July 2017 blood test

I had a blood test just before going away for 2 weeks to France so didn’t get the result until I phoned yesterday. The PSA level is still 0.01 so good news. This is the 4th blood test since my radical prostatectomy, 0.02, 0.04, 0.01 and 0.01, so things are as good as they can be at the moment.

I spoke to the specialist nurse today to find out what my Gleason score was after the pathology tests on the removed prostate and surrounding tissue. It was 3+4 so a total of 7. He said only 50% in my condition would get a recurrence and only 50% of them would go on to further treatment. An article I referred to in an earlier post gives this table:

WHAT THE NUMBERS MEAN
If you have a Gleason score of 5-7
Your PSA increased more than two years after surgery

AND your PSA doubling time was greater than 10 months:
Your chance of not developing metastasis(having a bone positive scan) in:

      • Three years:  95 percent
      • Five years:     86 percent
    • Seven years:  82 percent
OR your PSA doubling time was less than 10 months:
Your chance of not developing metastasis in:

      • Three years:  82 percent
      • Five years:     69 percent
    • Seven years:  60 percent
OR your time to first PSA recurrence was less than two years:

AND your PSA doubling time was greater than 10 months:
Your chance of not developing metastasis in:

      • Three years:  79 percent
      • Five years:     76 percent
    • Seven years:  59 percent
OR your PSA doubling time was less than 10 months:
Your chance of not developing metastasis in:

      • Three years:  81 percent
      • Five years:     35 percent
    • Seven years:  15 percent

I was also told that the post operation pathology on the tumours were graded at T3a. This implies a locally advanced cancer, i.e it has spread beyond the prostate capsule, but it has not spread to other organs. My seminal vesicles and a surrounding margin was removed to be on the safe side. Another paper concluded:

Survival was significantly different when comparing pT3a to pT3b groups. The 5-year overall survival (OS), cancer-specific survival (CSS), disease-progression-free survival (DPFS), and biochemical-progression-free survival (BPFS) were 96% versus 72%, 98% versus 77%, 97.3% versus 79.3%, and 60% versus 24.2%, respectively. Specimen Gleason score was the most significant predictor of OS, CSS, DPFS, and BPFS. The risk of death increased up to 3-fold when a Gleason score 8–10 was present at the final pathology. Conclusions. Radical prostatectomy may offer very good CSS, OS, DPFS, and BPFS rates in pT3a PCa. However, outcomes in patients with pT3b or specimen Gleason ≥8 were significantly worse, suggesting the need for multimodality treatment in those cases.
https://www.hindawi.com/journals/au/2012/164263/

This is also promising for me.

Exercise, not being over weight and maintaining a high level of general fitness and health, although there are no guarantees, are highly correlated with remission and higher survival rates. At the moment I am 13 stone 12 lbs, about a 10 lb heavier than when I had the operation last August. The plan now is to get back to 13 stone over the rest of this year. To this end I will be buying a smart trainer for my bike and start training and get involved in on-line racing using Zwift and a Facebook group called The Big Ring. This will involve a significant investment but but it is literally for life.

How Exercise Might Reduce Prostate Cancer Progression

“A new study suggests that vigorous physical activity will offer protection against prostate cancer progression because of its effects on DNA repair and cell-cycle pathways. The finding might help explain previous observations that men who exercise vigorously have a reduced risk for all-cause mortality and prostate-cancer-specific mortality”.

“Men who reported that they undertook vigorous physical activity for 3 hours per week or more were found to have a 49% lower risk for all-cause mortality and a 61% lower risk for prostate-cancer-specific mortality than those who exercised for less than 1 hour per week. The vigorous physical exercise consisted of jogging, cycling, tennis, or swimming. Men who reported this type of exercise for more than 3 hours per week before and after their diagnosis of prostate cancer had the lowest risk for all-cause and prostate-cancer-specific mortality”.

http://www.medscape.com/viewarticle/757935

Today’s post prostatectomy consultation

I made some notes on questions to ask Mr Sing in a recent post Decisions. He was able today to give me a little more detail.

The apex of the prostate where my tumour was pressing on the surface in fact has no capsule so dissecting this area is not so clear cut as the prostate goes right up to the pelvic floor muscle and it is not possible to take as wide a margin for testing as it is elsewhere. Dmaging the floor muscle could lead to permanent incontinence. The sample tissue sent off for testing showed some small areas of limited and focused cancer cells but there is no way of telling if these had gone any further into the surrounding tissue. The dissection is done with an electrical current and it is possible that any cancer cells outside of the incised margin may have been killed off anyway.

I was shown pictures of my prostate and there was an awful lot of cancer marked in red! I forgot to ask if it was confirmed as stage T3a but can ask on the phone which I will tomorrow.

My PSA was confirmed as 0.02, described as very encouraging, especially due to the small and focused positive samples. Although PSA is not a reliable indicator or prostate cancer while you still have one, once removed it is very reliable. It’s early days but there is a good chance it will go down to zero over a little more time and they will check again and arrange another meeting in 6 weeks time. If it rises, especially to over 0.2, then radiotherapy will be recommended. Even then, if left alone, it could be many years before it developed into a recurrence of a discernible cancer tumour.

The standard procedure from here on would be to simply monitor my PSA level and only offer further treatment if it reaches the 0.2 threshold. 50% of men in my condition will not need this. Of the remaining 50% a large proportion will still be cured and the rest most would be able to keep it under control fr many years before palliative care became the last option. This seems to warrant quiet confidence.

I still have to make a decision about whether to go into the trial in which I may be assigned to the group that has radiotherapy more-or-less immediately. At the moment my feeling is that I am likely to be in the 50% who won’t need it based upon my own strategy of nutrition and exercise to stop the cancer developing. I’ll need more information from Dr Owen next week.

Mr SIngh seemed mildly surprised that I have had no problems whatever with incontinence and that I played in my first racketball tournament last week, 9 weeks after my operation. I also mentioned I had just got back on my bike this weekend for very short distances. He didn’t say anything to dissuade me other than to remind me I had had major pelvic surgery. I’ll check this again by phone tomorrow. Also I need t check if it is advisable to not ride for a few days before PSA tests as was the case when I still had a prostate. Could it irritate the residual cancer in anyway and produce a higher reading?

The walking cure

On Wednesday 31st August, the day after my catheter and staples were removed, I started a walking regime to help me get as fit as quickly possible. It is now a week later and since then I have met the steps target set me by my Vivofit everyday. While I continue to hit the target the Vivofit increases the step target each day. Last Wednesday this was 7728 and by Tuesday 6th September it had increased to 9347. Over the week I walked 82,912 steps, an average of 11,845 per day, about a 5 mile average. Walking was the only form of exercise that was recommended for the first few weeks with no further instructions other than to “listen to my body”, which I did. Towards the end of the week I started to incorporate a few hills. I’ve been very happy with the way it’s gone and feel significantly better now than I did a week ago. More of the same for another couple of weeks I think although I will not be particularly worried if I don’t meet the targets set every day from now on.

I went to the squash club at Heaton on Thursday 1st September, 11 days after the operation, and had about a 10 minute knock by myself to see how it felt. I didn’t push it at all, just hitting to myself down the side walls in the channels and some figure of 8s at the front to minimise my movement and not damage myself. I felt fine with no twinges. I did the same again on Monday 5th with the same result. I will start going regularly to build on this but it will be a while before I play against an opponent, even socially. Thursday I should be able to return to doing a little coaching as before. My weight has stabilised at around 12 stone 9 or 10, about 6 lbs lighter than when I went in for the operation so my strategy to not put on weight seems to be working so far.

With a view to starting cycling again I have been researching saddles with a cut-out to relive pressure on the perineum. Normal saddles put pressure on this area and can be quite painful for quite a while after a radical prostatectomy as this bears directly on the area where the urethra has been joined up. This gets better over time apparently. I probably won’t ride until I’ve seen Mr Singh and I may need to know if I should delay until after radiotherapy if that is needed.

I have spotted on a couple of occasions a very small blood clot being passed in my urine but have decided not to worry about it. I have 4 weeks before my scheduled appointment with Mr Singh and the BRI (when I will get the histology report and learn if I need radiotherapy) and will mention it then if it continues.

Getting back to normal

On Tuesday 30th September August the catheter and staples removed. The catheter removal I had dealt with before but staple removal was new and I was quite apprehensive about it. The staples are more like the staples you hammer into wood to hold wires in place rather than the office type of staple that go through paper and bend round so the procedure was quick and painless apart from the odd brief sting. Normally staples come out between 10 and 14 days but it made sense to remove them at the same time as the catheter appointment in this case if the surgical wounds are sufficiently healed, which they were.

Then it was just a case of sitting in the waiting room and drinking slowly and steadily two 700 ml jugs of water in order to produce three sufficiently prodigious wees. This involved going to the gents’ toilet and weeing into a bottle with you name on it on a rack – there were 5 men going through this procedure. Every now and then Staff Nurse Sarah (who I thought of as Nurse Catheter) would check the bottles, record volumes and empty them. I managed this without too much difficulty and was allowed to leave at about 11.00 am when Julia picked me up to take me home. I was given a few incontinence pads to take home with me and I was advised to use one straight away before I got of the treatment table as there might be a sudden surge as I stood up. Nothing happened but it was better to be safe than sorry. It is not always as straightforward as this I discovered talking to the other men. Sometimes there is no flow and the bladder just fills up. In these cases a catheter had to be installed again. We were advised to only drink about one small gals of water per 15 minutes as in the past men keen to get away had drunk 2 jugs full straight off in their haste to get away only to find they couldn’t wee and put themselves through some serious pain before a catheter could be replaced.

On arriving home I went for a walk around the local park and felt immediately that I could walk better and in more comfort now the catheter had been removed and felt optimistic about gradually building fitness again although this would be restricted to a walking only programme for a few weeks. I wore the pads for the first two days but didn’t have any leakage problems at all so have pretty well dispensed with them although I’m not fully confident. Most men suffer to some degree or other form incontinence after the operation. For many it is only for a few days, perhaps a couple of weeks. For others it is a constant problem that requires further corrective surgery. It looks like I will be one of the few who don’t suffer at all. If this is the case I think it will be down to two factors, my general level of abdominal fitness through cycling, walking and racketball and the fact that I have been pretty assiduous in doing my pelvic floor exercises for a couple of months before the operation.

My key advice to any man who is going to have this operation is to try to lose a bit of weight and get fitter if necessary but in any case do your pelvic floor exercises. I was instructed to do the exercises as soon as the operation had been done and not wait for the catheter to be removed. While incontinence remains a problem you should do the exercises the recommended 3 times a day. Once continence is achieved this can be cut down to twice a day, for life. Given that you can do these any where at any time, standing up, sitting or lying down, and they only take about 2 minutes there is no excuse. I shall continue with 3 times a day.  I may yet have to have radiotherapy, depending on the histology reports on my prostate and the surrounding tissue removed. This can also produce continence problems as side effect so I want to be in as good nick as possible just in case. I will find out if I will be getting radiotherapy when I see the consultant again on the 6th of October.

Yesterday, Wednesday, I went on a fairly hilly walk of about 2.5 miles and am feeling stronger every day. I will be building up the walking over the next 3 weeks before I have a short easy bike ride, probably only 10 minutes or so somewhere flat, to see how that goes. I’ve had to withdraw from two racketball tournaments in both of which I was lying 2nd in my group. However, the 2016 Yorkshire Racketball Championships are to be held on November 26th and 27th and I hope I may be able to play in this, in the over 60 group.

Taking steps

In the last post I noted I had started cycling for fitness again in July 2012. This was very successful in terms of weight loss and by November 2013 I had got down to about 14 stone 7 lbs. It was then, partly because the weather was changing as winter approached, that I began to incorporate walking into my routine. This was reported in a post in my cycling blog Cycling, walking, hitting a ball in December 2013. I started doing specific walks round my immediate vicinity in the Aire Valley on the borders of Bradford with Leeds. Shortly after I began to use walking as an everyday form of transport often walking to Bradford centre and back for U3A meetings, or to Shipley and back for my U3A reading group meetings. Any trip of 3 miles or less is walked if I have the time or if longer and going by bus I will walk the first mile or so or the last bit of the journey. I try to walk every day that I don’t wither cycle or play racketball, even if it is only for 30 minutes or so although I usually manage up to an hour. The Garmin Vivofit I started using in December 2014, just over a year ago, has recorded about 2.5 million steps so far in 17 months.

Over the years I gradually put on weight and finally approached 18 stone about four years I still did some walking with my brother-in-law Kevin. The picture above was taken while on a walk along part of the Cleveland Way near Whitby in September 2012, when I was about 17 and a half stone. We didn’t do more than about 8 miles a day and, despite wonderful weather and scenery and some great evenings in pubs listening to live music and chatting with the locals, the trip was dominated by aching legs and sore feet more than anything else. This was deeply disappointing as I used to find walking a very enjoyable and rewarding activity. This greatly added to my motivation to get fit and lose weight for my retirement. Now Kevin and I are planning some longer walks. In fact last September 2015 we had a few days walking round Malham and part of the Pennine way covering, on one day, about 12 miles. By then I was down to about 13 stone so a very different story!

 

Prostate cancer and excercise

There was a news item on the BBC Today programme Thursday last week on some research being done on any possible connection with exercise and the speed of development of prostate cancer in men that have been diagnosed with a Gleason score of 6 or 7 and on active surveillance. This is the PANTERA study. Details of the study and how to volunteer to be a subject can be found on the Cancer Research website. I fit the criteria to join the trial on every count except I already exercise beyond the maximum specified in advance of the study, more than 90 minutes per week of moderate intensity exercise. However, I was sufficiently interested to contact the lead researcher, Liam Bourke, by email. I asked if there if there is any information on the exercise regime required of the supervised group and whether they will be given any advice on nutrition. I was also interested in the conduct of the trial, in particular how if at all the ‘self-help’ group will be monitored for any level of activity they may decide to adopt in the light of the information pack you will be giving them and what that information pack consists of.

Dr. Bourke’s reply contained details of the exercise regime: Participants will be asked to attend two group-based supervised exercise sessions a week, comprising up to 45 minutes of aerobic exercise. Exercise intensity will be 65% to 85% of age predicted maximum heart rate or 12 to 17 on the Borg rating of perceived exertion scale, in episodes of 20-30 minutes of continuous exercise for the first 8 weeks, progressing up to 45 minutes per session thereafter. Gym based aerobic exercise training will be conducted using standard ergometers e.g. stationary cycles, rowing ergometers or treadmills. In addition, men are required to undertake self-directed two exercise episodes of up to 30 minutes per week, using an exercise log book and heart rate monitor to objectively record independent exercise behaviour and support adherence and compliance. They won’t be providing any nutrition interventions. The care pack for subjects in the group not undertaking regular supervised sessions is the standard Macmillan move more information pack, available free from McMillan Cancer Support. This comparison group’s exercise behaviour will be checked via standard questionnaires and any change in fitness by sub-maximal treadmill testing.
I have now joined the gym at my squash club and aim to replicate the 2 supervised sessions a week 20-30 minutes for 8 weeks and thereafter building to 45 minutes. I will not do the additional unsupervised sessions of 30 minutes per week as I think I will already be doing enough with cycling, walking and racketball!

Trust me, I’m a doctor

A few notes on the first in the new BBC series, broadcast tonight. It was of particular interest to me as it dealt with the effectiveness of whey protein as a muscle builder, how to slow down or even reverse muscle loss as you get older and what are the best times to exercise for weight loss with respect to eating. It also looked at the claims of taking fruit smoothies as a source of antioxidants. To summarise the findings:

Protein powders do not increase muscle growth providing you are getting sufficient protein in your diet. Any surplus is burnt as energy, is stored as fat, or is peed out of you system. The role of protein powder as part of a weight loss strategy was not considered in the programme. However, tests showed that protein supplements pass into your muscles in about 3 hours and the uptake is more in muscles that have been exercised.

Muscle loss starts in the over 40s at a rate of about 1% per year and after 50 at about 5% per decade. This is inevitable and is part of the normal ageing process – sarcopenia. This leads to loss of strength and power output as well as part of the reason balance deteriorates with age. The programme demonstrated how a few simple exercises done in the home without special equipment and generally without raising a sweat (so presumably not a cardiovascular workout) enabled a group of late middle aged and older subjects, over a 4 week period, have a 3% increase in muscle volume, a increase in strength of 12% and a power output increase of 13%. No special diet conditions were set.

The effects of exercise for fat burning were measured comparing subjects that exercised before eating in the morning and those who exercised after. Apparently the fat burning effect takes place in the hours after exercise and not so much during. This was not explained but it may be because the fat is used to replace carbohydrate energy stores in the blood. The effect was about 3% to 8% additional fat burn for men who exercised before eating and the same for women who exercised after eating. This is a new finding and may be explained by men having more muscle than women and the way the different sexes utilise energy.

Antioxidant drinks have no effect. If anything they produce an antioxidant spike that the body responds to by decreasing the amount of internally produced antioxidants so that the normal level is reduced and does not recover for 24 hours. So the supplements are counter productive. In any case, free radicals are necessary as they signal muscle damage has been done and repair mechanisms kick in. The balance between antioxidants and free radicals is managed by your body automatically.

The final snippet of information concerned looking at if being overweight was necessary a bad thing and whether fat loss was always something beneficial to strive for.  Fat round the bum and legs, hips generally, was not seen as particularly dangerous but round the stomach and abdomen definitely bad. BMI is still seen as a reliable measure of weight for mos normal human beings and under 25 is the recommended target. However, between 25 and 30 is OK for more elderly people, say over 65. Bearing in mind BMI is sensitive to the ratio between muscle and fat, in older people a highish BMI might be because muscle loss effects the ratio rather than just a matter of excess fat.

Finally there was advice about reheating food. Generally OK but be careful with rice because the bacteria present, although can be killed by thorough reheating, may have produce toxic spore that are immune to heat.

Trust me, I’m a doctor web site.

 

Health and fitness – summary

Health and fitness is one topic I will be posting about here but by no means the only things. However, since my retirement in July 2013 at the

age of 67 and a doctor’s earlier warning that at nearly 18 stone with high cholesterol and blood pressure I had an excellent chance of not making it much beyond 70, I decided that whatever other plans I may have for retirement they would all depend crucially on staying alive and this should be my initial priority. In fact I had made a start on this in July 2012 when I was inspired to start cycling again by Bradley Wiggin’s Tour De France victory. I say ‘again’ as cycle racing, along with squash, had been my main sports between my teens and when I gave both of them up at 40. I had never quite given up cycling altogether and had,

August 2003 in France

for the previous 20 years or so, undertaken one or two purely social rides on flat, short mainly off road routes with friends. I still had a couple of bikes in the garage and a now 30 year old turbo trainer so I started doing 5 minutes on the trainer most days and eventually short rides of 5 miles or so round the local roads.

Around August 2013, a year later, I started playing racketball, a variant of squash, with a view to getting back into squash too. Racketball is less technically challenging but just as physically demanding in terms of endurance if not speed and flexibility.

Me and Laura Massaro May 2014 National Squash Championships, Hull

Some call it old man’s squash! I enjoyed it so much and, once I recognised I would never get the speed and flexibility at 67 that i had in my 20s, I decided to stick with racketball. For what I wanted, a good workout, sociability and competition, it ticked all the boxes. The full story of all this is recorded on another blog I started in October 2012 called Bicycle Diaries. Recently the posts have been about a mountain bike accident and my diagnosis of prostate cancer but most of what preceded these are mainly on cycling and fitness. In addition I started walking a few days a week; anything between 30 minutes and 2 hours. I tried to work this into my everyday activity as a mode of transport on the days I didn’t play racketball or go out on my bike. The idea was to have at least 40 minutes activity everyday or at least most days when this wasn’t possible for some reason or another.

I soon learnt that as far as weight loss is concerned exercise would not be enough so I started modifying my diet. I signed up to MyFitnessPal to record my food and calorie intake and, with the help of a Garmin Vivoifit, calculated and recorded my exercise calorie burn. This wouldn’t work for everyone and can get a bit tedious but for me it works and over the 3 years I’ve been taking this seriously I have got down from 17 stone 12 lbs to 12 stone 10 lbs. This has been slow and steady and by making fairly small incremental changes to my nutrition and life style. I’m now fairly confident that I can maintain this without too much effort. I still enjoy the occasional over large meal and fairly heavy drinking at family celebrations and other similar events but these are always now fairly isolated one-offs and I easily drop back into my normal routine. In fact even my over eating and drinking is quite a bit less in volume than it used to be.

That’s the summary. I will post here with a bit more detail on individual aspects of this – cycling, walking, racketball, nutrition – in due course, partly for my own record of ideas and information and perhaps if I get any, answers to questions.