proton don

Roller Coaster Express

2012-01-12T08:22:00.000-08:00

My latest PSA came in at an alarming 1.6 which represents a doubling of value in the past nine months. Many of the readers of this entry will realize that a doubling of one's post-treatment PSA within a period of one year is generally associated with biological failure or recurrence and an indication of aggressive progression. My initial reaction has been one of extreme anxiety. Once again, I thought, my quality of life is under attack. A limited research effort served only to reinforce this deep-seated fear.
Then comes a spirited data exchange between me and my case manager at UFPTI. The most recent UFPTI standard, she advised me, focuses on (1) each patient's PSA baseline, i.e., the first result immediately following the cessation of treatment* and (2) a patient's PSA trendline over an extended period. She regards the doubling of my PSA over the past nine months as a shot-term phenomenon and therefore relatively inconsequential. Furthermore, she reiterated, " I see nothing unusal or out of line with your PSA history".
Based on our conversation my state of panic has subsided substantially, although I admit to a wee bit of skepticism. In action and in deed I will consider myself as having dodged another bullet, that is, until and unless I receive clear evidence to the contrary. My next regularly scheduled PSA is due in April.
*My baseline score of 2.41 provides a degree of reassurance.

Don't Worry Be Happy

2011-10-26T05:00:00.000-07:00

In conjunction with a post treatment followup, I had a telephone conversation with my casemanager. Toward the end of our discussion I expressed my concern in regard to my erratic PSAs and upward trend. Her response appears below:

(1) "Everyone's post treatment PSA pattern is different."

(2) "I see nothing unusual or out-of-line with your PSA history."

(3)" It may take a full three years for your PSA pattern to settle down and/or become less erratic."

(4)"There appears to be a pattern to your PSAs that look to be laboratory related. The results conducted by the laboratory in Texas appear to be lower than those reported by the Michigan laboratory. These differences may be attributable to the differences in equipment and procedures used." (Personal note: the differences in laboratory results may also account for much of the apparent erraticism).

All in all I regard my casemanager's comments and observations as very, very comforting.Her astuteness represents another example of the competent, conscientious care provided by the staff of UFPTI.

It may be time for an attitude adjustment on my part, i.e., Don't Worry Be Happy. Conversely, who knows what conundrum may be lurking around the corner. My next PSA will be conducted in January by a laboratory in Texas. Stay tuned.

Worriesome Trend Continues

2011-10-13T16:52:00.009-07:00

The following letter serves as my current entry:

Dear Dr Gud E. Nuff:

Let me begin by expressing my appreciation for the excellent care you have provided throughout my treatment at UFPTI. I especially appreciate the patience you have shown answering all the questions I raised over the past two and a half years. My latest concern is an upward trend in my PSAs the last three of which appear below:

May .8

August 1.27

October 1.39

Shouldn't my PSAs have leveled out at this point in time? The upward trend is particularly worrisome. Is this concern justified? I would very much appreciate (1) your review of my medical records on file at UFPTI, and (2) your professional assessment of this unexpected rise in my PSA values.

Also as a matter of revelant interest: What does the pattern of a successful outcome look like over , let's say, a five year period? Same question for an unsuccessful outcome? If the answer to these questions depend on the age of the patient, his general health and his disease characteristics use my case as an example.

FYI The contents of this letter will appear as an update to my ongoing internet journal. Your reply will appear as my next entry.

Thanks again for the conscientious care you have provided throughout the course of my treatment.

Sincerely,

Don Oberlin

Another Bump in the Road?

2011-08-07T12:58:00.000-07:00

My most recent PSA registered a disappointing 1.27 an increase of .47. I wish it were lower, but it is too soon to panic. I have experienced minor blips before, and hopefully, this too will be nothing more than a minuscule bump in the road. I remain mindful of the following two UFPTI post-treatment standards:

(1) Any number under 1.5 is good.

(2) It is time for concern only when a patient experiences consecutive rises of at least two points.

October's result will undoubtedly be better. Right? Right.

Colonscopy Surprise:Research Completed

2011-07-24T11:12:00.000-07:00

Dr. A.N. Swer's response took the edge off my worry and concern. His final words of advice "Don't worry" support the gist of my additional research, a summary of which appears below:

(1)Bob Marckini

"The condition you describe is very common. It is a phenomenon called radiation induced neovascularization. New blood vessels form in the small area of the anterior wall of the rectum... in general it's nothing to be concerened about. The good news is that they intentionally treated a margin around your prostrate. This serves to kill the cancer that is in the margins. This includes any prostate cancer that might have been in the margins. Having an invisible scar is a small price to pay."

(2) UFPTI

The physician who planned and supervised my care at UFPTI responded to a letter outlining my concerns as depicted below:

(A) We refer to the condition you describe as radiation scarring---not damage.

(B) This condition is unlikely to progress.

(C)Be certain not to let anyone biopsy the affected area.

This message was delivered over the phone by his nurse.

(3)An Interactive Proton Radiation Website

This site provided a wide range of reponses. Perhaps the following two were the most relevant and the most diverse:

(A) "Based upon the fact that you were competently counseled based upon prior entries to your blog, and based upon your review and knowledge of the precise relevant passage of Marckini's book, I cannot imagine why you feel justified in saying evidence of radiation damage is a surprise."

(B) "Thanks for your post and your compelling blog which gives a guy like me a glimpse of one patient's real world post-protion treatment ups and downs. "

Case closed. The bottom line is that had I been prepared for the striking difference in the pretreatment/posttreatment colonscopy photographs, there would have been far less handwringing, agony, worry and concern.Hopefully the readers of this journal will be spared these emotions.

Post Treatment Colonoscopy: An Update

2011-07-19T16:22:00.000-07:00

As reported in my previous entry, proton radiation permanently damaged a small segment of my colon. This diagnosis triggered an immediate research effort on my part. I am particularly interested in its long term implications. My research is incomplete and ongoing. In view of the potential interest to others, however, I feel compelled to file this interim report based exclusively on the opinions of Dr. A. N. Swer.
Dr. Swer is a practising physician with a Phd. in microbiology from Harvard University. His specialty is nuclear medicene. His interest in prostate cancer and proton therapy has been augmented by personal experience with both. Based on a photograph posted on the internet Dr. Swer's colon looks a lot like mine. In response to several of my concerns, Dr. Swer opined, in part, as follows:
"I would consider angiodysplasia to be the word for the tissue changes that are associated with radiation proctitis. Since the procedure that cured my bleeding, I have not worried about my angiodysplasia (which is likely worse than yours). My bleeding didn't start until many months after the treatment though I imagine that a great many men who have had photon or proton radiation for Pca have angiodysplasia of one degree or another and one pattern or another, with or without problems from it. I haven't seen a publication documenting this, however, I think it would be quite interesting ... I can't guarantee that you will never bleed, but also my guess is that area will never heal..."
"Radiation for Pca likely creates a small increase in the risk of cancer in tissues that it doesn't kill, including but not limited to the adjacent bowel. The overall increase is probably lower with proton than with photon therapy. That consideration goes in the plus column for choosing protons...
In short, I think your gastroenterologist is right on target, including scheduling you for follow-up colonoscopy; and my final word of advice, for what it's worth is: Don't worry."

Dr. Swer's expert opinion may not qualify as the clean"Bill of Health" I may have hoped for , but
it is not the proverbial "Kiss of Death" it could have been. More specifically my worst fears have been substantially amelioriated.
In retrospect at this juncture the worst part of my colonoscopy mini-adventure is the complete absence of any expectation of permanent colon damage. None of my research before, during or after treatment prepared me for this outcome.

Post Treatment Colonoscopy: A Good Outcome with a Few "Inconvenient" Surprises

2011-07-01T12:16:00.000-07:00

My colonoscopy uncovered a precancerous polyp which my physician removed as a matter of routine. This outcome was not unexpected, since I had similar results with my two previous colonoscopies five years and ten years hence. This was welcome news nonetheless because of the uncertainty introduced by the intervening proton radiation.

Thanks to my wife and her conscientous record keeping, I was able to compare the photographs of my current colonoscopy with those taken in 2006. What I saw caused concern. Comparatively the current photographs showed substantially larger and considerably redder blood vessels. In two of the five photographs, it appeared as if bleeding had occured. Accordingly I contacted by physician; the phone discussion developed as follows:

Comment: Please explain the differences between the current photographs and those taken in 2006.

Response: What you see is the result of radiation. Such damage to the colon is concommitant to all forms of radiation.

Question: Is there a difference between the effects of proton radiation and photon radiation?

Response: In my 30 years of practise you are my first patient to have undergone proton radiation. I would say that comparatively speaking you have a considerably milder version of what I typically see.

Comment: Two of the photographs were particularly red; please elaborate.

Response: Those particular areas appeared atypical and required a degree of probing and compression; consequential bleeding occured. No doubt these areas have completely healed by now and should not be a concern to either of us at this point.

Question: How much of my colon has been damaged?

Response: A very small segment in the area of the prostate.

Question: What kind of problems can I expect in the future?

Response: Inasmuch as you have experienced no problems in the past, e.g., spontaneous bleeding, it is unlikely you will experience any problems in the future.

Question: Is the damage to my colon temporary or permanent?

Response: I would be very surprised if it looked much different when we reexamine five years from now. I do not expect further deterioration nor do I expect much improvement.

In conclusion I would say (1) There has been permanent damage to a small portion of my colon that I did not expect based on my (limited) research to date and (2) It may be something or it may be nothing. Perhaps this entry will generate enlightened comment.

The Tumultous Journey Begins to Smooth Out

2011-03-17T13:24:00.000-07:00

My two year post treatment anniversary PSA came in at .8. UFPTI considers any post treatment PSA under 1.5 as a positive sign. In retrospect over the past year and a half all six of my PSAs have been under this guideline. Hooray and hallelujah to a pleasant and satisfying post treatment trend!

A Promising Turn of Events

2010-12-07T09:45:00.000-08:00

Rather than continuing its upward trend, my PSA registered a reassuring .8 this trimester. A second positive step occurred in my recovery,i.e.,the total absence of colonic bleeding. The reader may recall 30% of us who undergo proton radiation experience such bleeding. Needless to say I am extremely pleased with these developments.
Other than routine PSA monitoring the next most notable milestone in my post treatment history will be a colonscopy which is overddue, but should take place next spring. In the meantime HAPPY HOLIDAYS!

Cause for Concern?

2010-09-19T17:07:00.001-07:00

My last five PSA results were as follows: Oct.2009, .55; Dec. 2009, .9; March 2010, .8; June 2010, .83; Sept. 2010, 1,03. There appears to be a modest trend in the WRONG DIRECTION! Accordingly I contacted UFPTI. "Not-to-worry," as goes my interpretation of their response,
"we do not believe cause for concern exists until a patient experiences consecutive rises in their PSA of at least 2 points. This would mean a rise of 4 points over a 6 month period. My modest, inconsistent elevation over the past 12 months seems inconsequential when compared to this standard. Even so, I would prefer that my PSAs trended downward, not upward.

DR TRUCAIR REVISITED

2010-08-18T16:41:00.000-07:00

Rather than return to Jacksonville for my belated one year follow-up exam, I arranged to be seen here in Michigan by Dr. Trucair. Although a thoroughly experienced oncologist who specializes in prostate cancer, I was the first patient of Dr. Trucair to have undergone proton radiation. He was noticeably impressed with my lack of side effects and even more so with the results of the DRE he conducted. "Your prostate feels more normal than any post-radiation patient I have examined to date; this is truly significant", he explained ," I must share this information with my colleagues." "Even so," he continued, "some effects of radiation take a long time to materialize. "Accordingly,"he indicated, "I would like to see you in six months."

Toward the end of our appointment Dr. Trucair made a few additional comments worthy of note. He mentioned the development of a new proton center in the Flint area here in Michigan. The first patient is scheduled to be treated at this facility in approximately one year. "Proton radiation is a very expensive proposition," Dr. Trucair commented,"but, in the absence of side effects to be medically managed, the costs of treating with protons will not be much different when compared to other treatment modalities over the long run." He then conjectured, "In the future I can see where proton therapy may become the preferred method for treating prostate cancer." I thought this was very positive way to conclude our appointment.

The next hurdle for me to negotiate will be my upcoming 18 month post treatment PSA test. This will occur in three weeks or so.

Double Lucky

2010-06-21T03:34:00.000-07:00

My most recent PSA came in at .83.Trimester by trimester my results tend to parallel Marckini's whose PSAs continued to drop to a nadir in the .4 range. If my PSAs continue to match his, I will consider myself well on the way to recovery thanks to Marckini. And thanks to George Lewis whose national news report called my attention to proton therapy and Marckini's phenomenal book "You Can Beat Prostate Cancer and You Don't Need Surgery to Do it".

We returned to Michigan in mid-April. There has been a major improvement in my potency since our return [and my prior journal entry]. The dramatic downturn was most likely situationally based, i.e. ,due to the increased physical activity I engage in while hiding out in south Texas to avoid Michigan winters. While some degree of permanent degradation may have occurred, it is [1] much less severe than initially reported, [2] managable, [3] less disconcerting and [4] most likely a result of the aging process. If radiation is a factor Dr Good E. Nuff would almost certainly catagorize it as negligible.

More Tumultuousness

2010-03-11T13:40:00.000-08:00

This entry marks my one year post treatment anniversary and represents my second good news bad news edition. First the good news. My PSA's for December and March were a reassuring .9 and .8 respectively. Although higher than my October result (.55), these measures are low enough and in the proper direction.

The bad news is my potency has taken a sudden and dramatic downturn. Rather than quantify its severity or explore its implications at this juncture, I prefer to postpone a discussion of this issue until I better understand its etiology. Factors other than proton radiation may be at work. More specifically I turned 74 last month so age is almost certainly a factor. Another factor may be situational. We are Michiganders , but spend our winters in Texas. The tennis courts in our southern abode are within walking distance, and weather permitting, I play two hours of fairly competitive doubles daily. In addition I spend an hour or so in the nearby gym three or four days a week. My summers are subsantially less energy intensive, since playing tennis involves a 60 mile round trip. Nor is there an exercise facility located conveniently nearby.

My wife who claims to know these things believes the situational factor is the primary factor. Time will tell, and we shall see.

A BELATED SIX MONTH CHECKUP

2009-11-27T13:11:00.000-08:00

Dr. Gud E. Nuff initiated our appointment by reviewing my chart and asking me how I had been doing in general. I told him I felt great and had been experiencing no ill side effects. He conducted a DRE, palpated the lymph glands of my neck and groin, then concluded these proceedings with the following assessment, "you have less than 1% chance of dying from prostate cancer." "Do you have questions?" he inquired. The following discussion ensued:

Comment and Question:
"I had been scheduled for a colonoscopy three months ago. I consulted with my case manager at UFPTI who advised me to wait at least one year. When ready she would mail my proctologist advisory materials on how to conduct his examination." I asked Dr. Gud E. Nuff to address these issues.

Answer
"Proton radiation irritates and reddens the bowel especially in the vicinity of the prostate. Proctologists are trained to biopsy in these circumstances. Such a procedure may cause an ulceration that is resistant to healing. Additional intervention may then be required. A year of healing following treatment is simply a precautionary measure."

Comment and Question
For perspective on the next few questions the reader should know I avoid "unnecessary" exposure to radiation and have done so most of my adult life. For example my dentist routinely provides his patients with an annual full mouth x-ray. In deference to my concerns in this regard my dentist reluctantly limited this prodedure to once every ten years for me.

Following my diagnosis of prostate cancer I readily agreed to any and all forms of radiation. This included a multitude of preliminary assessments including an MRI (or two) a Cat-scan and various other diagnostic procedures involving radiation. The treatment procedure per se consisted of 39 occasions of concentrated proton beam radiation assisted by innumerable
x-ray scans to ensure the proper placement of my prostate.

"What are the long term effects of all this radiation on my various body parts including my bladder, colon, rectum, bones and other tissues in the path of the radiation beams.

Answer
"Negligible".

Question
"Same question as above concerning the effect of radiation on my longevity."

Answer
"Negligible"

Question
"Am I at greater risk for other cancers as a result of my history of prostate cancer and radiation treatment."

Answer
"Negligible"

In concluding our appointment Dr. Gud E. Nuff pointed out that 30% of post-treatment graduates experience rectal bleeding at about the 18 month interval. I knew about this phenomenon from reading Marckini; on page 130, Marckini comments as follows:

"As. . .healthy tissue repairs itself, there is a phenomenon called radiation induced neovascularization. New blood vessels form in the rectal wall, and periodically some blood vessels near the surface leak blood, or a scab will slough off. This condition is not uncommon, it is self-limiting, and it almost always goes away after a few months."

I certainly hope I am among the 70% who do not experience this worrisome symptom, but all in all, I do not know how the results of my belated six month checkup could have gone much better.

A

2009-11-27T13:05:00.000-08:00

A Routine Journal Entry--- Eureka!

2009-10-11T18:31:00.000-07:00

Another favorable PSA reading to report,i.e., .55.Fantastic! My Free PSA also continued to drop,i.e., .05. This could be bad news, but probably isn't. UFPTI advises that Free PSA readings are collected on us gradutes at this point for future research purposes only. Conceivably I will discuss this topic in more detail after my belated six month checkup at UFPTI scheduled for November 12th. I should have other matters of interest to report, because, as usual, I intend to raise many questions.

Three Month Update

2009-06-13T13:44:00.000-07:00

This entry qualifies as a good news bad news edition. First the good news: (1) I am totally free of the nuisance side effects reported earlier, i.e., intestinal turmoil,urgency and incomplete voiding and (2) my PSA has dropped to a remarkable 1.10. I am unsure of what I expected, but I can say with absolute certainty it never occurred to me my result would be quite this low. The staff at UFPTI advised us not be be overly concerned if we experienced an occasional spike in our PSA during the two year monitoring period. In keeping with this advice I will try my best not to become overly optimistic in view of this phenomenally low, totally unanticipated reading.

For the record the reader should know UFPTI directed the lab to run a Free PSA; my result was 12 which signifies my risk of an existing cancer is less than 25 per cent. A Free PSA will be run periodically over the next 21 months.

Now for the bad news. My potency seems to have diminished (I am guessing) in the neighborhood of 10 to 15 per cent. This erosion may be due to the aging process., If it is due to proton radiation, however, it contradicts the prognostication of Dr Gud E. Nuff. On the other hand it places me among the 35 per cent of men who report some change in their sexuality as per R. Marckini , p.67. I suspect I am much better off than would be the case had I selected a treatment modality other than proton therapy.

Stay tuned. Who knows what the next three months will bring.

2009-03-11T13:38:00.000-07:00

A Semi-Final Word

As of today the proton treatment is complete.

Nuisance side effects should slowly fade completely.

The speech went reasonably well, though, it would have been better had I not been quite so emotional. Of course I wept, but the audience was patient and seemingly appreciative.

The initial PSA result looks very promising. it dropped from a high of 3.8 to 2.41. We will monitor my PSA very closely, i.e., every three months for the next two years.

From time to time I will provide progress reports so stay tuned if interested in outcome long term.

I wish to thank my family and friends who offered their welcome support throughout my tumultuous journey.

2009-03-06T07:07:00.000-08:00

The Final Stretch

As of this entry I have three treatments remaining. My intestinal turmoil at this point is minimal. A few minor bladder annoyances have arisen, but no major problems exist and none are expected. The minor annoyances, urgency and incomplete voiding from time to time, are said to be "self-limiting."

Each of us prostate patients is expected to make two presentations at our weekly luncheons. My second and final presentation will be delivered next Wednesday following my last treatment. Its content appears below for your consideration.

When I last stood before this group as a newbie I wept. I wept because I was so happy to be here. Today I may become a little misty eyed. This time because I am so happy to be through with my treatment. I am a full fledged graduate as of today, and I will be leaving soon, perhaps, tomorrow. And as all of you can appreciate that is a very good feeling.

I intend to try not to weep today, however, not because its unmanly, but today's presentation is about this institution and the staff who make it what it is. I wish all the people who contributed to my care could be here so that I could tell them personally how grateful I am. Inasmuch as this is not possible I am including this presentation as my next journal entry. It will be available to my family and friends who have followed my treatment, to certain staff member's who are aware of its existence and to all those in cyberspace whoever and wherever they may be.

My list of heroes is limited to those I interacted with most directly, roughly on a consecutive basis as follows:

- To the intake staff who answered all my questions and patiently assisted and guided me in the collection of all of the medical data which resulted in my acceptance by this center. Thank you so much for your caring assistance.

-To my case manager who shepherded me through the program. This key member of my treatment team answered innumerable questions and promptly returned my phone calls of which their were many. She coordinated responses to the blips and hiccups that occurred along the way. It takes a special person to do this job and she certainly qualifies in this respect.

-To my managing physician who developed my treatment plan and oversaw its implementation, who smoothed out the bumps and medical issues as my treatment progressed. In my blog I refer to him as Dr.Gud E.Nuff. In retrospect I wish I had named him Dr.Tu Gud because in many respects, like this institution and its staff, they are seemingly too good to be true.

-To the simulation crew who worked so diligently in preparing me for the real thing. I presented them with a very real challenge, in that, on the day of my work up I experienced the worst case of intestinal turmoil that I had suffered in the previous six or seven months. They responded by redoubling their efforts. I feel indebted to their unwavering patience and commitment to their important task.

-To the gentle conscientious caretaker who inserted my four gold rings. I think the urologist who conducted my biopsy could learn a thing or three from this accomplished practitioner.

-To the Patient Services Director whose enthusiasm for this institution is contagious. I knew I was fortunate to stumble upon proton therapy as a solution to my problem, but I did not realize how lucky I was to end up here in Florida until I took the guided tour. It was so educational, so encouraging and so entertaining that I took the tour twice; the second time I took notes. If ever there was a man who found his calling it is this fine gentleman.

-For the technologists and radiation therapists and the person who hired them. What a beautiful/handsome conscientious and competent crew. Thank you so much for your daily compassionate care.

And finally I want to pay tribute to my wife Marilyn who among other duties serves as my navigator, secretary, business agent and recreation director. As always we were joined at the hip
throughout this ordeal. She accompanied me on all the preliminary meetings and on each treatment trip we made to the center. Most importantly she kept me warm on each of the cold winter nights we spent here in Jacksonville--of which there were many.

Would each of you please join me in applauding the individuals I have cited and all those who have contributed to the great care each of us has received during our stay here.

2009-02-26T10:46:00.000-08:00

An Unexpected Procedural Change and Corresponding Concern

For the sake of emphasis and because of its relevance, I am including the following passage from my previous journal entry:

"When undergoing radiation for cancer, minor deviances produce major concerns. For a non-participant, it may be difficult to fully appreciate, but each unanticipated blip becomes a quality of life issue."

As the technologist escorted me to the dressing room one day last week, she advised me: "Today's treatment will take a little longer than usual, because of an adjustment to the beam aperture." "Less of the tissue surrounding the prostate will be radiated." What triggered this modification, I wondered? Had something shown up in the monitoring mechanisms that necessitated a change? Did the intestinal flareups indicate a need for a more focused approach? Had there been an error in the initial treatment plan that needed correcting? The technologist assured me (1)this was a preplanned change which occurs in about fifty percent of the patients she radiates and (2)the less collateral damage the better. Good reassuring information to be sure, but in my estimation ill-timed. I made a mental note to discuss this conundrum with Dr. Gud E. Nuff.

In my weekly discussion with the gud doctor I expressed my concern. To my surprise (dismay?) the doctor seemed unmoved. "It is a matter," he responded, "which the technologists are perfectly capable of handling." Perhaps so, I thought, but from my (patient's) perspective, there is room for improvement. In my humble opinion, the planned procedural change provides a golden opportunity for a meaningful doctor-patient dialog, preferably, early in the treatment process. I intend to address this issue in my exit interview.

2009-02-19T08:05:00.000-08:00

More Blip, More Anxiety

When undergoing radiation for cancer, minor deviances produce major concerns. For a non-participant, it may be difficult to fully appreciate , but each unanticipated blip becomes a quality of life issue. My intestinal flare-up reemerged this past weekend. On Monday when removing the balloon the attending technologist advised me to consult my doctor because of the apparent rectal bleeding that had occurred. Rectal bleeding is never a good thing. As a proton therapy patient it is a potential calamity. Accordingly my case manager arranged for a consultation with the on-duty physician within minutes following my treatment. TALK ABOUT RESPONSIVENESS; ABSOLUTELY AMAZING.

In any event the attending physician, an extremely conscientious caretaker, after reviewing my record and asking a host of relevant questions concluded: (1) This particular intestinal disturbance was most likely caused by dietary indiscretion. * I had consumed two beers and several handfuls of peanuts on Friday evening and (2) the bleeding resulted from a combination of the intestinal disturbance and the normal irritation which accompanies the usage of the balloon. In his professional opinion radiation was not a significant factor, and in due time I would be just fine. From my perspective, I had dodged another bullet.

*A note on diet. During the active treatment period, i.e., a five day work week, proton patients are expected to avoid gas producing foods and beverages including carbonated beverages, leafy green vegetables, fiber etc. Fridays are supposedly "free days" when it is acceptable to return to your normal diet. Apparently I found an exception to the exception.

2009-02-12T07:11:00.000-08:00

Progress Report

The gastrol-intestinal blip is substantially resolved. Dr. Gud E. Nuff appears to have been correct. The other really good news is I am half way through the treatment process. So far, so gud.

2009-02-06T06:46:00.000-08:00

An Unanticipated Blip

Sixteen down, twenty-three to go. So far so very, very good. I have experienced a couple of minor side effects. The most disturbing symptom to date has been "intestinal turmoil" which under normal circumstances would generate little or no concern. Because I am in treatment, I suspected I may be reacting to radiation. Consequently, I felt a moderate degree of alarm. In addition I was concerned the intestinal disturbance which included the production of gas may adversely impact the treatment process. We prostate patients learn early on intestinal distress must be avoided.

In my last journal entry I discussed the various measures taken to immobilize the prostate. Intestinal gas has the opposite effect. It creates a moving target and undermines the treatment process. Because of my two-pronged concern, I consulted Dr. Gud E. Nuff. In his professional opinion these symptoms were neither caused by radiation nor were they affecting treatment. "Let's monitor the situation and go from there," he advised, which sounded both reasonable and reassuring. Its comforting to feel as if you are receiving gud care.

2009-01-30T17:19:00.000-08:00

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.

2009-01-23T06:38:00.000-08:00

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.

2009-01-16T09:08:00.000-08:00

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.

2009-01-12T09:59:00.000-08:00

Pretreatment Meandering

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.

2009-01-05T07:53:00.000-08:00

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.

2009-01-02T07:09:00.000-08:00

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.

2008-12-27T10:47:00.000-08:00

Treatment Prelude

Last week I underwent a series of tests and procedures conducted by a group of highly trained professionals using a variety of sophisticated equipment to: (1) determine whether the cancer has spread beyond my prostate (2) properly align my body to administer the exact amount of proton energy to its target area and (3) provide a data base for developing a comprehensive treatment plan. It was indeed an impressive undertaking. I will not know the results of the diagnostic tests for a week or two.

Another major development occured this week. I was given a start date. My treatment begins January 14, 2009.

2008-12-23T09:53:00.001-08:00

Proton Treatment Delimma

While awaiting treatment for prostate cancer, time is your enemy; a quality of life, if not, life threatening enemy to be sure. The following factors come into play:

---Relationship of PSA to treatment outcome. A medical study conducted in April of 2002 by James Metz M.D. contains a chart which shows a clear relationship between PSA level and prostate cancer cure. Higher PSA scores are directly related to lower cure rates. As readers of this journal know my PSA levels are rising at a fairly rapid pace.

---Cancer cell development. As I understand it cancer cells reproduce along the following lines: A single cell materializes, this cell devides into two cancer cells which in turn devides into four, four into eight, eight into sixteen and so on. The larger your tumer becomes, the faster it grows and the more difficult it is to treat.

---Metatisis the longer your prostate cancer goes untreated, the greater the chance it will spread to other organs of your body. When and if this occurs you enter into an entirely different medical realm.

The worries and concerns associated with a delay in treatment tend to be offset by the fact that prostate cancer generally develops slowly. On the other hand your case might be the exception. It's not unlike having a timebomb strapped to your waist and not knowing when it may detonate. A friend of mine likened it to having a monster in your closet. In any event the tests scheduled this week here in Jacksonville are designed in part to determine whether the cancer remains contained to my prostate.

2008-12-19T08:20:00.000-08:00

Treatment Center Selection

I first heard of proton therapy by way of Bob Marckini's book, "You Can Beat Prostate Cancer." His book more than anything else convinced me proton therapy represented my best treatment option. Subsequent research has not dissuaded me from this personal choice. Doctors Ezee and Tuflov offered persuasive arguments for surgery and IMRT, respectively. Certainly other viable options exist depending on personal preference and individual circumstances. Any of us afflicted with this dreadful disease are inevitably confronted with difficult choices. There is no perfect solution, and most certainly there are no guarantees. In the final analysis you place your bet , roll the dice and hope to get double lucky.

I contacted four of the five proton centers in the United States. I made my decision primarily on which center could begin my treatment soonest. It turned out to be the University of Florida Proton Institute(UFPTI) located here in Jacksonville. Due either to an unfortunate miscommunication on their part or a regrettable misunderstanding on my part, the wait is considerably longer than anticipated. Even so the waiting period at UFPTI is no longer relative to the other treatment centers I contacted and briefer by a month in one instance. Preliminary measures are scheduled to begin here in Jacksonville next week.

2008-12-16T12:13:00.000-08:00

A Third Opinion

While awaiting the arrival of the radiologist I spent a few minutes in his office chatting with his nurse. She asked me about the book I brought in with me, namely, Bob Marckini's "You Can Beat Prostate Cancer". I told her how profoundly this book had influenced my treatment deliberations. "Let me show it to Dr. Tuflov", she responded, "he might be interested". I handed her the book, and she left the room. She reentered momentarily, returned the book and informed me, Dr. Tuflov had already read the book. "He will be in shortly", she added.

Dr. Tuflov entered the room. He reminded me of an animated Richard Drefuss. He certainly resembled him in terms of stature, facial characteristics and self confident demeaner. "You should know right from the outset", he began, "you are not special. There are thousands of others out there just like you. In my 25+ years of experience I cannot tell you how many patients I have seen no different from you". "No sir", he said shaking his head for emphasis, "in no way are you special". Not knowing quite how to respond to Dr. Tuflov's opening remarks. I made a conscientous effort to maintain constructive eye contact and listen attentively. "But that is just me", he continued, "I raised my children wanting them to appreciate the fact that they were not special. No matter what their teachers and friends might tell them, I wanted them to realize the limits of their potentials. These comments served to ease my concern. It was not only me Dr. Tuflov did not want harboring thoughts of speciality.

To initiate a more fruitful direction to our discussion I thought it may be advantageous to provide Dr.Tuflov an opportunity to answer a medical question that had been puzzling me for awhile. A few weeks earlier a representative of one of the proton treatment centers that I had been in contact with expressed a particularly keen interest in the fact I had been diagnosed with diverticulosis a few years back. She did not explain nor did I ask how this could affect my treatment. "Why might this be important?", I asked Dr. Tuflov. Without hesitation with more energy than the inquiry seemed to warrent, he replied "BECAUSE YOU HAVE THE COLON OF A 72 YEAR OLD MAN FOR HEAVEN'S SAKE." I probably should have known. I raised no further questions.

With these issues out of the way we began to focus on more relevant matters. "It is my understanding your interest in proton therapy is based on Mr. Marckini's book," Dr. Tuflov started anew. "While I have not read his book (contrary to his nurse's aforementioned report) I have read hundreds of others just like it. Personal testimonials are of limited value. We need to rely on scientific data and medical research. I recently attended a symposium of radiologists. This nationwide panel of experts 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."

"Here at this facility we offer Intensity Modulated Radiation Therapy (IMRT). IMRT is the latest, most sophisticated form of radiation treatment. Unlike proton therapy which is profit oriented and investment driven, IMRT is scientifically based. More importantly IMRT possesses the following concrete advantages relative to proton therapy. It is more accessible, you can be treated locally here in Michigan, the waiting period is virtually nonexistant, we can get you started in two or three weeks and the treatment is far less expensive."

In his concluding remarks Dr. Tuflov chose to share his views on outcomes. "Are you familiar with the normal curve?" Fortunately due to a course in statistics 50 years ago I answered affirmatively. "Well then" he continued, "a sizable majority of patients treated for prostate cancer regardless of treatment method have a satisfactory outcome. A relative few patients are double lucky; we cure their cancer and they suffer few, if any, side effects. Then there are those who are doubly unlucky whose outcomes are considerably less favorable. Another important variable is how patients perceive their outcomes. Let me relate two actual case histories from my practise. I treated two patients whose outcomes fell toward the less favorable portion of the normal curve. One of these patients could not have been more appreciative. Though he could no longer have intercourse, he and his wife loved one another and found other ways to satisfy their sexual needs. This fellow was happy to be alive and for him life was good. The other patient whose outcome was quite similar reacted quite differently. He complained bitterly and called me every name in the book." Dr.Tuflov concluded his outcome commentary with the following observation, "Such is the nature of our business."

Therap

2008-12-10T06:38:00.000-08:00

A Second Opinion

Dr.Ezee spoke so positively about prostatectomy and seed implantation and so negatively about proton therapy, I decided to consult another specialist. As mentioned earlier in this chronicle I attended two medical seminars as part of my research effort. An oncologist who specializes in prostate cancer by the name of Dr. Trucair conducted the first of these seminars. Dr. Trucair impressed me as being highly intelligent, well informed and deeply compassionate. In answer to a question I raised concerning my personal situation, Dr. Trucair advised me of how he would want his father treated under similar circumstances. This response struck me as being unusually empathic. Most physicians in my experience do not equate the treatment of their patients with how they would want close members of their family treated. I attended Dr. Trucair"s seminar prior to my diagnosis,i.e., while still hopeful I had nothing to worry about. By the end of the seminar I knew, if the need arose, Dr. Trucair was the type of physician I wanted on my treatment team.

I was not overly surprised that Dr. Trucair agreed to see me on short notice in a timely manner without a referral. He began the appointment by performing a mini-physical that included a fair amount of probing, prodding and thumping. He carefully examined by lymph nodes and listened to my heart and lungs through his stethoscope. Despite my recent back surgery and cancerous biopsy , Dr. Trucair announced his findings: "You are in very good health" He subsequently inquired "How can I be of service?" I summarized the results of my appointment with Dr Ezee and how enthusiastically he recommended either surgery or seed implantation. I also alluded to Dr. Ezee's comments concerning proton therapy. In the latter regard Dr. Trucair conjectured
Dr. Ezee may have based his conclusion on older forms of radiation treatment. "If I were you", Dr. Trucair continued, "I would not rule out surgery nor would I rule out radiation". "On the other hand," he confided, "you are not a candidate for hormone therapy nor do I recommend watching and waiting". The latter modalities are more appropriate for older or less healthy individuals who are not expected to outlive the progression of their disease(s). "And finally if you intend to pursue proton therapy, I recommend you consult a colleague of mine who knows everything there is to know about radiation." Since I trusted Dr. Trucair's judgement, and it seemed like the right thing to do, I readily agreed. Accordingly Dr. Trucair made the arrangements for yet another expert opinion.

Proton Don's Tumultous Journey

2008-12-03T06:42:00.000-08:00

A Definitive Diagnosis

As expected the urologist biopsied my prostate within an hour of my arrival. "Let's get to it," he said, "this will be quick and easy". From start to finish the procedure took about 30 minutes. In terms of discomfort it registered 3.5 on a pain scale ranging in level from 1 to 10.

A week later I received a call from Dr. Ezee's office. A member of his staff informed me the biopsy revealed one or more "anomalies" . "Is it cancer", I wanted to know? "I am sorry", she replied, "I am not authorized to disclose such matters over the phone. Dr. Ezee intends to discuss the results with you personally. We have arranged for you to meet with him on Friday, October 31, 2008". This conversation occurred on October 14 which meant a two and one half week delay before I would officially learn the outcome of my biopsy. " Under the circumstances that seems like an awfully long time to wait," I responded. "I am truly sorry", she replied "October 31 is the earliest possible date Dr. Ezee can see you". It seemed apparent that neither of us could do anything more; so we ended our discussion.

Upon reflection a two and one half week delay seemed wholly unreasonable and totally unacceptable. How to proceed became the question of the day. Should I contact Dr. Ezee directly, and plead my case, or should I contact my primary care physician and ask him to intervene? Neither of these options appealed to me .Remembering that Dr. Ezee practised in a clinic with several other urologists, I called his office later that same day and asked to speak to his nurse. I posed the following question: "Is there any chance that one of the other practitioners could see me sooner by working me into his/her schedule?" She agreed to investigate this possibility and get back to me. A few hours later she returned my call. Dr. Ezee arranged to see me the following Monday. My followup appointment would be in two and a half days rather than two and a half weeks.

"First the good news Mr. Oberlin" Dr. Ezee began, "only two of the twelve samples we took detected cancer. With a Gleason score of seven your results could have been far worse. Your cancer is only moderately aggressive, and I can almost guarantee you, it has not metastasized. I recommend robotic surgery. Unlike most other treatment modalities, adverse side effects show up immediately and most are reversible". "What kind of side effects can I expect", I wanted to know. "Roughly 50% of radical prostatectomy patients became impotent," he said. "Nearly all such patients experience a degree of incontinence, but typically this condition is temporary. Longer term incontinence can be ameliorated in a variety of ways." " What about impotence", I wondered, "can this be corrected with medication?" "In most cases no", he responded. Changing the direction of our conversation Dr. Ezee offered the following option. "If you prefer I can implant your prostate with radioactive seeds." "Seeds are easy", he added ."Whichever option you choose we can get this done in a matter of weeks. How would you like to proceed?" "Before deciding I would like to mull it over for a few days," I replied. Before we concluded I asked him what he thought of proton therapy. Dr. Ezee shook his head, with genuine concern, "once you injure your colon," he said, "it is extremely difficult to repair." On this relatively uneasy note, I thanked Dr. Ezee for his time and professional consideration.

2008-11-25T06:53:00.000-08:00

Additional Research Results

As my research progressed it became increasingly apparent that of the two alternatives offered by my primary care physician, clearly, I made the wrong choice. The more prudent course of action would have been an immediate referral to a urologist. In retrospect the prospect of a biopsy probably influenced my initial decision.

In any event I learned a rapidly rising PSA is highly indicative of prostate cancer. Exploring the source of my sciatic pain necessitated additional blood work. By September 4, 2008 my PSA had risen to 3.74. By October l,2008 it had risen to 3.97. A distinct pattern had emerged. My PSA was rising at the rate of .20 every four weeks. Combined with the doubling that occurred during the prior three year period, I concluded these elevations met the criterion of a rapidly rising PSA. I expressed my concern to my primary care physician. He agreed. An appointment with a urologist followed shortly thereafter.

PROTON DON'S TUMULTOUS JOURNEY

2008-11-24T09:52:00.000-08:00

Preliminary Research Results

Researching prostate cancer and determining what can be done about it turned out to be an intimidating exercise. My effort included reading five or six books, viewing two tapes (on hormonal therapy), attending two medical seminars, surfing the Internet and interviewing several of my friends who survived their prostate cancer ordeals. I quit researching when the material tended toward redundancy. As for treatment options it seems fair to conclude there is no perfect solution. It also seems fair to say that one person's preferred choice may be wholly unsuited or unacceptable to the next individual.

In addition to doing nothing, known in the literature as watch and wait, localized prostate cancer can be treated in a variety of ways. The prostate can be frozen or it can be baked, i.e., by radioactive seed implantation or external beam radiation. The prostate can be removed either by scalpel or robotic scissors through the stomach wall or through a lateral incision in the perineum, i.e.,that narrow patch of skin nestled between the scrotum and anus. Yet another treatment choice is castration which can be accomplished surgically or chemically. None of these modalities offer a sure cure ,particularly the latter ,which is palliative in character. All treatments cause collateral damage ranging in severity from minor abnormalities to stone cold demise.

I urge anyone confronted with this disease to read Bob Marckini's book, "You Can Beat Prostate Cancer" Mr. Marckini touts proton therapy as the treatment of choice, and if you read his book you will understand why. Mr. Marckini successfully underwent proton therapy after conducting extensive research on the subject. Mr. Marckini has evolved as an eloquent spokesperson for and advocate of proton therapy. It is his book that introduced me to the proton therapy concept. It is his book more than anything else that convinced me proton therapy offered the best chance for a favorable outcome with the least likelihood for adverse side effects. Armed with Mr. Marckini's information and perspective I continued my journey.

PROTON DON'S TUMULTUOUS JOURNEY

2008-11-21T08:53:00.000-08:00

Initial Indications:

My mental and emotional journey began in July of 2008. I had not seen my primary care doctor for three years. I discontinued my annual physicals because it seemed like a waste of every one's time to be found "perfectly healthy" year after year. Due to a severe case of sciatica, however, I scheduled an appointment to determine the cause of my pain and what could be done about it.

In addition to his findings regarding my back my doctor discovered that my PSA had doubled since I had seen him last. On April 4, 2005 my PSA was 1.39. By Aug.29, 2008 it had risen to 3.49. My doctor offered two alternatives. He could refer me to a urologist immediately for consultation, or we could retest in two months and determine an appropriate course of action. My impression based on our discussion was that I need not be overly concerned. After all my PSA was still within normal limits. I chose to wait; however, I began my research.

Proton Don's Tumultuous Journey

2008-11-20T11:34:00.000-08:00

INTRODUCTION:

This journal chronicles one man's experience with prostate cancer. It's objectives are threefold. It's primary purpose is to provide useful information to others like me or for those who may follow in my footsteps. I wish also to provide current information to my family and friends who have expressed an interest in being kept up-to-date. And thirdly for those few cyberspace surfers who stumble upon this site, I welcome you aboard. I hope you find the subject matter educational and/or entertaining.

The journey thus far has entailed numerous twists and turns with a great many surprises none of which have been any too pleasant. What the future holds only time will tell. The plan is as follows. While cooling my heels here in Jacksonville Florida, waiting for treatment to begin, I will trace my tumultuous journey through brief statements to be issued once or twice a week.When my treatment begins reports will be issued as the situation develops.