Dr. Leslie Ballas:
Hi, I'm Leslie Ballas. I'm a radiation oncologist at Cedars-Sinai in Los Angeles, and I am really honored and excited to be joined today by my patient, Mr. Fritz Dallmer. He is a patient of mine who recently received radiation for biochemical recurrent prostate cancer. I am not going to do him justice by introducing just details about his prostate cancer. So, Mr. Dallmer, tell us a little bit about you and who you are.
Fritz Dallmer:
All righty. Well, hello, my name is Fritz Dallmer. I am a 65-year-old male who was diagnosed initially with cancer at age 57 with a familiar history. My father passed away from prostate cancer. He was also diagnosed at about 57, so did have that. I'm retired now, so I was a corporate audit manager for the Department of Defense for 42 years.
Dr. Leslie Ballas:
Let's start with your diagnosis. You were diagnosed back in 2017 and at that time, you were found to have Gleason 6, Gleason Grade Group 1 prostate cancer. What did you get offered at that time? What did you decide to do?
Fritz Dallmer:
When I was first diagnosed, the initial recommendation wasn't for immediate surgery. However, I have an inside connection with our oldest son was a urology student at that time, and he suggested to look into active monitoring initially. So, I did look into that and felt... We did Oncotyping of my initial biopsy and it showed it as a very low-risk, slow-growth cancer. So, with my son's input and talking with my wife, I went ahead and decided that active monitoring was fine because it was such a low-risk, slow-growth cancer.
Dr. Leslie Ballas:
And how did you handle the period when you were doing the active monitoring? Were you nervous all the time? Were you able to put it out of your mind?
Fritz Dallmer:
I was actually very relaxed about it. I used to joke and tell people that I'm very healthy with just a little bit of cancer and getting the PSA blood draw every three months was really a very minor inconvenience and it just led us monitor and make sure that things weren't changing.
Dr. Leslie Ballas:
And how did your wife deal with it? I find that sometimes, I always joke with my patients that for 60 something years, up until their diagnosis of prostate cancer, the prostate was theirs, but the minute they get diagnosed with prostate cancer, it's the partner's prostate, suddenly their partner cares so much about it and it becomes stressful and obviously something that the whole family's dealing with.
Fritz Dallmer:
I think because of our son, my wife and I could talk to him at any time about what's going on, what's the current state of the art of treating prostate cancer, that it kept her extremely calm also.
Dr. Leslie Ballas:
Okay, good. So, eventually though, that Gleason 6 disease turned into Gleason 7 disease in 2023. So, it was pretty successful active monitoring, active surveillance, that you were able to watch it with a couple of biopsies in the interim for about a good four or five years.
Fritz Dallmer:
Correct. Correct. Yes. Actually, I wanted more biopsies. I did have, I think, four biopsies through it just to make sure that it was staying where it was supposed to be. And when I got to Cedars and was ready for my next biopsy, that's when we had an MRI done in conjunction with the biopsy and that's when they found tumors that were tested and those were then high risk.
Dr. Leslie Ballas:
Yeah. And so, at that point, you made the decision to undergo surgery. Was that influenced by your son who was a urologist or is that really what was the most comfortable for you?
Fritz Dallmer:
It was combination. So, talking with my actual urologist, not my son this time, made the decision that yes, with the tumors that were found, it was either surgery now or surgery later, and I opted just to go ahead and remove all of every... All of it, so that I wouldn't have to worry about it anymore or so not.
Dr. Leslie Ballas:
Right. I think that's what a lot of people think. They want it out of their body and they think that then that'll be the end of it. At the time of your pathology, it was organ confined, had not gotten to the seminal vesicles, thank goodness, had not gotten to any of the lymph nodes, but you did have a positive surgical margin or that final, I always tell patients that when the prostate and seminal vesicles comes out of the body, they mark the final cut line so that they can look at that very carefully under the microscope because if there are cells on one side of that cut line and touch that margin, likely, there are cells on the other side that are still left in your body. And so, how was this explained to you and what were your expectations after surgery?
Fritz Dallmer:
My expectations were that prostate's gone so I don't have to worry about it. I didn't really think about or know to ask about that potential. So, I knew I would get the PSA test after post-surgery just to monitor because there's always that risk that there could be some left over. And I was clean for the first, what was it, 12 months, I think, 18 months. At the 18 months is when it first became detectable again. And so, I talked to my son, let him know, and he said, "Yep, that's not unusual, dad."
Dr. Leslie Ballas:
Truthfully, depending on obviously the Gleason grade and some of the surgical criteria about a third of patients even sometimes more will end up needing some form of therapy after surgery because of microscopic residual disease or even spread before the prostate comes out of the body. So, while it's not uncommon, it is your first time with this happening.
Fritz Dallmer:
Correct.
Dr. Leslie Ballas:
And so, there is stress associated. From our records, you were undetectable and as you said, about 18 months later, it became detectable. What were your feelings at that point? Were you like, "I need to get something done right away"? Did you want to wait and see what happened? Walk us through that.
Fritz Dallmer:
Yeah. Well, when I first got the becoming detectable and going, well, darn, that's probably not a good thing, but let me talk before I freak out on anything and talked to my son and like I said, he told us that it's not unusual. There's things called salvage therapy. And so, he said, you don't just let doctor, let my urologist know. And so, I did. And so, we had a discussion and it was only 0.04 at that point and he said, wait until it gets to 0.1. And at that point, we would consider taking next steps.
Dr. Leslie Ballas:
Yeah. So, just to give our audience an idea, it took a number of months, a couple blood draws because you had a 0.04, and then you had a 0.08, and then it was not until May of this year that it actually hit 0.1. When you went from 0.04 to 0.08, some would say the writings on the wall, it's increasing. Were you okay waiting until 0.1? Did you understand why you were waiting to 0.1?
Fritz Dallmer:
I did. My urologist did a very good job keeping me informed. And again, I could ask Jeremiah about it. So, I was perfectly happy with waiting to the 0.1 because again, it's such a small number, a low reading, my PSA was only the high fours, the low fives before I had the surgery. So, you're talking 0.1 now, it's not a lot of cancer out there. So, I wasn't that worried about it. And I was told that 0.2 is standard, but 0.1 is where my urologist liked to start the early intervention.
Dr. Leslie Ballas:
Yeah, so let me just explain a little bit about how I think about that. Classically, the biochemical failure or the biochemical recurrence from prostate cancer was defined at 0.2; 2 consecutive readings of 0.2. That was in an era when PSA machines didn't read below 0.2 honestly. And so, it was an easy cut point.
As we've gotten ultra-sensitive PSAs that are reading down to 0.04, which was your first detectable level and even lower at certain institutions, we started to have to say, "Okay, are we still going to use this 0.2, this historic biochemical recurrence cut point?" And some places will do that, and there have been trials that have been performed looking at the addition of salvage therapy at 0.2 and what that adds. And there's also been trials looking at a different cut point of either two consecutive rises or a PSA of 0.1 and using that as a cut point.
And what they've shown is that it's this question of do we have to act right away because you had a positive margin or some high-risk feature, or can we wait to see what happens to the PSA? This idea of early salvage waiting until the PSA rises and the trials showed that if you wait until the PSA rises either consecutive rises or a PSA of 0.1 and act with salvage therapy, at that point, there's no difference in overall survival than if we would've acted upfront and maybe we could save some people from unnecessary salvage therapies.
And so, that is this idea of early salvage and where that 0.1 comes from. And that is at Cedars, that is what we use is either two consecutive rises or 0.1, and you actually had both at basically the same time. And so, then we met, which was so exciting for me because you're just a lovely patient, but tell me, what did you expect? What did your urologist tell you to expect in terms of salvage therapy?
Fritz Dallmer:
Well, he did say it would be the radiation treatment. And what I didn't know to ask at that point was how many treatments is typical and how often the treatments are administered. Because living out in Camarillo, it's a bit of a commute into Cedars. So, great care, very happy. I went in there, just made during treatment a little more challenging for me to make sure I was properly prepared and ready for the treatments.
Dr. Leslie Ballas:
True. And we're going to get to that. But when you heard radiation, what was your first thought? This wasn't something that you were familiar with. You didn't have a son who was a radiation oncologist as far as I know. Were you scared? Everybody has preconceived notions of radiation.
Fritz Dallmer:
I wasn't. I just considered it like a very focused x-ray when you go to the dentist only aimed a little lower.
Dr. Leslie Ballas:
That's true. I do always like to describe it as a super high energy x-ray because for the most part, that is what it is. We met and we discussed the treatment plan that we would give you radiation to the prostate bed or area where the prostate used to sit. And we talked about the preparation for treatment, which is I think what you were alluding to.
You need to have a comfortably full bladder, which means you drink a lot of water. And that can be tricky sometimes, especially after surgery when a lot of men have urinary leakage and it's hard to hold their bladder. How was that preparation for you?
Fritz Dallmer:
That's probably the worst part of the treatment was just trying to balance that out because of the hour to an hour and a half commute in and not knowing exactly how that commute was going to go and making sure that I was full when I got there was-
Dr. Leslie Ballas:
And we also want an empty rectum, which is a hard thing to control when you poop.
Fritz Dallmer:
Yep. So, once we got on a set schedule, then it was easy for me to make sure I was fully prepped. But that was the most difficult, honestly, because the treatments themselves are painless. Just get laid down, get a warm blanket put on you, and they're only two minutes long.
Dr. Leslie Ballas:
Yeah, the truth of the matter is that you had the extreme commute, but even patients who live close by have a hard time, especially in the beginning, learning when to drink, when to fill their bladder, is it full enough? What happens if they're rectum's too full and they have to empty their rectum but keep their bladder full? It leads to some long first days getting radiation and frankly frustration on the part of patients because something that they'd never been forced to control in that same way.
Fritz Dallmer:
True.
Dr. Leslie Ballas:
Did you feel frustrated?
Fritz Dallmer:
Only the couple times when I get there and, "Okay, I'm ready." "Well, sorry, you have too much gas in your system." "Okay, well, that's going to empty the bladder." So, got rid of the gas but got rid of the urine, too. So, I had to sit there and chug more water. So, that was frustrating, but I get frustrated or got frustrated on that solely because I didn't want to waste your time and the technicians.
Dr. Leslie Ballas:
Well, that is very kind. And actually, the most common thing we hear is that people are worried about everybody else's time. When we, I'm going to let you in on some inside baseball here, we know that people don't always fill their bladder and we build in the time. So, for those of you who are watching, don't worry about that.
Fritz Dallmer:
Okay.
Dr. Leslie Ballas:
And you got a total of 34 treatments, which is fairly common. Some places do 33, some places do 37. It's all about a small piece every day that adds up to the total dose that's necessary to kill the remaining prostate cancer cells. In your situation, we didn't need to recommend hormone therapy. Were you thinking that that was going to be a part of your treatment?
Fritz Dallmer:
No, I didn't at all.
Dr. Leslie Ballas:
And when I say to you now, we didn't recommend hormone therapy, when you hear hormone therapy, what does that make you think of? How do you feel about that medication or that line of treatment?
Fritz Dallmer:
Actually, I hadn't even considered it, hadn't looked anything up on it and had it been discussed, I would've then researched it.
Dr. Leslie Ballas:
Yeah. So, hormone therapy works by convincing your body that it has enough testosterone and it doesn't need to make more. And so, the effect is a lower testosterone in your system and that, of course, comes with side effects. The reason we do that is testosterone is effectively like food for prostate cancer cells and those side effects. Some people get all of them, some people get none of them. They range from some tiredness, some hot flashes, middle section tummy weight gain. You can have decreased libido or interest in sex. You can have some erectile dysfunction. Some people complain of their large muscle groups feel weaker.
So, it does have some more global side effects and patients get really nervous about that. I commonly get the question, "Okay, I'm going to get radiation, do I also need hormones?" And there are certain indications when we give both at the same time and certain patients, we don't. It's most commonly based on what your PSA is when you meet with the radiation oncologist.
And so, you mentioned a little bit about your experience during treatment that the hardest part was getting the bathroom stuff all right. What else would you say? Did you have fatigue?
Fritz Dallmer:
I did. I had very little fatigue. I would come home. I had just retired the week before I started radiation.
Dr. Leslie Ballas:
I remember it was your retirement present.
Fritz Dallmer:
That was my retirement present, gave me all the time I needed. So, I was able to come home and usually about 3:00 PM I might say, "Okay, 15 minute nap, 30 minute nap," sounds pretty good about now. And that was really the extent of it. I had no other side effects.
Dr. Leslie Ballas:
You're a young 65 and so, is a nap in the afternoon normal for you or is that not normal? Some people take naps.
Fritz Dallmer:
No.
Dr. Leslie Ballas:
Yeah. Okay.
Fritz Dallmer:
Not normal.
Dr. Leslie Ballas:
Okay. And what about other symptoms that you had? We had talked about the potential for more frequent urination, urgency, maybe even burning with urination. Did you have any of those?
Fritz Dallmer:
I was very fortunate. No, the only side effect that I felt was the occasional need for a quick nap.
Dr. Leslie Ballas:
Yeah. The other thing that we talked about that some patients experience is more frequent bowel movements. And again, that wasn't something that you experienced luckily.
Fritz Dallmer:
Correct. During the treatments, looser. But that made being prepared for treatments better, easier.
Dr. Leslie Ballas:
Yes. And what about urinary leakage? Did you have any return of any urinary leakage during treatment?
Fritz Dallmer:
I did not.
Dr. Leslie Ballas:
Did you do your Kegel exercises during treatment?
Fritz Dallmer:
No, I had stopped them after the surgery. I did them prep for the surgery and shortly after the surgery and once I post-surgery, had no more leakage, I stopped doing them.
Dr. Leslie Ballas:
Yeah. And we always tell patients that if they're particularly nervous to start doing them again or if they start to have a little bit of leakage to start doing them again, just to remind that pelvic floor muscle that it needs to do extra work. Were you happy with the treatment and other than the commute?
Fritz Dallmer:
Yes. I have no complaints about it. The care has been great. Just hoping now that the next PSAs continue to be undetectable or at least head that direction. So, that's probably the most nerve wracking thing I have right now. And it's not really nerve wracking, it's just, "Okay, what if it doesn't go down?"
Dr. Leslie Ballas:
That is the human nature. That's a very normal reaction. And as I tell my patients, there's so many branches to that tree that it's worth trying to calm those very natural feelings and just wait and see what happens. And it's never about one PSA. It's about trend over time. And so, god forbid, there is a rise and consistent rise in PSA. We have lots of different options available and it's not the end as some people like to say.
Fritz Dallmer:
So, we'll cross that bridge when we get there.
Dr. Leslie Ballas:
Basically, yes.
Fritz Dallmer:
All righty.
Dr. Leslie Ballas:
Is there anything that you want to tell other patients? Things you wish you'd known before or any last minute bits of advice?
Fritz Dallmer:
No, I think having the positive attitude really goes a long ways. I always was telling my coworkers, especially the men, I was very open about talking to them about it and said, "Go get your PSA test, get it all done." It just monitor it. You got to take care of. But if I'm going to get a cancer for men, I think prostate is the best cancer to get as it is treatable, easily detectable. Again, the attitude of I was healthy with just a little bit of cancer and that's the attitude I still carry.
Dr. Leslie Ballas:
It's true. You have a really good demeanor and really good attitude about it. All right, well, listen, again, thank you so much for joining us and for sharing your experience. Patients always want to hear from other patients and I think this is really helpful. So, you've done a lot for a lot of men today, so thank you very much, Mr. Dallmer.
Fritz Dallmer:
All right. You're welcome.