“Shotgun” Radiation Therapy

The following is Chapter 6 in my prostate cancer story.
(For the rest of the story, see my Prostate Cancer page).

A bit less than two weeks after Dr. G, my first medical oncologist, referred me to Marquette General Hospital’s Radiation Oncology Department, I had an appointment to see Dr. T, the radiation oncologist who ran that department.

My wife and I drove the three hours to Marquette (in Michigan’s Upper Peninsula) and first met one of the RNs. After asking a few questions (which they should already have known the answers to if Dr. G had done his job right), she say us down in front of a monitor and started a 20-minute video — everything you ever wanted to know about external beam radiation therapy.

External beam radiation equipmentIt was an interesting video with lots of good information, but most of it I’d already learned through my research. After it ended, we cooled our heels for a while until Dr. T walked in, introduced himself, and sat down.

“Any questions about the video?” he asked.

We really didn’t have any questions that hadn’t been addressed in the video.

He then performed a basic physical exam, followed by that dreaded DRE. He confirmed what I already knew about the condition of my prostate. He then pulled up my recent scans (CT and bone scans) and walked me through them, explaining exactly what they showed, or at least hinted at.

He was the first doctor who took the time to do that. We both appreciated his taking the time.

“So, is it curable?” I asked.

He nodded. “I think so. You will need 43 daily radiation treatments, about eight and a half weeks.”

“That’s a long time to be away from home. Can I go home on weekends if I stay here in Marquette?”

“Absolutely. We don’t do treatments on the weekend.”

“Shotgun” Radiation

He tapped the monitor with its bone scan image of my spine. “There is this suspect area on your sacrum that I think we should treat by just widening the radiation field a bit.”

“But the radiologist report said it’s most likely benign and just arthritic.”

He shrugged. “True. But I think it would be best to treat it, too, just in case.”

“What about surrounding tissues and organs?”

“We can plan the treatments to minimize that exposure.”

He gave me a “pitch” about how it would not be good to leave that area untreated because it might cause problems later. I don’t think I listened very closely to that description. My mind was mulling this over.

I knew he was recommending something like 75-80 Gy of total radiation spread over those 43 sessions with some portion of that aimed at what was most likely a benign lesion. I just did not like the idea of what seemed to me a “shotgun” approach.

Trained as an engineer with some coursework in nuclear physics, I really wanted to minimize the total amount of radiation I would receive.

I told Dr. T that I would think about it and let him know when I was ready to proceed.

Why Not Surgery?

In case you’re wondering why I haven’t mentioned a prostatectomy, I had determined through my research that my high-risk prostate cancer meant that I would almost certainly require salvage radiation after that surgery. That would mean I would get to deal with all the nasty side effects of surgery and recovery from it PLUS all the side effects of radiation therapy. And the statistics were clear that the long-term effects and cancer-free survival were almost identical for both protocols. So, I had ruled out surgery.

We had a nice lunch at Red Lobster and drove the three hours home. We discussed what we had heard and came back to my initial conclusion: Dr. T’s “shotgun” treatment of that probably benign lesion on my sacrum just did not seem like the right solution. There must be a better solution.

The next day, I called Dr. G’s office and asked them to get me started on Androgen Deprivation Therapy (aka hormone therapy). That would buy me some time to find a better treatment solution.

Walt's signature

My Favorite Tweet Memories

This post has nothing to do with Twitter. Instead, I’m going to reminisce about the Cessna T-37 “Tweet,” the USAF’s smallest jet trainer that retired from duty in 2008.

I can’t imagine another aircraft that could have served as well as the T-37 for so long. Certainly no other aircraft in the U.S., possibly the world, has started so many pilots down the jet road to military pilot’s wings.

 

Tweet in flight with speedbrake extended.

Tweet in its original polished aluminum garb with its speedbrake extended. (Kansas Aviation Museum photo)

Let me drift into a short reverie, as the Tweet holds a soft spot in this old pilot’s heart. I earned my USAF pilot wings at the now-defunct Webb AFB in west Texas back in August 1970. USAF, in its infinite wisdom, decided to keep me on at Webb as a T-37 instructor pilot. After three months of training, I was thrown into the fray as a fully qualified (that’s what they said) jet instructor. When I sat down across the table from my first two assigned students, I felt a bit anxious. After all, I was still a second lieutenant, with a whopping 200 hours more in my logbook than my students! (One month later, I magically became a “real” officer…i.e., a first lieutenant.)

In 1958, USAF’s first class of T-37 student pilots began training at Bainbridge AFB, Georgia. That initial test class had all completed basic training in the Beech T-34, but another class soon began T-37 training using the new “All-Through Jet” syllabus, meaning they jumped into a jet cockpit without ever flying behind a propeller.

From the beginning, maintenance personnel loved the Baby Jet for its ease of maintenance. Instructors loved its side-by-side seating and honest handling. Neither, however, loved the unique, incessant, ear-piercing whine generated by its twin turbojets. When first heard from a distance, one might think of a flock of canaries all singing at once. Up close, however, it proved far less charming. Within a few months of your first excursion onto a Tweet flightline, the sound began to annoy. After a year, you came to hate it. Most T-37 IPs, including me with some 800 flight hours in the beast, have measurable high-end hearing loss thanks to that whine. We all had to wear “Mickey Mouse ears” – big, bulky earmuffs (this was long before the era of noise-canceling ear protection). Maintenance personnel, who spent far more hours immersed in the racket, had to wear both foam earplugs and “Mickey Mouse ears.”

Once you closed the canopy and pushed the throttles to full military power, the “6,600-pound dog whistle” was a joy to fly. Responsive, stable, agile. Well, pretty stable except coming down the ILS or PAR glideslope when the nose tended to hunt laterally, making precise heading control difficult. Yet one adapts to such idiosyncrasies, and that flaw ensured students developed excellent instrument crosschecks.

With a nominal takeoff gross weight of 6,575 pounds and two miniscule turbojets producing a whopping 1,025 pounds of thrust each, who would suspect the little jet would have need for thrust attenuation? But it did.

The Tweet sports a pair of trapezoidal thrust attenuators mounted inboard in the exhaust section. Why? Those old, cast iron, centrifugal flow, single stage turbojets spooled up oh-so-slowly – you could advance the throttles for a go-around and wait several seconds for the engines to catch up. Several agonizing seconds, in some tense situations.

Closeup of extended Tweet thrust attenuator

Tweet thrust attenuator in the extended position (note actuator arm holding it open).

The thrust attenuators extended into the exhaust, reducing effective RPM by 10%, whenever you reduced power below 70% RPM with the speedbrake extended, such as on final approach. The combination of speedbrake and thrust attenuators forced you to keep the throttles well above normal idle (38%) and, therefore, reduced the spool-up time for a go-around or touch-and-go. When you retracted the speedbrake and pushed the go-levers forward, the attenuators retracted and provided an instant 10% thrust increase before the engines accelerated. Negotiating the military 180-degree final turn, you learned to listen for the attenuators deploying and to play them in-and-out with small throttle adjustments around that 70% point.

Lack of cockpit pressurization proved a major shortcoming for the Tweet. Although Cessna claimed an actual service ceiling of 39,200 feet, USAF regulations limited unpressurized aircraft to 25,000 feet. We routinely cruised between FL200 and FL250 where lower fuel flow and higher true airspeed optimized range. The combination of high altitude and no pressurization often created discomfort for those with any head congestion…or those who had consumed heavy Mexican meals the night before.

The Tweet’s limited fuel quantity required us to pay very close attention to fuel on every flight. Two thousand pounds (309 gallons) of fuel might sound like a lot, but not when the engines use more than 1,000 pounds per hour. My first flight commander wisely advised, “If you consider yourself in a minimum fuel condition as soon as the gear retracts on initial takeoff, you’ll be okay.” If only those words had sunk in, I might have avoided some very tense flights when I landed on little more than fumes. On one sortie, I shut down one engine during the long taxi back to parking, hoping to avoid an embarrassing flameout…and the disciplinary action it would surely bring.

Yeah, I hated its high-pitched squeal. But I do miss flying the little beast.

View looking aft from glareshield into cockpit with IP and student.

Tweet cockpit looking through the clamshell canopy. (USAF photo)

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.