Thursday, November 24, 2016

Decisions, Decisions

I had to make several decisions during the visit with my doctor at PTI Wednesday.

MRI: The next phase, the Simulation process. includes designing the exact size and shape of the proton beam. Before they can do that, they need an MRI to pinpoint the exact location of each part of the cancerous tissue, especially near or outside the boundaries of the prostate. Since it would take most of the rest of 2016 for CHP to approve payment for that MRI (assuming they would—not a given), and then additional time to schedule it, I elected to get the MRI in early January when Medicare will pay for it. It requires special high-quality MRI equipment and procedures, and the best nearby places for this are at teaching hospitals in Birmingham, Gainesville, and Jacksonville.  I chose Jacksonville.

SpaceOAR: This is the Spacing Organs at Risk device. The prostate is right next to part of the lower intestine, which we don’t want to irradiate. The most common way to reduce this risk is to insert a sturdy uninflated balloon through the rectum, fill it with water, do that day’s radiation, deflate the balloon, and remove it. With SpaceOAR, a liquid is injected between the prostate and the lower intestine. This liquid quickly expands into a semi-solid substance to provide more complete prostate-intestine separation. The SpaceOAR stays there throughout the treatment weeks, and after about three months simply dissolves. The doctor and I agreed that this would be best for me, but I need to get the MRI first, to confirm that the cancer is confined within the prostate.

Length of Treatment: The traditional course of treatment, for both IMRT (Intensity Modulated Radiation Therapy, the most common form of radiation) and proton beam therapy is once every week day for up to eight weeks. My doctor told me I could choose to have the proton therapy once every weekday for five and a half weeks, with a higher dose each time (but with a lower total dose). This method has been used for several years, but it’s not as common as the longer duration treatment and there isn’t as much data for its effectiveness and side effects. However, it seems to be about the same with regard to both, and I chose the shorter term.

Androgen Deprivation Therapy Treatment (ADT): Androgens are male hormones, mostly testosterone. Testosterone is well known to fuel prostate cancer growth, and permanent elimination of testosterone is often prescribed for prostate cancer that has metastasized outside the prostate. Testosterone reduction can also be used in conjunction with other treatments. My doctor suggested doing this to weaken or kill some of the cancer cells so as to increase the effectiveness of the proton therapy. Of course, there are side-effects. These may include hot flashes, sweats, fatigue, and other hormone related issues. It gives one new appreciation for what menopausal women endure. I decided that the temporary drawbacks are outweighed by the long-range improvement to my prognosis, so I chose to have the ADT. This means I’ll have a shot with a three-month dose before the proton beam treatment starts, then another shot that will continue the ADT for another three months. Therefore, the start of the proton beam therapy will be delayed, but the ADT treatment can start in early January—sooner than the proton therapy could have started.

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