My War With Cancer – Notes from the Front Line

I was diagnosed with advanced metastatic cancer of the prostate early in 2019. Metastasis means cancer has traveled beyond its originating location. It does this via the bloodstream and via the associated lymphatic network of the body’s immune system, and these can provide roadways for it to spread. This is what makes metastasis so very dangerous – as once it has started there is not knowing quite where it will stop. In my own case the process that proceeded over the course of the rest of 2019, and now into early 2020 as well, will, if all continues to go well, hopefully, lead to a complete cure, and the story of what has happened so far in this ongoing battle may be of interest to some of you reading this article. My family doctor became suspicious of possible prostate cancer following a routine blood test early last year, at the beginning of February 2019 when cancer indicating blood marker specific to prostate cancer suggested there could be a significant problem. This marker is called PSA (Prostate-Specific Antigen) and anyone worried about their prostate these days will hear a lot about it.

A confirming, and frankly quite intrusive, ultrasound-guided biopsy last March, organized by a hastily recruited Urologist, indeed showed the presence of aggressive cancer of the prostate, rated 10 on the so-called “Gleason” scale – which is as high as it goes. Then a PET/CT (Positron Emission Tomography/Computed Tomography) nuclear imaging scan in April indicated that metastasis had begun to spread cancer elsewhere, though fortunately not yet very far. Therefore, in May 2019 I entered the out-patient cancer program at the Rambam Hospital in Haifa, Israel – a teaching hospital that sits right next door to and is affiliated with, the Technion Israel’s Rappaport Faculty of Medicine.

The treatment plan 

The treatment plan designed for me by the medical team at the Rambam’s Oncology Center is intended to lead, if successful, to a complete cure by way of what is called “combination therapy”. This comprises, first, a pharmacological component deploying medications over a 24 months period that suppresses the production of testosterone in the body. Testosterone is a necessary presence for the growth of malignant prostate-related tumors it would seem. In this case, the current medication of choice has been Zytiga (generic: Abiraterone), ably assisted by the corticosteroid Prednisone. Two other, testosterone suppressing, compounds Decapeptyl (generic: Triptorelin) and Casodex (generic: Bicalutamide), were also deployed in a supporting role.

The second component of the combination therapy entails intense irradiation of all the now-known, and some hypothesized by extension, malignant cancerous areas of the body using powerful state of the art radiation equipment, over a period of two and a half months. The testosterone reducing medications began in May 2019 and, I am told, will continue into the Spring of 2021, and the radiation treatments began in mid-August, 2019 and were completed by the end of October.

Radiation treatment

Preparations for the radiation program began with a number of, essentially intelligence-gathering, preparatory “simulation” scans on CT and MRI (Magnetic Resonance Imaging) machines. These scans were designed to map out in detail, and then help define with precision, the prospective locations, scope, and intensity of subsequent planned intensive radiation treatments. These, combined with the pharmacological solution above, are supposed to kill malignant cancer cells wherever known to have been found up until then, and also in certain surrounding areas as well with a decent probability of finding more.

Both the original April PET/CT scan and the August MRI scan also showed the physical outline of the malignant tumor within the prostate itself, something having a total volume of about 20 cubic centimeters. These imaging tools thus allowed me to, if you like, visualize the face of the “enemy”- which is something very personal. And when you go to war, which is what this is, this certainly helps.

Prostate cancer that has remained confined within the prostate gland can sometimes be relatively (!) benign, and even if more advanced can often be treated by surgical removal. Once it has metastasized beyond the prostate gland itself, however, it becomes much more dangerous if not caught early in that process, and statistics demonstrate clearly it can then be seriously lethal.

The radiation treatments themselves, completed over a two-and-a-half-month period, were as follows:

First, there took place three SBRT (Stereotactic Body Radiation Therapy), ultra-high intensity, radiation sessions targeted at known aggressive malignant cancer cells which had spread beyond the prostate and attached to a single dorsal vertebra of the spine D5 (thoracic T5).

Then, there ensued twenty-eight high-intensity EBRT (External Beam Radiation Therapy) radiation sessions, (i) targeted at known aggressive malignant cancer cells within the prostate itself; (ii) targeted at the whole general pelvic area where possible additional cancer presence was inferred; and, (iii) targeted at known aggressive malignant cancer cells that had spread beyond the prostate and clustered among affected lymph nodes in the right Iliac. The Iliac regions of the body lie at the junction of the thighs and the lower abdomen, a.k.a. the groin.

Lymph nodes are glands that are part of the lymphatic system, which is a part of the body’s immune system. The lymphatic system acts all over the body, paralleling its network of arteries and veins. Over-simplified, in ordinary English, I am told it essentially acts as a drainage method for extracting and filtering toxins, viruses, bacteria, and dead or damaged cellular material. These become absorbed into a yellowish or white fluid called “Lymph”, where they are filtered and eventually end up being carried off by the bloodstream.

Lymphocytes are white blood cells that also play a key role in the body’s immune system. Lymphocytes mostly travel around the network of the lymphatic system (with some ever-present in the bloodstream as well), targeting and killing abnormal cells wherever they can find them. Then sometimes, when things go wrong, I understand this lymphatic network, and that of the bloodstream, can then perversely also provide ready-made super-highways enabling cancer to metastasize.

In my own case, I was told that, included in setting up the specific “strategic plan” for my radiation treatment, very careful targeting attention had therefore also been given to the known advanced cancerous areas that had become clustered in the lymphatic areas of the right Iliac, as described above.

The EBRT machine they used to irradiate the prostate gland, the pelvic area and the affected lymph glands in the right Iliac is a microwave-based Linac (Linear Accelerator) machine – in this case, a brand-new Elekta Versa HD unit, one that cost the hospital a number of millions of dollars.

The Rambam has actually recently installed two of these latest-tech machines, one of which I believe can also perform some CT scanning functions. Both are spanking-brand-new and are located in the hospital’s new Radiation Centre. This is part of a major investment in their new Oncology Centre, which was funded substantially by the family of the late Joseph Fishman, who were given naming rights to the building. The Oncology group are also installing two more latest-tech machines there next year as well, for which altogether four, separate, radiation hard-shielded rooms have been prepared.

Other existing radiation and scanning machines are located in the older parts of the hospital as well, providing overall a well-provisioned resource. The new Radiation Centre is actually placed three floors below ground level to protect from bombing in the event of war. In fact, I believe the whole underground parking lot morphs into an underground hospital itself at such a time when all patients would be moved down into it – with all the cars removed.

To irradiate the spine a somewhat smaller existing Elekta Linac machine was utilized. From the internet, Elekta appears to be a Swedish company, though one doctor told me it was American and another doctor told me it was English.

To assist in synchronizing precision-focused bombardment of the prostate itself by the new Linac machine, my doctors first inserted three near-pure gold “Fiducials,” or reference targeting “seeds”, into my prostate gland, using real-time ultrasound guidance, which I’m told will now stay there for life. To protect surrounding organs from being damaged by the intense radiation they then also inserted a radiation opaque “spacer” hydrogel, called by the somewhat awkward marketing name “Space OAR”. This was quite expensive, as it is not yet covered by Israel’s government health basket, but certainly should be at this point as it clearly did its job. Both procedures were performed under general anesthesia – thank goodness.

The total amount of intense microwave radiation absorbed by my body was:

My Spine (vert D5) 2,700 cGy over 3 days
My Prostate 7,000 cGy over 28 days
My Pelvis 5,040 cGy over 28 days
My Right Iliac 6,300 cGy over 28 days

The centiGray (cGy) is a standard measurement unit describing an absorbed dose of ionizing radiation. “1 Gray” is defined as the absorption of one joule of ionizing radiation by one kilogram of matter – i.e. in this case by me. The prefix “centi” stands for one-hundredth of a Gray. The joule is a standard measurement of work done, or of heat energy transferred. The Gray was named after the radiobiologist who defined it, Louis Harold Gray.

The technology deployed above is all very much up to date, vastly expensive, and seems completely state of the art. A friend of mine recently told me her French father-in-law had to go to Monaco to get exactly the same treatment arrangements – which were indeed completely successful. The health care system here in Israel is quite progressive, as indeed is Maccabi my local HMO (Health Management Organization), and so-far the standard of the medical care I have received, and of the necessary medical administration to back it up, which is not insignificant, have both been excellent.

Recent blood tests 

Recent blood test trends, which are now being done at regular two-monthly intervals to provide sign-posts to progress after the radiation concluded, seem to say mostly what one would hope for and, in particular, as of mid-March, 2020 the prostate critical blood marker PSA is now reduced to just 0.37. This marker is a density, or mass, indicator and is measured in nanograms per milliliter, abbreviated to ng/ml. What it means at a fundamental scientific level I have no idea, but one can readily infer that less is good and much less is better still. The statistical trend to date in my own case is given in the time series chart below.

The PSA upper limit is supposed to be 4, it seems, so it is now at least well on the right side having peaked at almost 40 in May of last year. When it hits zero (when not if!) this will become a major positive milestone as far as I am concerned.

Looking ahead, however, if there should be a continued increasing rate of change over several tests, even with low numbers, I am told there could still be concerns.

There are two other cancer-indicating metabolic blood markers for which I have been tested regularly as well, and the trends to date of all three are shown in the chart below. The PSA marker itself, specific to prostate cancer, increased rapidly early on before the treatments began, tumbling regularly since to its present near zero. However, the two other markers, which are known as CEA (Carcino Embryonic Antigen) and CA-19.9 (Carbohydrate Antigen 19.9), are indicators for other cancers and these have both remained steady throughout, and, I believe, remain within normal ranges.    

Three Cancer-indicating Blood Markers

Antigens are molecules that can selectively provoke a direct immune system response. The first such antigen-specific to cancer was the CEA antigen, which was discovered in 1965 in Canada by Professors Phil Gold and Samuel Freedman in relation to cancer of the colon. The PSA antigen had a much more involved, and even controversial, genesis and was studied by a number of scientists in the nineteen seventies. This antigen was eventually purified and defined by 1980.

The medical team in charge of my treatment at Rambam has been both decisive in aggressively planning for a total 100% cure, and yet very careful in its implementation, resulting in few side effects to date from either component. A key question I have now is what is the total effect that the combined radiation and pharmacological treatments completed to date have now had on all the previously identified malignant areas. A second question is whether more cancerous cells might have spread to other places in the mean-time. To find out the answers to both questions will, for sure, be more than interesting. A third question, too, is the implied probability of biochemical recurrence later, even if all cancer was successfully destroyed everywhere initially. This can only be inferred, as my case is a stratified sample of 1 amongst whatever global empirical statistics might indicate.

Zytiga  

So, radiation therapy is concluded, and the rest of the combination therapy continues until the Spring of 2021 to finish the job. During this period there will be more blood tests at regular intervals, to monitor the three important cancer markers as well as the many other blood components that such tests usually check.

The daily Zytiga, testosterone suppressing, therapy which began in May 2019, and the six-monthly injections of Decapeptyl, will continue their work of suppressing any and all tumor growth pharmacologically. Continuing for a total of two years until the Spring of 2021, this is intended to keep the lid on things, to inhibit further metastasis and eventually, if all continues to go as it is planned, administer the coup de grâce, as it were, and leave the body cancer-free.

Zytiga is fairly strong stuff, yet has been readily tolerated by my body so far, with only occasional quite severe shortages of breath as a significant side effect – there can be several others if you look at the product literature. In mitigation, this was when playing tennis last summer in 30 degrees celsius and with associated high humidity. In response, now I try to take the pills after playing tennis instead of before, and if I forget I do a lot of deep breathing exercises on court to compensate.

Sometimes, between the pills and the (presumed) after-effects of all the radiation, I have gotten really quite tired once or twice, and taken several days to recoup. With a 20 cubic centimeter malignant tumor having been burned up inside one by a high-powered microwave unit, plus similar impacts on the other radiation targeted areas, perhaps this is not altogether surprising. Other side effects have included ongoing anemia, too, which can also contribute to fatigue as the body fights for oxygen – especially whilst doing sports.

But it’s all good; healing takes time and is not constant in its rates of progress, with sometimes substantial ups and downs which one must be prepared for. Continuing exercise and sports have been key ingredients for me throughout and still are. Otherwise, the entire process has been basically business as usual, and the only real burden in the process, perhaps, was the 90-kilometer round-trip commute to Haifa four days a week, then waiting in line in a busy waiting room, just like one’s Dentist’s, altogether more than thirty times to be irradiated. Indeed “business as usual” is an absolutely essential ingredient for approaching something like this.

Positive thinking 

Positive thinking, and refusal to let difficult issues get on top of you, together with continued optimism no matter what, as deliberate acts of will, are essential attributes in facing what otherwise could be a process quite daunting to many.

I guess the mission has been to just kill every last one of these malignant cells before they kill me. And I am much too ornery to let them get there first.

Given the issues involved, and the specialized tests and consultations which all have had to take place in sequence over several months, followed by extended periods of treatment as well, things seem to happen relatively slowly in cancer treatment.

Even so, from initial diagnosis in March 2019 to where we are now to, prospectively at least, already a likely near-cure position that is still pretty quick.

Thirty years ago, none of this would have been possible at all. And Oncology specialists have other weapons in their armory today as well.

Even so, quite nasty adverse surprises could still emerge out of left-field, and one must still carefully respect what remains a highly dangerous, and unpredictable, enemy and stay the course: in a disciplined manner and without sentiment.

Such unquantified risks, particularly of, e.g., biochemical recurrence and possible return of cancer and ending up back at square one, is why this is all going to take some more time and my doctors are quite right to be careful. Once all the Zytiga treatments have concluded, in May 2021, I believe another PET/CT scan will be summonsed, which should then again show the continued presence or absence of malignant cancer cells anywhere in the body (from below the head down). Apparently, to work properly and get a clear picture it is important for this scanner that all the testosterone suppressing medications should have first totally cleared from my system, which I understand is why this will wait until the end of the process.

An overwhelming takeaway from my experience to date 

Finally, the overwhelming general takeaway to date from my experience above, worth stating loud and clear, is that Haifa’s Rambam Hospital now has a leading clinical position in cancer treatment, one which can stand up to the very best anywhere in the world and they deserve to be supported. Together with its new, adjacent, Eyal Ofer Heart Hospital, its new Children’s Hospital, and other projects underway the Rambam is parlaying its own multi-disciplinary approach into something quite special. My own twenty-eight visits to their underground radiation center last year also introduced me to a wide spectrum of fellow cancer patients, from all walks of life and multiple ethnicities, each of us sitting there in the waiting room there and all receiving exactly the same excellent standard of care. A particular, unique, kind of shared experience – something that one sensed all understood and somehow appreciated. A little surreal, yet totally awesome. Cancer is an equal opportunity disease.

 Clive Minchom, 74, is a semi-retired businessman who worked for most of his career primarily in industry, and in the field of corporate finance. He comes originally from England and now, after a small detour to Canada for thirty years, lives permanently in Israel – which altogether he finds to be a very wholesome experience.