Placing Gold markers and getting tattooed

CT Scan and Gold Markers: the start of the radiation process

Hi, today I had the CT scan that is needed to set up my radiation plan. It was easy; all I did was lie there. The treatment starts after Thanksgiving and will last for 35- to 45 sessions. More on this later.

First, I will catch you up on the latest in my treatment. I had a PSA at the beginning of November. It was officially ‘undectable,’ which means that it was below .10. In June it was .17 and in September it was .23 (before my surgery it was over 5). The rise is what triggered the current radiation treatment. In September I was injected with lupron, an estrogen, which combats prostate cancer. The lupron is working.

To arrive at today’s session, however, I had to have two gold markers “placed.” This next paragraph is a bit graphic, so you might want to skim it. In order to place them, I had to go through a regimen. On the morning of the placement—November 5, thankfully for what happened that morning I was still elated from the election--I had to finish eating by 9, take no food or liquid after that, and give myself a Fleet enema, which according to the package, causes a “bowel release,” in 1 to 5 minutes. The bottle has a long tip, which is lubricated. The releasee kneels on the floor, rather like child pose in pilates, and inserts and squeezes. The bottle empties into the bowel and the releasee heads for the toilet, magazine in hand. And the package was accurate. In about 1 minute came the first release and within 5 came two more. And so I was evacuated. Not knowing what the car ride in might be like I took along a second pair of pants and two Depends, left over from the incontinence period in January/February. I never needed them for accident management, but did need them later as you will see.

I have to point out that even though the night before was full of suspense and then great joy and then admiration for John McCain for making a gracious speech and finally for the Obamas who will be so fun to have in the White House, I was focused on myself. I realized that the next day I started on the cancer journey. Phase I had not worked. It wasn’t gone. Phase II is a sobering thing to begin. While I expect this to be Phase End, there is no guarantee of that. I slept well, but that chill is back there, waiting, like an arctic high stalled in Canada.

Anyhow, after the evacuation we left for Metro Urology in Woodbury to see Dr. Serson who would do the placing. (Well this paragraph is going to be even more graphic, and it has needles, so proceed at your own chosen speed. You can just skip to OK below.) After a brief stay in the waiting room, I was ushered into a room that had large chair that could unfold into a sofa-like arrangement. The nurse told me that they would be placing the gold markers. She had four out, though she was not sure how many he would actually insert. She asked me to remove my pants and underpants and put on one of those hospital gowns. She left. I did. There I stood feeling a bit silly as one does when your butt is hanging out; perhaps that is where those dreams of teaching naked from the waist down come from (“surely no one is noticing”). She asked me to sit down. The doctor came in. He told me as I sat there that he would move the chair back so that I was lying sideways and he would place two markers. I felt a relief—just two. Then he told me that this was done without anesthesia. He suggested I hold onto the edge of the chair. The placement began. A very large long object, thoroughly lubricated, slid up my rectum. He apologized. Actually, he apologized repeatedly throughout the procedure. One function of the object was to activate an ultrasound of my prostate bed. He had to place the markers on either side of the stitching where he sewed together the urethra after he removed the prostate. He talked through the entire procedure. First the lower one. Then he apologized again. This would hurt. The other function of the object was to unleash the needle that penetrated the rectum wall and other tissue to get the gold over to the appropriate spot. It went well. He could see it. He got it exactly where he wanted it. I felt every millimeter of progress, and held on tight. Then he did the other one, once again talking. Oops. Through scar tissue, which is thicker. You know, I could tell it was thicker. Eyes watering at this point. All of a sudden he asks, Where is it? He couldn’t see it. The only thing I could imagine was that he would have to do this again. I held tighter. Then Oh, there it is! Just where I want it. The needle retracted. The Object slid out. The procedure was finished in less than five minutes. I realized that I would never last at Gitmo—I would talk. But actually I had a root canal in 1973 and my recollection is that that was worse.

OK. No more needles. The nurse left. We sat there and talked about Gleason 9, which is categorized as High Risk. I asked what that meant. He told me that it meant that there was a high possibility of it recurring, which it has. So I asked, again, the fearful cancer question Was I on a timeline? He answered without hesitation. No. He is confident of controlling this. We chatted a bit more but I remember very little of it. He left. I went to put on my clothes, only to discover, surprise, that I was bleeding. I called Mary. She went to the car and brought me the Depends. I wore them the rest of the day and all the next. The bleeding never returned. We left about noon, drove to St. Paul, found University Avenue, stopped at the Russian Tea House, and had a fine meal of piroshkis, soup, and tea. That afternoon I went back to work.

This morning was much less traumatic. I had the same regimen. Eat early. No liquids or food after 7:30. The Fleet enema. The ride in. The only difference is that we stopped at 9:45 so that I could “void” at the rest stop just inside the Minnesota border. I had to empty my bladder 45 minutes before the scan. Fifteen minutes later I drank 16 ounces of water. The idea is that the bladder should be full so that it is out of the way during the actual radiation bursts.

In Maplewood at MOHPA we checked in; after just a few minutes I was called back for the scan. Once again I removed clothing and donned a hospital gown. Then began a really interesting procedure. I had to lie down on a cloth-covered wooden board that extended into a machine that looked like a giant doughnut. The wood was to ensure that my body would be in the same position the next and every time. My feet and calves were laid on some kind of plastic that was wrapped around, then hardened. This cast would be used every time to hold me in the exact spot. Up came the hospital gown. They made three marks on me—right, left hips and lower stomach. It turns out, if I understand this correctly, that these marks were the points that the three laser beams in the room, one on each wall, one in the ceiling, hit me. Think of the jewel robbery in The Shot in the Dark. They also used the ceiling beam to precisely line me up with the center line of the board, and thus of the machine. The beam hit my breast bone and the two attendants pushed and pulled me until I was in the right position. The doctor entered, and pushed something against my penis and that something ejected a stream of liquid up my urethra so that it would show up precisely in the images, and they would know where to not aim, and thus not microwave this important part of me. After that handling, I received an injection of what was called a ‘contast.’ This liquid, within 30 seconds, entered my entire blood stream, causing the images to show everyone of them. When all was set, I entered the machine. It whirred and took a number of images, which will be used to precisely aim the radiation beam. After the scan was over, they slid me out of the doughnut, and then tattooed three points on me. Those tattooed points and the gold markers will align the radiation machine, precisely directing the beam. Even though I asked, and they explained, I am not sure why they had to use the markers and then the tattoos. I hope to clear this up later.

After I dressed, Mary and I waited in an exam room to discuss the scan with the doctor. While we waited, a nurse entered and talked a bit about radiation. She assured me that I would not be radioactive. I could hold babies, sleep in the same bed as my wife, and hug pregnant women, none of which it had ever occurred to me to worry about. The doctor entered and we went over the radiation schedule. He thought I would need about 35 times, but they schedule 45 just in case. He explained the system which is that I come in, enter my name in a computer at the front desk, and when called enter the radiation room for the 10-15 minute treatment. On Wednesdays we would talk, just to keep in touch, though I will see what actually happens during those sessions. I could drink alcohol, I might get a sore rectum, if I lose my appetite and thus weight, I should eat ‘all the food we tell you not to eat because it is bad for you’—I remembered Simon wanting to eat junk food on the days after his chemo sessions, I might become exhausted, but might not.

Then I asked a question that had an interesting answer. Several times during the morning he or one of the nurses/attendants had referred to how they used to do it in the Old Days. I asked how long ago were those old days. The answer—6 years. It turns out that up to 6 years ago they used a technology called 3D something. I will get the exact name. That technology replaced a different one 15 years ago. Some places still use 3D. MOHPA was the second place in Minnesota to switch to IMRT, which according to Dr. McGuire, is the latest and current best. This technology allows them to send various dosages of radiation into me, lower dosages for the ‘good’ structures in me and higher for the ‘bad.’ Furthermore the amount that the radiation machine emits and the point on my body where it emits that level is computer controlled. Computerization allows the doctor and his team to run 2000 variations of dosages and locations in order to obtain the optimal combination. In the old days, they might do three. In the old days there was a lot of guess work. With this technology, there is considerably less; they shape the beam for my anatomy and my diseased spots.

One last thing about my diseased spots. I have what is called microscopic, as opposed to gross, infection (or whatever the correct word is). This technology allows them to deal with these tiny areas. To explain all this he sits with one hand on an examining bench covered with paper, the kind on a roll that you pull off and through away after the patient lies on it. The whole time he draws anatomy. It is amazing to watch.

My job when the treatments begin will be to drink the same amount of water at the same relative time to get my bladder to the same fullness, hence position, thus allowing the innards to assume the same relative position allowing the beam to hit the same spot. I assume that they have some margin of error built into this procedure since what I just outlined is clearly impossible at the microscopic level.

We finally left him to talk to the scheduler. Everyone wants to begin after Thanksgiving. Their schedule is very full. They will call me. We walked out to the car, drove into St. Paul, had lunch at Café latte, stopped to buy shoes at Shuler’s in Woodbury, arrived in Menomonie about three. Mary went to her Spanish class. I went to work, had a wonderful meeting with my Engagement Project group, and came home.

And so my journey begins. I have said before that I am neither worried nor afraid, but I feel that I need to add a bit to that. I can be flip, and have been. Cancer is an awful thing and now my life and my family’s is marked by how long I survive. I want to say, though, that my cancer does not have, at least at this point, the awful finality that many people’s does. People comment on my attitude, and I thank them for it. But I am very aware that my attitude is nothing compared to the one that many people must have. My worry, in a sense, is untested. For others that is not the case. Those people know the meaning of worry and fear and what it takes to counter them in ways that I do not. I hope that my detailing my plight can remove some of the fear of the word cancer; I even hope I can get you to smile sometimes. Cancer, curiously, brings a certain kind of gift—of love, awareness, and inner strength. I am thankful for those, but I would never want anyone to think that I am making fun of the disease or its often sudden and terminal consequences.

For all that I can report one more emotion. Today as I left that clinic, I felt, as I did after the placing several weeks ago, elated. I noticed the light on the buildings, the people on the sidewalk, the taste of the food, even the feel of the typewriter keys. The pleasantness of the meeting at 4:30 was so comfortable. As I say, strange gifts.

--November 17. 2009