'Manopause' and the Lack of Gumption: My Prostate Cancer Treatment

Editor’s note: In our lifetime, one in eight men will be confronted with the challenges presented by prostate cancer. This is the third story in a series of six articles where Jackson Rainer discusses the implications of prostate cancer diagnosis, treatment and the impact on quality of life.

According to the Harvard Medical School, very few men are diagnosed with prostate cancer after experiencing symptoms such as difficulties with urination, or from evidence that the cancer may have spread, as indicated by bone or back pain. Nine out of every 10 cases of prostate cancer are detected at the local or regional stage, i.e., contained in the gland or spread into nearby tissues.  When the disease is discovered at these early stages, the five-year survival rate approaches 100%.

Once diagnosed, there are several treatment options, including radical prostatectomy - the surgical removal of the prostate gland; radiation — including external beam, implanted pellets; and proton and hormonal therapy, which suppresses testosterone, known as the "fuel" for prostate cancer. 

Each of the treatments has pluses and minuses. Despite years of research and efforts to improve results, complication rates remain stubbornly high. Therefore, the choice of treatment involves complex tradeoffs. 

Procedurally, they can be employed alone or in combination, depending on a man's age, the stage of the cancer, and personal preferences regarding the side effects of the treatments and the lifestyle changes they may entail.

I was diagnosed with prostate cancer categorized as disease at an unfavorable intermediate risk.  Physicians gave me two options to consider: Radical prostatectomy or a combination of androgen deprivation therapy (ADT) and radiation.

Surgery that removes the entire prostate gland is called radical prostatectomy, long known as the standard treatment for this type of cancer. Not only does the surgery remove the prostate, seminal vesicles and pelvic lymph nodes are excised. 

Credit: Illustration by John Gilman for Next Avenue

Over the years, the surgery has evolved so that it is now performed as a laparoscopic procedure, involving insertion of instruments and tiny cameras through "keyhole" incisions. In this contemporary day and age, the surgery is robot-assisted, where the surgeon sits at a console and uses remote controls to move robotic arms that are holding laparoscopic instruments. 

Robotic surgery now accounts for the vast majority of radical prostatectomies performed in the United States. Because of the medical advances, research evidence shows that these surgical patients have less blood loss, less pain, fewer infections and shorter recovery time than patients treated with traditional methods.

Depending on the technique used and a man's health, recovery usually involves one to three days in the hospital and several weeks at home. For a week at least, a catheter is placed to allow the urethra to heal. Erectile dysfunction and urinary incontinence are the most common, and often most distressing, complications of prostatectomy.

Based on my own scholarly study and consultations, bolstered by the unanimous vote of my intimates, many of whom are medical professionals, I decided on an alternative course of treatment: I chose a combination of Androgen Deprivation Therapy and Proton radiation.

Androgens, the family of male sex hormones that include testosterone, function as a fuel for growth in normal development. In some men, including me, they also drive the progression of prostate cancer. 

ADT (also called hormonal therapy) treats prostate cancer by dramatically reducing levels of testosterone and other androgens. An injectable drug, Lupron, was prescribed as an LHRH agonist to stimulate my brain's pituitary gland – the gland whose hormones orchestrate the activity of other glands and hormones. The effect of the drug is to reduce, or in my case, block testosterone.  Essentially, I was thrown into manopause as I became "Mrs. Doubtfire."

Not surprisingly, ADT has a wide range of side effects because it involves blocking a major hormone. Sexual function is a figural causality of this type of treatment, primarily related to sexual desire. I lost all erotic energy and am fortunate to have a partner whose magnetic romantic energy was sustaining throughout the course of treatment.

I was prescribed ADT in conjunction with proton beam radiation to boost the effectiveness of treatment. Recent studies in the journal Cancer demonstrate that patients in a higher risk category receive greater benefits from the combination of radiation and hormone deprivation. The results show that six months of hormonal therapy with radiation slow cancer progression.

External beam radiation therapy (ERBT) is the standard of care for prostate cancer. During this procedure, rays of high-energy radiation are aimed directly at the entire prostate, seminal vesicles, and nearby pelvic lymph nodes. Higher radiation doses are directed to areas of the gland that contain the most cancer. The ERBT effectively destroys cancer cells but can also damage adjoining healthy tissue. 

For this reason, I was prescribed proton beam therapy, which uses protons, i.e., sub-atomic particles with a positive electrical charge, instead of photons (light particles) which are used in conventional radiation. During proton therapy, radiation is released is a very narrow band, theoretically minimizing damage to surrounding tissue. Proton beam therapy is available at only a few cancer centers because it requires a cyclotron — a type of particle accelerator that is prohibitively expensive for many hospitals — to deliver the radiation. 

Because of the expense and limited supporting evidence, few private insurers will cover it. I was fortunate; all proton radiation was pre-authorized before the first blast was administered. I received 28 proton treatments, delivered daily over the course of five and a half weeks. 

Preparation for proton therapy involved the implantation of prostate fiducial marker seeds and placement of a SpaceOAR.  Both are relatively brief out-patient surgical procedures. The purpose of the marker seeds is to guide the radiation by defining the place of the tumor in the prostate gland.  It places a high-tech bullseye on the prostate as a somatic dartboard.

By using the marker seeds, the radiation oncologist can clearly see the prostate on daily imaging.  They stay in the prostate permanently. Smaller than a grain of rice, the seeds do not hurt or harm the body in any way. The SpaceOAR is called hydrogel and was placed inside my lower quarters to add "a room with a view." It temporarily creates space between the prostate and the rectum, protecting the rectum from radiation exposure during therapy. After approximately six months, the hydrogel is naturally absorbed into the body and removed through the urine. 

The ADT was administered by infusion. About a month later, the surgical procedures were completed (In more private thoughts, the surgical center was redefined as a personal body shop where I was having luxury options installed). A week following the surgeries, I began the course of radiation.

In order for daily treatments to go smoothly, detailed and thorough instruction for bowel and bladder preparation were provided that were to be followed to the letter. My appointment schedule was in the evening, after dark. I described this process to others as taking daily rides on the USS Proton, accompanied by radiologists who were skilled and empathic technicians, attentive to my dignity, vulnerability and fear. 

Gratefully, they did their job to deliver the treatments properly and competently while psychologically holding and respecting my humanity. Lying still and naked on a table, with a full bladder and an empty gut, in a moving machine rivaling the best that "Star Wars" has to offer, takes some accommodation. Each treatment was about 20 minutes and pain-free.

The pituitary gland regulates growth, metabolism and reproduction through the hormones that it produces. The production of these hormones is either stimulated or inhibited by chemical messages sent from the hypothalamus to the pituitary. The prescribed ADT, Lupron, lowers hormone levels, particularly testosterone, and starves the aberrant cancer cells. Testosterone is a hormone produced according to those assigned male at birth. Its main job is to stimulate the development of male characteristics.

As testosterone is blocked, physiological shifts of maleness occur. Psychological shifts also occur, categorized by the medical community as side effects. For me, these "side effects" shifted my quality of life and became primary to the way each day unfolded. 

As my oncologist said, when I commented on how I was challenged, living as a stranger in a strange land, "Jack, I do medicine; my job is to kill cancer. Anything else is above my pay grade."

My friend, Jim, who struggled with cancer, exquisitely described impact of the somatic and psychological intersection of the ADT/radiation course of treatment as "a loss of gumption."  Growing up as a boy in the deep South, I know 'gumption.'  It defines initiative, enterprising energy, and the ambitious get-up-and-go that makes undertaking difficult things possible  

As I was taught, gumption is the know-how that comes from experience. Given the unknown roadmap of a cancer experience, the loss of gumption is alarming, since typical masculine coping styles are put on the shelf until metabolic balance is restored, post-treatment.

Much of the treatment for prostate cancer is delivered when physically naked. The metaphor of exposure is not psychologically lost when finding oneself bare and exposed to unknown and unexplored elements. 

The course of treatment is one that each man experiences by himself.  Intimates, loved ones and friends move the journey away from such isolating nakedness into a place of solitude, where procedures can be more easily tolerated and integrated. 

Without the energy of gumption, also known in my Southern vernacular as 'spunk,' the net of social, loving support is vital.

Jackson Rainer is a board certified clinical psychologist living and working in Atlanta, Georgia and Tryon, North Carolina.  He may be contacted  by [email protected].
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