A Day at the Gantry

In proton vernacular the radiation treatment area is known as a gantry; it resembles the inside of a gigantic washing machine drum. It is roughly 12 feet in diameter and 10 feet deep; it is painted in hospital white. There are currently three such gantries at UFPTI. The gantry in which I am treated is staffed with seven technologists (three or four per shift) most of whom are attractive, super-friendly attentive young women. The one male staffer I have encountered is clean-cut and no less friendly or attentive. On our first meeting this young gentleman alluded to the church group of whom he is a member and with whom he interacted the prior weekend.

Extensive efforts are devoted to ensuring that a given patient is properly identified thereby guaranteeing he will receive the appropriate degree of radiation using the lens designed especially for his treatment. Likewise extensive efforts are made to properly align the patient and his prostate.

A typical day in the barrel -like drum occurs as follows:

---The patient arrives thirty minutes early and dutifully empties his bladder. On cue from a technologist he consumes 15 ounces of water.

---A technologist escorts the patient to a small dressing room. The patient exchanges his street clothes for a hospital gown which is as you might expect open in the back and in this case for good reason.

---When summoned the patient takes a fifty-yard stroll down a hall to the treatment area. A gantry crew member scans the patient's identification tag and has him confirm his identity by reviewing three computer screens each with his printed name and one of which displays his recent photograph.

---The patient mounts the gurney and positions himself in the body cast designed during his three day workup for the purpose of properly aligning and immobilizing the lower portion of his body. Gantry staff make minor adjustments to the patient's positioning as needed based on laser technology.

---The prostrate per se is properly positioned and immobilized by the introduction of a measured amount of liquid infused by one of the technologists directly into the patients rectum or within the confines of an elongated, well-lubricated elastic balloon. This procedure is the most emotionally and physically discomforting aspect of treatment. I am not sure how the crew decides who will carry out this task. I do know the administering technologist changes from day to day. Perhaps its a democratic rotation. Conceivably its the short straw method. Then again it may be the way in which my sister and I decided who's turn it was to do the dishes when we were children. This process consisted of a potentially endless debate of "it's yourturn," "no it's your turn" until we reached some sort of trade off compromise or the ultimate arbiter in the matter, our mother, decided whose turn it was indeed.

---With the push of a button a technologist rotates the automated gurney into the washer drum portion of the gantry.

---Xray machines roll out, one on the side, one from the top, for a final check on the alignment of the patient's prostrate. The beam zeros in on four gold marker's inserted in the patient's prostrate during his three day workup.

---When all systems are go the proton beam is unleashed on its cancerous target. There is no sound or sensation to signal its operation. The patient knows he is being radiated when the gantry crew quietly leaves the area. In a matter of minutes the crew returns. The treatment officially ends when the balloon is removed and/or a technologist assists the patient with his dismount from the gurney.

---A return stroll down the hall, a visit to the bathroom and redressing completes the process.

Although the treatment plan varies from person to person, typically prostate cancer patients undergo 39 such treatments on consecutive workdays.

Prognosis

A physician by the name of Dr. Gud E.Nuff oversees my treatment at UFPTI. He is a radiation oncologist with over 15 years of experience. Dr. Gud E. Nuff's calm, cool, confident and somewhat laid-back demeanor belies the enormous responsibility he shoulders for ensuring the medical well-being of the patients under his care.

Based on the results of the battery of diagnostic tests administered in conjunction with my three day workup, Dr. Gud E. Nuff developed my treatment plan. Currently we meet weekly to discuss my progress. On the three occasions we have met I have managed to focus our discussions on what to expect in the way of outcome over the long term. Here is what I learned; in each of the areas which all prostate cancer patients share a particular concern:

CURE RATE
Cure is indicated by low-normal PSA readings and the absence of any biological indications of cancer. Dr. Gud E. Nuff estimated my chances of this type of outcome were in the 85 to 90% range.

IMPOTENCE
Dr.Gud E. Nuff is a glass full kind of guy. He talks in terms of potency not impotence. He advised me not to expect an improvement on this parameter. On the other hand, he reassured me I could expect to leave the treatment center with about the same degree of potency that, "I brought to the table."

BLADDER CONTROL/INCONTINENCE
"The likelihood of a problem in this respect," Dr. Gud E. Nuff opined, "are negligible, almost zero."

BOWEL/INTESTINE COMPLICATION
"The chance of a problem in this respect," Dr. Gud E.Nuff estimated, "are less than 8%."

In my estimation I am in gud hands with good prospects.

Treatment Begins

Good news: (1) the diagnostic tests alluded to earlier have been confirmed negative which means the cancer is limited to my prostate, and (2) my treatment has begun. The UFPTI program included a tour of the facility, consequently, I knew what to expect. The initial treatment proceeded flawlessly. My emotional reaction to the procedure, however, caught me by surprise. I experienced a mixture of gratitude, fear, concern and amazement. Underlying these emotions was the knowledge that cutting edge science, modern medical technology and a sophisticated team of highly trained physicians, nurses and support staff had been assembled, in part, to treat a 72 year old man's cancerous prostate in an effort to salvage what remains of his quality of life. A somewhat melancholy and extremely humbling experience for which I am deeply grateful.

The remainder of this journal will be devoted to the treatment process. I will address outcome expectations (prognosis) and side effects as they materialize.

Pretreatment Musings

At least two of the proton treatment centers I contacted provided a list of their former patients who expressed a willingness to discuss their treatment experiences with anyone who might be interested. Since my arrival here at UFPTI I have interacted with a number of proton therapy patients. At a recent luncheon I heard former patients discuss their treatment experiences and outcomes. I have also visited a few web-sites devoted to proton treatment and reviewed the testimonials of dozens of former patients. I have yet to hear an unfavorable comment. Without exception these individuals discuss the process and their outcomes enthusiastically in highly positive, near-reverent terms.

Maybe they exist, I have not researched the matter, but I have yet to see a book, a web-site or a list of patients extolling the virtues of prostatectomy, seed implantation, castration, other forms of external beam radiation or any other treatment modality. I suspect there may be an underlying reason or two.

The Proton Advantage In a Nutshell Moreorless

Healthy cells tolerate the destructive force of radiation better than cancer cells. Therein lies the effectiveness of radiation for treating cancer. One characteristic of a proton beam is known as the Bragg Peak. As described in an article by James Metz M.D. "...the absorbed dose of a proton beam increases very gradually with increasing depth and then suddenly rises to a peak at the end of the proton range." The energy level beyond the Bragg Peak is relatively negligible. Another important characteristic of a proton beam is it can be manipulated to deliver optimal levels of energy to precise locations within the target area. In layman's terms cancer cells can be nullified with pinpoint accuracy. By way of contrast an xray beam, the more common form of radiation, tends to deliver equal amounts of energy from the entry level through the target volume to the point of exit. These differences in radiation characteristics translate into less collateral damage from proton beam radiation. Herein lies the proton advantage.

I have no reason to doubt the validity of the above information. It is derived from a variety of presumably reliable sources. I feel obligated to mention, however, many well-intentioned, highly trained professional experts would disagree with the above-stated point of view. The reader may recall Dr. Tuflov who had recently attended a national symposium of radiation specialists who concluded clinical evidence does not support superiority of proton treatment over other forms of external beam radiation either in terms of long term outcomes or adverse side effects. It is the lack of unaminity among the experts that has made my journey all the more tumultuous.

Pretreatment Impressions

After being here in Jacksonville for awhile, touring the facility and interacting with a few of the institutes's medical personnel, I am satisfied with my treatment choices. Dr. Ezee's and Dr.Tuflov's persuasiveness notwithstanding, I am convinced that for me and my circumstances proton therapy represents the least unattractive option. Preliminary test results indicate the delay involved with this choice has not jeopardized my chances for a favorable outcome. Furthermore I am convinced UFPTI is the premiere proton treatment center in existence. It offers state of the art equipment and the most advanced technical procedures available.
By virtue of my modest research effort and a ton of dumb luck, I am at the right place at the right time to be treated for this dreadful disease.