WILLIAMSTOWN — “So now what?” I asked the urologist who had just told me I had prostate cancer. It was October 2016.
“It’s low-risk disease,” he said. “You’ll be fine.” A follow-up appointment was scheduled for several months hence, and the doctor then recommended a visit to a cafe known for the excellence of its cheesecake.
I was more in the mood for a Bloody Mary and a BLT, so my partner Deb and I headed for a big diner I’d frequented when I lived and worked in Troy, N.Y.
Over our “tea,” we reviewed the case.
“Prostatic adenocarcinoma. Gleason grade 3+4. Histologic score 7,” reads the pathologist’s report dated Sept. 29, 2016. “Tumor involves less than 5 percent of the tissue core present. No extracapsular [outside the prostate], perineural, or lymphatic vascular [nearby nerves or lymph nodes] invasion identified.”
During the office visit, the doctor told us that his description of my cancer as low risk was based on his belief that the pathologist had been mistaken in scoring my cancer as a Gleason 7. He turned out to be right: The biopsy samples were sent to a nationally-known expert at Johns Hopkins Medical Center in Baltimore, who scored the tumor as a Gleason 6 — low risk.
Before mixing the Bloody Marys, a word about the Gleason score. In what I’ve come to call “prostate world,” a cancer patient’s Gleason could be viewed as an identification code like those employed by secret agents.
Here’s how it works, according to online medical encyclopedia MedlinePlus: While examining cells under a microscope, a pathologist assigns a number (grade) to the prostate cancer cells from 1 to 5. The grade is based on how abnormal the cells appear. Grade 1 means they look almost like normal prostate cells. Grade 5 means the cells look very different from normal cells.
Most prostate cancers contain cells that are of different grades, so the two most common grades are used. The Gleason score is arrived at by adding the two most common grades. For instance, the most common cells in a tissue sample may be Grade 3, followed by Grade 4 cells. The Gleason score for such a sample would be 7. The higher the number (the chart tops out at 10 or 5+5), the more fast-growing and aggressive the tumor. The lowest grade is 3.
Generally, a patient with a 3+4 Gleason (as mine was found to be some years after my diagnosis) is considered to have a less aggressive cancer than a 4+3 since that score indicates the presence of more Grade 4 cells than the less abnormal and aggressive Grade 3 cells.
Until last year, my doctor and I employed an “active surveillance” strategy, formerly called “watchful waiting.”
I got more-or-less quarterly measurements of the amounts of prostate-specific antigen (PSA) in my blood. In this somewhat controversial test, the higher the number, the more likely there is to be cancer in the prostate. A PSA test is not diagnostic: Only a prostate biopsy (of which I’ve had three, no fun, but a lot more bearable than they used to be, I’m told) can diagnose cancer.
In 2022, my PSA crept just north of 10. A normal reading for a man my age (I’m 69) would be around 4.
It wasn’t so much the total score that worried my urologist. He was concerned by the relatively rapid rate of “acceleration” in the number.
Within six months, my PSA had gone up by almost three points. Another biopsy was done (another Gleason 3+4), but the doctor suggested that I consider treating my cancer. I settled on external beam therapy combined with hormone therapy.
To this point, only Deb and a few members of my immediate family had been filled in on my diagnosis. I saw no cause to worry — even momentarily — friends and extended family, at least until treatment was complete and its results known. I thought of one of my heroes, MAD Magazine’s Alfred E. Newman, and adopted his mantra as my own: “What? Me worry?”
Over 28 visits, five days a week in November and December, the friendly and professional staff at the Phelps Cancer Center in Pittsfield delivered carefully targeted X-ray beams at my prostate. I’ll know my “new” PSA number in March, but the odds are highly favorable.
The American Cancer Society places the five-year survival rate of patients treated with radiation for cancer like mine — confined to the prostate — at 98 percent, the same as those treated with surgery. The overall survival rate is conservatively estimated at 91 percent.
Last week, the American Cancer Society released a study showing that the number of cases of advanced prostate cancer is increasing for the first time in 20 years. Black men appear to be at increased risk. The incidence and mortality of prostate cancer in Black men is significantly higher than in white men, according to ACS.
For the record, I’ll admit to dragging my feet a bit on PSA testing, both early on and during the pandemic. I didn’t want to buy trouble, and I found ample support for an argument that PSA tests were of limited value.
Then, for reasons perhaps best explained by doctors in a different specialty (psychiatry?), I thought of Gen. George S. Patton Jr.
Quoting Napoleon, Patton declared “L’audace. Toujours l’audace” — “Audacity. Always audacity” — when explaining his bold strategy of near-constant advance and attack.
Another general, Sun Tzu, advised “know your enemy.”
It starts with a simple blood test.