A Not So Peculiar Dilemma

Christopher Lukas Health Guide
  • Since writing about Zack and Paul last week, things have changed.

    If you recall, I said that Paul was holding off on doing anything (his PSA had actually dropped with time), while Zack had decided on seed implantation (his PSA had risen by 4 over a year, and he had a biopsy with a Gleason of 6.) I got a phone call from his wife, however, which put a different slant on things.

    It seems that Zack’s oncologist (to whom his urologist had referred him) thought there were reasons to give Zack hormones, then external beam radiation, and then seed implantation. Zack’s wife wanted me to explain why the doctor wanted to do that.
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    I said that I had no way of knowing what was in the cancer specialist’s mind, but that I did know that oncologists suggest hormones when a tumor is particularly large. They can shrink the tumor with the hormones, making it easier to treat with radiation. If you radiate a large tumor, the likelihood is that you may hit other organs or, especially, the urinary tract or epididymis. Impotence or incontinence can result.

    But I didn’t understand why both seeds and external radiation were needed. I suggested Zack and his wife press the doctor for an explanation and get a second opinion from an oncologist at another institution. A day later, Zack told me that his doctor had said that the tumor was occupying almost all of one quadrant of his prostate, and therefore needed to be shrunk. I never got a clear explanation of the need for both kinds of radiation.

    I thought back to my own prostate cancer and the radiation treatment I got. I, too, had a Gleason of six. I, too, had a large quadrant-filling tumor. Both Zack and I, therefore, were at Stage II – cancer entirely contained within the gland, but with a Gleason higher than 2. So, why did I receive only external radiation for 40 days? Why was that enough treatment for me but not for Zack.

    The answer may lie not only in a) caution on the part of the oncologists; and b) differences in the specific configuration of Zack’s tumor, but differences in training and philosophy.

    There is a dynamite institution at Dartmouth Medical School, called The Dartmouth Atlas of Health Care (www.dartmouthatlas.org) which allows health care consumers (that’s all of us) and medical professionals to see what kinds of treatment are most common at different institutions in different states. The results are quite astounding. In Washington State, for instance, a particular hospital does lots of back operations. In Los Angeles, the same ailments are treated with medications. In Chicago, Boston, and New York, one hospital may do out-patient surgery, while another insists on the identical operation being done in an overnight stay. Empty beds, training of physicians, the presence of an older (or younger) staff – all lead to different philosophies and different practices of the same kind of ailment. Go figure!

    So, Zack will go to a different hospital in Manhattan, consult with a different oncologists, and I’ll report on the progress of this case in the next week or so.
Published On: August 15, 2006