The Preliminary Battle Plan
I decided to go to Africa and to put this subject out of my mind
until I returned. As I traveled through South Africa, Zimbabwe,
Tanzania, Kenya, and Zambia I marveled at many wonderful sights,
seeking a diversion from the overpowering reality and overwhelming
thought "I had cancer!". Still, I knew that I would soon have to face
my problem directly and that the decisions I made would affect the
rest of my life.
It was while bouncing along in a Land Rover, over the African
Savannahs and Maras that my soul finally absorbed the "Acceptance"
phase and I felt myself recharged for the next phase "A Battle Plan".
One I felt confident I would win, but first I must select the best
plan of attack and the most competent allies to victory.
Upon my return from Africa, four weeks later, I returned to
discuss the options with my Urologist, whom I now respected. The
possibility of surgery was discussed with my doctor who did not
consider it necessary but who would perform it if I desired. "Many
men just want it cut out" he said! My cancer was quantified as PSA
14.7, Gleason #6, and TNM T2B. The possibility of radiation was
I had read about and studied the new procedure of Intensity Modulated Radiation Therapy (IMRT) and it sounded like an ideal solution to the problem - high
rates of cure - minimal adverse side effects - virtually no
interruption of life style - a procedure involving 8 to 9 weeks, 5
days per week, plus the initial work up procedures. Still, this
seemed preferable to the potential side effects of surgery.
I opted to have the work done at Memorial
Sloan Kettering Cancer Center in New York City which is
one of the finest cancer research and treatment center in the U.S.
based on five consecutive annual awards of this honor by U.S. News
and World reports.(1992 - 1997 incl)
Of the 26 nationwide such centers to merit the National Cancer
Institute's highest designation - Comprehensive Cancer Center - two
are located in New York City: . To earn the title, both hospitals met
a series of rigid requirements set forth by the NCI, including strong
laboratory and clinical research, the ability to put these results
into practice, and high priority trials for promising treatments.
Because an array of specialists are housed under one roof, patients
benefit from the medical equivalent of one stop shopping.
Memorial Sloan Kettering had been using 3 D-CRT (Three Dimensional Radiation Therapy) since 1990 and had amassed a great wealth of experience in its use. They had been using the knowledge gained here to develop and perfect IMRT, which is a technical progression from 3D-CRT. I realized
that commuting to treatment for 45 daily sessions would involve four
hours cumulative travel of 200 miles per day times 45 days or 9000
miles by train, while I lived in a suburb of N.Y. The entire daily
regimen, including treatment, would require about 7 hours.
The difficulties or inconvenience of the daily journey were of
little consideration when I could have the finest treatment available
administered by superlative and dedicated cancer specialists who see
more cancer patients in a year than most doctors see in a lifetime.
While waiting for my appointment in New York I had some the
preliminary work done at local hospitals or health care centers.
These included: Bone Scan, MRI, more blood testing. A diagnostic CT
scan can be performed outside of the cancer treatment facility.
However, a CT Scan, for treatment planning purposes MUST be performed
in the same facility which will perform the ultimate IMRT procedure.
I had my appointment with Dr.
Michael Zelefsky. my radiation oncologist, in late
November 1996. Additional testing during that session downgraded my
PSA from 14.5 to 10.45. It is important to note the range possible in
PSA testing from different labs or even the same lab on different
dates in a short time span. The test is accurate to +/- 30%. My
Gleason number was upgraded to 7.0 from 6.0. My radiologist indicated
that both his hospital and some others tend to give sightly higher
Gleason Scores than regional labs. So with this final and expert
result in I could then quantify my cancer as: PSA = 10.45, Gleason =
7.0 and TNM = T2B. My cancer cells finally had a first, last and
The personnel at Memorial Sloan Kettering
Cancer Center recommended the IMRT
procedure. I was pleased at this because this recommendation agreed
exactly with my own thoughts after a highly intensive study of all
the appropriate literature I could find.
The procedure would begin with three months of Androgen Ablation
Therapy. Then the IMRT therapy would begin concurrent with an
additional three months of androgen ablation. At the conclusion of 42
treatment sessions both the androgen ablation and the radiation would
cease at 7,560 RADS. I could expect a 60% - 70% chance of a cure -
about as good as any other form of treatment.
It is important to understand that cure rates referenced in this
narrative are rough estimates based on the experience at the
treatment center I had chosen. They are based on radiation treatment
when the cancer cells are confined within the prostate gland.
Example: With 8100 rads of radiation the odds of having a positive
biopsy, after conformal radiotherapy is less than 10% or is reported
as a 90% chance of cure.
Prior to my meeting with Dr. Zelefsky, I studied the
potential side effects of the proposed treatment. However I was not
privy to much of the details of the technology at that time.
He would measurably expand my education over
the time we spent together in the coming months. I had arrived at the
decision the the IMRT therapy was best suited for my case.
Dr. Zelefsky agreed with me and then added the Total
Androgen Ablation protocol and submitted this entire program to a
multidisiplinary prostate conference consisting of Radiation
Oncologists, Medical Oncologists, Pathologists, and Urologists. This
conference concurred that this was the proper treatment for my case.
Baseline tests were done on liver function to monitor the Casodex
side effects and testosterone levels.