasis was given to the fact that it could have been an invasive adenocarcinoma even though the initial pathology report clearly stated this. By springtime, when appointments were finally solidified for a surgeon’s review, he became increasing aware that there was something substantial about his condition and that the medical solution could have life altering repercussions. Nothing was making any sense, so he dove into the literature on his cancer in an attempt to understand. What he found was a mountain of information featuring the entire spectrum of medical effort and anecdotal discussion on the topic. As a patient, he wanted to know what to expect. Finding the answers was a real struggle. Often the answers were not available until he actually went through the phase of diagnosis and treatment. After surgery advanced stage cancer was confirmed and a course of chemotherapy followed. During this time he wrote a book in an effort to record and understand what he found to be important facts and considerations on his cancer, from a patient’s perspective, in one easy to access place. When he finished that book it occurred to him that understanding and accessing the information for patients of other cancers was a problem as well. So he decided to research and write a series of books dealing with the most frequently diagnosed cancers. The intention is to point out reputable sources and examples that are readily available to the average layperson; then make sense of them in the context of the disease as a whole so that the condition and options can be better understood when in discussion with the one’s medical specialists. This book is part of the Silent Battle Within, A Patient’s View ™ series and discusses Prostate Cancer. Hopefully it helps in imparting some good, easy to access information. The Silent Battle Within, A Patient’s View of Prostate Cancer by Dale Hollenbeck, last revised in December 2012. A publication of KnowingHelps Corp. COPYRIGHT © 2012 ALL RIGHTS RESERVED

knowinghelps.com HEALTH / ISBN: 978-1-927768-03-7

THE SILENT BATTLE WITHIN, A PATIENT’S VIEW OF PROSTATE CANCER

217