Heisenberg and Your Prostate

Uncertainty Principle:  A principle in quantum mechanics holding that increasing the accuracy of measurement of one observable quantity increases the uncertainty with which another conjugate quantity may be known.

Perhaps it is because I just got back from Albuquerque, a city which has become like a second home to me, that I have Heisenberg on my mind. For the one or two of you out there who are not “Breaking Bad” fans, “Heisenberg” is the name that mild mannered chemistry teacher Walter White assumes when he decides to manufacture pharmaceutical quality methamphetamine after being diagnosed with Stage III lung cancer. His motivation is to be able to leave his pregnant wife and son affected by cerebral palsy a little cash when he dies.  The evolution of Walter from upstanding high school teacher to ruthless drug lord unfolds over six seasons where moral ambiguity is the coin of the realm—in uncertainty principle terms, the more single mindedly he pursues his meth business, the fuzzier his personal ethics become.

Recently I have begun to think of the dilemma of PSA testing and the diagnosis and progression of prostate cancer in terms of the Heisenberg uncertainty principle.  Nowhere is this more apparent than in the case of men who have a rising PSA level post prostatectomy.  For many men faced with the choice of surgery versus radiation therapy, the selection revolves around the perception of certainty.  In medical school we are given the mantra, “To cut is to cure!”   Many patients choose surgery because of that perception—the ability of the surgeon after the procedure to say, “We got it all” and the satisfying thud of that post op PSA falling to zero.  Life is as it should be, the offending organ is gone, and the PSA is the definitive proof of cure.  In my own career I have pointed out countless times that if a man wants it black and white, cut and dried as it were, he may be more satisfied with the surgical option, since the slow fall in the PSA level post radiation therapy, with its attendant subtle blips and variations can be maddening to the patient, his family, and of course the attending physician.

But what of the patient whose PSA post prostatectomy does not fall to an undetectable level?  Or the patient whose PSA becomes unmeasurable, but months or years later starts to rise again?  On the one hand, our ability to measure serum PSA levels as a proxy for prostate cancer still lurking in the body has improved to the point of being able to measure values as small as hundredths of a nanogram per milliliter of blood.  We call this the supersensitive PSA assay and we accept this as proof that the cancer is there, somewhere, waiting to recur.  But what this supersensitive test cannot tell us is exactly WHERE those cancer cells are.  Neither bone scan, nor CAT scan, nor Prostascint imaging nor ultrasound is likely to give us the answer.  So what do we do?  As radiation oncologists we offer the patient the best we have, treatment to the “prostate bed”—the area where the prostate used to be—and sometimes the adjacent lymph nodes.  We know statistically that over a period of years, large groups of patients who were treated for their rising PSA with radiation do better than those who were not, but sadly this tells us nothing about the individual patient.  And the individual must decide for himself whether to take the leap of faith, and the side effects of one treatment compounded with another, that the cancer cells are still localized and that the radiation will kill them.

As a clinician treating patients with rising PSA’s post prostatectomy, I wait with bated breath for the first PSA after radiation to the prostate bed.  The patient is equally anxious—that stark simple but highly precise number is the measure by which we judge success or failure of the treatment.  But in focusing on the PSA, we often forget the obvious—that a number, even a highly precise number, is just that and nothing more.  What the patient will die from, and when, remains uncertain.  If I can help my patients remember that, and go and live their life with zest and satisfaction, then I have done them a real service.

When Age is a Relative Thing

I remember when I was a medical student and an elderly patient would be admitted to the surgical service through the emergency room with a bowel obstruction, or a lung cancer, or blockage in the coronary arteries so severe that only a coronary bypass could save him.   The students and residents would gather around the attending, and debate the merits of operating on the patient, or “keeping him comfortable”, ensuring certain death.  One of the things I remember hearing, typically from the mouths of those advocating for aggressive management was always, “But he’s a GOOD ninety!”  Meaning, the patient may have been ninety years old, but he looked younger, and had no competing medical problems, and had been living independently and enjoying life.  As I grew in my radiation oncology career, and medical students and residents would debate the same with me, one of the things I always try to remind them is, “There’s nothing like radiation and chemotherapy to turn a GOOD ninety into a BAD ninety really fast.”  It’s the truth.

So when I returned from my mini-vacation at the dog show in Palm Springs at the beginning of last week, the first thing I did was check my schedule to see if any of the patients who were seen in my absence were on the simulation list for treatment planning so I could review their history and physical exams.  I found one unfamiliar name, so I picked up his chart.  It turns out, this man is an 86 year old retired figure skater, still active as an international figure skating judge, who had recently been diagnosed with an early stage intermediate risk prostate cancer, Gleason grade of 3+4=7, PSA of 9.  He had come in under duress to see one of my partners because, you see, he didn’t WANT radiation therapy.  He wanted a prostatectomy.  Now, in my world, and in the world of my referring urologists, 86 year old men do not get prostatectomies, robotic or otherwise.  There is too much risk of fluctuation of blood pressure and bleeding, and consequently heart attack and stroke. Dr. Donald Skinner, retired Chairman of Urology at the University of Southern California used to say, “I won’t even operate on a 70 year old man, unless he brings his 90 year old father to the consultation with him.”  This patient’s choices were watchful waiting, now known as “active surveillance”, hormonal therapy, or radiation.  After a long discussion with my partner, he chose radiation therapy.

When I walked in the exam room to get the patient to sign a consent before we started, I was fully prepared to try to convince him that at his age, it wasn’t likely to make a difference in his overall life span to be treated for this early stage prostate cancer.  What I wasn’t prepared for was a man who looked twenty years younger than his stated age, in great condition, holding hands with his equally attractive wife, also a retired skater.  My speech about the treatment being unnecessary “at your age” went unsaid.  Instead, I gawked and said, “Ice dancing or pairs?”  From then the discussion veered from the upcoming Winter Olympics, and then to the fact that he grew up in Seattle and came to San Diego on vacation, whereupon he discovered that there was a place where it didn’t rain every day and decided to stay. He was twenty when he met his fifteen year old bride to be at a skating rink in Orange County.  He was tall, with an elegant physique. She was petite and a beginner. He smiled at her as he told me the story of the “best pick up line EVER!”  He found himself next to her at the edge of the rink and said, “What are you doing there, standing in a HOLE?”

Perhaps it was not the best pick up line ever. But his vivacity, vitality and joie de vivre certainly bought him a definitive course of intensity modulated radiation therapy.  After all, he’s a GOOD eighty six.

The Techno-Freak in Me

At home, I have trouble working the audio-visual system.  A few years ago, my husband bought a television set for our family room with a huge screen, for better sports and movie viewing.  Gradually components were added on—a surround sound system, the keyboard to stream video from Netflix, the standard DVD player, and, a gift from a movie loving friend who knows how much I like foreign language films, a DVD player that plays movies released only in Europe.  The composite system required, at one point, five or six different remote controls to run and I was hopeless until Mick at the meat counter informed me that you could buy a single remote controller by Logitech that could run EVERYTHING.  I invested in one at Best Buy, but I confess–I still have no clue how to work it.

It is a mystery to me why I cannot figure out how to work the television or the coffee maker, but the inner workings of linear accelerators and cyclotrons, and the generation of high energy X-ray, electron, and proton beams pose no problem.  Thirty two years ago, when I started in radiation oncology, our tool box was very limited—treatment planning systems were rudimentary and “two dimensional”—in other words we could only visualize and calculate the trajectory of a beam from each direction separately, and sum the total, in one cross sectional plane of a patient’s body. Two developments in the last generation changed all of that: three dimensional treatment planning, where the body is reconstructed from a series of CAT scan images, along with intensity modulated radiation therapy, where the beams can enter the body from 360 degrees of rotation where tungsten rods not only shield the normal structures from every direction but also enter the path of the beam to block the “overshoot” of tissues beyond the tumor. “Star Wars” technology met radiation therapy at the turn of the millennium.

The last ten years have brought a new revolution in radiation oncology—the advent of the proton center.  In November I had the opportunity to spend a full day at an orientation for the new Scripps Proton Therapy Center here in San Diego. Six years ago, I traveled to the existing proton facilities at Loma Linda, University of Florida, Massachusetts General Hospital and MD Anderson as part of a task force to determine the feasibility of my own institution building such a center. I was surprised at that point in time to discover that the technology of proton beam radiation therapy had not advanced since my old days at the Harvard Cyclotron in the early 1980’s. The opening of the new Scripps Center will change all that—for the first time a scanning “pencil beam” of high energy protons will be able to “dose paint” the radiation directly onto the exact shape of the tumor, delivering the fastest, most accurate and potentially the least toxic radiation therapy ever.

So what does this mean for patients in an era of cost reduction and intensive scrutiny of new technology?  Of the utmost importance, it means that more and more children with cancer will be treated with a method which will not only save their lives, but will significantly reduce the risk of secondary complications from the radiation.  In 2010, 465 children with cancer were treated with protons.  In 2012 this number rose to 695.  For the children who receive cranio-spinal radiation for brain and spinal cord tumors, this means a 7 to 12 fold reduction in secondary malignancies and a significant reduction in loss of IQ compared to standard radiation therapy.  For patients previously thought to have incurable cancers such as hepatocellular carcinoma, local control rates of up to 80% are being achieved.  For patients with brain or spinal cord or bone tumors in critical areas which abut sensitive normal tissues, it may mean the difference between sight and blindness, or ambulation versus paralysis.

The critics of proton beam therapy cite the fact that the majority of patients currently being treated with protons are prostate cancer patients, where as yet no real benefit has been shown in terms of survival or complications over intensity modulated radiation therapy. This may change as we select younger patients with more aggressive cancers for the treatment. In the meantime, I remain as excited by this technology as I was when I first followed the physicist into the cluttered old cyclotron building on the Harvard campus in 1982.  Next month the techno-freak in me will be privileged to participate in the most advanced radiation therapy the world has ever seen.

Thank you to Dr. Carl Rossi for the statistics provided in this entry.

I Am Easily Charmed

There has been some confusion around the office due to the fact that my partner became suddenly ill, and it was important that the patients on treatment be seen once a week.  In addition to my own patients, I had seen all of his three weeks ago while he was on vacation, so I had a working knowledge of most of them, their cancers and the problems they were having during treatment.  Still, there were new patients to be seen, simulated and treated and it seemed that the most logical division of labor was for me to see the new patients, and the substitute doctor to see the old patients, many of whom were close to the end of their treatments.  It seemed that way anyway.

So when my partner’s nurse asked me to see a prostate cancer patient belonging to my partner this morning, I asked, “Didn’t Dr. Substitute see him yesterday, as she was supposed to?”  Our nurse answered, “She tried, but he wanted to see you.  He remembered you from three weeks ago. He is at the end of treatment.”  I said, “Okay, just this one time, but I will NOT see him in follow up.  He can return to his urologist for follow up as long as his PSA normalizes.”  A moment later, I was in with the patient, a kindly elderly man who described not his side effects and symptoms, but the fact that yesterday he went to the San Diego Fair with his two daughters, and what a delight it was that he got to spend time with his adult daughters alone without his wife.  Apparently this is a yearly ritual. We spoke about the art exhibits, the rose growing competition, and of course, the fried food.  I thought to myself, “Maybe Dad would like to go to the Fair.” I exited the room twenty minutes later, proclaiming to the nurse, “Okay, I will see him ONE time in follow up.  Just ONE TIME!”  She smiled.

At the end of the day there was another.  Just started on treatment, this prostate cancer patient had missed his on treatment visit yesterday because Dr. Substitute had to leave.  The nurse warned, “He’s a bit chatty.”  I entered the room, whereupon he declared, “No cancer patient is truly cured.  I just hope I outlive my cancer.”  This was a challenge indeed.  Despite the fact that I was quite certain my partner had already had this conversation with the patient, I felt the urge—no, the COMPULSION—to tell this patient of the multitude who indeed I had cured over a thirty year career.  It was a long conversation.  We both enjoyed it, heartily.  I added another patient to my roster.

What is it with these prostate cancer patients?  We have a mutual admiration society.  And I hear that the word on the golf course is, I give the best “finger wave” in the business.  Just sayin’…..

Something Old, Something New

When I was a radiation oncology resident in Boston in the early 80’s, a few brilliant minds in physics and medicine came up with the notion that it would be a good idea to treat certain cancers with a beam of protons.  Protons are the positively charged particles which are created with a hydrogen atom is split into its component parts, a proton and an electron.  When accelerated towards a human being by means of a cyclotron, the proton has a unique characteristic compared to the regular X-ray beams we radiation oncologists use—it rolls into the body creating very little disturbance at the surface, comes to a stop at the tumor to do its damage, and unlike an X-ray, or photon as we say in the business, it does not exit the body leaving injured cells in its wake.  It just stops.   This makes proton radiation therapy ideal to treat children, where the entrance and exit doses of radiation can cause growth defects and trigger secondary malignancies years and years down the line.  But the first patients treated back at the old Harvard Cyclotron were not children—they were old men with advanced prostate cancer, where conventional therapy with the doses needed to control the disease had a high likelihood of rectal damage.  My job, as the resident, was to insert a balloon into the rectum of said patients, to separate the posterior rectal wall from the prostate gland.  Each day I would hitch a ride with our physicist over to the huge brick building which housed the cyclotron, insert and inflate the balloon, and wait while the patient was treated.  I didn’t mind a bit—the technology was new and exciting, and the physicist was very handsome.

Tonight, thirty years later, I toured the new proton facility in San Diego, where my university, along with other institutions will soon be allowed to treat patients.  The building itself is massive, over 100,000 square feet.  There are five gantries and treatment rooms, and once the facility is up to peak capacity, the cyclotron will run sixteen hours a day, treating over 2,000 new patients a year.  At 8 pm this evening, a team of six engineers was still hard at work in the control room, honing the precision of a beam which will be responsible for curing cancer, for saving lives.  Patients with every kind of cancer will be treated here, but in the end, the population which has lived the longest and has the economic wherewithal to seek out the best and the latest treatments—our prostate cancer patients—will be the bread and butter volume income supporting the treatment of the youngest and most vulnerable of our patients, the pediatric cancer patients.  As one of my old colleagues who treats the kids at Massachusetts General Hospital said to me a few years back, “Finally we have protons in the clinic, and I can sleep again at night, not worrying about the horrible late effects of radiation on my pediatric patients.”

Many things have changed about the way protons are produced and utilized in radiation therapy over the thirty years since I was a resident, but some things remain the same—as we were touring, one of the physicians mentioned that rectal balloons are still used to stabilize the prostate away from the rectum during prostate cancer treatment.  I smiled inwardly and thought to myself, “Yes, but this time it won’t be ME putting the balloons in.”   San Diego is about to join a small cadre of cities that boast the best, most advanced and safest radiation technology available to cancer patients. And I say, “Long live the Brotherhood of the Balloon!”

The Things They Put on Their Skin

When patients start their radiation therapy, one of the side effects that we tell them to look for is a skin reaction.  Depending on the area of the body treated, and the dose given, the skin reaction at the end of treatment ranges anywhere from a mild sunburned look all the way to what we call moist desquamation, where the skin literally sloughs off, yet ultimately heals without even a scar. My nurse spends a great deal of time educating patients about taking care of their skin.  The instructions are simple—do not get a sunburn on irradiated skin (breast and prostate cancer patients take note:  NO NUDE SUNBATHING!), do not use perfumes or deodorants on irradiated skin, do not use harsh soaps or detergents, and DO use a fragrance free product that helps the skin retain moisture.  The two tried and true products which have been on the market for over thirty years are Aquaphor ointment, and Eucerin cream (which, for the record, is just Aquaphor whipped like egg whites turning into meringue!)  When I was a resident, we had giant vats of the stuff stored in a back room and when a patient would start his treatment, my job was to go and get a sterile urine cup, and a sterile tongue depressor and scoop the ointment or cream out with the tongue depressor, fill the cup, put the top on and voila,  hand it to the patient. Simple, and very cheap.

It seems that there is now a cottage industry which provides skin care products for radiation therapy patients.  Many of the concoctions are “all natural” and as a result, some are very expensive.   A few are made by the big pharmaceutical companies and tout ingredients with chemical names that only a terrorist would recognize. One of the “natural” creams made locally contains aloe, lavender and calendula—it was light, smoothed on well, and was very popular with me and my patients until it came to my attention that it was made and marketed by a competing radiation oncology group. This seemed a bit devious and self-serving to me—make money off treating the cancer, then make more money off of selling skin care products.  I dropped it from our “line up” and went back to the old tried and true.

Despite getting very explicit written instructions at the beginning of treatment along with a few samples, I am always completely astounded by the variety of unprescribed substances that patients find themselves compelled to put on their skin.  Just in the last few months, I’ve had grown men who fought in wars extolling the virtues of jojoba oil, coconut oil, crisco and almond butter.  It makes me wonder if the discovery of the healing properties of these substances was actually a by-product of a different sort of usage!  And the women too get into the act—women who think nothing of spending four hundred dollars for a small vial of a wrinkle cream waltz in and tell me that they used rubbing alcohol on their skin reaction, or betadine, not to mention products from their spice rack including turmeric and cayenne pepper.  And these are the things they will admit to!

Let me tell you two little secrets.  First, there is NOTHING that will prevent a radiation skin reaction.  So don’t waste a lot of money trying.  And second, no matter how bad it gets, it will heal quickly.  Without a scar.  So use your Aquaphor, and please, try not to scratch!

Showing a Little Restraint

 For Jack Oberdorf

In 1986, Hybritech released its first commercially available screening test for prostate cancer– the PSA test—triggering a torrent of newly diagnosed cases of this disease, and in turn, a flood of new technology to treat it, including the Da Vinci surgical robot, and proton beam radiation therapy.  In recent years, however, the medical community has come under significant scrutiny for the overtreatment of this cancer, which in most cases, men “live with” and don’t “die of.”  Although its report remains highly controversial, in May of 2012 the United States Preventive Services Task Force gave the PSA test a “D” rating, meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.  My friend Jackie Widen’s story illustrates the point better than I ever could.  For you, from Jackie.

<<On Sunday March 19, 1995 my parents played their weekly round of golf with their “regular Sunday group” – about a dozen golfing couples who all lived in a gated community just north of Houston.  Mom and Dad had retired in 1984, moved from their suburban home in Houston and built their dream house in this peaceful golf course community.  They played the game they loved 5 days a week, traveled on golf getaways and centered their social lives around this colorful group of friends.  Sunday play days were followed by burgers and beer at the Clubhouse.  This particular Sunday gathering however was special– a cheerful send-off to my Dad – because on Tuesday he was scheduled to have a prostate cancer “procedure” done at Methodist Hospital in Houston.  Toasts were made for him to hurry up and get home because the next big golfing trip was already being planned. Exactly one week later these same men were dressed in their Sunday best, standing shoulder to shoulder in the first pew of our Church, honorary pall bearers at my Dad’s funeral.  What a week.

A couple of months prior my Dad had dutifully had his annual physical.  Most men avoid and procrastinate about doctor appointments, but he always paid attention to these check-ups.  At age 75 he had some predictable aches and pains, but nothing really serous.  His PSA had risen to a concerning level after having been monitored the year prior, and after consults with his urologist it was decided that yes this was cancer and yes it required more than a “watch and see” choice.  The urologist scheduled an appointment where my parents were presented with the options.  Apparently having the prostate removed was not something either of them wanted, so they agreed that having radioactive “golden” seeds implanted with follow-up radiation was their preferred course of action.  I did not know about this until the week prior to his surgery.  Cancer is a hideous word, but combining prostate in the discussion with your daughter makes things rather delicate.  My mom would later bemoan the fact that I didn’t accompany them to the Discussion/Assessment Appointment.  But because there were of course sexual consequences being discussed for each procedure, my Dad would not have felt comfortable with his eldest daughter in the room.

Mom stayed with us in Houston while Dad had his surgery.  Things went well, and relief was palpable.  Wednesday evening after we visited him in his room, my sister and my mother and I celebrated with dinner and champagne at a nearby restaurant.  The phone rang at 4:00 AM – a doctor who I did not know was babbling that he was very sorry, but my Dad had passed away.  I asked a few questions but then immediately called my sister who lived nearby to come over –we had to get to the hospital.  As I stood in my room, in my nightgown, shock ran through my body.  I knew it was this moment was the last remnant of peace my mother would ever know.  I will never forget walking upstairs, holding my mother’s hands, and telling her that Dad was gone.  Even my children remember the primal scream that followed.  I remember at the hospital that we were all dressed in the same clothing that we had worn the night prior.  I remember the nurses quietly crying at the station.  One of the nurses told me that most of their patients were cranky and difficult but my Dad was pleasant and polite even though they knew he was uncomfortable and scared.  I remember going into the room and seeing my Dad for the final time, quiet and still, cool.  I remember kissing him good-bye.  A bit later I had to go down and formally pick up his personal belongings in a bag marked with a “Personal Effects” tag.  Horrible, miserable, gut wrenching.

It is almost impossible to describe the grief that rippled through my family.  My mother was lost. My parents were that special type of couple; two sides to a coin I always described, and now she had lost her anchor.  Sorrow hurts almost like a physical knife, tearing your heart into pieces and you wonder if the pain might kill you.  And thinking/hoping it might.  It was that awful.  As it turned out my dad had likely suffered either a heart attack or an aneurysm after the surgery. I declined an autopsy, I couldn’t handle it.  Later when the dust settled I wish I would have agreed as I will never truly know what happened.  What I learned later was that he was smoking secretly without my mother knowing – and of course when the doctor asked in front of her “Are you a smoker?” he fibbed and said No.  Did this play a role?  I don’t know.

It’s been more than 15 years, but that event has forever changed my life.  I was told by one friend how lucky I was to grieve so much, and I thought she was crazy.  But you see, she explained, you must have had a very special father to grieve so deeply.  Some of us are not that fortunate.   She was absolutely right on that score.   I have replayed this over and over in my mind since he died.  Was the surgery necessary?  If the doctor had known he was a smoker would he have proceeded?  If left unchecked would the cancer have spread, or would he have had more active years?  I will never know.  But this I do know – in some ways my Dad got the best deal.  He lived life to its fullest and went from a round of golf one Sunday to meeting his Maker the next.   He went out at 100% and loved his life until that last breath.

I still have that Personal Effects tag on my bulletin board.  Love you, Dad.>>

In an email to me that accompanied this story, Jackie wrote “There is so much more to this story, of a daughter’s love and of the loss of the little things that you take for granted until they are gone.  When I went off to SMU it was the first birthday I had ever been away from home.  I was taking finals still during December so he called me and said “Do you know what I got 18 years ago today, at 6:30AM?  The most wonderful daughter in the world.  Happy Birthday honey”.  He continued doing that every year because I was either at college or then I got married in 1974 and moved to San Antonio.  Regardless, I was never at home at 6:30 AM on my birthday ever again, so he would make this phone call a ritual.  December 18, 1995 I didn’t get a call.”

When I was at ASTRO in Boston, I had a chance to chat briefly with Dr. Anthony Zeitman, past president of the society, the head of genito-urinary radiation oncology at Massachusetts General Hospital and a true leader in our field.  He said that he is recommending “active surveillance” (the new term for “watchful waiting”) for most of his patients with prostate cancer now, rather than treatment.  I was with my best friend from residency who knows Dr. Zeitman well.  She asked him, “Do you get PSA testing?”  His answer—“No.”


A Room With a View

Space is always at a premium in any bustling medical office, and my department is no exception.  In the four years that we’ve been open, the patient volume has nearly doubled.  We’ve added a second physician, a second nurse and several additional radiation therapists.  My office manager does financial counseling in her tiny office that is more like a closet, and my physicist has doubled up with his own physics resident. Now we have a rad onc resident rotating with us and we’ve had medical students nearly continuously since July, both welcome additions to our daily routine but our “zen” is being stretched a bit thin. The question has come up—where do we put everyone?  As we walk the hallways looking for walls to knock down and more closets to turn into offices, all eyes turn to me, and it is clear that the vultures are circling.  Everyone wants my consultation room!

Long ago my mentors taught me two important concepts.  First, that it is the very first meeting with the patient and the family that gives them the lasting impression of the department and the doctor—first impressions do count.  Second, that talk about cancer and radiation therapy is threatening and scary and is best served up when the patient is fully clothed, in a comfortable chair, preferably in a room with a window.  Not that anyone wants to jump out of course, but somehow the sunlight pouring in makes patients feel like there is an escape hatch from that claustrophobic feeling they have when they suddenly realize that their lives have been forever altered.  As a consequence, all of the departments that I have built or directed have had a room, simply and comfortably furnished, where the patient and his family or friends are taken for the initial part of the consultation.   My consultation room has a couch, a coffee table and two large armchairs .  Landscape photos line the walls and the picture books on the coffee table are mine.  The large window faces south, and the sun streams in all day.

By the time we move to the actual exam room, there is an ease, and a familiarity, like we’ve all just met some old friends over coffee and the undressing and gowning for the physical exam goes smoothly and quickly. From our “customer satisfaction surveys” I would venture to say that most patients leave a lot happier than they enter.  So as we walk the halls looking for more space for our growing department, I tell my vultures to back off—that the large sunny consultation room is sacred and it is not going to go away because it is a neutral space between the fear of the waiting room and the vulnerability of the exam room. It is the space that makes my patients feel like they are human beings, not specimens, not tumors, and not cattle waiting to be prodded down the chute to an uncertain fate.

Now all that being said, there are two little issues I’d like to raise.  First of all, whoever took my coffee table book containing lovely photographs of our local community, could you PLEASE bring it back?  And second, when I sank into that armchair on that warm summer afternoon, I did not, I repeat DID NOT fall asleep as I was explaining radiation therapy for prostate cancer to you.  You only imagined that I fell asleep.  And it was only for a minute.  Really.

What Does Your Mommy Do For a Living?

The year was 1997, and my youngest was having his sixth birthday.  What he wanted for his party was for me to take him and his friends to the local amusement park.  They would have free access to the rides, swarm the arcade, play on the ersatz beach with its immense man made waves, and just generally be the hooligans that little boys are.  The reward at the end of the afternoon was a pizza party complete with cake and ice cream, provided by the park. All I had to do was drive seven of these fine young cannibals in my big Suburban and survive the trip.  So amidst jovial punches punctuated by squeals of pain and newly learned curses muttered under peanut butter breath, we set off.

As the boys settled in for the long drive, the physical combat waned while the verbal combat was just warming up.  The six year olds were actively engaged in a game of “mine is bigger than yours”.  Only they weren’t talking about their sexual prowess—that would be years in the future.  They were talking about everything else—who had the biggest bedroom, who had the biggest house, who had the biggest dog, and ultimately, whose Daddy had the best job and made the most money.  As the competition escalated, my son grew quiet and thoughtful.  As I glanced in the rear view mirror, I could almost see the cogs turning in his brain.  And then, the zinger!  He pulled himself forward in his seat, and announced, with great authority: “My Mommy makes her living putting her finger up men’s assholes!”.  Let’s just say that that was a show stopper.

Yes, I treat prostate cancer.  I have ALWAYS been interested in this disease, and several of my first research papers dealt with novel radiation sensitizing drugs for locally advanced prostate cancer.  Early on in my career, I worried and fretted about how to best “approach” (both literally and figuratively), these men who were more than twice my age and who were definitely NOT used to having a young female physician performing, shall we say, a rather delicate exam.  I discovered that the trick was putting them at ease with me as a person first, giving them time to tell me about themselves, making their wives comfortable in a consultation room, not an exam room.  And finally, joking with them that my fingers were “oh so very small, compared to those giant urologist hands!”  It was a cakewalk after that.

Years and years went by, and I had no problems whatsoever convincing these sometimes grumpy old men that it was just fine to have a female physician.  But late last year, despite all my efforts to build my reputation with patients and urologists alike, there was a problem.  My secretary told me that a prostate cancer patient had been referred, and his wife was insisting that he would ONLY see a male physician.  She said he was adamant—NO LADY DOCTORS!   Now this was a touchy situation—at the time, I was the ONLY physician at my facility, and his insurance dictated that there were no alternatives.  Once she understood that it was me, or no one, she accepted the appointment.

The day came for the consultation, and I escorted the patient and his wife into our consultation room, a lovely room outfitted with a couch, a coffee table and two chairs, a living room away from home.  We discussed his case at length, and after fully assessing his symptoms, we left his wife in the consult room and went into the exam room for his physical exam.   I knew that he would be nervous, despite the fact that he didn’t LOOK nervous.  In an effort to put him at ease, I said, “Mr. S, I know that you didn’t want to be examined and treated by a female physician, so I want to assure you that I will be very gentle with you and very discrete.”  His blue eyes crinkled and he looked at me sideways, and a low chuckle  emerged from a bright smile.  He said, “Who told you THAT?”  I said, “Well, your wife, sir.”  At that point he was laughing so loud his eyes welled up with tears.  He exclaimed, “That wasn’t ME who didn’t want to see a woman doctor, that was my JEALOUS WIFE!”   This man was 80 years old, and his wife not a day younger.

I don’t worry about these things anymore.  I know my patients love me for who I am.  And the word is out on golf courses all over town—I give the best “finger wave” in the business!

Blame it on the radiation!

“Blame It On The Bossa Nova”

(Barry Mann and Cynthia Weil)


I was at a dance when he caught my eye Standin’ all alone lookin’ sad and shy
We began to dance, swaying’ to and fro
And soon I knew I’d never let him go

Blame it on the bossa nova with its magic spell
Blame it on the bossa nova that he did so well
Oh, it all began with just one little dance
But then it ended up a big romance
Blame it on the bossa nova
The dance of love

(Now was it the moon?)
No, no, the bossa nova
(Or the stars above?)
No, no, the bossa nova
(Now was it the tune?)
Yeah, yeah, the bossa nova
(The dance of love)

Now I’m glad to say I’m his bride to be
And we’re gonna raise a family
And when our kids ask how it came about
I’m gonna say to them without a doubt

Blame it on the bossa nova with its magic spell
Blame it on the bossa nova that he did so well
Oh, it all began with just one little dance
But then it ended up a big romance
Blame it on the bossa nova
The dance of love

(Now was it the moon?)
No, no, the bossa nova
(Or the stars above?)
No, no, the bossa nova
(Now was it the tune? )
Yeah, yeah, the bossa nova
(The dance of love)(Now was it the moon?)
No, no, the bossa nova
(Or the stars above ?)

No, no, the bossa nova  (Fade)

What drives me really crazy is that if a patient has radiation, everything BAD that happens to them for the rest of their lives MUST be due to the radiation.  And it’s not just the patients that think that’s true.  It’s their referring physicians, the emergency room physicians they see in five years when they have their diverticulitis, their hair dressers, their dentists….the  list goes on and ON.

Here is my own version of this song:  you can Karaoke it but you’ll have to provide the music!

I was going for my cleaning and the dentist caught my eye.

She said, your gums are bad and your mouth is really dry.

She began to use that instrument that scrapes and makes you bleed.

I didn’t have the courage to tell her t’was my prostate got those seeds!

Blame it on the radiation!  With the killing rays.

Blame it on the radiation!  T’will be the end of days.

Oh it all began, with the big “C” word

But it ended up—Let me tell you life’s absurd!

Blame it on the radiation!   I’m in nuclear distress!

Was it my heart? (No, no, the radiation!)

I’m falling apart (Yes, yes, the radiation!)

Was it my brain? (No, no, the radiation!)

Am I insane?  (Yes, yes, the radiation!)

The rays of DOOM!

Now, I’m glad to say, that I am cured.

And I’m gonna write my blog, and make my feelings heard.

But when my friends ask how it came about,

I will be the first to shout:

It’s the acai berries, the magic mushrooms, have no doubt!

But any complications—well,

Blame it on the RADIATION!

The rays of DOOM!


My latest case was a man who has a very curable prostate cancer.  He’s a sweet guy, but lives alone and maybe his hygiene isn’t perfect but he tries.  On the day of his treatment planning, we photographed the area to be treated—it’s routine to do so.  My therapists noticed he had a very ugly rash on his anterior abdomen.  When he started his radiation treatments a week later, the rash was worse. I do not have the ability to look for fungal or bacterial infections in my outpatient clinic.  So I sent him back to his primary care physician for the appropriate studies to be done to determine the best treatment for this rash.

The primary care doc told the patient that his skin rash was DEFINITELY a radiation reaction. Would I send a patient with a radiation reaction back to his primary care doctor for management?  NO, I WOULD NOT! I would manage it myself, of course. This patient had only had one or two treatments.   I sent the primary care doctor the photographs from the treatment planning session with a note saying that this was not a radiation reaction—he had this rash BEFORE he had radiaton.  So far, I have not heard back from him.  But the steroids are working…..

Blame it on the radiation!  A song I know very well. Apologies to Mann and Weil!