He has a youthful face, a ready smile, is charming and kind, and like many men over the age of 70, he has lived through a trying time brought on by prostate cancer. His name is Steve Patterson, and he is grateful to be a prostate cancer survivor.
It began in March 2009 when Steve’s prostate-specific antigen reading spiked to 3, then to 4, and then to 6. His internist advised him to make an appointment with a urologist as soon as possible. Steve was at his primary residence in Florida at the time, and one of his neighbors recommended a urologist who subsequently performed a biopsy. It revealed that Steve had cancer in two cores of his prostate with a Gleason score of 6. The higher the Gleason score, the more likely a cancer will grow and spread rapidly. A Gleason score of 6 or lower indicates a less aggressive cancer, while a grade of 7 or more indicates an aggressive cancer.
Steve was immediately consumed by anxiety, worried that any treatment would leave him impotent and incontinent. Unsure of what to do next, Steve turned to an old friend who had undergone surgery to remove a cancerous prostate gland. The friend advised Steve to go to Johns Hopkins, praising its urology department and singling out a surgeon named Alan Partin, who is a professor of urology and urologist in chief in the hospital’s department of urology and oncology.
Steve resigned himself to the inevitability that he would have to undergo serious and risky surgery, but Dr. Partin’s empathy helped him relax. Sitting opposite Dr. Partin, Steve wasn’t sure he heard the words correctly: “You barely have prostate cancer.”
The cancer was small and not aggressive, and Steve was advised to take part in the Watchful Waiting program at Johns Hopkins. The doctor explained that Steve would have a P.S.A. test every six months and a biopsy once a year. He also gave Steve a packet of information about the Expectant Management program.
A major emphasis in Expectant Management involves a healthy diet. Steve was urged to make changes to his diet and give up breads and desserts made from white flour, give up red meat, give up white rice, white sugar, and white potatoes. Replace white pasta with whole-wheat pasta. Then add the following anti-cancer foods: turmeric, pomegranate juice, soy milk, fish, fish oil, and extra-virgin olive oil. Steve should also give up drinking alcohol and participate in a daily exercise program, but this part of the program didn’t work so well.
Like a fading fog, Steve’s anxiety lifted. He felt reassured. He was in the hands of a top doctor who imparted a depth of knowledge and experience. Steve was not out of the woods, but at least there was a path that he could follow, and Dr. Partin had given him a compass.
After six months, Steve’s P.S.A. had not increased. Good news. After a year, a biopsy revealed no changes in his Gleason score. More good news. It was becoming increasingly easier to smile. The idea of surgery was now an old discarded route on a map that he would not have to consult. He imagined a new route mapped by Dr. Partin. For months, or perhaps even years, he would undergo regular P.S.A. tests and annual biopsies. Chances are the cancer would be contained. He drank his pomegranate juice and soy milk, took his fish oil supplements, and cooked with olive oil.
Steve felt no anxiety when he went to Johns Hopkins for his third biopsy in June 2011. He had endured the unpleasant procedure before, and the results had always been positive.
A few days afterward, it was a beautiful summer morning in East Hampton. Steve was on his deck reading a newspaper when his phone rang. Dr. Partin asked to see him. Steve made an appointment for the following week. A new anxiety had entered his life.
Steve learned that two cores of cancer had grown to four cores. More important, one of the cores was a Gleason 7: a bad rating for an aggressive cancer. Steve felt that his luck had hit a roadblock. He was no longer a member of the Watchful Waiting club. His membership had been revoked. What now?
Dr. Partin once again outlined the path to follow. He explained Steve’s three treatment options: surgery, external beam radiation, and radioactive seed implantation. Though a highly regarded surgeon, Dr. Partin recommended that Steve undergo external beam radiation. Steve expressed reservations about radiation because he had friends who had serious side effects from the procedure. The doctor indicated that radiation treatment of the prostate had undergone major advancements in the last few years, and he concluded by saying that surgery involved real risks that were not present in noninvasive radiation. And yet, both procedures produced effectively the same results. So why take the risk?
Like many men in his position, Steve subsequently spoke to several physicians about the efficacy of radiation and about its side effects. One close friend, who was also a doctor, said he would choose external beam radiation. Steve weighed the advice and went that route.
Now he had to choose where to have the treatment. The facility closest to his home in Florida was 45 miles away. In New York, he could receive state-of-the-art treatment at Memorial Sloan-Kettering. When he learned that he would require 10 weeks of treatment, 5 days a week, he decided it would be necessary to rent an apartment in Manhattan. His niece found him a sublet on the Lower East Side in the same complex where she and her family lived. An express bus that stopped four short blocks away would let him off in front of Memorial Sloan-Kettering.
By September, Steve had his initial consultation with an oncologist and was scheduled to undergo treatment. The process began with the insertion of three beacon transponders into Steve’s prostate. These markers, which remain in one’s prostate for a lifetime, permit a radiologist to deliver beams of radiation precisely to the targeted area without destroying healthy tissue. A half-body plaster cast was then made to cover the area from Steve’s chest to the middle of his thighs. Tattoos were imprinted on his thighs so that the radiologist could properly align Steve’s body with the radiation machine.
Placed in his body cast on a table, Steve was ready for the first of 48 treatments. The table was raised about six feet, and the radiation machine circled his body, moving clockwise, issuing brief shots of radiation at 6, 10, 12, 2, and 4 o’clock on an imaginary timepiece. Each zap of radiation took less than 2 minutes, and the entire process took 15 to 20 minutes. The procedure produced neither pain nor discomfort.
Following the completion of 48 treatments in December 2011, Steve was scheduled to have his P.S.A. tested in June 2012. It was 1.4, a dramatic decrease from the 6.6 it had been prior to his treatment. The grueling experience had come to an end. Steve’s doctors believed that his cancer had been successfully eradicated by radiation. He could once again lead a normal life.
When I spoke with Steve at his home in East Hampton, he said: “Each person who is diagnosed with nonaggressive prostate cancer should have a serious conversation with his doctor about Watchful Waiting. Watchful Waiting was an important period f