Memento mori

Gustave Dore - Death on the Pale Horse (WikiCommon)

This week I saw the movie "Dr. Strange". If you haven't seen it, there are rather deep questions (for an action movie) about mortality. For example, the Ancient One tells Stephen Strange, "Death is what gives life meaning. To know your days are numbered and your time is short."

I'm 54. It seems to be about this age that the Reaper really starts mowing. Two weeks ago a childhood friend died after battling heart failure for 15 years. He was born just a few weeks before me. Last week my sister-in-law died of cancer. This week I learned that one of my favorite teachers (young at the time) from elementary school had died of Alzheimer's. 

I feel my age. This wasn't always the case. In my 40's I felt younger. In my 30's I could pass for 21--and I felt like it. At 21 I looked like 16--and acted like it. No longer.

I think I've beaten prostate cancer. I'm so happy that I got on top of it when I did, especially the salvage radiation after surgery failed to cure me.

But that means that something else will be my demise. Another cancer, maybe, or heart disease. Or maybe dementia. Right now I think I'd opt for door number 2.

I sometimes get an unpleasant squeeze in my chest. Nothing serious, the cardiologist says. A little valve leakage, a little rhythm disturbance. But just the fact that I'm seeing a cardiologist says a lot. Right now I'm the youngest person in the waiting room. But I know that, in a flash, that will change. In a heartbeat.

Anyway, just a reminder that death is a part of life, essential to the natural order of things, and that I will kick from something at some point, and I have far fewer days ahead of me than behind. So I should stop and smell the coffee, enjoy the pizza, the bike ride, the rising of the full moon.  And I should shift my focus to serving others.

As the Ancient One teaches Doctor Strange, the "simplest and most significant lesson of all": 

It's not about you.

Salvage Radiation Nomogram Updated

This is exciting stuff for people contemplating salvage radiation after prostatectomy.

https://consultqd.clevelandclinic.org/2015/10/updated-nomogram-predicts-modern-outcomes-after-salvage-radiotherapy-following-radical-prostatectomy/

"A contemporary update of a 2007 predictive nomogram for salvage radiotherapy after radical prostatectomy offers a modernized forecast of cure compared to its predecessor."

"The updated 2016 nomogram takes into account the more recent trend of treating patients at lower PSA levels than in the past (“early SRT”). Randomized trials published since the original nomogram was created have demonstrated the benefit of early SRT in high-risk patients."

Various things on my mind..

It's Halloween. Here's hoping you have more treats than tricks this year.

My PSA 9 years, one month after salvage radiation (SRT) ended, is still less than 0.1.  I had an employer health screen earlier this month and checked it.

In the meantime, I have developed heart palpitations (preventricular contractions), a murmur (mitral valve prolapse) and right bundle branch block. None of these are currently dangerous in my case, according to my cardiologist, but they have my attention.  They're a reminder that despite apparently beating prostate cancer, I'm still mortal, still in late middle age, and one day the Reaper will come mowing for me.

Here's a question that I once asked, and I see asked all the time on discussion boards like HealingWell and CancerForums.net:

"I had a prostatectomy x years ago, and now my PSA is rising.  It's at 0.4, up from 0.1 a few months ago.  Should I get radiation? I hear there's only a 50/50 chance it will work."

Well, how old are you?  That's a key question.  If you're 85, you may well want to skip radiation, see how your PSA tracks, and look into hormone therapy if things progress far enough.  If you're 45, I would run, not walk, to the best radiation oncologist I could find.  The reason is that if you're young enough for prostate cancer to progress and kill you, you need to pursue a cure.  Hormone therapy (ADT) won't cure you. If you're elderly, it might be as good as a cure, but if you're young, it's only going to--maybe--stall the cancer.  A 50/50 chance?  It's more nuanced than that, if you want to look into nomograms. Most people don't.  When you get prostate cancer under 50, your youth is a double-edged sword. You will heal faster from treatment, but you have decades for it to come back and...BOO! get you. 

These days, compared to when I was treated, there is a chance you can locate mets with a sensitive scan, and attack those spots specifically. But your PSA has to advance significantly first, and the higher your PSA before salvage radiation, the lower your chances for success (google Andrew Stephenson and salvage radiation outcome).  

Sometimes a layperson or even a doctor will advise the patient that they can wait until PSA gets to something like 2.0 ng/ml.  But that's not wise.  (Again, look up what Andrew Stephenson at Cleveland Clinic found out in long-range studies).  

So if you're a young guy, say, 50 or younger, and you are diagnosed with prostate cancer, my nonprofessional advice to you is to strongly consider a treatment with a known track record, like surgery.  It seems to have a slight edge in long term success for younger patients--less so with older ones.  And, youngster, if your PSA starts climbing after surgery, look into salvage radiation and don't delay. 

If you've had a prostatectomy, salvage radiation is probably going to be a walk in the park. So don't get overly anxious about it. It's a painless, easy treatment. If you have side effects, they'll probably be mild and temporary.  There's no guarantee it will work, but let's say your chances are 50/50.  Isn't that better than zero?  With any luck, you'll be like me, looking forward to some spectacular cardiopulmonary event to shuffle off the mortal coil.

Cue Haunted Mansion music.  (It's Halloween, after all).

An update on the age distribution of prostate cancer

The median age keeps slipping downward. Recent SEER statistics show the median age at diagnosis is 66. When I started checking these age-related statistics the median age was 68.

Still, 0.0% are diagnosed under the age of 35. This is not, despite the occasional outlier, a young man's disease.  At the time of my diagnosis (age 43) I was in a rarefied group. Only 0.6% of patients are diagnosed between 35 and 44.

The median age at death is 80.  That has not changed.

Well, this is interesting.

Test for Postoperative Radiation Response in Prostate Cancer

http://www.medscape.com/viewarticle/871062

Had a PSA test done as part of an employer-sponsored health screening.  Less than 0.1 as usual.

Now 10 years from diagnosis and surgery, nearly 9 years from salvage radiation (SRT).  PSA has been undetectable on the standard assay since September 2007.