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When a doctor gets cancer...
[ by Niall Hunter, Editor www.irishhealth.com]
"It was quite a shock. As a doctor you're used to telling patients bad news but when you're at the other end and are told what's wrong with you it really is like a slap in the face."
Co. Donegal GP Paul Stewart was 56 when two years ago he was given the bad news that he had prostate cancer with a Gleason score stage seven - designated as moderate - as opposed to low or high grade tumour. Paul knew he was faced with potentially life-changing events.
"If you have a diagnosis of stage five or less, the usual treatment is ‘active surveillance' where they keep an eye on you, do tests on you from time to time and then intervene if things get worse."
"Mine had got to stage seven. Stage six upwards means more active treatment. The good news is that the treatment usually works, but it's not without its side effects and lifestyle consequences."
Paul points out that prostate cancer is one of the most common non-skin cancers in Irish men and it is a disease that usually progresses slowly. "In most cases, prostate cancer can take up to 30 years to kill you, by which time you might well have died of something else."
The lifetime risk of developing prostate cancer in a 50-year old man is 42% but the lifetime risk of actually dying from prostate cancer is only 3%.
Paul admits that this poses a dilemma when it comes to screening and treating people for the disease, as prostate cancer is often not like other faster growing cancers such as breast or lung.
"Experts debate whether you should screen men for the disease or whether this creates ‘worried well' patients who might only have a very small amount of cancer that will progress very slowly, and who may in any case die from some other unrelated disease when the time comes."
"It is in fact a big decision for men to go down the road of testing and treatment because what lies ahead can be life-changing. Everything has to be weighed up."
How do people find out they have prostate cancer? The first test is a blood (PSA) test. Paul carried this out on himself, which he admits is not a good idea, as ‘physician treat thyself' is frowned on nowadays.
Usually at the same time as a PSA test is carried out, a doctor examines you for signs of possible cancer by doing a digital rectal examination. This uncomfortable test involves the doctor putting his finger up your rectum so they can feel the prostate. This can show any unusual lumps in the prostate which could also indicate possible cancer.
"MY PSA level was high, which is an indication of possible cancer but not conclusive. As is the usual practice, I then waited six weeks and had a second PSA test, which was again high, so I went then for a transrectal ultrasound scan (TRUS)."This is another test that can be uncomfortable and eye watering while it lasts, according to Paul.
It is however necessary to confirm a diagnosis of prostate cancer. A small device called a probe is passed into your back passage and an image of the prostate appears on a computer.
At the same time as this ultrasound is being taken, a transrectal biopsy of the prostate is carried out. This involves passing a needle through the wall of your back passage to take tissue samples which are then examining under a microscope to confirm and grade the cancer.
"With a Gleason grade seven, it was decided that the best course of treatment for me would be surgery. I went to the Galway Clinic, where I had robotic surgery. This involves a keyhole type surgery using a magnified operating field. Its ‘selling point' is that, you lose less blood and the recovery period is quicker."
"I was in hospital for 36 hours and had a catheter in for a week afterwards. With open surgery you are usually in hospital for a week with a catheter for three."
Paul points out that both urinary incontinence and erectile dysfunction are usually big issues for people who have had prostate surgery. The position of the prostate is such that is difficult for any surgery not to affect the parts of the body that control bladder and sexual activity.
"The length of time you remain incontinent with robotic surgery is said to be less than with the open version. I had urinary incontinence for a number of months afterwards. This has now improved greatly, but if I am, for example, going to a long walk I still wear a pad just in case."
"An important part of the recovery process is pelvic floor exercises. Men use their prostates to help retain urinary continence, so when it has been removed, obviously this is affected. You have to relearn how to use your bladder sphincter. I took about six weeks off after the surgery."
Erectile dysfunction (ED), or what used to be called impotence, is also a significant problem for many after treatment for prostate cancer and its extent tends to vary according to the patient's age.
Paul says things can improve more quickly in that department if the surgery has been nerve-sparing- whether or not this type of surgery is carried out will depend on the extent of the cancer.
"Generally, while sexual function returns, things tend not to be quite as spontaneous and pharmaceutical help (Viagra etc) is an option here. It tends to improve up to 18 months after the operation. Also, you have retrograde ejaculation - it goes upwards instead of downwards- which takes a bit of getting used to."
Other treatment options for prostate cancer include external radiotherapy and brachytherapy - where radioactive seeds are implanted in the prostate; hormone therapy and chemo therapy. Sometimes, therapies can be combined, eg surgery with radiotherapy. All these therapies are effective but also have side-effects.
"While the treatment outcomes with prostate cancer are effective, living with cancer is never easy. You go through the usual grieving phases of denial, anger and depression before eventually coming to terms with it. You just have to work your way through it. You've got no choice really"
"Family and friends are of course, very important for support, but they have to get on with their lives as well, so ultimately you are on your own. Dealing with the whole experience, from deciding on testing and treatment and then living your life afterwards, is basically your call."
Coming to terms with getting cancer is difficult, Paul says. "As with most things, you might brood about. It's your first thought on waking every morning."
"The Irish Cancer Society can help a lot with advice and support and it has a very good specialist nurse service. Another good resource is Men Against Cancer (MAC). Of great help to me was getting in touch with someone who had gone through the whole treatment process a year before I did. It really does make things easier to talk to someone who has experienced it."
One thing Paul doesn't think is very helpful for people with prostate cancer is the internet.
As a GP he is used to seeing patients who have sometiems overloaded themselves with conflicting internet data, and this generally doesn't do them much good. "In my case, I found it difficult to get unbiased information about my condition."
"I think the key message is you need to be very sure about going down the road of getting the PSA test done, because there may be serious consequences leading on from that."
Paul believes that general population screening for prostate cancer, such as the screening that is currently done for breast or cervical cancer, is not a good idea.
"Especially for older men, I don't think screening would be that beneficial, given that it is usually a slow-growing cancer that you can live with for a long time, and given that the testing and treatment are not exactly a walk in the park."
Paul believes however, that people who urinary have symptoms, eg frequency, pain or discomfort and those with a family history of prostate cancer, should get themselves checked out.
"It should be stressed however, that in my case, with a grade seven cancer, without treatment, I had a one in six chance of dying from the cancer within 10 years - that would have been in my mid to late 60s."
Paul is in no doubt that doctors usually make bad patients. "I shouldn't have done my own PSA for a start and I should have referred myself to a colleague. As patients, doctors hate losing control and entrusting their care to someone else. Colleagues often don't like treating fellow doctors and find it difficult to talk to them as patients."
"Patients are often surprised when doctors get sick themselves, as if there's some law against us getting sick. However, coming through a serious illness yourself can make you a better doctor and in particular a better listener with your patients."
If you are concerned about prostate cancer and would like to talk to someone, contact the National Cancer Helpline at 1800 200 700.
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