In my last post, I mentioned that I wanted to get to CrossFit three times last week, and my body wasn't ready for that yet. This week, apparently, it was, and I even returned to a few movements that I hadn't done since surgery. And now, on Friday morning, I'm a bit tired, but feeling pretty good. Today is a rest day before skiing all weekend.
Tuesday: Power snatches and clean and jerks for strength, and then thrusters, pull-ups and burpees for time. These were my first burpees since the surgery and they didn't hurt at all. Well, other than the fact that burpees suck, I suck at burpees, and they always hurt. But, the burpees caused no unexpected pain. I have to admit that I'd had a rough day at work and I didn't want to be in the gym, so I probably didn't push as hard as I should have or could have. But, I still got through the workout.
Wednesday: Strength work was 7x3 split jerks, starting at a very easy 95# and gradually moving to 115#. My best ever on this lift is 195#, but that was before my shoulder injury last year, so between that injury and the surgery, I was happy to lift as much as I did. After that, we did 10 minutes, as many reps as possible, of snatches (light at 65#), dumbbell strict presses, and rope jumping. This was my first time doing rope jumping since the surgery, and I was worried about any potential incontinence issues. The things most likely to cause issues related to incontinence, in my opinion, are rope jumping, box jumps, or lifting really heavy weights (squats or deadlifts). No problems so far.
Thursday: Strength work was alternating sets of (10 of each movement) of 3 deadlifts at 225# and 5 bench presses at 95#. The deads were still nowhere near my max from last summer of 440#, but it's still a decent amount of weight to pick up. The bench presses were for form and deliberately light - less than half of my lifetime best. No incontinence problems or pain with the deads, so I may increase again next week. Then, we did a workout, as fast as possible, of rowing 1000m, 50 kettlebell swings, and 30 box jumps. I opted to the the box jumps as step-ups. I think box jumps will be the last movement I return to doing.
Tonight is the first workout of the CrossFit Open, where people try to qualify for a regional meet, where they can then qualify for the CrossFit Games. I did this last year, and it was kind of fun, but opted out this year due to the surgery. So, while everyone is killing themselves with double unders and snatches tonight, I'll be going out for a beverage with my wife and a friend and then going to see Ratdog at the Flynn Theater in Burlington.
Friday, February 28, 2014
Monday, February 24, 2014
Seven weeks out from surgery
A week ago, we finally got some real snow in Vermont. For the first time all season, I spent the weekend teaching off-piste. We explored tree runs all weekend and had a great time. I was fighting a cold through the weekend and I was a bit tired, but we had a lot of fun.
Last week, I hoped to get to CrossFit three times. I made it on Tuesday and Wednesday, but by Thursday, my entire body ached. I felt so beat up that I wondered if I had the flu. But, a couple days of anti-inflammatories, and I felt a lot better by Saturday. Regretfully, a rain storm on Friday changed the ski conditions drastically for this past weekend. The kids seemed oblivious to the weather conditions and wanted to simply charge into the trees again. For the most part, when we ventured into the trees, I felt the runs were much tougher and more dangerous than the week before, yet the kids did not seem to believe this at all.
My rule on the hill is that safety considerations trump all other considerations. Twice on Saturday, my students deliberately ignored me and went into a tree run that I had expressly said we would not ski. I was not happy, and the main offender got to go home early for the day on Saturday. After some discussions with her parents on Saturday, she returned on Sunday much more willing to listen to directions. Hopefully that will continue for the rest of the season.
This coming week looks cold and snowless. Snowmaking is done for the season, so we are likely to be looking at firm conditions next weekend. The children are really getting restless on the slopes at times. This is an "adventure" program and they want more adventure. But, despite record snowfalls in some parts of the country, and a fairly cold winter, snow is still less than normal in my part of the country.
In some ways, and I almost hate to say this, the lower snowfall amounts have been better for me physically. It is less demanding for me to teach on groomed trails than it is to teach in the trees or on steep icy terrain or steep mogul terrain. Yet, despite the easier than normal demands on my body, I am still struggling somewhat to keep up.
In the past two weeks, I've been fighting an illness, which has led to coughing (I did get some cough medicine that helped there) and sneezing. After a lot of sneezing, I noticed that I was starting to feel some discomfort near the center of the surgery - right where my prostate used to reside. This is a good indication that I'm still not fully healed. Of the six incision points for the robotic surgery, the largest incision has still not completely healed, although it's close.
I've been pretty lucky with incontinence, which normally resolves in 2-4 months. Even sneezing and coughing, I haven't been having any problems, so I seem to be at least 99% contintent. Other surgical side effects are taking longer to resolve.
But, the bottom line is that I'm still not 100% recovered. I'm napping and sleeping more than usual. A day at the gym or a day on the mountain tires me out more than it would have before the surgery. Even being at my desk for a full day of work can be a bit of a chore, and I find myself getting tired by the end of the day.
I know I've pushed myself back to a fairly full life much faster than most patients after surgery like this. For this particular surgery, I was probably a decade younger than the typical patient, so I think it's reasonable to expect that my recovery would be better than average. But, better than average has not translated into "full and complete" in a very short timeline.
So, I need to remain vigilant and do what my body lets me do. I'm glad I'm skiing again. I'm glad I'm in the gym. I'm hopeful the cancer is completely gone. I have my annual physical in March and my next appointment with the surgeon in April - 14 weeks after the surgery. PSA has a half life of about 3 days in the body. That means that my PSA level of about 5 should be undetectable within a month or so of surgery. I won't be tested at my physical, most likely, but I will be tested for the appointment with the surgeon. If the level is not undetectable, that will likely indicate that some cancer remains, and I'll be looking at radiation therapy. The surgeon thinks this is unlikely, but we need to do the blood test to verify.
All in all, I'm guessing I'll really start to feel 100% by the end of March or so - right about the time that ski season starts to wind down. That will leave me 9 more months in the year to regain the fitness I've lost in the first three months of the year. If I can end this year as fit as I ended last year, I think that will be a very acceptable outcome.
Despite the fact that I'm enjoying being on the mountain again, I have to admit that I'm starting to dream of fly fishing and hiking in the high peaks with my wife. I'm always happy that I live in a place like Vermont, where we have real seasons that push us towards different activities throughout the entire year.
Last week, I hoped to get to CrossFit three times. I made it on Tuesday and Wednesday, but by Thursday, my entire body ached. I felt so beat up that I wondered if I had the flu. But, a couple days of anti-inflammatories, and I felt a lot better by Saturday. Regretfully, a rain storm on Friday changed the ski conditions drastically for this past weekend. The kids seemed oblivious to the weather conditions and wanted to simply charge into the trees again. For the most part, when we ventured into the trees, I felt the runs were much tougher and more dangerous than the week before, yet the kids did not seem to believe this at all.
My rule on the hill is that safety considerations trump all other considerations. Twice on Saturday, my students deliberately ignored me and went into a tree run that I had expressly said we would not ski. I was not happy, and the main offender got to go home early for the day on Saturday. After some discussions with her parents on Saturday, she returned on Sunday much more willing to listen to directions. Hopefully that will continue for the rest of the season.
This coming week looks cold and snowless. Snowmaking is done for the season, so we are likely to be looking at firm conditions next weekend. The children are really getting restless on the slopes at times. This is an "adventure" program and they want more adventure. But, despite record snowfalls in some parts of the country, and a fairly cold winter, snow is still less than normal in my part of the country.
In some ways, and I almost hate to say this, the lower snowfall amounts have been better for me physically. It is less demanding for me to teach on groomed trails than it is to teach in the trees or on steep icy terrain or steep mogul terrain. Yet, despite the easier than normal demands on my body, I am still struggling somewhat to keep up.
In the past two weeks, I've been fighting an illness, which has led to coughing (I did get some cough medicine that helped there) and sneezing. After a lot of sneezing, I noticed that I was starting to feel some discomfort near the center of the surgery - right where my prostate used to reside. This is a good indication that I'm still not fully healed. Of the six incision points for the robotic surgery, the largest incision has still not completely healed, although it's close.
I've been pretty lucky with incontinence, which normally resolves in 2-4 months. Even sneezing and coughing, I haven't been having any problems, so I seem to be at least 99% contintent. Other surgical side effects are taking longer to resolve.
But, the bottom line is that I'm still not 100% recovered. I'm napping and sleeping more than usual. A day at the gym or a day on the mountain tires me out more than it would have before the surgery. Even being at my desk for a full day of work can be a bit of a chore, and I find myself getting tired by the end of the day.
I know I've pushed myself back to a fairly full life much faster than most patients after surgery like this. For this particular surgery, I was probably a decade younger than the typical patient, so I think it's reasonable to expect that my recovery would be better than average. But, better than average has not translated into "full and complete" in a very short timeline.
So, I need to remain vigilant and do what my body lets me do. I'm glad I'm skiing again. I'm glad I'm in the gym. I'm hopeful the cancer is completely gone. I have my annual physical in March and my next appointment with the surgeon in April - 14 weeks after the surgery. PSA has a half life of about 3 days in the body. That means that my PSA level of about 5 should be undetectable within a month or so of surgery. I won't be tested at my physical, most likely, but I will be tested for the appointment with the surgeon. If the level is not undetectable, that will likely indicate that some cancer remains, and I'll be looking at radiation therapy. The surgeon thinks this is unlikely, but we need to do the blood test to verify.
All in all, I'm guessing I'll really start to feel 100% by the end of March or so - right about the time that ski season starts to wind down. That will leave me 9 more months in the year to regain the fitness I've lost in the first three months of the year. If I can end this year as fit as I ended last year, I think that will be a very acceptable outcome.
Despite the fact that I'm enjoying being on the mountain again, I have to admit that I'm starting to dream of fly fishing and hiking in the high peaks with my wife. I'm always happy that I live in a place like Vermont, where we have real seasons that push us towards different activities throughout the entire year.
Thursday, February 13, 2014
Two days of CrossFit
For the first time since my surgery, I made it to CF two days in a row. I would have made it twice last week except for the head cold I was dealing with. Well, the doctor said it was viral bronchitis. Whatever it was, it knocked me down for about a week, and I'm still taking some cough medicine.
Last night's workout was as follows:
20 split jerks, ever minute on the minute. I did the first 10 at 95 pounds and the second 10 at 105 pounds. My PR is 195 pounds, so this was definitely taking it easy. But, it was easily the most weight I've had overhead since my surgery.
Then, as quickly as possible:
3 rounds:
15 x 65 pound front squat
15 band-assisted pull-ups
15 x 2 x 25# dumbbell strict presses
The three rounds took me 10:50.
Today was a "work your weakness" workout. For the first 20 minutes, we alternated between two movements, and as yesterday, did it every minute on the minute. I did the following:
4 x 185# deadlifts (vs. a best opf 440)
5 x 2 x 35# dumbbell bench presses (I could do this easily with 50s before the surgery)
Partway through this portion of the workout, I removed the stupid pad I'm wearing due to intermittent incontinence from the surgery. The incontinence is not bothering me during workouts, and the pad was uncomfortable.
Then, as many reps as possible in 12 minutes of the following:
15 Abmat sit-ups
15 x 35# kettlebell swings
15 x 20" box step-ups (I'm not ready for box jumps yet, which is what everyone else did)
I was most nervous about the sit-ups, so I took my time with them, but they didn't bother me at all. In 12 minutes, I completed 4 rounds plus 31 reps.
The big east coast snowstorm is almost here and I'll be skiing hard this coming weekend. Because of that, tomorrow will definitely be a rest day.
Last night's workout was as follows:
20 split jerks, ever minute on the minute. I did the first 10 at 95 pounds and the second 10 at 105 pounds. My PR is 195 pounds, so this was definitely taking it easy. But, it was easily the most weight I've had overhead since my surgery.
Then, as quickly as possible:
3 rounds:
15 x 65 pound front squat
15 band-assisted pull-ups
15 x 2 x 25# dumbbell strict presses
The three rounds took me 10:50.
Today was a "work your weakness" workout. For the first 20 minutes, we alternated between two movements, and as yesterday, did it every minute on the minute. I did the following:
4 x 185# deadlifts (vs. a best opf 440)
5 x 2 x 35# dumbbell bench presses (I could do this easily with 50s before the surgery)
Partway through this portion of the workout, I removed the stupid pad I'm wearing due to intermittent incontinence from the surgery. The incontinence is not bothering me during workouts, and the pad was uncomfortable.
Then, as many reps as possible in 12 minutes of the following:
15 Abmat sit-ups
15 x 35# kettlebell swings
15 x 20" box step-ups (I'm not ready for box jumps yet, which is what everyone else did)
I was most nervous about the sit-ups, so I took my time with them, but they didn't bother me at all. In 12 minutes, I completed 4 rounds plus 31 reps.
The big east coast snowstorm is almost here and I'll be skiing hard this coming weekend. Because of that, tomorrow will definitely be a rest day.
Tuesday, February 11, 2014
Looking Forward
I've had a cold for the past few days. It hasn't been terrible, but coughing and sneezing have been somewhat painful in the area where I used to have a prostate. I got some hi-test cough syrup from my doc yesterday and that is helping.
I managed to ski some moguls this past weekend and I felt pretty good. The weekend before, moguls were a tiny bit painful. I even hiked a decent distance on the Long Trail to get to some terrain that was open, but without lift service. I had a small group of students and that hike was our adventure for the weekend. Without a doubt, it was my best ski run of the season so far.
My time away from the gym and skiing and lots of other activities has given me time to think about what I do with all of the time in my life. And, what do I want to do?
My wife is very interested in getting back into hiking this summer. For a few years, we were intently working our way through the highest peaks of New York and New England. And, by "working", I mean having fun. And then, we pretty much stopped. So, this summer, we are going to return to the mountains. I've done over half of the 4000 foot peaks in NY and NE, but my wife has only done half as many, if that. We will try to spend weekends in NY and NH, hiking higher peaks.
I want to get back to running. In 2008, when Western States was cancelled, I was in really good ultra shape, ready for a great race. A year later, I tore a hamstring tendon, got pulled early from Western States because of that injury, and ended the year with fewer than 1000 miles for the first time in many years. From 2010 through 2013, my running really dropped off. I want to get back to some regular running this year, just because I want to. I have no mileage goals, no race plans or any other reason to do this. After a few years away, I finally miss running and I want to do more of it.
I still want to go fly fishing as much as I can. I really enjoy my time on the rivers, whether I'm solo or with my son. In my many years of running ultras, I really got away from fly fishing. Now that I've returned to fishing, I want to stick with this hobby, which I find a very peaceful way to relax while still actively doing something.
I intend, of course, to continue with skiing, CrossFit, riding my bike, etc.
I intend to continue to work hard for my company. I've recently been promoted to Chief Technology Officer of the company and I intend to do what I can to make the company successful.
And lastly, I want to be a more social animal. I have a tendency to have a small, core group of friends that I spend my time with. Outside of that group, I'm often uncomfortable and a bit of a loner. During the last six months, I've received such an outpouring of support from close friends and many, many past friends (high school) and acquaintances. I need to make the effort to be more social, to be more available to others, as they have been to me. After all, what do we really have here other than each other?
I mentioned George Sheehan in a recent post, talking about the battle he lost to prostate cancer. One of my favorite quotes from George was not originally his, but rather stolen (and re-interpreted somewhat) from Ralph Waldo Emerson: "First, be a good animal."
The web is full of more on what this quote means, and what both Sheehan and Emerson meant when they wrote it. The googling is left as an exercise to the reader.
But, my real goal, going forward, is to be a better animal than I've been in the past.
I managed to ski some moguls this past weekend and I felt pretty good. The weekend before, moguls were a tiny bit painful. I even hiked a decent distance on the Long Trail to get to some terrain that was open, but without lift service. I had a small group of students and that hike was our adventure for the weekend. Without a doubt, it was my best ski run of the season so far.
My time away from the gym and skiing and lots of other activities has given me time to think about what I do with all of the time in my life. And, what do I want to do?
My wife is very interested in getting back into hiking this summer. For a few years, we were intently working our way through the highest peaks of New York and New England. And, by "working", I mean having fun. And then, we pretty much stopped. So, this summer, we are going to return to the mountains. I've done over half of the 4000 foot peaks in NY and NE, but my wife has only done half as many, if that. We will try to spend weekends in NY and NH, hiking higher peaks.
I want to get back to running. In 2008, when Western States was cancelled, I was in really good ultra shape, ready for a great race. A year later, I tore a hamstring tendon, got pulled early from Western States because of that injury, and ended the year with fewer than 1000 miles for the first time in many years. From 2010 through 2013, my running really dropped off. I want to get back to some regular running this year, just because I want to. I have no mileage goals, no race plans or any other reason to do this. After a few years away, I finally miss running and I want to do more of it.
I still want to go fly fishing as much as I can. I really enjoy my time on the rivers, whether I'm solo or with my son. In my many years of running ultras, I really got away from fly fishing. Now that I've returned to fishing, I want to stick with this hobby, which I find a very peaceful way to relax while still actively doing something.
I intend, of course, to continue with skiing, CrossFit, riding my bike, etc.
I intend to continue to work hard for my company. I've recently been promoted to Chief Technology Officer of the company and I intend to do what I can to make the company successful.
And lastly, I want to be a more social animal. I have a tendency to have a small, core group of friends that I spend my time with. Outside of that group, I'm often uncomfortable and a bit of a loner. During the last six months, I've received such an outpouring of support from close friends and many, many past friends (high school) and acquaintances. I need to make the effort to be more social, to be more available to others, as they have been to me. After all, what do we really have here other than each other?
I mentioned George Sheehan in a recent post, talking about the battle he lost to prostate cancer. One of my favorite quotes from George was not originally his, but rather stolen (and re-interpreted somewhat) from Ralph Waldo Emerson: "First, be a good animal."
The web is full of more on what this quote means, and what both Sheehan and Emerson meant when they wrote it. The googling is left as an exercise to the reader.
But, my real goal, going forward, is to be a better animal than I've been in the past.
Thursday, February 6, 2014
Some Prostate Cancer Numbers
I'm going to use the frequently used PCA abbreviation to denote Prostate Cancer at times in this post.
One in 6 US men will be diagnosed with PCA in his lifetime. Approximately 1 in 36 will die from the disease. The cancer tends to strike late enough in life and there are enough medical techniques to slow the progression of the disease that men frequently die from another cause. Many estimates claim that by age 85, 50% of all men have some level of prostate cancer, but this has never, to my knowledge, been unequivocally determined. Most of the data is derived not from diagnosed cases, but from autopsies on older men.
I remember when Runner's World columnist George Sheehan was struck by prostate cancer. After it became obvious that he could not be cured, he decided that he was going to make the disease kill him. He was going to take such good care of himself that nothing else would get him. And, in November of 1993, he died from the cancer.
According to the CDC, prostate cancer was the most common cancer (non-melanoma skin cancers excluded) in the US in 2010, with 126.1 out of every 100K men being diagnosed that year. Female breast cancer was the second most common (male breast cancer exists but is uncommon and was not included in the charts I used).
When looking at death rates, lung cancer jumps to the top and then breast and prostate cancer are nearly tied at number 2. But, lung cancer kills at more than twice the rate of either breast or prostate cancer.
Funding for cancer research provided by the NCI shows some very interesting disparities in how research money is spent. Per case, among the more prominent cancers, (this data is from 2006, not 2010 as above), prostate cancer received $1318 in funding, while breast cancer led the pack at $2596. Lung, colon and pancreatic cancer were in between these other two in terms of funding, but lung cancer was the only other cancer to receive less than $2000 per new case - closer to $1500 actually.
In terms of deaths, the number of dollars spent are even more intriguing. Breast cancer still leads the pack, but the relatively low death rate from PCA pushes PCA to second in funding per death. In some ways this is confusing because 2010 data showed rates of prostate and breast cancer deaths to be nearly identical per 100K people, while the 2006 data shows that there were 1/3 more deaths from breast cancer than prostate cancer (absolute numbers vs. rates per 100K people). Lung cancer drops way to the bottom, at only 12% or so of the funding per death that breast cancer receives. I'm curious if lung cancer seems to lag because it's seen as a self-induced cancer, with most cases tied to smoking. Or perhaps it lags because it's also quite deadly.
So, those are some interesting statistics. I'm not going to comment much more on this, but I do think some things seem a bit skewed here. For men, prostate cancer is very much the equivalent of breast cancer in women. PCA is less deadly overall, but both cancers profoundly affect how people see themselves as sexual beings, and the treatments for both can involve the loss of a lot of dignity. Let's just say that I've become quite used to the command to "drop my pants" in the past few months. I don't even look around the room any more to see who is there. I just drop my pants. This morning, it was two nurses at Dartmouth. I dropped my pants on command and didn't think twice about it. I'm sure that breast cancer carries similar indignities for women and I'm sure if this post gets read, someone will tell me they are worse. At that point, the second half of this post might be informative, in terms of the indignities that men go through.
So, why is it that men seem to have done nothing like what women have done to raise awareness, raise money for research, or turn this into a cause? Is it just a difference in the sexes? Why the federal funding discrepancies between the two diseases?
Now, onto a second set of numbers. These are my personal numbers from my experience.
Late last summer, I had a series of PSA readings around 5, with 4 being the top of the normal range. A digital rectal exam (and there were many of these) showed no real issues. It was noted that one side of my prostate seemed larger than the other side, but this discrepancy is not statistically important when looking at actual cancers found. So, my blood test was out of range and my DREs were nearly normal, with one slight anomaly noted by one (of many) providers.
At this point, a biopsy was suggested. I did my homework, and I realized that the chance that a biopsy would show cancer was about 25%. The odds were in my favor, but I lost that round.
After talking to lots of docs, I picked a treatment technique and I'm now on the other side of that treatment. I chose surgery without any adjuvant therapies - radiation or androgen deprivation. The surgeon said that nomograms showed the chance that I'd have an affected lymph node to be about 1%, and he never removes lymph nodes at that low a chance. This shortened my surgery by 30 minutes.
I got my post-op pathology report and it essentially matched the pre-op estimates. Using some nomograms from Sloan Kettering, I have a 99% chance of being cancer free at two years with no more treatment at all. At 5 years and 7 years, it's 97%, and at 10 years, 96%. That says it's very likely that I'll be defined as "cured" at the five year mark. Unless I'm unlucky again. Yes, even in my low risk category, there are recurrences, and I'll spend the rest of my life getting blood tests to monitor for that possibility.
The three major goals of the treatment are, in order, to cure the cancer, maintain urinary control (continence) and maintain sexual function (potency). I've already covered some cure statistics above. Next, I'll talk a bit about the latter two of these.
For most men, full return to continence (and the definition of this is often debated) has a median time of just under four months. For certain patients, primarily younger patients who had nerve sparing surgery with a highly experienced surgeon, mean time to return to continence is closer to two months. I'm at one month right now, and I'm almost there. I am guessing that by two months, three at the outside, I will be considered fully continent. But, I am a younger than average patient, I had nerve sparing surgery, and my surgeon was very experienced, so I fit into the second category.
(This next section might be TMI - Read at your own risk).
Almost all patients are impotent immediately after this surgery. Due to a catheter for the first 1-2 weeks after surgery, sex is not possible at all (OK, I'm sure someone, somewhere has done it, but it wasn't me). For four weeks, at a minimum, there are internal stitches in the urethra and bladder that are healing, and doctors tend to steer patients away from sex during this period of time, even if possible.
But, after four weeks, most doctors begin a period of treatments frequently known as "penile rehabilitation". The rehab has two purposes. First, it's hopeful that this will speed the patient back to potency by drawing blood into the penis and helping the tissues to stay active. Secondly, if the rehab isn't done, the penis tends to permanently shrink during this inactive period. I'm just not going to say anything more about that.
Penile rehab can include the use of PDE5 inhibitors (they tend to not work well, if at all, early on), vacuum erection devices, and injected drugs that result in erections (and yes, they are injected into the penis. Did you just wince?) Insurance companies, for the most part, cover absolutely none of the costs for this "rehab".
Younger, healthier patients often start to see some recovery by 3 months. For many, it takes at least six months for a partial recovery. Many patients take up to two years, and improvements out to four years is possible.
In the end though, even with nerve sparing surgery, for a younger patient who was potent at the time of the surgery, approximately 30% of patients will remain permanently impotent. Everyone going into the surgery knows these odds, and everyone hopes to beat them. But, some people simply never recover.
So, I had a 75% chance of a negative biopsy. I lost. I have a 96% chance of a long term cure. Only time will tell. I should be fully continent in another month or two and even where I am today really isn't bad compared to many. On the other issue, just like recurrence, I simply need to wait and hope.
A friend recently told me that he didn't think he could have dealt with all I've gone through the past six months. I disagreed with him. While no one wants to go through it, when things happen, you have to deal with them. You might not be happy about it, but you have to move on.
And, on that note, I skied twice last weekend, took a rest day, and then went to CrossFit on Tuesday. Today, I'm going to work out again after work, before I take another rest day to get ready for a weekend of skiing. I'm getting better and life does go on.
One in 6 US men will be diagnosed with PCA in his lifetime. Approximately 1 in 36 will die from the disease. The cancer tends to strike late enough in life and there are enough medical techniques to slow the progression of the disease that men frequently die from another cause. Many estimates claim that by age 85, 50% of all men have some level of prostate cancer, but this has never, to my knowledge, been unequivocally determined. Most of the data is derived not from diagnosed cases, but from autopsies on older men.
I remember when Runner's World columnist George Sheehan was struck by prostate cancer. After it became obvious that he could not be cured, he decided that he was going to make the disease kill him. He was going to take such good care of himself that nothing else would get him. And, in November of 1993, he died from the cancer.
According to the CDC, prostate cancer was the most common cancer (non-melanoma skin cancers excluded) in the US in 2010, with 126.1 out of every 100K men being diagnosed that year. Female breast cancer was the second most common (male breast cancer exists but is uncommon and was not included in the charts I used).
When looking at death rates, lung cancer jumps to the top and then breast and prostate cancer are nearly tied at number 2. But, lung cancer kills at more than twice the rate of either breast or prostate cancer.
Funding for cancer research provided by the NCI shows some very interesting disparities in how research money is spent. Per case, among the more prominent cancers, (this data is from 2006, not 2010 as above), prostate cancer received $1318 in funding, while breast cancer led the pack at $2596. Lung, colon and pancreatic cancer were in between these other two in terms of funding, but lung cancer was the only other cancer to receive less than $2000 per new case - closer to $1500 actually.
In terms of deaths, the number of dollars spent are even more intriguing. Breast cancer still leads the pack, but the relatively low death rate from PCA pushes PCA to second in funding per death. In some ways this is confusing because 2010 data showed rates of prostate and breast cancer deaths to be nearly identical per 100K people, while the 2006 data shows that there were 1/3 more deaths from breast cancer than prostate cancer (absolute numbers vs. rates per 100K people). Lung cancer drops way to the bottom, at only 12% or so of the funding per death that breast cancer receives. I'm curious if lung cancer seems to lag because it's seen as a self-induced cancer, with most cases tied to smoking. Or perhaps it lags because it's also quite deadly.
So, those are some interesting statistics. I'm not going to comment much more on this, but I do think some things seem a bit skewed here. For men, prostate cancer is very much the equivalent of breast cancer in women. PCA is less deadly overall, but both cancers profoundly affect how people see themselves as sexual beings, and the treatments for both can involve the loss of a lot of dignity. Let's just say that I've become quite used to the command to "drop my pants" in the past few months. I don't even look around the room any more to see who is there. I just drop my pants. This morning, it was two nurses at Dartmouth. I dropped my pants on command and didn't think twice about it. I'm sure that breast cancer carries similar indignities for women and I'm sure if this post gets read, someone will tell me they are worse. At that point, the second half of this post might be informative, in terms of the indignities that men go through.
So, why is it that men seem to have done nothing like what women have done to raise awareness, raise money for research, or turn this into a cause? Is it just a difference in the sexes? Why the federal funding discrepancies between the two diseases?
Now, onto a second set of numbers. These are my personal numbers from my experience.
Late last summer, I had a series of PSA readings around 5, with 4 being the top of the normal range. A digital rectal exam (and there were many of these) showed no real issues. It was noted that one side of my prostate seemed larger than the other side, but this discrepancy is not statistically important when looking at actual cancers found. So, my blood test was out of range and my DREs were nearly normal, with one slight anomaly noted by one (of many) providers.
At this point, a biopsy was suggested. I did my homework, and I realized that the chance that a biopsy would show cancer was about 25%. The odds were in my favor, but I lost that round.
After talking to lots of docs, I picked a treatment technique and I'm now on the other side of that treatment. I chose surgery without any adjuvant therapies - radiation or androgen deprivation. The surgeon said that nomograms showed the chance that I'd have an affected lymph node to be about 1%, and he never removes lymph nodes at that low a chance. This shortened my surgery by 30 minutes.
I got my post-op pathology report and it essentially matched the pre-op estimates. Using some nomograms from Sloan Kettering, I have a 99% chance of being cancer free at two years with no more treatment at all. At 5 years and 7 years, it's 97%, and at 10 years, 96%. That says it's very likely that I'll be defined as "cured" at the five year mark. Unless I'm unlucky again. Yes, even in my low risk category, there are recurrences, and I'll spend the rest of my life getting blood tests to monitor for that possibility.
The three major goals of the treatment are, in order, to cure the cancer, maintain urinary control (continence) and maintain sexual function (potency). I've already covered some cure statistics above. Next, I'll talk a bit about the latter two of these.
For most men, full return to continence (and the definition of this is often debated) has a median time of just under four months. For certain patients, primarily younger patients who had nerve sparing surgery with a highly experienced surgeon, mean time to return to continence is closer to two months. I'm at one month right now, and I'm almost there. I am guessing that by two months, three at the outside, I will be considered fully continent. But, I am a younger than average patient, I had nerve sparing surgery, and my surgeon was very experienced, so I fit into the second category.
(This next section might be TMI - Read at your own risk).
Almost all patients are impotent immediately after this surgery. Due to a catheter for the first 1-2 weeks after surgery, sex is not possible at all (OK, I'm sure someone, somewhere has done it, but it wasn't me). For four weeks, at a minimum, there are internal stitches in the urethra and bladder that are healing, and doctors tend to steer patients away from sex during this period of time, even if possible.
But, after four weeks, most doctors begin a period of treatments frequently known as "penile rehabilitation". The rehab has two purposes. First, it's hopeful that this will speed the patient back to potency by drawing blood into the penis and helping the tissues to stay active. Secondly, if the rehab isn't done, the penis tends to permanently shrink during this inactive period. I'm just not going to say anything more about that.
Penile rehab can include the use of PDE5 inhibitors (they tend to not work well, if at all, early on), vacuum erection devices, and injected drugs that result in erections (and yes, they are injected into the penis. Did you just wince?) Insurance companies, for the most part, cover absolutely none of the costs for this "rehab".
Younger, healthier patients often start to see some recovery by 3 months. For many, it takes at least six months for a partial recovery. Many patients take up to two years, and improvements out to four years is possible.
In the end though, even with nerve sparing surgery, for a younger patient who was potent at the time of the surgery, approximately 30% of patients will remain permanently impotent. Everyone going into the surgery knows these odds, and everyone hopes to beat them. But, some people simply never recover.
So, I had a 75% chance of a negative biopsy. I lost. I have a 96% chance of a long term cure. Only time will tell. I should be fully continent in another month or two and even where I am today really isn't bad compared to many. On the other issue, just like recurrence, I simply need to wait and hope.
A friend recently told me that he didn't think he could have dealt with all I've gone through the past six months. I disagreed with him. While no one wants to go through it, when things happen, you have to deal with them. You might not be happy about it, but you have to move on.
And, on that note, I skied twice last weekend, took a rest day, and then went to CrossFit on Tuesday. Today, I'm going to work out again after work, before I take another rest day to get ready for a weekend of skiing. I'm getting better and life does go on.
Monday, February 3, 2014
And, I Think I Passed the Test
Ski conditions in the northeast are less than optimal given where we are in the winter. Sugarbush has only about 100 inches of snow so far this winter, vs. an average annual snowfall close to 300 inches. Plus, there have been a few rain events that have melted a lot of the snow we have received.
So, I knew that by returning to work this past weekend, I wouldn't be skiing in the trees and I wouldn't be skiing tough moguls, but I would get tested on steep terrain. It was great to be back at the mountain, hanging out with friends and my students again. As I left the locker room on Saturday morning to take some warm-up runs, I told a friend that I just hoped I wouldn't take a fall during the weekend.
I opted to warm up on a very easy run (for me at least) - an intermediate trail that was well groomed. I was skiing by myself, in my ski school uniform, and I somehow managed to cross my ski tips and take a fall. One of my skis popped off (bindings doing their job!), and I stood up unscathed. Emboldened by that, I went to a steep double-black diamond run next. The snow was a bit funky due to a few hours of snowmaking over an icy surface, but I survived the run just fine. I even returned there later with my students.
For the first time all season, all 9 girls in my group showed up on the same day. And, after being gone for three weeks, I spent a lot of Saturday regaining control of the group. Apparently, they didn't behave well at all for the instructors who covered for me. One of those instructors went to my boss on Friday and allegedly said "Please tell me that Damon is returning tomorrow as scheduled." One of the parents later told me that he thinks the kids can "smell fear" in a substitute coach, and they had been kind of rough on the substitutes. Multiple parents told me that the girls were very happy to have me back, which always makes me feel good. One of the toughest parts of the job as an older coach is to truly engage with young students and make sure that not only are they safe and learning, but they are also having fun on a daily basis.
If I take the group for a day, no one gets hurt, and everyone wants to return to ski again the next day, I'm doing a good job. If the kids learn some new skills during the day, it's even better.
I did notice early on Saturday that the group had regressed in a few skill areas since I'd last seen them. I wanted to keep the first day back light and fun, so we had a simple focus for the day, and and tried to apply that focus to both racing and steep terrain.
On Sunday, I spent most of the morning doing some more formal teaching - much more than I do in a typical day. The girls weren't crazy about that strong a teaching focus, but I saw improvements through the morning, and some afternoon racing confirmed that some things had changed.
By Saturday afternoon, I was tired. By Sunday afternoon, I was exhausted. But, I had a great time, we are expecting some snow this week, and I have five days to recover before I do it all again.
It is nice to be getting back to my normal activities, even though I am far from 100% healed. But, it's better every day.
So, I knew that by returning to work this past weekend, I wouldn't be skiing in the trees and I wouldn't be skiing tough moguls, but I would get tested on steep terrain. It was great to be back at the mountain, hanging out with friends and my students again. As I left the locker room on Saturday morning to take some warm-up runs, I told a friend that I just hoped I wouldn't take a fall during the weekend.
I opted to warm up on a very easy run (for me at least) - an intermediate trail that was well groomed. I was skiing by myself, in my ski school uniform, and I somehow managed to cross my ski tips and take a fall. One of my skis popped off (bindings doing their job!), and I stood up unscathed. Emboldened by that, I went to a steep double-black diamond run next. The snow was a bit funky due to a few hours of snowmaking over an icy surface, but I survived the run just fine. I even returned there later with my students.
For the first time all season, all 9 girls in my group showed up on the same day. And, after being gone for three weeks, I spent a lot of Saturday regaining control of the group. Apparently, they didn't behave well at all for the instructors who covered for me. One of those instructors went to my boss on Friday and allegedly said "Please tell me that Damon is returning tomorrow as scheduled." One of the parents later told me that he thinks the kids can "smell fear" in a substitute coach, and they had been kind of rough on the substitutes. Multiple parents told me that the girls were very happy to have me back, which always makes me feel good. One of the toughest parts of the job as an older coach is to truly engage with young students and make sure that not only are they safe and learning, but they are also having fun on a daily basis.
If I take the group for a day, no one gets hurt, and everyone wants to return to ski again the next day, I'm doing a good job. If the kids learn some new skills during the day, it's even better.
I did notice early on Saturday that the group had regressed in a few skill areas since I'd last seen them. I wanted to keep the first day back light and fun, so we had a simple focus for the day, and and tried to apply that focus to both racing and steep terrain.
On Sunday, I spent most of the morning doing some more formal teaching - much more than I do in a typical day. The girls weren't crazy about that strong a teaching focus, but I saw improvements through the morning, and some afternoon racing confirmed that some things had changed.
By Saturday afternoon, I was tired. By Sunday afternoon, I was exhausted. But, I had a great time, we are expecting some snow this week, and I have five days to recover before I do it all again.
It is nice to be getting back to my normal activities, even though I am far from 100% healed. But, it's better every day.
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