The initial entry here was sent to Yana on 4 July 1999. The man who wrote it chose the nom-de-plume A Private Gentleman. He wanted to remain anonymous because of his choice of treatment - which at that time was termed Watchful Waiting. There was virtually no support for this choice and men who made it were often harrassed by friends, family and the medical world to "do something". Today, in 2009 and eleven years later, there is a more enlightened view and the choice of Active Surveillance, as this is now termed, is summed up perhaps by well known pathologist Dr Jonathan Oppenheimer who has said:
For the vast majority of men with a recent diagnosis of prostate cancer the most important question is not what treatment is needed, but whether any treatment at all is required. Active surveillance is the logical choice for most men (and the families that love them) to make.
Here is the Private Gentleman's story:
I am aged 76 and was diagnosed in January 1998 when, whilst being treated for pleurisy, blood was drawn in my internist's office for a battery of tests which included, without my knowledge, a PSA test - which came back with the figure 11! Referral to a Urologist determined a follow-up PSA at a different lab as 17 (three weeks later) and a biopsy returned a Gleason score of 6. I determined from the Partin Tables that the likelihood of the cancer having spread outside the prostate was about 80% which indicated to me that if I underwent the recommended surgery or radiation or brachytherapy, the likelihood that the treatment would not prolong survival was 80%.
[It is not clear how these figure were arrived at.
Using the current Partin Tables (which admittedly have been refined over the years) the following figures are shown - Probability of: Disease being organ confined: 70% Range 66%-74%; Extraprostatic extension: 27% Range 23% - 30% ; Seminal Vesicle Invasion: 2% Range 2% - 3%; Lymph Node Invasion: 1% Range 0% - 1%
The HAN Table that is used in trying to predicate probability of recurrence after surgery show the following figures: \3 years after surgery: 3% Range 1% - 11%; 5 years after surgery: 6% Range 2% - 18%; 7 years after surgery: 8% Range 2% - 24%; 0 years after surgery:10% Range 3% - 31%]
I opted therefore to follow the PSA serially to determine the doubling time as an indicator of the aggressiveness of the cancer and not to subject myself to the side effects of treatment. I felt that one year of life at this stage when I have no other illness, is worth three years at a later time when chances are likely that I will be incapacitated by some of the other illnesses and frailties of advanced age.
I informed my wife and children of my decision and made out a Living Will directive indicating that I am not to be kept alive by heroic means. My most recent PSA (one month ago) was 8 - but I know that eventually it will start to climb. The past 18 months without the side effects of therapy have been a gift to me. [This is another area where this gentleman is poorly informed. If, as seems likely, his PSA resulted more from an infection of the bladder or the prostate gland, then his PSA would more likely vary considerably from test to test, unless the infection was dealt with - see PSA 101.]
In a recent best seller "A Man in Full", one of the characters relates the following anecdote about the Stoic approach to life and death:
It seems in the time of Nero, the 'Stoics' were considered a threat to the State and one day, one of the students of Epictetus, the Stoic Philosopher, came running to him and said:
"I have received a summons to go to Rome to be castrated or else I will be killed"
Epictetus responded: "I have received the same summons."
The student was shocked, and said: "Tell me master, what shall we do?".
Epictetus said: "You will be castrated and I will be killed."
The student asked: "Why should I be castrated and you killed?"
"Because you considered it," said Epictetus.
I believe that a man's personal philosophy of life and death is as important as a knowledge of the medical literature in the decision as to what form of treatment to undergo. The reason I prefer anonymity is that I am by nature a private man, but of greater importance is the controversial nature of the option which I have elected, "Watchful Waiting". I am fortunate in having the full support of my wife and children in my decision, but I find in discussions with other members of the prostate cancer community that the term "Watchful Waiting" pushes a hot button.
All other treatment options of presumably localized prostate cancer whether surgery, radiation etc,are aimed at cure and are therefore considered acceptable but the option of "Watchful Waiting" signifies to them an acceptance of death and defeat and is therefore intolerable. Not only intolerable but stupid, cowardly and a violation of the fundamental religious and ethical foundations of society. People react with passion against those who propose it.
I believe these attitudes deserve to be discussed but feel that discussion can best be accomplished if those who do so can remain anonymous and identified only by the power of their argument. Perhaps this website can provide such a forum. Let me close with the words of Seneca the Younger who succinctly states the case for "Watchful Waiting" -as I see it.
"A man should live as long as a man should live, not as long as a man can live."
or in the words of a toast that my wife and I say to each other and our friends...
"May you live and die in good health"
o0o o0o o0o o0o o0o
All is well at this end with no dramatic change since last I wrote you ( a predictable but still gradual increase in PSA is the only change). I continue as before without curative or hormonal therapy, feeling well and at peace with my own decision for "Watchful Waiting". This is not a decision I would recommend to a young man with family responsibilities - but for a man of my age it allows me to be in full control of my own destiny...
Thanks for the letter which you forwarded and your inquiry as to my progress. I experienced an episode of "Shingles" two months ago which has now largely subsided without the painful residual which sometimes follows. This probably indicates that my immune system is under stress - although whether from the prostate cancer or from age, my Urologist does not know and probably is at this stage unknowable. I am otherwise feeling very good, both physically and mentally and continue as usual, enjoying the things I like to do, socializing, reading, attending classes at our local Elderhostel and travelling, unburdened by the side effects of treatment. My PSA remains stable and my bone scan does not show evidence of metastases but I am under no illusions - I know I will die of prostate cancer unless I die first from trauma or some of the other diseases which afflict mankind. I do not put my faith in miracles or a "magic bullet".
Having accepted the inevitable, I am not depressed but am rather comforted, and in the words of Nikos Kostanzakis:
"I desire nothing; I fear nothing; I am free".
IT WAS WITH GREAT SORROW THAT WE LEARNED OF THE DEATH BY SUICIDE OF THIS PRIVATE GENTLEMAN SOON AFTER THIS LAST POSTING. HE WAS INDEED FREE. AS WE HAVE GAINED MORE KNOWLEDGE WE KNOW THAT HIS PESSIMISM ABOUT HIS CERTAINTY OF DYING FROM PROSTATE CANCER WAS NOT JUSTIFIED. HE MAY HAVE HAD A SLIGHTLY GREATER CHANCE OF THIS HAPPENING, BUT WHEN ALL IS SAID AND DONE 97% OF MEN'S DEATHS ARE FROM SOMETHING OTHER THAN PROSTATE CANCER. ANYONE INTERESTED IN READING MORE MIGHT LIKE TO GO TO THE ELEPHANT IN THE ROOM.