Early ductal prostate cancer diagnosis

I’m Marsh, and here I describe my prostate cancer journey. My father had this condition but succumbed to cardiac arrest brought about by lung cancer complications. I had this in the back of my mind when I found that I routinely woke up to use the toilet, sometimes several times in a single night, and that this had gone on for the better part of a year. My wife Kana was concerned and brought this to my attention, but I was dismissive; I like a drink and wrote these toilet visits off as usual.

It was a cold but fine July winter’s day in Melbourne, and I was visiting my mate Regina in Camberwell. She had to go back inside for something, and in the interim, I was overtaken by an overwhelming desire to urinate. I knocked on the door, trying to do the right thing and use her toilet, but she did not hear my knocking. Even though it was cold, I had not encountered such an urgency to urinate; I felt like I was going to piss my pants if I did not find a solution in the next minute. In desperation, I ended up urinating in her garden. Anyway, she came out, and I embarrassedly admitted that I had sought relief in her garden.

She was bemused but cool about the situation. I voiced my suspicions to Regina about the possibility of prostate cancer. I had experienced urgency issues before, but this one was strange for a reason I couldn’t identify at the time; perhaps my intuition was serving me well. She put me in touch with her mate David, who recently had the operation and counsels men going through the procedure. I felt dropped into the lap of benevolence; David continues to be very supportive and a good mate throughout this process.

I decided to enlist my medical team, describe the situation and then tell them about my family history with prostate cancer. I undertook prostate-specific antigen (PSA) testing. The test returned a reading of 4.78, elevated beyond normal, but not drastically so. I was told to refrain from activities that might stress or irritate the prostate and that I would undergo another test. The test result 1 month later, 2.56, revealed a return to normal levels.

This might have been the finish of the investigation; many GPs would write this off as a temporary irritation of the prostate. Given my family history, I was referred to a urologist, Dr Brendan Dias, who ordered an MRI of my prostate. The imaging came back with anomalies detected, so it was decided that I would undergo a biopsy.

I suspected that something might be in the wind. I had this weird masculinity concept going on, where I had to man up and face this alone, so I asked Kana not to come; a decision we both regret. The biopsy returned positive for cancer. I remember a wave of sickness from the shock of this news, prompting a request for a glass of water. Dr Dias reassured me that the cancer was discovered early and that intervention with minimal unwanted impacts was possible, utilising less invasive robotic surgery and nerve-sparing techniques. He also ordered a PET scan to assess cancer migration. Dr Dias’s personal assistant, Lisa, scheduled me for a radical prostatectomy for 6 December.

That night, I Googled prostate surgery complications, impotency and incontinence, and decided to investigate NanoKnife surgery to avoid the above complications. I felt that I needed to conduct due diligence regarding my diagnosis, and I sought a second opinion. My medical staff arranged for the second opinion through Professor Homi Zagar, a colleague of Dr Dias.

Kana insisted that this time she would attend future appointments, which was a good thing because I hate explaining complex medical data that I do not fully understand myself. But more importantly, it allowed her to be part of the process; guys don’t do this masculinity bullshit of trying to face these medical crises solo, as it just creates misunderstandings and heartache later. We drove to the second opinion appointment in Epworth Richmond, where we met with Professor Homi Zagar.

At the time of the appointment, I thought this was not much of a ‘second opinion’ because the two surgeons work in partnership; my medical centre misconstrued my request. Professor Zagar echoed Dr Dias’s assessment and emphasised the cancer’s cribriform structure, indicating a degree of severity and a hint of news to come post-surgery. Eventually, an appointment with Dr Luke Wang was arranged for an assessment of suitability for NanoKnife. By the time of my appointment with Dr Wang, the PET scan was ready. Dr Wang pointed out that the cancer had not yet migrated outside the organ but was starting to form in another quadrant of the prostate. To be considered for treatment, tumours should appear in only a single quadrant. Additionally, my prostate itself was small and ablative therapy risked trauma that was comparable to the radical prostatectomy, which was looking inevitable in the future. It was determined that I would not be a good candidate for the NanoKnife surgery. I contacted Dr Dias through Lisa and confirmed the booking for 6 December. During that time, I conducted some Kegel exercises to try and bolster my pelvic floor in anticipation of the coming loss of bladder control, though not as religiously as I should have.

My surgery was conducted at the Epworth Freemasons Hospital by Dr Dias, and I awoke with minimal pain. I passed blood in my urine only for about one day, attesting to the precision, efficiency and skill of Dr Dias and his team. Dr Dias made a quick appearance to let me know that the surgery went well as I recovered.

The worst part about the whole surgery was the urinary catheter, which produced a sensation of urinary urgency. Yet, I could not pass urine in the manner to which my nervous system was accustomed. Running water and being in the bathroom exacerbated the urgency, leading me to try to arrest the sensation before it caused pain. This occurred intermittently over the 11 days the catheter was in place. The catheter was removed, and a flexible cystoscopy was performed under anaesthesia.

That night, I was prepared for the inevitable onslaught of bladder incontinence, so I prepared with specialised Molicare adult incontinence ‘nappies’. Predictably, I woke with heavy nappies and resigned to the belief that continence was going to be a problem. I opened Amazon and bought a bedside commode raised toilet seat, which was delivered the next day. However, I found that this was the only night that I had complete incontinence, and that I have retained most of my continence function, with slight leakage at times, circumventing the need for the bedside toilet. Additionally, without venturing into the excessively personal, I found that erectile function was returning. This is currently managed with daily low-dose tadalafil (and high-dose when required). This is further evidence of the efficacy of robotically assisted surgery and nerve-sparing techniques, as well as of Dr Dias and his team’s skill.

Five days later, I attended another appointment with Dr Dias. He informed me that the primary 4 mm tumour was ductal prostate cancer, a rare (approx. 1 in 200 prostate cancer diagnoses) and aggressive cancer associated with early metastasis and minimal symptoms. I also had a 3 mm common acinar variety tumour. Had this been apparent to me around the time of the biopsy results, I might not have bothered investigating the ablative therapy and brought the surgery date forward. To their credit, Dr Dias and Professor Zagar strongly advised against ablation.

Ductal prostate cancer is associated with initial low PSA returns (4.78, returning to normal levels), urinary frequency, weak flow, and, in my case, urgency, but these symptoms are often vague. I hold onto hope that the cancer had not yet migrated outside the prostate, as indicated by the PET scan. Still, there was evidence of multifocal perineural invasion, but only time will reveal its effects. I am quietly confident that I have ‘dodged a bullet’ on this and remain under the monitoring of Dr Dias and my medical team.

I emphasise the importance of early screening for prostate cancer, especially in the context of an associated family history. I also stress that PSA levels are not the ‘gold standard’ of testing, given that the cancer I was diagnosed with is notorious for deceptively low returns. Additionally, I stress early engagement with a trusted urologist. And for God’s sake, relegate the ‘I’ll be a tough guy and face this alone’ maladaptive masculinity c*** to the bin! Thank you for reading, and I wish you well on your individual journey.