Get Thee to Radiation!

The following is Chapter 5 in my prostate cancer story.
(For the rest of the story, see my Prostate Cancer page).

In the week following receipt of the bad news from my urologist, I had a whole body bone scan and a CT scan of my abdomen and pelvis. These were to help determine if my high-risk prostate cancer showed any signs of metastases.

My next doctor’s appointment was the following week, this time with the local medical oncologist. Also another foreigner, this time from Jordan. [Not that I have any particular problems with foreigners; after all, in the USAF I trained a lot of foreign pilots and as an engineer in defense industry I worked closely with many of our allied pilots and engineers.]

This guy — I’ll call him Dr. G — spoke English better than my urologist and with less accent, thus easier to understand. He reviewed the radiologist’s reports from those scans, which I later received copies of.

Radiology

Here’s the radiologist’s conclusion from the bone scan:

Increased activity is noted in the major joints, likely due to arthritis. There are no abnormal activities identified to suspect metastatic disease. Increased activity of the midcervical spine on the right side, could be spondylosis, but may be correlated with the radiograph.

OK, I knew I had some arthritis. The last sentence essentially noted that there was some uptake of the radioactive tracer in the mid-cervical spine (creating “hot” spots on the images) that could be either just arthritic or possibly indication of a tumor. In other words, the jury was still out.

From the radiologist’s conclusion on the CT scan:

Combined lytic sclerotic lesion involving the left sacral promontory measuring about 1.5 cm, nonspecific. It could still be a benign lesion as it is well-dcmarcated with narrow zone of transition but secondary lesion not excluded.

So my sacrum showed a lesion that was probably benign, likely arthritic, but could be a metastasis.

Dr. G had discussed these results with the radiologist, and they felt these lesions were most likely benign. I wished they were more positive but didn’t press the issue (although I probably should have…more on that in a later post).

Radiation

Radiation warning signDr. G insisted that my prostate cancer appeared completely “curable” but that I needed to do two things right away:

  • Start hormone therapy (aka ADT or androgen deprivation therapy) to put the brakes on the cancer. I had read enough about this systemic therapy to know I was less than eager to start. What man wants to take drugs that will eliminate his testosterone? I told Dr. G I’d think about it and let him know soon.
  • Get over to Marquette General Hospital to consult with Dr. T, the radiation oncologist who ran their excellent regional Radiation Oncology department. Dr. G said that Dr. T would most likely recommend I receive 43 sessions of radiation therapy aimed at my prostate and pelvic region to zap (my word, not his) the cancer and, hopefully, kill it. I agreed to that referral, and Dr. G said he’d arrange it.

Those 43 sessions of radiation therapy would entail almost 9 weeks of daily, Monday-Friday, treatment. Marquette is a three-hour drive from home, meaning I could not make the round trip every day. I’d have to stay in Marquette during the week and come home only on weekends.

I didn’t care much for that idea but knew I was going to have to do something.

Once again, I started reading everything I could get my hands on. Within a week, I had amassed a substantial library of books about prostate cancer and its treatments, some in print and others on my Kindle.

And, yet again, I was in the waiting and worrying mode as I waited to hear about the scheduling of my referral to Dr. T.

A-37 Dragonfly Overview

Add beefed-up wings, weapons hardpoints, a Gattling gun, tip tanks, armor plate around the cockpit, and bigger engines to Cessna’s T-37 and what do you get? The world’s smallest combat jet — the A-37 Dragonfly!

T-37 Tweet and A-37 Dragonfly in formation

A-37A Dragonfly with a T-37 on its wing.

A Dragonfly is Born

Fifty years ago this August, USAF pulled a previously retired prototype YAT-37D (based on the T-37C) from the USAF Museum for evaluation as a replacement for the aging Douglas A-1E Skyraider. Cessna modified it into the YA-37A prototype, and company test pilot Jim LeSeuer flew its maiden flight.

USAF signed a contract for 39 A-37A aircraft and sent them to South Vietnam for combat testing under the Combat Dragon program. Cessna rerouted 39 airframes from the T-37B production line and converted them to the A-37A configuration. Combat Dragon ended in December 1967, after completing 5,000 sorties in five months — 40 sorties per month per aircraft — with no combat losses. USAF later upgraded all 39 to the improved A-37B configuration and issued a $3.6-million contract to Cessna for 127 new A-37Bs with deliveries beginning in May 1968.

According to John Macartney, Weapons Officer for the 3rd Tactical Fighter Wing at Bien Hoa in 1968, the Wing’s battle damage records showed that the “A-37s took proportionately less hits from ground fire than [the wing’s faster] F-100s, despite the fact that the [F-100s] flew ordnance delivery at up to 400 KIAS while the A-37s delivered at 300 to 350 KIAS.” He said the A-37’s smaller size seemed responsible for the difference.

B-Model Dragonfly

The B-model specifications included a 15,000-pound max gross weight; 2,850-pound-thrust J85-GE-17A engines (non-afterburning versions of the engines in the supersonic Northrop T-38 Talon); aileron boost tabs; redundant elevator control cables for survivability; automatic inlet deicing; an inflight refueling system; layered nylon flak curtains around the cockpit; and mission-specific avionics.

OA-37B Dragonfly in flight from left aft quadrant.

Illinois ANG OA-37B in late 1970s.

In July 1970, USAF returned the prototype YA-37A to the USAF Museum, and Jim LeSeuer, who had flown the exact same airframe on maiden flights as the T-37C, YAT-37D and YA-37A, flew the well-tested jet from Wichita to its final home in Dayton, Ohio.

USAF provided 254 A-37s to the South Vietnamese Air Force (VNAF), and in March 1969 the 524th Fighter Squadron became the first combat-ready VNAF A-37B unit. By January 1973, VNAF had ten combat-ready A-37 squadrons, making it the VNAF’s most common combat aircraft. Although the aircraft was an effective and accurate bomb delivery platform, its 7.62mm minigun proved only marginally effective against anything other than troops in the open (even heavy vegetation reduced its effectiveness). USAF also operated its own A-37s out of Bien Hoa, Pleiku, and Tan Son Nhut.

Spurred by losses to shoulder-fired, heat-seeking SAMs, VNAF and USAF modified their A-37s with infrared countermeasures (decoy flares) in underwing dispensers, which reduced the amount of ordnance that could be carried. Dragonflies later received an improved system with 16 flares in a fuselage-mounted dispenser. However, the proliferation of these SAMs forced A-37 pilots to raise their ground-attack altitudes, resulting in reduced accuracy and effectiveness.

After the Vietnam War, USAF transferred most of its A-37s to the Air National Guard and Air Force Reserves with 130 redesignated as OA-37Bs for forward air control missions, replacing the Cessna O-2 and the Rockwell OV-10. The OA-37B never saw combat, and USAF retired all of it’s A/OA-37s by 1990.

By the end of the aircraft’s production, Cessna had manufactured a total of 577 A-37s.

Pathology and the Bad News

The following is Chapter 4 in my prostate cancer story.
(For the rest of the story, see my Prostate Cancer page).

A few days after my prostate biopsy, my wife and I met with my urologist for the results of the pathology report.

I wasn’t looking forward to this meeting but definitely wanted to get it over with.

He walked in, shook hands with both of us, offered his best empathetic smile, and opened the folder.

What’s Intermediate?

“The pathologist has graded this an 8.”

He never mentioned Gleason grade, although I knew that’s what he meant based on my recent research.

“That’s an intermediate grade,” he continued.

No, I thought, an 8 on a 2-10 scale is certainly not intermediate.

He added, “Cancer was identified in 10 of the 12 biopsy samples.”

Ouch! That is certainly not good news.

He made a few more comments about other tests and possible treatments. I think my mind wandered as I don’t recall much of his specifics other than hearing him say he felt sure the cancer was confined to the prostate itself.

I’m positive he never offered a clinical staging and, frankly, at that point I never thought to ask.

He did say that surgery was possibly and option and he’d be glad to refer to a friend of his in lower Michigan who had started doing robotic-assisted prostatectomies. He did not do that surgery because there was simply not enough call for it in our rural area for him to maintain proficiency.

Most of the rest of that session was a mental blur of conflicting emotions. I’m sure he never showed me the pathology report or his own surgical report from the biopsy.

He then said, “We will schedule a CT scan and a bone scan right away to rule out any metastasies. And I can refer you to an oncologist, who might take a more aggressive approach.”

What, I wondered, is more aggressive than major surgery? Anyway, I agreed to the referral and the imaging tests.

I stopped by the hospital’s medical records office for copies of the pathology and surgical reports. I wasn’t sure what I was going to do with them but knew I had to read them for myself.

Surgical Report

The urologist’s surgical report was succinct and informative:

The prostate and seminal vesicles were scanned. There was no pathology found, specifically there were no hypoechoic lesions, cysts or stone evident. Seminal vesicles are within normal limits. Prostate measurements were taken in the transverse and longitudinal planes. The prostate was found to be 4.99 cm long and 5.29 cm wide with an AP dimension of 4.45 cm. The prostate volume was calculated to be 58.7 mL. A sextant biopsy was then performed at the paramedial sagittal plane at the apex, middle and the base of the prostate bilaterally. Additionally, six biopsies were taken from the lateral aspect of the prostate lobes, three on each side (base, middle and apex). Altogether, twelve biopsies were taken.

I remembered each and every one of those 12 samples extracted from my nether regions during the biopsy. Just thinking about it again made me twitch a bit.

I also knew that a normal prostate should be around 30 mL, so mine was enlarged. That made sense given my urinary issues that had started this journey. His comment that no lesions, cysts, or stones were observed by the ultrasound was good news as was the comment that seminal vesicles were “within normal limits.” So, not completely bad news.

Pathology

Portion of my pathology reportI’d never seen a pathology report before, so I took some time to read and reread it and then do some more research.

You can see a portion of my pathology report to the right, showing the results of the pathologist’s analysis of the first four biopsy samples taken.

I could see right away that the first sample (A) was the worst of the lot and was the one ultimately responsible for my overall Gleason 8 grade. Every overall Gleason grade is composed of two numbers with the first one being the most prevalent grade and the second one the second most prevalent grade. So that sample A was 70% cancerous with 4s being the vast majority of it.

After reviewing the whole report, I had to put together a chart to help me get a good mental picture of what was going on. Here’s what I came up with, an engineer’s view of my prostate cancer.

Diagram of my prostate pathology

OK, maybe looking at something like that doesn’t help everyone, but it really helped me understand my situation.

A little more research brought me to the inevitable conclusion that my cancer was officially in what is called the high risk category. For prostate cancer, high risk is defined as a PSA over 20, a Gleason score equal to or higher than 8, OR clinical stage T2c-3a. Note that the definition says “or” not “and.” Any one of those factors means high risk, and I already knew I had at least two of the three factors.

What exactly does high risk mean? Simply put, it means that I had a high risk of recurrence no matter what treatment protocol I chose.

At that point, I had to sit back and wait some more, first for those additional tests and then for the appointment with the medical oncologist.

Waiting and worrying were becoming a way of life.

And Then the Biopsy…

The following is Chapter 3 in my prostate cancer story. (For the rest of the story, see my Prostate Cancer page).

This third chapter in my prostate cancer story covers the dreaded biopsy. After a DRE, you probably think there’s not much worse they can do through that southern bodily opening.

Guess again, amigo.

This leg of my journey covers a short span of time from that scary 25.6 PSA to my actual cancer diagnosis.

Brief side note: In mid-August, I had to take my wife to the ER twice, the second time followed by two days in the ICU. Stress piled on stress.

On September 5, 2013, I walked into the office of the only urologist within two hours of our rural home. Nice guy. Personable. Seemed like he truly cares about his patients. Small language problem, though, as he was Israeli and tended to hem and haw a bit searching for the right word.

Naturally, the urologist conducted a thorough exam including the old DRE (hey, I may not have liked it but I was starting to get used to this). His comments were essentially the same as my GP’s NP. He insisted I should really have a biopsy as soon as possible.

Not really shocking news. I’d already come to the conclusion that a biopsy was inevitable.

We scheduled the biopsy for September 19. He informed me that he did not use general anesthesia or even sedation, just a bit of topical anesthetic. He said it would hurt as it sample was taken and be generally uncomfortable, but that it would be over quickly. He assured me that none of his prostate biopsy patients had been unable to tolerate the procedure with just the topical anesthetic. He prescribed a single dose of antibiotic to be taken prior to the procedure to preclude post-op infection.

I decided to trust him.

Biopsy Day

Disrobed and put on usual hospital gown. Laid on left side on table, knees bent, right leg well forward. Pillows helped support my legs.

“Ready?”

“No. But go ahead.”

Ultrasound probe inserted up rectum. Deeper. Still deeper. Moving around. Removed while he studies images.

“Now we start.”

I tried not to tense, but I’m sure I did anyway.

First, he applied the topical anesthetic carefully then pushed that damn probe in again. Then he inserted the tool that would capture the tissue samples.

“We will take 12 samples. Here’s the first one.”

Shit! Loud snapping sound. Intense pain for a brief second. I know I flinched.

“It will get easier,” he assured me from his unseen position.

SNAP!

Shit! I wasn’t sure which was worse — that loud snap (realizing it meant he’d just taken out a piece of me) or the pain. However, I didn’t flinch as much that time.

SNAP!

Shit! That’s three.

SNAP!

Shit! That’s four.  How could I not count?

SNAP!

Shit! That’s five. No, wait, I’d rather think only seven to go.

SNAP!

Shit! Six to go.

SNAP!

Only five left. Am I just getting used to it or has the repeated pain numbed me?

SNAP!

Four to go.

SNAP!

Only three left. Will this ever end?

SNAP!

Two. Why aren’t you doing this faster?

SNAP!

One more. I really want this to be over…

SNAP!

Thank you, God. C’mon, doc, get that hardware out of my butt. Please.

“All done.”

Whew! Probe’s out now. Finally, I can relax.

His nurse reviewed the dozen tiny samples in their tubes and pronounced, “These all look good.”

I wiped my now somewhat sore anus and got dressed. The doctor returned and said, “Everything went okay. I will see you in the office tomorrow.”

Aftermath

As I walked down the hall, I realized that there was no longer any pain or discomfort. I decided the doctor was right about just that topical anesthetic.

I drove myself home. Never had any discomfort and side effects of any kind (although he had said I might see some blood in my urine or semen).

Now, back to nail chewing and waiting. I doubted I was going to get much sleep that night.

Actually, I did sleep pretty well. Release of built-up tension, I guess.


One thing I should mention is that the NP had put me on a daily 0.4 mg dose of Flomax back in mid-July. It really did help to reduce the nighttime bathroom trips (known as nocturia by the medicos). However, I did experience one disconcerting side effect. Something called retrograde ejaculation, meaning some of the semen goes into the bladder instead of being ejaculated. Not painful. Not a problem needing fixing. Just weird. But, trust me, sex gets even stranger as this journey progresses (most of which I will probably not share on this blog as it’s pretty personal and I and others have shared it on the UsToo Prostate Cancer online support group).

O-2 FAC Heroes

During the Vietnam War, no O-2 Forward Air Control (FAC) pilots received the nation’s highest combat medal — the Medal of Honor — but at least seven earned the USAF’s second highest medal — the Air Force Cross.

If you want a quick overview of the Vietnam-era O-2, see The Cessna O-2 – Every Man’s P-38?.

FAC Air Force Crosses

FAC O-2A in flight from left front quarterThe first O-2 pilot awarded the Air Force Cross, Captain Donald Stevens, received the medal for his actions on 19 August 1967, only a few months after the first O-2s arrived in country. Captain Stevens flew cover and provided radio relay for a downed pilot for eight hours until the stricken aviator could be picked up by helicopter.

On Christmas Day of that same year, another O-2 FAC, Captain Jerry Sellers, earned a posthumous Air Force Cross for deliberately provoking enemy ground fire to allow him to locate the enemy and direct fighter aircraft strikes.

Combat action on 30 January 1968 resulted in the awarding of Air Force Crosses to three O 2 pilots:

  • Captain Kenneth Sellers earned his AF Cross by providing close air support for Army ground troops from his lightly armed O-2.
  • Lieutenant Colonel Karl Feurriegal directed air strikes despite heavy ground fire to prevent an enemy overrun of friendly forces and was awarded an AF Cross.
  • During missions that began on 30 January and ended on 1 February, Lieutenant Colonel Allan Baer demonstrated “extraordinary heroism” in the face of enemy ground fire, including difficult nighttime FAC missions, for which he was awarded the AF Cross.

Captain Phillip Maywald received an AF Cross for providing support and directing air cover for a downed pilot for over two hours while coordinating a helicopter pick up.

On 12 November 1968, Captain Donald Marx intentionally drew enemy fire away from unarmed support aircraft and was awarded his AF Cross.

Heroism But No Medals

This may not represent all of the O-2 pilots who earned Air Force Crosses during the Vietnam War. It most certainly is not an exhaustive listing of all who showed courage and heroism while flying Cessna Skymasters in a shooting war. It is, however, a sample of the kind of courage evidenced by the many brave FACs who repeatedly faced enemy fire in an unarmored and barely armed lightplane and yet launched on the next mission anyway.

Despite these significant combat awards, the ratio of AF Crosses, Air Medals, and Distinguished Flying Crosses to the total number of FAC pilots consistently seemed low, particularly to the FACs. Part of this might be attributed to a perception on the part of some commanders that FACs just did not really deserve such awards. At one point, the Commanding Officer of the 504th Special Operations Squadron told his FAC pilots that he had “never heard or read of a FAC mission that deserved a DFC.”

In fact, on one strike, the pair of F-100 pilots and their O-2 FAC were all submitted for DFCs — the fighter pilots rreceived theirs, but the FAC did not.

Prejudice? Perhaps. Unfortunate? Definitely.