December 23, 2024 • 38 mins
In this episode of Q&A with Dr. K, Dr. Doug Kuntzweiler takes us on his personal journey of being diagnosed with and getting treated for prostate cancer. With 1 in 8 men being diagnosed with prostate cancer at some point in their lives, and with it being the second leading cause of cancer death for men, get the benefit of both Dr. K's personal experience and expert professional knowledge about what the prostate is, what puts someone at risk for prostate cancer and the screening and treatment options.
If you have a question for Dr. K, email QandAwithDrK@mpqhf.org. Your question will remain anonymous.
Additional resources for this episode
American Cancer Society - Information and decision-making assistance: https://www.cancer.org/cancer/types/prostate-cancer.html
American Society of Clinical Oncology - https://society.asco.org/news-initiatives/current-initiatives/geriatric-oncology/specific-cancer-types/prostate-cancer
National Cancer Institute - Overview, screening and treatment information: https://www.cancer.gov/types/prostate
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Beth Brown (00:00):
[Music] Welcome to Q&A with Dr. K, a podcast by
Mountain Pacific Quality Health,where we sit down with Dr. Doug
Kuntzweiler and get your healthquestions answered, because on
(00:21):
Q&A with Dr. K, the doctor isalways in,
Hi, everybody. This is BethBrown, your host. And with us,
as always, is Dr. DougKuntzweiler, our chief medical
officer at Mountain Pacific, andwe appreciate your time being
(00:45):
here again, Dr. K to answer somequestions about prostate cancer.
So here are the two questionswe're going to focus on today,
but of course, we're going tosprinkle some others in there as
well, just to get a clearunderstanding what we really are
talking about. But the questionsare, what exactly is the
prostate, and what are the prosand cons of being screened for
prostate cancer? So let's startwith that first question, what
(01:08):
exactly is the prostate and whatdoes it do?
Dr. Doug Kuntzweiler (01:11):
Well, the prostate is a gland that only
males have. It is about the sizeof a walnut, and it sits right
underneath the bladder. Now theurethra, the tube that runs from
the bladder through the penis tothe outside world that empties
urine from the bladder, runsright through the center of the
prostate, and your colon sitsjust right behind it, so that
(01:36):
kind of helps to orient. If youare sitting down, you're kind of
sitting right on top of yourprostate. And in fact, people
who do long distance bicyclingoftentimes will get their
prostate irritated, becausethat's kind of, you're sitting
right on top of that. So that'swhere it's at. That's about what
size it is. Its function is tomake the fluid that sperm swim
(02:00):
around in. We call that semen.
The sperm, you know, have alittle flagella, sort of a
little whip on the end of it,and they whip that back and
forth, and that's how they movearound and try to find an ovum
to fertilize, an egg tofertilize, but they have to have
a fluid to swim in, and that'swhat the prostate does. That
fluid also provides nourishmentfor the sperm, because they
(02:22):
might have several hours ontheir journey to find an egg,
and they would die if theydidn't have the semen fluid to
support them. So that's where itis and what it is.
Beth Brown (02:35):
Got it - very important part of reproduction
for all of us. And so then whenit comes to prostate cancer,
then, who is at risk fordeveloping prostate cancer?
Dr. Doug Kuntzweiler (02:46):
The biggest risk factor is age, and
what cancer is - Generally,cancer is uncontrolled growth of
cells, and that in almost everymale at some point, usually late
in life, 70s, 80s, they willdevelop an area of cancer
something like 80% of autopsieswill show that there is some
(03:09):
cancer cells in the prostate, ifyou live long enough. Now, when
we talk about how common is it,it's the second leading cause of
cancer in males, second only tolung cancer. So it is actually
very common, but because ittends to grow slowly, and
because it tends to be slow tospread, it oftentimes doesn't
(03:31):
really cause any harm, becausemen tend to die of something
else before the cancer reallyhas a chance to impact them. But
unfortunately, that's notuniversally true, and it does
cause about 35,000 deathsannually in the United States.
So it's common. It often doesn'tcause any trouble, but it is
(03:52):
also responsible for significantnumber of deaths.
Beth Brown (03:55):
So it's one of those sneaky cancers? It doesn't
really have symptoms? Or couldsomebody develop symptoms to
indicate they might haveprostate cancer?
Dr. Doug Kuntzweiler (04:04):
Yeah, that's one of the problems with
it is, as it tends to not have alot of symptoms early on. Now,
as men age, somewhere around,typically, their late 40s or
50s, the prostate glandenlarges, and that probably
happens because of hormonalchanges. But that's pretty close
to universal. More than half ofall men develop an enlarged
(04:26):
prostate. We call that benignprostatic hypertrophy, Latin
words that just mean enlargementof the prostate. When it
enlarges, then because of itsposition, wrapped around the
urethra, like we talked about,it makes it difficult to empty
the bladder, and so the symptomsof that are men have to urinate
frequently. Oftentimes, theyhave to get up at night,
(04:48):
sometimes more than once,sometimes a couple of times
during the night, to empty theirbladder, because they're never
emptying it completely. And thensometimes they will get a sudden
urge to urinate because thebladder's being distended as
being, you know, full all thetime. You can see blood in the
urine, but you can see that withbenign problems, too. So usually
(05:11):
there's not a lot of pain,unless the cancer metastasizes,
and metastasizing means that ithas spread to other organs.
Every cancer has a typicalpattern of spread, and prostate
cancer likes to go to bone. Soif you have metastatic cancer,
typically what you have issevere bone pain. It likes to go
(05:32):
to the pelvis bones, the hips,ribs and the spinal column. If
that's how it first presents,usually things are bad. The
cancer has already spread ifyou've got bone pain, and once
it spreads, and we call thatstage four, if it goes to
another organ, like bone orliver or lung, but once it
(05:54):
spreads, it it really is prettymuch not curable. There are
treatments that help, but beingcured of it pretty much is not
possible once it is spread. Soit's a sneaky disease that way.
Oftentimes it has no symptomsuntil it spreads, and then it
has bad symptoms, and theoutcome is often not good. Which
(06:15):
brings us to screening.
Beth Brown (06:17):
Yeah, and I do want to talk about screening, since
it sounds like that's going tobe a key part in identifying it.
But before we talk about that,do we know what causes prostate
cancer? And on the other side ofthe coin, if we do have some
idea, do we know how to preventprostate cancer?
Dr. Doug Kuntzweiler (06:33):
No and no.
Beth Brown (06:34):
Oh shoot, that's a bad coin. Ok.
Dr. Doug Kuntzweiler (06:38):
We we don't know exactly what causes
it. We do know that there candefinitely be a genetic
component. So if in your familyhistory there are people who
have had cancer, and pretty muchany kind of cancer, breast
cancer, cancer of the bladder,cancer of the liver, pretty much
anything, it raises your risk ofhaving prostate cancer. And
(06:58):
certainly if in your familythere are males who have had
prostate cancer, then your riskgoes up quite a bit, especially
first degree relatives, whichwould be a parent, a sibling or
a grandparent. It's also morecommon in black men. There are
probably other risk factors,just like there are for all of
the cancers, and probably theusual suspects, alcohol and
smoking would probably be thetwo most common, maybe sedentary
(07:22):
lifestyle maybe a diet with alot of processed foods, but we
don't know any of that for sure,but, but there certainly can be
genetic components,family-related components, and
so you know you, as we've talkedabout in other episodes, you
should find out your familyhistory and relay that to your
primary caregiver, because youmay be at increased risk. And
(07:42):
what that means is you mightneed screening, and you might
need it at an earlier age thanif you didn't have those risk
factors.
Beth Brown (07:49):
Okay, so good. You brought up screening again.
Let's talk about that. So whoshould get screened for prostate
cancer? You talked about peoplewho might be at risk. When does
screening start, and what doesthat look like?
Dr. Doug Kuntzweiler (08:01):
Well, that's very controversial, and
I'm going to just relay my ownstory, because I had prostate
cancer, and so I went throughthis, actually, fairly recently.
Screening is difficult, becausewe don't have a really good
screen. The best thing we haveright now is called PSA. PSA
stands for prostatic specificantigen, and it's a blood test.
(08:26):
It detects a protein that ispresent in the prostate, and it
can go into the bloodstream, andthen we can detect that with the
blood test. Lots of things willraise your PSA level. Riding a
bicycle, for instance, willraise it. Having benign prostate
enlargement can raise it, anytype of irritation of the
(08:48):
prostate. And the prostate,because of where it's at, is
somewhat prone to infection.
Bacteria can sneak in throughthe urethra and find their way
to the prostate and causeprostatitis, which means an
infection and inflammation ofprostate, so that can raise it.
So there aren't great guidelinesfor when your PSA level
indicates that you might havecancer. It tends to go up as you
(09:10):
age also, but it's the bestscreening tool we have now. Some
people say you shouldn't screenanybody 70 years of age or
older, because even if it'selevated, they're probably going
to die of something else,because prostate cancer tends to
be slow growing and slow tospread. But as we talked about,
if you're one of these peoplewho has a risk factor, you might
(09:31):
want to start getting screenedat age 45. Some people say start
at age 40. Some people say 50.
It really is kind of all overthe map, which usually means we
just don't know for sure. Myadvice is, if you have a family
history of prostate cancer, oryou have a family history of any
(09:51):
type of cancer, I think youshould talk to your primary
caregiver and see about gettinga PSA test. And I would, I would
say, do that at age 40, err onthe safe side. Once, once you've
had the test, then it's a matterof, how do you interpret it?
Now, in my situation, I think Istarted screening probably about
(10:12):
10 years ago, but it was sort ofintermittent, like every two
years they would check a PSA,and it was always less than
four, and four is sort of a cutoff. If it's less than four,
your chances of having prostatecancer are fairly slim. If it's
less than one, there's verylittle chance that you have
cancer. But if it's between oneand four, there's a small
(10:33):
chance. If it goes above four,then your risk of having cancer
increases. If it goes above 10,your chances are about 50/50.
About half of the people whohave levels of 10 or above will
have cancer. So mine was alwaysunder four, but it was going up
every time it was checked, andthat seems to be a risk factor
(10:57):
as well. It was still withinnormal limits. I think my last
one was 3.98 so it was stillunder four, but had it had
started out at about 1.2 and soI had it tested maybe four times
over those 10 years, and it wassteadily increasing.
Serendipitously, I was seeing aurologist because I'd had kidney
stones, and I had to have aprocedure to remove the kidney
(11:20):
stones, and it was a urologistwho did that. I get my health
care from the VA system. And soI saw a urologist at Fort
Harrison here in Helena, and shetook my stones out of my kidney,
and then she noticed that my PSAwas steadily rising, and she
offered to do a digital rectalexam. Nobody really wants that
(11:43):
exam. It involves thepractitioner putting their
finger in your bottom andfeeling through the colon for
the prostate. And you can onlyfeel the back part of the
prostate, but that's also wherecancers most commonly arise, and
it's not a very precise exam, asyou might imagine, because
you're feeling through the wallof the colon, but if you are
(12:05):
experienced, you've done a lotof these exams, if you find
something that is suspicious,and that would typically be a
hard nodule, then that needs tobe investigated. And so she did
the digital rectal exam, and shetold me there's a suspicious
area. So the next step is,typically, then to do imaging.
And the imaging that works thebest is an MRI. It used to be
(12:28):
when MRIs first came out incommon usage, about 25 years or
so ago. They weren't verypowerful, and they didn't really
image the prostate very well,and so they weren't helpful. But
like everything else inmedicine, MRIs have gotten more
and more sophisticated and moreand more powerful. So now, if
you have an MRI with ahigh-field strength, it images
(12:50):
the prostate pretty well, andthey give you contrast through
an IV, and the contrast is takenup in areas that have increased
blood supply, and that's onething that's fairly
characteristic of all cancers.
They are abnormal cells that aregrowing quickly, and to support
that growth, they have a richblood supply. So when you see a
cluster of blood vessels, that'sthat's very suspicious. Now, I'd
(13:12):
never had an MRI before. I'd hadCT scans for my kidney stones.
CT scan is a breeze. That's likejust laying down on your bed.
The MRI, they put you in alittle tube that you barely fit
in. And if you have any sense ofclaustrophobia at all, you
should demand that they sedateyou, at least give you something
(13:34):
to kind of take the edge off. Ididn't think I had
claustrophobia, but I did notlike the MRI. It's very close
quarters, and to image theprostate, it's a long procedure.
It's 45 minutes, and it's veryloud. There are some alarming
bangs that go on that soundslike you're in a garbage can
(13:55):
with somebody beating on it witha hammer. It's a very unpleasant
exam, and they gave meheadphones, but they didn't go
loud enough. So at any rate, Itolerated it. But I would just
say, if you're at the stagewhere an MRI is offered, take
it, because it's a great way toimage the prostate, but ask for
sedation if you think you'regoing to have trouble. So what
(14:17):
the MRI showed was an area thatlooked like it probably was
prostate cancer, and it wasmostly on the left side of the
prostate. Now, if there is aquestion of whether or not
there's a cancer, the answer isto get a sample of it and have a
pathologist look at it under amicroscope. You have to have a
biopsy. So the biopsy is not alot of fun either. They have a
(14:40):
skinny needle that when itpasses into tissue, it gets a
core sample that is some of thetissue goes up in, stays inside
the needle, and then thepathologist can look at those
samples. As you might expect,they do it the same way they do
the digital rectal exam. They gothrough the rectum, and they
have these needles that aretriggered by a spring. They're
(15:02):
spring loaded, and they take 10to 12 samples. She took 12
samples. They numb the area upfirst. It's not horrible, but
it's it's kind of unpleasant.
But then you've got tissue tolook at. So the pathologist
looks at this tissue and hegrades it. This is called the
Gleason score, named after theguy who developed it. So the
(15:26):
score reflects how abnormal thecells are and what their
architecture is. That is, howare they organized, and then
also what percentage of thesample are cancer cells. And the
Gleason score runs from one to10. If you have a score of six
or less, those are verybenign-acting tumors, and those
(15:51):
are the kind that you might notwant to have anything done for
depending on your age. If you're75 or 80 years old, and your
Gleason score comes out six orlower, that cancer is probably
never going to cause you anytrouble, and it can just be
watched. If your score is sevenor above, that's a bit different
story. And the higher the score,the worse things are. My score
(16:14):
was a seven, so I was sort ofright on the cusp of where I
should consider treatment. I'm73 years old now. I'm in
relatively good health, though,for 73. I walk every day, I lift
weights, I'm active, I ski, Ihike. So the odds - and my only
real comorbidities, that is,what else is wrong with me, is
(16:35):
that I have high blood pressure,but it's well controlled, and
I've had kidney stones, but theyhaven't recurred, high
cholesterol, but I'm onmedication for that, and I,
because I exercise and watch mydiet, that's been controlled. I
have a weak spot on my aortathat was found when they were
when they did the CT scan for mykidney stones, and for that, I
(16:56):
have an annual ultrasound of it,and as long as that doesn't
progress, that's never going tobother me, and I've known about
it now for about eight years,and it hasn't progressed. So the
bottom line is, I'm fairlyhealthy. The odds are that I
will probably live into my 80s,barring getting run over by a
truck or doing something stupid.
So I felt like I should seektreatment, and my urologist
(17:19):
agreed with me, but everybody'sdifferent. And you know, if
you're 40 and you have a Gleasonscore of seven or above, the
answer is pretty simple, yeah,you ought to do something about
that, because you have enoughyears ahead of you that the
cancer may spread and it's amiserable way to die. So yeah,
you should probably do somethingabout it. If you're 75, 70, but
you're diabetic and you'remorbidly obese and you've had
(17:43):
coronary artery disease, youknow, maybe you don't want to
put yourself through that,because there's a good chance
that you're probably going todie of something else,
congestive heart failure orsomething else before that,
cancer bothers you, and there isa risk in all of the treatment.
I'll talk about that in a bit.
And there's also a risk justfrom the biopsy itself. Now,
(18:05):
it's a pretty simple procedure,but infection is possible,
bleeding is possible, can injurethe bladder, so it's not a
completely benign procedure. Soif you're aren't contemplating
doing something about whateveryou learn about the prostate,
then you you shouldn't undergothe biopsy. Do you see what I'm
saying? If you don't really planon treating it, there's no point
(18:26):
in doing the biopsy, because thebiopsy is what really shows
where you're at and what's goingon. So because I thought, well,
I'll probably live into my 80s,I should do something about
this. And one option would be tohave an annual MRI and an annual
biopsy and just watch and see ifit progresses and if it becomes,
(18:46):
you know, more dangerous to you.
I didn't like that option. Ididn't like the idea of living
knowing I've got cancer andknowing that I've got to have an
MRI. I would rather havesomebody just beat me with a
stick. So I decided, I decided Iwanted treatment, and my
urologist concurred that thatwas, given my general state of
(19:07):
health, that that was areasonable thing to do. So there
are two main forms of treatment.
The first is surgical, justremove the prostate, and I'll
talk about that in a moment. Andthe second is radiation.
Radiation involves every daygoing and laying on a table and
getting bombarded withradioactive particles. Now they
(19:30):
do it from a variety ofdifferent angles, so that most
of the radiation is concentratedin the tumor and a minimum
amount of radiation is hittingthe other normal structures. And
what are the normal structures?
Well, the bladder, the sphincterthat keeps urine in the bladder,
not sprayed all over your house,your colon, and so you can wind
up with injury to all of those.
(19:53):
Now, the radiation, especiallyin the last decade or so, has
gotten much better. They're muchbetter at targeting the tissues
they want to kill and avoidingnormal tissue. But it's not
perfect, and the side effectscan be incontinence of urine and
impotence, damage to thebladder, damage to the colon.
And the other thing aboutradiation is, because it damages
(20:15):
and kills tissue, that damage ishealed by scarring, so you wind
up with a big ball of scar whereyou used to have a prostate
gland, and that can be aproblem. For one thing, if if
you have a recurrence, thatmakes it very, very difficult to
go in and operate on it. If youhave radiation first, and some
of the cancer cells survive andthey grow and become a problem,
(20:37):
it's very difficult then totreat them again. You can't
really use more radiation,because the normal tissues have
already had as much as they canstand, and it's very difficult
to operate because it's a bigball of scar. It's not
impossible, but not very manycenters are doing it. So I
wasn't enthusiastic aboutradiation. Surgery used to be
(20:58):
fairly brutal. They'd make apretty big incision in your
lower abdomen, above your pubicbone, and they would dissect
down to the base of the bladder,and doing it rather clumsily
with their hands and scalpelsand scissors and then cutting
the prostate up. Now they dolaparoscopic procedure,
minimally invasive. So insteadof having a big wound in your
(21:21):
abdomen, you have about a twoand a half inch long wound
through your abdominal wall,right above your belly button.
The camera goes in there. Thecamera is quite small, but gives
beautifully clear pictures. Andthen they make a couple of other
incisions in your lower abdomen.
And they put, they can putinstruments in little tiny
scissors and little tinyscalpels, little tiny retractors
to pull tissue out of the way.
(21:46):
And so instead of having thesurgeons big, clumsy hands
inside of you, you've got thesetiny little instruments so they
do far less damage. So that'swhat's meant by minimally
invasive laparoscopic. And thesetiny little instruments are
controlled by a robot, so thesurgeon isn't actually even at
the surgical table. He's sittingin what looks like a gamer
(22:09):
station. It looks like he'splaying a video game. He's
hunched over. He's sitting in avery comfortable chair, but he's
hunched over what looks like agamer station, and he's he's
looking at exactly what thecamera is seeing and seeing it
very, very close up. He's gotcontrols that manipulate these
fine little instruments that areinserted inside you. Now there's
(22:31):
an assistant at your side, atthe table, who is putting these
little instruments in and movingthem around a little bit and
exchanging them for otherinstruments as the surgeon
needs, but it's pretty hightech. And so they do minimally
invasive. Then they can do nervesparing. The nerves that are
necessary to run your sphincterto make you continent, so that
(22:52):
you know you're not leakingurine everywhere. Those nerves
are right on the prostate gland,and the nerves that are involved
in erection are right there onthe prostate gland, and they can
spare those nerves by usingthese tiny little instruments.
And basically they're operatingthrough a microscope. So that's
that's what I opted for. Nowthat's not available every
(23:13):
place, but the VA has a veryexperienced urologist who is
doing this technique in Denver.
So I went to the Denver regionalVA hospital and had very good
care. I had my surgery, and whenthey take the prostate out, I
mean, they cut the whole glandout. Now remember I told you,
the urethra runs right throughit, so that comes out with it,
so then they have to hook thatback up, and it's cut off right
(23:35):
at the base of the bladder,right where your sphincter is.
So they have to be very carefulnot to goon the sphincter,
because then you won't have anycontrol over your urine. And
then they have to sew thaturethra back together. And it's
not a very robust structure,really, so it's a fairly
delicate procedure to sew thatback together. And then they put
a Foley catheter, a catheterthat runs through the penis, up
(23:56):
into the bladder, so that itwill support that rather
delicate connection they've madeuntil it has time to heal. And
that actually was probably theworst part of the procedure was
I had to have that catheter infor seven days. I had put lots
and lots and lots of cathetersin people, and never really
understood how awful it is. It'squite uncomfortable. The
(24:20):
catheters are - They used to bemade of soft rubber, but because
we had problems with peoplebeing allergic to rubber, latex
rubber and blah, blah, blah,we've switched to silicone.
Silicone is not nearly as kindof material as rubber is. It's
irritating to the bladder andwalking around on the catheter.
So you have the catheter in, andthat goes into a bag to collect
(24:41):
the urine, and that attaches toyour leg, so you're walking
around with a load of urinehanging up your leg. I wouldn't
really wish that on anybody, butit's temporary. Seven days and I
got it out, and so theneverything was pretty good. So
far, I've had a good result. Ididn't have any trouble with
(25:02):
continence, the erectilefunction takes time for that to
come back, but everything'sgoing well in that direction.
And there are things,medications and other things
they can do to assist with that.
And the good news, if I shouldhave a recurrence now, I could
have radiation, because Ihaven't had it before. So if I
were to get an early recurrence,you know, I could still do
(25:24):
something about it. So whathappens after that, then, is
once you've had your prostateout, after things calm down,
your PSA level should prettymuch go to zero. I've had one.
I'm about eight weeks post op,something like that, and I've
had one PSA done, and it was0.03, so not exactly completely
(25:46):
zero, but pretty close. And sonow, every three months, I will
have a simple blood test towatch that PSA and make sure
that it doesn't start to riseagain. The surgery isn't
guaranteed to go that well. Youstill there's a risk that you
will be incontinent. There's arisk that you will be impotent,
have erectile dysfunction thatdoesn't really ever respond very
(26:08):
well. There's the risk ofinfection, the risk of bleeding.
So there's a lot to think about,but what I believe about my own
health right now is that I don'thave a prostate gland anymore. I
don't have prostate cancer.
Everything's working pretty muchthe way it's supposed to. So I
feel like I bought myself 10years of life. Now, as I said,
the decision really depends onhow old you are, depends on your
(26:30):
health status, it depends onwhat your Gleason score is, and
it really kind of depends onwhat you feel like you can
tolerate what you want to do.
But I'm back to running. I'mback to lifting weights. I don't
have any restrictions. I'mdrinking too much [laughs], but
life is good.
Beth Brown (26:49):
Thank you so much for sharing that journey. We
forget sometimes that our healthcare professionals find
themselves on the other side ofthat examination table
sometimes. So that adds adifferent perspective of having
both your personal and yourprofessional insight on this
topic. I'd like to kind of goback and ask you some of the
questions that popped in my headas you shared your journey
(27:10):
through all this. So my firstone is, typically, do you wait
for your provider to offer thatdigital exam? Is that how that
usually goes? That the PSA showssomething and so then the
digital exam happens. Or can youtalk to us a little bit about
the typical process there?
Dr. Doug Kuntzweiler (27:28):
So it's actually recommended that you're
not bothered with a digital examanymore, and that is because
primary caregivers weren't doingit enough to maintain their
Is a urologist where someoneshould go to kind of have that
skill level to make itworthwhile. And it's, as I said,
it's a fairly low yield testanyway, because you're only able
to feel the back part of theprostate, and it's difficult
(27:49):
because you're pushing throughother tissues. So it's not
recommended that you even haveit. What is recommended is that
you just have a PSA, and that'snot even recommended unless you
have high risk factors, or untilyou are, some people say 50,
some people say 60. But you haveto realize those recommendations
are based on the average of whathappens in a huge population.
(28:12):
Everybody is an individual, andif you're worried about it, and
particularly if you have somecancer in the family, I would
say, at 40, ask for a PSA. Ifyou are seeing a urologist, they
are the most skilled at doingthe digital rectal exam, as was
mine. And so if you havesomebody who is really good at
it, then it can be worthwhile. Ithink, had I not had that exam,
(28:34):
knowing now that I had cancer,my PSA would have continued to
rise, and at some point shewould have recommended that I
get an MRI. But because she didthe digital rectal exam, she
found mine pretty early. Well, Idid not mention - so once they
take your your prostate glandout, then the pathologist has
the whole gland there to look atit when you do the biopsy. Even
(28:57):
though she took 12 samples,they're skinny little needles,
and that only represents about1% of the total volume of the
gland. So when the pathologistcould look at my whole prostate,
he found an area on the leftside where it had actually just
protruded from the capsule ofthe gland, so it was trying to
grow outside the gland, and thenext step would have been, it
(29:20):
would have been spreading. So Ifeel very fortunate in my
decision making. I think it wascorrect, and that probably
spared me from developing worsesymptoms, worse a worse outcome.
But anyway, as I said, there's alot of controversy about the
screening. It is a rectal exam.
A lot of primary caregiversaren't even offering it, aren't
asking about it. They're justfollowing the PSA. And the PSA,
(29:42):
as I said, is not a perfect testeither. You can have a high PSA
and not have cancer. You canhave a fairly low PSA and have
cancer, and my primary caregiverwasn't alarmed at my PSA,
because it was always belowfour. But my urologist said,
"That's true, but look at thetrend. The trend is it keeps
going up every time we sampleit. I think something's going
(30:05):
on." And they should be shareddecisions, as we talked about.
Your caregiver, whoever it is,whether it's primary care or
urology, should talk to youabout, you know, where this
might lead. What are the risks,what are the potential benefits
and help you make the decisionof whether or not you want to go
through this.
(30:30):
conversation of, should I pursuetreatment or not? Or who should
a guy talk to to get that inputso that they can make an
educated decision?
Yeah, I think your best sourceof information is going to be a
neurologist. So if you've had aPSA test, your primary caregiver
can do that, you know. And ifit's less than one, you got no
worries, you probably shouldhave it done at least every two
(30:52):
years, you know. And as I said,starting maybe at age 40, or if
you've got a clean familyhistory, maybe wait till 45 or
50, but you should keep an eyeon that. And you know, if it
remains less than one and you're80, you can probably safely stop
checking it, because it's nevergoing to cause you any trouble.
But I think if you have a PSAthat goes above four, or if, as
(31:15):
in my case, it's steadilyclimbing, then you should talk
to your primary caregiver aboutseeing a urologist, and they can
talk to you then about imagingand follow up on the imaging
biopsy, if there looks likethere's something suspicious on
the MRI or digital rectal exam,but I would see a urologist.
They're the ones who do this dayin and day out, for your
screening, your follow up, yourprimary care is just fine, but
(31:38):
then, depending on the result,you will get your best guidance
from a skilled urologist.
Beth Brown (31:44):
Okay, and so for those men who decide to not seek
treatment, either because theyhave other health issues or
they're older, what is thetreatment or monitoring or
whatever that happens then? Andis it the PSA that you kind of
track to see if the cancer isgrowing, or you just sort of let
it go, because the person didn'tseek treatment?
Dr. Doug Kuntzweiler (32:06):
I think it depends. If - certainly you can
follow the PSA. If they developmetastatic disease, they're
going to have symptoms at thatpoint. They're going to have
bone pain at that stage. Nobodyhas found any chemotherapy that
is helpful. It just doesn't.
This is not a tumor thatresponds to chemotherapy. So the
the next step to halt theprogression of the disease is
(32:28):
castration. You have to removethe testosterone, because
testosterone stimulates thegrowth of prostate cancer. Now,
sometimes they actually removeyour testicles, but you don't
necessarily have to have that.
There are medications that blocktestosterone, and that's
typically what's done, and thathelps with the bone pain, it
(32:50):
helps with the symptoms, and ithelps to slow down and retard
the growth of the cancer, buyingyou more time. Eventually, the
cancer will continue to grow andspread. Even taking the
anti-testosterone drugs won'tprevent that, but it will slow
it down. And I had a good friendwho died in his 50s of
metastatic prostate cancer, andhe presented with severe bone
(33:12):
pain, and at first it was in hislow back, and he thought he had
just tweaked a muscle orsomething, and his primary
caregiver gave him some painmedicine, and things got worse.
And then they did a scan, andthey discovered he had bone
mets. And at that point, therewasn't much to do. He went into
hospice, and he was in his mid50s, so it can be really bad
deal. But as I said, everybodyis an individual, but I would
(33:35):
recommend early screening, andthen if something suspicious is
going on, see a urologist andmake them explain everything to
you and talk to your family andcome to some sort of consensus
about what you want to do aboutit. And I have to say, I had one
provider try and talk me out ofthe surgery, but at that point,
you know, I'd read all theliterature, and admittedly, I
(33:56):
had an advantage, because Ispeak the language, and I had
dealt with people with prostatecancer and prostatitis. It
wasn't foreign to me. And I feltlike I was a pretty informed
patient. And you mentioned, youknow, being on the other end of
things. I always thought it mademe a better doctor whenever I
had a medical problem on my own.
It gave me that perspective,that, like I said, I if I ever
(34:17):
had to order a Foley again, Iwould cringe and then do it.
Beth Brown (34:23):
Well, I have to say, I've had an MRI, and I
definitely understand theclaustrophobia aspect, but it
didn't bother me as much as itsounds like it bothered you. It
is a tight spot and it wasnoisy, but I did just hang out
and try to focus on the musicthrough the headphones and not
all the banging. So yeah, forthose folks listening, I think
(34:45):
it depends on the person if youcan handle it.
Dr. Doug Kuntzweiler (34:48):
That's good. I'm glad you didn't have
any trouble with it. I hadenough trouble that I didn't
really ever want to do it again.
I could, but I might ask for alittle Ativan or something.
Beth Brown (34:59):
Yeah. People, then, who opt for the radiation rather
than the surgery. So I'massuming your risk for
reoccurrence of prostate canceris nil because you no longer
have a prostate, and maybethat's not entirely true, but
what is the risk for gettingprostate cancer again after
you've had it and soughttreatment, either through
(35:20):
surgery or through radiation?
Dr. Doug Kuntzweiler (35:22):
Both are quite good, less than 10% chance
of recurrence. But that's notzero. And if it were to recur,
and you would know that, becausewhether you have radiation or
whether you have surgery, peopleare going to follow your PSA.
Like I'm getting it every threemonths for the first year, and
then, depending on what happenswith that, we might go to
annually, and it would be thesame if I'd had radiation. But
(35:46):
if it, if it comes back and ifPSA starts rising again, then
you've got a met somewhere. Andprobably the next thing that
would be done would be eitheranother MRI or, more likely, a
PET scan. The PET scan, theygive you a radioactive labeled
medication, and it's taken uppreferentially by tumor cells.
(36:07):
And so they put you in anothertype of scanner that detects
that radiation, and it willlocate where the metastatic
disease is. If it's in bone,then you might have the option
of having radiation to that areaof the bone to help with the
pain and to slow down the tumor.
So there are other things thatcan be done. Anti-testosterone
drugs could be given, but itjust depends on what happens
with the PSA and and where yougo after that. And again, you
(36:31):
might elect not to do anything,and like my friend, you might
just go into hospice. He didn't- he was suffering enough that
he didn't want to haveradiation, and his was
widespread enough that it wasgoing to be pretty futile to try
that sort of thing anyway. So soit really depends on the
particular situation.
Beth Brown (36:51):
Again, thank you for sharing your experience. I just
want to make sure that any menwho are listening, or those of
us who have men in our livesthat, you know, we like quite a
lot, what do you want to makesure we hear today? What's our
takeaway message?
Dr. Doug Kuntzweiler (37:08):
Well, the takeaway message is, know your
family history. If you're havingtrouble emptying your bladder,
and in some men it startsearlier, like in their 40s, by
all means, see your primarycaregiver, get a PSA test, and
if that looks suspicious, thenask to see a urologist. There
are some very good websites youcan go to. The American Cancer
Society has an online decisionaid, as does the American
(37:32):
Society of Clinical Oncology.
These are websites where theywill ask you questions about
your health and about your age,and if you've had a PSA, what
that level was, and they willhelp you make decisions about
what your next step should be.
Beth Brown (37:46):
That's great. All right, awesome. Thank you again.
Dr. K, really awesome journey,and so glad it worked out as
well as it did for you.
Dr. Doug Kuntzweiler (37:54):
Yeah, I'm going to be around for a while,
unfortunately for you guys.
Beth Brown (37:57):
No, that's not unfortunate at all. Thank you
very much. And thank you forlistening. We'll include the
resources that Dr. K mentionedso you can get information about
prostate cancer and decisionsyou may need to make. And if you
have a question for Dr. K,please email us at
QandAwithDrK@mpqhf.org, and wewill put that email address with
(38:19):
this episode as well, so thatyou can get your questions
answered anonymously. Thanks somuch and be well.
[Music] Welcome to Q&A with Dr. K, a podcast by
Mountain Pacific Quality Health,where we sit down with Dr. Doug
Kuntzweiler and get your healthquestions answered, because on
(00:21):
Q&A with Dr. K, the doctor isalways in,
Hi, everybody. This is BethBrown, your host. And with us,
as always, is Dr. DougKuntzweiler, our chief medical
officer at Mountain Pacific, andwe appreciate your time being
(00:45):
here again, Dr. K to answer somequestions about prostate cancer.
So here are the two questionswe're going to focus on today,
but of course, we're going tosprinkle some others in there as
well, just to get a clearunderstanding what we really are
talking about. But the questionsare, what exactly is the
prostate, and what are the prosand cons of being screened for
prostate cancer? So let's startwith that first question, what
(01:08):
exactly is the prostate and whatdoes it do?
Dr. Doug Kuntzweiler (01:11):
Well, the prostate is a gland that only
males have. It is about the sizeof a walnut, and it sits right
underneath the bladder. Now theurethra, the tube that runs from
the bladder through the penis tothe outside world that empties
urine from the bladder, runsright through the center of the
prostate, and your colon sitsjust right behind it, so that
(01:36):
kind of helps to orient. If youare sitting down, you're kind of
sitting right on top of yourprostate. And in fact, people
who do long distance bicyclingoftentimes will get their
prostate irritated, becausethat's kind of, you're sitting
right on top of that. So that'swhere it's at. That's about what
size it is. Its function is tomake the fluid that sperm swim
(02:00):
around in. We call that semen.
The sperm, you know, have alittle flagella, sort of a
little whip on the end of it,and they whip that back and
forth, and that's how they movearound and try to find an ovum
to fertilize, an egg tofertilize, but they have to have
a fluid to swim in, and that'swhat the prostate does. That
fluid also provides nourishmentfor the sperm, because they
(02:22):
might have several hours ontheir journey to find an egg,
and they would die if theydidn't have the semen fluid to
support them. So that's where itis and what it is.
Beth Brown (02:35):
Got it - very important part of reproduction
for all of us. And so then whenit comes to prostate cancer,
then, who is at risk fordeveloping prostate cancer?
Dr. Doug Kuntzweiler (02:46):
The biggest risk factor is age, and
what cancer is - Generally,cancer is uncontrolled growth of
cells, and that in almost everymale at some point, usually late
in life, 70s, 80s, they willdevelop an area of cancer
something like 80% of autopsieswill show that there is some
(03:09):
cancer cells in the prostate, ifyou live long enough. Now, when
we talk about how common is it,it's the second leading cause of
cancer in males, second only tolung cancer. So it is actually
very common, but because ittends to grow slowly, and
because it tends to be slow tospread, it oftentimes doesn't
(03:31):
really cause any harm, becausemen tend to die of something
else before the cancer reallyhas a chance to impact them. But
unfortunately, that's notuniversally true, and it does
cause about 35,000 deathsannually in the United States.
So it's common. It often doesn'tcause any trouble, but it is
(03:52):
also responsible for significantnumber of deaths.
Beth Brown (03:55):
So it's one of those sneaky cancers? It doesn't
really have symptoms? Or couldsomebody develop symptoms to
indicate they might haveprostate cancer?
Dr. Doug Kuntzweiler (04:04):
Yeah, that's one of the problems with
it is, as it tends to not have alot of symptoms early on. Now,
as men age, somewhere around,typically, their late 40s or
50s, the prostate glandenlarges, and that probably
happens because of hormonalchanges. But that's pretty close
to universal. More than half ofall men develop an enlarged
(04:26):
prostate. We call that benignprostatic hypertrophy, Latin
words that just mean enlargementof the prostate. When it
enlarges, then because of itsposition, wrapped around the
urethra, like we talked about,it makes it difficult to empty
the bladder, and so the symptomsof that are men have to urinate
frequently. Oftentimes, theyhave to get up at night,
(04:48):
sometimes more than once,sometimes a couple of times
during the night, to empty theirbladder, because they're never
emptying it completely. And thensometimes they will get a sudden
urge to urinate because thebladder's being distended as
being, you know, full all thetime. You can see blood in the
urine, but you can see that withbenign problems, too. So usually
(05:11):
there's not a lot of pain,unless the cancer metastasizes,
and metastasizing means that ithas spread to other organs.
Every cancer has a typicalpattern of spread, and prostate
cancer likes to go to bone. Soif you have metastatic cancer,
typically what you have issevere bone pain. It likes to go
(05:32):
to the pelvis bones, the hips,ribs and the spinal column. If
that's how it first presents,usually things are bad. The
cancer has already spread ifyou've got bone pain, and once
it spreads, and we call thatstage four, if it goes to
another organ, like bone orliver or lung, but once it
(05:54):
spreads, it it really is prettymuch not curable. There are
treatments that help, but beingcured of it pretty much is not
possible once it is spread. Soit's a sneaky disease that way.
Oftentimes it has no symptomsuntil it spreads, and then it
has bad symptoms, and theoutcome is often not good. Which
(06:15):
brings us to screening.
Beth Brown (06:17):
Yeah, and I do want to talk about screening, since
it sounds like that's going tobe a key part in identifying it.
But before we talk about that,do we know what causes prostate
cancer? And on the other side ofthe coin, if we do have some
idea, do we know how to preventprostate cancer?
Dr. Doug Kuntzweiler (06:33):
No and no.
Beth Brown (06:34):
Oh shoot, that's a bad coin. Ok.
Dr. Doug Kuntzweiler (06:38):
We we don't know exactly what causes
it. We do know that there candefinitely be a genetic
component. So if in your familyhistory there are people who
have had cancer, and pretty muchany kind of cancer, breast
cancer, cancer of the bladder,cancer of the liver, pretty much
anything, it raises your risk ofhaving prostate cancer. And
(06:58):
certainly if in your familythere are males who have had
prostate cancer, then your riskgoes up quite a bit, especially
first degree relatives, whichwould be a parent, a sibling or
a grandparent. It's also morecommon in black men. There are
probably other risk factors,just like there are for all of
the cancers, and probably theusual suspects, alcohol and
smoking would probably be thetwo most common, maybe sedentary
(07:22):
lifestyle maybe a diet with alot of processed foods, but we
don't know any of that for sure,but, but there certainly can be
genetic components,family-related components, and
so you know you, as we've talkedabout in other episodes, you
should find out your familyhistory and relay that to your
primary caregiver, because youmay be at increased risk. And
(07:42):
what that means is you mightneed screening, and you might
need it at an earlier age thanif you didn't have those risk
factors.
Beth Brown (07:49):
Okay, so good. You brought up screening again.
Let's talk about that. So whoshould get screened for prostate
cancer? You talked about peoplewho might be at risk. When does
screening start, and what doesthat look like?
Dr. Doug Kuntzweiler (08:01):
Well, that's very controversial, and
I'm going to just relay my ownstory, because I had prostate
cancer, and so I went throughthis, actually, fairly recently.
Screening is difficult, becausewe don't have a really good
screen. The best thing we haveright now is called PSA. PSA
stands for prostatic specificantigen, and it's a blood test.
(08:26):
It detects a protein that ispresent in the prostate, and it
can go into the bloodstream, andthen we can detect that with the
blood test. Lots of things willraise your PSA level. Riding a
bicycle, for instance, willraise it. Having benign prostate
enlargement can raise it, anytype of irritation of the
(08:48):
prostate. And the prostate,because of where it's at, is
somewhat prone to infection.
Bacteria can sneak in throughthe urethra and find their way
to the prostate and causeprostatitis, which means an
infection and inflammation ofprostate, so that can raise it.
So there aren't great guidelinesfor when your PSA level
indicates that you might havecancer. It tends to go up as you
(09:10):
age also, but it's the bestscreening tool we have now. Some
people say you shouldn't screenanybody 70 years of age or
older, because even if it'selevated, they're probably going
to die of something else,because prostate cancer tends to
be slow growing and slow tospread. But as we talked about,
if you're one of these peoplewho has a risk factor, you might
(09:31):
want to start getting screenedat age 45. Some people say start
at age 40. Some people say 50.
It really is kind of all overthe map, which usually means we
just don't know for sure. Myadvice is, if you have a family
history of prostate cancer, oryou have a family history of any
(09:51):
type of cancer, I think youshould talk to your primary
caregiver and see about gettinga PSA test. And I would, I would
say, do that at age 40, err onthe safe side. Once, once you've
had the test, then it's a matterof, how do you interpret it?
Now, in my situation, I think Istarted screening probably about
(10:12):
10 years ago, but it was sort ofintermittent, like every two
years they would check a PSA,and it was always less than
four, and four is sort of a cutoff. If it's less than four,
your chances of having prostatecancer are fairly slim. If it's
less than one, there's verylittle chance that you have
cancer. But if it's between oneand four, there's a small
(10:33):
chance. If it goes above four,then your risk of having cancer
increases. If it goes above 10,your chances are about 50/50.
About half of the people whohave levels of 10 or above will
have cancer. So mine was alwaysunder four, but it was going up
every time it was checked, andthat seems to be a risk factor
(10:57):
as well. It was still withinnormal limits. I think my last
one was 3.98 so it was stillunder four, but had it had
started out at about 1.2 and soI had it tested maybe four times
over those 10 years, and it wassteadily increasing.
Serendipitously, I was seeing aurologist because I'd had kidney
stones, and I had to have aprocedure to remove the kidney
(11:20):
stones, and it was a urologistwho did that. I get my health
care from the VA system. And soI saw a urologist at Fort
Harrison here in Helena, and shetook my stones out of my kidney,
and then she noticed that my PSAwas steadily rising, and she
offered to do a digital rectalexam. Nobody really wants that
(11:43):
exam. It involves thepractitioner putting their
finger in your bottom andfeeling through the colon for
the prostate. And you can onlyfeel the back part of the
prostate, but that's also wherecancers most commonly arise, and
it's not a very precise exam, asyou might imagine, because
you're feeling through the wallof the colon, but if you are
(12:05):
experienced, you've done a lotof these exams, if you find
something that is suspicious,and that would typically be a
hard nodule, then that needs tobe investigated. And so she did
the digital rectal exam, and shetold me there's a suspicious
area. So the next step is,typically, then to do imaging.
And the imaging that works thebest is an MRI. It used to be
(12:28):
when MRIs first came out incommon usage, about 25 years or
so ago. They weren't verypowerful, and they didn't really
image the prostate very well,and so they weren't helpful. But
like everything else inmedicine, MRIs have gotten more
and more sophisticated and moreand more powerful. So now, if
you have an MRI with ahigh-field strength, it images
(12:50):
the prostate pretty well, andthey give you contrast through
an IV, and the contrast is takenup in areas that have increased
blood supply, and that's onething that's fairly
characteristic of all cancers.
They are abnormal cells that aregrowing quickly, and to support
that growth, they have a richblood supply. So when you see a
cluster of blood vessels, that'sthat's very suspicious. Now, I'd
(13:12):
never had an MRI before. I'd hadCT scans for my kidney stones.
CT scan is a breeze. That's likejust laying down on your bed.
The MRI, they put you in alittle tube that you barely fit
in. And if you have any sense ofclaustrophobia at all, you
should demand that they sedateyou, at least give you something
(13:34):
to kind of take the edge off. Ididn't think I had
claustrophobia, but I did notlike the MRI. It's very close
quarters, and to image theprostate, it's a long procedure.
It's 45 minutes, and it's veryloud. There are some alarming
bangs that go on that soundslike you're in a garbage can
(13:55):
with somebody beating on it witha hammer. It's a very unpleasant
exam, and they gave meheadphones, but they didn't go
loud enough. So at any rate, Itolerated it. But I would just
say, if you're at the stagewhere an MRI is offered, take
it, because it's a great way toimage the prostate, but ask for
sedation if you think you'regoing to have trouble. So what
(14:17):
the MRI showed was an area thatlooked like it probably was
prostate cancer, and it wasmostly on the left side of the
prostate. Now, if there is aquestion of whether or not
there's a cancer, the answer isto get a sample of it and have a
pathologist look at it under amicroscope. You have to have a
biopsy. So the biopsy is not alot of fun either. They have a
(14:40):
skinny needle that when itpasses into tissue, it gets a
core sample that is some of thetissue goes up in, stays inside
the needle, and then thepathologist can look at those
samples. As you might expect,they do it the same way they do
the digital rectal exam. They gothrough the rectum, and they
have these needles that aretriggered by a spring. They're
(15:02):
spring loaded, and they take 10to 12 samples. She took 12
samples. They numb the area upfirst. It's not horrible, but
it's it's kind of unpleasant.
But then you've got tissue tolook at. So the pathologist
looks at this tissue and hegrades it. This is called the
Gleason score, named after theguy who developed it. So the
(15:26):
score reflects how abnormal thecells are and what their
architecture is. That is, howare they organized, and then
also what percentage of thesample are cancer cells. And the
Gleason score runs from one to10. If you have a score of six
or less, those are verybenign-acting tumors, and those
(15:51):
are the kind that you might notwant to have anything done for
depending on your age. If you're75 or 80 years old, and your
Gleason score comes out six orlower, that cancer is probably
never going to cause you anytrouble, and it can just be
watched. If your score is sevenor above, that's a bit different
story. And the higher the score,the worse things are. My score
(16:14):
was a seven, so I was sort ofright on the cusp of where I
should consider treatment. I'm73 years old now. I'm in
relatively good health, though,for 73. I walk every day, I lift
weights, I'm active, I ski, Ihike. So the odds - and my only
real comorbidities, that is,what else is wrong with me, is
(16:35):
that I have high blood pressure,but it's well controlled, and
I've had kidney stones, but theyhaven't recurred, high
cholesterol, but I'm onmedication for that, and I,
because I exercise and watch mydiet, that's been controlled. I
have a weak spot on my aortathat was found when they were
when they did the CT scan for mykidney stones, and for that, I
(16:56):
have an annual ultrasound of it,and as long as that doesn't
progress, that's never going tobother me, and I've known about
it now for about eight years,and it hasn't progressed. So the
bottom line is, I'm fairlyhealthy. The odds are that I
will probably live into my 80s,barring getting run over by a
truck or doing something stupid.
So I felt like I should seektreatment, and my urologist
(17:19):
agreed with me, but everybody'sdifferent. And you know, if
you're 40 and you have a Gleasonscore of seven or above, the
answer is pretty simple, yeah,you ought to do something about
that, because you have enoughyears ahead of you that the
cancer may spread and it's amiserable way to die. So yeah,
you should probably do somethingabout it. If you're 75, 70, but
you're diabetic and you'remorbidly obese and you've had
(17:43):
coronary artery disease, youknow, maybe you don't want to
put yourself through that,because there's a good chance
that you're probably going todie of something else,
congestive heart failure orsomething else before that,
cancer bothers you, and there isa risk in all of the treatment.
I'll talk about that in a bit.
And there's also a risk justfrom the biopsy itself. Now,
(18:05):
it's a pretty simple procedure,but infection is possible,
bleeding is possible, can injurethe bladder, so it's not a
completely benign procedure. Soif you're aren't contemplating
doing something about whateveryou learn about the prostate,
then you you shouldn't undergothe biopsy. Do you see what I'm
saying? If you don't really planon treating it, there's no point
(18:26):
in doing the biopsy, because thebiopsy is what really shows
where you're at and what's goingon. So because I thought, well,
I'll probably live into my 80s,I should do something about
this. And one option would be tohave an annual MRI and an annual
biopsy and just watch and see ifit progresses and if it becomes,
(18:46):
you know, more dangerous to you.
I didn't like that option. Ididn't like the idea of living
knowing I've got cancer andknowing that I've got to have an
MRI. I would rather havesomebody just beat me with a
stick. So I decided, I decided Iwanted treatment, and my
urologist concurred that thatwas, given my general state of
(19:07):
health, that that was areasonable thing to do. So there
are two main forms of treatment.
The first is surgical, justremove the prostate, and I'll
talk about that in a moment. Andthe second is radiation.
Radiation involves every daygoing and laying on a table and
getting bombarded withradioactive particles. Now they
(19:30):
do it from a variety ofdifferent angles, so that most
of the radiation is concentratedin the tumor and a minimum
amount of radiation is hittingthe other normal structures. And
what are the normal structures?
Well, the bladder, the sphincterthat keeps urine in the bladder,
not sprayed all over your house,your colon, and so you can wind
up with injury to all of those.
(19:53):
Now, the radiation, especiallyin the last decade or so, has
gotten much better. They're muchbetter at targeting the tissues
they want to kill and avoidingnormal tissue. But it's not
perfect, and the side effectscan be incontinence of urine and
impotence, damage to thebladder, damage to the colon.
And the other thing aboutradiation is, because it damages
(20:15):
and kills tissue, that damage ishealed by scarring, so you wind
up with a big ball of scar whereyou used to have a prostate
gland, and that can be aproblem. For one thing, if if
you have a recurrence, thatmakes it very, very difficult to
go in and operate on it. If youhave radiation first, and some
of the cancer cells survive andthey grow and become a problem,
(20:37):
it's very difficult then totreat them again. You can't
really use more radiation,because the normal tissues have
already had as much as they canstand, and it's very difficult
to operate because it's a bigball of scar. It's not
impossible, but not very manycenters are doing it. So I
wasn't enthusiastic aboutradiation. Surgery used to be
(20:58):
fairly brutal. They'd make apretty big incision in your
lower abdomen, above your pubicbone, and they would dissect
down to the base of the bladder,and doing it rather clumsily
with their hands and scalpelsand scissors and then cutting
the prostate up. Now they dolaparoscopic procedure,
minimally invasive. So insteadof having a big wound in your
(21:21):
abdomen, you have about a twoand a half inch long wound
through your abdominal wall,right above your belly button.
The camera goes in there. Thecamera is quite small, but gives
beautifully clear pictures. Andthen they make a couple of other
incisions in your lower abdomen.
And they put, they can putinstruments in little tiny
scissors and little tinyscalpels, little tiny retractors
to pull tissue out of the way.
(21:46):
And so instead of having thesurgeons big, clumsy hands
inside of you, you've got thesetiny little instruments so they
do far less damage. So that'swhat's meant by minimally
invasive laparoscopic. And thesetiny little instruments are
controlled by a robot, so thesurgeon isn't actually even at
the surgical table. He's sittingin what looks like a gamer
(22:09):
station. It looks like he'splaying a video game. He's
hunched over. He's sitting in avery comfortable chair, but he's
hunched over what looks like agamer station, and he's he's
looking at exactly what thecamera is seeing and seeing it
very, very close up. He's gotcontrols that manipulate these
fine little instruments that areinserted inside you. Now there's
(22:31):
an assistant at your side, atthe table, who is putting these
little instruments in and movingthem around a little bit and
exchanging them for otherinstruments as the surgeon
needs, but it's pretty hightech. And so they do minimally
invasive. Then they can do nervesparing. The nerves that are
necessary to run your sphincterto make you continent, so that
(22:52):
you know you're not leakingurine everywhere. Those nerves
are right on the prostate gland,and the nerves that are involved
in erection are right there onthe prostate gland, and they can
spare those nerves by usingthese tiny little instruments.
And basically they're operatingthrough a microscope. So that's
that's what I opted for. Nowthat's not available every
(23:13):
place, but the VA has a veryexperienced urologist who is
doing this technique in Denver.
So I went to the Denver regionalVA hospital and had very good
care. I had my surgery, and whenthey take the prostate out, I
mean, they cut the whole glandout. Now remember I told you,
the urethra runs right throughit, so that comes out with it,
so then they have to hook thatback up, and it's cut off right
(23:35):
at the base of the bladder,right where your sphincter is.
So they have to be very carefulnot to goon the sphincter,
because then you won't have anycontrol over your urine. And
then they have to sew thaturethra back together. And it's
not a very robust structure,really, so it's a fairly
delicate procedure to sew thatback together. And then they put
a Foley catheter, a catheterthat runs through the penis, up
(23:56):
into the bladder, so that itwill support that rather
delicate connection they've madeuntil it has time to heal. And
that actually was probably theworst part of the procedure was
I had to have that catheter infor seven days. I had put lots
and lots and lots of cathetersin people, and never really
understood how awful it is. It'squite uncomfortable. The
(24:20):
catheters are - They used to bemade of soft rubber, but because
we had problems with peoplebeing allergic to rubber, latex
rubber and blah, blah, blah,we've switched to silicone.
Silicone is not nearly as kindof material as rubber is. It's
irritating to the bladder andwalking around on the catheter.
So you have the catheter in, andthat goes into a bag to collect
(24:41):
the urine, and that attaches toyour leg, so you're walking
around with a load of urinehanging up your leg. I wouldn't
really wish that on anybody, butit's temporary. Seven days and I
got it out, and so theneverything was pretty good. So
far, I've had a good result. Ididn't have any trouble with
(25:02):
continence, the erectilefunction takes time for that to
come back, but everything'sgoing well in that direction.
And there are things,medications and other things
they can do to assist with that.
And the good news, if I shouldhave a recurrence now, I could
have radiation, because Ihaven't had it before. So if I
were to get an early recurrence,you know, I could still do
(25:24):
something about it. So whathappens after that, then, is
once you've had your prostateout, after things calm down,
your PSA level should prettymuch go to zero. I've had one.
I'm about eight weeks post op,something like that, and I've
had one PSA done, and it was0.03, so not exactly completely
(25:46):
zero, but pretty close. And sonow, every three months, I will
have a simple blood test towatch that PSA and make sure
that it doesn't start to riseagain. The surgery isn't
guaranteed to go that well. Youstill there's a risk that you
will be incontinent. There's arisk that you will be impotent,
have erectile dysfunction thatdoesn't really ever respond very
(26:08):
well. There's the risk ofinfection, the risk of bleeding.
So there's a lot to think about,but what I believe about my own
health right now is that I don'thave a prostate gland anymore. I
don't have prostate cancer.
Everything's working pretty muchthe way it's supposed to. So I
feel like I bought myself 10years of life. Now, as I said,
the decision really depends onhow old you are, depends on your
(26:30):
health status, it depends onwhat your Gleason score is, and
it really kind of depends onwhat you feel like you can
tolerate what you want to do.
But I'm back to running. I'mback to lifting weights. I don't
have any restrictions. I'mdrinking too much [laughs], but
life is good.
Beth Brown (26:49):
Thank you so much for sharing that journey. We
forget sometimes that our healthcare professionals find
themselves on the other side ofthat examination table
sometimes. So that adds adifferent perspective of having
both your personal and yourprofessional insight on this
topic. I'd like to kind of goback and ask you some of the
questions that popped in my headas you shared your journey
(27:10):
through all this. So my firstone is, typically, do you wait
for your provider to offer thatdigital exam? Is that how that
usually goes? That the PSA showssomething and so then the
digital exam happens. Or can youtalk to us a little bit about
the typical process there?
Dr. Doug Kuntzweiler (27:28):
So it's actually recommended that you're
not bothered with a digital examanymore, and that is because
primary caregivers weren't doingit enough to maintain their
Is a urologist where someoneshould go to kind of have that
skill level to make itworthwhile. And it's, as I said,
it's a fairly low yield testanyway, because you're only able
to feel the back part of theprostate, and it's difficult
(27:49):
because you're pushing throughother tissues. So it's not
recommended that you even haveit. What is recommended is that
you just have a PSA, and that'snot even recommended unless you
have high risk factors, or untilyou are, some people say 50,
some people say 60. But you haveto realize those recommendations
are based on the average of whathappens in a huge population.
(28:12):
Everybody is an individual, andif you're worried about it, and
particularly if you have somecancer in the family, I would
say, at 40, ask for a PSA. Ifyou are seeing a urologist, they
are the most skilled at doingthe digital rectal exam, as was
mine. And so if you havesomebody who is really good at
it, then it can be worthwhile. Ithink, had I not had that exam,
(28:34):
knowing now that I had cancer,my PSA would have continued to
rise, and at some point shewould have recommended that I
get an MRI. But because she didthe digital rectal exam, she
found mine pretty early. Well, Idid not mention - so once they
take your your prostate glandout, then the pathologist has
the whole gland there to look atit when you do the biopsy. Even
(28:57):
though she took 12 samples,they're skinny little needles,
and that only represents about1% of the total volume of the
gland. So when the pathologistcould look at my whole prostate,
he found an area on the leftside where it had actually just
protruded from the capsule ofthe gland, so it was trying to
grow outside the gland, and thenext step would have been, it
(29:20):
would have been spreading. So Ifeel very fortunate in my
decision making. I think it wascorrect, and that probably
spared me from developing worsesymptoms, worse a worse outcome.
But anyway, as I said, there's alot of controversy about the
screening. It is a rectal exam.
A lot of primary caregiversaren't even offering it, aren't
asking about it. They're justfollowing the PSA. And the PSA,
(29:42):
as I said, is not a perfect testeither. You can have a high PSA
and not have cancer. You canhave a fairly low PSA and have
cancer, and my primary caregiverwasn't alarmed at my PSA,
because it was always belowfour. But my urologist said,
"That's true, but look at thetrend. The trend is it keeps
going up every time we sampleit. I think something's going
(30:05):
on." And they should be shareddecisions, as we talked about.
Your caregiver, whoever it is,whether it's primary care or
urology, should talk to youabout, you know, where this
might lead. What are the risks,what are the potential benefits
and help you make the decisionof whether or not you want to go
through this.
(30:30):
conversation of, should I pursuetreatment or not? Or who should
a guy talk to to get that inputso that they can make an
educated decision?
Yeah, I think your best sourceof information is going to be a
neurologist. So if you've had aPSA test, your primary caregiver
can do that, you know. And ifit's less than one, you got no
worries, you probably shouldhave it done at least every two
(30:52):
years, you know. And as I said,starting maybe at age 40, or if
you've got a clean familyhistory, maybe wait till 45 or
50, but you should keep an eyeon that. And you know, if it
remains less than one and you're80, you can probably safely stop
checking it, because it's nevergoing to cause you any trouble.
But I think if you have a PSAthat goes above four, or if, as
(31:15):
in my case, it's steadilyclimbing, then you should talk
to your primary caregiver aboutseeing a urologist, and they can
talk to you then about imagingand follow up on the imaging
biopsy, if there looks likethere's something suspicious on
the MRI or digital rectal exam,but I would see a urologist.
They're the ones who do this dayin and day out, for your
screening, your follow up, yourprimary care is just fine, but
(31:38):
then, depending on the result,you will get your best guidance
from a skilled urologist.
Beth Brown (31:44):
Okay, and so for those men who decide to not seek
treatment, either because theyhave other health issues or
they're older, what is thetreatment or monitoring or
whatever that happens then? Andis it the PSA that you kind of
track to see if the cancer isgrowing, or you just sort of let
it go, because the person didn'tseek treatment?
Dr. Doug Kuntzweiler (32:06):
I think it depends. If - certainly you can
follow the PSA. If they developmetastatic disease, they're
going to have symptoms at thatpoint. They're going to have
bone pain at that stage. Nobodyhas found any chemotherapy that
is helpful. It just doesn't.
This is not a tumor thatresponds to chemotherapy. So the
the next step to halt theprogression of the disease is
(32:28):
castration. You have to removethe testosterone, because
testosterone stimulates thegrowth of prostate cancer. Now,
sometimes they actually removeyour testicles, but you don't
necessarily have to have that.
There are medications that blocktestosterone, and that's
typically what's done, and thathelps with the bone pain, it
(32:50):
helps with the symptoms, and ithelps to slow down and retard
the growth of the cancer, buyingyou more time. Eventually, the
cancer will continue to grow andspread. Even taking the
anti-testosterone drugs won'tprevent that, but it will slow
it down. And I had a good friendwho died in his 50s of
metastatic prostate cancer, andhe presented with severe bone
(33:12):
pain, and at first it was in hislow back, and he thought he had
just tweaked a muscle orsomething, and his primary
caregiver gave him some painmedicine, and things got worse.
And then they did a scan, andthey discovered he had bone
mets. And at that point, therewasn't much to do. He went into
hospice, and he was in his mid50s, so it can be really bad
deal. But as I said, everybodyis an individual, but I would
(33:35):
recommend early screening, andthen if something suspicious is
going on, see a urologist andmake them explain everything to
you and talk to your family andcome to some sort of consensus
about what you want to do aboutit. And I have to say, I had one
provider try and talk me out ofthe surgery, but at that point,
you know, I'd read all theliterature, and admittedly, I
(33:56):
had an advantage, because Ispeak the language, and I had
dealt with people with prostatecancer and prostatitis. It
wasn't foreign to me. And I feltlike I was a pretty informed
patient. And you mentioned, youknow, being on the other end of
things. I always thought it mademe a better doctor whenever I
had a medical problem on my own.
It gave me that perspective,that, like I said, I if I ever
(34:17):
had to order a Foley again, Iwould cringe and then do it.
Beth Brown (34:23):
Well, I have to say, I've had an MRI, and I
definitely understand theclaustrophobia aspect, but it
didn't bother me as much as itsounds like it bothered you. It
is a tight spot and it wasnoisy, but I did just hang out
and try to focus on the musicthrough the headphones and not
all the banging. So yeah, forthose folks listening, I think
(34:45):
it depends on the person if youcan handle it.
Dr. Doug Kuntzweiler (34:48):
That's good. I'm glad you didn't have
any trouble with it. I hadenough trouble that I didn't
really ever want to do it again.
I could, but I might ask for alittle Ativan or something.
Beth Brown (34:59):
Yeah. People, then, who opt for the radiation rather
than the surgery. So I'massuming your risk for
reoccurrence of prostate canceris nil because you no longer
have a prostate, and maybethat's not entirely true, but
what is the risk for gettingprostate cancer again after
you've had it and soughttreatment, either through
(35:20):
surgery or through radiation?
Dr. Doug Kuntzweiler (35:22):
Both are quite good, less than 10% chance
of recurrence. But that's notzero. And if it were to recur,
and you would know that, becausewhether you have radiation or
whether you have surgery, peopleare going to follow your PSA.
Like I'm getting it every threemonths for the first year, and
then, depending on what happenswith that, we might go to
annually, and it would be thesame if I'd had radiation. But
(35:46):
if it, if it comes back and ifPSA starts rising again, then
you've got a met somewhere. Andprobably the next thing that
would be done would be eitheranother MRI or, more likely, a
PET scan. The PET scan, theygive you a radioactive labeled
medication, and it's taken uppreferentially by tumor cells.
(36:07):
And so they put you in anothertype of scanner that detects
that radiation, and it willlocate where the metastatic
disease is. If it's in bone,then you might have the option
of having radiation to that areaof the bone to help with the
pain and to slow down the tumor.
So there are other things thatcan be done. Anti-testosterone
drugs could be given, but itjust depends on what happens
with the PSA and and where yougo after that. And again, you
(36:31):
might elect not to do anything,and like my friend, you might
just go into hospice. He didn't- he was suffering enough that
he didn't want to haveradiation, and his was
widespread enough that it wasgoing to be pretty futile to try
that sort of thing anyway. So soit really depends on the
particular situation.
Beth Brown (36:51):
Again, thank you for sharing your experience. I just
want to make sure that any menwho are listening, or those of
us who have men in our livesthat, you know, we like quite a
lot, what do you want to makesure we hear today? What's our
takeaway message?
Dr. Doug Kuntzweiler (37:08):
Well, the takeaway message is, know your
family history. If you're havingtrouble emptying your bladder,
and in some men it startsearlier, like in their 40s, by
all means, see your primarycaregiver, get a PSA test, and
if that looks suspicious, thenask to see a urologist. There
are some very good websites youcan go to. The American Cancer
Society has an online decisionaid, as does the American
(37:32):
Society of Clinical Oncology.
These are websites where theywill ask you questions about
your health and about your age,and if you've had a PSA, what
that level was, and they willhelp you make decisions about
what your next step should be.
Beth Brown (37:46):
That's great. All right, awesome. Thank you again.
Dr. K, really awesome journey,and so glad it worked out as
well as it did for you.
Dr. Doug Kuntzweiler (37:54):
Yeah, I'm going to be around for a while,
unfortunately for you guys.
Beth Brown (37:57):
No, that's not unfortunate at all. Thank you
very much. And thank you forlistening. We'll include the
resources that Dr. K mentionedso you can get information about
prostate cancer and decisionsyou may need to make. And if you
have a question for Dr. K,please email us at
QandAwithDrK@mpqhf.org, and wewill put that email address with
(38:19):
this episode as well, so thatyou can get your questions
answered anonymously. Thanks somuch and be well.
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