My urologist, Dr. Iriye has been following me since he took care of my bladder stone 2018. He’s not very demonstrative, but has gotten used to how I think about myself and my values. We both agreed immediately it was time for a biopsy. But apparently, there wasn’t a lot of urgency, as it was scheduled for two months later. February 9th.
During the interim, I enjoyed two ten-day long ski trips, in addition to the hectic fun of the holiday season. The biopsy, and its attendant risk of upending my life, simmered below the level of my awareness for two months.
I read up a bit on the procedure. The prostate is tucked between the rectum and the bladder, making the best approach through the rectum. After blocking the local nerves with lidocaine, like a dentist would for a filling, a special ultrasound probe is (gently) placed there, with a spring mechanism enabling a rapid insertion and withdrawal of a long needle into and back out of the prostate, like taking a core sample of a tree or a glacier. An enema, and two antibiotic doses are employed to minimize the risk of infection. Lying on my side facing away from the doctor, all I felt apart from the slight discomfort of the probe itself, was a bubbling vibration as each of the ten “shots” went into and out of my offending organ.
Two days after the procedure, I left for my third ski trip of the season to spend a week with my son, sister and brother-in-law for what would turn out to be my final time on the slopes this year.
Nowadays, there’s no need to wait for the doctor to call with the results; I got a text message during our first dinner out that the results were available. I thought I was prepared for what I read. But when I read that the biopsy showed three of the cores were positive, I felt a rush of dread. I looked for silver linings. The size seemed small – 4-5 mm each. Two of them had a Gleason score of 6; the one from the left apex was 8.
What’s a Gleason score? A medical pathologist examines each of the specimens under a microscope, looking for any cells which appear abnormal. The less they look like normal prostate cells – the more “undifferentiated” they appear – the higher the score. Oddly, the range is almost always from 3 to 5. Two grades are given for each positive site. One grade is assigned to the most dominant pattern in greater than half the slide examined; another grade to the remaining area. The term used to assign the number is well- moderately- or poorly-differentiated. The key sign is whether glands are still apparent in the tissue. A lot of glands = well-differentiated; no glands = poorly-differentiated. These findings can be used to help predict how “aggressive” or likely the cancer is to grow and spread.
A few days before the biopsy, I decided to secure a second opinion, no matter the result. I began the process through the Fred Hutchinson Cancer Care Center, associated with the University of Washington (UW). My brother-in-law (wife’s sister’s husband) had prostate cancer @ age 62, 18 years ago, operated on by a UW surgeon. Anita (his wife) is an RN and a very assertive, inquisitive lady. She probably knows more about his case than he does, and he’s an MD! So I asked her for advice on whom I should consult for a second opinion. Within 2 weeks, I had appointments with the head of surgery at UW, and the former urologic oncologist there.
My initial conversation with Dr. Iriye on Feb. 15th was typically brief and clarifying. I told him my immediate emotional reaction was to “have this taken out, gone,”, and that I would be talking soon with a couple of other urologists. He endorsed that, then ordered a CT and Bone scan to look for spread and metastases.
The scans, performed on Feb 27th, were both negative – no evidence of spread or other lesions were seen. On Feb 20th, I Zoomed with Dr. Tia Higano. On March 1st, I had an in-person visit with Dr. William Ellis. On March 3rd, I spoke again with Dr. Iriye. Those discussions, plus more reading I had been doing, confirmed my inclination to have surgery rather than radiation. Dr. Iriye referred me to Dr. Brian Winters, a Kaiser surgeon in Bellevue, WA, who specializes in laparoscopic prostatectomies for cancer, using the Da Vinci surgical robot. Dr. Winters followed his urology residency with a fellowship under Dr. Ellis at the UW. They both spoke highly of each other. Dr. Winters called me that afternoon, and his scheduling team contacted me a few days later, setting up the surgery for April 5th. I felt like Atlas relieved of the mountain on his shoulder. Less than five weeks to go!