Dr. Eric Kim:
Hello everybody. I'm Eric Kim. I'm Chief of Urology at the University of Nevada, Reno and Renown Health. I have the pleasure of taking care of Stu Harrington, who's joining us today. Stu, do you want to introduce yourself?
Stu Harrington:
Sure. My name's Stu Harrington. I'm a retired educational psychologist. I'm 78 years old, and I would assess that I was in pretty good health coming into this situation.
Dr. Eric Kim:
Yeah. And Stu, I think we met, it was back in the spring, maybe around May when your PSA had gone up to about five or six from previously normal. But it's probably helpful if you're able to just walk us through from maybe even your decision making or thinking as to why get the PSA screening because I know that's something a lot of people still feel is controversial. And then from that point, from the elevated PSA, how did we arrive at the diagnosis of prostate cancer and kind of what that journey was like for you?
Stu Harrington:
Okay, so the reason I was getting annual PSA tests was that about five years ago, I had kidney stones and those stones were broken up through laser process. The urologist in Carson City wanted to do a PSA annually, I think just as a routine matter. Until about five years ago, my PSAs had been measured on a fairly routine, about every other year basis because I've been a pilot most of my life. And so I am used to having semiannual physical exams. So what I had gotten in the practice of doing previously was getting a flight physical one year and a general physical the next, because flight physicals aren't very rigorous. They are intended to determine whether or not you're going to suddenly die in the cockpit, not whether your general health is good.
So I was in this, I had been watching my PSA for a long time, and it was consistently in that two and a half range. Then we went through the kidney stone episode, which I would not recommend to anyone, and then started the annual PSAs and there was a steady upward trend year by year. So by the time I saw you, I had this steady upward trend, which had finally passed that about, I think our first test was about five and a half. There was little question in my mind that there was something seriously wrong.
Dr. Eric Kim:
Yeah. And I think for you, and not to pick on you, Stu but, and it may have felt like we were picking on you. We did some extra testing when that PSA was elevated, we got a 4K score, we got an MRI. We don't do that for everybody, especially younger patients with a PSA that's, let's say 10 or 20, maybe those extra tests aren't as helpful, but I think for you, it really was a rational way to try to avoid anything unnecessary. I think we were really deliberate about, hey, Stu, do you really need a biopsy? Let's get the additional data. Okay, you do need that biopsy. Let's go ahead and do that, so.
Stu Harrington:
Yeah, it seemed very rational to me. We took it in a very step-by-step process, and by doing that in a methodical way, it relieves the doubt. I had a pretty good sense of what was going wrong, and I think we took it in a very cautious fashion. This was not an illness that seemed to me to require immediate action, but it also seemed from possibly before I ever met you, it was very likely that I was going to have to have a serious intervention.
Dr. Eric Kim:
Yeah. And maybe for those that are kind of scared or nervous about the potential for a biopsy, are you able to speak to your experience during the biopsy? I think we did it transperineally and we did it with some sedation, so hopefully you were comfortable.
Stu Harrington:
Yeah. I was. In fact, I've been comfortable throughout this procedure and from start to finish, I have never had any real discomfort of any significance, just very minor discomfort. The biopsy was, it was under sedation. I went to sleep. I woke up. I was a tiny bit sore, and that was about the worst of it. So the biopsy certainly was not intimidating.
Dr. Eric Kim:
Good. No, I'm glad to hear. Glad to hear we didn't torture you too much. Well, and then so upon the biopsy, we did find Gleason seven intermediate risk, but clinically significant prostate cancer. At that time, Stu, I know we had talked about potentially active surveillance. Again, not to pick on you for the second time this morning, but at your age, a little different than someone whose maybe 48 years old and diagnosed with prostate cancer, where a younger gentleman, we'd be as aggressive as possible.
As men get older, we want to be, again, thoughtful and rational about treatments because all treatments have potential side effects. So maybe if you're able to just talk to us about active surveillance, what that meant to you and if that was something you were willing to do or what your thoughts were about it.
Stu Harrington:
To be candid, I did not think that was going to be a viable alternative almost from the start, because I have been watching this progress for quite a while, and I guess some of this depends on what my expectations for my future are and my expectations for my future are that I'm probably going to live another 10 or 15 years.
And on the outside of those numbers, active surveillance probably would've not been a very effective solution to my problem. We would've eventually had to intervene surgically anyway. And if the surgery is coming, it seems to me it's better to intervene while I'm young and strong or younger. I mean, 78 isn't young, but I feel young, so better young than late when I'm old and weak and probably not as physically able to recover.
Dr. Eric Kim:
Yeah. No, I think we jokingly ask people when they, at least I jokingly ask people when they bring up treatment versus surveillance, I ask, well, how long do you plan on living? And just to your point, I think if you have a good life expectancy, you're healthy, you're in good shape, active surveillance really is delayed treatment. It's a punt, but again, if you're going to live long enough, you'll probably get the ball back and then you may not be in as good a position to run with the ball five years from now.
Stu Harrington:
Yeah.
Dr. Eric Kim:
So I think your point is spot on.
Stu Harrington:
Yeah. I use the same reasoning with my knees. I've run all my life and I eventually wore out my knees and I tried to pick the optimal time to do the repair given the technology at the time. They said at that time, which was about, that was 2015, so 10 years ago, that I could expect the repair to last for 20 years, and I thought that that probably fit with my life expectancy.
Dr. Eric Kim:
Yeah.
Stu Harrington:
So it's the same reasoning I think that we used for the prostate surgery.
Dr. Eric Kim:
Yeah. And I think in order to help us make that decision, that's when we got that Decipher test, which is the genomic test on the biopsy tissue. For men, and I think I would've felt differently. I don't know if you would've, but I would've felt differently. If that came back really low, I think I would've tried to push a little hard Stu to say, Hey, look, this really might not change in 10 or 15 years. It really would be okay to not poke the bear. But fortunately, unfortunately, and maybe in some ways it confirmed your suspicion based on the PSA trend because it's a really good depiction of the tumor biology, that test.
And so what you knew from years of watching your PSA, the treating physician may not know because I just met you this past year, and so I don't have that history to go off of and Decipher kind of captured that. It said this prostate tumor, which looks to be intermediate risk, it definitely has some growth potential. The trajectory of growth has been like this. It's not a slow burn. So I mean, hopefully the Decipher was valuable to at least confirm your thinking and kind of confirm what we should do.
Stu Harrington:
Yeah, it definitely made a significant difference because the pathology really suggested truly intermediate sort of risk, but the Decipher testing suggested it was higher than intermediate. I mean, it was not an imminent disaster, but the potential was therefore, for this to grow into something serious.
Dr. Eric Kim:
Yeah. To grow and metastasize, and again, you shouldn't pick on yourself, Stu. I think you're in really good shape, and I think you'll be around a long time. And yeah, I think when you add the additional complexity of watching this and punting for several years may open up the possibility of metastasis, then I think it becomes a no-brainer we should intervene now versus later. All things aside from what we talked about before.
Stu Harrington:
Yeah. That was really my thinking, better to address the problem when it's identified than use watchful waiting to just sort of see how things are going to change. We were able to address the problem while it was still pretty confined. I mean, I can't really read the pathology but, in the way you folks can, but it appeared to me that it was still relatively small, relatively good chance that if we acted decisively, that we could greatly lower the risk.
I recognize that you never eliminate risk, but at least we can lower it to the point that I can go through the next few years not worrying every minute about what's coming or that's probably an exaggeration because I don't worry about much of anything like that, but that's just not my personality. But nevertheless, it is comforting to know that we have lowered the risk substantially.
Dr. Eric Kim:
Yeah. And Stu, maybe you can talk us through, and again, for folks out there who are in a similar position, they've done all the testing, they've realized in that shared decision-making, that conversation, they've realized, okay, I do need to consider treatment now, not put that off.
We talked about both treatments, both surgery and radiation being definitive. We don't always say the word cure without adding some quotation marks for the reason you said, risk is never zero, but both surgery and radiation are definitive treatments. What made you choose surgery rather than radiation? What was your thought process behind that? Maybe that would help people too.
Stu Harrington:
Well, then I need to tell people a little about my family. I've had a lot of support from a very fine group of people that is my family, but I am most lucky to have a very supportive wife and a daughter-in-law who is a physician's assistant. Now we're talking about Liz. She has acted as a case manager for me and brought her experience because she spent 20 years treating gynecological cancers. And while that's not directly applicable, she has a certain depth of understanding about the alternatives of these that you were presenting to me.
And I greatly appreciated the fact that Liz took the time to question you about the alternative treatments and what the risks and benefits of those alternatives were. She probably spent 15 minutes just questioning you about the radiation options, asking questions that I was not really prepared to ask, but which I thought were entirely germane.
And she didn't pull any punches. She asked tough questions and got your answers on those issues. We also questioned you in detail about the risks and benefits of the surgery. I think my wife probably asked, prompted more questions than Liz in that stage. I knew regardless of what happened, the intervention was going to change my life, but I appreciate the help that both of those women gave because they forced me to consider the whole spectrum of issues that I might otherwise not have addressed.
I was personally, kind of already decided on surgery, so good or bad, right or wrong, I'd already sort of made up my mind. But they provided the perspective that I really appreciate after the fact because I can look back and I feel like I made a sound decision based on all the options that were available, not just the one that I had initially settled on.
Dr. Eric Kim:
Yeah. And I think married men live longer, and it's probably the same concept. And I think on the treating side, obviously I see a lot of men who are 50 to 70 something that are dealing with some serious issues, especially prostate cancer, and those that come with their spouses, their partners, and have family support, they do so much better.
And it's probably peace of mind, better care at home, thinking through what the relevant options are, what the right things are, another voice to speak up and another voice to ask questions. And I think in my mind, you hit the nail on the head. I think you can't say enough about having a good partner, having good family support.
Stu Harrington:
Yeah, I'm really blessed. What we haven't mentioned before is that about six, no, maybe eight months ago now, I had a subdural hematoma that nearly killed me, and that was the cause of the black eye that you have commented on, on several visits. And during that time, I really began to appreciate the breadth and the depth of support that I had within my own family. And it extended far beyond Liz and my wife. My daughter-in-law and my wife certainly saved my life, but I have many family members who, for some crazy reason, are concerned about my welfare.
Dr. Eric Kim:
And for some crazy reason, they like you, Stu.
Stu Harrington:
I don't know why, but it's nice to know.
Dr. Eric Kim:
Well, how are you doing now? You know the days, honestly, and not to be funny, but I don't even remember when... Was surgery in September? So it's been about, was it October? Has it been a couple months now? And how are you doing? How's your recovery been? To what we had talked about before, pathologically things were contained, margins were clean, everything went very well from my perspective. But from your perspective, how are you doing and what's it been like?
Stu Harrington:
Well, you know, obviously it's not fun to be on a catheter for a week, but I'd had a little experience with that previously. So I knew what I was getting into, and I think I dealt with it pretty well. That was fine. It's just annoying. I was expecting urinary incontinence when I came off the catheter, and that did not happen. I have, I'm sure some decision you made along the way. You left a nerve that was essential, and I had control of those sphincter muscles as soon as the catheter came out. I have not had any leakage, frankly, my urination is like when I was 20.
So that's a positive benefit. There's no restrictions anymore. There was certainly a little issue with capacity. It's taking time. I think at this point, and I suppose we are just about two months out, a little over, I think I'm almost back to normal on urinary capacity. I did have considerable fatigue for two or three weeks right after the surgery. I guess I was being a little optimistic. You forget that these surgeries take a lot out of you.
Dr. Eric Kim:
Yeah.
Stu Harrington:
They did. It did have an effect on me. I was really tired for a couple of weeks. Pain was virtually non-existent for the first 10 days. I had the annoyance of the catheter, but I just didn't have any pain even after the catheter came out. Then about after 10 days, I noticed a little bit of mild discomfort right after urination for about the next 20 days, and that disappeared just about the time we had our follow-up visit.
There's no discomfort at this time. Everything works great. Now, obviously with the surgery came impotence, that's still there, although I'm starting to see some signs that that's going to end. It's just going to take a little time. So you suggested it would probably be a year before those symptoms went away, and I think that's probably going to be a good estimate. So all in all, it's progressed just about as you anticipated, except that I haven't had any problem with leakage.
Dr. Eric Kim:
Yeah. Well, Stu that's because you're superhuman. You survived the subdural and-
Stu Harrington:
Boy, is that not true. That's not true, but-
Dr. Eric Kim:
No.
Stu Harrington:
I'm damn lucky.
Dr. Eric Kim:
Well, I think, yeah. I think that's fair to say for you as it is for all of us.
Stu Harrington:
But I'm Irish too.
Dr. Eric Kim:
Oh, yeah. There you go.
Well no, and I guess to wrap it up, and hopefully your insights are beneficial to those people trying to again, make a decision about not just screening, but once they're diagnosed, getting Decipher testing or any additional testing to help them make the appropriate decision on treatment or waiting. And then I think, again, really nice to speak to surgery as again, I think we talked about it earlier, sometimes the lay press makes it seem like surgery's a very dangerous thing, fraught with terrible complications. And although those instances occur, I think there's more men in your shoes than men who have a terrible time.
And so with all that being said, what pearls do you have for all those newly diagnosed patients or all the patients out there that are going through the journey that you went on?
Stu Harrington:
I don't suppose I really have any pearls of wisdom. Every person has to make their own decision based on their own personality and their own situation, their own family, and their own support network. So I can't tell anyone else what to do, but I can say that the process has been great for me. It worked. I'm happy. I'm healthy, getting stronger, and I think I made the right decisions at the right time.
Dr. Eric Kim:
Yeah. No, I think that's really well said, Stu. It is probably because you have more white hair than I do, that that was based in a lot of wisdom, what you said. But no, and I always tell people, and hopefully this has been true for you, Stu, and I don't want to put words in your mouth, but I think it's important to just make sure as the patient, that you get along with your provider, that you can be on the same wavelength. Obviously, not everyone's going to get along like fast friends, but I think that that relationship does help because as we talk about stuff, there's a lot of trust involved. I'm kind of acting as your Sherpa through this journey of what to do.
Stu Harrington:
I think we've had a good relationship. I hope we continue to have a good relationship. I've had really good experience with medical providers so far in my life, and so I have a positive view. I don't have any reason to doubt that you have my best interests at heart and will use your best judgment. And I think that kind of confidence makes going forward in these situations much easier.
Dr. Eric Kim:
Yeah. No, Stu, that's because you're a nice guy and a great patient.
Stu Harrington:
Well, thank you.
Dr. Eric Kim:
Well, you're so patient, so it makes you a wonderful patient because you have so much patience.
Stu Harrington:
Well, maybe that has to do with being an educator. Having taught special ed for several years, patience kind of comes with the territory.
Dr. Eric Kim:
Yeah. Yeah. That makes sense. Cool. Well, thank you so much, Stu, for sharing your insights and your experience. Again, I think it's going to be really helpful for a lot of people out there.
Stu Harrington:
No, thank you.