Glad to be hereBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3356 (Published 19 August 2009) Cite this as: BMJ 2009;339:b3356
- Adrian Manning, retired consultant physician, Shipley, West Yorkshire
In December 2007 my 56 year old younger brother, living and working in a major city in the United States, underwent his routine yearly company medical examination. He phoned me afterwards to ask what the “PSA” was, because his was high. I, an NHS gastroenterologist, gave him our party line: the prostate specific antigen (PSA) test can indicate prostate cancer but has too many flaws to be useful for screening. He had a transrectal biopsy, which he described to me vividly, and it showed cancer. His urologist proposed robot assisted laparoscopic radical prostatectomy. The urologist said that this was the only operation considered these days; he did no other. It was, he said, best for reducing blood loss, for speed of recovery, and for nerve sparing and hence potency; any right thinking second opinion giver would say the same.
I did what many patients, relatives, and doctors do: I consulted the internet. Among many helpful (and unhelpful) things I learnt was that a major risk factor for prostate cancer is a positive family history. We had no history of the cancer in our family, and I, aged 59, was asymptomatic. Working for the NHS, I had no routine yearly medical examination, and even if I had it would likely have not included PSA testing. I filled in my blood test request form and checked the result. My PSA concentration was twice as high as my brother’s. I bumped into a urological colleague on my way home, and we took matters from there.
One history and examination, two transrectal biopsies, and a magnetic resonance imaging scan and bone scan later and I too had confirmed prostate cancer, mine T3, indicating that it was “locally advanced” but without obvious distant metastases. All the information went to our local urology multidisciplinary team meeting; and then my wife and I sat with my consultant colleague and a cancer nurse specialist. Options were discussed, the pros and cons of different ways forward: do you opt for greater chance of cure or for nerve sparing (at the age of 59)? Do you go for radiotherapy or leave it as an option for later, if it should come to it? We were given information sheets, directions to the consultant’s website, contact details for any further questions. What would you have done if you were, as I was, asymptomatic? I chose the greatest chance of cure under the circumstances, open radical prostatectomy.
In February 2008 my brother had his robot assisted prostatectomy, at a clinic 100 km from home, and was discharged the next day—his departure being delayed for several hours because of concern over his low haemoglobin concentration. The aftercare contact information was the surgeon’s email address. The next day I had a worried call from my sister in law: he was in pain, and the catheter was not draining. Undoubtedly the problem was clot retention—undoubted to anyone with that knowledge or who had been given the information. Being 5600 km away I could offer no practical assistance but suggested that they contact the nearest hospital. Matters were eventually resolved but not without aggravation and protracted discomfort.
Six weeks later I had my operation, on 1 April, the 21st anniversary of my starting as a consultant at the hospital. After my open surgery I needed no oral analgesia and no blood transfusion. I was in hospital for 36 hours after the operation. I had printed aftercare and contact information, for the hospital and district nurse, and all the kit and spares for the “plumbing.” I had no postoperative complications, yet the district nurse contacted me to ask whether all was well and that I had everything I needed.
Happily we have both recovered well from our operations. My brother, after laparoscopic surgery, went back to work more quickly than I did after my open procedure. We both had our initial struggles with continence, but they settled with time and concentration. Effects on potency? Difficult to compare, with different operative approaches, different personalities, different attitudes. I can, however, compare and contrast the medical advice given by a Texan surgeon and by an NHS urologist together with a cancer specialist nurse and can attest to honest information leading to more realistic expectations and less frustration.
We anticipate that my brother will have no further problems with his cancer; I may need more treatment at some stage.
This is more than just another doctor going on about what it is like to be a patient; these concurrent experiences invite comparisons. The thinking clinician’s assessment of this narrative might touch on such issues as:
PSA screening and the inequalities inherent in a system that relies on opportunistic checks during annual company medical examinations versus the absence, as yet, of targeted population screening in the UK
The potential for biases to influence practice and the presentation of choices
The true differences between open and robot assisted laparoscopic approaches in the short and long term
The importance of good aftercare and contact information.
However, this feeling person is grateful that his cancer, locally advanced but asymptomatic, was diagnosed and treated, before demonstrable metastasis, as a consequence of his brother’s unanticipated diagnosis. And he has appreciation for his local NHS and the pre-, peri- and postoperative treatment, information, and contact that it provides.
Cite this as: BMJ 2009;339:b3356