I searched Dr. N’s name in both Bing and Google and had trouble finding him. There was another doctor back east with the same last name. I did get a few hits to newspaper articles about the new center at our local hospital for radiation oncology and his name was in the articles, but it did not give a phone number. Somewhere on page 2 of the search results I found a rating site for doctors that mentioned his name and had an office number, but I was surprised that he didn’t have a website in his own name or with his partner, Dr. K. I called the number, which was in a different area code indicating it was near the hospital to our south, although when I finally got the name of the medical practice and found its listing, I saw that it had two locations, one near me and one 10 miles south. I told the receptionist that I was a new patient referred by my family physician and wanted to set up an appointment with Dr. N for a second opinion on my prostate cancer. She gathered the usual information. I told her I preferred to meet at the office near me if that was possible. She said if I wanted that location I would have to see Dr. K, not Dr. N. She repeatedly asked me if I wanted to meet at the northern office or did I want Dr. N.  I said I wanted Dr. N and I didn’t mind driving to the other location. She set up the appointment. I should have seen this as a problem in the making, but I didn’t.

The next day I got a call from that same office and the woman said she saw that I was closer to the other office so I would be seen there and that I would get a call from the assistant there to schedule that. This was puzzling and exasperating since I was fine with driving south and now had to change my schedule, and also because if Dr. N saw people in the nearer office, then why was I given such a hard time when I requested it. As it happened, the appointment time was the same time (in two days) that I had a follow-up appointment with Dr. A to give him my decision about what I would do. I called to cancel that appointment saying I was getting a consultation on radiation therapy. I saw Dr. N in the local office. His manner was excellent. He had my records, forwarded by my family physician. He told me right off that he had examined the biopsy results and recommended brachytherapy, that’s the implantation of radioactive “seeds” to kill the cancer in the prostate, followed by external beam radiation therapy (EBRT) to kill any cells in the surrounding tissue. He gave me details of the biopsy Dr. A did not, including the fact that my cancer had been found in three of four quadrants. Dr. A had simply said my cancer was spread throughout my prostate, which sounds more ominous to me. I had only two needles with grade 4 cells, but I don’t know if they were both in the same quadrant. I may only have the 4’s in one quadrant, at most in two.

He gave me a lot of statistics about life expectancies and side effects, basically saying that brachytherapy patients have better outcomes than prostatectomy patients. I quizzed him about bias, i.e. surgeons like to cut, radiators like to radiate, how do I know who’s right? He admitted that there could be inherent bias towards one’s own practice field, but he encouraged me to look up the statistics for myself and to go back to Dr. A and ask about brachytherapy. He answered all my questions completely, including the details of the procedure, such as the fact they make the entry between the scrotum and rectum, not rectally like the biopsy. I thought he meant the incision; it was not until the day of my surgery I learned they do it all with needles. The isotope used is Cesium 131, with a half-life of 9.7 days, which is a newer isotope for this purpose. The elements mostly used before, and still used today, are palladium and iridium, with longer half lives. In a month the Cesium would be 88% depleted (decayed), thus the radiation doesn’t last very long. The Cesium is stronger, but of shorter duration killing the cancer faster and minimizing the length of side effects, which include urinary urgency. They shield the surrounding tissues. There would be about 33 seeds and they stay in indefinitely. I got more information than that, but I’m not going to try to give a detailed medical explanation. Go to a doctor’s website or cancer society site for that. Procedures vary a great deal from patient to patient. There is also an option for some patients for fast-acting brachytherapy, where an even stronger dose is given and then removed, but this as not offered to me.

Perhaps the most important question for me was whether to treat the cancer at all. Dr. N was very helpful in this regard. He agreed with Dr. M that statistically those who do not treat early stage prostate cancer have about the same longevity statistics as those who do treat them, although those who don’t get treated have a higher rate of symptoms that must be treated soon such as difficulty urinating, and they definitely have a higher rate of death from prostate cancer. He pointed out that there are a lot of differences between patients. Many prostate cancer patients are in their 80’s or 90’s when the cancer is discovered, or even if younger, have other health problems like high blood pressure, obesity, heart problems and so forth. These people are more likely to die from something else in the next few years anyway so treating the cancer doesn’t increase their longevity very much in most cases. So their experience skews the statistics. I’m relatively young and very healthy. My father lived to be 94; his mother 93, his grandfather 91. My other grandmother lived to 88. I am NOT likely to die of something else any time soon, so removing the one major health risk factor, prostate cancer, is likely to have significant benefit for me. Absorbing this information I also had to weigh two other significant family history events. My father-in-law died of prostate cancer at just about my age. That was a big motivator in my decision to treat it. On the other hand, my grandfather had a prostate problem – enlarged prostate, not cancer, or so I was told – and went in for a “routine” prostate operation. He died from it. He had a post-surgical pulmonary embolism that clogged his lung and prevented his blood from being oxygenated. I had pointed these out to Dr. A and he had correctly said, “There’s a risk in treating it and there’s a risk in not treating it.” In the end, my grandfather’s experience did not weigh too heavily on me, since that was in 1951 in a rural Wyoming hospital where they did not have the technology of today such as better anti-coagulates, transurethral microwave thermotherapy (TUMT), and robotic surgery. More importantly, the brachytherapy is less invasive than the prostatectomy, with much less bleeding. They keep you overnight after a prostatectomy, but send you home the same day after the brachytherapy.

Dr. N minimized the side effects of brachytherapy, and especially of the EBRT. He kept comparing it with prostatectomy, not with choosing no treatment. See this article for a clinical discussion. I think he was doing the same thing Dr. A was doing in this regard, trying to steer me toward his area of practice. Both seemed to think saying these risks are low or are rare is sufficient for the patient, but I think it’s rather patronizing. Rare things happen, like my reaction to the Cipro and my grandfather dying from his prostate surgery. Still, Dr. M’s earlier statement that his other patients who have had either procedure seemed to do well in the long term gave me considerable assurance the treatment was the right choice.

I left Dr. N’s office leaning toward brachytherapy but I wanted to consult with Dr. A again to be sure I was getting the full story. Dr. N said when I was ready to “call us and let us know what you decide.” That’s when the Keystone Cops scenario started. See my next post.