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					                   Dr G B H Lewis
                  A Positive Margin




                Dr G B H Lewis
              A Positive Margin
A Doctor’s Experience Of Radical Prostatectomy
 Prostate Cancer Screening And Quality Of Life




                        1
                                 Dr G B H Lewis
                                A Positive Margin

                                  Dedication

This book is dedicated to my wife, Elizabeth Spencer Lewis. She has always
supported and encouraged min all I do in the adventure of life together in this
fabulous world.


                             Acknowledgements

I wish to acknowledge the help provided by all those friends and colleagues
who have become members of a loose band of prostate cancer survivors,
who communicate with me on matters of mutual interest and concern. Some
of them have read and provided comment and criticism of this text. They
include men from many walks of life, including behavioural scientists,
radiologists, pathologists, and a geneticist; our little mutual support group.

I wish to thank Oncologists Dr David Bell and Dr Nic Pavlakis of Royal North
Shore Hospital, Sydney – for reading and giving their expert opinions o the
scientific accuracy of the manuscript, specifically, verifying that the contents
contain no significant scientific errors.

In addition I want to thank Mrs Caroline White for her considerable effort in
typing the manuscript.




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                                      Dr G B H Lewis
                                     A Positive Margin

                                        Preface

In Australia, as in other countries, there is no national prostate cancer screening
program, despite the fact that prostate cancer in men is comparable in regard to
morbidity and mortality with breast cancer in women. Every day perhaps seven or
eight men, some two thousand six hundred citizens annually, die from prostate
cancer. Sadly, there are no larger studies which prove conclusively that screening
men annually with digital rectal examination and prostate specific antigen blood
testing leads to early diagnosis, treatment and reduced mortality, though research
projects are directed towards this end. Never the less many doctors screen their
patients and if a rising prostate specific antigen (PSA) level or a level which is found
to be in excess of the normal range is found, further referral to a urologist is made,
with further investigation, usually with ultrasound guided biopsies. As a result many,
many men undergo surgery involving a radical prostatectomy or alternatively other
potential curative treatments such radiotherapy, with a high expectancy of a cure.
Without such treatments, many men particularly those in their fifties and sixties who
get prostate cancer are doomed to die a painful death.

I wrote this account of my experience after my own doctor declined to order a PSA
and on ordering it myself, found that it was elevated and referred myself for further
investigations. If I had not done so my Gleason Grade 7 tumour, which had already,
as it happened, spread outside the prostate capsule by the time I had my radical
prostatectomy, would have spread to the nearby lymph nodes with likely widespread
dissemination to other sites such as bones, brain, liver and lungs. Locally the cancer
would have invaded my bladder and rectum, most likely before I suffered any
symptoms, and then there would be no real hope of a cure. After over two years
after my radical prostatectomy with a positive margin, there is about a 40% chance of
a recurrence, so I check my PSA levels very regularly and if my PSA rises I plan to
have radiotherapy soon, with a probable 75% chance of a cure.

This book is written for men, their partners and possibly family members who are
interested in knowing more about prostate cancer, with a particular plea that all men
should give careful consideration to being screened annually for this common and
dangerous cancer.

Lange and Ad……… wrote Prostate Cancer for Dummies in 2003 after Lange was
treated for prostate cancer. As chairman of the department of Urology at the
University of Washington Seattle, co-director of the Gentourinary Laboratory of the
University of Washington and a respected researcher, he strongly recommends men
from the age of 50 (or sooner if there is a family history of prostate cancer) should be
screened annually. As a doctor with three sons, I would not agree more. His book is
well worth reading for a wider view on the subject, whereas the account is more
concerned with the subject of radical prostatectomy from a patients point of view. In
addition, as I am doing research on patient quality of life, happiness and distress for
a Doctor of Health Science degree, I have focused more on these aspects of life,
which are so important to us all.

Finally, in Australia, the PSA tests involve taking a specimen of blood, one receives
the results within hours and with public, bulk-billing laboratories like ours, cost to the
patient nothing, so there is no financial bar to testing and I for one, would not date to
avoid undergoing the test. If you don’t look after yourself, who do you expect will?




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                                 Dr G B H Lewis
                                A Positive Margin

14.10.2004
I awoke early, as I often do, and was prepared for my radical prostatectomy.
It was considered that I should be premedicated with Temazepam®, then
transferred to the operating theatre suite, where I met the anaesthetist again.
He inserted a (large) 14G intravenous cannula and then said he would give
me 2 milligrams (mg.) of midazolam, a very effective drug which wipes out
your memory for events, as well as being a strong sedative. Later, I was told
that two 14G cannulae were used for the intravenous infusions and drugs,
plus an arterial line to monitor my blood pressure and blood gases. The
anaesthetic technique involved a general anaesthetic and a spinal block with
added morphine, for the almost three hour procedure. Eight-hundred millilitres
of blood were lost. There was no blood transfusion, but I became a little
anaemic. The first thing I remembered after the midazolam at 8 a.m. was
waking up in the recovery room at 12.30 p.m. Pain relief was not a problem,
there was a ‘PCA’ (Patient Controlled Analgesia) button to press which
injected 1 mg. doses of morphine, whenever I pressed the button, with a
safety lock–out, which was infrequently required. Over the next day or so, my
pain was mainly from my mild chronic low back pain, not related to the
surgery and relieved by Digesic® until I was allowed up. The first 24 hour
post-operative period was strictly bed rest. No shower, therefore, and two
nurses gently sponged me all over, instead.

As soon as I returned to my nice, spacious private room at about 2 o’clock, I
found that my wife Elizabeth was wating. She was happy that everything had
gone well. As with any major surgery there is a low but significant mortality,
possibly 1% - but so far, so good. The TED stockings, which I put on before
the operation, have to be worn for weeks to reduce the chance of deep
venous thrombosis (DVT) and pulmonary embolism (PE), and daily
anticoagulant injections were to be given post- operatively, during my stay in
hospital.

Though I was still a bit sedated, it did not prevent me from making numerous
phone calls to family and friends, during the latter part of the day. I do not
remember being distressed or particularly unhappy. In fact, I was pleased that
all had proceeded accordingly to plan. My surgeon spared my erectile nerves
on both sides – what a blessing.


15.10. 2004.
There is nothing special to report. Pain is not a problem. Time is passing
quickly, as I read some chapters of a sociology text by Crotty, and make and
receive phone calls. My surgeon expects to get the pathologist’s report about
next Monday and this is Friday. He assured me that he is very confident that
all the cancer has been removed.


16.10. 2004.
Today, I have been out of bed and showered under supervision, sitting in a
chair. There is a corridor about 100 metres long outside my door, and I am
encouraged to hold my catheter bag carefully and go for a gentle walk. One


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                                  Dr G B H Lewis
                                 A Positive Margin

kilometer, or ten lengths of the corridor, were considered enough, though I am
confident that I could do more. I am eating well, from the excellent menu and
used my bowels for the first time – very gently, as there is to be no straining or
lifting, thank you. There is plenty of time for more reading and phoning, I am in
good spirits and I am sitting out of bed, writing and receiving visitors.


17.10. 2004.
Another good day, and I was able to walk five kilometres, before I noticed a
slight tinge of blood in the catheter, as the catheter moves a bit when you
walk, and this must irritate the other end of the catheter, sited in the bladder.
Enough is enough! More visitors, and more reading! Further reassurance of a
good outcome from my surgeon keeps me in good spirits.

Who are my visitors, besides my immediate family, including my two sisters?
T is Chinese, from Singapore and now long settled in Sydney. We were at
University together, though he was in another faculty. We both played hockey
and cards. He was living in the same building across the road from Sydney
University, opposite my apartment, before Elizabeth and I got married at the
end of 4th Year. My family and his are close. We discuss Sydney’s Chinese
Christian Churches and comparative religion. A few years ago, I completed
my studies to qualify for the Anglican Ministry, complete with New Testament
Greek and its five hundred verb endings. Many of my friends are from very
different backgrounds.

M was another visitor, and another friend from University days. He, like many
of my friends, still plays cards a lot. In my last three years of Medical School,
I spent more time playing cards than attending lectures. I would not have
played if I wasn’t winning, and substantially. After third year Medicine, I gave
up driving cabs, working as a waiter at a club and similar less agreeable jobs,
in favour of gambling. Much more enjoyable, exciting, and remunerative!
Playing back- pool at the Governor Bourke Hotel, for pies and beers, was
another winning habit – but how many beers and pies can you consume and
still get home? M and I discussed the differences between Shias and Sunnis.
He came from Pakistan, married an Australian girl, went back to Pakistan,
then finally settled in Australia. She converted to Islam and they now have
sixteen grandchildren – all Muslims and the most beautiful, gentle people you
can imagine. I remember his eldest daughter as a baby. She is a very
successful architect today.

 Whilst he is visiting me, another visitor, a doctor from my class, arrives. He is
a Jew and just popped in, to check on how I am getting along. I have had a
lot to do with Jewish people; in fact my mother- in- law was Jewish. A Jewish
girl I met in Los Angeles, in 1986, was a psychologist from Manhattan. We
write regularly, and when the opportunity arises, we see each other. She has
stayed with us, here in Armidale, and visited us in Pontremoli (between La
Spezia and Parma, in the foothills of the Appennines), in the far north of
Toscana, where we have our Italian holiday home.




                                       5
                                  Dr G B H Lewis
                                 A Positive Margin

We have visited her sometimes, when we are in New York, and she has
shown us all sorts of interesting old architectural gems, as well as Little Italy,
Chinatown and walked with us all over Manhattan, showing Elizabeth the
garment district, and places to buy things for her sewing. Enough of my
rambling!

My friend V is a surgeon, but we were medical students when we went to a
Billy Graham crusade in Sydney, and he became a Christian. He comes from
Thailand and was formerly a Buddhist. He regularly attends prayer meetings
and church services near his home in Sydney, though for some years he
practiced medicine in Bangkok. Sadly, his wife K died suddenly of a cerebral
aneurysm some years ago. He has married again, a Thai girl, and they have
a little son. Like another friend L, from Hong Kong, V enjoys cruising – as on
the QEII from New York to Sydney last Christmas. All my Asian friends are so
gentle and kind. V gave me a beautiful new batik shirt when he visited me
and I know I shall wear it a lot.

My sister C and her husband have just arrived back from their holiday home in
Bali, which they love to visit. She has told me that we are welcome to stay at
their house, if I have to come to Sydney for further treatment. Everyone is just
so kind! I am so blessed. I also spoke to N, another old friend from university,
and originally from Sparta, in Greece, who is a very dedicated thoracic
physician, today.

Yet another friend G, a busy general practitioner, rang, but is occupied in his
practice in the Hunter Valley of New South Wales, in the midst of the vineyard
country. His first wife also died of a cerebral aneurysm, and he has a second
family. He came from Malaysia, and is Chinese. He was best man at our
wedding. Our groomsman, D, strangely enough, worked close to our home in
the New England area of New South Wales, for many years, as an
ophthalmologist, until his retirement, last year. We have visited him at his
retirement home in southern Queensland, since his return from the United
States. Friends from overseas have rung, too.

Normally, at home, we spend hours every week on the phone to our sons.
There’s always some interesting news. My most constant visitor and closest
friend is, of course, Elizabeth .Since we met in January 1961, we have never
stopped talking!


18.10. 2004.
At last-- it is Monday. However, the Pathologist has been away and there is
no report for anyone – Disappointment! Tomorrow will be the day! More
walking, but five kilometers up and down the corridor brings on a little tinge of
blood again. There is now a small leg bag attached to the catheter – less
cumbersome, and they say less embarrassing – not an issue to me. My
recovery continues uneventfully.




                                       6
                                  Dr G B H Lewis
                                 A Positive Margin

19.10.2004
Steady progress. I walked another five kilometres up and down this corridor
and there is still no news for me, though everyone else seems to have their
pathology reports. My source of information is from other men in here, who
have also had radical prostatectomies last week, and they have been happy
to learn that their cancer was confined to their prostate gland-- and has been
completely removed. I must admit to being apprehensive, but can do nothing
but wait, some more.


20.10.2004
At last, on Wednesday evening, comes the bombshell, that my cancer has not
been contained completely, and has not only penetrated the capsule, it has
extended, at least to the edge of the specimen. This is called a positive
margin. Maybe it is only right on the very edge, and I am potentially cured.
On the other hand, some extension may have a viable foothold, at the edge of
the prostate bed, and form what is called a local extension, which will require
further treatment, if I am to have a chance of cure. My surgeon says that after
my follow up visit in six weeks, all will be clearer, and early, adjuvant
radiotherapy should still offer an 80% chance of cure.

 Another option, for patients in my situation, is to closely follow prostate
specific antigen (PSA) levels, and only have radiotherapy if there is a rise. I
could, optimistically, have an approximately 40% chance of being clear at this
moment, in regard to local extension. There is no sign of cancer in the
seminal vesicles or regional lymph glands, so distant spread is not likely! This
is all a lot to think about! I shall have to make extensive enquires about all
these options and their potential side effects. First of all, I am to go home
tomorrow, if my catheter is removed without a problem, and they will tell me
all about the joys of buying pads to wear, until I (hopefully) get back control of
my bladder function. Some people never get to have good control. In other
words they end up incontinent. This is not my best day in hospital.


21.10. 2004.
A week today-- since surgery-- and bright and early, the nurses remove my
catheter, without any trauma. Is there going to be any problem with retention
of urine, a clot, a blockage? Time will tell! An hour or two later and, after
passing urine without difficulty, my confidence increases. My surgeon’s nurse
has come and given me information, relevant to my discharge from St.
Vincent’s.
“Here are a couple of pads to start you off! You will need to buy a box of
these, to wear inside your underpants to absorb leakage, which is common!
In a few weeks or months you should be dry, but even then a few drops here
and there,”—et cetera, et cetera, and so forth.

A few years ago, maybe a third of men would have problems with
incontinence after radical prostatectomy, and there are instructions, on how to
do pelvic floor exercises, which should start a week or two, pre-operatively.
Some men are expected to have major problems for life, but my surgeon says


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                                   Dr G B H Lewis
                                  A Positive Margin

his recent review, of some 200 of his patients, revealed that only three ended
up with long-term incontinence. I shall go back to my son Garry’s home with a
pad and see how things ‘pan out’, so to speak.

The discharge process is straight-forward, and I am glad to be leaving
hospital feeling better than I had been led to believe. An optimist always, I am
planning to be back at work sometime next week. My wound is healing nicely.


22.10.2004
Hooray! Last night I wore the pad, but I woke up during the night and urinated
at the toilet, without wetting anything, and seem to have control. I am not
going to wear a pad and shall see if my confidence is justified. Perhaps I
should feel tired and rest, but frankly it seems that I am recovering quickly and
the only thing that I am really careful about is avoiding getting constipated as I
surely aim to avoid any straining of my pelvic floor muscles. In terms of
quality of life (QOL) I am ‘as good as can be’ but worry about how my prostate
specific antigen (PSA) level, will be. If it does not diminish to un-recordable
levels, then I am in big trouble. The presence of detectable PSA would
suggest that some prostate cancer cells are still present.


23.10.2004
Last night again everything was fine and no need for a pad. We are going
home today. Young Garry, Lisa – Jane, Alexander, Sophie, Elizabeth and I all
crowd into their Volvo wagon and drive to Watsons Bay to have a fish dinner
at Doyle’s before we are dropped off at the airport. The flight is uneventful
and a friend kindly meets us in Armidale and drives us home. It is rather a
relief to be home and we spend time going through our accumulated mail.
Our shared cat, Lucky, is soon at hand to greet us.


24.10.2004.
Sunday is a quiet day. My waterworks are trouble free which is a real
blessing. I packed away the box of pads, which it was assumed I would need.
After attending the service at the Cathedral where everyone has been praying
for me, we later go out to the University Oval where we enjoy a gentle walk of
a few laps. Much time is spent talking to friends on the phone. There is little
doubt in my mind that I can easily cope when I start work again in three days.
If I had possessed this confidence before the operation, then I would not have
given my operating list away on Tuesday and would be seeing booked
patients tomorrow. Seriously though, it is expected that men should take
things easy and not plan too many arduous activities. Having no incontinence
is a great start and first on the 22nd and again today there is a little evidence of
returning capacity to have an erection – but not enough to get excited about,
for the present.




                                        8
                                   Dr G B H Lewis
                                  A Positive Margin

25.10.2004
My thoughts are focusing on the subject of future radiotherapy. When I walk
around the garden I see plants growing everywhere, some at a seemingly
alarming speed, now that spring is here. They remind me that if there are
residual cancer cells around the operation site, then they could be growing
wildly too. Everyone says prostate cancer grows very slowly, but I’m not sure
and intend to find out as much as I can from a literature search. Our
Librarian, Jan, is very kind and helpful so I anticipate that in a short time I
shall be better informed. Radiotherapy is no one’s idea of fun and more
modern methods of reducing the dose of radiation to sensitive normal tissue
reduce the severity of bowel and bladder complications. The idea of watching
and waiting before starting radiotherapy if, if, if my PSA level goes down to
around zero has appeal if, as my surgeon says, there is maybe a 40% chance
that he has effectively excised the cancer and there is no malignancy to
irradiate.

Ignorance in this field is rife. Many doctors do not recommend that men be
screened with a PSA and the old idea that prostate cancer generally grows so
slowly that one is likely to die of something else is not true in a population with
a climbing life expectancy. How can you assess the pros and cons of
different possible courses of action if you don’t know the facts. The Internet is
a good place to start and remember, progress is occurring all the time and
what is commonly thought to be current is often years out of date. Look up
Prostate Cancer, Prostate Surgery, Prostate Cancer and Radiotherapy,
Hormones and Radiotherapy sites, for a start. QOL is important to consider in
any consideration of therapy. All curative and palliative therapeutic agents for
prostate cancer are going to affect QOL, some very seriously, or may even
lead to a fatal outcome, from the procedure or treatment. Are the results from
some centres better than others? One is never going to know everything, but
I’m sure going to try and get all the information I can.


26.10.2004.
Maybe it is appropriate at this point to focus on life satisfaction and happiness,
for we have homeostatic mechanisms which function to keep people feeling
positive and homeostasis may be defeated by major negative events, such as
cancer.

Professor Robert Cummins in 2000 described the application of the
Homeostatic Theory of Subjective Well-Being (SWB). We typically have an
individual set-point-range of an average of around 75% of the maximum score
possible for happiness and life satisfaction. Within quite a wide range of
circumstances we maintain a pretty steady state of well-being. The majority of
people in Australia have all they really, basically need, so extra wealth tends
to have little effect, and rising incomes over the past decade have had
minimal effect on national levels of well-being. Of course, a decrease in
resources or challenging circumstances can cause this mechanism to fail.

In another paper, Cummins (2000) proposed that people who are rich have a
higher SWB because they can readily purchase personal resources. These


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                                 Dr G B H Lewis
                                A Positive Margin

resources can thus be used to buffer potentially adverse circumstances.
There would appear to be merit in his proposition. When informed that the
pathologist who reported on my twenty-nine biopsies said that two were
suspicious of cancer and recommended further biopsies, I chose to request
another opinion and referral which resulted in confirmation that these biopsies
showed that I had cancer and required early surgery, which I have had.
Otherwise, with less resources, I may be yet awaiting further biopsies whilst
my cancer spread further. If we did not have private health insurance, then I
would not have been treated in St. Vincent’s Private Hospital. If I were poor, I
would still be unaware, in many parts of the world,that I had a problem, for I
would possibly not have easy access to specialist services and certainly not of
the quality which I have been privileged to access.


27.10.2004
Since we returned from Italy a month ago, there have been changes in our
lives which could have triggered negative responses such as helplessness,
hopelessness, anger, guilt, depression, et cetera. Thomason and Thames
presented a paper in 1998 in which they explored how families may
experience sadness and frustrations due to life changes, whereas there are
others who are more resilient. They reported a study from South Carolina
which revealed the common strengths that help families cope during change
and transition.

They listed, purely in alphabetical order, communication, contentment, history,
humour, optimism, resiliency and values. They emphasised the importance of
families utilising resources to become empowered to become stronger,
though different, as a result of change and transitions in their lives.

How does this study relate to my situation? We have tried to apply the ten
common strengths as far as possible starting with communication between
family members. Where I have perhaps gone beyond the focus of the paper
is, in including my circle of friends in The Network. Right from the start
following my surgery, on the same day, whilst still really recovering from my
anaesthetic, I spent time ringing, not only family members, but friends and
colleagues, communicating, communicating. This was a way of stimulating
perhaps all of the other strengths listed. Contentment was engendered by
listening to the comforting words of family and friends. Our shared history
goes back many years and we share a sense of humour, optimism and
arguably all the other common strengths mentioned. There are those who
keep everything to themselves, not even confiding in family members a word
about their life–threatening illness and surgery. How sad that they cannot
stretch out a hand, even to their family.


28.10.2004
An eventful day! The day began with me working in the Private Hospital –
two weeks since surgery – and ended with me being admitted as a patient
there.



                                      10
                                 Dr G B H Lewis
                                A Positive Margin

The morning was chilly, just 14C. when I left home – but all morning I was
feeling cold and in the afternoon after lunch I slept in the sun for two hours
and awoke feeling feverish. Perhaps I was developing a wound infection or
UTI (urinary tract infection) so I drove the Mercedes to the A&E Department of
the Public Hospital. My suspicion that I had a fever was confirmed
(39degrees), so blood cultures and other tests were taken, plus intravenous
therapy commenced with keftriaxone and gentamycin. Soon I was transferred
to the Private Hospital, but not before my fever was on the way down, and
there was no evidence of anything suspicious in my urine – so far, so good.
In fact I feel fine though my doctors suspect early septicaemia, which is not to
be ignored. My wife has garaged the Mercedes nearby, in one of our
properties and has now gone home.

She brought the mail to the hospital and there was a letter from my surgeon
with a photocopy of a good journal article (2004) on the value of rescue
radiotherapy following radical prostatectomy. My friendly colleague, a medical
oncologist, has told me I could be dead within about five years in a worst case
scenario (I had asked him his opinion) – but this new series is more
comforting. Ninety percent of people survived at least seven years and more
when electively given radiotherapy and the .earlier the treatment the better.
  How do I feel? My QOL “is as good as can be” - I experience no trouble
adjusting to my fever, which is now going and it is possibly one of those
complications of surgery, I suppose. At present I am feeling 100%, really, I’m
happy and not a bit distressed. It is known that septicaemia (infection in the
bloodstream) is a possibility after such major surgery and if neglected it can
be fatal, so a fever is not to be ignored, is it?
Now that I am settled comfortably in hospital, I have a chance to review some
recent events and changes made.
I am progressively trying to optimize my QOL This morning, I left for work five
minutes earlier and drove more slowly, not racing at the last minute. I played
a new CD on my way to the hospital, which was good and therefore, I must
change CDs in the car and have the best music choice.
 At lunch on the terrace at home I observed a bee as it landed on my salad,
first on the lettuce, then on a slice of mushroom, What a beautiful creature!
She flew off to a flower nearby soon enough, but I am taking more time to
appreciate simple events such as this, now!
When I saw my patients today, who were to be assessed, mainly for general
surgical and orthopaedic operations, I made some notes for later analysis.
Why? I just wanted to see how healthy they were as a group. It is easy to
look at a beach crowd and assume everyone is in perfect health. I examined
eight patients.
Let us summarise the health status of the eight, from oldest to youngest:–
1) An 84 year old woman who is “happy enough,” who has “never worried
     about anything much” and has had “a pretty good run for my money.” She
     commented that “your twenties are the golden years and the thirties OK
     but after that –no good.” “I have since then hated growing old”. She is a
     widow, lives alone and cooks for herself, despite a withered right arm.
     What does she do otherwise? “not much”, “too old”. She has severe
     hearing impairment and lip-reads.



                                      11
                                  Dr G B H Lewis
                                 A Positive Margin

2) An 82 year old blind lady who realized some two years ago that there “is
    not much of life left”. “When I was younger I could do anything”. “I played
    tennis until I was 69. My 65 year old brother is dying of prostate cancer. It
    is terrible – his having blood transfusions.” “I cannot open a jar”. “I am
    useless”.
3) A 79 year old man with advanced vascular disease, who has a stent in a
    femoral artery and can only walk “half a block” despite a total hip
    replacement this year. He has anaemia for investigation. He has been a
    keen gardener but this year all his vegetable seeds failed to germinate.
    He is disheartened and has planted lawn seed in his vegetable patch. “No
    more!” What can you do? “not much”.
4) A 74 year old retired academic (professor) female, frail, together with her
    husband, depressed, due to a family suicide years ago.
5) A 66 year old man who had a radical prostatectomy last year and his
    cancer was seemingly completely removed in the specimen. There is a
    small chance of a recurrence. He is now impotent and has not had any
    sign of an erection since his surgery.
6) A 60 year old obese lady who has advanced arthritis of both hips. She
    has a very restricted life style and can barely manage to struggle up a
    flight of stairs. Her surgery is unrelated to this problem.
7) A 50 year old overweight male who runs a small business. He has worked
    hard and now is focusing more on his family and trying to spend more time
    “smelling the flowers”.
8) A 48 year old man who had angina, then major coronary artery bypass
    surgery (four vessels) at the age of 40. He has a high cholesterol level
    and is overweight, with a responsible job.
Comment –No Olympians here! Note that even in this small sample, we learn
of two men with prostate cancer. I am not surprised.

When you are 67 years old, as I am, if you have always considered the future
to be a long and healthy one, you may not have paused to reflect on a less
rosy future, as you must, when you learn you have cancer! I am privileged to
be able to glimpse some of the realities of existence, as a doctor. I feel
strongly that the more information and knowledge I have about my disease
and the treatment options, then the better able I should be to make a wise
decision, which could be a compromise between longevity and quality of life
years. I continue to be amazed at the general level of ignorance about
prostate cancer, both amongst the public and in sections of the medical
profession.


29.10.2004.
I slept well and my fever is gone – my temperature is 36.9C, but I still have a
slight ‘cold’ which is probably relevant to my previous elevated temperature. I
am hoping to go home later in the day with oral antibiotics, perhaps after the
blood culture results.

Subjective well being is excellent – since reading the research report
yesterday my optimism has improved. I remain determined to have early
elective radiotherapy in January, despite the negative side effects and to


                                       12
                                  Dr G B H Lewis
                                 A Positive Margin

focus primarily on long term cure or survival. This may adversely affect the
return of sexual function, but this is a price I may have to pay. At present I
have really no libido, so sex is not an issue, today at any rate, and this is
really strange for me. It has always been of great importance, an integral part
of my masculinity. I just love women and have worked very closely with girls
all my professional life in the operating theatre, so am a very lucky man. I find
that I can be very open with women and discuss anything, without any
inhibitions or shyness. Men, in a social environment, are often less open and
more reserved. I belong to a Wine Tasting group and have done so for more
than twenty years. There is a primary focus on wine and the occasional ‘dirty’
joke. Membership is restricted to men, as group members would feel inhibited
about telling jokes in front of their partners! This does not equate with my
views. Men’s groups and clubs have little appeal for me. My fifty year school
reunion was held recently and I brought up the topic of PSAs and Prostate
Cancer. One former schoolmate said he had had a radical prostatectomy last
year and was doing fine. Then another fellow in the group of six, having a
drink, interrupted and said – “Do we have to talk about this – we’re men!”.
They looked down at their feet and the conversation died.


30.10.2004.
Yesterday I spent a lot of time at home, on a gate pass, just returning to
hospital for my intravenous antibiotics. I slept at home and this morning after
my intravenous ’shots’ drove with my wife to the car museum to give a couple
of my cars a run and prevent their batteries from going flat. My wife and I had
lunch with a doctor friend, in town there – 130km. from here.

At the museum I chatted to someone who had a radical prostatectomy four
years ago and until now, everything has been ‘clear’. Now he is experiencing
more problems passing his urine and is to see his doctor. His family are very
long lived, and though he is in his 70’s if he has a recurrence this could well
affect his longevity.

We left home late because a friend rang. He had an abnormal PSA last year
and six biopsies, one of which showed cancer, they thought. He is about 60
years old and his PSA has risen further and he is going to another urologist
for more biopsies. I hope he is going to be all right. Maybe it was reported to
be a very low-grade malignancy. What more can I say?

After our most enjoyable outing we drove back home, having driven, in total
on the trip, over 300kms. I have been told that all my blood tests are normal, I
had my intravenous cannula out and was officially discharged from the
hospital. It is now seventeen days after by surgery and I have been reflecting
on all the research papers that I have been sent. There is still an article I
wish to read on the details of the complications of radiotherapy and I shall
speak again to my friend who has undergone radiotherapy, when his prostate
cancer was too advanced for surgery. He is ‘clear’ of disease and with a
normal PSA now for 3½ years. My QOL is excellent as is my wellbeing and I
have no distress.



                                       13
                                 Dr G B H Lewis
                                A Positive Margin



31.10.2004.
It is somewhat cloudy now as I sit at the BBQ table under an apple tree. We
were going to go to church at 9.30am, however this is the day we change over
to daylight saving time and we were too late and still in bed. Elizabeth was
nineteen and I was twenty-three when we met at a family wedding. There
was dancing at the reception and I asked her for a dance. At the end of the
evening we were still dancing and talking. It was some ten days before we
got engaged, with me driving a taxi, completely broke and starting third year
medicine.

Forty four years later our three sons spend hours on the phone to us and our
grandchildren have a devoted Nonna ( a tribute to our Italian connection) and
Papa. Some things don’t change and we still spend a lot of time in bed
together, talking – in fact much of this morning and again this afternoon.

Yesterday, I went to pass urine and looking down (my writing is temporarily
interrupted by a call from our eldest son) was pleasantly surprised to see that
something had grown. Always the scientist, this phenomenon was not
ignored and immediately measured at 12cm. Shrinkage soon occurred and
then the measurement was a ‘resting’ 8cm. A little bit more time, length and
rigidity, then my QOL may be completely back to normal.

This is probably an appropriate point to talk about the common complication
of impotence with all forms of prostate cancer treatment. It may be
permanent and this is naturally a great concern to many men. For now
though, for me, it’s early days and time will tell. This problem does not mean
a loss of intimacy and I spend more time than ever with my wife, loving her,
caressing, cuddling and caring for her. I am not going to go into the intimate
details, but any husband at all knowledgeable about this sensitive matter and
with some awareness of female anatomy and sexual responses should be
able to help his wife achieve orgasm in the event that she is not already
perfectly aware of what is needed. Start with love and finish with love and
grow even closer. Happiness and quality of life will increase and distress will
melt away. It is time for us to go for a walk now.


01.11.2004.
This morning I was nearly late for work! Lucky, our shared feline friend, got
me up to cut up his rump steak – he’s not spoiled – and it still being early I
went back to bed for a cuddle. Fifty minutes later we reluctantly interrupted
our embrace as otherwise I would certainly have been late. Beneath the
sheets nothing of any world shattering consequence occurred, yet I went off to
work extremely happy and relaxed. My present impotence made me wonder
about this phenomenon. For many years past it has been a different story.
Time for me to play what I call one of my Mind Videos,


Wake up early, feed the cat, get the coffee or whatever and return to bed.
Spouse not thinking of sex really, and sex often leads to her being tired,


                                      14
                                   Dr G B H Lewis
                                  A Positive Margin

before the day has begun, but she never says no – ‘you have yours’! The
culprit in this saga is the erect penis. He wants to find his little home! A quick
search and….. there …he’s in. A few minutes later it’s all over and I’m into
the shower and off to work.

My guess is that there is a lot of this, going on. Husbands and wives rushing
to work, children bursting into the bedroom, at any time, everyone tired at the
end of the day – so with the testosterone circulating, any chance for a quickie
is taken. Its not good sex and it’s not something that is ideal in a relationship.
It’s what happens when those idyllic first months, or years, are superseded by
pressures of work and family. For years, we mostly had one, or even two kids
coming in to our bed, during the night and it gets a bit crowded.

When we first married – any day we had completely to ourselves – not
answering the door or the phone – we had a meal called BRLTEA which is a
contraction of “breakfast – lunch and tea” because we stayed in bed until it
was pretty well dark. No quickies then – we had time for each other. After all
these years, because of my impotence we are actually spending more quality
time together – we used to, on holidays of course – and there is no pressure
to perform, to ejaculate! Perhaps I am more like Lucky now, who is less
stressed and less competitive with other cats due to his operation. Meow! Let
us think some more, about this.

  An increasingly busy life is likely to encroach on a couple’s sex life, until it is
very difficult to find enough time for each other. Such time is vital in a
relationship, to my mind. A late night, busy at the hospital, no time to spend
with wife and children who have gone to bed. Flop into bed exhausted. An
early morning start does not allow real time for each other but an
understanding and loving wife does not begrudge the hurried encounter at the
start of the day. There’s love and devotion to each other, but so little time. I
look back on much of my life and very much appreciate the many, many times
that my wife has lovingly catered to my needs. A quickie, before rushing to the
ca, is much, much more. It is her willing acceptance of me. It is homage I
pay…… only to her. It is a holy sacrament. It is my gift of potential life,
released in joy from my body and deposited with the most indescribable
pleasure …..an all too fleeting moment of true communion, as the two of us
become one flesh. It makes the day worthwhile and feelings of contentment,
happiness, of pervasive wellbeing, persist. No one can possibly do more for a
man than a loving wife and I have been truly blessed. Equally, a man must
balance a too busy life with some compensations.

 I have neglected my family too many times, intent on research at the
university. But there has never been golf or Rotary. We have always had –
well for the last 30 years – eight to twelve week’s holidays. What the heck! If
I had failed medicine and become a teacher, then I would have had at least as
much time off – protests from my two sisters – both teachers – not
withstanding. Less money and more QOL. This last year we have had two
weeks over Christmas in Victoria with two of our sons, a week at Easter, lots
of weekends with another son and our grandchildren, five and a half weeks in
Portugal, Paris, Tuscany, South Beach--Miami, San Juan and Antigua,


                                        15
                                  Dr G B H Lewis
                                 A Positive Margin

followed some weeks later by a return trip to Italy, for a Pain conference in
Siena, after attending the Italian Grand Prix. This helps to make up to
Elizabeth, for the rest of the year, and we value our trips overseas, very, very
highly.

2.11.2004.
No work today. We started off with a new resolution to improve our QOL.
Instead of Elizabeth taking a long bath with a book – well, she can still do this
– and me having a shower – we have decided to shower together, as in times
long passed. My impotence ensures that there is no awkward manoeuvring
and we have an enjoyable time washing each other. If there is time, it’s a
good idea.

The Internet is really informative if you ask the right questions. Being
interested in treatments for impotence I started trying to find out about
Vacuum Erection Devices.       Not too romantic and interesting for the
mechanically minded! A bit of practice, quietly on your own and there is a
good chance of success. Go and look up the Internet. No drugs and the right
sized silastic ring…… can give you half an hour of practical engorgement
which should be long enough for some action.

After this Internet interlude, I visited my mate the pharmacist. I told him a
Viagra 50mg on the twelfth day post-- operatively was a waste of money. He
has no cupboard full of these Vacuum gadgets and suggested I reply to one
of the advertisements for those suffering impotence or contact my busy
urologist. Jayne is a nice girl who works for my urologist and after assuring
me that my enthusiasm was rather premature, agreed to send me a pamphlet
which would explain the attributes of a number of VEDs, their prices and if not
a star rating guide, then at least some information, regarding the popularity of
various models. She promised to put it in the post within five minutes. Well –
there’s no harm in asking! If I’m to have radiotherapy on top of my radical
prostatectomy this is going to threaten my erections again and I would like to
explore my options to enhance my performance potential, as soon as
possible. Physically I’m about 100%. No lethargy, essentially no discomfort,
happily back at work for more than a week and happier, (meaning peaceful
and content) with my life, than I would have expected. I have no doubt I could
jump in a car and drive 500km or walk 10km without the slightest problem.
We walk every day as usual, in the evenings. Incontinence? What’s that!


3.11.2004.
Yesterday evening Elizabeth told me she had to get up early to drive a friend
to the airport. On the other hand I did not have to start work until 8.30am.
This morning she awoke, rolled over towards me and asked me the time. I
told her, I must get up in a minute, she said, but didn’t seem to want to move.
My hand went down – swelling-tightening-climax and into the shower in eight
minutes – and me with no usable erection. A very good start for the day!

I took a cake Elizabeth had made to work at the Pain Clinic – a chocolate ring
without sugar – just Splenda® sugar substitute, and a low fat recipe –


                                       16
                                      Dr G B H Lewis
                                     A Positive Margin

everyone loved it. A patient told me her son is going to Iraq tomorrow. He
explained to her that he is working for a private contractor, defusing and
blowing up bombs for a year, to save money to buy a house. She and her
husband are concerned. What a surprise. My wife is concerned about me
too – yet I am probably no more worried about my cancer than her son is
about security in Iraq and defusing bombs for a living. It makes you think. In
the past (well mostly in the past) I have been prone to drive fast, very fast,
particularly on mountain roads where there are few police and many sheer
cliff-faces – just for the joy of it! It’s a rush but life is full of risk. A doctor friend
enjoys riding his motor cycle at high speed in the mountains, too. In the past,
I’ve spent two and a half hours in the water, in bad seas, in the Pacific,
without so much as a life jacket, after a sailing accident and been rescued by
a fishing boat, against all odds – so the forty-nine years since, have been a
bonus. …… maybe when I nearly vomited to death from pyloric stenosis in
1937 at the age of five weeks was my first crisis. Driving, skiing and scuba
diving have all provided their ‘moments.’


At lunchtime I returned home and hugged my wife. Before I knew it we felt a
sizeable erection coming between us. No action taken but hope for the future.
Who knows what tomorrow, or the next day may bring. I shouldn6t talk so
much about these matters but that’s what’s on my mind and that’s what
counts.


04.11.2004
A beautiful sunny spring day and the temperature is perfect. We showered
together and I went to work with the sunroof open. Life is good. I am now at
my desk in the Private Hospital and waiting for a patient to complete having
an electrocardiograph. Three weeks today since surgery. Everyone is asking
how I am – my workmates, especially the girls, are my friends – in fact I
cannot think of anyone that I am not on good terms with. There is not the
slightest embarrassment, at least on my part, when discussing prostate
cancer issues.

My wife is concerned about the complications which may result from
radiotherapy and has some reservations about this treatment. Proctitis and,
even worse, bowel complications, come to mind. Here in Armidale a dentist
friend’s father aged 60, has a permanent colostomy secondary to severe
scarring of his bowel with radiotherapy for prostate cancer. A local politician
suffered a bowel perforation, septicaemia and death after radiotherapy for
prostate cancer and there is the general impression that you are likely to get a
sore bum, some cystitis, probably some impotence if the surgery hasn’t
already caused that – and maybe a urethral stricture. I am still waiting to find
out the complication rates, so I can consider all these health related QOL
issues. On the good side, there is much improved chance of cure of the
cancer and at least a longer life than if the cancer is not treated when
needed.




                                           17
                                  Dr G B H Lewis
                                 A Positive Margin

5.11.2004.
An early start and a 130km drive in a hospital car to work in another hospital
today. The drive is very pleasant and you have to watch out for the odd
kangaroo or wallaby close to the road and all the pretty little parrots along the
way. There are also cattle around the road on open common for some
distance. This is a good time of the year and the countryside is a picture.
Generally the trip takes about one hour and twenty minutes. You can spend
nearly that time driving around Chatswood, in heavy traffic, to drive a fraction
of the distance. About two days in most cities is enough for me. Just enough
time to visit an Art Museum or some local treasures. New York is a bit of an
exception. It is interesting to walk around Manhattan, visit Jazz clubs, see
Broadway Shows, 42nd Street, The Metropolitan, The Guggenheim…. and the
Museum of Modern Art. I have decided to add a visit to New York to our
annual round the world adventures, strategically between the Caribbean and
Europe. This is a sort of compensation for my cancer diagnosis.


Seeing we are on this subject it is appropriate that I say a little about our
retirement plans. The earliest thoughts I can remember, of relevance to the
development of our plans, date back to our first trip overseas. We left
Australia in late January, 1967, with a toddler and a seven week old baby. We
sailed from Sydney via Brisbane, Hong Kong, Colombo, the Suez Canal (just
before the 1967 war), visiting Cairo and Beirut, to Athens, then through the
Corinth canal to Brindisi, on the heel of Italy, thence by train via Rome to
London. A year in England, a holiday in Scotland, migration to Canada, which
saw us visit nine out of ten provinces, go ice fishing on frozen lakes, see
wolves in the wild, practice medicine 133 miles from the nearest other doctor
in northern Manitoba, camp in National Parks, start my research in
pharmacology and anaesthetics and a host of other things, then return to work
in Brisbane after two and a half years. That adventure whet our appetite for
travel.

 It was our dream to travel more, when the opportunity arose, and a lot more
in retirement eventually. In the ensuing years, we have migrated to Canada
again and seen a fair bit of the world, some fifty-seven countries, if I
remember correctly.

In 1993 our firm retirement plans began, after one of our sons told us how
fabulous he found Antigua and Barbuda, a former British colony in the Lesser
Antilles in the West Indies. We made some enquiries and bought a weeks
time share in a resort set amongst acres of gardens right on Dickenson Bay,
often rated among the four best beaches in the world. A mile long white fine
sand beach, raked each morning, is a great start. The water is always clear
and warm and you can walk in and watch the fish swimming around at the
end of the beach. There is a dive boat base there and we got our PADI
diving licenses, that first year.

Since then, we have flown there every year and increased our investment so
that we now have three weeks at ‘Antigua Village’ and a share in a 51ft
catamaran, so we can explore dive sites, exotic islands and fabled ports every


                                       18
                                            Dr G B H Lewis
                                           A Positive Margin

year. In 2006, we fly via Sydney, Auckland, Los Angeles, San Juan, St.
Thomas in the U.S. Virgin Islands, to Tortola, in the British Virgin Islands,
where we board the catamaran, for a week of diving, around the sixty islands
of the ‘BVIs.’ It is not far then for us to fly to St. Kitts and Antigua. A later
conference in New York and another, on the shore of Lake Como, will
precede our return to Pontremoli, and finally to Beaulieu sur Mer. Our 2005
plans are a little uncertain, at this stage,

Any treatment regime must take into account our retirement plans. I must be
well enough to travel for six months of the year. Not for me sitting here in the
winter, reading the newspaper.


06.11.2004
This morning is the twenty-third day since my radical prostatectomy and worth
noting. I’ll tell you why!

On the eighth morning I detected a little bit of response in my flaccid penis.
Nothing exciting mind but very positive. Again on the tenth and so, ever the
optimist, I purchased a pack of four-50mg Viagra. On the twelfth I swallowed
one hopefully, despite all advice that this was ridiculous. A modest increase
in rigidity resulted but otherwise a waste of money – but we had a good
cuddle anyway.

Since we started showering together and getting extra friendly there, my wife
can provide a sizeable response but quite fleeting and not rigid enough to
contemplate leaping into bed.

It is the weekend of the Flower Festival and Elizabeth has been busy
gathering heaps of roses and other flowers, cooking slices and making
sandwiches for the multitudes. She was up early and off. The tree lopping
team is here, busy with their chainsaws.

Time for a shower.
When I was a jackeroo up on the Queensland border and before that, one of my jobs was to milk the
cows. The relevance of this to my situation encouraged me to grab the relevant video from my mind’s
library. For those of you not used to the rural life here is some information. The cow is in the bails, so
she can’t move too much at the head end and she has a leg rope, on to reduce the chance of her kicking
the bucker, or the milker. Seated strategically on a small stump or stool one is faced with a large udder
and four tits. They are often dry and thin before you start. Milking is what it says. You start at the
udder and ‘milk’ downwards. The first drips help to lubricate the tit, which fills with milk, and gets
bigger. Squeeze from the base down, in the right direction and mild squirts into the bucket. I think you
get the idea.

I am going to be more indelicate than usual but this is a good story.Lately I
have read about these Vacuum Erection Devices, which by creating a vacuum
around the penis, allow it to fill with blood. When it is dilated nicely, a rubber
or silastic ring is fitted around the base, to stop the blood escaping and in
theory you are ready for some action. Release the ring and down he goes.

In the shower, I look down and here this limp little willy, reminding one of the
milking cows little thin dry tit. That is, before a bit of milking. Starting deep at


                                                   19
                                   Dr G B H Lewis
                                  A Positive Margin

the base – gently, I’m still healing up,– I start encouraging the blood into my
penis. It doesn’t take too long before the glans is much more hopeful looking.
More sensitive, too! It is worth mentioning that a flaccid penis is not really
very sensitive – unless touched by a girl. The more engorged the better! A
bit more milking of my well-soaped organ and though not completely rigid I
estimate it has lengthened to about 6 inches or so – in the good old days it
could reach eight inches. Anyway, I give an extra ‘milk’ from the base and
clasp it firmly to keep the blood in the glans and several inches of erect tissue.
With the other hand I start masturbating. This is rare for me. Sex is what it’s
all about. I persist and the glans is quite sensitive now and my hopes are
high. Not having my watch on I cannot say how long it took – perhaps three
or four minutes, with me leaning against the wall under the shower, standing
on my toes and remembering sex sessions in the shower. Suddenly, deep
within my penis there was a contraction followed rhythmically by three others
and I felt some sort of mild gratification, sexually so I shall claim it as my first
post-op climax. There was even a little lubrication, at the urethra – I don’t
know from where. I shall tell my wife when she gets home! Another friend
has just rung from the church enquiring about me – I feel 100% really – and
especially optimistic this morning.


07.11.2004.
Elizabeth is up early again making more slices and sandwiches and off to the
church. We plan to visit the floral displays at the Cathedral and visit the
gardens on display this afternoon.

I know you must be sick of my obsession with sex, but I figure that if I am
pretty certain of an adequate if not spectacular sex life, even after
radiotherapy, then all will be right with the world! Today is a real milestone, in
this regard and my future QOL is pretty well assured – I think?

Let me explain that after many, many interviews with cancer chemotherapy,
chronic pain and pre-operative clinics patients, I have concluded that it does
not matter so much if QOL activities are only threatened. If you can still
achieve your occupational goals, even with some difficulty, you are still
hanging in there and achieving what you want. When things get so bad that
the return is not worth the effort and you abandon the activity – that is the real
change. Reality is altered and the new ballgame has different rules, perhaps
meaning a real downgrade in QOL. This is where a lot of people experience
genuine difficulty in adjusting to a new situation. This is particularly true for
those with few other interests.

Back to the bedroom and shower! A small experiment was undertaken first.
After appropriate stimulation and holding on firmly with one hand I saw there
was about 3 inches of useful erection, whilst I kept a good grip. We tried a
few positions and were able to achieve penetration and a few thrusts. Decent
sex it was not, with me condemned to holding on to the shaft. It was proof to
me that with a vacuum erections device and the appropriate ring we would be
quite successful in the future. If I do not have any more treatment it is very
likely that I shall recover more sexual function, in my opinion. Radiotherapy


                                        20
                                  Dr G B H Lewis
                                 A Positive Margin

has a very negative impact as it damages the rich plexus of blood vessels
involved in the process of erection and most men are going to be affected by
a diminution of blood flow to the penis. The vacuum erection device is my
next method of choice, to give me a fair chance of still functioning. Maybe a
lot of older men are not so interested in this aspect of their lives. Impotence is
commoner with increasing age and I read that 15-25% of men over 64 years
suffer with this problem. On the other hand I have friends, otherwise quite
healthy, who wouldn’t have sex once in a month, despite being active in their
profession and stable in their relationships.

The next time I tried masturbating. It did not take long before there came a
few rhythmic contractions and I rubbed the glans for a few more seconds.
Now there was a decent response with many contractions, the achievement of
the rumoured ‘ dry orgasm.’

This is my twenty-fourth post-operative day. I am feeling positive towards any
future treatment. I am now able to masturbate at will, have no incontinence,
in fact I can wait for an hour after I feel the urge to urinate and never lose a
drop, feel strong and healthy, able to walk as far as I like, mow the lawn, work
all day without getting tired and it is nearly two weeks since I started work.
Who could ask for anything more after such major surgery. Is must be
emphasised that I have never claimed to be a team player, sticking to
whatever advice I am given. I judge what is all right for me and listen to my
body to guide me as to what is okay for me. The recommended maximum
speeds often have little relationship to what speed one can actually negotiate
a bend. For heavens sake don’t follow me, you may run off the road! My
QOL and happiness are great and I have no distress. So far I have not
become ‘an old man’ in its perjorative sense!




08.11.2004
Work was fine today and I received a message that an old friend, a retired
urological surgeon, had rung. I phoned back later and learned that Royal
North Shore Hospital has a new conformal Radiotherapy unit which is meant
to be able to deliver the therapy with a reduced chance of long term side
effects. When I see all the specialists on the 3rd December I shall bring up
this topic – for I suspect that both the hospitals where these specialists work
may have older units. The articles I have seen suggest that more serious side
effects have resulted from older units and higher doses – which would seem
logical. I suspect that if I was not a doctor and a very curious one at that, I
would just meekly accept whatever I was offered and live or die with the
consequences. My mood is that of an active shopper who is looking for the
best of what is on offer. All these specialists are busy and appointments need
to be made quite far in advance. That doesn’t mean that you are not an
individual and must just accept what you are told. After I have seen my
surgeon and two different radiotherapists from different centres on the 3rd
December I shall be in a better position to choose – and hopefully make the
right decision.


                                       21
                                 Dr G B H Lewis
                                A Positive Margin




9.11.2004.
Today I have an early start and have to give twenty anaesthetics and drive
130km home after collecting my wife down town. We drove over from
Armidale yesterday evening and stayed in a motel after a Malaysian meal at a
local restaurant. The drive is always very pleasant and the countryside looks
the picture of a perfect spring.

The information given to me warns that urinary incontinence or “leakage’ is
prone to occur in those who have gained control fairly well, at the end of a day
or when tired. Today would be a test and I was wearing a pad. After a
pleasant day’s work and drive home, I returned the hospital car after 6pm. No
problems at all. Every one at the operating theatre thinks that I am making a
very rapid recovery and look well. Certainly healing cannot be complete yet
and as I was on my feet all day by the end of the operating list in the
afternoon I felt a little pressure around my pelvic floor muscles and was glad
to sit down in the car to drive home. Enough was enough I thought and
relaxed in front of the TV on a beanbag for the evening.


10.11.2004.
There was a clinic in both morning and afternoon today but at lunchtime I
went home and phoned one of the companies that sell erection devices, that
work on the vacuum principle. They described their three models, which were
illustrated on the brochure sent to me by my surgeon’s nurse. I did not want
to make an immediate decision and after work phoned a cheery lady at the
other company selling such devices. Their models were comparable and they
were the original developer of the Vacuum Erection Device. The more up-
market model is priced at $660 but has a life time warranty and a money back
guarantee, if the purchaser fails to achieve an erection after consulting their
technician. They also claim to have a very good range of rings made of
superior materials. I accepted their offer of a video to be sent by mail for my
wife and I to get a clearer idea of what is involved. The lady said one could
soon learn to get a satisfactory erection within two or three minutes, which
sounds good to me. A success rate of 95% is claimed and of course there
are no drugs, injections or ongoing costs. The device is meant to be effective
for just about all causes of erection failure. I asked about people with
depression as I see quite a few with erection problems in my Pain Clinic who
have depression – and was told it works for those too. Perhaps the
commonest cause of ‘failure’ is rejection by a partner who is turned off by a
mechanical contraption. We await the arrival of this video which is said to be
rather explicit – how surprising!

Just as my confidence was high, at the end of the day – once when climbing
out of the Mercedes to go shopping I lost a drop or two of urine – no more –
but perhaps I was tired. To be cautious I put on a pad for a few hours and
took it off again – with no further problems when I went to bed. I am still
awaiting one more reprint of journal articles which describe the side effects of
radiotherapy – then I shall write a few comments. We are still going for our


                                      22
                                   Dr G B H Lewis
                                  A Positive Margin

walks around a university oval. In the shower I tried masturbating again with
a fairly firm organ and not only had some quite strong contractions but also
ended up emotionally satisfied and breathing deeply – I am going to wait now
until we get a Vacuum Device and give it a good road test.


11.11.2004.
A sunny start to the day, but Armidale often has such beginnings to the day
and then it starts to cloud over by 10 or 11am. This morning I did a pre-
operative clinic, which, like all my work I thoroughly enjoyed. It was actually
quite amusing when I interviewed a lady in her forties who had undergone
complicated surgery. She showed her now healed but very widely scarred
midline abdominal incision to me. I mentioned that I also had one just four
weeks old. She indicated that she would be interested in viewing my nicely
healing narrow scar so I showed her the upper part of it for a second. I don’t
suppose that constitutes unethical conduct and it is a really good scar!

Yesterday I was discussing vacuum erection devices with a couple of girls in
administration and they were quite interested. It is hard for me to understand
why so many men are so secretive, shy, embarrassed or whatever over such
matters when women, in the main, are not!

Today, at 5.30 pm, there was a free lecture in the Town Hall by Professor
Mike Morwood who led the team from the University of New England with
others who discovered the species of small humans on an island in Indonesia.
There was standing room only for many and as we left, we ran into my cousin
and her husband who had heard of my cancer, so we talked for a few minutes
then had to run, as rain was starting. I feel pretty stable with a continuing
good QOL – ‘as good as can be” really. In two weeks I shall get another PSA
and of course am hoping that it is down to about zero, with no sign of
remaining local (or other) cancer – I know that even if this is not so I shall still
opt for radiotherapy and have a good chance of long term survival, but not as
good as if the PSA is about zero. My wife continues to ply me with herbal tea
to ‘fight’ the cancer. In the circumstances I am a very lucky man and love my
life.


12.11. 2002.
I am not working today and have time to reflect on some aspects of QOL, now
that I have returned from an hour and a half walk.

On Wednesday afternoon 10.11.2004 I assessed two people who are waiting
to have hip replacements. Both patients signed consent forms for formal
interviews concerning QOL, Happiness and Distress as participants in my
studies for the University of Sydney degree of Doctor of Health Science.
Many such patients, as well as chronic pain patients and cancer
chemotherapy patients, have been participants in my study.

Mr A is aged fifty and is off work due to disability and pain caused by
osteoarthritis affecting his left hip. He is quite independent in regards to his


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                                A Positive Margin

ability to perform activities of daily living, he feels well, has good emotional
support and a good outlook on life, meriting a score of 8-9/10 for health
related quality of life. He has many interests, such as his work building
bridges, woodwork, gardening, golf, fishing, and family sport. He occupies
himself by gardening, doing the housework whilst his spouse is at work and
preparing meals. In the afternoon he helps his sick parents and then helps
his children with their homework, then spends time with his wife. He enjoys
music on the stereo and reading.

Mr A rated his level of distress as 8/10 due to pain and sleep disturbed by any
movement. He describes himself as a happy person with a score of 7.5/10
which is normal, and rates his overall QOL as ‘as good as can be,’ which puts
him the top 18% of the community. Screening for Anxiety, Depression and
Somatisation was completely negative.

He defined QOL in the following way “QOL is to be able to perform all your
normal daily functions and duties, plus the work aspect – I seriously want to
get back to work – I’m in pain and I’m bored. Also the satisfaction you get out
of what you do – say mowing the lawns – they look sensational after mowing!
(He went on to detail his love for motorcycles, trips he had made and
described his family life - all part of his QOL)

The second patient awaiting hip replacement surgery was an 84 year old lady.
She rated her health related QOL on the Spitzer Instrument as 10/10. She is
independent, able to fully look after herself, feels well, has good support and
is emotionally unimpaired. Her self-assessment of distress was zero, her
happiness ‘very happy’ with a score of 10/10 and overall QOL ‘as good as
can be’ – again in the top 18% of the community. She has no evidence of
Anxiety, Depression or Somatisation (-the tendency to dwell on bodily
functions or impairments)

When asked to list her interests she mentioned very many – gardening,
sewing, church activities, radio, walking, watching football on TV, puzzles,
holiday activities, movies, listening to classical music, lectures, visiting,
mending reading, travelling, television, concerts, camping!, clothes,
handcrafts, cooking and shopping. One may have suspected that she would
be living a quiet life at 84 and with a bad hip. My record of her occupational
questionnaire reveals that she is having a cup of tea by 5am and by 9am she
has left her home to attend craft classes or meetings such as the Women’s
Auxiliary or Uniting Church, or visiting friends until lunch at midday. She
continues with craft, crocheting, knitting or going to the library, though
sometimes she takes a rest from 2-4pm. She always gets on with knitting if
she watches the TV but goes to bed early at 8pm and reads until 10.30 when
she goes to sleep.

She defined QOL as ‘you have QOL as long as you are able to do what you
want to do and getting a lot of pleasure out of it. You enjoy doing it so you do
it. I have done a lot of things for other people. I’m not a very good home
visitor to nursing homes unless I’ve got something to take there? (She makes
rugs as gifts for many people).


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                                  A Positive Margin



When I first started interviewing patients concerning QOL I tape recorded
interviews with cancer chemotherapy patients and after a while reviewed and
analysed them. The message was clear! Patients, one and all, were saying
essentially the same thing!

They were defining QOL as: “QOL is being able to do what you want to do,
when you want to do it – together with the satisfaction or happiness that
accompanies what you do”.

By now, I have modified my interview method, as patient after patient agrees
with the above definition and instead, utilise a brief non – structured
questionnaire recorded in note form, as detailed in the two illustrative cases
from Wednesday. It is quite practical in a clinic, to ask patients the simple
question – What is QOL and they will describe their individual life. I have
incorporated this into my routine, for patients at my Pain Clinic and Early Joint
Clinics. It is not just an idle question. It is extremely valuable.

You may be tempted to ask – is it only patients in these particular situations
who define QOL as above? I did a survey of hospital staff and when I had
surveyed twenty-five staff in a single 100 minute session, directors of nursing,
doctors and administrative staff, finding that they all agreed, then I felt more
confident, that here we had the crux of QOL. This might sound simple, but I
belong to the International Society for QOL Studies and there is depressingly
little agreement on what is QOL – in fact over one hundred definitions have
been detailed, at last count. The problem as I see it, is that QOL researchers
appear to be the ones dreaming up the definitions, not, as in our case
consumers, citizens or patients. How do you like definitions such s “Quality of
life is both objective and subjective, each axis being the aggregate of seven
domains: material well-being, health, productivity, intimacy, safety,
community, and emotional well-being. Objective domains comprise culturally
relevant measures of objective well-being. Subjective domains comprise
domain satisfaction weighted by their importance to the individual.” Another
researcher (Board 1998) proposed “QOL is the human condition determined
by the interactions between health and happiness”. These and other
definitions were proposed and criticised at a meeting of the ISQOLS. There
was no agreement and I am sure the patient generated definition that seems
to suit our situation could be roundly criticised. Never the less it seems very
relevant and acceptable to the population under consideration.

I shall return to the topic of QOL at a later date. More personally, today I feel I
am essentially healed. I have read much advice to men having radical
prostatectomy surgery over the last few weeks, a lot of it outdated and rather
frightening to one recently diagnosed. “Up to 40% may suffer urinary
incontinence”. My surgeon’s figures are closer to 1.5% for long-term
incontinence and I have had no problems right from the start. “Everyone will
need a blood transfusion”. I did not, as I lost 800ml blood and my
haemoglobin was never lower than 97. My surgeon transfuses 5% of
patients. “Take a month off”, “Most men return to work in 4-6 weeks” I started
work after 12 days and could have started on the Monday, two days before,


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only no clinics were booked for me. “You are liable to feel tired, weak, listless,
etc, etc, for six to eight week, as after any major surgery”. Not me! “After
about three weeks or so it should be time for the catheter in the bladder to be
removed”. One week – thank you! “X-rays will be taken of the bladder”.
Negative! It is a possibility – not a certainty. “Don’t go for long walks”. I went
for a 5km walk up and down the corridor outside my room on my third post-
operative day. “No attempt at sexual intercourse for six weeks – to prevent
strain on the abdominal muscles”. When I get my vacuum erection device on
Monday or a slightly better erection in the next few days I shall not mount up
in the missionary position and test out my abdominal incision. We shall
simply, as a surgical colleague is prone to remark, concerning his morning
activities, “throw a leg over” and, facing each other for preference, quite
comfortably, do it on our sides – no stress and strain. There are a few other
positions you can probably think of, which are not going to damage your
wound, and are better than waiting and waiting, if you are sex-obsessed, like
me.

As soon as my wife gets back from down town, we shall go for our evening
walk. It has been a glorious day, weather wise and approval from the council
for my building application has been granted today, so now we can make
some progress with our storage complex.

A 69 year old friend I was talking to today, has recently lost two old friends
and he is wondering just how many useful years he has left. Recently he
went fishing, up the coast, and although he and his friends caught many fish,
were up at 5am and in bed at midnight – by the end of the week he felt tired –
which was not something he had considered in past years. He is aware that
one of his recently deceased friends had a long and terrible death and the
other died suddenly. It is just as well we don’t know – but it has given him
cause to ponder as he, like me, until I got cancer, had hardly paused to think
of the future, other than as a continuing idyll. We agreed that we must do the
things we really want to do in life, whilst we can, and that surely involves
achieving optimum QOL.


13.11. 2004.
A very windy day! No clouds in the morning but later on, scattered clouds and
a temperature in the twenties. We had a good shower - this habit is now well
established – and went shopping, especially for clothes for our grandchildren.
My wife has a new kitchen toy, which allows her to make ’wraps’ filled with a
range of fillings. We had some for lunch – very tasty. Then I had my walk.

Down the street, I was very aware of all the younger people, to my mind
blissfully unaware of the sands of time running out – as I was, until recently.
Every moment is precious. Life is about the most precious thing we possess,
so surely its quality must be arguably of paramount importance. Many
religions are focused on the attainment of some form of continuing life,
however I am not going to focus on that at present. The quality of our lives at
this point in time, is something we generally spend a good deal of effort trying
to optimise.


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                                A Positive Margin



It is time for another old mind video. The year is about 1994 and I am at a
real estate auction in Armidale.            Potential buyers, like myself are
metaphorically sitting on their hands and gazing at the floor. Sellers and
agents seem over optimistic and nothing is sold. I wander over to the
newsagency nearby, and spy something unusual – a European Property
magazine. A year or so earlier, a friend had enthralled me with tales of
properties in France, specifically up toward the Swiss border, which could be
purchased for a song. On our next trip to France, we hired a car and explored
the area, noting that very picturesque little villages, with substantial houses
abounded and these were priced at about ten times what my friend had
mentioned. Out appetite was whetted, more particularly mine, as my wife is
not given to so many flights of fancy. I started to consider where we might
really like to spend a lot of time in retirement. Greece is one of my favourite
countries, but a little isolated from where a lot of the action is. Italy seemed
more what we were after as a base, full of historical buildings, crammed with
art and culture and gorgeous, unforgettable scenery.

At that time we had been flying to the United States from Europe each year –
at least for a few years, to then catch an American Airlines flight to Antigua,
which was an add on expense, to our round the world ticket. Now KLM no
longer was flying to Australia and we found we could fly around the world on
Qantas and its allied airline partners, British Airways and American Airlines,
the ticket including Antigua, and no other sensible choices existed. We now
spend a month in the Caribbean and once almost purchased a villa in
Antigua, but the sale fell through. I shall play that mind video another day.

 ( Back to Europe.)
In the European Property magazine, there was an advertisement for a
semidetached two story stone house in a tiny village near Florence, which
needed ‘restructuring’. The enthusiastic English owner told us that the
conductor of the Florence Symphony Orchestra would be our next door
neighbour, gave us instructions on how to get there and kindly invited us to
stay with him and his wife in their 14th Century Tudor house outside London.
We had a lovely trip and even managed to visit a former Nuclear Shelter, built
by the British Government, near his home. However, sadly, the title of the
property near Florence was not clear, and it required an enormous amount of
work, so – no sale.

Second time round, another house in Tuscany, advertised in The Times
newspaper, also proved to have no clear title and one must, simply must,
have an unblemished title for the past twenty years. One suspects some
owners simply hand over the deeds and accept cash from buyers, without
bothering with all the paperwork, without bothering about consulting lawyers
or obeying any regulations! We had a good Italian lawyer who avoided all
these traps and we finally bought, the third time, Sogni D’Oro – literally
Golden Dreams – but more freely translated Sweet Dreams – our little piece
of heaven in Tuscany. The tower is over nine hundred years old. Perched up
the hill above is Castello Piagnaro, a hundred metres as the crow flies, and it
is at the entrance to a medieval town.


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                                   Dr G B H Lewis
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 Our apartment in this tower, is up thirteen stone steps and the walls are 75cm
thick. Our ceilings are vaulted, and from our windows, we look out over the
river to a vista of grapevines, olives and fruit trees. In the background are the
foothills of the Appennines covered in pine and chestnut forests. In the
autumn, one can easily fill a back pack with chestnuts to roast and in town
there are evenings when the people gather, roasting chestnuts, down by the
river, drinking local wine. The local wine is red and has a spritzig quality – tiny
bubbles – not surprising really, as we are only about 50km south of Parma,
the home of Lumbrusco, Parma ham and other delicacies. In the forests are
wild boar, which one can eat in the local restaurants. Trattoria Pellici is only
fifteen metres away from our front door and they specialise in local porcini
mushrooms from the forests, where there are also wild boar. Testaroli is a
local, possibly pasta- based, flat round delight, which literally only takes a
moment in boiling water, to cook, and, together with cheese, pesto, tomato,
prosciutto and other appropriate accompaniments, it is an almost instant
meal.

In our marble bathroom, is something I had always wanted – a bidet. It has
played its part in our lives, but I suppose now that my prostate and seminal
vesicles are gone, I shall have less use for it. We shall see. Pontremoli is in
the Massa Carrara administrative region of Tuscany, hence marble is used
widely, All of the steps in the local, seven storey hospital, are marble, for
instance. We see the vast quarries, down on the coast, from whence some
chap called Michelangelo used to obtain his needs.

Although there are always taxis in the nearest piazza and at the Station, we
normally walk to and from the trains, which run frequently and of course can
take us anywhere in Europe.. Recently we had a two-day trip. Leaving home
in the morning we journeyed to Milano and caught another train north through
the lakes area, including Stresa, on Lago Maggiore, and through Switzerland
to Zurich. From there the terrain is not as steep, on the way to Geneva,
where we explored the lakefront and had dinner. On the train again, we slept
through the night and awoke, before we arrived in Firenze (Florence). It was
nice and early when we reached the Uffizi Gallery, so we were among the
earliest to get in. Whilst we waited in line we were entertained by a string
quartet, playing nearby. A full day in the Uffizi is memorable at any time and I
recall seeing a painting of baby Jesus, smiling, as Mary tickled him under the
chin. At long last we caught the train home, in time for a late dinner. Life
does not get much better than that, and I am tempted to write on and on,
detailing our life in Italy. Last trip, in September, we made two trips from our
home there, firstly to the Italian Grand Prix at Monzaa, near Milano and
secondly to Siena. In June we explored the Palace of Isold Bella, just a train
ride away. An hour away, leaving home at 9am, sn the Cinque Terre, or five
lands or really five villages, where millions of tourists, like ourselves, go
walking along the steep tracks between the villages on the edge of the
Ligurian Riviera. A little further, towards Genova, one may spend a beautiful
day alighting at Santa Margarita and walking up to Portofino, as we have
done, many times.


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                                  Dr G B H Lewis
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I get carried away, as I play this mind video, as memories of our fabulous
experiences in Tuscany keep flooding back. Before you conclude that all this
is beyond you, consider that it cost no more to attain our dream holiday
haven, here in Tuscany, than the price of a holiday unit on the New South
Wales coast. Our round the world fares with our frequent flyer points, before
the end of May, cost the same as a pack of 25 cigarettes per day each, but of
course, we don’t smoke. We make our annual pilgrimages, lasting six weeks,
during semi-retirement now, and in full retirement in 2007, we shall stay
overseas for many months, for no more than it costs to live at home. We
practically never eat out overseas, and spend no more on food and
incidentals than when we are home in Armidale. But it has been a long-term
plan, carefully conceived, and now come to fruition. Our Italian is improving
and it is doubtful if we could have any higher QOL or be more happy, than
when we are in Tuscany – and of course I shall tell you about our friends
there, later.


14.11. 2004.
Sunday morning, and we are busy getting ready to entertain our friends from
up the coast, for lunch. The back terrace is rather sunny, so I strategically site
the barbecue table under an apple tree and chill a bottle of local Petersons
Semillon to accompany Elizabeth’s chicken in orange.

J and his wife M formerly resided in Armidale. He was an animal behavioural
scientist and he used to belong to our wine tasting society. A few years ago
he was diagnosed with prostate cancer and the biopsies showed the cancer
had reached the prostatic capsule, just about everywhere. It was suspected
that it had probably spread through the capsule locally somewhere, and would
be too advanced for a radical prostatectomy to be effective. Consequently he
underwent radiotherapy in Sydney every weekday for some weeks. Recently
he was told, over three years later, that he is probably free of disease.

This couple’s life style has some similarities to that which we have envisaged
in retirement. They love France, especially the little villages of Provence, so
they rent a car from Nice or Lille and take off for the hills of Provence on their
annual pilgrimages. Curiosity got the better of me, and I enquired about how
his side effects of radiotherapy affect their travels. Thoughts of urinary
incontinence, bleeding or strictures, urgent diarrhoea, reduced rectal capacity,
anal strictures, rectal bleeding, impotence, which may take two years to
develop, pharmacological complications of anti-androgen therapy that he had
with the radio therapy, skin sensitivity problems, over the irradiated area and a
few rarer problems. He has had a couple of bleeds from both his bladder and
rectum and suffers chronically from the need to empty his bowels at short
notice. Very occasionally, he may have faecal incontinence mildly and have
to change his underpants. None of these problems have grossly interfered
with his quality of life, and they travel as much as ever, accepting his
limitations.




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                                   Dr G B H Lewis
                                  A Positive Margin

It is worth informing the reader that bleeding from bladder or rectum is
normally not sinister, but results from radiation damage to the areas blood
vessels and the subsequent overgrowth of many small fragile blood vessels,
which can be seen with a cystoscope or colonoscope, respectively. The latest
that I have read is that at least the rectal bleeding problem can be
successfully treated with laser therapy, after years of less effective therapies.
Some articles suggest that nearly 7% of survivors are left with significant long-
term problems of radiotherapy.

When one considers all the help that is now available to assist travellers with
disabilities, images of people being chauffeured along major airport walkways
in electric carts, zooming past their fellow airline passengers are reassuring.
Help is at hand in many situations, especially if staff are warned in advance,
so many cancer patients are still able to travel.

Experience has taught me that the maintenance of personal QOL is a
common goal, and all sorts of difficulties are often surmounted, and at least
an acceptable approximation of a desired QOL, achievable. In my own case,
I am prone to speculate on my future ability to be able to sail around the
Caribbean on the catamaran that we share, diving, snorkelling, sea kayaking,
exploring locations in the British Virgin Islands, St Barts, St Martin, St Vincent,
Guadalupe. Anguilla, the Grenadines and so on, that we have on our agenda
for the years ahead. First things first, so survival is paramount, and that may
mean having radiotherapy. There is a very good chance of surviving for quite
a few years, but we are aware of a significant chance of some unpleasant
side effects, which hopefully will not prevent us realising most of our dreams,
even if I must relax on the deck of the big Cat, watching the sea, instead of
diving, and living the life of an old man! I am reminded of a patient aged sixty
years who has Parkinson’s disease. She and her husband are retired,
previously enjoyed overseas travel and now, after a recent trip to New
Zealand, realise that the difficulties faced, in getting around, impactvery much
on their QOL, climbing, walking about, getting in and out of buses and planes.
They are going to restrict their travels, in future, to local trips.


15.11. 2004.
The video that I ordered last week, arrived today, so after my Pain Clinic,
having read the accompanying literature, I watched it – twice. Elizabeth said
she had no wish to see a video about penises, and went to take my eighty-
eight year old mother from her dementia hostel, to the dentist.

As the girl from the company said, it was educational, and rather explicit.
Assembly, use and care of the apparatus were all clearly explained. Feeling
encouraged and confident that this is what we shall find appropriate and
effective I rang up and ordered one. It should arrive on Friday. The buyer is
warned it may take a bit of practice, so some dress rehearsals are needed,
before Act I and hopefully Act II and more. You can expect a more detailed
update when it arrives, hopefully, before next weekend.




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                                  Dr G B H Lewis
                                 A Positive Margin

It is a month since the radical prostatectomy and everyone says how well I
look. My weight has gone down a little, trousers that were a little too tight are
now not so, and I’m full of energy, not aware of any reminders of my surgery.
Yesterday was the last time I used my support stockings, for I am confident
that there is no significant risk of deep venous thrombosis and pulmonary
embolism by now. Apart from the fact that my returning erections don’t last
nearly long enough I am as fit now as I was a month after my open
cholecystectomy, years ago and have not found the radical prostatectomy
more traumatic really. Certainly when I had peritonitis and surgery for a
ruptured appendix in 1980 I was much worse and in hospital for ten days.
Then, on the other hand I had an inguinal hernia repair one morning in 1994,
was home before lunch and went (carefully) for a walk in the afternoon. For
none of these operations have I had so much as a week off work after leaving
hospital. Until recently too, I would work all day, drive 1160km through the
night to Victoria, arriving early in the morning, then go skiing for the day. But
then, I’m a bit crazy and don’t like to waste a minute.


16.11. 2004.
I read in a research paper last night that men were considered for
radiotherapy following radical prostatectomy (only) when they were at least
one month post-operatively, had full continence of urine, had good wound
healing and were as physically well as they were before surgery. That
description seemed to apply to me and my review appointment is not for
another two weeks and three days. Therefore I thought it a good idea to ring
my surgeons nurse assistant and enquire what are their minimum time and
fitness criteria for candidates for radiotherapy. In two days it will be five
weeks since my surgery and if my surgeon was not going to be absent for a
week, I would have my post-operative PSA done in two days, and see him a
week later (instead of another week later still). If my PSA is taken this
Thursday then maybe I could start anti-androgen therapy, in preparation for
earlier Radiotherapy and get it all over sooner. I suspect though, that the
Christmas holiday period will mean an interruption to long therapy courses,
which take about six weeks to complete. There is no halm in asking!

She rang back and we had a good chat. My surgeon prefers men to be well
healed – that is three months – before having radiotherapy. It is agreed that I
have my PSA at the end of the week – five weeks post operatively. If it is
back to zero I shall be very happy and wait another week for my review. If it is
still elevated somewhat, I may be able to start some anti-androgen hormone
therapy to shrink and kill some of the cancer cells before starting radiotherapy
but these are only my own thoughts, and this may not be appropriate. From
what I have read Bicalutamide (Cosudex or Cosodex) is the best choice if
such therapy is indicated. Why? It stops testosterone encouraging the
cancer cells to multiply, it seems to have a milder side effect profile then
others and has less effect on any libido one still might treasure. The dose is
150mg daily for this indication.

If one is optimistic, the PSA will be around zero and my chances of cure – or
at least being free of any signs of disease after five years, will be nearly 90%



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                                   Dr G B H Lewis
                                  A Positive Margin

rather than 80%, though there will still be a risk of the cancer showing up even
later – but not a high chance, unless you have some more negative features
such as invasion of the seminal vesicles or lymph glands, which I have,
thank heavens, not had.

Today, for the second time this week, I lost a drop or two of urine as I went to
get out of the car. Perhaps it was the momentary increase in bladder
pressure as I leaned forward to get out. I shall practice my pelvic exercises
more regularly! By the end of the week I may receive some reviews on the
newer radiotherapy machines and complication rates with them.                 My
surgeon’s nurse warned me not to get enthusiastic with my vacuum erection
device for another week after it supposedly arrives, at the end of this week, as
vigorous pumping of blood to the area could still injure the recovering blood
vessels in the prostatic area. Six weeks is said to be the earliest starting date
– Oh well!


17.11. 2004.
It is a lovely spring day today and there are flowers and bees everywhere.
Especially bees! My wife has discovered that a swarm has set up
headquarters in the flue of our family room wood heater. We have been
wondering why so many bees are hovering around the vicinity. There is really
no alternative to having them moved, and no amateur beekeepers are
interested in dismantling the top of the flue to get access to them. A nice guy
arrives in response to my wife’s call and informs us that this is the fifth call he
has had of this nature, in two days. Our earlier attempt to smoke out the bees
seemed futile-nevertheless we hope that the queen bee has got the message
and moved out, saving her swarm. We shall never know. In due course a
sizeable area of beautiful honeycomb with some honey and a lot of
developing bee pupae is removed. It is so delicate and wonderfully designed.

For the rest of the day, I reflect on the fate of our bees and countless others
dispossessed and probably destroyed in this manner. Over the years, I have
become an environmentalist, carefully avoiding any unnecessary destruction
of flora and fauna, putting daddy long legs spiders outside and avoiding
treading on ants. As a child brought up on a farm, the idea seemed to be that
it was good to ringbark trees, burn them later and sow crops to feed the world.
Kangaroos were a menace to crops, thereby meriting nightly trips on vehicles
with spotlights with us standing in the back of utilities or on trucks shooting as
many as we could. In one three month period as a fifteen year old, I shot 105
kangaroos, as well as thousands of rabbits. Naturally I was proud of my .303,
.303/.25, double-barrelled shotgun, .22 and 25/20 Winchester. Similarly I was
keen on fishing. Later on in life, I brought a 5000 acre property and cleared
1000 acres of scrub – for crops and cattle.

It took me a long time before I got rid of my firearms, sold the property and
gave up fishing. There were some exciting times in my days jackarooing up
on the Queensland border near Boomi. We would gallop after wild pigs,
armed with unregistered revolvers, pistols and sawn off high power rifles. The
idea was to ride up as close to a large boar as possible – lean over and shoot


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                                  A Positive Margin

him in the back of the head as he ran, hopefully avoiding having one’s horse
trip over the animal. The horses did not like this sport at all. If a pig was
merely wounded and took cover in a nearby lignum bush, it was even more
exciting. Our pig dogs, of various breeds, would try and encourage the
enraged pig to leave his or her cover, whilst I, armed with a .38 Smith and
Wesson revolver, or a .455 Webley, would cautiously approach to within firing
range on foot. When the pig made a dash for another safer spot, it might head
in any direction, including towards me. Everything happened very quickly
then, and of course it wasn’t part of the plan to shoot one of the dogs in hot
pursuit. On foot, with a large wild boar approaching rapidly and his wicked
little tusks visible, it is of supreme importance not to lose your nerve, for there
is very little time to aim and fire. There were a few close calls.

There were other exciting occupations for a jackeroo, on a big property, with
9000 sheep and 600 cattle. One of them was chasing half grown young bulls
which had missed being castrated as calves. They could, when tired enough
from being chased by a stockman, be grasped by the tail and encouraged,
with much help from a skilled horse, to fall over, be pounced upon by three of
us and swiftly castrated. My job was, at that time, to leap from my horse, grab
the bull by the horns, before he got to his feet, and try and twist his neck to
one side, whilst a stockman roped his legs, and the third man acted as
surgeon. From the look in their eyes, it was obvious that these animals were
not exactly overjoyed with the whole procedure. One time, a young bull got up
and pushed me right through a large lignum bush, with the others twisting his
tail and trying to slow him down. He was not a happy animal, nor was I. My
mates, however, thought it all vastly amusing, and laughed so much, I don’t
think that they were able to help me, too much.

It is possible that some of these adventures could have ended badly for me
and one time my horse fell, with me still in the saddle and pinned down, but
nothing was broken, only a badly bruised thigh. We rode so much that we had
to change horses every three or four days .In our endless days of youth, we
may take risks with little thought of the future – yet now at the age of sixty-
seven, the possible negative outcomes from prostate cancer progress or the
side effects of treatment occupy my thoughts very often. This is hardly
surprising, for we tend to become more cautious, conservative and averse to
risks, as we age. Over the years, I have had many exciting times on the road,
yet nowadays, apart from going as close to others as I dare, on roundabouts
and sliding around alpine roads, when I get the chance, my road behaviour is
quite sedate, most of the time.

In the nineteen-seventies, I sold my Lamborghini Espada V12 coupe and
accepted a metallic blue Jensen Interceptor as a trade in. It costs a lot less to
maintain than a Lamborghini and has a 330HP Chrysler V8, so it can go pretty
well. One winter morning, years ago, I was out early on a wet, foggy road,
heading towards another town, to give anaesthetics. Three slower cars
heading in the same direction were impeding my progress, so I passed them.
There was plenty of space to pull back in to the line of traffic, but two further
slow-coaches were not much further ahead so I decided to pass them as well.
The fog was starting to close in, I was half way past them at about 150kph


                                        33
                                   Dr G B H Lewis
                                  A Positive Margin

when a small Japanese sedan appeared, heading towards me. Braking, to be
able to get back behind the two I was passing, I made the error of turning
whilst still braking on a wet road, with rather worn tires! The Jensen did a
sudden 180 turn as I took my foot off the brake and neatly slipped back into
the line of traffic. There were the three cars facing south, me facing north and
skidding backwards, then the two cars that I hadn’t passed, also facing south.
My car slid off the side of the bitumen, opposite where the Japanese car had
stopped, and the other cars passed me. As soon as they did so, I pulled back
onto the road and passed the five, before the next patch of fog, resolving to
buy some new tyres soon! I still have my Jensen, and the memories!
Perhaps the other drivers have some memories too. Real life is made of such
events. Cars have always been one of my passions, and in the good old days
before real speed limits, I would usually try to average 100mph from town to
town. Later, came the era of endless numbers of high speed chases, with all
the adrenalin rushes they engendered. Alas, times change. Today, a Hyundai
or Kia will easily keep pace with more exotic machinery, for to speed is to be
considered antisocial, and these dream machines meekly follow the rest of
the traffic, only to be unleashed on closed roads or circuits.


Many car enthusiasts love to rebuild, repair, modify, polish and generally
spend time working on their cars. To me, driving is the thing, though of
course the look and sound of special cars goes with it. Probably, my wife and
I have now rather sublimated our desires, regarding driving, as we focus on
watching all the Formula I Grand Prix races on television, whatever the hour,
and attending them, when we can. Over the years, we have attended races in
Australia, both in Adelaide and Melbourne, England, Italy and France more
than once, Monaco, China and Canada. This year, we stood twenty feet from
where the cars were passing us at 340kph at Monza. Even with earplugs, the
noise was unbelievable.

I have found that there are plenty of thrills in down-hill skiing, and once almost
skied right off the edge of a mountain on an icy run, the tops of fir trees visible
a long way below.

As I am not a team player by nature, and there are many rules for pilots, it
was probably best that I sold my plane. Sticking to the regulations is no fun
for me, and anything else is likely to get you killed. Strangely enough, I am
perfectly content as a passenger in a plane, flying over 100 hours per year,
relaxed enough to fall asleep before the plane takes off, enjoying all the food,
drink and new movies provided. We are all different.

One of our sons, when a flying instructor at Dallas – Fort Worth, in Texas, flew
advanced students all over the United States on navigation exercises and had
a great time himself, though it could be challenging at major airports, and
sometimes, when landing at night. He has also done a lot of deep scuba
diving. Our other sons have also had their moments. One, armed with a
pistol, whilst boarding an illegal fishing boat, from his Navy Patrol Boat, took a
step on to the flimsy craft, and the timber gave way, throwing him into the
water. He has had his moments, during bad storms, during ocean yacht


                                        34
                                   Dr G B H Lewis
                                  A Positive Margin

racing, in the Sydney – Hobart and other ocean races too, and night diving for
the Navy. These experiences demonstrate how commonly we indulge in
dangerous adventures, and surely we wouldn’t do so, without balancing the
risks and the pleasures and heightened QOL we gain. Cherries on the cake
of life!


18.11.2004
Today my new toy arrived. After I had finished at the Hospital, I watched the
video, read the instructions carefully, then methodically assembled the
Vacuum Erection Device. It all looked a bit bigger than I had imagined and I
carefully lubricated the parts indicated. My surgeon’s nurse had warned that it
was OK to purchase but not use it yet, whilst I am healing up. The question
had to be answered though – did it actually work?

The instructions were accompanied by graphic diagrams of what happened
and yes, with a few very slow pumps of the lever and waiting about 10
seconds for a response, my penis enlarged as it filled with blood. Pressing
the button to terminate the applied vacuum, the erection drooped. Just to be
sure, I pumped it up again, this time with the largest of the rings supplied fitted
to the cylinder. With a sizeable and hopefully useable erection achieved, I
slipped on the ring and yes, it stayed erect until I slipped off the ring, which
though the largest felt a little uncomfortable when applied. Satisfied with the
result, I washed the equipment and put it back in its bag. My opinion is
reasonably positive. When I am healed more completely, we shall give it a
road test. If it was a car it would not be the one has as a teenager, but the Kia
Rio one might purchase as basic transport, reliable but hardly pleasurable –
when the Ferrari is in the museum and cannot be driven any more!

There is a famous study of men, from the time they attended Harvard
University until they were 80 years of age, together with several comparison
groups, men from another background and a group of privileged woman – all
over the lifetime. It appears that I may be a little foolish, in seeking continuing
sexual fulfilment. The 75-80 year old men enjoyed sexual intercourse on
average once every 10 weeks. There were exceptions among these elderly
couples studied, but let us not get our hopes too high.


19.11.2004
All day today, I saw patients at pre-anaesthetic clinics. One man, aged 71,
had recently had a radical prostatectomy and the cancer had spread outside
the prostate. He had been advised that radiotherapy was a further treatment
option, to destroy any localised cancer cells remaining, which is similar to my
situation. His operation was four months ago and he has seen a radio-
oncologist in Sydney. On hearing of the possible complications of therapy,
including possible bladder and bowel problems, he was distressed, and has
refused therapy, unfortunately. I spend some time with him, discussing the
potential good, as well as the risks of complications of therapy and he is now
willing to reconsider his decision, when he is reviewed soon, by his surgeon in
Sydney. Of course it is frightening, when one is told of all the possible nasty,


                                        35
                                  Dr G B H Lewis
                                 A Positive Margin

damaging side effects, when normal tissues are irradiated, and there are no
guarantees that treatment will always result in a cure. It is a very serious
matter, for which I feel many men are ill equipped to rationally make an
immediate decision. If one decides to refuse potentially curative treatment
offered, then one expects that any untreated cancer which has not been
removed may spread both locally, and possibly distantly. If it does, there is
less chance of later radiotherapy being effective, and hormone therapy,
though helpful, is not considered curative. My worst fear is of secondary,
metastatic spread and I am willing to risk possible side effects of radiotherapy
to minimise the chacge of the cancer spreading.

This afternoon, I contacted yet another radiotherapist, or radio-oncologist, at
another hospital, and he asked me to send him copies of my biopsy and
histopathology reports for his consideration, and I shall talk to him next week.
Briefly, he expects that I would need conformal radiotherapy with a 3D-CRT
unit providing about 60 Gy, and that they have much experience with this
regime. By now, I am most interested in learning of the complications, or side
effect profile, of different hospital radiotherapy centres. It appears that there
are real differences in the complication rates from different centres. I am just
shopping around!


20.11.2004
It is a rainy Saturday, good for writing and thinking. The morning started with
a good lie in bed together, then a shared shower. At some risk of being
wrong, I would say that my mood, which has been more labile since my
diagnosis, has more or less returned to normal, which could be described as
an almost irrepressible positive cognitive bias. The idea of people seeing life
through rose coloured spectacles has been tested and found to be true for
most people, most of the time. It seems that people with symptoms of
depression are more likely to see reality for what it is, without any false
overlay of optimism. Apparently a tendency towards euphoria helps us to
face the world with a smile. As in the old song “accentuate the positive –
eliminate the negative,” as in life!

How many people buy lottery tickets, or more hopefully still – Art Union tickets
for a million dollar home? The chances of a disease free medical report in
five years after my preposed radiotherapy, according to my surgeon, are
around 90% and even with the chances of later recurrence, a cure is likely in
80% of cases. Though the chances of longer term bowel and bladder
problems are significant with radiotherapy about 85% of patients are not
worried by complications and overall QOL is not inferior to aged matched
controls. Yesterday, I examined patients attending the pre-anaesthetic clinics,
who have unstable insulin dependent diabetes, ischaemic and valvular heart
disease, chronic obstructive pulmonary disease, sleep apnoea,
cardiomyopathy, asthma, morbid obesity, Alzheimers disease, advanced
osteoarthritis, serious arrhythmia’s and I cannot recall what else, many of
them younger than I, and seemingly coping satisfactorily. Put in perspective, I
have much to be thankful for, and should count my blessings – which is what I
intend to do.


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                                  Dr G B H Lewis
                                 A Positive Margin




21.11.2004
An early morning trip to give the Limousine and the Jensen a run, took four
hours and I was home by 12.30pm. The cars started easily and the drive was
enjoyable. On the way over – 130km to the car museum, my mind videos
were playing, one after another, as I reviewed various subjects.

The main theme that was reviewed, was employment over the years. As a
boy growing up on a farm, one learned many skills, milking cows, trapping
rabbits, riding horses, mustering sheep and cattle, ploughing, scarifying the
land and sewing crops, building and repairing fences, driving trucks and
utilities, shooting, clearing out troughs, hand feeding animals – really, the list
is seemingly endless. After leaving school at the end of year nine, it was a
case of more of the same, plus spells working in woolsheds for neighbours
until I ended up working on a big property on the Queensland border near
Boomi, north of Moree..

There were floods that year, and sheep and cattle had to be moved to higher
ground. There were still huge numbers of bones in one paddock corner,
where sheep had been trapped and drowned in 1948. We swam our horses
over flooded water courses and had a busy time saving the animals.

When I was a boarder at a Sydney school, I really became aware that the life
style enjoyed by many people on the land, who basically are self-employed
and have to do all the work themselves, was vastly different from that enjoyed
by many of my school mate’s families. Vast land holdings, with full time
managers for different divisions such as sheep, cattle and farming, and plenty
of station-hands, were not unusual in those days. Wool prices were at a
record high and there was plenty of money for motor cruisers, overseas
holidays and new American cars, the best of horses and whatever their hearts
desired. Some of these properties were nationally famous for their studs.

Later, when working at a large Trustee Company, first as secretary to the
manager, then later on the staff of one of the Trust Officers, I learnt more
about the differences between the elite graziers and their more humble
cousins, likely to be known as farmers, Country people are brash enough to
ask “where exactly is your property?”, “how big is it?” and “how many acres of
cultivation and how many stock do you have?”. The answers provided,
obviate the need to simply ask to be shown one’s tax return and financial
statements. There is a pretty clear pecking order. One learned that wealthy
families make provision for their offspring. On the birth of a child, a trust fund
can be established with a generous cheque, so that upon reaching an age of
maturity, the child is financially independent. Families often have many other
interests, that are not obvious. A friend at school was brought up on an
orchard, and many others wondered how the family lived so well. Whilst I was
walking up Pitt Street, in the heart of Sydney, one afternoon with him, he
pointed out a building –“Dad owns that,” then, pointing out another, further
along-- “Dad owns that”. Puzzle solved. One boy, who sat next to me at
school, turned fourteen, and I asked him what he received for his birthday.


                                       37
                                 Dr G B H Lewis
                                A Positive Margin

The reply was-- “forty houses”. His father was a builder who had built many
developments in Sydney.

Another side of the coin was also brought home to me at the Trustee
Company. At one stage, I was in charge of the cheque writing department,
from whence all company cheques were made out, for signing by company
officers. One duty was to personally hand regular payments to recipients of
family trust funds, who for some reason were considered not likely to be
responsible, if the money was deposited in to accounts, as we usual did.
People appeared weekly or fortnightly, cash was handed over and a receipt
signed. Most were neatly dressed, some men appeared with frayed shirt
collars, and a pervasive impression of genteel poverty, was frequently gained.
One such person confided that he was regarded as the black sheep of the
family, and had no personal contact with his prominent relatives. I am
reminded of the popular television program-- Keeping up Appearances.
Though this might seem unrelated to the situation, families are sometimes
motivated to keep embarrassing members, at arms length or even further
away.


22.11. 2004.
Another week begins with a pleasant time at my Pain Clinic. My focus is now
on having my first post-operative PSA test on Wednesday, in two days time,
which will be one week before I see my surgeon. The PSA result will give a
good indication of the presence of any active prostate tissue, in my case,
since my prostate has been removed, it would most likely indicate whether
there are sufficient numbers of cancer cells to be detected. There is the more
remote possibility that some remnants of normal prostate tissue could be
producing a little PSA.

Hopefully my PSA will be around zero, for I think that the higher the reading,
the less chance I have, for a cure!


23.11. 2004.
An early 6am start -- on my 130km drive to the town where I shall be giving
anaesthetics for the day. As always, the trip is relaxing and enjoyable, in a
Hospital V6 Toyota Camry, and I arrive well in time. In terms of QOL at
present, I have to say it is ‘as good as can be,’ in line with the Bowling &
Windsor instrument for overall QOL. The answer ‘as good as can be’ puts
one in the top group of 18% of citizens. In terms of my patient generated
definition of QOL (being able to do what I want to do, when I want to do it,
together with satisfaction or happiness that accompanies it) I must give myself
full marks today. Hospital staff, surgeon and patients are all very friendly, as
always. The atmosphere is more like a social occasion than one might think.
Find an occupation that you love and you will never have to work again, or
words to that effect, applies very much to my life, and has done for years. My
wife has packed me a nice lunch, as always, and the day ends with another
great drive home. Only the thoughts of tomorrow’s PSA test intrude to spoil it
a little!


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                                  Dr G B H Lewis
                                 A Positive Margin




24.11. 2004.
At lunchtime, I went to the Pathology Laboratory at the Hospital and it only
took a minute to have my PSA blood sample taken. The results will be known
tomorrow morning.

Hearing that someone in town, who had had radiotherapy for cancer, was
most favourably impressed by her Sydney specialist, at a major teaching
hospital – I rang him and had a very enlightening conversation. Briefly, he
said that if my PSA fell to around zero, that is to say undetectable levels, then
there was no hurry to go and have radiotherapy, unless there was later
evidence of an increase in the PSA – indicating a problem. This opinion was
good news to me, as I realised that early radiotherapy, for all patients in my
situation of local positive margin pathology, meant that those with, as well as
those without, residual local cancer, would all be at risk of the very real
complications of radiotherapy.

As I do not know if my PSA remains elevated or not, I am not able to say if
this news will affect me – for unless my PSA is right down to around zero, I
have little option but to proceed with early radiotherapy – called Adjuvant
Radiotherapy, in January. If the PSA has not so diminished, my future is less
rosy, for the odds then would be on continuing cancer cell activity, probably
locally or conceivably more distant – though much less likely.

Jan, our Librarian, has been requesting reprints from journals on the subject
of reviews of the effects of radiotherapy on prostate cancer, including toxicity.
Over the last weeks, my hours have been devoted to reading various articles
on aspects of radical prostatectomy, including complications and side effects
of different treatment, and a lot more, besides. Nearly everyone I speak to
has ideas on cancer, and my wife is brewing Willow herbal tea at every
opportunity to enhance my chances of cure. A surgical friend recommends
Zantac® to prevent secondary spread of cancer, on anecdotal evidence.


25.11. 2004.
My PSA is as close as possible to zero – 0.01 nanogram/ml,(usually
abbreviated to ng/ml), so I am overjoyed, as are my wife, children, friends and
colleagues. I pack some more journal articles, and in the afternoon, our
youngest son Andrew, together with my wife and I, towing a four-wheel trailer
behind the Range Rover – full of building materials, take off for Victoria,
1160km away. The plan is to stay in a motel in Dubbo and complete the trip
the next day.

QOL is, at this stage, truly excellent. The weather is great and we anticipate a
full weekend in the Victorian Alps, walking around Lake Guy, inspecting our
houses and enjoying staying with our son in his beautiful new home, which he
designed and built, himself. There is to be a church dinner on the Friday after
we arrive – our son Andrew being the Associate Pastor of the local Baptist
Church. A negative factor is my continuing failure to manage to get a useful


                                       39
                                  Dr G B H Lewis
                                 A Positive Margin

erection, but Elizabeth is not worried, so I suppose I should be philosophical!
As I have the Vacuum Erection apparatus as a fall back measure, if all else
fails, at least I can look forward to some action after I have seen my surgeon
next week.

Before Dubbo, is the town of Gilgandra, where I had my farm for thirty years,
before selling to a goat farmer. He is a very practical guy and when he has
electrified thirty six kilometres of fencing, to ensure his goats do not escape,
then he may be able to relax a little. I am convinced he will do well. Better
than running cattle I think – and trying to run the property from four hundred
kilometres away, in Armidale! It is strange really, that I do not miss having the
property – less headaches now too. Gradually, my farm origins sink further
into the past. Overseas travel means more and more to us, and is
established as integral to our present and future QOL.


26.11. 2004.
Today proved to be a long, hot day, with several punctured tyres on the
heavily loaded four-wheel trailer – finally necessitating the purchase of three
new tyres in Wagga Wagga. We arrived in Mount Beauty just in time to get
ready for the planned Church dinner. My son’s home is now complete
upstairs and he is quite advanced in building an apartment and garage plus a
ski-drying room downstairs.

We are well known in the Church community and people have been praying
for me. My good news of a PSA officially in the undetectable range, is
evidence that God is looking after me. At Armidale, the Church members
have been praying for me too, and I appreciate the concern of so many
people in the last weeks. Once I read a published study which reported that
coronary care patients who were prayed for, had a significantly better
outcome than a matched control group. It makes you think! I have never
been particularly prayerful, tending to spend more time giving thanks to God
for all my blessings. It is my belief that God is in charge, and consequently
the words of the Lords Prayer ‘thy will be done on earth – as it is in heaven’
are particularly apt.

My son, in his Baptist Church studies, has learnt hundreds of verses of the
bible, verbatim. Sometimes I test him on verses he is learning and discuss
passages he is to preach on. It is some years since I completed my Licentiate
in Theology, a basic qualification for ordination in the Anglican Church, which I
did over five years, whilst continuing with my Anaesthetic practice. New
Testament Greek I found hardest, with five hundred different verb endings.
Such study makes one better able to interpret scripture, which surely is of
importance to those who are seeking a life after death, but study per se, does
not make one a better Christian.


27.11. 2004.
Saturday! Elizabeth and I drove to Bogong Alpine Village and had a pleasant
walk around the shore of Lake Guy, which is really a HydroElectric scheme


                                       40
                                  Dr G B H Lewis
                                 A Positive Margin

dam. Part of the walking track takes one through the dam wall. At the other
extremity of the dam are the two feeding mountain streams which are fed from
dams higher up the valley. There is a big dam or lake, up the top at Falls
Creek ski resort, some fifteen kilometres up a steep, winding road.

Before the meeting of cabin owners’ starts in the afternoon, we inspect our
two houses, to check that all is in order for the summer season. We bought
them some years ago and totally re-furbished them – more accurately,
perhaps one could say that they were almost restructured to make them more
contemporary, but with some added stonework, as well as drying rooms for
ski gear, spa-baths and more open living areas. Whenever we visit these
houses we feel our lives are enriched. The views are spectacular, of
mountains, forests, sparking mountain streams, on site botanic gardens and
pleasant walks among tree ferns and tall trees. Another aspect of our QOL,
which we plan to continue in retirement, for a couple of months per year.
Recently we bought a double garage at the Village and store our caravan
there. Elizabeth helped her father build this van, when she was a child and I
have had it brought up to modern specifications for our future trips in Victoria,
visiting wineries and the beautiful countryside of much of the state.

The meeting is long, but fruitful, and we meet some new cabin owners and the
new management team, operated by the committee of cabin owners who now
run this village. My mood since the latest PSA, is continuously positive.


28.11.2004
An early start was necessary, as our son drove down to Albury Airport for our
flight to Sydney and thence home. A car magazine was testing twenty-two
cars for a car of the year award, at the Airport and doing some filming. We
saw cars travelling at up to 250kph on the Albury airport runway. Then the
drivers came into the Airport café for coffee. Once upon a time, I would just
have driven 1160km home in the day, but I have to work tomorrow and I am
older, so the plane is an easier option.

We arrive home to find, Lucky our shared cat, is missing. He has not been
seen for two days. A drive encompassing all the local streets is fruitless. Our
elderly neighbours are heart-broken. Our previous cat Johnno disappeared
just the day before we arrived home from overseas, some years ago. No
sightings or responses to radio broadcasts or newspaper advertisements
turned up the slightest information. Everyone is sad and I am reminded that
just when everything seems so positive, one can have an unexpected loss.


29.11. 2004.
This is going to be a big week, as in two days I am to see my surgeon. By
now, I have read a lot of research papers on treatment for people in my
situation. My initial decision, to have early radiotherapy, in the light of my
reading, does not seem such a great idea. Suggestions that the important
factor in the timing of commencing radiotherapy is the value of the PSA at the
time when treatment starts were made as long ago as 1997. The PSA value


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                                   Dr G B H Lewis
                                  A Positive Margin

over, or above which results take a real most-dive -- has been suggested to
be less than 1.0 nanogram/ml. Further publications that I have read, have
shown that there is no significant difference between low, measurable PSA
readings up to <1.0ng/ml, in terms of percentage of men who are free of any
signs of cancer –( biochemically) in five years time after radiotherapy. A PSA
equal to, or above 1.0ng/ml, when one commences radiotherapy, is bad
news, comparatively speaking, for the 5 year ‘cure’ drops from maybe 80% (if
your initial PSA after surgery dropped to ‘zero,’ before rising again) and you
started treatment when it started rising, and certainly before the magic figure
of 1.0ng/ml. The figure for a ‘cure’ measured in 5 years time for the
⋝1.0ng/ml group, drops to about 30%. That is a hell of a difference! To
make this clearer, I shall include a copy of the most recent research reports in
the Appendix. It is what decided me (plus the opinion of the senior radio-
oncologist at a Teaching Hospital previously mentioned). I am not going to
have radiotherapy in January, but to simply closely monitor my PSA, and if it
starts to climb – then start radiotherapy. There is no clear evidence that
routine early therapy is any better as far as I can see, and I may already be
cured by surgery, if my surgeon is right! This is, naturally a QOL decision, for
a decision to go ahead with adjuvant radiotherapy would hit any residual
cancer cells now, before they have longer to multiply, so I am relying on these
reports, very substantially. The desire to avoid the potential adverse effects of
radiotherapy is a strong motivating factor in making my decision, which I have
to live or die with, if I get a recurrence, which fails to respond to radiotherapy,
later.

It is a busy day, with clinics all day long. These days I have practically
forgotten about my operation from a physical point of view, for I have healed
up well and even if I become a bit constipated and have to strain at the toilet,
it does not seem to affect my pelvic floor, as far as I am aware – and earlier
on – it did! Naturally I try and eat sensibly and not get constipated!


30.11. 2004.
Today is my mothers wedding anniversary. I visit her at Ningana dementia
hostel, but decide it is not a good idea to mention the anniversary. My father
died in 1978 and my mother only really lives in the present. If my father is
mentioned she may get upset. One of my sisters casually mentioned ‘when
Dad died’ to her, in conversation, and she certainly became upset “What!”
“He’s dead!” “What happened”, but then, in five minutes the episode was
forgotten.

My mother is having dinner and playing with a surprisingly life like toy cat,
which is battery operated. It meows, purrs, lifts its tail and moves its head in
response to being activated by touch. I am not sure how my mother regards
this life sized toy! She has a large collection of stuffed animals in her room
and tends to talk to them. What is reality to her? In any event she is happy
and recognises me and wishes to introduce me to all at her table. I spend my
time with her, paying her some attention, but also observing the behaviour of
her fellow dementia residents, as they have their evening meal. They are



                                        42
                                    Dr G B H Lewis
                                   A Positive Margin

certainly not all happy like my mother is and many seem to take little pleasure
in eating their evening meal.


01.12. 2004.
Forty-two years ago today, we were married in my old school chapel. Thirty
eight years ago today our second son was born and our eldest son is forty
years and six months old today – not a day to be forgotten!

After a busy morning Pain Clinic I fly to Sydney for my post-operative
appointment with my surgeon. On the plane is John Anderson, Deputy Prime
Minister, and I talk to him, mainly about the problem of global warming. He
feels that it is very difficult to be sure of the relative roles of human activity and
other factors, in a complicated picture. As minister for Trade, he sees an
awful lot of coal exported and its role in contributing to global warming, I’m
sure is on his mind. He has been visiting a daughter at school in Armidale
and we have mutual friends. I hurry to catch a taxi to St Vincent’s Clinics but
there is no need, as I have to wait half an hour on arrival.

I hand my surgeon a two page summary of my reasons for deciding not to
proceed with early radiotherapy. My PSA is negligible (0.01) and there are
five scientific papers suggesting that as long as I monitor my PSA closely and
start therapy soon, in the event that the PSA starts to rise – and certainly
before it gets close to 1.0 ng/mL, then I have as good a chance of a five year
biochemical cure as if I started in January. He agrees with all I say and
volunteers that if he were in my position, he would do exactly the same. In
addition, he is confident that as I am having partial erections now, things will
get better and better. As I leave, we agree that I shall monitor my PSA closely
and ring him up each time I have a progress PSA done. There is no point in
keeping my appointments now, with the radio-oncologists, so I cancel them.

My birthday son, Garry, collects me after the appointment and drives me
home to his place. My wife Elizabeth is driving down tomorrow from Armidale
and we shall then all attend a Ballet Concert in which my grandchildren are
performing. All things considered, I cannot expect a more positive outcome.
My surgeon also told me that where the cancer perforated the capsule and
extended through a 1mm diameter hole, there was only a thin ‘finger’ of
malignant cells where the perforation of the capsule occurred, near the edge
of the specimen, and he used cutting diathermy (which is really a very hot
electric knife) for his dissection. It not only cuts, it coagulates and stops blood
vessels bleeding and any cancer cells it cuts through are destroyed –so he is
pretty confident that there is little chance of a recurrence. My feeling is not
quite as positive, as he, with his perpetual optimism about everything, seems
to have a positive cognitive bias, at least whilst talking with patients. I shall
certainly be keeping a very close eye on my serial PSAs, ready to start
radiotherapy if necessary.




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                                  Dr G B H Lewis
                                 A Positive Margin

02.12.2004
As my son has been working up to midnight recently on Navy plans, he is
taking a day off, today, so together with my daughter- in- law, we leave early
for my grandchildren’s school and watch, as they play the violin (Alex) and
cello (Sophie) in a sixty instrument string group for an hour before school.
The children are all very well behaved and play well. Chatswood Public is a
very music orientated school.

Elizabeth arrives in the early afternoon and the household is focused on
getting ready for the Ballet Concert. There are many costumes for the
children to wear and we are to be there very early, to be sure of being ready.
My daughter- in- law’s mother, from Brisbane, plus other relatives, are to be in
our party.

Everything proceeds smoothly and I am particularly impressed by Sophie's
dancing, consistent with her 95% mark, in her ballet exam. She is a very busy
seven- year –old, and is doing well, since she has been selected for pre-
Olympic squad training in gymnastics. Alex learns tennis and has swimming
coaching, so it is just as well that she is very disciplined and does her
homework, without needing to be prompted. All the activities of our children
and grandchildren contribute very much to my QOL. Alex received the class
prize for Mandarin last year, in a class half- full of Chinese children. He has
prizes for creative writing and poetry. Sophie also received a Dorothy
MacKellar award for her poetry. Alex is a serious boy, and at nine years of
age, aims to become a Pathologist. Time will tell. The family swim practically
daily, Garry and Lisa-Jane do a lot of marathon and half marathon running
and they all go cross-country skiing. On the fourteenth of this month, they
leave for Thailand, then Germany, where Garry, who is Navy cross-country
and biathlon champion and number five in the Biathlon in Australia, is
competing in southern Germany, in international cross-country and biathlon
competition. There is never a dull moment.


03.12.2004
No real plans today, except it would be interesting to visit the Bang and
Olufsen outlet in Willoughby. Their sound systems and televisions appeal to
me very much, and I have an ageing B&O set up, at home. My daughter- in-
law Lisa Jane, accompanies Elizabeth and I to the shop, after purchasing a
‘mute’ for Alexander’s violin, at the violin shop in the same suburb.

This simple scenario triggers my interest in agendas. Mention an agenda and
most people think of the formal agenda for a meeting. People have agendas,
though it seems we are frequently unaware of how important they are. Lisa-
Jane has promised Alexander she will get him a ‘mute’ and incorporates the
planned purchase into her day’s agenda. No problem, we have plenty of time.
My agenda is even simpler, so we spend some time listening to fabulous
Danish sound systems and examining home theatres, all beautifully crafted
and at least I now have some idea of what one can buy, if money is no object.
Fifty-seven thousand dollars for what is essentially a state- of- the- art
television plus DVD, and top of the line speakers, is not really an option for us.


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                                  Dr G B H Lewis
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That’s Okay! My agenda was merely to see what they had, and I leave,
planning to look at alternatives.

Agendas are more frequently more complicated. The fact that I have had
prostate cancer surgery forces me to modify my agenda, in this instance, to
accommodate changes in my life. The nature of the problem means that a lot
of uncertainties are introduced, which may or may not force me to alter some
cherished life plans. Quantity and quality of life are still paramount, and are
central foci of my life agenda. Until now, I had judged that I might expect that
my useful life would be another thirteen years. By that time, Elizabeth or I
could be too decrepit to travel the world. One expects that one’s last year or
years may be far from one’s best, so I factor that in, to my agenda. A senior
radio-oncologist estimated that with my present situation, I may well have
another 10-12 years to live – close enough to my earlier estimate. We have
shares in a Caribbean Resort, in Dickenson Bay, Antigua, on a time-share
basis, which last another thirteen years. This resort- sharing purchase
commenced in 1993 – an example of long term QOL planning. Cancelling our
annual pilgrimage to Dickenson Bay, is not an option, as long as I have the
strength to get there. Frequently I have noted the frail passengers being
transported, on little electric trolleys, around airport terminals and have
imagined myself in that situation, too. A villa set in tropical gardens, facing
the Caribbean, on what is frequently rated as one of the best four beaches in
the world, is as good as it gets, truly heaven on earth. Next week I shall book
our next trip there – possibly starting with a visit to Ireland, then two weeks in
,Roquebrune- cap- Martin, on the border of Monaco, followed by precious
time in our holiday home in Tuscany, before we jet to New York, see the
extensions to the Museum of Modern Art in Manhattan and a Broadway
Show. From there we intend flying to the Caribbean, for a few weeks sailing,
diving and swimming. To get home we fly to several other islands including
Mustieque and Barbados then via Miami and Los Angeles to Sydney and
Armidale. The year after and as long as I’m able to travel my agenda is May
to October around the world, no winters, two months in the Victorian Alps and
the rest of the year based in Armidale, but travelling to stay with our children
and grandchildren.

To my mind, agendas are commonly almost as fixed as those drawn up for
meetings. There are very good reasons for them and much thought and
planning goes into them. One is aware that annual elections of office bearers
of organisations are frequently a foregone conclusion and the meeting simply
confirms what is already certain. What are the implications of this finding? A
meeting agenda, on the surface, foresees a logical decision making process
following thought and consideration by attendees anticipating the agreement
of a preponderance of informed decision makers, on a course of action
considered best for the organisation. Behind the scenes, it is often a numbers
game. Which power broker can muster the most support for his own personal
agenda, some aspects of which remain hidden from view. One is reminded of
the early days of Adolf Hitler!

Over the years, I have been a member of quite a few car clubs. Simplistically,
new members might think that everyone interested in a certain make of car,


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                                  Dr G B H Lewis
                                 A Positive Margin

for example, or a certain category, would think similarly. All too commonly,
the club comes to reflect the outlook of the executives gathered around the
chairman or president or secretary. Secretaries have the means to bias the
minutes to reflect their personal agendas, and often progress in time to
formally head the organisation. Leaders attract people who think similarly and
dissidents tend to fade away and leave.

The first time I really became aware of people’s agendas, was after
graduation from medical school. Hospital jobs for interns meant that the
intern slotted in to a clearly defined position, which was expected, but interns
were subject, primarily, to the authority of whoever was the consultant
surgeon, physician or whatever. Some of these people were tyrants and
could make life hard for those they considered juniors, subservient, or of little
consequence, and merely there to do what they were told.

Many people today change their employment, and often it is because they are
not happy working with ‘difficult’ colleagues or bosses, rather than any
difficulties fitting in with the company or department agenda. The more you
think about it, the more you are alerted to the realities of coping with other
people’s often unstated, but frequently obvious, agendas.

Some years ago I was a PhD student in Physiology, following gaining my
Masters degree, in the same department. My supervisor had an agenda
which did not sit well with me. Briefly, he though my practice of seeking
advice and help from statisticians was inappropriate. He was very keen on
statistics and thought I should learn to be more proficient in this area. At the
end of my first year, my research was going very well, papers being presented
at scientific meetings and new evidence on the patho-physiology of
intravenous infusion failure led to the acceptance of a paper to be published in
the British Journal of Surgery. The Ph D committee was satisfied with my
progress. Then came the bombshell! It was recommended that I complete
formal studies in Statistics as part of my requirements for my Ph D. There
had been no interview, discussion with me, or hint that this course of action
was contemplated. Obviously my supervisor had engineered this! When I
told him that I had to enrol in Statistics, he said ‘and so you should’ with a big
smile. He had won!

I left school at the end of year nine. In mathematics, I got 52% in Maths 1,
being the average of 96% in Arithmetic and 8% in Algebra. My teacher was
quite unhappy that the rules were, that Arithmetic and Algebra marks had to
be added up, and that came to a mean 52% - a pass indeed in Maths I, when
he felt that a pass in each section should be required. To face statistics
whilst working full time as an Anaesthetist, required me to enrol in second
year Bio-statistics, which was an external course – with no lectures to attend –
only assignments, tutorials during vacations and, of course, exams. First of
all, I needed to read up a lot of algebra and remedial maths, so I would have
some idea of what it was all about. I resented having to spend a lot of time
,which I could have spent on my research, on all this unnecessary study, as I
saw it, but my supervisor was as pleased as punch. He was achieving his



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                                  Dr G B H Lewis
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agenda. My research progressed well and what with a busy medical practice
I had little time with my family, as I wrestled with statistics.

At the end of the year, I was able to report to my supervisor, that I had
completed my second year statistics with the highest marks in the course and
had written to the Ph D committee, informing them that I had topped the year
and was withdrawing from my Ph D studies. I hope they were all happy!

An agenda, once decided upon, can be all consuming. Another student in
first year medicine was a girl from Estonia, I think – or at least one of the
Baltic States, and I was attracted to her, and meant to ask her out, at the end
of the term. On the last day, she did not turn up to lectures, so I could not ask
her out. Not having a phone number or address, I asked one of her friends
where she lived. Her friend could not remember the street name, but
described what her house looked like, and told me that it was definitely in
Hornsby. I obtained a map of Hornsby and started looking for her house.
Over the next three days, I must have walked many miles, but late in the
afternoon on the third day, I found it! She was home with her mother and
rather surprised to see me. Agenda achieved!

So much of one’s life seems to involve doing things one would prefer not to
do, in order to enjoy positive outcomes, perhaps delayed for years, which it is
anticipated, will accrue. For most of my professional life, there has been little
option but to participate in a night and weekend roster for intensive care and
anaesthetic related emergencies. Once upon a time, this involved a roster of
every second night, every second weekend and up to two weeks continuously
on my own, when my partner was on holidays. Combine this with an animal
breeding program and related experimental septicaemia studies in mice, at
different environmental temperatures, with frequent trips to the University at
night, together with a busy daytime practice, and a family of growing sons,
and it was really more than I needed. Never, have I begrudged an hour spent
on research. Nights and weekends tied to the telephone are another matter.
When the phone rings, you start imagining all the possible road accident
disasters, emergency caesareans, poor risk bowel obstructions, diabetics,
geriatrics, asthmatics, and other emergencies possibly prompting the call, but
it is all part of the job.

 What I really love to do is research, whether on acupuncture, microbiology,
anaesthesia, pathology, pharmacology, physiology, or social sciences. When,
as a young man, I surveyed the possibilities for a research career with a good
income, independence and no lectures or practical classes to do, and a bare
minimum of administration – they were practically non-existent. Life has been
a compromise, but my career of provincial anaesthetist and pain medicine
specialist has been the best option for me, in medicine. Psychiatry was
another option that I considered, though I see a few psychiatric problems in
my pain practice, and do not feel that I would have enjoyed it as a full time
occupation, as much as what I am doing now. For the last three and a half
years, I have been able to negotiate to work no nights, no weekends. Today,
I do exactly what I wish, resulting in my QOL being professionally and
personally as good as can be. This is the culmination of steadfastly sticking


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to my agenda. Is an agenda a goal? – I think there is a subtle difference,
which I may argue, later!


04.12. .2004.
An eventful day! About 30 kilometres along the expressway, between Sydney
and Newcastle, on the F3 freeway, we have a puncture. We have with us our
grandchildren’s pet rabbit –Rosie- Peter. Named Rosie mistakenly – Peter is
definitely male. The hutch containing Peter is packed just above the spare
wheel and we have great fun accessing this wheel several times, as we later
have to purchase a new tyre at East Maitland and Peter is moved in and out
several times. At last we all arrive home safely. Driving is my idea of a
relaxing activity, unless in the city. At tis best, it resembles a roller coaster
ride, as one negotiates a series of bends on the limit, but today’s run is very
sedate, with our bunny on board, and on arrival, we carry him in his hutch,
inside the house and set him up in the gallery. Later he will experience
outside existence. Today is notable for our focus on Peter and scarcely a
thought is given to my healing prostate bed. There is no incontinence. As far
as my waterworks is concerned all is well and the long drive provokes no ill
effects, whatsoever.


05.12..2004.
A quiet Sunday. Time to reflect on my possible future QOL, particularly
important being contemplation of a scenario involving a reduction in my life
expectancy and physical capacities before then, if the worst happens. The
risk of this happening is perhaps 20%, but this is certainly not to be
considered lightly.

My first thoughts are, that if quantity of life is threatened, then an enhanced
QOL could be some compensation. The easiest approach, requiring little
alteration to one’s daily activities, is to optimise every routine moment. As I
see it, one simply divides a day into functional segments. In assessing my
patients at the Early Joint Clinic, who are to undergo total hip or total knee
replacement, I get them to complete an Occupational Questionnaire. Simply
put, they are asked to describe what they do for every half-hour from 5am
until 11.30pm, on a typical day. It is commonly found, that many hours are
spent lying in bed, having a cup of tea or coffee, showering, getting dressed
preparing meals and so on. How can once optimise this situation?

Start in the bathroom! Is the toilet paper one ply, two ply or three ply? Buy
what suits you best in your bathroom. Essentially, the same applies to the
rest of the bathroom. Do not put up with inferior soap! Once upon a time I
used electric razors, which used to invariably be reliable, though gradually
deteriorating, until there were no stocks of spare parts. Then they failed and
had to be replaced. Today, I use Schick’s three bladed disposable razors.
They work very well and last for weeks and weeks. Cheap disposable razors
do nothing for one’s QOL. They are never aesthetically pleasing and quickly
become dull. Cheap they are! Top quality disposables last a long time, and
give a good shave. They make you feel better, increasing your subjective well


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being. Italian shaving soap is relatively expensive. but I buy mine in Italy at
the local supermecato for much less, and one green container lasts for more
than six months. A lot of men just use ordinary soap – it is not as good –
don’t put up with it. Find the soap you like best, for bath or shower. Don’t be
mean and use the last few scraps in the bathroom, they may be useful in the
laundry. – you deserve better! Likewise with bath towels – big fluffy good
quality towels are incomparably better than smaller, thin little towels, which do
not make you feel good. Best of all, since the prostatectomy, I shower with
my wife. In the old days this was hardly practical, as one thing led to another
and after sex in the shower, one seemed to get to the hospital late and
perhaps too relaxed to concentrate on work – at present this is not a problem
and showering together is just great!



06.12. 2004.
A new week, and an agenda is crystallising. Now that I have seen all the new
Bang & Olufsen hi-fi and television set-ups, it is time to look at alternatives,
then finally decide on a replacement for our 1986 model NEC television and
VCR. After work, Elizabeth and I start our inspection of plasma, LCD and
other available televisions and get a few more ideas. If we are to be happy
with whatever we purchase in the long term, then we must satisfy ourselves
that we have considered available alternatives carefully. If we have second
thoughts later, then we can reassure ourselves, that with the available
information, we chose as well as we could. This principle has served me well
over the years, with other purchases. Buying on a whim is OK for small
disposable items possibly, but the time spent looking carefully for major items
is well spent – even if you end up buying what you first looked at. One is also
generally happy looking at all the alternatives, like examining a menu in a
restaurant, or trying out new cars.

Talking of cars, I am privileged to drive a range of Health Department cars,
pretty well exclusively Holden Commodores, Toyota Camrys, Mitsubishi
Magnas and Ford Falcons. For someone who really enjoys driving, this is a
real bonus. It is always a pleasure to be out of town, driving in the country, in
a late model vehicle, on a road that is practically free of police. One has to
watch out for stray cattle, beautiful little birds, wallabies and kangaroos, but I
know pretty well where to expect them. Mechanically, I would vote for the V6
Camry or the Falcon. The Camry is full of cheap plastic and is aesthetically
below par but if one opted for the Lexus equivalent, like a Chinese doctor
friend of mine, who has a back up Mercedes coupe, then leather is part of the
specifications. I could go on all day about the problematic gear ratios on the
Commodore and various other niggles but, what the heck, it is good fun on a
winding road trying out their cornering capacities, with no one else in sight.
As the ad says, Life’s Good!


07.12. 2004.
A busy day today! Twelve hours, 200kms driving and thirteen anaesthetics to
give, including an emergency. No time to reflect much, except whilst driving.


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                                   Dr G B H Lewis
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Now, things are looking pretty good for the future, possibly an 80% chance of
being biochemically and clinically free of cancer in five years time, give or take
10%. After that, still a chance of some secondaries popping up in ones bones
– a bad deal – or maybe somewhere like the brain, liver, lungs or less
frequent sites, or even a local recurrence.

Let me bite the bullet! Sometime down the track say, there has been a rise in
PSA, a course of radiotherapy, then the news that one is in the unlucky 20-
30%. What is on offer? How about a course of hormones, followed by tender
breasts, maybe contemplating a small bra! Let’s get down to the nitty gritty. I
remember my late neighbour, ending up with bony secondaries, weeping in
the night. A bit of local radiotherapy and various other measures may hold it
for a while. One might even have a coronary, a stroke or some other event
which will finish you off, before the cancer does. One of the guys from my
graduation year has prostate cancer with bony secondaries now – will he be
attending our 40 year graduation dinner next month? Let’s wait and see – but
don’t hold your breath.

Why am I cheering the reader with this information? I am listening to classical
music on a CD and sipping another glass of red, sitting up in the new room –
an addition to our home, which is eighteen years old! This may be the main
room where I spend my final months, if things go badly and I am past
travelling.

Elizabeth is as kind and caring a wife as anyone could possibly be blessed
with – so I expect I would have to be pretty far gone, for a transfer to palliative
care or some nursing home to be necessary – God forbid.

How are we equipped to deal with a palliative care situation here? There are
practically no steps in the house. There is a really comfortable leather recliner
chair, purchased when Elizabeth fractured her shoulder. There is a sunny
back terrace, just outside of the three sliding glass doors of this room, with a
large barbecue and plenty of flowers and fruit trees. My present focus on
purchasing a Bang & Olufsen TV and sound system with a motorised stand
that can turn the TV in any direction by remote control, is part of this long term
QOL plan, but maybe some other system will suffice. I shall need plenty of
DVDs and Jazz plus classical music to play, and some books, if the worst
happens.

Elizabeth is a superb cook and could tempt any invalid to the table. I had
homemade sushi before a dinner of fillet steak and salad, just now. That’s
everyday fare! How about wine! I have been an active member of NEWTS –
The New England Wine Tasting Society --for about twenty years or so. In
storage in Brisbane and here, in Armidale, are about 1000 bottles of some of
the best wine in the world – the best Australian reds, from Penfolds Grange
downwards, and the best of the European reds and others, Chateau Latour,
Chateau Mouton Rothschild, Chateau Y’Quem and other top chateaux. This
did not happen overnight – long term planning again. I prefer to think that



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                                 A Positive Margin

these wines will be consumed with family and friends celebrating a positive
long term outcome, but I remember the alternative scenario.

How about pain relief? A surgeon friend with a lot of experience in caring for
the terminally ill, once told me – a cancer patient for whom no more active
treatment is indicated, is to be ordered an appropriate dose of narcotic. If this
is insufficient, I simply double the dose, and keep on doing so, until the patient
no longer complains! A career in anaesthetics and pain medicine gives me
plenty of ideas, which I trust will not be needed.


08.12. 2004.
I was reading a paper ‘Development and Regulation of Subjective Well-Being’
by Alexander Grob (1997) and one of the findings reported, was that
“perceived personal control increases Subjective Well-Being (SWB) cross-
sectionally, but lowers SWB in the long run, if the level of perceived control
relates to an unrealistic over-estimation of one’s possibility.” In considering
our modern Western societies, the question was raised, as to whether the
striving for individual self realisation, defining and pursuing personal goals, is
leading to losses as well as gains, and if so, what are the psychological and
interpersonal benefits and costs of extreme self centredness?

These matters will keep many researchers occupied almost indefinitely, I
imagine. At an individual level, in our earliest years we will come to
experience many new occupational categories, and at some level appraise
them as positive or negative. Positive feed back is a powerful encouragement
and hopefully we are able to find where our talents lie, and develop our
interests, appropriately..

In my own case, if one considers sport, a national pre-occupation, I soon
found my limitations at competitive sport.           Running, cricket, football,
competitive swimming, in fact all the really esteemed sports at school,
seemed to require more talent than I was blessed with, for any modicum of
success. Football was compulsory, and my father expected that I would be a
star like he was, until he saw my lack of skill and talent. Golf was just another
way to quantify my ineptitude. The answer was years in the future! Walking
is good for you and only as arduous as you make it. It was only in 1989 that
Elizabeth and I took up down-hill skiing. In 1993, we earned our PADI licenses
for SCUBA in Antigua. Formerly, I liked shooting and fishing, but no longer
have any desire to kill so much as an ant. All enjoyment and no competition –
I can feel good about myself and enjoy excellent SWB, without competition.

When I was about six or seven, I became a reader! By the time I started high
school, I was reading a novel from the school library every day – instead of
running endlessly around the Oval or somesuch. Later, having started on the
William series, I then progressed through Biggles, Zane Gray, Shakespeare,
Jane Austen and whatever else the library had, then I became more
interested in Greek Tragedies. All this pretty well ceased, when I left school –
expert at burying myself in literature. Once I open a book – that is it – I hear
nothing around me – really! At some stage, there came the realisation that


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life could be filled with novels, fiction,-- escapism for me,-- which was likely to
lead me nowhere. When I’m too old for anything else, I shall bury myself in
books – possibly. A fruitful alternative, is to read studious texts, history,
geography, science, goal-oriented, even degree focused books, which if you
enrol in some courses, will get you places – and its enjoyable. When you get
to the borders of knowledge – even better – there is research. You may
discover something of value, it is fascinating, all absorbing, enriching ones
QOL. As far as SWB is concerned it can actually give you a thrill, comparable
with Love, very fast driving, skiing and personal and family achievements.

How does one avoid the pitfall of lowered SWB due to “unrealistic over-
estimation of one’s possibility,” whilst still claiming personal control? Personal
control is a bit of a two- edged sword. If you really believe you have total
personal control, then who is to blame, if you fall short of your goal? Other
societies frequently give little personal control, but have more limited
expectations. My favoured ploy, when starting to plan something that could
be unrealistic and involves an over-estimation of my capacity, or a systemic
problem, is to “idealise then compromise”. If money, time, alibility and other
factors pose no limits, then what would be ideal? Say – a flight to London, for
example. Ideally, a personal Boeing Business Jet, would be about right! Have
you a spare $US 16-20,000 per flying hour? I thought not! First class, on a
commercial jet? Still impossible! Business? A bit much! Welcome to
Economy! You still go, though, and make the journey. Many things can be
achieved with this ploy, which might look impossible. But not everything!
Sometimes you cannot compromise. Practically everyone I met, tried to put
me off doing Medicine – ‘Too long’! ‘Too difficult’! ‘Most people fail’. ‘Where
are you going to find the money’? My mother gave me her moral support but
was pretty silent on the subject of my likely success. Did all the doomsayers
put me off for a moment? - Not for a moment! In first year, at the beginning
of the year, a lecturer said to the crowd in the Wallace Theatre at Sydney
University “Look carefully to the left and then to the right – one of you three is
going to make it!” In second year in 1960, there were 720 students in
Medicine. Three hundred of us passed!

Okay then – what about the ‘idealise and compromise’ Ploy? Did I have a fall-
back position if I failed and simply could not continue? Well yes – and quite a
few students had thought about this. If I failed there was really no chance of
simply giving it a go, somewhere else, I had no resources to consider that, so
here there was no realistic compromise, on my definition. So I developed an
alternative plan, if disaster struck, in the examinations. My planned alternative
was to become a marine biologist, and work up on the Barrier Reef, if it came
to it. Still sounds like a pretty good way to live, and with plenty of SWB, my
QOL could have been near idyllic – there is that word again!


09.12. 2004.
This afternoon an old friend rang up to enquire about me. We were students
together, shared a room, played cards in the same group, and he was best
man at our wedding. Later on we were in General Practice together and he is
still working in the Hunter Valley, living, surrounded by grapes at Pokolbin.


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Eventually the subject of impotence came up and it is nearly two months from
the prostatectomy. He is going to give me a Christmas present. The drug
representatives are kinder to him than to me – at my Pain Clinic they never
give me any actual Viagra – yet I am presently writing this with a Viagra red
and white biro – given to me, at my clinic. Anyway, he has lots of different
samples and is going to bundle up these aids to erections, and send them to
me. I am looking forward to this opportunity, to see what eventuates.
However I try and rationalise it, sex means a heck of a lot to me and the
Vacuum Erection Device is a bit harsh and off putting. If all else fails I would
consider even an implant – lets hope it doesn’t come to that!


10.12. 2004.
Steven Rodie and Ellen Paparozzi wrote a paper on Backyard QOL:
Assessing Landscape Design as an Enhancement Factor, in 1997. They
commented that a wide variety of research has verified the importance of the
human connection to plants and nature. They found that many people have
emotion changed reactions to landscape scenes and of course, their more
positive feelings were associated with the better designed landscapes. As far
back as 1978, I realised the importance of a pleasant environment in our
Intensive Care and Coronary Unit where, unfortunately, some patients spend
their last hours or days. I introduced the use of radio/TV/tape players on bed
trolleys, where formerly there were bare walls, apart from frightening medical
paraphernalia. They were a great hit. People vote with their money when it
comes to paying for waterfront properties, or even a distant sea view.

In order to optimise our holidays in Antigua, I have developed the habit of
sitting comfortably on a banana chair or similar, on the terrace of our Villa, in
the shade of overhanging tropical flowers. Once so situated, with the
inevitable rum punch handy, I focus on the scene and really concentrate on
remembering it. Even now, I can visualise the various little black birds, those
smaller golden beaked ones, larger black birds and occasional more colourful
ones, flying about and diving down to dine on various crumbs which we offer
them, on the terrace. The details of the plants in the gardens between the
Villa and the beach, the sight of Cap’n Nash’s twenty-nine foot sloop, riding at
anchor, occasional jet-skis or other water craft, the blue of the sea – all are
stored in my home video memory. Of course, annual trips since 1993 do help
to embed the details in my mind and I can access this vision, or many like it,
at any moment. The same principle applies to memorising views of
Caribbean islands, as we fly over them, and all the beauties of nature we
experience in our favoured overseas and Victorian Alpine haunts. They
contribute mightily to our QOL! It is more the God made environment that we
yearn for on our journeys, than the pleasures of socialising and man made
vistas.


11.12. 2004.
The Christmas Party season is upon us and last night we attended a car-club
dinner and entertainment. We sat at a table with friends whom we have
known for twenty-five or thirty years. An observer would have thought that


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no-one had a care in the world and indeed we all, I assume, had an enjoyable
time. Do you suppose that these successful people have had easy or
uneventful lives – or if they have had serious problems, then they are all in the
past? Not so! One could write pages and pages on past and present family
woes – ongoing tragedies. None of which, of course, were mentioned at
dinner.     When we socialise on such occasions, how much do we
communicate? If you can believe what you read on the role of socialising,
particularly among those who have retired, then this activity must be very
important. Why then, is it that most of my knowledge of these friends lives
comes, often, from sources in the Medical world, or from Elizabeth, who hears
much, indirectly. Quite frankly, organisations such as Lions, Rotary and Golf
Clubs have no attraction for me. Rather would I chat to a fellow passenger on
a plane or take a history from a patient. I would learn more of interest. On
planes, I have been entertained for hours by such fellow passengers in
Economy, mind, as the Head of the Precious Metals Division of Mitsubishi,
which does things as diverse as manufacturing two billion dollars worth of
gold bullion annually, and develops silver that will not tarnish – he showed me
his untarnished silver watch. He told me much about life in Tokyo, his family
and his other interests, his loneliness, when away from his family. Another
man, an Australian, divides his time between his beach clothing
manufacturing business in Indonesia and his primary love, fashion
photography, among the models on the catwalks of Milan and Paris.
Elizabeth sat next to a man whose wife had died, and he was taking her
jewellery to her sisters in England, and taking them on a trip, subsequently.
He had no children.

In our busy lives, technology changes, including air travel, have created a
post modern world, that relies much less upon stable contexts and is more
connected to fragmented episodic interactions. Kevin Lyons, in 1998, wrote a
paper titled “A Sense of Community in Post Modern Life: Examining the Role
of Leisure”. His view is that “research that examines a sense of community
within a stable context, fails to capture the more transient components of this
experience”. In many leisure activities, including those involving air travel,
events occur of a discrete and episodic nature. Leisure activities are
frequently fleeting, yet provide an alternative context for community, more in
line with post modern life as we experience it. Lyon’s paper offers an
alternative ‘sense of community’ construct that takes the episodic nature of a
post modern sense of community into consideration. A sense of community is
no longer dependent on slow stable growth, but may be rapidly constructed
during our lives on the move. Traditionally, the sense of community is
perceived as developing automatically and is not an individual matter. Now, a
sense of community may develop through the conscious seeking out and
creating of experiences within one’s travel and leisure experiences. He
regards this as a quality of life (QOL) experience that needs to be taken into
consideration.

Millions of Australians travel. At any one time there are about 250,000 leisure
travellers and 750,000 Australians living and working overseas, who still call
Australia home. Their post modern lives are full of such experiences as I
have described, transient maybe, but an integral part of a life on the move. I,


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for one, feel a sense of belonging to a world community, many members of
whom are always on the move as, really, citizens of the world, not restricted to
any one geographical region. Why should my holiday home be in Coffs
Harbour, or indeed anywhere in Australia, when I can be in Tuscany or the
Caribbean just as easily, and meet so many fascinating people. When we are
overseas, I never miss Armidale, and many of my good friends here, I see but
infrequently. We are still close.


12. 12. 2004.
I have been speculating on the touchy subject of future expectations! Shall I
be pessimistic about the future and retire now? If I work for longer, then if I
have no cancer recurrence, or respond optimally to radiotherapy (if it does
occur), then I shall have more post-retirement income. We have a definite
tendency to focus on our anticipated future financial well-being. A paper “The
Differential Impact of Current Versus Anticipated Future Financial Well Being
on Subjective Well-Being” was written by Ploter et al (1998). Ask someone
about his/her current financial well being, as it affects SWB, and he/she will
typically rank it as less important than her/his family, job and leisure. When
speculating on the future, however, personal financial well being ranks higher
as an important determinant of future well being, than all other life domains.

I am happy enough, doing what I am doing at present, and optimistic enough
about my chances of survival for at least a good five years yet, to continue
living as I am, and still do not plan to retire before May, 2006. But who knows
the future?


13. 12.2004.
A QOL study asked individuals what they would do if they had less time. Ann
Damerbeck et al (2000) found that, given less time, many people would not
cut anything out. They felt that they would just have to be more efficient with
how they used their available time. The researchers feared that with equal
demands on less time, individuals would feel more stress and experience less
satisfaction. I agree with them. If one has a delayed start in the morning,
there is much stress, if one aims to catch up and finish on time, and far less
satisfaction, besides any diminution in the quality of the work done.

Rushed travel, planning to see nine countries of Europe in one week, rushed
writing of Christmas cards to friends – it doesn’t matter, trying to squeeze too
much into limited time is not a great idea. Time spent ‘smelling the flowers’ is
not wasted. Many activities which may have been valued in the past, can
often be abandoned quite happily, if time and energy, with increasing disability
so dictate.


14.12 2004.
Today, I drove to the Transport Museum and took first my Armstrong-Siddeley
Limousine, then my Jensen Interceptor, out to get their annual inspections for
motor registration. All the people I dealt with were most helpful. The auto-


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service proprietor drove the Jensen (and I) to a spare parts/braking system
specialist where we obtained a new brake master cylinder kit for this rare car
and I shall take the car from the Museum to his workshop, next Monday, and
he will fit it. Try that in the city!

For years past, I have contemplated what on earth I am really going to do with
my Limousine – ex. Harold Holt and used by Queen Elizabeth on a Royal
Tour. If I live long enough, I aim to employ a part-time chauffeur, to ferry us
around, when I am too far gone to drive! I wonder if that will really eventuate?

Arriving home from the 130km drive, I find Elizabeth in tears. One of her best
school friends has been killed by an old lady on the wrong side of the road, in
Brisbane. The funeral is to be at 11am on Friday, when we shall be in
Brisbane anyway, on business!


15.12. 2004.
At lunchtime today, after my Pain Clinic, in the mail was the expected small
parcel from my friend. He had written some explanatory notes as well.
“Enclosed Experimental Material”
1. Viagra – light up like James – snort triumphantly like the British Bulldog –
    Moneypenny knows you are coming!
2. Cialis – 36 hours of Proactive Honeymoon activities – watch out for your
    lower back!
3. Levitra – As good as it gets – As hard as it gets – But short-lived Paradiso
    – only 4 hours.

One might suspect that he has road-tested them himself. The Viagra 50mg
and Cialis 10mg are not the highest dosage pills available (100mg and 20mg
respectively) but the one sample of Levitra is not 5mg or 10mg, but 20mg. If
the others fail then this top strength pill promises more. I hope he is right.
Tomorrow we are leaving for Brisbane, and will stay at a good hotel for a
couple of nights. An excellent opportunity to try out one or more of these
Christmas gifts!


16.12 2004.
Today, we packed the Audi for our weekend in Brisbane and headed north. A
long country drive is one of life’s pleasures, and we were in no hurry. We
bought the latest comprehensive map of Brisbane, and had no difficulty
finding the Windsor International Motel along Lutwyche Road, in the late
afternoon. Elizabeth had been told recently, by a man, that he only ever
booked in for one night at a hotel, as his wife was bound to find problems and
wish to move. The room allocated to us was facing the main road, with all its
noise, did not have any balcony that we could access, and was not very big.
Bearing in mind what the man had said, she asked for another, quieter room.
Soon we were in a much larger, quieter room, with a balcony we could use,
with a part kitchen equipped with a little stove and a microwave. This was
soon put to good use, for we saw from the restaurant menu, that a meal
could easily cost one hundred dollars per person, if one was not careful.


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As last, I had the opportunity to try out a Cialis tablet. It was meant to start
working after 16 to 30 minutes and last up to 36 hours. Well, disappointingly,
apart from a bit more turgidity than before, my semi-erection was still Mr
Floppy! I shall just have to wait and let nature take its course, for I think, that
probably, things are gradually improving. Again, I had my back-up plan and
used the vacuum device. As before, all the preparations made our efforts
mechanical rather than romantic. The erection was actually quite effective
initially, with a slightly tighter ring, but the circulation is, of course, pretty well
cut off, with the ring in use. This means that the glans became perceptibly
colder, and sensation consequently was inadequate. Penetration was deep
enough in the several positions we tried, but there was no hope of a climax,
for either of us. Never mind; apart from that, we are having a great time
together, as we always do, especially when we travel. Our son Stephen,
called in after work, and left very late – we all had an enjoyable evening
together and plan to use the swimming pool later.


17.12. 2004.
By 7.20 am, we are at Audi of Brisbane, checking the A6 in, for its routine
annual service, there being no dealer at all handy to Armidale. We are driven
back to the motel, then by 9 am arrive by taxi at the office of M.A.P, a super-
annuation fund for doctors, in which we have a small stake. Having been
given so much poor professional advice by so-called experts in the past, we
trust no one. Many, many thousands of Australians have their own DIY (do it
yourself) Super Funds, and this morning we are responding to an offer by
MAP for us to invest in their Australian Equities Fund, which is projected to
earn possibly nine percent, invested in about 100 Australian listed companies.
Our adviser there tells us all about it, and we write out a cheque. This is one
of a number of managed investments we have, as well as a portfolio of
individual shares chosen by ourselves, with the help of a Macquarie broker.
Too many eggs in one basket, is not a good idea. In terms of QOL, we enjoy
managing our own financial future, very much. One always feels a little sad if
shares are sold too early or head in the wrong direction, but keep a close eye
on them. At least we only have ourselves to blame if things don’t work out,
and learn from our experiences.

Too many husbands keep their wives in the dark, and ignorant of financial
details. It is very likely that I shall die years before Elizabeth. She does all
the accounts, banking, BAS statements, deals with the accountants generally,
and knows how to run our routine finances. Already we have divided our
superannuation holdings and know what assets we shall each have
individually. The holiday home in Italy is mine, and she is to have one of
those in Victoria. I have transferred the Audi A6 to her. A good QOL in
retirement for us, demands a lot of planning. I know all the details of our 2005
holidays, our itinerary is planned, and we return in October – God willing and
unless I need radiotherapy then!

The Audi people are as good as their word, and we collect the A6 in time to
drive north to Albany Park, where Elizabeth’s school friend’s funeral is held at


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11 a.m. Jenny had lived in Brisbane for several years and with many social
contacts, most of the mourners were locals. Her school friends had flown up
from Sydney. It has been quite a few years since I have seen some of these
‘girls’, and of course, they are grandmothers, and some hardly recognisable.
They would certainly not look out of place in a retirement village, and if I am
honest about it, neither would I. This growing old business is a most
unfortunate reality. My eyes are not as good as they were, though I passed
my driver’s eye test this week OK. My hearing is not the best, but since an
ear problem in childhood, this has been part of life and I don’t think I need a
hearing aid.(WHAT? WHAT?) On the good side, I awaken early, can work all
day and go to bed at midnight, walk for miles and am looking forward to
practicing my SCUBA diving skills over Christmas, in the Hume Weir.




18.12. 2004.
Last night, we had a sort of early Christmas with our son Stephen, in our
motel room. He gave me some very thoughtful gifts, beautifully wrapped as
always. I shall try out the CDs in the Mercedes, if not on the way home.

This morning, I am soon down to the pool and do thirty-two laps, which is
unusual for me. I am not a great swimmer. Young Garry and his whole family
swim daily. Even Alexander, aged nine, can do 100 laps. I remember Garry
throwing little Sophie, as a toddler, into a Navy swimming pool, and she just
came up laughing and swam to the side of the pool. Elizabeth used to teach
swimming and is a better swimmer by far, than I.

After leaving the motel, we meet friends at a restaurant and Stephen joins us.
Bruce is a ship’s engineer and very keen on sound engineering, too, so we
discuss Hi-fi systems. We arrive home after another pleasant 450 km. drive,
at 9pm, and I watch a French film. It has been a worthwhile trip and it is time
for bed.


19.12. 2004.
This morning after Church, I came across a paper by Lee L Keener, Jr titled
‘The Impact of Critical Thinking on Quality of Life’ which has some relevance
to my decision not to elect to have radiotherapy, unless my PSA starts to rise
– but then not to delay! Keener (2000) defines ‘critical thinking’ as ‘an
approach to problem solving and analysis characterised by the collection of
relevant and reliable data, logical and unbiased consideration of alternative
hypotheses that explain the data, and actions based on the most plausible of
these hypotheses! Whether individual, institutional or government activity, he
claims that its presence or absence can have profound consequences on
QOL. I recall an old educational slogan ‘Knowledge is Power’! For some
reason or reasons many people, faced with life threatening illnesses, avoid
critical thinking, yet their chances of survival may be jeopardised by their
inertia, to put it kindly. In recent years there has been a great increase in
patient desire for information.


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Today there are many sources of information. If you are at all computer
literate, the Internet is a fruitful source of information, but beware, not all
information has the same value and this is a rapidly changing world.
Professional medical organisations may be helpful and of course a second
medical opinion is a common option taken by patients, in their search for
knowledge.

Schiffman and Sherman (2000) claim that the Internet has the potential to
provide us with substantial opportunities as instanced above. However, it is
easy to access information on topics other than health.             Recreation,
entertainment and a wide range of products and services can heighten
satisfaction and provide a higher QOL. We accessed information on
accommodation in Pisa that resulted in us staying at a hotel in the same street
as the Leaning Tower, for 60 Euros (about $100), with a large room, marble
bathroom, hand painted ceiling (it was part of an old Palazzo), and a
comfortable large bed! Wow!


20.12. 2004.
People have asked me, since my cancer surgery, if I intend to retire earlier
than I had formerly planned. This is a very relevant question and may be
difficult to answer. Obviously one is influenced by the prognosis given, which
can only give an overall guide. For the individual person, who can know?
Time is running out for all of u, and common wisdom is that QOL is going to
be better in retirement, if you have more money. Higher levels of income are
associated with higher levels of well being through consumption, is often
claimed. It sounds as if it could be true, but, I think, critically, it is an
economist’s way of looking at it. Fuentes and Rojas (2000), in a study in
Mexico explored the question of how important income is, to an individual. .
They wondered about the relationship between subjective well-being and
economic well-being. In two Mexican cities, they surveyed the impact of
demographic, social and economic variables, on subjective well-being. In
brief, they found that income does not have a strong influence on well being
or the probability of being happy.

 Certainly, it seems that people overemphasise the predicted impact of
additional income on their happiness. People are very keen therefore, to
increase their income, yet once the higher income level is achieved they
remain relatively unsatisfied. More interesting is the finding that subjective
well being or happiness is positively related to the sense of basic need
satisfaction, but not to income. As a long term retirement planner, one tries to
ensure that basic need satisfaction is likely. Where is one going to live, and if
health deterioration dictates a further move, then, to where? These sorts of
questions should be faced, before someone else has to make the decision!
Many other decisions must be made, but trying to work for longer, once there
is every chance that genuine needs will be satisfied, may not be the best
course. None of my retired friends are less happy, despite less income.




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21.12. 2004.
In the back of my mind, I have been concerned by a few unresolved issues
concerning my decision to opt out of having early radiotherapy, which would
have started next month. A visiting oncologist was working, seeing cancer
patients, in the office next to mine, yesterday, so I decided to seek yet another
opinion, to try and clarify a few points of concern.

It has been reported that some patients may suffer a recurrence of their
cancer which is ‘PSA silent’! Thoughts of the cancer silently progressing,
whilst I diligently have my PSA levels analysed, and reported as continuing to
be zero, occurred. Doctor B was very reassuring and told me that my history
has shown a gradually rising PSA before radical prostatectomy, so there is no
good reason for the tumour to alter its behaviour. Yes, it is possible to have a
‘PSA silent’ recurrence, but he considered it a remote possibility, which should
not cause me to change my decision.

Secondly, the general advice to have PSA levels monitored every three
months, seemed to me fairly laid- back advice, and rather arbitrarily
infrequent, though time and again people are told ‘prostate cancer grows
slowly!’ My decision has been, to call in at our pathology department twice as
frequently and, hopefully, learn significantly earlier, if my PSA in on the rise.
One of the reasons men are urged to have early radiotherapy in my situation,
is that some patients tend to forget, or to ignore the instructions to have three
monthly PSA tests, and present with evidence of cancer recurrence, too late
for radiotherapy to have the best chance of effecting a cure! Again, Doctor B
agreed with me, one cannot be too careful, and PSA tests every six weeks or
so could well provide an earlier indication of trouble. Our laboratory bulk-bills,
so I am not out of pocket, for the tests.

Thirdly, I had read research reports that suggest that, prior to radiotherapy,
better ‘cure’ rates could be obtained if adjuvant hormone treatment is
commenced, say two months prior to radiotherapy, with ani-androgen drugs,
and continued for a further four months, rather than having radiotherapy
alone. Doctor B agreed that this is a controversial area, and is of the opinion
that it is certainly worth considering, if a patient has a ‘bulky’ tumour, to
reduce tumour mass, prior to radiotherapy. On the other hand, it is known
that some patients never recover from the effects of these anti-androgen
drugs, and suffer from a lack of androgens. forever after. The thought of
feminising effects, tender enlarged breasts and osteoporosis, flashed across
my mind! He hastened to reassure me, that on my history, and with careful
PSA monitoring, he felt that if I were to need radiotherapy, then there should
be no reason to start a course of hormone therapy. I was relieved by all this
news, and his final comment, that he believed that there was a very good
chance that I would never need radiotherapy.

As a natural worrier, I am relieved by this confirmation that watching and
waiting very carefully, is the best option and again, the one this oncologist
would choose if he were me. We know that there are no absolutes in life, and
there are controversial issues in prostate cancer treatment, but one can only



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try and find out all one can. Then one may make the best- informed decision,
in the light of current knowledge.


22.12. 2004.
Yesterday, after a morning in the operating theatre, I saw fourteen patients at
a pre-anaesthetic clinic in another town. One lady had a family history of
bowel cancer and was booked in to have a colonoscopy, to check that she
was healthy. She mentioned that her husband had been seeing his general
practitioner as he has a rising PSA. This had been checked several times in
the last few years and last time the reading was 6 ng/mL, significantly in
excess of the normal maximum of 4.5 ng/mL for this laboratory. The other
day he had yet another PSA blood test ordered and is awaiting the result. He
has been told it is rising slowly and has not had any biopsies done yet. He is
forty-seven years old. My PSA was 6 ng/mL in January, and 7.28 ng/mL in
July, and my cancer had already perforated the prostatic capsule, when I had
surgery, less than three months later. What is his doctor waiting for?


23.12. 2004.
Today we are to travel by train from Armidale via Sydney to Albury, arriving at
about 4 a.m., to be met by our son Andrew. We are to stay with him in Mount
Beauty for Christmas and New Year.

The day starts with our morning vitamins and my anti-hypertensive agents
Karvezide® 150/12.5mg, Noten® 50mg and Felodur® 2.5mg. I treat my own
hypertension, with occasional informal advice, keeping my blood pressure
level as low as possible, yet still being able to function. This means feeling a
little faint at times, if I get up quickly after lying down, or on a hot day! This
way, according to an American text, written by the Director of Critical Care at
a major Chicago hospital, statistically, one lives longer. He also, having
reviewed the literature comprehensively in relation to measures one might
take to prolong useful life, recommends various vitamins. Vitamins C, E and
Multi-B, are the prime ones. In addition, we take a small dose of Aspirin, to
reduce the chance of heart attacks and stokes, together with fish oil EPA
capsules.

Regular exercise, avoidance of saturated fats, in favour of cooking with extra-
virgin olive oil, and calcium tablets for Elizabeth, but not for me, are part of our
routine.

Lycopene is found in tomatoes and especially in cooked tomato products.
One can hope to obtain useful levels of this chemical, which is alleged to
prevent and/or help with prostate cancer. Every day, I try and drink tomato
juice and eat tomatoes in various dishes. Is this just another unproven
measure? Possibly not, for recently, researchers gave regular Lycopene and
Vitamin E to mice who had grafted prostate cancer – poor things! It was
found that those mice given Lycopene and Vitamin E, had a reduction in the
growth of the cancer by 74%, compared with the controls. There are studies
planned to explore the effects of Lycopene more thoroughly in men – but why


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should I wait? It is known that Australians have one of the highest chances of
dying from prostate cancer, 19 deaths per 100,000. Only the Scandinavians
beat this, with a figure of 20.5. At the other end of the spectrum, are the
Koreans 5.0 and Japanese 5.1. Men from Mediterranean countries, including
Israel, suffer 8.2 deaths per 100,000. The Mediterranean diet is high in
tomatoes! The Koreans have the lowest amount of meat, high soy and high
cruciferous vegetable intake. Cruciferous vegetables include cabbage,
mustard, broccoli, cauliflower, bok choy, cress, radish, turnip, horseradish and
brussel sprouts, plus a few others, amongst over three thousand cruciferous
plants. We eat our share of cabbage and broccoli, mainly. These vegetables
contain, among some other possibly valuable compounds, a number of
sulphur – containing antioxidants, the thiocyanates.

Anyway these death rates quoted are from the WHO Mortality Database , and
there sure are some big, big differences in mortality in different countries. Diet
cannot be discounted as a factor, in my opinion.

When one looks down the list of possible dietary related causes for the
differences in mortality, one sees that the countries with the highest prostate
cancer mortality rates are those where a high meat and animal fat intake are
common. James Scala, who wrote a book, ‘20 Natural Ways to reduce the
risk of prostate cancer,’ in 2001, claims that a study showed red meat
consumption of five portions a week versus once monthly, shows over 350%
increase in cancer risk. Whatever the actual figures, I have decided to curb
my consumption of red meat, continue to eat quite a bit of fish and chicken
and have more vegetarian meals. Elizabeth is a superb cook and we already
have a lot of salads. We are still looking forward to having roast venison with
Andrew at Christmas, after a friend of his shot a Samba deer, the other day
and he has much venison in his freezer!


24.12. 2004.
It has seemed to be a long day, today. After the train arrived late, at 5 a.m. in
Albury, we all lay down on the riverbank outside the town, then had a long
walk, before running around shopping in town, until lunchtime. Andrew
bought some more timber, which we shall use in the wall construction down
stairs, in his house. Andrew and I planned some of the jobs that we hope to
get done tomorrow.

I must say Elizabeth, Andrew and I had a most enjoyable day, and my QOL is
‘as good as can be’ and so is my happiness. I don’t even think about my
prostatectomy, in my daily activities, and have developed a very positive
attitude. This does not mean that I am ignoring any measure which offers the
slightest chance of a cure, or reduced chance of an early recurrence. In
Albury I purchased many tomato products, soup, fresh tomatoes, diced
tomatoes and a huge jar of sun dried tomatoes, to put in salads. We enjoyed
tomato soup at lunch.




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25.12. 2004.
Christmas in Mount Beauty and the weather is perfect. None of us have given
each other any gifts so far, nor do we feel the need, somehow. Yesterday, I
bought Andrew some needed timber to build the frame of a wall downstairs
which I shall help him with – but that’s about it. I am wrong – Elizabeth
reminds me that she had bought me a book on prostate cancer, and a new
towel!

Life is somehow easier to understand, if you have a theoretical model of how
and why life is, as it is. When you have a problem, then you may be able to
analyse and hopefully understand it better, with your model. For some time, I
have been meaning to write about the model which appears appropriate to
me, and how valuable it may be. As I am now on holidays, it is time I started.
Occupation appears to be central to our perception of QOL, so I turned to the
field of occupational therapy, in my search for guidance in this area of
concern. You may not wish to read the following summary. If you are really
interested, then you can easily purchase a text, which will explain the ‘model’,
in far greater detail. For those who wish to skip this summary, you will not
miss anything specific to prostate cancer.

Professor Gary Kielhofner is head of the Department of Occupational Therapy
at the University of Illinios at Chicago. The second edition of his textbook ‘A
Model of Human Occupation: Theory and Application’ was published in 1995.
Now, scholars and clinicians the world over, contribute to its further
development. The model is intimately concerned with the motivations for
occupation, occupational behaviour, patterning into lifestyles and routines,
skilled performance, and how the environment influences occupational
behaviour. It is intended for people of all ages, and may be used for anyone
with an occupational dysfunction.

The simplest way to define occupation is to think of ‘anything that one does
when awake!’ My son is occupied on the telephone. I am occupied writing.
The following arguments about human’s occupational behaviours are made
by the model and these are quoted from page 188 of the second edition of
Kielhofner’s text ‘Conceptual Foundations of Occupational Therapy (1997):’-
(a) The human being is a complex organisation of three subsystems (volition,
    habituation, and mind – brain – body performance).They motivate,
    organise and make possible performance of occupation.
(b) Occupational behaviour emerges from interaction of the human systems
    with the environment. Further, occupational behaviour shapes the
    subsequent organisation of the human system.
(c) The volition subsystem arises from a need for action, and is composed of
    personal causations (beliefs and feelings about one’s capacity and
    control), values and interests. This sub-system anticipates, chooses,
    experiences and interprets occupational behaviour.
(d) Occupational behaviour demonstrates a pattern that is influenced by one’s
    habituation subsystem. This subsystem is composted of habits and
    internalised roles.




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(e) Occupational performance is composed of motor, process and
    communication/interaction skills that emerge from the interaction of one’s
    mind-brain-body performance subsystem—with the environment.
(f) The social environment (including occupational forms and social groups)
    and the physical environment (including objects and spaces) provide both
    opportunities and constraints that shape occupational behaviour.

Originally based on concepts of general and open systems theory, the model
now incorporates dynamical systems concepts. Other concepts come from
many sources, such as ego psychology (in regard to human needs and
motives), sociology, social psychology, philosophy, early occupational therapy
literature, environmental psychology and anthropology.

Tomorrow, I shall continue to explain this model. We have been out walking
around the golf course, getting quite close to dozens of kangaroos, then
strolling the quiet streets into the night, viewing all the houses with Christmas
decorations, some of them quite spectacular.


26.12. 2004.
Another beautiful day, Andrew and I inspected the new rock garden plants we
put in yesterday after digging, weeding, rolling out and securing weed matting,
and fertilising the garden. A layer of straw over the surface, a good watering,
and it looks pretty good.

This morning, lying in bed, Elizabeth and I further crystallised our thoughts on
retirement living. Provisionally, we are to conduct an experiment. In sixteen
months we could rent our home in Armidale, travel overseas as planned, until
the beginning of October, then base ourselves for the whole summer and
autumn up here, in the Victorian Alps. Living in this region is really enjoyable
and I view the upper Kiewa valley with the mountains each side, every time I
glance up across the front sundeck. Down below, Andrew is building the
apartment at ground level, incorporating my ideas to make it wheelchair
accessible, with all the facilities of a disabled unit, with large shower and toilet,
and no steps. One can drive up to the very door and there is the new rock
garden outside the kitchen window. Of course we trust that neither Elizabeth
nor I will need to use a wheelchair, however there is no harm in planning to be
close to your youngest son, in a beautiful, clean, secure environment. The
house and cars are quite safe here, without being locked up, and there are
excellent community services in town. Whilst we are fit and energetic, we can
always stay up at Bogong Alpine Village, enjoying lake and mountain walks
and boating too, if we desire – it is only fifteen kilometres up the road and
another fifteen to Falls Creek Ski resort.

Let us now continue from where we left off in our consideration of The Model
of Human Occupation. I shall start logically, with a consideration of the global
situation, then work our way through the subsystems, occupational behaviour
and the environment.




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According to the Model of Human Occupation, our occupational behaviour
relies on three subsystems, in an environmental setting. In the model, a
second theme is that the occupational behaviour, or action of the human
system is a central force in health, well being, development and change
(Kielhofner p55 1995). We humans are dynamic, self organising systems,
always changing over time. As a result of our ongoing occupational
behaviour, we undergo progressive changes. In other words, as we work,
play and engage in daily living tasks, we maintain and/or change our own
capacities, beliefs and dispositions. How true! Initially after I left St Vincents
Hospital, I was just as keen as ever to engage in foreplay with my wife and
optimistically counted the days until my erectile capacity returned to normal.
We still cuddle and have kept to our new habit of showering together, but
there’s no point in taking your golf clubs to the course at midnight – you are
just not going to be able to complete one hole (- I shouldn’t have said that).
So yes, The Model has forecasted correctly – less foreplay, less confidence
and lowered libido.

The Volitional Subsystem asserts that we acquire individual disposition
towards acting in the world. As we act, if our recent actions are successful,
we gain an increasing sense of our own effectiveness, an awareness of
potentials for enjoyment and satisfaction, and a view of life that commits us to
behave in certain ways. Volition is the term given to these dispositions and
images. It is so important, that it is worth spending some time explaining
volition more fully. For now though, it is time to go to church and have our
evening walk around the golf course.


27.12. .2004.
Kielhofner (1995) defines volition as a ‘system of dispositions and self
knowledge that predisposes and enables persons to anticipate, choose,
experience and interpret occupational behaviour.’ Dispositions refer to
cognitive and emotive orientations towards occupations, such as enjoying,
valuing, and feeling competent to perform them. Self-knowledge refers to
one’s commonsense awareness of acting in the world. It is a store of
knowledge about what one experiences and accomplishes when performing
an occupation.

The following further information is found in pages 190 onwards, of the
Second Edition of Kielhofner’s (1997) book-- Conceptual Foundations of
Occupational Therapy.

Volitional dispositions and self-knowledge comprise three areas: personal
causation, values and interests. These pertain to what one holds as
important, how effective one is, in acting on the world, and what one finds
enjoyable and satisfying. Personal causations, values, and interest are
interrelated and together constitute the content of our feelings, thoughts, and
decisions about engaging in occupations. The personal causation, values
and interests that make up one’s volition, enable one and bid one to
anticipate, choose and interpret occupational behaviours.



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Personal Causation is the composite of a Knowledge of Capacity and a Sense
of Efficacy, as one learns from experience what one can and cannot do well
and as a result, one is confident or conversely, insecure, about one’s physical,
intellectual or interpersonal abilities and awareness of and attitude toward
one’s present and potential abilities. This is one’s Knowledge of Capacity.
Secondly, with experience is revealed to one how effectively capacities are
used. ‘The resulting sense of efficacy includes the perception of whether and
how one controls one’s own behaviours (and underlying thoughts and
emotions), as well as the sense of one’s effectiveness in achieving desired
outcomes of behaviours’ (Kielhofner 1997)

We define what is worth doing, what goals and aspirations deserve our
commitment and how we ought to perform them, as our values. This is the
sense that guides the kind of life individuals aim to achieve in their culture.
People have strong feelings concerning how life should be and what
behaviour is appropriate. If one behaves otherwise, then one’s internalised
values are breached and the action is commonly followed by feelings of guilt,
shame, failure and adequacy.

Kielhofner defines values as ‘a coherent set of convictions that assign
significance or standards to occupations, creating a strong disposition to
perform accordingly,’ ‘The concept of Personal Convictions’ (Kielhofner 1997).
Is important, for they are what matter in life. We see ourselves in a world
situation in which we make sense of things and behave in ways which have
worth. Our way of seeing life, together with our strong emotions relating to
how we act in the world result in strong emotional dispositions called
commitments, to do the right thing. When we do the right thing we may feel
important, worthy, secure, purposive and that we belong. It is likely that we
are greatly influenced in our life situations, values and commitments by our
parents and more widely, our culture.

When we engage in occupational behaviour that provides us with pleasure
and satisfaction, we become interested in that occupation. This is the result
both of what we have acquired and natural dispositions. We anticipate that if
we further engage in this activity, we shall experience more pleasure.
Interests, therefore are felt as desires for such occupations, whether they be
intellectual or physical. Kielkofner 1995 defines interests as ‘dispositions to
find pleasure and satisfaction in occupations, and the self knowledge of our
enjoyment of occupation.’ The dispositions to enjoy certain occupations or
certain aspects of performance is referred to as Attraction (Keilhofner 1997).
There are all sorts of attractions related to an occupation, such as it’s
challenges, products, the interaction with others, such as in a team activity, or
its aesthetics. One soon learns that some activities are boring and others
fascinating. One develops Preferences which are ‘the knowledge that one
enjoys particular ways of performing or particular activities over the others’
(Kielhofner 1997).

With time and experiences we learn about our world, through our knowledge
of capacity, sense of efficacy, personal convictions, and interests. Past
experiences of a variety of occupations allow us to better judge the prospects


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of future choices being attractive. There is an ongoing cycle, a process of
choosing, experiencing and interpreting our occupational behaviours and this
sustains and transforms our volition. One’s occupational behaviour then is
both the motive for, and product of, personal causation, values and interests.

Kielhofner (1997) defines activity choices ‘as short-term, deliberate decisions
to enter and exit occupational activities.’ We fill our days with the occupational
activities we have chosen. Watering the garden, changing the oil filter in the
car, making a wooden ladder – all are activity choices. Of course we also
make longer term occupational choices, as when we enter a new role, as on
entering university, getting married, becoming a parent. In between, are fairly
long-term choices which involve intermediate levels of commitment – taking
up hockey, building a house or travelling around Australia. Occupational
choices are defined by Kielhofner (1997) as ’deliberate commitments to enter
an occupational role, acquire a new habit, or undertake a personal project.’

Do you see yourself in your mind as the principal actor in an ongoing play,
which opens at your birth? Are you the one who not only experiences the ups
and downs of the actor in the play but actually anticipates, chooses and
interprets all that you do, in this play of life? Are you also filming and editing
this play into an integrated production of your personal life story? Well if you
said yes – then join the club! Helfrich and Kielhofner (1994) called such
productions Volitional Narratives, incorporating volitional thoughts, feelings,
choices, present circumstances, past memories and possible future events.

  People have a tendency to integrate their past, present and possible future
into a story, in which they are the central character. These authors say that
these volitional narratives ‘embed the issues, concerns, hopes, and fears
related to personal causation, values and interests in the events and
circumstance of ones’ life.’ ‘They may energise’ or paralyse one’s volitional
choices. We tend to make sense of our lives through these conditional
narratives. It is up to us, how we construct them. Personally, perhaps
because I have studied painting, I tend to see life beginning with a new
canvas upon which the individual brushes on paint over time. Earlier efforts
may be painted over, but still remain underneath. The painting may be
touched up, altered, planned, more or less meaningful, and is some sort of
representation of the individuals past, present and perhaps visual hopes for
the future. Some of us live from day to day and others are amazing planners.
A fellow university student once told me ’I am going to finish my degree this
year, find a girl and marry next year, commence my career at X, ----‘ and he
actually did! This, perhaps represents, as Kielhofner (1995) observes – the
truth that ‘people strive to continue the story in ways that they believe are
important, that bring satisfaction, and that they can achieve.’ We not only tell
ourselves and others where we are and where we are going, but we really try
to live out our volitional narratives.

Since I have been diagnosed and treated for prostate cancer, I have not
altered my plans for the future, except to fine tune any plans, with the aim of
absolutely optimising my QOL – no frantic extra activities, no more or less
work (which is so enjoyable that it represents a positive aspect of life) – only a


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desire to educate other men, floundering in a sea of uncertainty, concerning
treatment options, outdated information and half-truths, as I was, so short a
time ago, when my cancer was first suspected.

Now we have covered – in our consideration of The Model of Human
Occupation – volition and roles, we are ready to consider disorder, in my case
impotence, as it relates to volition and roles! Let us continue with that,
tomorrow.


28.12. 2004.
Disorder, in The Model of Human Occupation, may result from problems with
volition, roles, habits and restrictions in motor, process, and
communications/interaction skills. As yet, we have not covered the sections
on habits and beyond, so we shall restrict ourselves to volition and role
problems, as causes contributing to disorders. (I am beginning to see myself
as a University professor again, harking back to my period of teaching
pharmacology and anaesthesia to Medical students and post-graduates—a
long time ago).

Volition can lead to occupational dysfunction and maladaptive activity under a
number of circumstances.        Firstly, when a person feels inadequate.
Secondly, when deviant, internally conflicting values are held, and thirdly
when a person lacks attraction to or pursuit of interest in occupations.

Furthermore, volition may be affected or restricted by limitations of capacity,
for example, in the following circumstances:-
a. When one faces painful knowledge of restricted or lost capacity.
b. When one has difficulty assessing capacities in the face or progressive
    disease or changing environments.
c. When one falls short of social values.
d. When one cannot perform in ways that are personally important.
e. When one has to relinquish values or meaningful activities.
f. When one has limited experiences to develop attractions and feel pleasure
    in occupations.
g. When one needs to rechannel or discover new interests to replace old
    ones.

.

Kielhofner’s (1997) words on role disorder analysis point out that roles may
be disrupted, as a consequence of psychosocial dysfunction and may cause
psychosocial dysfunction. Roles may be disrupted or terminated by acquired
physical impairment or may be unavailable to, or restricted for persons with
disabilities.

The next section of the Model of Human Occupation, is concerned with the
Habituation Subsystem, but I have written enough for now. We are going to
practice our SCUBA diving skills at Albury tomorrow with Andrew, to get us up



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to the mark, before we go diving every day, down in the Lesser Antilles of the
Caribbean, on the catamaran, next year.

29.12.2005
Today, it was quite cool and overcast in Mount Beauty. By the time we
collected all our dive gear and arrived at the dive pool in North Albury, which
we decided was a better idea than practising in the Hume Weir with dubious
visibility, the weather was much warmer and clearer. Our previous diving
instruction and trips diving on the Barrier Reef and in Antigua were not
forgotten after all. Andrew went through our routines with us and we spent
most of the day practising buoyancy control and emergency procedures, until
we were pretty confident again. The water temperature was 26º, which made
our diving very pleasant.

Later, we drove out to Tallangatta and had dinner with Andrew’s boss’s
parents and met his boss and family. Andrew and Tony also fitted some new
disc pads to the BMW, before dinner. All- in- all, a very pleasant day. I had
my first glass of wine in a week. I read of unsubstantiated claims that men
and women who drink alcohol, other than a glass per day, over the long term,
may be 41% more likely to get prostate or breast cancer, respectively,
allegedly due to their greater production of ‘hormones’. One wonders how
much alcohol increases the cancer risk, if this is really true, and I intend to
follow this up! In the mean time I am not drinking – which is pretty easy down
here, surrounded by committed Baptists, except for Andrews boss’s father
Tony, who opened a nice bottle of white wine.

I hope that there is no proven link between drinking wine and prostate (or
breast) cancer as wine is one of life’s pleasures. If there is, I shall pretty well
give up alcohol. What with eating sundried tomatoes, drinking tomato juice,
having tomato soup and Vitamin E to slow any possible cancer growth, and all
the other Vitamins, plus my wife plying me with herb tea concoctions to
achieve the same effect, if my PSA starts to go up, I can say I have taken
what action one can!


30.12..2004.
First thing this morning, we drove up to Bogong Alpine Village and saw the
managers. Elizabeth and I inspected our houses there and put in a few new
things, as tenants were about to move in. Lake Guy was as full as possible.
It is really a State Electricity Hydroelectric Dam and the water was right up to
the top of the spillway and pouring over into the river below. There were
ducks every where on the dam, some with baby ducklings and the village as
beautiful as can be.

In the afternoon, we all drove up to Bright, which was crowded with tourists,
some down on the river, swimming and boating. Changing quickly, I thought I
would take a swim! Stepping into the water I found it was freezing cold – well
certainly well below 20ºC. So, spoiled by my experiences in the Caribbean,
where the water is always warm, Elizabeth and I opted not to swim. Andrew



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did! Are we too fussy and, used to the highest QOL, unwilling to accept
anything less?

Now, let’s get back to the Model of Human Occupation and discuss habits.
People are creatures of habit. One gets out of bed and performs a series of
habits which we have learned in the past, and which can be performed
automatically. Kielhofner (1995) teaches that habits organise occupational
behaviour by:
- influencing how one performs routine activities
- regulating how time is typically used, and
- generating styles of behaviour, as in being fast of slow paced.

He defines habits as ‘latent appreciative tendencies acquired from previous
repetitions, operating at a pre-conscious, automatic level and influencing a
wide range of behavioural patterns’ (Kielhofner 1997). Habits really serve as
props, that keep us on the right pathway, on our routines of daily activities.
There is a concept known as a habit map, which is an internalised
appreciative capacity ‘that allows one to recognise familiar event and
contexts, and to construct action for accomplishing a process or reaching a
goal.’ One rock at a time and you will eventually build a wall, or a rock
garden!

Our occupational behaviour is appropriate for our internalised roles. An
internalised role is ‘a broad awareness of a particular social identity and
related obligations that together provide a framework for appreciating relevant
situations and constructing appropriate behaviour’ (Keilhofner 1997). At
various times one may occupy different roles, anaesthetist in the operating
theatre, counsellor in the pain clinic, husband when I get home and father, on
the phone to one of our sons. One’s role-related behaviour makes use of
role scripts, ‘appreciative tendencies that allow one to comprehend social
situations and expectations and to construct behaviour that enacts a given
role.’ One behaves in a way appropriate to the role. Others around us expect
certain behaviour from us when we occupy a certain role. When one goes to
work one dresses in a manner appropriate to social expectations. I wear a tie,
though I am not keen on ties.

Put more formally – roles affect our behaviour in our occupations in three
ways. Firstly, they tend to dictate the manner and content of our interpersonal
actions. Secondly, they demand the performance of routine tasks. Thirdly,
they help to divide our time into appropriate role related segments, such as
work, sport and family roles. We then easily slip in to appropriate behaviour
expected in the role, more or less automatically.

Habits and roles together allow us to perform learned tasks automatically,
allowing us to concentrate on more important challenges. One can plan what
to say at a meeting, whilst tying shoelaces or cleaning teeth.

Disorders related to habits can constrain effective occupational performance,
maintain dissatisfying routines, or habits may be restricted, altered or
invalidated by disability. It is this last mentioned disorder, which applies to me


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at present. My long-standing sexual habits are restricted, altered and partially
invalidated by my impotence – that is correct!


31.12. 2004.
New Years Eve! Before the party tonight at a friend’s home, Andrew and I
plan to do some garden landscaping and planting of shrubs and trees. Time
is running out now for me to leave here on Monday morning, less than three
days away. Today, I want to finish writing about the Model of Human
Occupation. Kielhofner’s third Subsystem relates to occupational performance
and skill. Performance, he states, involves a complex interplay of musculo-
skeletal, neurological, perceptual and cognitive phenomena, organised into
the mind-brain-body performance sub-system. Any breakdown along the
integrated sub-system leads to problems with occupational performance. Skill
is part of the characteristic of performance and is subdivided into three areas:-
- Motor skills, which refer to moving objects and oneself in space
- Process skills – involved with modifications and management of
    procedures,
- Communication/interaction skills – how we deal with and share information
    with other people.

All of the above require special skills.

Finally, occupation behaviour is influenced by the environment, in that the
environment gives opportunities to, or affords performance and it presses or
requires, certain behaviour. In other words, there are environmentally related
opportunities and constraints which influence behaviour.

There are both physical and social environments. Objects and spaces
constitute the physical environment and we attach social affording
opportunities for recreational behaviour, and a book is an object with a social
value and meaning. Social environments include occupational forms that
people perform such as a football team or an army and also the people that
perform them. Certain behaviours are expected –that is called environmental
press.. ‘Occupational forms are rule-bound sequences of actions that are at
once coherent, oriented to a purpose, sustained in collective knowledge,
culturally recognisable, and named’ (Kielhofner 1997). There are occupational
behaviour settings too, which are places of being, and acting in life. They
situate us in our activities of life. In my case, on a typical day, this would be a
hospital. My behaviour is appropriate to the setting.

In disorder, restrictions in motor, process and communication/interaction skills
can limit effectiveness, and involve neurological, musculo-skeletal and part of
the mind-brain-body performance subsystem. Restrictions can originate from
the physical and social environment.

In my case, since my radical prostatectomy, I have essentially been impotent
because my mind-brain-body performance subsystem is impaired by
neurological and vascular damage. My habits are restricted by my disability.
Volition has been affected. I am aware of my lost capacity, realising that I


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cannot perform in ways that are personally important, relinquishing or at least
modifying my efforts to maintain my meaningful sexual activities.

How has this disorder in occupation affected my overall QOL? This is not so
easy to answer. The definition generated by my cancer patient interviews is
relevant, namely—QOL is being able to DO what you want to DO, when you
want to DO it, together with the happiness/satisfaction that accompanies/or
follows it. I do not apologise for repeating and repeating this definition. I shall
explain in fine detail, my reasons, in my Doctor of Health Science thesis. I am
able to DO just about everything as before, in particular, I have to all intents,
no urinary incontinence, though the valve mechanism is not quite as strong.
My assessment is that my QOL is, in terms of the Bowling and Windsor
(2001) scale – very good.

 Realistically, QOL is not, in my opinion, totally, actually, doing what one
wants to do, necessarily, but the knowledge that one could (or could not)
when circumstances are appropriate, and the knowledge of a disability like
impotence remains, focused in one’s consciousness almost constantly, or at
least every time one sees an attractive girl, though there is absolutely no
expectation that one would consider indicating to her, that one was the
slightest bit interested. One is not coveting, any more than one covets a new
Ferrari that drives past – there is though, still the knowledge that I could drive
the Ferrari, even though I shall never get the chance – and my appreciation of
fine cars remains unimpaired. Sexuality is all pervasive and knowledge of
impairment is likewise all pervasive. I’ll say it again – I hope I recover!

If I try and compare my situation with someone rendered paraplegic in an
accident, it is a different story. Of course I am aware that I have had and
continue to have a fabulous life and I do truly count my blessings. Every
week I see miserable but healthy patients and happy, disabled patients. My
son Garry and his whole family were in Thailand, at the time of the Tsunami
and were unaffected – they could have been in Phuket!

As it is New Year’s Eve I thought I would give you something to consider,
regarding SCREENING FOR PROSTATE CANCER. In a magazine called
Living Well, which I receive from my Private Health Insurance provider, MBF,
one of the major Australian funds, there is an article, on page thirty-two, of the
April, 2004 issue, on prostate cancer, titled ‘The facts about PROSTATE
conditions .Under the section on ‘Preventing death and disability from prostate
cancer’, is a sub-heading, ‘Early diagnosis through screening well men.’ I
would like to quote from this section, then make some observations, as I
believe that this topic is of great interest to readers.

QUOTE—‘Screening for prostate cancer involves looking for evidence of the
disease in well, or symptom – free, men. This involves both a Prostate
Specific Antigen (PSA) test and a digital rectal      examination. PSA is a
chemical that is secreted by the prostate and, often, prostate cancer causes
an increased amount to enter the blood. It exists in the blood as a bonded
form and a free form. The routinely measured PSA level (the total PSA)
measures both.


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QUOTE (continued)-- There is much argument about whether PSA screening
provides an overall benefit. To understand these arguments, it is important to
know that:
# in general, screening is considered effective if its benefits outweigh the
harm that can occur from the adverse effects caused by both investigations
and treatment
# the benefit from a screening program is a community one – that is,
measured by its overall effect on a large group of people. There can be no
guarantee that any individual will benefit, while some will be worse off.
At present, general consensus is that there is insufficient evidence that PSA
screening results in a sufficiently better community outcome to enable doctors
to advise patients whether or not to take a screening test. For this reason,
current legal/medical opinion is that the decision is up to the patient. Of
course, for patients anxious about their condition, this is not a great help.
Hence it is important to be armed with the facts--end of QUOTE.

The magazine article then goes on, to pose ‘Questions to consider when
making your decision about screening.’ The first question posed, is –
‘Am I worried about prostate cancer?’ The article informs us that ‘Prostate
cancer is the second most common cause of cancer death in men.’ There is
no mention of the fact that about as many men die from prostate cancer, as
women die from breast cancer. This translates into about seven or eight men
dying from prostate cancer in Australia, every day. In America, the figures are
about 35,000 men, annually. Just a few more than the numbers of Americans
dying in Iraq, at present. If a suicide bomber wipes you out, it tends to be
pretty quick. Ask your doctor to describe what it is like to die of prostate
cancer.
The second question posed, is –‘Do I have a family history of prostate
cancer?’ It is pointed out that men with a strong history of prostate cancer (a
father or brother) are at increased risk. Earlier in the article, it was stated that
about one man in eleven get prostate cancer before the age of 75 years. I had
no family history of prostate, or any other type of cancer. I have three sons,
and there is a very high risk that one, at least, of them may get prostate
cancer.
The third, is – ‘What tests can help diagnose prostate cancer early enough to
allow a cure?’ The answer given, is that PSA testing is really             the only
method available. I have a PSA test every six or seven weeks, and have the
results within hours. A small amount of blood is taken from a vein. Simple!
The fourth – ‘Am I prepared to wait until there is clear evidence that prostate
cancer screening is beneficial before having the test, realising that it may
have been beneficial in the meantime?’ The article points out that the results
of studies, designed to prove the benefits of screening, will not be available
until the year TWO THOUSAND AND EIGHT-- OR THEREABOUTS.( Do you
really want to wait? How many times do you look up and down the street,
before you step on to the road?)
The fifth question is – ‘Does it worry me that there are many false positive
tests and I may have unnecessary (and uncomfortable) investigations/suffer
unnecessary anxiety? It is pointed out that a PSA may be raised for other
reasons, and it is even possible that you could have cancer, with a normal
PSA. Sure, that is correct, but in most cases, other causes of a raised PSA,


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such as benign enlargement, are easily discovered by a urologist. Most
abnormal PSA results are not due to cancer, but about 25% to 34% are.
The sixth –‘Does it worry me that screening may find (and result in me having
treatment for) a cancer that was never going to cause me problems.’ As we
are informed, it can be hard to be sure, sometimes, whether a cancer is going
to kill you, never-the-less, a urological specialist is able to advise you. The
Gleason score indicates the severity of the malignancy, if there is a positive
biopsy.
The second last question is—‘If cancer is diagnosed, would I want treatment
that may also adversely affect my quality of life?’ Both surgery and
radiotherapy can result in incontinence or impotence, and bowel function can
be affected by radiotherapy, they point out. Only too true, and I have spoken
of these possible complications in this book. With a Gleason score of seven, I
did not hesitate to have surgery, as life is important to me. I know men with
raised PSA results, who refuse to even have a biopsy. It is your life!
Finally----‘Do I want treatment that has not been proven to increase life
expectancy?” The article says –‘there is no definite proof (yet) that the
treatment of prostate cancer itself increases life expectancy. However, this is
MUCH MORE LIKELY (my emphasis) to be the case in younger men.’ If you
like to wait until there is probable proof, in about 2008, good luck to you.
Possibly, I, my friends and colleagues who have been screened, diagnosed
with prostate cancer, and had surgery or radiotherapy, should still be waiting
too, but we do not think so!

01.01. 2005.
An industrious New Years Day, spent loading up the trailer with tons of large
rocks, then carefully distributing them to make garden edges. After digging up
the soil and watering the area, weed matting was rolled out and secured with
wire pegs. Later, shrubs and trees will be planted and a layer of straw
distributed. It is looking good in the area Andrew and I have completed so far.
There is nothing I would rather be doing really, so happiness is labouring,
carting rocks around in the hot sun, if you are doing it to help someone, and
make a difference. Numerous people still say to me, since my cancer
diagnosis, ‘Are you feeling well?’ or ‘you are looking well’ as they appraise my
state of health. This is certainly evidence that they are interested in my
welfare, however there seems to be an expectation that my energy and
vigour will have been compromised by my cancer or the treatment. All I can
say is that ‘yes – I feel 100% well and full of energy.’ Some seem a bit
surprised!


02.01. 2005.
Since I read that Korean men have the lowest mortality from prostate cancer
(5.0 deaths/100,000 in 1999) compared with Scandinavian figures of 20.5 and
Australia’s 19.0/100,000, I have been thinking about he high soy diet of
Koreans and Japanese men (5.1 deaths/100,000).

Some years ago, I tried a bland soy chunky preparation which did not impress
me. Consequently soy did not rate highly in my estimation of food choices.
Now my interest is more vital, as the book by James Scala, on reducing the


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risk of prostate cancer, has some plausible information. It claims that cancer
in laboratory animals is reduced by the two isoflavones produced by soy.
Also, more interestingly, these two isoflavones inhibited the growth of
implanted human prostate cancer cells in animals. It is claimed that
testosterone and its metabolites (break down products) stimulate prostate
cells to grow, and dysplasia and even cancer may result. This perhaps is the
result of these substances becoming attached to the prostate cells. As part of
the isoflavones are structurally similar enough to the testosterone and
metabolites attachment sites, they may become attached instead and block
the attachment of testosterone, hence preventing cell stimulation and possible
cancer development. Early days still – but there could be something in it. For
sure, those Koreans eat lots of Tofu and other soy products, and they have a
much, much lower death rate from prostate cancer.

My next move was to try some soy milk substitute, with some muesli and fruit.
It tasted quite OK. Down to Coles Supermarket and there I found a whole
range of flavoured Tofu products to use as a protein source (60% protein). I
brought home a few Tofu samples, also soy hamburger patties to make a
non-meat burger, plus soy mild cheese substitute (there is a range of these)
and an ice-cream substitute – called for want of a better name, So-Good swirl
– and containing some boysenberries. I shall try them all out. The book
claims that 36 ounces (that’s about 1 litre) of soy beverage, is about
equivalent to the dose of soy isoflavinoids given to the animals to reduce the
prostate cancer growth. Perhaps this dietary advice is good, and if one uses
soy as Tofu and patties instead of red meat, plus drinking soy milk, instead of
cows milk, it will reduce prostate cell growth and more particularly, prostate
cancer cell growth. As a side benefit, there should be less chance of
developing ischaemic heart disease or other vascular disease-- with less
animal fat. Over the next weeks, one will discover whether this diet is
palatable enough and if so, adopt it!

Andrew and I labour on, lifting up rocks and planting oranges, passionfruit, a
lemon, nine Fijoas, a patch of strawberries and a few other things – they look
good!


03.01. 2005.
Andrew left for a Christian camp, where he is to be a leader. Elizabeth and I
got away, after watering all the new gardens and packing up, on our way to
visit old friends, on the way home. Arriving in the late afternoon we enjoyed
catching up with all their news. They are flying out to Dubai in two weeks and
I am a little surprised that R is still able to fly. A long-term asthma sufferer, he
has more recently developed diabetes and has had stents in three coronary
arteries. He really needed coronary artery by-pass surgery. Unfortunately the
origins of his coronary arteries were so diseased that stents were the only
option. He still gets angina if he has a cup of coffee or exerts himself unduly.

I asked him how he has adjusted to his serious health problems. R says there
is nothing much he can do about it, so he just gets on with life. Retired for
some years, he is my age, writes articles in motor magazines, restores cars,


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judges cars at concours, is on the local Parish Council and goes on as many
classic are rallies as possible. He is also a world authority, perhaps the
leading one, on his particular favourite make of car, of which he has four, as
well as his every- day cars. Poor health and a ‘guarded prognosis’ as far as
his life expectancy is concerned, are not stopping him and his wife from
leading an active and enjoyable life. Would his situation, in practical terms, be
much different, if he had prostate cancer? Probably not! We all know that we
have a use-by date – though some labels are harder to read than others.

Lifting heaving rocks, up to 50-60kg, is not good for my lower back –
especially the area around my left sacro-iliac joint. I can only bend with
difficulty, and Elizabeth has to take off my shoes and socks. We elected to
sleep together in a single bed, instead of each having one to ourselves. We
always do this, when staying at our son Garry’s place. Togetherness!


04.01. 2005.
Sleeping in that bed together, was not a good idea! My back is definitely
worse and we are driving to see friends for lunch in Queanbeyan then, on to
Sydney to collect my Bang & Olufsen television, DVD and VCR. Before then,
we watch as an Alvis and an Armstrong-Siddeley are loaded on to a truck for
Queensland. It would take over 3000 hours to restore the 3-litre Alvis and
frankly, R is not up to that – despite having done many other restorations in
the past. He is facing reality and has enough ‘occupations’ to keep him
happy.

I am giving serious consideration to the whole question of how many, or
much, of this world’s goods-- are really needed. Already, I take very little
luggage with me on a trip, a maximum of 3.5 Kg. It is very unlikely that I shall
ever need to buy another suit or even another tie. So owning six cars is a bit
crazy, especially if we are to travel all over the place – but each has a history
which is part of me. Never-the-less, many others have been sold in the past
and only very few have been really missed. One, a Porsche prototype, is in
the Porsche factory museum in Germany – so I could see it again, if I became
keen enough. In actual fact it is an impractical car at best, with a very highly
tuned, high revving engine, not suitable for city use. A 7 litre Shelby Cobra is
extremely fast, but mine drank petrol so ferociously, that it once won a prize
for the least economical vehicle – 5 miles per gallon. Two others, both
Lamborghini’s, though beautiful, fast and with fantastic exhaust notes, are
frighteningly expensive to own and maintain. If you think of lady friends, rather
than cars, then think of Mick Jagger with Bianca, Gerry Hall and a Brazilian
super-model or two. Mick has far, far, more resources than I, and at present
appears to live quite well without them! Of course, when one sells a car,
maintenance costs cease. His, perhaps-- do not! I don’t think I shall write any
more, as I’m wondering how the reader may try and interpret all this rambling!


05.01. 2005.
The Bang and Olufsen television and other gear fitted in the Range Rover,
and we decided to stay overnight in the Hunter Valley wine region, near


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Pokolbin, last night. Driving around for an hour proved that we were too late.
Reception offices were closed or the resorts were booked out. A motel near
Cessnock airport was open and had plenty of vacancies. Early this morning I
was awoken by the sound of aircraft engines starting up. Looking out the
window, I spied a Piper Twin pilot, barely one hundred metres away, warming
up his engines. Another eight planes were noted, and I realised that the place
where we were staying, now a motel, was CATA –the Civil Air Training
Academy where my youngest son trained as a commercial pilot, some
seventeen years ago. He graduated as the youngest commercially qualified
pilot in Australia – at seventeen years of age. Later, I bought a plane – a little
Cessna, and he taught me to fly. Then later again, we rented a Beechcraft
twin, one weekend, and flew over to the farm at Gilgandra, flying all over it. It
was interesting, viewing it from the air. It only took a chance night in this
motel, to trigger a trip to my video-library of memories --and replay some of
my previous QOL outstanding events, with much pleasure. Soon I recall other
trips.

Flying down to Wellington, New South Wales, to inspect a wild-flower venture
that we unwisely invested in – growing and exporting Australian wild flowers
to America and Asia. Flying up to Brisbane, across inhospitable, mountain
forest terrain, in my little Cessna. Landing in gusty conditions in the rain,
worrying, as storm- clouds closed in. Paying endless bills – for hundred-
hourly inspections, maintenance and fuel. Finally, this caused me to decide to
sell it. One can always hire a plane, but I neve have, and I am quite content to
travel commercially. Sit back and relax, watch a movie, have a drink, a meal,
a sleep! So many people seem to complain about flights – it seems strange
to me. Perhaps I’m lucky, being able to go to sleep before the plane takes off,
if I wish, and never getting jet-lag. Last year I would have flown about one
hundred and thirty hours as a passenger and spent a fair few in the Qantas
Club Lounge or their equivalent overseas – Elizabeth and I both love travel
and look forward to each trip we plan. In fact planning it is another joy and
increases with our knowledge of different airports, as our confidence is raised
higher. It doesn’t worry us one bit – even with the current focus on terrorist
attacks, it’s not an issue.

Before we left the motel, getting back to the present from my reverie,
Elizabeth had a swim in the pool, after breakfast, and we arrived home, to find
everything as expected and the lawns mown, as arranged. Work tomorrow!
There is lots of mail, as usual, and tonight we are going through as much as
we can.

06.01. 2005.
It doesn’t seem that I’m back at work for long this morning, before I’m
reminded of both time running out and prostate cancer again. One patient is
five years older than I, and has a number of health problems, including
Parkinson’s disease. He has a white beard and, if I did not know his age,
would think him much older. The next man is a year older than I, works hard
manually and has no desire to retire. He is healthy except he has a work
related injury, which requires minor surgery. He has no desire to retire like his
father did. ‘Dad just faded away, and died!’ Curious, I asked how old his


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father was, when he gave up work and died? ‘Well – in his eighties!’ Fair
enough, I thought.

Next, a man of eighty, with serious respiratory disease and advanced
Parkinson’s disease, questioned whether he should have his proposed routine
colonoscopy. He gets exhausted just having a shower and needs help with
his activities of daily living. I tell him that it may be wise, to make another
appointment with his surgeon and discuss it. My experience has been that all
to frequently, once one starts to get increasingly exhausted with the slightest
activities, then one is living on borrowed time. Even if he were to be found to
have bowel cancer requiring major surgery, his chance of surviving to enjoy a
meaningful future, would seem minimal. These patients are not too rare.
They have no diagnosis of cancer yet, and if they do turn out to, on
investigation, need surgery, are hardly in good enough shape to benefit from
treatment.

On interviewing a lady I know, the subject turns to prostate cancer. A family
member apparently started to have some urinary symptoms, and prostate
cancer was diagnosed. A prostatectomy was scheduled, but abandoned at
the start of surgery, when the cancer was found to have spread beyond the
gland. Next week he is to commence an eight week course of radiotherapy
following his present hormone treatment, which is being given to reduce the
volume of the cancer. This man has worked hard all of his life. He is two
years younger than I. This story causes me to remember the story of another
local man, who regularly had PSA tests and when his PSA gradually rose
over time, his GP referred him to a urologist. Biopsies were done which
showed prostate cancer. Before his PSA exceeded the normal maximum
value to be expected, he had a radical prostatectomy. The cancer was
confined to the gland and several years later, his PSA is zero. It is very likely
he is cured. PSAs are not thought by Australian authorities, to be routinely
necessary for men, as a health screening measure.                    Neither are
colonoscopies! Only if you have symptoms, or a family history, are PSA
estimations for prostate cancer tested, or colonoscopies for bowel cancer
screening-- official policy. Prostate cancer and bowel cancer are major killers.
Are we crazy?
If I had not actually written out a request to the pathology laboratory for a PSA
test, when I was quite asymptomatic, I would have prostate cancer cells
invading my bowel and/or bladder, and spreading more widely, by now,
beyond any hope of a cure.

07.01. 2005.
A perfect summer day, with nary a cloud in the sky, and a temperature of
around 30C. Today we collected Peter Rabbit, our grandchildren’s pet, from
where he was being minded, whilst we were away. Peter looks well and we
learn that he has been munching whole carrots and certainly does not need
them to be grated! Lots of little jobs to do. Club registration of the Jensen
and Armstrong-Siddely Limousine are now complete, and the Range Rover is
greased and ready for its LPG gas inspection for registration on Monday. A
trip to the Hospital Library to return one book, and I return home clutching a
sombre text on prostate disease, a recent CD on prostate cancer, a locally


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authored text Your Guide to Prostate Cancer by Doctor Prem Rashid and a
team of contributors, for patient information. I note its date of publication,
2003. Prostate cancer knowledge quickly becomes outdated and a 2000 year
publication is way behind, and just frightens you.

I turn to the section on Decreasing the Risk of Prostate Cancer, on page 10.
Briefly, it is stated that there is evidence that Vitamin B, Isoflavinoides,
lycopene, Selenium and Vitamin E, may all help reduce prostate cancer risks.
Most of them are anti-oxidants, which prevent or slow down oxidation,
inhibiting the production of free radicals, which may damage our cell
structures and DNA. This may protect us against cancer formation. I am not
going to go into all the details here as you can buy the book yourself, or get it
from the right library. It does confirm that my daily Lycopene from tomato
(skins), and now isoflavinoides found in Soy products, plus Vitamin E
capsules taken daily, are good to help in reducing cancer risks. Vitamin B
comes from orange, red and green leafy vegetables in my salads and I have
been taking Selemin.

The bad news! Each morning I give two calcium tablets to Elizabeth – to
prevent osteoporosis-- and take one myself. Rashid quotes two studies that
have shown a link between increased calcium intake (particularly from dairy
products) and a higher risk of prostate cancer! No more calcium tablets for
me.

I admit that I am jumping the gun by assuming that everything that reduces
the risk of getting prostate cancer in the first place, will be helpful in reducing
the rate of growth of any cancer cells one still has, after a radical
prostatectomy with a positive margin, like mine. Some studies do support this
line of thought.

Kristal et al (1999) found that taking Vitamins C, E and Zinc may be protective
and I was taking all of these whilst my PSA was rising, before diagnosis. Did
they slow the cancer growth perceptively? Who knows! Anyway Vitamin E
also decreased the risk of colon cancer and last time I had a colonoscopy, a
minute polyp was discovered and I am due for another colonoscopy at the
end of 2005.

Rashid lists age, long term high level of testosterone, a high saturated fat diet
and calcium exposure as factors leading to an increased risk of prostate
cancer. Age, one cannot help, but I would comment that back in 1960, men
typically worked until 65 years of age and died around the age of 67 years.
Perhaps this is the main reason that it used to be said that one would die with
prostate cancer, not from it. Now, in Australia a man’s life expectancy has
risen by 10 years or more and the cancer has sufficient time to spread and be
a potent cause of mortality. One out of every eight men develops prostate
cancer, that is, over 10,000 new diagnoses annually with 2,600 deaths from
the disease, according to Rashid (2003). Every three minutes, an American is
diagnosed with prostate cancer! My three sons, because I have prostate
cancer, have a 25% chance, or more, perhaps a one in three risk, of
developing it, so there is a very high chance that at least one of them will


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develop it. I shall certainly be counselling all of them on measures they may
take to reduce their risk and urge them to have regular PSAs. The eldest is
already forty years old.

Before we leave the field of dietary measures to reduce risk, it has been
shown that substances in green tea inhibit the growth of prostate cancer cells
and in high concentrations, destroys them (Rashid’s text 2003). He quotes
papers, which found that drinking green tea is potentially helpful in protecting
against prostate cancer.

One of the most controversial topics related to prostate cancer is the question
of who needs to be screened with the PSA test. Currently, the Urological
Society of Australasia states the ‘Population screening of men with no
complaints or symptoms is not recommended”. In the United Kingdom
similarly, the UK Healthcare Evaluation Unit suggests that “screening not be
recommended until further information becomes available”.

The American Urological Association and American Foundation for Urologic
Disease state ‘Annual screening should be recommended for the general
population of men beginning at he age of 50 and from the age of 40 for men
with a family history of prostate cancer’. Great news! But hold on! This was
going to become firm US policy until the government realised it could cost
$US27 billion. As a patient, I have become a bit paranoid about the
reluctance to recommend PSA screening for men of 50 or more.

On present Australian policy, I would be happily ignorant of my prostate
cancer, inexorably spreading as I sit here, until too, too late. I am really glad
that I, as a doctor, was able to order my own PSA tests, simple, quick tests,
done in a matter of seconds with the blood results in a matter of hours, at a
cost to me of showing my Medicare card! Sure, it’s not perfect but the PAP
smear for cervical cancer screening is not perfect! Mammography is not
perfect. We use them, recognising they have problems! In a few years we
will look back, especially those prostate cancer patients not fully informed on
PSA testing, who are still alive, and shake our heads at out present policies.
But I am not in charge of the Public Purse but an evangelist for the welfare of
the individual man, at significant risk of prostate cancer.


08.01. 2005.
Saturday morning! Another beautiful summer day and it is really good to be
alive and feeling completely fit and healthy. Last night, I read the case-
studies of thirteen patients, which comprise the last section of Rashids (2003)
text. Too frequently, they appeared to be too brief and ‘sanitised” in my
opinion. They did reveal, again in my opinion, a depressing ignorance of
prostate cancer, by many patients, and maybe a few of their doctors, as I
have found in patients and doctors of my acquaintance!

At the end of Rashids (2003) discussion of erectile dysfunction following
radical prostatectomy, there was an interesting final paragraph which made
me think – ‘some men are still able to achieve orgasms after a radical


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prostatectomy. This can sometimes also be achieved without a firm erection.’
I did not realise how lucky I am.

Curious to know if any improvement was occurring, I unpacked my vacuum
erection device and, achieving an erection, only used the largest ring. There
was no awareness of coldness of the glans and penetration in the missionary
position allowed for a few minutes of intercourse. Sensitivity was still not as
before, and the erection faded a bit with time – which is easily fixed with a few
pumps of the re-applied pump. Not very romantic, but worthwhile, for both of
us, despite no feeling that we were going to achieve orgasm. On the positive
side, there was some tightening of vaginal muscles, but negatively, this made
a softish erection less able to penetrate. Progress though, and with time there
should be further improvement. Manually, before taking off the ring, I had
quite a reasonably satisfying orgasm – the best since the prostatectomy. As
always, it is better to choose a time when there are no other pressures on
one, as on a lazy day at home. We have always enjoyed long holidays, so
retirement should be even better than our rather idyllic present existence.

Yesterday I went down town to Black Dot Music and had a long discussion
about flutes. For some time, I have been contemplating learning a new
musical instrument and thought that the flute, or maybe the clarinet, would be
suitable. The proprietor plays the flute, as well as other instruments, and he
was practising the guitar when I entered his shop. A flute is very light, comes
in three segments which are easily assembled, does not require inordinate
respiratory efforts to play, there are many many pieces of music suitable for it
and it comes in a nice little case which can be easily taken anywhere,
including overseas. Besides, good flute music has great appeal to me. As a
child and beyond, I learned to play the piano, well enough to play in bars for
beers, and went up to seventh grade formally. It would have been great if I
could have composed worthwhile music but, alas, few are so gifted. Music is
an excellent way to relax and if I apply myself to learning the flute, when I
have plenty of time to do so then I should get great pleasure from it – though
initially I had best practice in isolation! I shall possibly buy a flute and take
lessons, in the foreseeable future. Just now, my spare money has gone into
the Bang and Olufsen, which is being set up by an expert, on Monday after
work.

This afternoon, after enjoying Tandoori Chicken and a bottle of Petersons
white wine with Elizabeth, I plan to listen to the CD Urology Lectures: Prostate
Cancer, authored by Mr C Dawson.

Finally, some good news about prostate cancer and alcohol. According to
Rashids (2003) text, there is no evidence that alcohol consumption is in any
way a factor in the development of prostate cancer. For one who has enjoyed
alcohol, especially wine, for fifty years, this is indeed excellent news. For
years, as a student, one set up a coffee percolator with Malaysian coffee
beans, freshly ground, a packet of Greys ready rubbed tobacco and cigarette
papers, plus a flagon of ‘Burgundy’ with a glass, to fortify one late at night,
reading medical texts, whilst Elizabeth slept.



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Times change – no more coffee, or indeed any caffeine, as these days the
smallest amount gives me ventricular ectopics, bigemini and trigemini, very
frequently, which, it they occur, I am very aware of. No more smoking – after
leaving school, when on holidays in Melbourne on 28th August 1953, I started
smoking – anything from 20/day to 50/day when driving a double-shift as a
taxi driver as a student. On the 20th June 1965, because I was sick with
measles and had a high fever and did not feel like a cigarette – I quit. So the
last of my three drug habits, alcohol, remains.      As a student, one added
caffeine powder to coffee to stay awake at times, and once I tried
amphetamines, but after one tablet, I stayed awake for three days and that
was it. Marijuana or other recreational drugs, I have never tried. A thought
has crossed my mind though, about the popular drug ecstasy – these kids
don’t pay good money for nothing – would it stimulate me sexually, or finish
me off?

Speaking to a friend on the phone today, I became quite worried about him. A
busy 52 year old developer, he told me that over the past couple of years he
has had increasing discomfort and now, pain down the left side of his
abdomen. When I enquired as to whether he had seen a doctor about it and
possibly had a colonoscopy, he told me that he is booked to have a
colonoscopy on the twenty-eighth of this month. Had he ever had a
colonoscopy before? Well, yes, some ten yeasr ago. And what was found. A
lot of polyps and bleeding! Not wishing to worry him more, I though it best not
to ask any further questions, but I just had to ask him, had he been advised to
have follow up colonoscopies, after the polyps were found? Rather vaguely,
he remembered that something was said about a further check, but he had
been so busy that he had not thought much about it, until recently. After his
colonoscopy he is going to ring me up – I will be worried about bowel cancer
until then.


09.01. 2005.
Last night we received a phone call from Austria. It was M, whom we first met
in Antigua in 1993. She was director of guest entertainment at a beautiful
resort and had thoughtfully sent a presentation of Tropical fruit and Moet et
Chandon Champagne to our villa, prior to our arrival. M was the girlfriend of
one of our sons, and invited us to stay a night around at her resort at Half
Moon Bay, one of the magic places on this earth, and showed us around the
sights of Antigua. Later she visited our son (and us) in Australia – a delightful
girl.

Now she is married, with two kids, and working as a teacher – a completely
different life. Last night she said she still has the beach and even the sand of
Antigua in her head. It is that sort of place. Our son jointed us Antigua last
year and I watched as he skin-dived in the sea at Dickenson Bay. He was
able to catch lobsters with his bare hands and swim in to the shore – delicious
they were, too. Antigua seems to have us under a spell. Just a few days
there and one loses all sense of time, in an endless ritual of life on the beach,
in the pool, in the sea, watching the fish, watching the people, the locals
selling beach wear and shells, ladies plaiding dreadlocks, action at Coconut


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Grove, Warri Pier, The Beach Bar, Sandals, Halcycon Cove, sounds of waves
lapping the shore, steel bands at weddings and receptions on the beach,
laughter and Caribbean songs, meeting friends, old and new! As the locals
say – “why worry – be happy?” – in the words of the song. No stress – no
hassles – no urgency – no phones – always warm – always the sea – always
different-- yet the same.

Our future plan for retirement has required much time and thought. We intend
to spend three weeks in Antigua, (or to give the nation it’s full title, Antigua
and Barbuda) and two weeks sailing and diving on ‘Free Spirit’, the
catamaran, each year initially. If this is not enough, we shall reduce our time
in Italy from our intended thirteen weeks, out of a total twenty-one weeks
round the world annual sojourn. The remainder, two weeks on the Cote
d’Azur – generally covering the area from Cannes to Monaco, and a final
week, to cover time flying and a few days in New York, would make up our
five months. May until September, inclusive, are the best five months to be
overseas. Conversely, the best attractions to us in Australia, apart from the
question of skiing, occur in our summer.

Skiing is, or has been, important to us. Until 1989 Elizabeth and I were still
paying off properties and supporting our children. In fact we were still
embroiled in money losing, poor investments, having taken advice from
financial planners! That year, we tried skiing for the first time, in Queenstown,
New Zealand, and we were hooked! Over the years, we have skied at the
major Australian resorts, Thredbo, Perisher, Mt Koskiusko, and Mr Selwyn, in
New South Wales, plus Falls Creek, Mr Buller, Mt Hotham (where we bought
a unit at the Arlberg) and Mt Buffalo, in Victoria. Further afield, the first place
we tried was Innsbruck in Austria, and later in the Dolomites, at Cavalese,
Bolzano, Cortina D’Ampezzo and Pampeago in Italy, then later, Switzerland,
France and three resorts in the Canadian Rockies. My enthusiasm was
diminished by several strains and sprains of arms and knees, whilst following
one of my sons, at high speed, down ‘black’ runs all day – for he is a far better
skier than I. Several months passed before my limbs more or less recovered.
Elizabeth has also had her share of fractures over the years – so if I were to
opt for winter in Australia skiing, or going overseas, then I guess the skiing
loses. There is always the winter in Europe and North America though. If
money permits, there is the option of spending a few weeks, perhaps even at
Pontreuoli, where there are at least two ski resorts within an hours drive, one
at Zeri, the other on the border between Toscana and Emilia Romagna. One
shall have to think a bit more, about this option!


10.01. 2005.
Psychological distress and mental illness are seen sometimes in people
attending the Pain Clinic. Part of my routine involves assessing all new
patients for depression, anxiety, somatisation, distress from physical, spiritual,
psychological, family and practical causes, subjective well-being or
happiness, QOL (two measures) and positive and negative affect, as
measures of extraversion and neuroticism.



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Somewhere about one third of chronic pain patients suffer from depression,
often together with anxiety and elevated focusing on bodily symptoms.
Naturally there are many others with a variety of psychological and psychiatric
problems. There are some commonalities between chronic pain patients and
cancer patients, if one cares to think about it. Initially their diagnosis may be
in doubt and may require a good history, examination and special
investigations, before the diagnosis is confirmed. For some chronic pain
patients, as for some cancer patients, it is possible that their problem may be
curable. For many others, they may have to live with a process which can be
controlled for years.

A man of forty one, a truck driver, married to a woman who has been in
hospital for eight weeks, and still is, with two little children, has chronic pain.
He was twelve when he first started to suffer back pain. At sixteen he
underwent first, a lumbar laminectomy and later a spinal fusion, which
thankfully provided much, but not complete relief of his pain. Since then, he
has always been a manual worker and insidiously, he has developed arthritis
in his neck over the years. Presently, his pain ranges from 4-6/10 usually,
occasionally accompanied with ‘spasms’ of severity reaching 10/10. In
addition, he has developed pain in both hips over the last eight years. He is
adamant that he is not prepared to have any surgery on his neck – even
though he has numbness and pins and needles in both hands, suggesting
nerve foot pressure up in his neck. His present medications, including
Morphine which was started by his GP last week, whilst he was in hospital
with pneumonia, provide inadequate relief.

A background of such long-term pain in a man of forty-one, does not suggest
that medical science has any quick remedies! Is he anxious? Yes! Is he
depressed? Yes! Does he focus on his symptoms? Yes! Do we expect him to
suffer these problems? Of course – and this is where I begin my day.

Later in the morning, a patient appears without an appointment. More pain
medication is requested, as he has taken more than the prescribed dosage.
On the other hand, he has not been taking his medication for his paranoid
schizophrenia. Soon, his psychologist and a psychiatrist intervene to help.

The instrument, or questionnaire, that I use to assess distress in pain patients,
is the same one that I had introduced for cancer chemotherapy patient’s
routine assessment. If patients self-score themselves 6/10 or more for
distress on admission, or rather presentation, to the cancer chemotherapy
department, they are offered what may be a fairly unusual service. There is
no cancer - experienced psychologist available in Armidale to counsel
distressed patients. If such patients agree, they are introduced to a
psychologist in Sydney by phone, and have regular weekly counselling
sessions, with the opportunity of more frequent contact if desired. It has
proved to be an effective method of providing a skilled service to our country
patients. The questionnaire, called the Distress Thermometer, was developed
by Professor Jimmie Holland, a very nice Psycho-Oncologist at Memorial
Sloan- Kettering Cancer Center, in New York, and she gave one to me.



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11.01. .2005.
On Friday the fourteenth, it will be exactly three months since my radical
prostatectomy. Only the other day, the nurse in charge of the Clinics asked
me if I remembered ringing her, the afternoon of my operation day for I had
sounded a bit sleepy! My phone account in hospital was $250 which is an
indication of my post-operative phoning of friends. It makes me think about
those cancer patients who have decided not to tell anyone about their
diagnosis or treatment. Or, who are for some reason isolated, from overseas,
elderly and without close confidants, deaf or otherwise disabled, short of
funds or, for a host of other reasons, are unable to telephone others. Visitors,
other than the closest family members, are not encouraged to visit early,
postoperatively, but there is the telephone. I remember being awake enough
to read a book within an hour of awakening postoperatively, and feeling no
adverse effects at all from my anaesthetic, at any time. At this time following
the surgery, my experience is remembered as no big deal. There is always a
small chance of death or disaster, which, as a born optimist, was of no
concern to me, any more than the small chance of septicaemia following the
two separate prostatic biopsy procedures. These are risks which weigh
heavily on those who do not favour advising men to have screening for
prostate cancer. For those men, who undergo prostate surgery and who may
have succumbed to some other fatal disease or injury, before untreated
prostate cancer may have killed them, there will be those who get
complications, even fatal ones, and also those who do not have             very
invasive cancer or require surgery. Maybe all those with a raised PSA on
routine screening, can make their own informed decision, as to whether they
have further investigation or treatment. All of us who do have PSA tests make
up our minds about what course of action we consider best, having mostly
taken advice, from advisors of our own choosing.        Knowledge is power, in
my book.

Off we went to the Transport Museum today and gave the Limousine and
Jensen a good run and f few litres of fuel each.


12.01.2005
Sophie turns eight tomorrow. Tonight, Elizabeth rang her family on young
Garry’s mobile. Cross-country skiing is on their menu, Garry’s team is
practicing for the Military championships in Germany. They are staying in
Southern Austria, near the Italian border. The kids are having a marvellous
holiday. Though Alexander finds it cold after Bangkok, he particularly enjoys
skiing down the slopes, first thing in the morning. Less enjoyable are the
uphill sections, especially by lunchtime, when the snow is starting to melt. By
now, both children at 8 and 9 years, are pretty good at cross-country skiing
and the whole family can ski together. Just about ideal QOL – doing what
they want to do, when they want to do it, together with the satisfaction and
happiness that accompanies the skiing, together as a family. Enough to make
a grandfather proud! We wished Sophie a very happy birthday.


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The last time they all skied in Austria, was when young Garry was over in
Europe attending university seminars in Berlin, Prague, Vienna and Inusbruck
in International Finance as he was completing his MBA. The Navy paid for his
costs, but not for the family.
A few years ago, I studied a unit of Gerontology, with a rather academic
attitude to it. Chronologically I was in my sixties, but in my mind, no way was I
‘old”! A diagnosis of prostate cancer-- and all its implications-- havs made me
alter my views. On the phone, my son and all his family asked me how I am
feeling? Am I well? This happens quite often now. Sure, it is well meant and
to an extent appreciated, but it is also a reminder, that, feeling well or not,
time is marching on for me, whatever the outcome of my cancer in the future.
At 6.15am I awoke, went to work and so on, and it is now after midnight. My
back is recovering from the damage I did to it, lifting tons of rock over New
Year and otherwise I am 100%. Perhaps, I sometimes think, I should ‘colour’
or dye my hair from mostly ‘grey to white,’ back to something close to the light
brown of years ago. Women think nothing of such a measure, and I am
happy Elizabeth will not let herself go grey! No matter, if grey is old and I am
vain enough – I might just do it, when I retire next year, while there is still
plenty of hair. Will I feel younger? Will less people ask if I am well? Who
knows!

Our eldest son Stephen, who has been working in Brisbane for a good ten
years now, often rings me up. Typically, we talk for ages on topics of
common interest, especially cars, on which he has encyclopedic knowledge
and a vast collection of models. Music is an absorbing interest too, Stephen
attends many concerts featuring famous overseas artists and has literally
thousands of records, tapes and CDs. He has written a book on the drum kit,
but has never tried to publish it. Worse than my situation? I think not, for
there are shelves and boxes full of more than a dozen unpublished,
unsubmitted, research papers in the garage, which Elizabeth keeps
encouraging me to submit. Some of them are relevant to cancer patients, for I
studied the effects of many anti-cancer chemotherapy drugs on a model using
sheep, in fact 114 sheep, with experimental infusions into their veins. My
colleagues and I were going to publish it and now one, a physiologist, is dead,
and the other, a pathologist, retired. Similarly, I studied the effect of these
drugs and many others, on human endothebal cell cultures, using cells from
placentas obtained from our obstetric unit and cultured. After incubating the
cells, and with drug exposure for one minute, I photographed the cells after 15
minutes, 30 minutes, one hour, two hours, etc. (as they died or recovered
from the drug damage) with a Nikon phase contrast microscope/camera set
up. There is an album full of these photos somewhere – fascinating – I must
publish them! One must have spent untold hours, running out to the
Physiology department in the middle of the night, taking photos, going through
the rituals of cell culture techniques and experiencing the joy of discovery!
That’s QOL, and I have been able to do all this sort of thing for thirty years
here, when not in the operating theatre. I am truly blessed.

This morning, I renewed my acquaintance with a lady, whom I remember as a
school girl, who lived nearby and now has returned to Armidale. She and her


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family now live just around the corner. Now in her thirties, she suffers
troublesome headaches, for which no cause has been found by two
neurologists. An Ear, Nose and Throat surgeon thought the problem lay in
her sinuses. After sinus surgery she is worse. Her doctor referred her to me
for acupuncture and relaxation therapy. Some doctors are suspicious of me, I
feel, because I use acupuncture in suitable cases, yet I find it has its place
and may be very effective for headaches.

Well do I remember visiting the Chulalongkorn Hospital in Bangkok, where I
met Queen Sirikit’s physician, an anaesthetist with post-graduate
qualifications in pharmacology. She runs a special clinic for patients with
hypertension, treating them solely with regular acupuncture. I saw her
records and she pointed out that where patients missed a treatment, patient
blood pressure readings increased. Those attending regularly, and there
were many, were able to maintain normal blood pressure. Western medicine
is not always the only way. Patients claimed to have no side effects, as they
had experienced with anti-hypertensive medication. I like to keep an open
mind about at least some aspects of alternative medicine.

13.01. 2005.
Well, tomorrow it will be exactly three months since my operation. How has
this affected my QOL, as I see it today? “Being able to do what you want to
do” is part of the definition of QOL generated from cancer patient interviews.
Perhaps, if one substitutes the word desire for want, in the definition, it would
be more appropriate for me at present. In essence, the only QOL activity that
has been temporarily (?) lost to me is the ability to enjoy spontaneous sexual
intercourse. Three months makes a difference though, and my libido has now
somewhat diminished. Therefore, with diminished desire, the importance of
being able to have useful erections is less of an issue, in terms of QOL. My
self-assessment of QOL has gradually increased, for there is an altered set
point for judging QOL. A new acceptance of limitations is necessary perhaps,
if one is to age optimally. Fifty years ago my wife, who was a good athlete
and I before we met, would go for a run just for the heck of it, being young and
full of energy. Today we walk pretty sedately around a university oval
together, not caring when the odd runner passes by. We do run to catch a
train if we have to, but that youthful desire is gone. Thinking about it, there
are probably plenty of former activities that, like heavy luggage weighing down
the slowly sinking ship of our lives, are thrown overboard, so that our ship
continues to sail a little longer. Some acceptance of the fact that the voyage
may not last for countless years, is also appropriate.

Tomorrow I shall have blood taken for a check of my PSA. Naturally, the best
result would be a level of zero (less than 0.05ng/ml in our laboratory) and then
I would continue to have six weekly checks. Disappointment would follow any
sign of a rise and a further one would signal the need for radiotherapy, long
before the PSA reaches a value of 1. Perhaps the PSA will never rise but
eventually there is probably a 60-70% chance that it will. Radiotherapy would
then give me perhaps an 80% chance of a five-year freedom from disease
and an almost 100% chance of still being alive, unless hit by a bus or wiped
out some other way. Beyond that horizon-- who knows.


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Elizabeth and I are planning on twelve years sailing and diving on ‘Free Spirit’
when we are in Antigua, so don’t think for a minute that we are not optimistic.
At present, I am sitting, writing, in perfect summer weather. The temperature
must be about 27ºC. with blue skies and a gentle breeze. Pots of geraniums
are flowering on the back terrace, apples and plums dropping occasionally
from the trees, grapes on the trellis. Elizabeth is out again, collecting a friend
with sciatica from the physiotherapist and ferrying her back to her home, miles
out of town – having collected her earlier. Soon she will return and we shall
lunch together. Life doesn’t get much better at our age, and we appreciate
every minute of it – happiness 10/10, QOL ‘as good as can be’, and distress
level – nil! Time to select a bottle of wine, for lunch. There are enough
bottles in temperature controlled storage for us to enjoy the best Australian
and French wines regularly until I am 80!


14.01. .2005.
It is three months today, since my radical prostatectomy and time for me to go
to the pathology department for a check of my PSA. If I have blood taken this
morning, I may even have the result this afternoon. Of course, I am
concerned about what the test is going to show, but there is no point in
procrastinating, especially concerning health.

Now It is time for me to write to my three sons. Talking about the possible
measures they may take to reduce their chances of getting prostate cancer is
not enough. Each of them has an increased risk, perhaps as high as 33% risk
of getting prostate cancer in later life. Routine annual PSA tests from the age
of 40 years is the best screening method, with an examination by their down
doctor.

My experiments with dietary modification have convinced me of the need for
habituation. As I wrote in this journal on 30.12.04 – people are creatures of
habit! The Model of Human Occupation (Kelkhofner 1995) teaches that habits
organise occupational behaviour. Habits keep us on the right pathway on our
routines of daily activity. If you wish to remind yourself in greater detail, re-
read what I have written and read some of Kielhofner’s many publications.
Anyway, if you don’t make dietary changes part of your routine, the chances
are, you will forget.

Simply go down to your favourite supermarket and buy a supply of sun-dried
tomatoes, tomato soup, tomato juice, Vitamin E capsules, Soy substitutes for
ice cream (So Good swirl for example), Soy spread instead of margarine, Tofu
meat substitutes in a variety of flavours and Soy cheese substitutes. Walk
straight past all those temping trays of red meat and buy some fish and
chicken instead.

Perhaps you may do better shopping for your wide variety of fresh fruit and
vegetables at a specialised vegetable market, not forgetting some cruciferous
vegetables such as broccoli, cabbage, bok choy, turnip or radish.



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For many years we have avoided animal fats and use extra-virgin olive oil
sparingly with cooking and in salads. The men in Scandinavia apparently eat
a lot of animal fat containing foods and red meat. They appear to have the
highest risk of prostate cancer in the world.

What you eat at home is what you have purchased, so if you develop the
habit of buying the right foods, you are on the right track. Skip desserts, as
another habit change, and try a piece or two of fruit instead.

Finally, I shall be encouraging my sons to exercise regularly. For two of them,
who have successfully had stress tests and gone right through the limits of the
treadmill tests, which very few people can, this is not necessary. Regular
exercise becomes a habit, which is definitely missed if you fail to keep to your
routine.

By the time I reached the pathology department, I was too late to have the
blood specimen processed by this afternoon. My PSA results will be known
on Monday morning. Whilst down town, I purchased a 2005 dairy with one
foolscap page for each day. This will allow me to keep a record of anything of
possible interest, related to my cancer, during the year. Ideally my PSA
estimations will remain zero and my impotence will soon be a thing of the
past. Humans have a tendency to want to live in a fantasy world at times!

Reality can be harsh and a little escapism can provide some welcome relief.
There is a real danger of using the defence mechanism of denial, when facing
up to reality is likely to be unpalatable. Perhaps this explains why some men
conveniently forget to get their PSA’s checked regularly, if at all, after
prostatectomy and present to their doctors, too late for radiotherapy to have
an optimum change of being effective.

Last night I was contemplating a notice I received in the mail for a medical
conference. Talk about fantasy and escapism!

The conference is held annually at Cortina d’Ampezzo in January. One is
reminded that this was the site for the 1958 Winter Olympics. The conference
hotel, the Villa Argentina, is right on the snow, with excellent facilities and a
superb atmosphere. Let me quote a little from the ‘flyer’ ‘You can sit at a table
in the bar where Ernest Hemingway wrote one of his novels. Or sensualise
Elizabeth Taylor refreshing herself after a day’s shooting ‘Ash Wednesday’.
Or sit at an outdoor table, where Ingmar Bergman contemplated life and
Cortina was the backdrop for 007 in ‘For Your Eyes Only’. You may also run
into the German World Cup Women’s Ski Team, who bunk here annually for
the Cortina event’. One’s chances of actually seeing any of the rich and
famous, even here, is about zilch. Fantasy land! Yet travel brochures are full
of this nonsense. Yes, these people do come to the most beautiful places on
earth and one can generally rely on seeing beautiful scenery, world sporting
events, plenty of art museums, excellent restaurants, cleanliness and freedom
from crime, at top destinations. Hemingway, Bergman, film producers, sports
stars ---all had or have, the where- withal to go where they want, and the fact
that they go to a certain destination is a good indication that one will enjoy it


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too. For this reason, it is worth noting haunts which keep being mentioned. In
fact, if you miss the height of the season, in many cases you may enjoy it
more, with less crowds and lower prices, as in some ski resorts.

Cortina is as attractive as its pictures indicate. In winter, high mountains,
forests, plenty of snow, happy people, and a picturesque village. The Villa
Argentina is twenty metres from ski runs with access to Olympic and World
Cup runs, yet you can be skiing down a tree lined glade, alone, in silence, in a
few minutes. Cortina and Pampeago, also in the Dolomites, are the most
memorable places I have skied, enriching my QOL immeasurably – not
because of the people, but because of the natural (and man made, one must
concede) environments. Beauty is always memorable. Ideally, who would
live anywhere that is not beautiful, for beauty is a continuing joy and never
forgotten. If things work out OK health wise, and we can afford it, then we
shall go there again, next January.

Saturday 15th January 2005
More summer weather. Everything should be as good as can be, except for
one thing! I detect an increasing level of tension in the house. There is no
prize for guessing the reason. Monday is the day when I find out about my
PSA. Until then, we shall increasingly focus on the results.

In the afternoon we spent some time over at Butler Street, watering the
garden, weeding the garden and giving the interior of the building an extra
clean. There have been a number of potential tenants in to look at it, but as
yet no one has taken it. The rows of camellias are doing well.

The guy we are expecting to fix up the TV aerial arrived today rather then next
week and now both TVs have excellent reception.

On Monday I am going to give Caroline my auto-ethnography notes to
complete a journal of three months duration, from the date of my radical
prostatectomy. This is my first day of just writing up a diary to keep track of
any news. Let’s pray that there is a zero report on my PSA level on Monday.


Sunday 16th January 2005
Hot and sunny to start with – so one did what tradition demands. I washed
the Mercedes and watered the lawns again. Storm clouds gathered and it
rained. Lightning also knocked out two TV channels in the evening.

The PSA question hangs in the air. We are not relaxed.


Monday 17th January 2005
As it happened, the pain clinic was so busy, that it was a couple of hours
before I could make a quick trip to the pathology department. The results are
not as clear as they might be. In November the result was typed < 0.01 ng/ml.
And now I see <0.1 ng/ml in black and white. Most strange! Is it to be



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interpreted as an increase in PSA? The phone number of the Biochemistry
department in Tamworth, where the test was done, is requested.

Back in my office I phone Tamworth. It seems that a zero is missing and the
report should read <0.01 ng/ml. The laboratory analysis is ultra-sensitive and
this figure is to be interpreted as an undetectable PSA level – never the less it
will be checked again and an updated report printed out.

We relax and smile again.




Tuesday 18th January 2005
Yesterday, I was asked to do some more work over the next two months, on
Fridays. I agreed to work all day at the Public Hospital doing pre-anaesthetic
clinics, at least until Easter. The phone rang a few minutes ago. A request
that I do routine private pre-anaesthetic clinics on Thursday, in addition to
those already booked. I enjoy doing clinics and naturally I am going to do as
requested. This will mean working pretty much full time – well, say about 36
hours/week. There will still be time and opportunity to continue my QOL
research.

In the last weeks, over Christmas and until the present, the Christmas holiday
period, with ‘emergency cases only’, if it just means sitting around socializing
and playing with my cars and taking up the flute, may not be any more
enjoyable than continuing to work, part time. There is a shortage of
anaesthetists and who else is going to run the Pain Clinic? Time will tell. I
remember the saying ‘if you find what you love doing – you never have to
work again’! Some years ago, I took art lessons, together with other
neophytes. This introduced me to something called, mysteriously, The
University of the Third Age. For most of my adult life, I have been associated
with universities, as an under-graduate or post-graduate student, or staff
member, so continuing to study and taking up new interests is a possibility,
though we shall hopefully spend all our winters overseas, where we intend to
concentrate on improving our Italian and French.


Wednesday 19th January 2005
An old patient of mine, aged 59, came for review of her pain medication this
morning. She has a long history of osteoarthritis affecting her spine, for which
she has had a lot of surgery. Subsequently, she had a morphine pump
procedure, at which a catheter is inserted to the specific site of her spinal pain
and fixed in position at the spinal cord origins of the nerves involved. A small
metal reservoir is inserted in her abdominal wall and is attached to the
catheter, under her skin. The reservoir also incorporates a tiny mechanism
which controls the flow of morphine at a constant rate, over several months.
Tiny quantities of morphine are given, say one milligram per day, with very
little risk of any drug side effects. It provided almost complete pain relief, but
she had repeated technical problems with the catheter and eventually had it


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removed. Large doses of oral morphine make her very sick and cause severe
vomiting. Since the pump has been removed she has been and continues to
receive, pethidine once (and only once) daily for five years. This provides her
with about four hours of excellent pain relief, during which time she actively
works in her home. She is very happy now – 10/10 in fact, so I wrote a letter
recommending that she be allowed to continue to receive this regime.
Pethidine is often very problematic, but not for her.



Thursday 20th January 2005
I saw a friend who is my age and retired. A son runs the family business but
he often spends time there. Like me, he loves life and he is in excellent
health. As time goes by, he finds that he gradually has less energy and
enthusiasm, even for things in which he has always been interested. Ageing,
in fact is something that he accepts reluctantly and he realises there is little to
be done about it. Youthful vigour is remembered and for the present, some
regret is felt, as time marches on. I feel the same. But not everyone is so
accepting.

There is a television series on Altered Statesman screening currently. Both J.
F. Kennedy and Winston Churchill dosed themselves with amphetamines, to
give an appearance of energy or a level of arousal more in keeping with the
image they sought to display. Steroid administration and liberal doses of
alcohol were their other respective drugs. An article in the paper on
testosterone attests to its popularity among men, and also women, to increase
aggression, sexual interest and waning powers. Amphetamines are illegal
and as prostate cancer cells rely on testosterone for their growth, any one
with a history of prostate cancer would be crazy to try and boost their energy
with this potent hormone.


Friday 21st January 2005
A very relevant research paper for people in my situation is titled ‘Positive
resection margin and pathologic T3 adenocarcinoma of prostate with
undetectable postoperative prostate specific antigen after radical
prostatectomy’ To irradiate or not?’ It is to be found in the International
Journal of Radiation Oncology, Biology and Physics 2002 (Vol 52 No.3 pp 674
– 650 ).

Basically, the authors compared patients like me – with a positive margin
following radical prostatectomy for adenocarcinoma with an undetectable
post-operative PSA, with or without radiotherapy. Sure, those who had the
radiotherapy did better, with a 94% 5 year actuarial survival and 88% relapse
free rate, including an undetectable PSA after 5 years. But 65% of those
untreated with radiotherapy were disease free. About 30% had a rising PSA
and the other 5% had local or distant spread. On these figures, my chance of
having a rising PSA within 5 years are only about 1 in 3 and if I then quickly
start radiotherapy, I should join the winning, possibly 80%, disease free men,
assessed after five years!


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Saturday 22nd January 2005
The same article mentioned yesterday, by Choo et al (2002) has much more
information, not all of it encouraging. It has been found that men in my
situation who elect not to have further treatment may have a PSA relapse rate
of 75% within 10 years, though in this series 65% were free of PSA failure at
five years. One must watch for a PSA rise very carefully.

In this series they concluded that with radiotherapy ‘This was accomplished
with minimal risk of serious RT morbidity’. Two patients developed serious
genito-urinary complications (out of 73 men). One developed a urethral
stricture requiring dilatation and the other, hemorrhagic cystitis – bleeding
from the bladder – which needed treatment. None had serious bowel
complications. Only eight patients out of the 73 were potent before
radiotherapy (not many!) and another two (of these) developed ‘erectile
dysfunction’. It doesn’t sound as though one should hold one’s breath waiting
for good erections to return after prostatectomy! Interestingly, 25 men were
incontinent after prostatectomy before radiotherapy and in 9 of these,
incontinence actually improved with radiotherapy and none were worse in this
regard. Not all good news, but I could face up to it, when or if my PSA rises.


Sunday 23rd January 2005
Our weekends are relaxed and laid back usually, not like this last few days.
Coffs Harbour is warmer, that means hotter, than Armidale, and we spent
Friday and Saturday with friends just north of the city. It was through the
Lamborghini Club that we first met F and C. F restores exotic cars and has
three Lamborghinis of his own, an early model Countach and two Urracos,
both of these later models, in his workshop, close by my little green and white
Mini Cooper S, which is now in an advanced state of its complete restoration.
My car has been a hill climb competition car with modified suspension and
engine and I am looking forward to driving it in a couple of months.

Luncheon at Petersons vineyard drew us home, as one of my colleagues has
just retired. A is going to give (or administer) anaesthetics in his retirement ,
just like another doctor here in Armidale. J, who is retiring at 69 in October, is
going to teach anaesthetics in Niger, a poor African nation, where the vast
majority of anaesthetics are administered by nurses. She will teach at a
mission hospital where she is already known, having worked there in her
holidays, for years.. In April, when I turn 68, I shall continue as an
anaesthetist as well. We all agree that we still enjoy being doctors and
continuing to work, if part time, which vindicates our choice of occupation.
Everyone is spending hours watching the Australian Open tennis at present..


Monday 24th January 2005
There is a late night television program on ABC TV on death. Last night’s
program examined the role of ‘fighting’ cancer or other potentially fatal
conditions, such as Crohn’s disease, and a definitely fatal disease, cystic


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fibrosis. Lung cancer patients often do not last long after diagnosis – 80% are
dead within three months – but the patient in the program lived three years!
The will to live, positive thinking and support from family and friends makes a
difference.

Most patients want to know what the future holds, but 60% of the time, their
doctors, not wishing to be the bearer of bad tidings, are loath to tell them! So
the program informs us! My GP today did a snow job (treated with carbon
dioxide ‘snow’) on a couple of solar keratoses on my hands, and agreed.
Visiting a centre where melanoma, a notorious killer, is treated, the therapist,
on being asked what he told the patients, simply said that for many, he told
them they were probably cured. My friend said – ‘but that is all lies’-- and the
therapist agreed! We are only human, but if you suspect that you are being
reassured without good reason, think about it, even consider getting another
opinion.

Tuesday 25th January 2005
A born optimist, it is somewhat reassuring to be told by a radio-oncologist who
has studied my pathology report, that I may never need radiotherapy and may
live another ten or twelve years. Then again, prostate cancer of grade T3, a
NOMO, such as mine, is somewhat unpredictable, and despite all dietary
modifications, monitoring of PSAs and early radiotherapy if there is a rising
PSA, it may spread into bladder, rectum or pelvis locally or more distantly into
bones, liver, brain, lungs or elsewhere, at some future date. T3 a means the
tumour has spread on one side of the prostate, seen as one positive margin.
NO indicates there has been NO spread to regional lymph nodes and MO
means there is no detectable distant spread (metastases).

The old Boy Scouts Motto “Be Prepared” is applicable. Our double bed is
fairly low, has an eggshell mattress and is close to our ensuite bathroom.
There are no more than two steps to climb from one room to another, in our
home. One would need to be very disabled before one had to move from
home. Our youngest son is industriously building a ‘disabled’ apartment, with
no steps, at his home in Victoria, where there are many services. We think
ahead.


Wednesday 26th January 2005
I am hopeful that my comments on my experiences as a prostate cancer
patient will be of interest to other men. My worry is that my writing is rather
uninhibited. None of my family has read a word of it and they may not wish to
face embarrassment. Caroline, our clinic secretary, while typing these words,
has no reservations as to the content. Perhaps, if my experience is anything
to go by, some men may feel I have said far too much. A lot of other prostate
cancer literature is less confronting and less controversial, in some respects.

The literature seems to suggest that spouses are often more distressed than
prostate cancer patients, some of whom are very reluctant to discuss their
diagnosis. It is possible that partners of patients may see this book as a
source of information as they read about how one man, a doctor with a keen


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interest in quality of life, has coped as a patient undergoing radical
prostatectomy.


Thursday 27th January 2005
Rashid (2003) in his consideration of factors which may decrease the risk of
prostate cancer, mentions two dietary measures which I have not so far
incorporated into my daily regime.

Green tea contains a polyphenol known as EGCG which a Mayo Clinic study
found inhibits or even destroys prostate cancer cells in high concentrations.
Those in China and Japan, the homes of green tea drinkers, have a much
lower death rate from prostate cancer. The figure for Australia-- at 19 deaths
per 100,000-- is far higher than the Japanese rate of 5.1 deaths per 100,000
in 1999, though it is certainly not claimed that green tea drinking is the only
factor.

Selenium is the other dietary factor, which I have been following up. It is toxic
in high dosage (750 mcg/day) but Clark et al (1998) found a decreased
incidence of prostate cancer with selenium supplementation. Two hundred
micrograms per day is suggested. So far, the highest doses I can find in
pharmacies, in men’s health preparations, contain 26mcg per capsule, at
great expense, with a lot of other supplements. I shall search for a more
suitable product.


Friday 28th January 2005
Today we are driving to Sydney to attend my fortieth anniversary medical
graduation dinner. The same people seem to attend these five yearly events.
One friend says he will not attend this year, as he is worried that he will be
depressed when he learns of those who have dropped off their twigs! Well, it
will be worse next time, so I am still keen to go.


 If you are thinking of trying to review the literature on prostate cancer, then I
would encourage you to seek the help of an experienced librarian, who can
make the task easier. There is plenty to read and much of it is outdated.
Perhaps the greatest difficulty that I have had, is finding that many studies
have tended to combine patients with different problems into too few
categories. When they undergo a standardised regime (if it is actually
standardised and not varied, as they often are) it is like comparing apples and
oranges. For instance, following radical prostatectomy one’s PSA may or
may not fall to undetectable levels within a few months of surgery. If it does
you are in a different category to the people with persistently elevated PSA. It
is an important distinction.


Saturday 29th January 2005
We arrived in Sydney yesterday afternoon and are staying with my sister H in
Willoughby. Her husband C drove us to the Intercontinental Hotel for the


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dinner this evening. Admittedly, it was hard to recognise some of the one
hundred and fourteen graduates and their partners, though a lot of our friends
were there and a good time was had by all. Only fifteen of us have retired,
according to the figures given, out of two hundred and fifty six graduates..
Thirty have died and some are not well. One attendee has secondary
prostate cancer deposits in his bones. Another, one of the twenty-seven
doctors who have made their careers overseas, has leukaemia and is to have
a bone marrow transplant. Most of us, though still happily working, are not
still on call at nights or weekends for emergencies, any more. Some friends
have no retirement plans and are looking forward to working forever,
apparently.

In five years time we shall meet again, God willing. The remarkable thing is,
in my opinion, how few of us have retired. Simply put, we enjoy ourselves,
are happy with our professional lives and are in no hurry to retire. One of our
number Is President of the American College of Surgeons. Some others have
dropped out of Medicine, as a career. One is now a famous mathematician,
another is an Industrialist of note, a third is now a professor of Anthropology.


Sunday 30th January 2005
Last Thursday, I was investigating the possibility of obtaining selenium in a
suitable preparation that would allow me to take 200 micrograms daily without
undue expense. I rang my friend J, a retired CSIRO research scientist and he
was very helpful. He has had radiotherapy for his prostate cancer and all is
clear on PSA testing for three years now. Another veterinarian, a friend of his,
was diagnosed with metastatic prostate cancer in his bones. After reading all
he could, on dietary modifications aimed at inhibiting prostate cancer cells, he
started taking selenium – 200 micrograms daily, I believe. Yes, he died – but
not for thirteen years! Selemite-B is made by Blackmores®, contains the
equivalent of 50 micrograms of elemental selenium per tablet and is about
$16 for 100 tablets. Possibly the vet was just lucky, possibly it is worth taking.
It is available at pharmacies and each morning I take four Selemite-B tablets
with all my other vitamins and blood pressure tablets, washed down with
tomato juice. Salute! Ciao! Cheers! In this area of NSW and to our north,
there is widespread selenium deficiency and animals are given supplements.
It makes you think!


Monday 31st January 2005
This evening, a friend rang up, knowing that I have had prostate cancer
surgery recently. A routine screening for prostate cancer by his doctor
revealed a PSA of 4.1 ng/ml. As he is 64 years old this level is still within the
limits suggested for his age. It has risen since his last check from 2 ng/ml, so
his doctor here in Armidale referred him to an urologist. Biopsies were done
and were positive and his Gleason score is 7, intermediate in the range for
aggression, like mine. He was given the options of surgery or radiotherapy
with the recommendation that surgery would be best in his circumstances, but
he was also referred to a radio-oncologist. The radio-oncologist said that if he
were older, say seventy or more, or had poor health, making surgery


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dangerous for him, then radiotherapy would be a reasonable option,
otherwise, on balance, surgery, being a radial prostatectomy, offered the best
chance of complete cure. He asked for my opinion as he was still unsure.
Nothing is certain or free of potential complications but he is now convinced
that surgery is his best option and relieved that my experiences with the
operation was positive in that I made a good, quick recovery and without
incontinence.


Tuesday 1st February 2005
Last Saturday night, at our Medical reunion dinner, I sat next to D, a
gastroenterologist friend and keen pilot. Every five years I see him for a
colonoscopy, and so does Elizabeth. Patients having this procedure are at
risk of a bowel perforation, which would require a laparotomy to repair the
damage. There is a risk of peritonitis and even, rarely, death. Curious to
know the latest on this subject, I asked D what the latest studies report.
Amazingly, a series from the famous Mayo Clinic reported an incidence of one
perforation on average, for every five hundred and fifty colonoscopies.
Another institution reported one in seven hundred. Why so many? Probably
because in these teaching institutions trainees are learning and the risks are
higher than the commonly quoted figures of one in one thousand. Are all men
equal? Why would I prefer to go to my friend, other than that he’s a nice guy?
He has had one perforation (in a woman in her eighties with diverticulitis), in
his last seventeen thousand colonoscopies!


Wednesday 2nd February 2005
In terms of quality of life, happiness and distress, marriage is central in my
existence. Elizabeth and I decided to marry just ten days after we met, when
she was nineteen. Never, in the more than forty-four years since, have either
of us, for a moment, considered a divorce. Professor Kim Halford of Griffith
University (Sunday Life, May 16, 2004 P13) says ‘There’s an argument that
successful couples don’t have one long relationship but have five and six
relationships going in eight to ten year cycles. They re-invent themselves,
redefine the way they spend their time and find new ways to have fun
together. The things you enjoy at 28 are different to how you want to spend
your time at 38 and different again at 68. If, as a couple, you can continue to
develop new interests, you’re going to enjoy spending time with each other’.

In 1993 we flew to Antigua, for the first time, at the urging of our son Andrew,
who had fallen in love with this earthly paradise. Elizabeth was reluctant to
spend our week there on a diving course (which I had enrolled us for) which
culminated in us obtaining our PADI licences. She is keener on diving now
than I, and it was she, who later bought a share in a catamaran, for annual
Caribbean diving trips. Shared interests enrich our lives.



Thursday 3rd February 2005



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We have fun, taking responsibility for our investments. Elizabeth belongs to a
share investment club and attends regular meetings in town. She encouraged
me to join with her in a chart trading group, expensive to get in to, requiring
close monitoring of the share market and potentially able to increase one’s
chances of market success – but it is not for the lazy or faint hearted. We
each often speak to our broker at our Investment Bank and quite often follow
his recommendations. Elizabeth runs my medical practice, sends out
accounts, writes up everything including our DIY(do it yourself)
superannuation fund affairs and runs a portfolio of her own.

Real estate purchases, development of properties and more recently sales,
are other joint interests which occupy us both. Elizabeth also makes curtains
for rental properties, we have done repairs and I even painted one house
myself. All this is done in a very small way, but it involves us both and our
boys, at times – a family interest which strengthens our marriage, our finances
and our family.


Friday 4th February 2005
It is thirty years ago since my family and I left Canada for Armidale, perhaps
foolishly, for our children were growing older and we thought this move would
provide a stable educational environment Soon thereafter, I commenced
research in the Microbiology Department of the University of New England
(UNE), investigating the effect of environmental temperature on the mortality
rate of mice with experimental Escherischia Coli or Staphylococcus Aureus
septicaemia. Nearby was the Department of Genetics and here I met my
friend H, from Egypt and later, a Professor in Libya.

Today H rang me, as he has had a rising PSA and now has been told the
results of his recent prostate biopsies. He has prostate cancer, Gleason
score 7, the same as mine. It affects most of one side of his prostate, but is
seemingly well localised within the capsule. His PSA recently was 6.0
nanogram/ml. He is to have a radical prostatectomy. He has published
research in the journal Nature, on some genetic effects of radiation and is
aware of the side effects of radiotherapy. His surgery is scheduled for later
this month.


Saturday 5th February 2005
A typical summer Saturday, so I shall describe what I mean by optimal quality
of life, these days, for me. We got up later than usual, on a fine, but cool
sunny day and soaped each other thoroughly in our long shower together.
Elizabeth packed a picnic lunch. I checked the oil and water in the Range
Rover, topped up the gas tank and we enjoyed our drive to the Transport
Museum at Inverell, where we greeted the volunteers, who open the museum
from 10 a.m. to 4.p.m. each day.

Elizabeth climbed in to the back seat of the Limousine, which also has
‘occasional’ seats in the rear for attendants, and we drove out of town for
some miles, admiring the beautiful summer scene. The country side is a


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picture. Her namesake, (Queen) Elizabeth, has also used this Limousine on a
Royal Tour, whilst it usually was allocated to Harold Holt by the
Commonwealth Government.

Later, we gave the Jensen Interceptor a run, enjoying its 330 horse power and
stopping at a park for a picnic. On the way home we chose to return via
Bundarra. We met a friend who was flying home from Tasmania, calling in to
have drinks with his family, before Elizabeth started watching Parkinson on
ABC TV whilst I spent a little time at the computer. I think Sunday will be
another fine day!


Sunday 5th February 2005
Larry Writer (The Australian Financial Review Sept 3-5 2004) wrote an
interesting article on life after cancer. He profiles the experiences of some of
the 85,000 Australians annually who have been diagnosed with cancer and
survived their initial therapy. After diagnosis, there is typically a scary and
stressful period of despair, hope and ‘gruelling treatment, when life, literally, is
in the balance’. And then? They reassess their existence, as they recover.
His interviewees reassess their life priorities, focus on what is important to
them and abandon the worthless. Life, not endurance!

Firstly, they avoid stress and discord at work and at home. Some leave jobs,
to concentrate on occupations which they find more worthwhile and give them
pleasure. Others work part time. Life is precious and each day is highly
valued, like the day I described yesterday. John Fahey, former NSW premier,
does what brings him joy and, like others, advocates a positive attitude to
survival. He gives thanks and says a Hail Mary for every new day. Some
take up new hobbies, careers, and quests, exercise more, spend time with
their families and, importantly, spend less time with those who affect them
negatively.

It is another nice day and time for my walk. I may see some kangaroos.


Monday 7th February 2005
As time goes by, I learn more from my patients about the meaning of Quality
of Life. Last Friday at a pre-operative clinic, I examined an 86 year old lady
who was accompanied by the manager of the Aged Care Hostel in which she
lives. Both agreed when shown the proposed definition of QOL. ‘Quality of
Life is being able to do what you want to do, when you want to do it, together
with the satisfaction/happiness that accompanies it’ generated by my studies
with cancer patients.

We also agreed that the knowledge that one is able to do things is an
important factor in people’s assessment of their QOL, even if they rarely
actually do what they say they like to do.

Many of the patients attending my early joint clinics express an interest in
many more occupations than they actually seem to generally do, when


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assessed with detailed occupational questionnaires. On reflection, I admit
this is true for me, as well. One reads and thinks about, plans and organises
to do many activities days, weeks, months or years ahead. Is this aspect of
existence an integral part of QOL? Is designing a building part of building it?
And the pervasive memory of a good holiday – is that not part of the
experience?




Tuesday 8th February 2005
A minority of patients express interest in very few occupations. For many of
these individuals, their chief occupation, be it paid employment or a hobby, is
their main interest in life. For as long as such a person is capable of
continuing to perform well, perhaps exceptionally well, at their sole or
predominant interest, all remains generally well, from the psycho-social point
of view. Such a person may be outstandingly successful in a profession or
business or have the best garden in their street. Patients awaiting joint
replacement surgery, with very few interests, are at risk of psycho-social
decompensation if they are no longer able to function acceptably in their
chosen occupation.

I fear for the colleague who has just retired after a long career as a
cardiologist, with absolutely no plans for the future, or other abiding interests.
‘I’m going to sit down for six months or so and think about it’! It is wise to
develop other interests prior to retirement. Another colleague who retired,
attempted to take up golf after retirement – it was not his game. He went
back to work – one of many doctors to return to the only thing they know. A
loss of interest in previously valued activities may be a sign of depression and
cancer patients with a history of significant depression, earlier in life, prior to
their diagnosis of cancer, may be at risk of depression, again.


Wednesday 9th February 2005
Yesterday, at a Pre-operative Clinic, I interviewed a sixty-three year old man
who went to his doctor for a health check in 2002. Blood tests were taken to
check for any problems and included a PSA test. He was requested to see
his doctor soon afterwards and told his PSA was 5.6 ng/ml – somewhat
above the maximum expected. This man told me he had never had any
problems with his health and had never heard of a PSA test. He was referred
to a urologist and six biopsies were taken, which showed he had prostate
cancer. The choice he was given was to have a radical prostatectomy or
radiotherapy. Concerned about the substantial risk of impotence following
surgery, he chose to have a course of radiotherapy. It is gratifying that he has
little problem with his bladder, though he has to pass urine more frequently,
and more frequent need to empty his bowels. Well then, I asked – is
everything all right otherwise. His wife nodded repeatedly when he told me
that after more than two years since radiotherapy, he has had no return of
erections! There is no sign of cancer.



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Thursday 10th February 2005
This week is a very busy one. This afternoon is the only time that I can go
and see my friend C, who is a principal of a thriving travel agency. If you
enjoy planning your own itineraries, it is much less likely that you will
experience problems if you consult an agent who is experienced and can
think laterally. Our original plan for our next holiday has had to be altered as
the hospital is short staffed and they cannot grant me ten weeks leave without
finding a locum. Six weeks is our limit.
Last night after eleven o’clock, it was possible for me to ring up our friend
Andrea and rearrange our accommodation in Antigua for two weeks in June,
then arrange to have the catamaran available for a week before this, in St
Martin. At the travel agency, C took twenty minutes to plan our trip and book
our tickets. We leave on 3rd June from home, flying to Sydney then Los
Angeles and arrive in New York at 5.20 p.m. the same day – in time for dinner
and a Broadway show. Next morning we fly to St. Martin, go diving, around
Anguilla and St. Barths, before flying on to Antigua for our two weeks, then on
to London and Pisa. Three hours later, we shall be in Pontremoli. How we
miss our sunny home there, overlooking the river Magra, below.


Friday 11th February 2005
If QOL is being able to do what you want to do, when you want to do it,
together with the satisfaction/happiness associated with it, then when does
our QOL start to reap the benefit of our firm arrangements to actually do what
we want to do? In the case of our forthcoming holiday plans, briefly
mentioned yesterday, perhaps it is right now, if I wish.

Elizabeth is out at a meeting of dementia patient’s relatives and the television
is off. Future plans can be experienced to a degree, sufficiently accurately to
be seen as a virtual reality, right now. This is possible as this trip will retrace
many treasured past experiences. Sit back, with eyes closed and no
interruptions. Friends arrive and drive us to the airport, which is recalled in
fine detail. Every little move one makes, from checking in, to climbing on
board, fastening seatbelts, listening to the pre-flight directions, taking off and
gazing at the country side, then clouds below. Thus our recollections and
anticipated pleasure combine. Many times we have journeyed to Sydney, Los
Angeles, New York, St Martin, London, Pisa and Pontremoli – gazed at the
beauty of the blues, turquoise and greens of the Caribbean below the plane.
Is not my QOL already enhanced?


Saturday 12th February 2005
Last evening, we were entertained by our friends R and A, at their home and
enjoyed the best Indonesian cuisine I have ever tasted. They spent nine
years in Indonesia working on different projects for the Australian
Government, recalled many interesting experiences and showed us an
interesting Dyak rug and other artefacts. R was occupied with science
laboratory analysis and related equipment. A is a clinical psychologist, so I
was soon asking her, her views on QOL. I told her that, essentially, cancer,


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chronic pain and pre-operative patients were in general agreement that QOL
is being able to do what you want to do, when you want to do it, together with
the satisfaction/happiness associated with it. The extent to which planning
and organising an occupation contributed to         QOL really interested me, A is
of the opinion that not only the planning and thinking about the activity, but
also the recollection and memories of the occupational activity afterwards, are
also relevant to overall QOL. This might be minimal in the case of activities of
daily living, but very significant in the case of major events such as a wedding,
sporting competition, or the painting of pictures.


Sunday 13th February 2005
Elizabeth and I flew to Sydney yesterday and attended the annual Australian
Acupuncture College Chinese New Year Dinner-Dance with about ninety odd
other guests. Some people had come from interstate and it was good to chat
with old friends. I asked S if he had reduced his long working hours. S said
that now his son is fifteen years old, he has ceased working in his medical
practice on Saturday mornings, to spend more time with his family, though he
is still working full time, from Monday to Friday. C, from Queensland, has
spent the last nine years working from 7a.m. to 2.p.m. in his medical practice
and the rest of the day, every afternoon, without pay, on the secretarial duties
he has shouldered, as Secretary of the College.

There are many doctors, far from all being Chinese, who practice
acupuncture, as part of their medical practice. R, like me is keen on research
and is now most of the way through a University of Sydney Ph. D degree in
the use of medical lasers, which are widely used as an alternative to needles
in Acupuncture. Sometimes I borrow a laser unit from the physiotherapy
department for my acupuncture patients.



Monday 14th February 2005
This morning a lady with lung cancer consulted me, having been referred b y
her doctor for a review of her pain management. She started having
problems last September, had a biopsy at bronchoscopy, confirming cancer,
as she had suspected, and decided against high risk surgery due to her other
serious health problems. I noted that she had recently lost ten kilograms,
though she is eating well. In the past, she has smoked for fifty years and is
now sixty-four years old. Two of her friends have recently died of lung cancer
and she is not at all surprised that she now has it. The importance of
personality cannot be over-emphasised. There is no evidence of anxiety,
depression, somatization or distress (despite high levels of unrelieved pain).
She has endured constant nausea and vomiting during the chemotherapy,
which lasted until January, yet claims she is pretty happy, with a score of
8/10, which is as good as the average of the rest of the community and rates
her overall QOL as good. The support she receives from her family is
excellent. She is quite independent, but requires home help for vacuuming
and in the garden. I have completely changed her medication for pain and will



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see her again next week. Braving down the face of the enemy is not confined
to military battle fields.



Tuesday 15th February 2005
Although it is still summer time, it was foggy when I left home at 6 a m and it
took several minutes, fiddling with air conditioning controls and windscreen
wipers before my vision was ideal. The traffic was light and moved slowly
with the poor visibility for about seventy kilometres of my journey north. This
morning I was tired and a long day giving anaesthetics and doing a clinic, lay
ahead. Circadian rhythms sometimes seem to mean the difference between
a good day and a bad day, but there are no excuses. In bed after midnight
and awake at twenty to five, what can one expect. In the past, there have
been countless times when emergency cases lasting many hours during the
night have followed a busy day and another lay ahead. It was not expected
that a list would be cancelled. Some years ago, I heard that an English junior
anaesthetist had qualified for ranking in the Guinness Book of Records for
having worked the most hours in a week, somewhat over 140 hours of actual
time in the operating theatres. Ridiculous and dangerous! There is more
recognition of the need for adequate rest and relaxation now, and this applies
to us all. Overtiredness is a killer on the roads too.


Wednesday 16th February 2005
Politics is a touchy subject and so is the Health System. My parents were
conservative and my father active in the Country Party before it became the
Nationals, being a branch secretary and always talking about political
meetings. Life as a doctor has constantly focused my attention on the
differences between the Public and Private Sectors of the heath system.
There must be many in our electorate, like myself, who do not vote for either
of the major political parties, as our Federal and State members of Parliament
are Independent. Sometimes I wonder how much State Premier Bob Carr or
Prime Minister John Howard care about the plight of so many Australians who
rely on our Public Hospitals. They tend to blame each other.

This morning a lady aged 53 years wheeled herself in to my consulting room
in a wheelchair, referred from a distant town, over 100 kilometres away, by
her doctor, for a review of her severe pain. She has severe osteoarthritis of
both knees—‘bone on bone’-- at arthroscopy last year, and in April (10
months ago) she was placed on the Public waiting list at Tamworth, for
bilateral knee replacements. Her pain on a typical day ranges between 6-9 ½
/10. Her hope is that she will have her operation ‘in July’. A private patient
could have surgery without waiting more than two weeks.


Thursday 17th February 2005
My Egyptian friend rang last night, to discuss his forth -coming trip to hospital,
to have a radical prostatectomy next Monday. Though he had received
detailed information from his Urologist, it is hard to think of everything at the


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time of consultation. Occasionally, patients jot down the questions that they
wish to ask, knowing that otherwise they are likely to think of something
important, after they have left the surgery or rooms. His questions were
simple enough, and perhaps they had been covered at the time and forgotten,
as so often happens, when thoughts may be focused on other aspects of
care. How long will the incision be? Will it be horizontal or vertical? Are there
stitches to be removed? How long will the procedure take? How much pain
am I likely to have and how effective is pain relief? How should I prepare
myself optimally for surgery? He will learn the answers when he gets to the
hospital, having an opportunity to discuss these details with his Surgeon,
Anaesthetist and staff. I told him to get plenty of exercise, like walking, before
he goes to hospital. My experience was that pain was not a major problem for
me and did not require much use of the PCA provided.


Friday 18th February 2005
One wonders if a prostate cancer education program to make men more
aware of this common cancer could enlist the help and support of prominent
men. Rupert Murdoch, the Emperor of Japan, the Duke of Edinburgh, Roger
Moore and Robert de Niro are a few of those I have read about, who have
been diagnosed with prostate cancer. Imagine the good publicity campaign
that could follow, if the influence and knowledge of such people could be
harnessed in a world wide effort. People associate prostate cancer, all too
commonly, with men who are old, yet it is certainly not unknown in men in
their forties and fifties. The mantra is all too commonly voiced ‘Prostate
cancer grows slowly, and you will probably die with it, not from it’. Someone
told me that today! Imagine the concern in the community and the flow of
donations to research, if prostate cancer caused the death of 2,600 little boys
each year, instead of their grandfathers, in this country.


Saturday 19th February 2005
It is my experience that, in life, it is better to try and face reality. Frequently,
this requires time and effort to be spent in learning as much as possible about
the problem or situation one is facing, in order to have the best chance of
ensuring the most positive outcome. Many years ago, I was kept awake all
night by severe abdominal pain, resistant to antacids and simple analgesics.
It settled in the morning. Let’s just forget about it? No way! Investigations
showed I had gallstones and abnormal liver function. If I ignored this
information I could end up overseas somewhere, needing emergency surgery.
I chose elective surgery, an open cholecystectomy and operative
cholangiogram and spent four days in hospital. Three days later I was back at
work, giving anaesthetics. Post-operatively, it was more painful than my
radical prostatectomy, by the way!

As a doctor, I have seen countless patients who have ignored warning signs
of something wrong, such as rectal bleeding or a change in bowel habit, a
lump somewhere, unexplained weight loss, or a strange looking mole. Once,
a forty year old painter, who had continued to work whilst suffering a cough,



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breathlessness and chest pain, was brought to hospital and died three hours
later of pneumonia!


Sunday 20th February 2005
Spinoza (1632-1677) wrote that we shall readily see the difference between a
man who is led solely by emotions or opinions, and a man who is led by
reason. The former, whether he will or not, performs actions whereof he is
utterly ignorant; the latter is his own master and only performs such actions,
as he knows are of primary importance in life, and therefore chiefly desires;
wherefore I call the former a slave, and the latter a free man.

Writing on the Right Way of Life, Spinoza said that in life, it is before all things
useful to perfect the understanding, or reason, as far as we can, and in this
alone man’s highest happiness or blessedness consists. Wherefore of a man,
who is led by reason, the ultimate aim or highest desire is that whereby he is
brought to the adequate conception of himself and of all things within the
scope of his intelligence. Therefore, without intelligence there is not rational
life.


Men need to look after themselves, have regular health checks and in my
opinion include a PSA, certainly as they get older! One sees so many men
and women, every day, who unfortunately, have not looked after themselves
and have to live with the consequences.



Monday 21st February 2005
Today is the scheduled date of my friend H’s radical prostatectomy. He was
going to travel down to the city, where he is to have his surgery, with his wife,
I, ready for admission, well in advance. On Wednesday, I shall ring up and,
hopefully, speak with him. Next weekend, Elizabeth and I plan to take Peter
Rabbit back to our grandchildren in Sydney. We intend to return via the
coast, travelling up through Newcastle, Port Macquarie, Coffs Harbour and
thence through Bellingen and home. H will almost certainly still be in hospital,
so we intent to visit him, if possible, during the weekend.

After this visit we are to inspect my 1966 Mini Cooper S Mark I, which is
rapidly nearing the completion of a total restoration in Coffs Harbour. I
mentioned recently that the restorer was to have a colonoscopy for persistent
left sided abdominal pain, and with his history of polyps, I feared bowel
cancer. Thankfully his colonoscopy was clear and further testing suggests
irritable bowel syndrome. He and his family are relieved. The only
modifications that I am having on the Mini is the fitting of an alloy roll cage,
padded and leather trimmed, to provide more protection, in the event of a roll
over and a walnut dashboard, for aesthetic reasons.




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Tuesday 22nd February 2005
Good news! Excellent news! Progress with the Vacuum Erection Device!

Young Garry rang, early this morning, just before he went to work at Garden
Island. More Australians are scheduled to be sent to Iraq, so that is certainly
going to make life busier for him, as the officer in charge of the Naval
Operations desk for Iraq. Anyway, that is not the news that I am talking
about.
After the phone call at 6.45 a.m., as I have a day off today, Elizabeth and I
had plenty of time for a cuddle. After an hour and a quarter, it was time to
assemble the Vacuum Erection Device, and use it. I have learned not to aim
for a really hard erection, using a tighter Silastic ring, which tends to hurt and
make the glans cold. A larger ring, the largest provided, in my case, is a
better choice, less stiffness, but less discomfort.         A few minutes later,
success.      Multiple orgasms for Elizabeth, though despite improving
sensations, not any orgasm for me. This is the first real, proper, dinky-di,
traditional missionary position, success for Elizabeth since my surgery. In
fact, her first multiple orgasm since we were at our home in Tuscany in
September. A little more time and I can probably succeed too. Four months
and eight days since my radical prostatectomy!


Wednesday 23rd February 2005
In our lives we seek beauty. In these pages, at times I have described in
some detail, the beautiful Caribbean area we visit and other scenes. The
choice of a certain car, or even a television, will be influenced by our
perception of it as being more or less beautiful. We think that beauty enriches
our lives. Immanuel Kant, though of Scottish ancestry, was born in Koenigber
in 1724 and died in 1804. He was a professor of logic and metaphysics for
forty two years and had a few words to say on beauty which one has always
believed enriches QOL and happiness.

He believed that the beautiful pleases immediately. It pleases apart from any
interest. The freedom of the imagination is represented in judging the
beautiful as harmonious with the conformity to law of the understanding. The
subjective principle in judging the beautiful is recognised as universal, that is,
as valid for every man, though not cognizable through any universal concept.
We often describe beautiful objects of Nature or art and that may explain, in
some measure, the public’s preference for Princess Diana over Mrs Camilla
Parker Bowles!


Thursday 24th February 2005
We are anticipating having a fruitful weekend away. Our QOL includes a lot
of tripping around and we shall drive to Sydney to return Peter Rabbit to our
grandchildren and spend time with their parents. On Saturday we leave, visit
my friend who is still in hospital after his radical prostatectomy.

Perhaps we have a desire when young, to buy or have an object, go
somewhere or achieve an ambition which does not eventuate at the time.


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Later, circumstances may change and, years later, our previous enthusiasm is
re-ignited. Once, when we lived in England and the kids were very young, we
had a second hand Morris Mini Minor 850, a blue one, with a white top! It was
a great little car. The year was 1967 and I could not afford a Mini Cooper S,
World Rally Champion, three times Monte Carlo Rally Champion, winner
against all comers at Bathurst! Now I have taken the opportunity to acquire
one. This car has only 19, 904 miles, a racing history and is British racing
green with a white turret. So far as I am aware, it has never suffered any rust,
or tin-worm, as it is sometimes known. Completely restored to original, it
should never depreciate. I am looking to enjoy its performance and maybe a
sense of nostalgia for a time, now long past. Certainly, it will represent the
achievement of an ambition long held.

Friday 25th February 2005
After work this afternoon, we drove to Sydney later than expected and our
grandchildren have gone to bed. Young Garry and I carry the hutch
containing Peter Rabbit, to the back lawn. We are going to miss Peter, who is
now quite tame.

Whilst Garry and his family were in Thailand, my friend B ( the father of C, the
Thai student who stayed two years with us and who is now married, with a
family of his own), asked Garry to give me a present. It is a beautiful, pure
silver, medallion, commemorating the King’s 50th Anniversary of accession to
the throne. The family are not poor. The family paid for Elizabeth, Lisa-Jane,
young Garry and I, to fly to B’s son C’s wedding, plus accommodation in
Bangkok. Bangkok traffic was halted as our motorcade of one thousand
guests crossed the city to the wedding reception. B introduced me to the
guest speakers at his son’s wedding, the President of the Diamond Dealers
Club of New York and the Heads of the Thai Police and Thai Army. C’s bride
wore more than a million dollars worth of diamonds, including a diamond tiara.
B’s home in Bangkok is surrounded by a moat and there were twenty house
servants, when we were there. They had eighteen homes around the world. I
am wearing the gold and steel Rolex that C gave me, whilst in Australia at
school. Some family!


Saturday 26th February 2005
Early this morning Sophie and Alexander leave for their tennis lessons.
Sophie has missed two weeks of gymnastics training, through being away
skiing in Austria and Germany and this afternoon she will have much to learn.
Young Garry and I spent the morning changing his Mercedes number plates
to the personalised ones that I have given him, first at the RTA Office then at
the service station. He does some shopping for family bicycle spares and a
pump whilst we spend quality time together. I encourage him concerning his
onerous duties concerning Naval personnel who have to be transported with
equipment, to Iraq, Garry is contemplating requesting a trip to Iraq, to see first
hand, the situation that the Navy people will face there.

After Sophie has finished her gymnastics, and Elizabeth, her shopping, it is
after 5 p.m. and we leave for the north. There has been a major truck


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accident north of Newcastle and the Pacific Highway is closed for seven
hours. The detour is long and slow, but I enjoy driving, as always. We arrive
at Taree just after 8.30 p.m. and decide to stay the night. It is, as we
expected, a full weekend.


Sunday 27th February 2005
Elizabeth and I arrive at a private hospital on the NSW coast at 10.15 a.m. to
visit our friend. When I spoke with him on 22.2.05 following his radical
prostatectomy, two days previously, he had sounded sleepy. Now he is
resting in bed and is pleased to see us. He and Elizabeth belong to the local
Share Club which meets regularly, to discuss various share market
investments. At present he is disinclined to read newspapers or learn of any
negative news events. Since his operation he has not regained a healthy
appetite. Yes, he goes for a walk, he said, indicating the nearby walking
frame. It is now six days since his surgery. Three days after my radical
prostatectomy I was confidently walking five kilometres daily and I never
sighted a walking frame. There is no report from the pathologist yet but his
surgeon is confident all will be well. I hand him a copy of my first three
months journal entries, some 50,000 words, which he will read, consider and
write a commentary on. We discuss some aspects of genetics as relevant to
prostate and breast cancer. When he returns to Armidale we shall see each
other again. He has no pain.


Monday 28th February 2005
Living with cancer or the threatening potential return of cancer, is an everyday
cloud in the lives of many early cancer survivors. This morning, a middle
aged lady, who works as a diversional therapist with elderly people, consulted
me at the Pain Clinic. Last November, following the onset of pain in her back
she was diagnosed with a plasma-cytoma, which was, as she said ‘eating
away my seventh thoracic vertebra’. Her doctors recommended a course of
radiotherapy, which promised to rid her of this problem in a month. Her faith
was shattered, when her course of radiotherapy, made ‘not the slightest
difference’. ‘It was still consuming my vertebra, as before’. Major surgery,
with the replacement of the now destroyed vertebra with ’a cage and screws’
was required. The surgeon is optimistic that now, all will be well. Morphine
was required for initial pain relief then scaled down and Endone® plus
paracetamol provided good pain relief. Now the Endone® is no longer
effective, her pain levels in her chest and mid-back area are increasing again.
All investigations so far, are negative. They will be repeated. She is
depressed, anxious and needs pain relief.


Tuesday 1st March 2005
Today will be a busy, twelve hour day and I shall be giving anaesthetics all
day. Yesterday morning, it being six weeks since my last PSA, which showed
no sign of cancer with an undetectable level of PSA, it was time for another
test, on my self imposed regime of having PSAs twice as frequently as
commonly recommended. An earlier indication of trouble with a rising PSA


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may allow me to start radiotherapy three months earlier, if indicated, I figure.
The down-side is that the build up to the test, then the wait before the result is
known is not a very joyful period. My blood sample was taken just after 9 a.m.
whilst I had a patient filling out his own pain assessment forms. At 4 p.m.,
when I returned to the Pathology Department, in the middle of another clinic,
the result was in the computer. My PSA level is <0.01 ng/ml, in other words,
undetectable. Relief! No need to start thinking of cancelling our planned
holiday overseas. Time to think about what date I should have my next test.
No wonder some men just ‘forget’ to have follow up PSA tests. I am more
frightened not to have them!


Wednesday 2nd March 2005
On my way home yesterday, I called in to see my friend J and his wife A. It is
now over two years since he had his radical prostatectomy and he is still
having regular PSA checks, despite the successful complete removal of his
cancer at operation. Each time we are about to have our blood tests, our
level of anxiety mounts. Relief follows reports of undetectable levels of PSA.
Other men are in a similar position after prostate cancer surgery, again and
again. How should we view this, philosophically? I have always had a good
deal of respect for the philosophical views of Spinoza, so I plucked a volume
of his writings from my study shelves and shall share a few of his thoughts
with you, relevant to the situation.

Baruch Spinoza was born in Amsterdam in 1632. His family belonged to the
community of Jewish emigrants from Spain and Portugal who had fled from
Catholic persecution and now lived in the ghetto in Amsterdam. Despite his
upbringing, he was changed by the writings of Descartes, culminating in his
excommunication by the Jewish authorities in 1656. He devoted himself to
his writing, including his Treatise, Ethics and other works, supporting himself
by grinding optical lenses. He was offered the position of Professor of
Philosophy, refused the appointment and died at the age of forty-four, of
tuberculosis.


Thursday 3rd March 2005
Spinoza wrote that the mind has greater power over the emotions and is less
subject there to, in so far as it understands all things as necessary. But
human power is extremely limited, and is infinitely surpassed by the power of
external causes. ‘We have not, therefore, an absolute power of shaping to our
use those things which are without us. Nevertheless, we shall bear with an
equal mind all that happens to us in contravention to the claims of our own
advantage, so long as we are conscious that we have done our duty, and that
the power that we possess is not sufficient to enable us to protect ourselves
completely; remembering that we are a part of universal nature, and that we
follow her order. If we have a clear and distinct understanding of this, that
part of our nature which is defined by intelligence, in other words the better
part of ourselves, will assuredly acquiesce in what befalls us, and in such
acquiescence will endeavour to persist. For, in so far as we are intelligent
beings, we cannot desire anything save that which is necessary, nor yield


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absolute acquiescence to anything, save to that which is true; wherefore in so
far as we have a right understanding of these things, the endeavour of the
better part of ourselves is in harmony with the order of nature as a whole’.
Also ’the mind has greater power over the emotions and is less subject
thereto, in so far as it understands all things as necessary.’ Think well on
these words! There are those, perhaps all of us, at times, who find occasions
when the emotions have greater power than the mind. I cannot remember
who wrote that ‘the erect penis has no morals.’


Friday 4th March 2005 and Saturday 5th March 2005
All day today I am assessing patients referred for pre-operative assessment
prior to scheduled surgery. They are only referred if they have health
problems posing increased risks with anaesthesia and surgery. At the
conclusion of my examination, having reviewed their past history and current
electrocardiograph and physical findings, we discuss the risks they face. In
the forty years since I graduated, the risks associated with anaesthesia have
plummeted, from one death in every five thousand to more like one death in
fifty or sixty thousand. We operate on very many patients, often for major
procedures with advanced, life threatening diseases. Healthy patients face
risks associated with anaesthesia too. All these risks are discussed, as
patients have the right to be aware when they given consent.

The vast majority of patients recognise there is a small risk of, as I put it to
them ‘death and disaster’ and are not overly concerned. Neither was I, prior
to my radical prostatectomy. Last year I anaesthetised an obese lady in her
eighties with a heart murmur. She had an anaphylactic (severe allergic)
reaction to an antibiotic given to her, collapsed immediately, required
resuscitation and an adrenalin infusion for twenty-four hours in intensive care.
She made a complete recovery. I vividly recall the other three patients who,
on receiving an intravenous drug at anaesthesia, within a minute had no
recordable blood pressure and almost absent pulse, with anaphylaxis.
Without immediate resuscitation, they would have died, as many patients
have, over the years, perhaps most frequently, from penicillin. The numbers
are small. In my whole career four patients, all successfully treated, out of
about fifty thousand patients that I have anaesthetised, in total. Some of my
colleagues have never had one – but then I have never seen a case of
malignant hyperthermia, which can be rapidly fatal, and is associated with
anaesthesia, requiring very specific and intensive therapy.

Spinoza wrote that human power is infinitely surpassed by external causes
and patients accept that there are risks outside their control, just as most of us
do, when we climb aboard an aircraft. We pass the responsibility associated
with performing necessary surgery, or of getting us safely to the next airport,
to professionals. There is then, no point in worrying further. A quick death is
no worry to me. I am sometimes asleep before my plane takes off!


Sunday 6th March 2005



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The Australian Formula I Grand Prix is run today and I am watching it on
television. Qualifying for positions at the start is over and there is time to write
a few words about QOL. On our overseas holiday we shall spend two weeks,
from the second to the sixteenth of July, in the heart of the summer high
season, at Roquebrune- Cap- Martin, on the border of Monaco. We
exchanged two weeks of time-share holiday time, accumulated at Port Pacific
Resort at Port Macquarie, for two weeks at Le Golf Bleu, overlooking the
Mediterranean, six hundred metres from the beach, with a gymnasium and
swimming pool and within walking distance of the heart of Monaco. The
accommodation cost for two weeks will total less than one thousand dollars
and the apartment is self contained and big enough for four. This morning, it
took me five minutes on my computer, using Google, to find an apartment
overlooking the sea at Monaco, with three bedrooms, yes, all with ensuite
bathrooms. It is for sale for ten million five hundred thousand Euros, or about
nineteen million dollars Australian, including taxes and furnishings. When you
look up at apartment buildings in Monaco at night, there are few lights on, as
many apartments are rarely occupied. With a little planning, we shall enjoy
top QOL at minimal cost, as we have before.


Monday 7th March 2005
You do not have to own a time-share week or weeks at a resort, such a Port
Pacific, to get really good accommodation overseas. We actually bought our
‘week’ for five and half thousand dollars, half the price that it had been a
couple of years earlier, during a recession, many years ago. There are
organisations such as RCI, Resort Condominiums International, which
arrange swaps with thousands of other time-share resorts. We have enjoyed
wonderful holidays in Sardinia, Switzerland, Prissian and Cavalese in the
Italian Dolomites and elsewhere, in two or three bedroom luxury units, which
would otherwise have cost thousands of dollars per week. Without bothering
with time-share purchase, just look up the accommodation you want on your
computer, on Google, or whatever is your choice. Today, if you look up
Cannes apartments to rent, you will find a beautiful apartment for four, close
by The Croisette, the beach front area in Cannes, where the Cannes Film
Festival is held, for 400-650 Euros per week, though not at the time of the
Festival, of course. Others are available for 70 Euros per night. No more
expensive than going to the coast, apart from airfares. In our view, it is
another world, with off shore islands to explore too. QOL at close to its best.


Tuesday 8th March 2005
All in one morning, I heard three cancer stories, in the last twenty-four hours.
One patient of mine told me about her brother aged sixty-six, who has
metastases from his prostate cancer, in his lungs. He has been given local
radiotherapy and chemotherapy which has affected his bone marrow, she
said. There is talk of a possible bone marrow transplant – news to me. A
friend who has had radiotherapy for his prostate cancer and is doing well,
rang to tell me about another man who has had radiotherapy for his prostate
cancer, followed by severe and persistent bleeding from his bladder. He is
having treatment in a hyperbaric chamber, he was told, to aid healing. I am


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telling you these stories as they give an indication of the possible pleasures in
store for me too, if my PSA goes up and treatment leads to complications, or
is ineffective. My attitude is, foolishly, the same as people often tend to think
applies to those who have road accidents – they happen to other people – not
me. Who’s kidding? The third story also told by my friend who rang up,
concerns a school friend of his, with inoperable pancreatic cancer, who is
having radiotherapy and chemotherapy – he is not well! All I can do is
optimise my QOL and not waste my precious time.




Wednesday 9th March 2005
Elizabeth went out for the evening for her computer course lesson. It was up
to me to provide a tasty supper and I saw the Osso Bucco we had bought.
Although Elizabeth has best part of two hundred recipe books, I am happier
doing my own thing in the kitchen. A couple of cloves of garlic, three onions,
a dash of oil over the Osso Bucco and I am on my way. A touch of bacon,
half a small cabbage and tomato juice, fresh tomatoes, some celery, diced
potatoes, basically whatever takes my eye. Two hours later, after pouring a
little Lamborghini wine into the Osso Bucco pot (Ferrucio Lamborghini didn’t
just make cars, he had his own vineyard), I was sipping some more, when
Elizabeth returned and pronounced my efforts successful. She is now resting
for a few minutes, as we finished the bottle of 1994 Sangiovese, Ciliegiolo and
Gamay “Sangue di Muira” – named after the famous Lamborghini Miura – one
of the most beautiful cars, ever produced. Now it is 11.23 p.m. and I am
writing this, sitting at our thirteenth century reproduction Spanish dining room
table – it is rather ornate. I like Spain and we have a rather nice Spanish wall
hanging in our gallery, from Toledo, that I remember purchasing when I
attended a conference in Madrid, in 1974.                  A pleasant evening!



Thursday 10th March 2005
Over the years I have read a lot about sex. There are hundreds of pages of
articles related to sexual happiness in my study. One wonders if other men
take much of an interest in the literature. If not, they may be missing out on
something. Well – I have been missing out on something, which I had always
ignored, when erections were not a problem. Recently I read again about a
technique that I had not seriously considered.. The idea is, one commences
with some appropriate foreplay, then at the right time, approximates the
missionary position, even with a softish partial erection, which is the best I can
mange. No penetration is attempted, merely the approximation of penis
against the clitoris is sufficient, with mutual thrusting. No successful orgasm
for me, but never mind, close and very stimulating contact and definitely
satisfying for Elizabeth, without all the mechanical and unromantic efforts
associated with the Vacuum Erection Device. This is all natural and she is
certainly not disappointed. As for me – well if she is happy then so am I and I
can masturbate any time.



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Friday 11th March 2005
Do you like to day-dream? It costs nothing and when there is little else to do,
then why not! A little knowledge concerning a favoured subject can enrich the
experience, if that is the appropriate term for a fantasized QOL. When we
arrive in Monaco in July, we shall wander around the yacht harbour. We
always do and there are some fabulous yachts to see, among those moored
there. There is every chance that we shall see some of the largest super
yachts in the world there, such as Atlantis II and Lady Moura, numbered
amongst the ten largest and most glamorous anywhere. I can visualise, in my
mind video, just where they will be moored. One reads yachting magazines
and learns about them. Atlantis II is 379 feet 7 inches long and the Niarchos
family keep her in Monaco, seemingly for most of the year. Since Stavros
Niarchos died a few years ago the family rarely use her. Lady Moura is just
beautiful, with a sizeable helicopter aboard. Nasser al Rashid, a billionaire
businessman in Saudi Arabia and advisor to King Fahd, has owned her since
new. She has a top speed of over 20 knots and is 349 feet long. Not all art is
in art galleries. Jon Bannenberg, an Australian who died in 2002, designed
about 200 megayachts and was one of the world’s foremost designers for 30
years.


Saturday 12th March 2005
Since Tuesday 8.3.05, more cancer news has come to my notice. My sixty
year old friend D who had his radical prostatectomy on Monday, has spent
most of the week in an intensive care unit, and told me his pain has been a bit
much for him. On the good news front his cancer was confined to the
prostate and seemingly completely removed.

A middle aged lady presented to my Pain Clinic this week, and incidentally,
the subject of cancer came up. In 1992 she had a lumpectomy (removal of
cancer ‘lump’ from a breast) plus radiotherapy. The good news is she has no
evidence of cancer, any more. Then she showed me a large area of very
unsightly scarred skin, the result of her radiotherapy. She does not wear
swimming costumes any more! Her second story is very relevant to men.
When her fifty-seven year old husband had a check up with his GP, a PSA
was ordered, just as the doctor went on holidays. The locum doctor saw him
for follow up, telling him his PSA was 6 ng/ml and it was best to just watch
and wait. His own doctor on returning home, immediately referred him to an
urologist, and now he has had a prostate biopsy procedure..


Sunday 13th March 2005
The biopsy showed cancer in most specimens, one almost bordering on the
capsule. Soon he underwent a radical prostatectomy and there was no
evidence of capsular penetration. A year later, his PSA is unrecordable, he
has no incontinence and no impotence. Just imagine the possible scenario if
he had waited another six months for biopsies. He would probably have been
told, like my friend up the coast, that it was too late for surgery and that



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radiotherapy was the only chance of cure, as he had ‘watched and waited’ too
long, on the advice of his GPs locum!

The lady that I am treating for pain from her lung cancer metastases, is doing
really well on her Durogesic®, fentanyl patches, and continues to be in good
spirits. There will probably be more cancer stories to tell next week. What
worries me is, I am one country doctor in one little town of twenty-odd
thousand people. There are over twenty million of us in Australia, so how
many stories are there of prostate cancer, threatening men’s lives, and still a
lot of men have no idea of what PSA stands for – there is no routine screening
program and much ignorance.


Monday 14th March 2005
Today I was told of another University academic, who had a radical
prostatectomy last week, for cancer. Though I have heard of him, he is not
known to me – is there an epidemic hereabouts, or is this pattern just a
reflection of the nation-wide situation?

At present I am conducting a little survey of hospital staff, concerning holidays
and QOL. Whenever Elizabeth and I have a holiday, if I were asked how my
QOL is affected, there is no doubt in my mind that I would say it is enhanced,
greatly enhanced or memorable. So far, no staff members are of the same
opinion. A holiday is one facet of their year’s activities, a chance to recharge
their batteries, catch up with home projects and have a few days down at the
beach with the family, before heading back to work. Sometimes they travel to
visit relatives. Many of my medical colleagues hardly realise that holidays are
just around the corner, until reminded by their spouses. Some only spend
one week away per year, resting! Their QOL is undisturbed. Possibly their
year is spent bordering on ecstasy, or alternatively holiday plans may lack
imagination. My curiosity remains.


Tuesday 15th March 2005
A busy day spent in the operating theatre, enjoyable as usual. The surgeon,
originally from India, discussed various aspects of Indian life with me. India is
a very rapidly developing country. Once, when Elizabeth and I were attending
a conference there, she become friendly with a man, whose father was to
travel back to Malaysia on the same plane with us. We offered him a lift to
the airport in our taxi. It transpired that he was a director of the airline and a
word from him resulted in an immediate change of boarding passes. We were
all in first class together. Whenever I am upgraded to First Class, which is
rare, I take great pleasure in it and enjoy every minute. The little touches, like
hand made chocolates and superb service are memorable and I literally
remember every instance. Perhaps we were born lucky, but we frequently get
upgraded to business class, in fact pretty well every year – a distinct upgrade
in QOL. Even down in our usual haunt, Cattle Class, there is plenty to be
happy about. One is not exactly suffering, plied with food, drink and often
meeting interesting fellow passengers. If I have the time, then trains or buses



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are okay too. Once, we travelled from Los Angeles up to Vancouver and
across the Rockies, in winter, to the middle of Canada on a bus, with the kids.



Wednesday 16th March 2005
Today I had cause to ring up an Oncologist concerning the patient who has
had surgery on her spine for a plasmacytoma, mentioned on 28.2.05.
Apparently there is a 25% chance of a recurrence, with serious connotations.
Happily her pain control is now much improved. It seemed that here was
another chance to discuss prostate cancer. The oncologist disturbed my
peace of mind when he expressed the opinion that in the field of cancer of the
prostate, little is certain and few published studies impress him. He believes
early radiotherapy is the best option for someone with a positive margin like I
have, if one is to hit any cancer cells remaining before they have a chance to
establish themselves and spread. Only if the Gleason Score were low or the
patient in his seventies would he advise ‘watching and waiting’. He accepts
that many men would be treated unnecessarily, with no remaining cancer,
possibly suffering significant bowel and bladder complications – he thinks if
you have a radical prostatectomy and are left with a positive margin, go for
broke early, for the greatest chance of cure, not trusting present literature. I
cannot really argue, except on QOL issues, of course!


Thursday 17th March 2005
On Monday (14.3. 05) I mentioned my little survey, concerning QOL for staff
at hospitals both at work and on holidays. Well, today at a clinic, after the
discouragement or learning previously that the first five participants
experienced no elevation of QOL on holidays, things were more positive. A is
an effervescent, positive, friendly girl, who very much enjoys her life and
regularly works with me. At the age of twenty-two she was diagnosed with
cancer. Treatment was successful and to her, life is a gift which she very
much appreciates. A considers that every week of her holiday leave is worth
four weeks of time spent at work, in terms of QOL. Yes, she plans, organises
and achieves her goals, whether occupied with handicrafts charitable work, or
travel, and experiences heightened QOL on her holidays. X is an ex-Navy
man, another cheerful person who enjoys his work, yet assesses his holiday
QOL as being worth twice that of his ‘normal life’. Next week, in the operating
theatres, I shall ask more staff the same question. Many of these people
have been my friends for more years than I can remember. Their answers will
be interesting!


Friday 18th March 2005
This morning, I awoke at about 4 a.m. with lower abdominal pain. For the last
three days I have been constipated and had left sided lower abdominal
cramping pain, intermittently. Perhaps it might not settle down spontaneously,
I thought, so I left for work early and K, the nurse on duty called the duty
doctor, who ordered abdominal x-rays, to exclude any evidence of a
developing bowel obstruction. K has been through much tragedy as her


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teenaged son died from bowel cancer a few years ago. The family tried
everything, including seeking treatment overseas, to no avail. Anyway, the x-
rays were okay but there was blood in my urine, so, between patients at my
clinics, which went all day, I dropped in to have an ultrasound to check my
kidneys, bladder, prostate area and tender bowel. All negative! Finally I saw
my GP and told him my blood results were normal. Luckily, all this was
managed without disrupting my clinics and my pain has gone. I wonder what
it was. A more eventful day than one had anticipated the night before, when I
hosted a wine tasting of Grenache, Mourvedre, Cinsault, Carignan and other
wines from Southern France.


Saturday 19th March 2005
Gwen Stefani is singing ‘Rich Girl’, a remake of the old Topol number ‘If I
were a Rich Man’, as I write, on Video Hits this morning. Less well known is
that Richard Pratt, yes, the billionaire, sang that song at his birthday party – a
man with a good sense of humour. Now there is a number ‘Over and Over’
with a background of planes playing and I am reminded first of flying in my
little Cessna, then of flying off on holidays. The connections one makes are
endless and enriching. Again, its Delta Goodrem singing with a London cab
as a backdrop and my mind turns to good times in London, lying on my back
in Hyde Park in July, - then cruising down the Thames. Let your mind video
play as the Video Hits play and you have two sources of enjoyment and also
keep up with what is new. Oh Good! Mariah Carey is next! Maybe you are
not into this music? Opera is more your scene? Well scene is right, for I
appreciate the sets as much as the music. Now I am recalling real live horses
on the set of Carmen in the Vienna Opera house. Just spectacular. And who
wouldn’t enjoy Bizet’s music! Back on Video Hits there is a good guitarist.
‘Sitting, waiting, wishing’ with Jack Johnson – I am tempted to buy it. Past
QOL thus influences present QOL.


Sunday 20th March 2005
Nobody seems to talk much about Quality of Death (QOD). Two events
occurred on Friday to focus my attention on this subject. Whilst waiting to see
my GP, I read about Samurai culture in an (old) National Geographic
magazine, in the waiting room. These guys ran Japan for six hundred years
until the mid nineteenth century. Defeat was dishonourable-- if you lived. Life
was for the winners, so losers performed a bit of surgery on themselves,
normally disembowelling! This proved to be a painful way to go, so they
modified the ritual, allowing an attendant to finish them off. Just after they
stabbed themselves in the middle, the attendant stepped up and chopped off
their head. At least it was quicker than some other forms of death.


 A patient I saw is to have a total hysterectomy and her remaining ovary
removed. There were changes in her other ovary suggestive of cancer and it
was removed. And now more changes make this operation necessary. She
is a vivacious girl in her early forties and works in a nursing home as a nurse.
We talked of death and cancer and agreed we had no fear of a quick death


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(not that I am any Samurai warrior!). Her nursing home patients consume a
lot of Zoloft® (for depression) she says, and have, in her opinion, little QOL,
many being demented and/or quite unable to care for themselves. They may
exist in this state for years. She would rather be dead than end up in a
nursing home. This is quite a sensitive topic, for quite a few of us may
eventually deteriorate sufficiently to warrant assessment for possible nursing
home accommodation. When does existence become a slow death?


Monday 21st March 2005
A gentleman presented at the Private Hospital for a pre-anaesthetic
assessment prior to knee replacement surgery today. In 1996 he was
diagnosed with prostate cancer and had a PSA level of 56 nanogram/ml.
Treatment consists of hormone suppression implants and his present PSA
level is less than 1 nanogram/ml. The only problem he experiences is, he told
me, laughingly; frequent hot flushes ‘as if I were a woman’. He and his wife
are enjoying a long and happy retirement in a local, modern retirement village.
His health is otherwise very good and he is eighty-five years of age. I have
waited a long time, before coming across such a positive prostate cancer
story. If only I had waited until I reached the age of seventy-six – as he was,
at diagnosis, then I too might look forward to many years of excellent QOL
with few treatment problems. The sort of patient that I have always heard
about, looking forward to dying with prostate cancer, not from it! Alternatively,
had I been born forty or fifty years earlier, then my life expectancy would have
been about sixty-seven years, as it was in the 1960s, and as that was my age
at the time of my diagnosis, I could have died without realising I had cancer!
There were no blood tests for prostate cancer screening in those days.


Tuesday 22nd March 2005
Yesterday, I saw a thirty-eight year old man who presented to the Pain Clinic
with severe chronic pain affecting both lower limbs. He has been fully
assessed at a multi-disciplinary Pain Centre in Sydney and diagnosed with a
rare cerebral nervous system disorder and has only recently come to live in
Armidale. A rheumatologist in Sydney wrote, in his assessment, that this
patient complained of impotence, but had tried Viagra and injections with little
benefit.

I questioned the still young, man, concerning his impotence and learned that
whilst Viagra was ineffective, he has effective erections with Caverject®
injection of prostaglandins and he does not find them painful. He does feel,
however, that his QOL has definitely suffered in that he knows that he is no
longer spontaneously potent. Only by artificial means can be achieve an
erection and have intercourse and all spontaneity is lost in the process. He
feels this as a continuing loss of QOL, as I do. It is just not as good as before!
I am encouraged to try the Caverject® injections, perhaps over Easter, to see
if there is a worthwhile benefit. Hope springs eternal!




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Wednesday 23rd March 2005
A NEAR DEATH EXPERIENCE WITH LEUPRORELIN
 XXX told me his story today at my clinic. In the year 2000 it was suspected
that XXX might have prostate cancer. Biopsies were taken but proved
negative (just like my experience last year in January). In 2001 more biopsies
were taken which showed, he said, ‘traces of cancer’. His Gleason score was
4 and his PSA was 26 nanogram/ml. ‘“The news did not distress me as I had
faith in my doctors and I was glad they had got on to it early’. He was 67
years old, the same age as I was, when diagnosed.

In November 2001 he was prescribed Androcur® to shrink the cancer, which
caused almost immediate impotence and such severe groin pain that it was
ceased. Leuprorelin as Lucrin® injection was given. This drug lowers the
level of testosterone in the body and may be used to reduce the production of
luteinising hormone in the pituitary gland, so lowering testosterone levels and
shrinking the tumour, or slowing down its growth.

XXX became anxious and depressed and focused on his impotence which
can also be caused by leuprorelin. He was told that his impotence would be
temporary and disappear in a few months. He became more depressed and
wanted to go into hospital. He was told not to worry about his impotence and
his depression, a known possible side effect of leuprorelin, was not taken
seriously, XXX is a hunter and a former national competition rifleman, but this
time he missed his heart at close range and shot himself through his small
bowel. He was resuscitated and required an ileostomy, which was later
closed. His suicide attempt had failed. XXX was used to having intercourse
about six times per week and was married in March 2002. His erections did
not return in a few months. It was about ten months- but then it was time for
his radiotherapy and that will be tomorrow’s story.

Note XXX presented as affable and well adjusted, with his wife present.
Screening revealed no evidence of anxiety, depression or somatisation. He
was pretty happy, with a self assessment of 8/10 and global QOL is “Good”.
He has no distress. Since his radiotherapy he feels drained and fatigued.
XXX came to be assessed, as he is to have a knee replacement soon.


Thursday 24th March 2005
XXXs Adventures with Radiotherapy.
After XXX had recovered from his self-inflicted wound he commenced a
course of radiotherapy. This lasted from January until March 2003. The
treatment was at a major interstate teaching hospital and consisted of 35
treatments. There were technical problems with the equipment and half way
through therapy, treatment was halted for a month. XXX suffered radiation
damage to his lower bowel. He found this problem very trying as he had
bleeding and clots from his bowel, for which he needed to wear pads for
fifteen months. His wife interrupted to say that finally another doctor gave her
husband, treatment with formaldehyde ‘which made him 99% better
immediately and six weeks later he had another treatment and was then quite
alright’.


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You must be wondering about his impotence? Well, he found Viagra useless
and tried Caverject® prostaglandin injections, used too big a dose and got
priapism –a long lasting painful erection (6 hours). Cialis tablets make a
difference and sometimes       with it, he can get a rather floppy but just
adequate erection with ejaculation at intercourse and his wife says it is alright
for her. XXX says his QOS (quality of sex) rates 4/10 compared with 10/10
before.


Friday 25th March 2005
XXXs Quality of Life Today.
He agrees with the proposed patient definitions of QOL – that QOL is being
able to do what you want to do, when you want to do it, together with the
satisfaction/happiness that accompanies it. In addition he wrote in the
comments section ‘also companionship’. I pointed out to him that when he
had completed his Occupational Questionnaire he documented that he spent
time talking in bed with his wife on awakening, they had coffee together,
before working together in their extensive ‘yard’ from 9 a.m. to 6 p.m., with a
brief break for lunch. There is a small pine plantation, hundreds of trees and
shrubs and they breed canaries and bantams. They spend all day together,
then after tea go to bed together and watch television from 7.30 p.m. until he
goes to sleep at 10 p.m. and she, at about 11.30 p.m. Hows that for
companionship? It is intrinsic and integral to his QOL. It is what he does and
he is doing what he wants to do. Before he was shown the proposed
definition of QOL, he had told me that he wanted to be around for another
twenty years (he is 71 now), that each day you live is a bonus. He is not
afraid of death. He values being happy in his home with a good relationship,
accommodation, income and better than average health. He enjoys being
able to get out and enjoys travel, seeing as much of the countryside as he
can, the fauna and flora and quality dining, being careful what he eats. This is
his QOL, after prostate cancer!


Saturday 26th March 2005
Hormone suppression therapy for prostate cancer patients is said to reduce
libido as well as reduce testosterone levels. XXX commenced his Androcur®
then leuprorelin therapy when his libido was very high, several months before
his marriage.       Certainly the medication resulted in almost immediate
impotence, presumably with a reduction in testosterone levels. There was no
reduction in libido. In fact XXX told me that the cause of his depression was
his extreme desire accompanied by absolutely no ability to have an erection,
after previously enjoying sexual intercourse six times weekly. He described a
feeling- as if his head was about to burst, in fact- as if his head was going to
explode. His anguish was extreme. An old surgical colleague used to
describe the teenage years as the times when ‘the hormones are stronger
than the neurones’. Here we have a man of sixty-seven, presumably deprived
of testosterone, yet so stressed with a strong libido, unable to get help from
anyone, who became so desperate that he tried to kill himself. Libido is, or
can be, a very powerful force, not to be ignored, even at sixty-seven. My trips


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to Italy, and observations on trains and buses, of some couples there close to
ecstasy, remind me of how passionate people can be. Interfering with
passion can be dangerous.


Sunday 27th March 2005
The other night we invited half a dozen friends around for dinner. Elizabeth
worked hard and excelled in her production of five memorable dishes, as well
as hors d’oevres . All our guests are connoisseurs of food and wine, so every
effort we made was appreciated – from the J. Lassalle Champagne to the
Benedictine. Our guests agreed that their regular overseas travels enhance
their QOL considerably – to France and Italy in particular. More evidence that
people can enhance their QOL, if they plan and work towards something out
of the ordinary. L remarked that this enhancement of QOL also applied to this
meal. A roast with baked vegetables followed by jelly and ice-cream would
not have been remarkable, exceptional or have enhanced the guest’s QOL.
The effort expended is appreciated. Over the years our QOL has been
influenced by our attendance at exceptional dinners, frequently associated
with Anaesthesia or other conferences. My mind videos access evenings at
the Conciergerie, at the Ritz in Paris, at the Grand Prix of Monaco, at the
Museum of Comics in Brussels, Birdland in New York, at the 40th Anniversary
of Lamborghini for a fabulous three days in the environs of the factory at Sant
Agata- at castles, dinner dances, al fresco meals in vineyards, all experienced
once, but remembered for ever, still affecting my QOL, every time I recall
these exceptional happenings.


Monday 28th March 2005
Aldous Huxley wrote a book called The Perennial Philosophy in 1946. If one
is concerned with such questions as who we are, where God is to be found
and the ultimate reason for human existence, with liberal references from
world religions, then it provides food for thought. I inherited my copy from my
grandfather, Frank Walter Edgar Heyner, sometime Anglican cleric in this
Diocese.      Leibniz coined the phrase ‘philosophic pere unis’ for the
metaphysics that recognises ‘a divine Reality, substantial to the world of
things and lives and minds,’ ‘the psychology that finds in the soul something
similar to, or even identical with knowledge of the infinite and transcendent
Ground of all being – the thing is immemorial and universal’. The origins of
this Perennial Philosophy may be seen in other cultures as well as in the
higher religions. Maoris regard humans as composed of four elements, the
toiora, or divine eternal principle, an ego, which is extinguished when we die,
a psyche, or ghost-shadow (which survives) and of course- body. Huxley also
refers to the Ogallala Indians, who call the divine element the sican which is
identical to the ton or divine essence of the world together with the nagi or
personality and Niya or vital soul.


Tuesday 29th March 2005
The sican is reunited with the divine Ground of all things after death; the nagi
lives on in the ghost world of psychic phenomena and the Niya disappears


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into the material universe. Huxley argues that the ultimate reason for human
existence, is ‘in…. knowledge of the divine Ground. (that is, God, a spiritual
Absolute) – the knowledge that can come only to those who are prepared to
‘die to self’ and so make room, as it were, for God’. Initially success will be
achieved by few, but eventually the path leads to a realisation of who we are!
We can attain ‘to the infinite….. knowledge of God only when we become in
some measure Godlike, only when we permit God’s kingdom to come, by
making our own creaturely kingdom go’.

There is much to contemplate and digest for people from a wide variety of
backgrounds. It might whet your appetite for this sort of literature or even
change your life and future. My unflagging zeal for optimising my QOL with a
formula laced with elements of hedonism, which threatens to overwhelm the
more religious aspects of my being, may be tempered by more thoughtful
contemplation and further reading, in the foreseeable future. Huxley’s words
and many of his quotations ring true!


Wednesday 30th March 2005
My sixty year old friend, who had his radical prostatectomy on 7.3.05 is now
feeling much better and is walking many kilometres daily. Yes, he had a
blood transfusion, but more positively, though he was initially incontinent, he
is improving rapidly and now has quite good bladder control. He has started
asking other men about their PSA levels and knowledge of prostate cancer.
Most of his respondents have no idea of what the letters PSA stand for and he
is surprised that so many take little interest in preventive health care. As long
as you are feeling well now, then ’why think about the future’, seems to be a
common attitude.


 Yesterday, I saw two women who have had breast cancer. The first, aged
sixty-five years, has had two operations, as the first time, the cancer was not
completely excised. She said it took about one year to come to terms with the
diagnosis and she is now seemingly alright and taking Tamoxifen®, with
regular check-ups. The second had breast surgery a little over a week ago,
and I have anaesthetised her for an unrelated problem. She says she has not
had the slightest distress and at seventy-five, feels she has a lot more living to
do. She is taking Tamoxifen®. Yes, a ten year age difference, but also a
difference in adjustment.


Thursday 31st March 2005
Today, I have the feeling that life is rushing by, perhaps slightly perturbed that
photos, taken only about ten years ago, show me looking considerably
younger and the patients I see, just a few years older than I, certainly look old,
to me! A lot of things seem to be coming to fruition, if that is the term for it.
The bricklayers are working hard on our courtyard, the contractors are starting
on my development project today, the restoration of my Mini Cooper S is
almost complete, we are finalising our plans for an early June departure to
New York, considering hotels there, and before we know it, we shall be on the


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plane. Sooner than I think I shall give up Anaesthetics after over forty years,
though continuing with my clinics and Pain Medicine practice. There are no
new plans on the horizon, of any significance, sensibly, for if my PSA starts to
rise, I shall have to undergo radiotherapy and may not feel well enough or
enthusiastic enough, to continue working. Once upon a time I was fond of
five-year plans. Now I am more concerned with maintaining my present
situation, aware that my future is subject to my health status. Nevertheless I
believe that I have every chance of maintaining a good QOL for many years.


Friday 1st April 2005
Radiotherapy is naturally a topic of great interest to men with prostate cancer,
as the only other available therapy apart from surgery which may offer a
‘cure’. Whenever I ponder my decision to postpone any radiotherapy until, if
ever, there is a detectable PSA on my regular 6-7 weekly tests, I think of the
likely side effects. Today, a fifty year old patient told me her story. In late
2003 she was diagnosed with breast cancer and soon underwent
chemotherapy which was accompanied by persistent nausea. Following an
episode of severe lower back pain, she subsequently had a spinal fusion
before commencing radiotherapy early last year. At the start of therapy she
was feeling well, having recovered from her chemotherapy, and surgery. The
radiotherapy caused fairly mild regional skin changes which are not a
significant worry to her. Of greater interest was her comment that, by the end
of her course of radiotherapy, she felt exhausted and had no energy for
anything. Today she looks well and happy and attended with her husband.
Has she regained her previous vigour and energy? No! She still lacks
energy, a year after therapy. Thank goodness there is no sign of her cancer.
Should one plan an immediate retirement if planning radiotherapy? It makes
you think!


Saturday 2nd April 2005
Overnight, I have been thinking about the lady mentioned yesterday. Is she
sitting quietly at home? At the end of her appointment, her husband reminded
her that it was time he drove her back to work. Her appointment was during
her lunch hour! Unless one was aware of her history, one would never guess
that she lacks energy, by her standards. On reflection, I would say she was
about the liveliest woman I interviewed all day and still has a lot of living to do.
How energetic was she, in the past? That, I cannot answer, and who knows if
her energy is still returning. Let us be optimistic. My forty year old friend who
spent time at the Jean Colvin centre in Sydney, saw a lot of men there, during
their prostate cancer radiotherapy treatment at the nearby treatment centre.
Okay, most were pretty subdued after weeks of therapy, but one younger man
remained full of energy and keen to go out on the town, right to the end of
treatment. Why such differences? Yes, he was younger, but we are all
individuals and react differently. Keeping as fit as possible sounds like a good
idea before any challenge. As for work and retirement, wait and see.


Sunday 3rd April 2005


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Prince Frederik of Denmark told journalists ‘The main thing is to enjoy life, be
straightforward, use your intelligence’. He has been chosen Dane of the Year
in several opinion polls. Whilst we were still reading about the recent Royal
Tour, and especially ‘our Mary’, our attention was turning to another subject
of popular interest, the Pope’s failing health! In yesterday’s Sydney Morning
Herald, it is reported that the Pope encouraged and the Vatican sponsored
Scholars of the Pontifical Academy for Life to debate the ‘ambiguities’ and
‘tragic consequences’ inherent in such commonly used phrases as ‘the quality
of life’. He said life was precious, irrespective of its quality. In his 1984
apostolic letter Salcrifici Doloris he argues that suffering is not only part of the
human condition but, approached rightly, offers an insight into the true nature
of a person and into the ultimate meaning of human life. This week Terry
Schiavo, a severely brain damaged American died after her feeding tube was
removed, after an argument that she had ‘no quality of life and to keep her
alive was pointless’. The last news broadcast I watched last night, gave
details of the Pope’s feeding tube – quite a coincidence! The headlines
proclaim ‘Pope fades serenely’. Surely they haven’t removed his feeing tube!
I have to agree with Fred. When the time comes that I am not able to enjoy
life and have no QOL please leave me without a feeding tube and don’t argue
about it!

My QOL decision not to have elective radiotherapy is a calculated risk!
Logically, if cancer is still present in my prostate area, the earlier it is treated
the better – but there is a good chance it may not still exist! QOL without
radiotherapy is very much valued but I still am concerned. Ending up with
bowel and bladder problems with no present evidence of cancer, is not a
pleasant prospect either. There are no absolutes, if I have radiotherapy.




Monday 4th April 2005
Pope John Paul II died yesterday. According to the Sun-Herald, the Pope’s
last act was ‘to show the world the value of human life in all its stages,
including in the midst of suffering’.

Suffering is the act of one who suffers. the Macquarie Dictionary (1981) gives
many meanings of the word suffer
1)      To undergo or feel pain or distress (every week I formally assess
patient pain and distress)
2)      To sustain injury, disadvantage or loss (perhaps impotence or
incontinence after radical prostatectomy)
3)      To undergo a penalty, especially of death (likely to happen soon to my
patient with lung cancer, following 50 years of smoking)
4)      To be the object of some action (one thinks of lawyers)
5)      To endure patiently or bravely (the meaning appropriate to the Pope’s
final days and to so many patients that I see every week)
6)      To undergo, experience, or be subjected to pain, distress, injury, loss,
or anything unpleasant (one thinks of the people of Iraq)
7)      To undergo any action, process, etc, to suffer change (the Iraqis)


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8)     To tolerate or allow (the Australian people, in regard to policies with
which the majority disagree)
9)     To allow or permit (see (8). Latin- sufferer replacing ME sufferer (n)
from AF sufferer, from L.L. sufferer.

Suffering, according to the Cambridge Learner’s Dictionary (2001) is when
someone experiences pain, or unpleasant emotions. A sufferer, though, is
someone who suffers from an illness or other health problem


What does it all mean? On some of these definitions, few people do not
suffer at some time. Nevertheless, many people that I have interviewed deny
that they have had any distress in their lives, including those who have such
pain, disturbed sleep and disability that they are on the waiting list for joint
replacement surgery. Certainly people can have pain, major illness and major
surgery without suffering or distress, according to their own understanding of
the language. The Pope, of all people, being confident of salvation, should
have been emotionally joyful in his final days and, like many of my patients,
should have felt that any pain or discomfort did not amount to suffering, in the
light of future expectations. I wonder if you agree?




Tuesday 5th April 2005
The sound of the telephone awoke me at 5.45 a.m. It was my eldest son
Stephen, to wish me a happy sixty-eighth birthday. Andrew rang last night,
and before she came to bed, Elizabeth gave me an interesting card, showing
two beautiful cats together ’Happy birthday to the one I will love my whole life
– times nine!’ Soon one of my sisters rang. Young Garry would have left
home very early for work and we shall speak tonight.

The weather promises rain, but I drove the Mercedes to work with the sunroof
open and a Brazilian CD playing. Work was stimulating and as enjoyable as
usual. In amongst it all, I managed to interview ten patients on their views of
the meaning of QOL. One in particular, was particularly thought provoking. A
man suffering severe chronic pain from a pancreatic cyst which keeps re-
accumulating, despite drainage and requiring coeliac plexus block and slow
release morphine therapy also has diabetes, and angina, despite stents in his
coronary vessels. He still works and maintains an unimpaired QOL in his own
self assessment. After my morning clinic, doctors joined staff to sing ‘Happy
Birthday’ over a chocolate mud cake and candle before I responded to a call
to the operating theatres. There, another party with cream cake and candles.
This is shaping up to be a great day, today!


Wednesday 6th April 2005
Tomorrow, after work, Elizabeth and I are driving down to an olive grove, just
this side of Tamworth and about 100 km from here. A patient kindly gave me
two bottles of his own label Extra Virgin Olive Oil and we are to visit his farm


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to see the harvesting of the olives. In addition I shall see how he is coping
with his chronic low back pain over this busy period, for which he is receiving
a temporary increase in medication.

There have been some interesting patients today. One, a twenty-two year old
with severe chronic pain and disability following a motor vehicle accident, is
prone to fits of uncontrollable anger. We have managed to get him to cease
using marijuana and give up all forms of caffeine. He needs a further
psychiatric review but there are no available appointments for over four and a
half months. He has been violent to family members and recognises his
problem. Psycho-therapy has not been helpful, so I shall try, myself. Another
man has been waiting for a hip replacement for eighteen months on the Public
Hospital Medicare list. He is a self made man with a vast collection of
restored cars and tractors. We are a strange species, all with our own
problems and priorities. Life is never dull in Medicine – an ideal choice for
me.


Thursday 7th April 2005
Today I saw another two patients who have had radical prostatectomies for
cancer. The first, now aged eighty-two years, is in good health and has had
left and right knee replacements, since his radical prostatectomy in 1995. He
told me that the cancer was still contained in the prostate and all is 100% with
him. He recalls having a blood transfusion but otherwise the procedure was
uneventful. He is single and I made no enquiries about any impotence.
There is no urinary incontinence.

Shortly after seeing this first patient, I saw a sixty-six year old who had his
radical prostatectomy twelve months ago, when his PSA was 7 and his
Gleason score was 9 – a very highly invasive tumour. Happily, although the
tumour had perforated the capsule in one place it was still just within the
specimen removed. There is no evidence of a recurrence on his PSA tests
and he is fit and active and about to celebrate his sixty-seventh birthday. Mild
initial incontinence has completely – well – 99.9% resolved. Blood was taken
from him pre-operatively and re-infused at surgery. As for impotence –
unfortunately he remains completely impotent and is resigned to it!


Friday 8th April 2005
Over the years, I have interviewed many patients regarding their occupational
details. It appears that retirees tend to actually do very much less than their
aged matched working controls. The wife of an active retiree agreed that he
did still cut and polish gems, participate in the running of his church and many
other things but ‘he has an awful lot of naps in between’. This week, a retired
professor, two years post-retirement, and having written two chapters of his
book on Greece, is now plagued by a lack of enthusiasm and resolve to finish
the rest of the book, despite all his research, completed referencing and life-
long interest in his subject. He told me that his next trip to Greece will be his
last, as he would rather stay at home in his very comfortable house, than
travel any more. I asked him if he believes he would complete his project and


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he said that he doubted that he would ever complete it and even worse, that
this did not worry him, yet in the past, he had published numbers of text
books. Other retired academics have told me the same story. One knows
that, on holidays in idyllic places, one day drifts into the next and the next, so
that all sense of time is lost.
Perhaps as time goes by, the less one does, the less one cares to work!



Saturday 9th April 2005
Last night we flew to Sydney, to spend Elizabeth’s birthday tomorrow, with our
son, daughter in-law and grandchildren, who learn ballet. We all went to
see’La Sylphide’ ballet. Composers are fond of dreaming up mythical
creatures and this plot portrays the male characters as easily mesmerised by
the Sylphide, to the ruin of all. Evil triumphs. Later, having an interest in
movies. I went to the Valhalla at Glebe and saw Young Adam, co-incidentally
also set in Scotland and also ending with the triumph of evil! Based on a
novel by Alexander Trocchi, the action takes place in the 1950’s on a coal
barge and thereabouts, on the Clyde. The acting is superb, by Tilda Swinton
and more famously, Ewen McGregor, his best work according to The
Reviewer. The film has won many awards with excellent cinematography,
credible characters and outstanding acting. Trocchi was, however, a flawed
character, who wrote his second novel, Cain’s Book paid by the chapter, so
he could afford to buy his heroin. Earlier, he acted as a pimp for his wife, to
gain drug money and actively recruited others to heroin. This did not stop him
from being a good writer.

We renewed our friendship with Peter Rabbit and spent much of the day with
our grandchildren, so we are all having a very pleasurable weekend and my
QOL remains excellent.


Sunday 10th April 2005
Alexander, Sophie and I spend much of the morning, after breakfast, doing
Maths problems. Sophie will start her pre-Olympic gymnastics program,
tomorrow, with four hours training per day on Mondays, Wednesdays and
Fridays during the school holidays. The kids spontaneously brought me their
advanced maths books and started work. It was my job to correct and guide
them if needed. Sophie is in year three but does year five maths and Alex is
also very advanced but doesn’t believe he is as good as he could be. He still
wants to be a pathologist and Sophie, a surgeon. Yes, I first thought of doing
Medicine at her age, but the idea of a specialty had not entered my mind! It
will be fascinating to follow their progress.

This afternoon, young Garry came with us to the airport as he was flying to
Darwin to give another lecture to the troops going to Iraq and had a cab
charge account. I asked him to buy me a new good crocodile leather belt in
Darwin. We arrived home, having had an excellent weekend and are now
planning to fly to Victoria to see Andrew next weekend, as I have a couple of
days off at the end of this week. Time is getting short until my next PSA is


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due, on the 14th and I keep wondering if it is still going to stay unrecordable
and allow us to go away on holidays? Carpe Diem (- seize the day) is our
motto at present? Carpe QOL.


Monday 11th April 2005
As it is almost six months since my radical prostatectomy, I have been
focusing on my progress, or recovery, as well as thinking about whether my
PSA this week will still be unrecordable. Impotence is still a problem which
is a factor definitely diminishing my QOL, if judged on my former standards. It
is no use pretending otherwise. Last night there was more satisfaction with
the sensation and penetration achieved after using the Vacuum Erection
Device. Elizabeth said ‘you are actually smiling!’ There have been some very
minor twinges of discomfort in the area of my surgery, mainly in my abdominal
wall, which I interpret as improvements in my sensory perception, or nerve
transmission rather than any organic problem and I am more aware of urethral
sensations. Erections are marginally better and longer lasting but still
inadequate, without the erection device. I have resisted the temptation of try
Caverject® prostaglandin injections. By now I have quizzed a lot of people
who have had radiotherapy for various cancers and nobody says it is much
fun.


Tuesday 12th April 2005
A momentous decision was made today. I shall give up giving anaesthetics at
the end of next month when we are about due to leave for our holiday. When
I return (if tomorrow’s PSA is OK) I shall, if my initial negotiations are
confirmed/approved by the Health Region authorities, commence doing more
pain medicine. The plan is for me to conduct regular pain clinics in Inverell,
which would reduce patient travel by hundreds of kilometres, in many cases
and I would bulk bill patients, many of whom are on pensions. Over the
years, I have been well rewarded in Medicine and I don’t mind doing
something for the community for a nominal return and there is great
satisfaction in helping people with chronic pain. Many people over the years
have travelled up from the coast around Coffs Harbour, a major undertaking
for anyone in pain. I am considering starting regular pain clinics, perhaps
around Bellingen, which is close to the coast and less than two hours drive
from here. It is too early to take any action yet. Let us see how things pan
out at Inverell and tomorrow morning I shall get my PSA done. On Thursday
morning, the six months is up and we shall fly in to Albury, thence to stay in
Bogong Alpine Village hear Falls Creek, at one of our houses for a few days
and see our son Andrew, which will be good, for we haven’t seen him since
Christmas.


Wednesday 13th April 2005
At 9am I went over to the Pathology Department and had blood taken for my
PSA test. Luckily I was very busy at my clinics today with phone calls, extra
patients and a busy time with patients, so I could not dwell on the chances of
a good result. The blood specimen is to be processed in Tamworth. Just now


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L, from Pathology rang, at 3.15 p.m. to say my PSA level is less than 0.01
ng/ml, the same as my previous tests. I told her I would give her a kiss and a
hug if she were here, I am so happy. Now we can definitely say that we shall
be able to go away in June for our holiday – at least for three weeks, even if
there is an increase in PSA value at my next test, a few days before we are
due to leave! Wow! I can hardly wait to get away and can imagine flying into
JFK, seeing New York again, which is always a great experience. Then there
is the Caribbean – but for now, I shall rush home and tell Elizabeth, get
packed and fly to Sydney. Of course there are phone calls to make, informing
all the family who have been praying, as I have, that the test is clear. One
lives from PSA test to PSA test. A patient I saw this afternoon has had
radiotherapy for his prostate cancer in 2003 and still lacks energy and has
osteoporosis!     He had hormone suppression medication as well as
radiotherapy.


Thursday 14th April 2005
We were up early this morning, as we had to leave Garry Junior’s home just
after 5.30 a.m. He had agreed to drop us near a taxi rank at Circular Quay on
his way to Naval Headquarters at Garden Island and he starts work at 6 a.m.
There is much he cannot tell us about his area of responsibility, such as the
United Arab Emirates, Qatar, Kuwait, and of course Iraq and Afghanistan,
except to say-- things aren’t good over there. There will be about 300 e-Mails
on his computer and these must be assessed and signals generated, to be
transmitted to all relevant bases, as well as the Prime Minister’s Department
and General Cosgrove’s office. Whilst he was in Darwin on Monday, he
bought me a beautiful crocodile skin belt. Soon we arrived at the airport and
flew to Albury where Andrew met us. We did some shopping and drove to his
home at Mount Beauty. Much progress has occurred with our apartment
downstairs, including an impressive rock walled kitchen. We chose custom
granite and blackwood panelled cupboards for the kitchen bench area which
should be most attractive. Lastly, we all drove the 15 kilometres to Duck
Down, our lakeside cabin at Bogong Alpine Village, for the weekend. It is just
idyllic and tonight we are enjoying some rain.


Friday 15th April 2005
Amongst the books that we keep for guests at Duck Down-- a rather silly
name, prompted by the large number of ducks on the lake in front-- is one by
Ian Fleming called ‘You Only Live Twice’ and I am reading it. Fleming was a
good writer, not just for his James Bond series but also, surprisingly, as a
children’s writer. When our boys were small, they loved us reading Fleming’s
story of a mythical flying car, ‘Chitty Chitty Bang Bang!’

Since I have been asking friends who have had prostate cancer therapy to
read my records of my progress and experiences since surgery six months
ago, there has been a lot of positive feed - back, especially concerning their
readability. Over the years, occasionally I have thought of writing a book or
two, perhaps adventure stories or thrillers, for I have few literary pretensions.
Now my ideas are becoming more focused. Why not! There are about 500


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words on each of the actual 180 pages of ‘You Only Live Twice’ – that’s only
90,000 words – so one could possibly manage that or a bit more – the trick
seems to be to do some appropriate research for the background, use one’s
somewhat vivid imagination and work on it studiously, one step at a time.


Saturday 16th April 2005
Last night we went with Andrew to his Pastor’s home for dinner. Recently his
daughter and one of his sons, with the son’s girlfriend and another young
man-- another Pastors son-- had a very serious accident. Their four wheel
drive left a mountain road outside Mt. Beauty and rolled many times down a
steep mountain side for 120 metres until it ended up upside down in the water
of a creek. The Pastor’s son and daughter did not have seat belts on and
were not injured. The other girl was airlifted to Melbourne with spinal injuries
and a fractured sternum but is recovering. The other young man has a
fractured collar bone. They are convinced, as I am, that truly, God was
looking after them. The people there are amazed, as were the search and
rescue team.

Sunday 17th April 2005
Today, we are on the train home. Last night we left Albury and slept well on
the train to Sydney. We had three hours to spare and I bought Elizabeth a
very attractive natural pearl necklace. Now I have just finished my James
Bond adventure and am enjoying gazing out at the passing scenery, or rather,
the scenery that the train is passing. A friend, S, is to collect us when we
reach Armidale at about 6.30 p.m. On reflection, we had a great few days
walking around Lake Guy a number of times and enjoying much roast venison
with Andrew. There are a lot of deer in his area of Victoria.


Monday 18th April 2005
Sunroof open to the warm sunny weather, I sped to the Hospital, a couple of
minutes late. My golfing patient rang me at my Pain Clinic from Sydney,
having just returned from his trip to New Zealand. The clinics are booked out
for ages ahead, but he needs to see me – it is possible to squeeze him in on
Wednesday if I forego morning tea – so I shall see him then. Soon, he tells
me, he is returning to the PGA circuit in the United States!

The decision seems to be made, for me to start writing fiction. An opportunity
to question my friend on the behind the scenes picture of the PGA is too good
to miss. Such information will be useful if one is to envisage a scenario
involving a golfer in a novel. Without detailed information, a believable
description would be difficult. Similarly, I need to take detailed notes of places
and experiences during our imminent trip to New York, the Caribbean and
Europe. I know that Tiger Woods has a New Christiansen 155 foot yacht and
is a keen diver. Our experiences whilst diving in the Caribbean in June,
together with descriptions of ports and people, may provide valuable
background material for the story that is slowly crystallizing in my mind. This
should be fun.



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Tuesday 19th April 2005
Six weeks or so ago, a friend had a radical prostatectomy and initially
appeared to make a slow recovery. Now he is well again. The pathologist
was able to report that the cancer was confined to the prostate gland, which
was removed. Of course he is to have follow up PSA tests, the next in a
couple of weeks, with a clear report expected.

He told me that his initial urinary incontinence has become less of a problem,
though he still has some leakage which appears to be settling down. Early
days yet! One might anticipate that with a little more time this problem is likely
to resolve and his need for pads will cease.

Asked about his erectile function, my friend emphasized his complete lack of
any sign of an erection. ‘Absolutely nothing – nothing at all!’ This is a real
disappointment to him and we discussed our mutual loss of function. Of
course we live in hope and in his case it is only six weeks since surgery so he
has more chance than I – who had signs of returning function in days – but
then no real further improvement – never mind, we are alive, well and
optimistic.

Wednesday 20th April 2005
Very interesting is the life of Professional Golf Association of America players.
My informant is about to return to the PGA circuit. When he has his spinal
surgery in America he anticipates a significant improvement, and this is not far
off now.

So what can he tell me about life on the circuit? It is busy, busy, and busy.
There are forty- five matches or tournaments, each lasting four days, or 72
holes, with 18 holes played each day. Therefore there is a lot of travel and
games are played in the same area of the United States before moving on to
a different region. The British Open is the only non American round. Players
typically are very fit and practice about six to eight hours daily when not in
competition. Some practice more than ten hours daily – practice, as always,
makes perfect.

As I am going to incorporate some information on the lives of players in the
novel I am starting, I asked about life off the fairway. No details to tell you yet,
but there is a lot of sex and infidelity, cocaine use is not too unusual,
testosterone is easy to obtain and many players use beta-blockers to steady
them down when putting! No drug testing and a lot of exotic cars.

Thursday 21st April 2005
While I was interviewing patients at the Private Hospital this morning, when
the opportunity arose, I asked them their opinions on QOL. Four out of five
questioned agreed that QOL is being able to do what you want, when you
want to do it, together with the satisfaction/happiness that accompanies it.
The fifth felt that it did not go far enough. She believes it should mention a
sense of fulfilment or achievement, for one needs to do something of value.
All the older adults, whose children have grown up, believe their holiday QOL


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is somewhat enhanced and also recalled that this was not the case when
children were growing up, as they could never relax. The thirty- six year old
man with a four year old daughter-- and twins aged two years-- said there was
no enhancement of QOL on holidays. The last time he had a ‘good’ holiday,
with elevated QOL was with his wife, before the children were born. One
would have to agree, with some exceptions. This morning’s research ‘on the
run’ is consistent with opinion polls suggesting couples with children are very
marginally happier and with comparable QOL when compared with couples
who have never had children. No wonder the birth rate is seemingly going
down, year by year.


Friday 22nd April 2005
I forgot to mention that a patient, seen yesterday, had breast cancer.
Following surgery she had a course of radiotherapy without any problems
whatsoever, and is seemingly free of disease now, many years later. This is
good news indeed, for anyone who may need radiotherapy after
prostatectomy – although the operation site is obviously different. We like to
be told good news!
[See Thursday 26th May though]


Monday 25th April 2005
A staff member in the clinic building where I often work has her own idea of a
dream holiday. She wishes to travel by car with her family across Australia to
the north-west of Western Australia, taking her time to enjoy all her
experiences. How many of us seek to experience the best quality of life
possible? Many Australians aim to travel around Australia when they have
the opportunity.

When we went to Elizabeth’s friend’s funeral in Brisbane, we were told that J,
a keen traveller, had always wanted to experience a trip on the Orient
Express across Europe and to fly on the Concorde from England to America.
Happily J achieved both of these life quality enhancing goals, before she was
killed in a car accident.

A lady receiving chemotherapy told me that she had always dreamed of
taking a long trip up to far north Queensland. ‘Now I have cancer and feel that
it is too late for me. I shall never make the trip’. Hopefully, she will respond
well to therapy and make the trip. My parents often used to say that ‘one day
we are going to go around the world, first class, on P and O’. Long after we
grew up, and they inherited enough money to do so, they spent it on an
extension to their two-storey home. Maybe that was a lesson to me. They
waited too, too long.


Tuesday 26th April 2005
Our first experience of sea travel was in 1967 when we sailed to Europe on
the Patris, of some twenty-four thousand tons. After two years as a resident
medical officer, following graduation, I was off to England to commence my


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specialty training in the United Kingdom. From the moment we cast off, the
weather was appalling, with seventy foot waves off the Queensland Coast and
the ship listed up to thirty degrees in torrential rain. The Captain later said the
cyclone was the worst he had experienced in thirty years. We had never
been in a ship before and wondered why all doors to the open decks were
securely closed. There seemed to be hardly anyone at dinner and plates slid
everywhere. A day was lost due to the weather and apparently many people
were seasick. For all I knew, this sort of experience could be expected.

Since then we have had smooth seas almost where-ever we have voyaged.
There have been many trips around the Pacific over the years, visiting New
Zealand, Fiji, Vanuatu, French Polynesia, Tahiti, the Marquessa islands, the
West Coast of the United States and to Acapulco. Not forgetting a few
European ports on Mediterranean cruises – that first trip merely aroused our
desire for sea travel, which always enhances our QOL. Elizabeth loves scuba
diving and recently took advantage of an opportunity to purchase a share in a
catamaran, with the promise of sailing to Caribbean dive destinations. The
sailing involved is about as safe as sailing ever gets. Islands are generally
close together, the catamaran is a sailing catamaran equipped with twin diesel
engines, has all safety gear, a tender with outboard and an experienced
crew. Naturally, one is not going to venture out in the hurricane season, when
the boat takes shelter, down in the Grenadines.


Wednesday 27th April 2005
My ongoing survey on how respondents view their QOL on holidays is very
interesting. There are those who prefer their time working to that spent on
holidays. They are obviously very dedicated to their jobs and can apparently
hardly drag themselves away from their very greatly valued occupations.
Many workers regard holiday QOL as on a par with work focused QOL. When
questioned further, it becomes apparent that such people place little emphasis
on holidays. It used to amaze me, years ago, when surgeons cancelled lists
suddenly when the school holidays were scheduled, frequently at the
insistence of their wives, for they oblivious to the fact that their children were
looking forward to a trip. Time after time they failed to realize that holidays
were imminent. When they reluctantly took a break, many travelled the same
road to nearby coastal resorts, the same one, year after year – probably
looking forward to returning to the operating theatre – which, according to
previous surveys I have conducted, is the preferred environment of surgeons,
over consultations, ward rounds, meetings and so on. Only the ritual weekly
game of golf, with other men of course, interrupts their focus for a few hours.


Thursday 28th April 2005
Life is short. Life is precious. The old saying ‘find a job that you love and you
will never work again’ is pretty true. One often comes across workers,
professionals, academics, tradesman, people from all walks of life, who love
their occupations and by spending much of their time so occupied,
experience, on my patient generated definition, first class QOL. Doing
medicine was the right decision for me and any spare time is usually spent


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doing research. Never- the-less, if the same enthusiasm is devoted to
planning and experiencing holidays, then life may be even further enriched.
Personally, as a doctor, I need to attend conferences to keep up to date and
many are attractively packaged, in all manner of very desirable locations.
They are tax-deductable as well. Rarely do I attend Australian conferences.
Last year Elizabeth and I ventured to conferences in Portugal, Florida, and
Siena. It is really worthwhile, for one is able to meet many workers with
common interests from diverse backgrounds, in my case anaesthesia in
Portugal, Cancer Support in Florida and Pain Medicine in Siena. It was
culturally stimulating and also environmentally attractive, for conferences were
held in warm weather when it is cold here. QOL is definitely enhanced, so we
do this every year. Why not!


Friday 20th April 2005
‘It is better to travel well, than to arriv’-- is an old saying which is worth a
comment. Though attracted to the idea of exploring our wonderful world,
many people are discouraged from planning to venture forth by a variety of
negative experiences. A surprising number of people suffer from sleep
problems. Besides those that I have even observed on planes with sleep
apnoea, there are many others who sleep poorly at the best of times. These
people, when subjected to a situation where they must attempt to sleep sitting
up in a somewhat noisy and strange environment, compounded by an often
marked change in time zone, possible indigestion, and excess alcohol intake,
sleep extremely poorly, arrive exhausted and complaining of jet-lag.

Enormous backpacks, heavy cases filled with all manner of unnecessary
‘essentials’ and camera bags attractive to thieves, are observable at any
international airport. Practice makes perfect if one learns from experience.
Luckily, I always sleep well, never get so -called jet-lag, aim to carry no more
than about three and a half kilos in my little back pack and have no other
luggage. One feels a sense of freedom, travelling light.


Monday 2nd May 2005
Another one! Another man who has had prostate cancer attended one of my
clinics today. He was sixty when, last year, he went to see his doctor for a
health check. A PSA was done and was found to be significantly elevated, at
6.3 ng/ml. Biopsies were taken which showed cancer in most specimens and
a Gleason score of 7 – the same as mine. The day before I had my radical
prostatectomy, he had his radical prostatectomy. The good news is that the
cancer was still within the capsule and his PSA now is undetectable.

He is to be admitted for a cystoscopy to check on his water works, as he is
still, since his surgery on 13th October 2004, suffering from significant urinary
incontinence! Not exactly fun for him, wearing pads.

What about impotence. No sign of a spontaneous erection, just like my other
three informants over the last months. Of interest though, is that he injects his
penis with prostaglandin, using Caverject®. How is it? ‘Painles’! --- ‘Slow to


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grow and slow to go’ he says-- with some massaging. Not ideal, but better
than nothing.


Tuesday 3rd May 2005
This evening I called in to see an old friend, on the way home from giving
anaesthetics in another town. These days his health is failing, he has little
energy and frequently he feels too hot or too cold! It is almost four years
since he was diagnosed with liver cancer but he is very careful with his diet
and conserves his energy. It is remarkable that he has survived to reach the
age of sixty-six years with medically acquired AIDS following a transfusion
because of his haemophilia.

When he has the energy, he works painstakingly, to restore his daughter’s
six-horse float, complete with sleeping quarters -- and even a shower. In
years gone by he has built his stone home, and is an expert in matters
mechanical, working on model aeroplanes, exotic cars and motorcycles.
Nevertheless he feels time is running out for him, even faster than for the rest
of us. The time is late, too late for him to take me for a drive in one of his
cars. Tomorrow, after I have finished work he will come around to my place
and we will go for a drive.



Wednesday 4th May 2005
All day at work, I looked forward to the promised ride in my friend’s sports car.
He decided when his liver cancer was diagnosed to buy a special car and
later bought one. I know of other men who have done the same. . One of the
many who agrees with the proposed patient definition of QOL as ‘being able
to do what one wants to do, when one wants to do ti, together with the
satisfaction/happiness that accompanies it’, he bought a car that he really
enjoys and has now owned it for two years. Idling out of town, he then
demonstrated its acceleration, nought to one hundred kays takes about four
and a half seconds, with a good shove in the back and some wheel spin. If he
had kept his foot on the accelerator, we would have reached over two
hundred and eighty kilometres per hour rather rapidly, but he eased off. It is
the knowledge that he can do it that is important, rather than risking his
licence at every opportunity.

Time is too precious he feels, for him to waste the time he has left with
activities which are meaningless, so he divests himself of non-valued
occupations, objects and hobbies which have lost their relevance. When I
was first told that my cancer had spread beyond my prostate and beyond the
specimen removed, I came to realise that I should focus on the most
meaningful occupations and weed out the irrelevant. I very much enjoy myself
on mountain roads in the Victorian Alps, so plan on pursuing this interest. If
my time, like my friend’s, is possibly to be reduced by cancer or anything else,
for that matter, then am I not sensible to follow the example of my friend.
Nowadays I worry little over non-core interests, just like he.



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The days pass rapidly and this week we are trying to finalise our
arrangements for our June 3rd departure for our holiday. Before then, my
1966 Mini Cooper S should have its padded and upholstered roll cage fitted
and be ready for the road. When it is run in, I am sure that it will give me
much pleasure, as it did for its previous owner, my age and now dead, who
competed in hill climbs for years with it. One day I intend to drive a car
around some of the Monte Carlo Rally course roads near Monaco and gain
some feeling that drivers may have had in the nineteen sixties in these
amazing little cars which swept all before them in their day. Optimum QOL is
the aim, as it is with my friend. Life is too short to do otherwise.


Friday 6th May 2005
This week appears to signal a change in direction. Though I have been
happily giving anaesthetics this week, both in Armidale and Inverell, time is
running out for me as a practising anaesthetist. I have pulled the plug. On
24th of May I shall give my last anaesthetic – after starting my experience as
a fifth year medical student at Royal Prince Alfred Hospital in Sydney in
1963.After Elizabeth and I have enjoyed six weeks holiday overseas we shall
return in July to a rather different life.

Already there is agreement that I shall start practicing as a Pain Specialist at
Inverell Hospital, as well as continuing my pain clinics here in Armidale, as I
have for the best part of twenty-one years.

Today I made an appointment to see the Medical Superintendent and the
Director of Anaesthetic and Surgical Services at Coffs Harbour Hospital next
week. We shall discuss the provision of chronic pain services, as I have been
urged to do so by doctors in the area and may end up travelling to the coast
regularly to do pain clinics, on my return from overseas. It sounds like an
enjoyable challenge, but time will tell!


Saturday 7th May 2005
Elizabeth and I finalised the arrangements for our trip this morning. In less
than four weeks we are leaving. Four weeks exactly until we check out of the
Waldorf Astoria – an extravagance, but hopefully a memorable experience –
and fly out of New York for St. Martin, the French part of that Caribbean
island. shared with the Dutch. We are excited about boarding the catamaran.

On QOL – a ninety year old lady told me today that she is just as happy and
has just as good a quality of life as she has always had – and gave
Elizabeth’s sore knee one of her professional massages. It is always
encouraging to those younger, to hear such a positive opinion.


Sunday 8th May 2005
We are anticipating helping my patient who has an olive grove, to harvest his
crop. It should be interesting working with a lot of church volunteers and I
believe there is a barbeque to follow, as there was yesterday.


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(later) We have had a most enjoyable and educational day in the olive grove –
with my contribution being to use the machine which separates the freshly
picked olives from sundry leaves and olive twigs, then to fill the crates. Later
they will be cold pressed to produce extra virgin olive oil, which we always
use.


Monday 9th May 2005
Incontinence of urine following radical prostatectomy is thankfully diminishing
as a major problem for the vast majority of men. I am really blessed though,
to be among those with no urinary problems following surgery. No – I
exaggerate a little. Very occasionally, when I bend forward to get out of the
Mercedes, I feel as though I am about to lose a few drops – even though I
hardly ever do. Why mention the Mercedes? Well, it never ever occurs when
I drive my Range Rover, which has a superb driving position and I do not
have to bend forward to get out of the driver’s seat.

Anyway, a nurse, at the hospital today described her brother’s predicament.
Fifteen years ago he was diagnosed with prostate cancer and underwent a
radical prostatectomy. The good news is that he has no evidence of disease
today. Post-operatively, he was incontinent and has remained so ever since.
His sister is of the opinion that life is no longer worthwhile for him. A supra-
pubic catheter drains urine from his bladder into a bag strapped to his thigh. It
often leaks, requiring pad changes (which he carries, always). His life has
been plagued by repeated urinary tract infections. He rarely goes out of his
home. It is not for me to question his management. One supposes other
options have been considered. There, but for the grace of God…………….

Tuesday 10th May 2005
Yesterday, after work, Elizabeth and I drove down to the coast and stayed
overnight in Sawtell. Later I spent an hour or so discussing the possibility of
starting a service for chronic pain patients at Coffs Harbour Hospital. There is
no point in starting a clinic unless there is sufficient interest from at least one
individual with the potential to take over management of the unit, when I
eventually retire. There is a state of the art new hospital and the Medical
Superintendent is to explore the proposal. Anaesthetists would be willing to
be involved if practicable, though they are very busy and it is always difficult to
attract suitable people to the country, as any centres outside the real
metropolis are regarded. I took the opportunity to visit a medical practice
down on the coast on the way home, to discuss patient referrals from the
area. They agree that it is a long way to send patients all the way to
Armidale, but still feel it is worthwhile. Perhaps we shall succeed in
stimulating enough interest to be able to establish a regional Pain Clinic in the
future – I certainly hope so.


Wednesday 11th May 2005
Further to my remarks on 25th April on holiday goals which optimise QOL and
my mention of the Waldorf Astoria on the 7th May. I would like to explain my


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reasons for booking into that hotel. Firstly, it is such a famous land-mark in
New York that I am curious to experience staying there. Secondly, I am
writing a novel partly set in New York. Thirdly, it is very centrally situated and
we have to stay somewhere. Finally it is not as expensive as one might think
and my pharmacist friend, who stays there whenever she visits Manhatten,
assures me that it is well worthwhile.

William Waldorf Astor tore down his fifth avenue mansion and built the original
Waldorf Hotel in 1883. Only in 1931 was it replaced by the current Waldorf
Astoria, in Park Avenue, Manhattan. Naturally, famous guests have included
numerous Heads of State but some stories are worth retelling. The Prime
Minister of New Zealand was waiting for a lift and was joined by Bob Menzies,
when Prime Minister of Australia and Harold McMillan, Prime Minister of
England. Both ‘up’ and ‘down’ buttons were pressed. On arrival the lift driver
announced ‘Your elevator, my Prime Minister’. There was general confusion
until Menzies replied “There are so many dammed Prime Ministers here, we
don’t know which one you are referring to.”


Thursday 12th May 2005
Prince Faisal had toy trains placed on his table so he could play with them
during dinner, whilst King Ibn Saud brought a herd of goats, so he could have
fresh goat milk at will. When Nikita Kruschev stayed, the Hammer and Sickle
flag flew over Park Avenue. He brought his own chef so he could learn from
the Waldorf’s chefs.

A glance at a book of recipes from the Waldorf is enough to raise one’s serum
cholesterol. Page after page lists heavy cream, such as 1 cup heavy cream in
the shrimp sauce; six tablespoons of butter in Avocado Coquille Medley; 1
cup light cream in Shrimp Sauce a la Eugene and the list goes on. There are
some healthy choices available but, turning to a list of seventy-three desserts,
only seven are free of either eggs, butter or cream and frequently all three are
included. By way of contrast a dinner cooked there by members of the
explorers club listed raw lambs eyes, two hundred year old turtle eggs, beaver
liver, roast possum, wild boar and chocolate covered ants. A stay there
should provide some good memories.


Friday 13th May 2005
Tomorrow it will be exactly seven months since my prostatectomy. Yes, I
know it is possible that my erectile capacity may return-- up to possibly two
years following surgery but things are still the same. How do I feel about my
QOL now? Well, I still feel that if only I could raise a decent erection my QOL
would be significantly better, for I have certainly not lost interest in sex. It is
hard to imagine anyone not being keen on sex actually. Elizabeth and I are
still close, lie in bed talking and cuddling, shower together each morning and
life is excellent in many ways. While ever my PSA remains undetectable and
I feel so well I shall continue to live life to the maximum. Working full time,
staying up to midnight or later, going on regular walks, taking all the dietary
measures suggested which allegedly help reduce the chance of prostate


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cancer recurrence and monitoring my PSA closely. Somehow I feel more
confident that if I have to have radiotherapy, I shall cope with it with little
impairment of my present function. One day soon I shall try the prostaglandin
injections too.


Sunday 15th May 2005
A quiet day spent attending church, having a walk around the University Oval
we favour and then reading and writing. Another thousand words or so were
added to my novel’s first draft.

In the afternoon, S came around to help me rid my computer of Spyware – we
failed. She is off to Sydney tomorrow to have eight weeks of hyperbaric
oxygen therapy for the infection in her skull, secondary to radiotherapy for her
parotid gland cancer. Even $29,000 worth of antibiotics recently, failed to
cure her. Let’s hope two hours per day in the hyperbaric chamber will!


Monday 16th May 2005
Distress is the subject on my mind today. Two years ago, a patient told me,
this morning, he had a stroke. One moment he was fine and the next, he just
fell over. He had suffered a cerebellar/thalamic stroke which caused pain and
loss of function on his right side. Initial treatment entailed eight weeks in
intensive care including tube feeding. After he was moved to rehabilitation, he
started to improve more rapidly and after two weeks there he could eat solid
food. By the time he was discharged from hospital, after a total of four and a
half months admission, he was in many ways back to normal. He came to
see me as he still suffers pain on the right side of his body, especially his
head, right upper and lower limbs, which may often reach 7-8/10 in severity.
As part of his assessment I asked about his level of distress. It is 2/10 which
is the same at it has been for over twenty years. What distresses him is
running a business, which he is again coping with; full time, and especially
distressing is paying taxes. He is not poor and could easily sell up and retire
if he chose, with no financial problems. The strange thing is, he has never
been distressed by his cerebro-vascular accident or his pain at any stage.
Unexpectedly, he has started to improve further in the last four weeks, so I am
not going to change him from his Neurontin® medication. A new drug,
Lyrica®, has just been made available and if he does not continue to progress
adequately it may be helpful in treating his neuropathic, burning pain. His
only other complaint is impotence since his stroke. However this does not
surprise him, for a number of his friends also in their early sixties have been
losing their interest and capacity to have intercourse in recent years. It is also
of interest that his pain, which of course is central pain, is not present at all
when he is concentrating at work, so I did not encourage him to leave work
and spend more time focusing on his pain. I shall review him in two months.
Medicine is an interesting profession most of the time and fascinating the rest
of the time. It is never, ever boring.

Next Tuesday, the 24th will be my last day giving anaesthetics in the
operating theatre. How times have changed since first I gave an anaesthetic


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under supervision as a fifth year medical student. Already I am booking pain
patients in to my additional Pain Clinic which will commence on my return
from overseas in July.


Wednesday 18th May 2005
Ah! The joys of anticipation! Anticipation enhances QOL when related to
planned positive events. Though it was two and a half weeks yesterday,
before we go on our holiday I, having the day off, carried out a trial of packing.
Last week I had made out my list of things to pack so with this list in hand,
clothes were plucked from cupboards. Six weeks away is quite a holiday, so
swimmers, towel, diving goggles, shorts, shirts and so on, soon filled my little
Audi back pack. There is little room left now and it weighs all up nearly four
kilograms. My plan was to wear joggers on the plane and pack a pair of
shoes. I hold them in my hand and contemplate what is to be done. No
shoes this trip. Five weeks will be spent on the yacht and at beaches in the
Caribbean and the Cote d’Azur. Elizabeth and I were going down- town to fix
up our travel insurance, a very, very important task, so, I thought, I shall
simply buy a new pair of classy joggers and, at the only hotels we shall stay
at, in New York and Geneva, the staff can frown, if they want. Anyway, I
rationalise, I am always telling patients with chronic back pain to avoid jarring
their feet and spines, so they should wear good supporting footwear. These
thin r soled leather shoes look better than they really are.




Thursday 19th May 2005
My computer has been suffering a severe virus infection and is nearly
moribund. An expert is coming today to effect a radical cure. The amateur
efforts of S and myself have been futile and no more time is to be wasted.
Tomorrow, after work we drive to Brisbane to see our eldest son Stephen. All
the family will be able to ring us overseas and vice versa if we set up our
mobile phone correctly – we hope! It does not always work out as
successfully as we plan.


Friday 20th May 2005
After work we left for the drive to Brisbane to visit Stephen, about 5 p.m. Just
after we left Wallangarra on the Queensland border, in the dark, with our
lights on low beam as we were following another vehicle, it braked suddenly
and so did we. Only then did a kangaroo appear in our headlights. In an
instant, suddenly, with my foot hard on the brakes we hit the poor animal.
The grille of the Mercedes bore the brunt of the impact. No water leaked from
the radiator and we continued after a brief roadside inspection of the damage.
It could have been worse.

A nurse I know, told me that in less than six months, she had hit three
kangaroos in three different hospital cars. All cars suffered at least $5,000


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damage . At night in the north of the state, in a drought, the risk of meeting
kangaroos on the road is ever present. In the early morning I often see them
by the side of the road and the other morning two very large roos were
standing close to each other on the road, perhaps having a conversation, and
only reluctantly hopped away when I was quite close. We humans are
intruders in their territory, I feel.


Monday 23rd May 2005
Elizabeth and I met our friends H and his wife in Coles supermarket today.
He has recovered quite well from his radical prostatectomy now, having
regained the weight he lost and now tells me that his subjective well being is
generally excellent. A strange tightness or pressure feeling in his bladder
area persists and he, like my three other friends and myself is impotent. We
are all rather sad about this and have no confidence that we will regain our
function. We wait!

H is emphatic that subjective well being has little, if anything to do with
happiness. One may feel perfectly well and as fit as can be, whether one is
happy or not. Some QOL workers tend to see QOL as consisting of objective
and subjective aspects. I would agree that happiness and subjective well
being are not synonymous, however if one is feeling full of vigour, lively,
energetic and ready for anything, then the stage is set for happiness to follow.
Conversely it is harder to feel really happy when one is lacking a feeling of
well being. Is happiness all pervasive or may one be happy with ones exam
results, unhappy about finances, happy about a forth coming holiday and
unhappy about the weather?


Tuesday 24th May 2005
The first six patients on my list of patients having cataract surgery today, all
have diabetes. Four of them have insulin dependent diabetes and two are on
tablets. The other six have their problems, it is true, but diabetes is seemingly
more and more commonly seen, affecting the lives of many Australians.

Today I formally applied to start a Pain Clinic at Inverell Hospital, having had
agreement in principle already. There will be a meeting of credential and
appointment committees, over the next weeks and if all goes well, I shall start
my clinics there about the beginning of August. My life is governed to an
extent by my regular PSA tests and I told the Executive Officer that my plans
could be disrupted if I have to have radiotherapy!


Wednesday 25th May 2005
Psychiatric illness is still a somewhat forbidden subject. The other night, a
patient that I had seen two weeks previously at my Pain Clinic, suicided. He
was a young man who had major surgery to one ankle in Brisbane and his
discharge summary documented a borderline personality disorder. Because
he was suffering some back and hip pain, he was referred to me for
assessment. I found that his pain was usually mild and never severe. One


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leg was now a little shorter than the other and this was affecting the way he
walked. I referred him to a foot clinic for possible orthotics to correct his gait
and prevent back problems. Brief screening revealed that he rated his overall
QOL as ‘good’ and that he admitted to no significant distress.

A relative, interviewed following his death, told the hospital that this former
patient had been diagnosed in the past as having schizophrenia and was on
substantial doses of Largactil®. Rarely do patients tell me that they have a
psychiatric disorder and this is often discovered on reviewing their
medications prescribed for depression, panic attacks, anxiety, psychotic
illnesses and so on. On asking them if they have ever had any serious
illnesses they are likely to say – No! People only tell you what they want to
and we know that many medications prescribed are not taken. Sometimes, as
in this case, they are not mentioned.


Thursday 26th May 2005
P was my age when he was diagnosed with caner of his prostate. He
consulted a specialist in Wickham Terrace, Brisbane, and was advised that he
had three choices-- do nothing and be dead in a few years; have a radical
prostatectomy; or have radiotherapy. Little guidance was given apparently,
just the opinion that his chances were probably about the same whether he
chose surgery or radiotherapy. He chose to have radiotherapy.

Now, some eight or nine years later, he attended my pre-operative clinic today
as he is to have a colonoscopy to check again on his radiation proctitis,
caused by his radiotherapy and still a trial for him. Two weeks ago he was in
hospital and had a cystoscopy and optical urethrotomy, for his radiotherapy
has caused a serious urethral stricture which has been interfering with is life
ever since. Post-operatively he suffered rigors and a sudden drop in blood
pressure, plus a fever due to bacteria entering his blood stream at operation.
Intravenous antibiotics were given and he recovered – to face a problematic
future. He wishes he had chosen a radical prostatectomy! There is no
evidence of cancer – that is the good news.


Friday 27th May 2005
We are relieved to be having a more or less quiet weekend at home. Every
time we go away we seem to get behind with things and have to catch up.
Our experience has taught us that there is quite a bit to do when preparing to
go away, whether it is a short trip or rather longer. In retirement, we are
convinced that it will be simpler and less work to go away for fewer long trips
than a lot of shorter ones. One also saves money on fares and the increase in
well-being, following a brief sojourn, seems to dissipate sooner.

It has been a busy but unremarkable day at work and we have had an
enjoyable walk at the University, observing the soccer players and rugby
players practicing under the flood lights, as we walked. Later we went
shopping at Coles. It was just a thoroughly pleasant day with the latter part
spent together, enjoying each other’s company.


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Saturday 28th May 2005
Elizabeth and I had a most enjoyable evening at a dinner party where there
was stimulating conversation, excellent food and wine. No one went home
before midnight, an advantage of not having to get up and go to work, as on a
week day.


Sunday 29th May 2005
A quiet Sunday morning, spent lying in bed together, then having our leisurely
shower together, enjoying our QOL. A lot of patients have described
happiness in terms of peace and contentment. This is a morning filled with
happiness. We are looking forward to many such days on our holiday, which
is mainly centred on relaxed days on the beach. In Antigua we get up very
early to walk a few kilometres up and down the beach, watch the fish in the
shallows, swim and return to our Villa before the sun gets too hot. In the late
afternoon we do the same again. The simple life.


Monday 30th May 2005
Life in the country is sometimes simple. Last week, it took very little time or
effort to organise the repair of my little Mercedes. I simply left the car with a
local panel shop associated with the Mercedes dealer and they quoted on the
job and obligingly got another repairer’s quote. Four thousand dollars worth
of damage for a seemingly minor meeting with a kangaroo!

Next, I notified the insurance company, AAMI, and I won’t even lose my no
claim bonus. The assessor inspected the car later at the panel shop and
approved the job. Now the car is garaged at the Mercedes dealer where parts
will be obtained and the job done whilst we are overseas. They will then
return my car to my home and lock it away in its garage – awaiting our return.
Who could ask for anything more! No unhappiness! No hassles! No distress.
A little greater damage and we could have been stranded, with the car
undriveable and in Queensland, many miles from any needed services. We
are blessed, indeed. The top of the radiator was cracked but still water proof.


Tuesday 31st May 2005
Bright and early this morning I drove to the airport and collected the fire
protection engineer who is to inspect the installation today. Back in town we
met the plumbers at his office and all went to the site. As soon as the
Pathology Department opened I made a bee line for it and had my blood
taken for my PSA test – now seven and a half months after prostatectomy.
Elizabeth and I then travelled to Inverell where she had an appointment and
we gave the Armstrong Siddeley and Jensen Interceptor a run to keep their
batteries charged and of course to enjoy the drive.

All during the day, the thought of my PSA was ever present. As soon as we
returned to Armidale at 3.30 p.m. I went to Pathology and was informed my


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PSA was <0.1 ng/ml. It took two phone calls to Tamworth and a conversation
with the Laboratory Chief before the report was revised and the true reading
PSA <0.01 ng/ml confirmed – this happened once before! Fantastic news!
What a relief! Now we can happily leave for our holiday without any worries
about starting chemotherapy, or even having to curtail our trip. My QOL is
now as good as can be if I do not think about my impotence.


Wednesday 1st June 2005
A busy day spent working and in between everything else, seeing the project
engineer who is to supervise the concreter whilst we are away. The bricklayer
came, I saw the bank, collected some keys, arranged a rental, checked on a
watch which I had ordered for diving, rang Stephen as it is his birthday, saw
the plumber, saw the tenant, and Lord knows what else. As winter
approaches there are holiday makers arranging to go skiing in Victoria and we
have a long list of bookings – which the resort management will take care of –
but one of my colleagues and our son Garry also wish to have
accommodation at the same time and Elizabeth is trying to sort this out. One
house is booked for the entire season.

This evening I sorted out some last minutes things, laid out clothes I shall
wear on the plane, finalised packing and weighed my bag – about 4.1kg – just
the weight of the marijuana found in Schapelle Corby’s bag in Bali. Mine will
be with me on every flight and never have the risk of some interference by
others. Everyone – staff, patients and friends are wishing us a marvellous
holiday and want some cards from overseas. Anticipation of the good times
ahead is growing by the day.


Thursday 2nd June 2005
Last night, on ABC television news it was reported that earlier diagnosis of
prostate cancer is improving outcomes but that with an aging and growing
population there could be an increase in reported cases of up to 25%, in the
foreseeable future. More education of men was recommended but there was
no mention of PSA screening. Perhaps in another ten or twenty years-- it
might be considered a good idea! The other day a laboratory scientist told me
that his father had entered hospital with urinary obstruction and was found to
have prostate cancer, from his description, at transurethral resection of his
prostate. A few months later he had further obstruction and was catheterised
for about five weeks, in hospital. He was given hormone suppression tablets
and developed bony secondary deposits, where metastases are very
common. He died within two years of diagnosis, at the age of seventy one.
Without PSA screening I could envisage a similar fate befalling me. Early
diagnosis is giving many men a much better chance of cure in my opinion,
often with radical prostatectomy, before too late.


Friday 3rd June 2005
As 6.30 a.m. this morning our overseas adventure commenced. We
anticipate landing in New York at 5.20 p.m. New York time, this afternoon.


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It is my intention to take plenty of photographs and some notes on this journey
overseas, partly with a view to incorporating some of the material in the novel
I am writing. Perhaps I shall become seduced by the tropical ambience! We
shall see! Any interesting experiences of any interest to others may be noted
and possibly find their way on to these pages too!

It is time to go. I am just so happy that my PSA is <0.01 ng/ml and I am sure
that I shall be concentrating on other things than prostate cancer. David Grob
was being interviewed the other night on his life as musician, now in Foo
Fighters and formally with Nirvana. He feels so happy to be having such a
good life doing what he wants and not regarding it as work at all. He realises
how lucky he is-- to make it in the music world. I too feel that I have been
able to be a doctor-- as I wished, to enjoy my professional life as I still do and
have an idyllic existence with my close family.


03.06.05
It is 9.35 a.m. and we are in the Qantas Club in Sydney, having left home at
6.30 a.m. on the Dash 8 and are to board QF107 for Los Angeles
International Airport (LAX) and JFK airport in New York at 10.05 a.m. The
day is slightly cloudy, with the winter sun shining through. At Armidale it was
crystal clear. Breakfast here consists of two slices of brown toast, two
glasses of Saltram semillon and a large red apple. Not my normal breakfast
of one cup of Ecco, a barley coffee substitute, made in Italy. Already I have
met an Australian, whilst we were making toast here, who has been working
at Boeing in Seattle for five years. He said he will see me again on the plane.
Travel presents many opportunities to meet interesting people. Elizabeth is
diligently completing some accounts she wishes to post here before we leave.
Within the few hours before we left, all our boys rang up to wish us a great
holiday, Andrew confirming the time he will arrive in Antigua on the 15th, so
we shall meet him at V.C. Bird International Airport there.

When we checked in for our LA Flight, we were not upgraded to Business
class but given three seats for the two of us in Economy, which is appreciated
as we shall obviously have more room to spread out and relax - even sleep,
perhaps. Already I am anticipating watching some new movies on the flight of
fourteen hours. Knowledge gained from past experiences enhances our
experience of our holiday, to optimise our QOL. Later in the day, I shall make
a few more observations.

It is now breakfast time, an hour or two before we land at LA and the extra
room, with three seats, has allowed us to get some sleep. How lucky we are!
We should not forget the plight of others, and I was reminded of this when
reading today’s issue of the Australian newspaper. On page twelve there is a
report from the Russian Interior Minister, Rushid Nurgaleyev. Today, in
Russia there are two million orphans, two million teenagers who are illiterate,
four million young people who have used drugs, many starting by the age of
eleven, and of whom one million are adults. Prior to the collapse of the Soviet
Union, literacy was approximately 100%. Widespread poverty, lack of


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parental control and economic problems have been accompanied by
homelessness and crime. Drug related deaths have soared forty-two times in
twenty years. He calls for all state organisations and citizens to address
these problems. How distressing it must be for the Russian people. One
wonders about the situation in other former Soviet Union countries. Andrew is
at present in Dominica, preaching Christianity to primary school children.
Dominica is a poor country in the Caribbean but a lush, forested, mountainous
and beautiful island, where plentiful fruit and fishing mean there is no problem
with obtaining the basics of life. Little money, but none of the social
dysfunction that Russians are suffering, and of course a tropical climate. I
went to Russia once, and to India, and to Africa more than once. Probably, I
shall never go to any of these places again. South America beckons!
Perhaps in a couple of years – but each year we return to Italy, France and
the Caribbean, as we always enjoy these places so much, looking forward
with great anticipation to each trip. But first, now, is New York City. I can
hardly wait!

04.06.2005
On our arrival at the International Airport in Sint Maarten, on the Dutch part of
the island, we caught a taxi over to Marina Royale on the French side, where
our catamaran is moored, left our luggage and explored the water front, where
there are plenty of restaurants, bars and moored pleasure craft. Further away,
behind the restaurants, is the tourist- focused town, with plenty to interest
shoppers.

I chose a port cabin aft, complete with its ensuite with electric toilet, on our
catamaran There are three other couples, all American; a cotton farmer, a
Parks and Wildlife administrator and a computer engineer and their respective
wives. The captain is from South Africa and his partner and our cook is
Australian with a Dutch background. There is an open bar at all times, with
every drink you can think of, even soft drinks! Unless the weather is
inclement, we shall dine aft, under the bimini top, the social centre of this
sailing cat with twin diesels. It is about fifty feet long. After breakfast
tomorrow, we weigh anchor and head out of the harbour.

Sint Maarten/Saint Martin is, as the name suggests, an island shared in
governance by The Netherlands and France. It is situated in the Eastern
Caribbean, south of the British (and American) Virgin Islands. Even closer
are the Island of Saint Barthelemy – now ruled by France, (though with an
interesting period of past Swedish rule) and the British Isle of Anguilla, both of
which we shall be visiting, this week.

The concept of fractional ownership is probably best known in the Executive
Jet industry, where it is possible to buy a fraction of a jet, say a quarter share
or an eighth, for that matter. Some companies sell blocks of time. The options
available may range from an eight hour block of time in a Boeing Business
Jet, great for up to 18 people – it is really a customised Boeing 737 – for $US
125,000 down to much more affordable aircraft. It is economically unrealistic
for a business to buy a jet, unless it is to be used, say 500 hours annually or
more. If there is reason to use a plane for 100 hours or even 25 hours per


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year, then it makes sense to purchase a share and the plane can generally be
supplied exactly when needed, complete with crew. The idea has spread.
We are all familiar with time-sharing in resorts, as we have invested in, both in
Australia and Antigua. You pay for just what you wish to use. Now property /
resort sharing has gone up-market, and one can purchase four weeks of
accommodation each year at a development at Beaver Creek ski area near
Aspen, for up to $US1,500,000 – complete with concierge and every amenity
one can think of. Most are much less, say $US 200,000 for 3 weeks annually
at a lesser resort. These prices are astronomical, compared to the familiar
‘time-share’ week, which may be purchased for as little as a few thousand
dollars, and a modest maintenance fee each year, depending on the quality,
season and site.

Now the idea has reached the yachting world and we have joined others, so
we can enjoy yachting in the Caribbean at a more affordable price. The more
we use it, the more we pay, and if we wish to have the cat all to ourselves,
then it costs four times as much. The average yacht owned by a single owner
is used just 20 days a year, so it makes sense.


05.06.2005
After breakfast, we had to motor across Simpson Bay Lagoon to where there
was a road bridge that opened to let shipping through by nine o’clock. Then
we set our sails and headed out in the channel on the north side of St. Martin,
on our way to Anguilla, so we could spend the rest of the day at Prickly Pear
Cay, secluded and with clear turquoise water, after lunch, served on board.

We paddled to a nearby beach in the sea kayak, and put our gear at the
entrance to a small cave out of the sun, before putting on our snorkels and
flippers and spending the afternoon exploring the sea below some nearby
cliffs. There were alleged to be turtles and rays thereabouts but we missed
them, but saw plenty of blue (and I mean vivid blue) fish and prolific sea life.

Later we sailed to Road Bay, further around the coast of Anguilla and enjoyed
ourselves in the sea, near Johnno’s Bar and Restaurant – but we dined on
board again. The weather remains warm to hot and I use plenty of block-out
and am avoiding getting too burnt. There is plenty of room to spread out on
deck or just read in the saloon, which has cherrywood timberwork, as has the
aft area, and cabins, so everyone is enjoying the ambience and we are getting
to know each other. Everyone seems to retire early, and so we do too.


06.06.2005
QOL is what our yachting and diving holiday is all about. Soon after a
breakfast of croissants and tropical fruit, we sailed over to a small offshore
cay by the name of Sandy Island with a surrounding circular coral reef. High
and dry at one end of this cay is the remains of a sizeable boat, dumped there
by the last hurricane. One can walk around the little isle in a matter of
minutes and most people took a swim in the crystal clear water off the beach.



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The catamaran was moored outside the reef and we took the tender to the
beach and only returned for lunch.

In the afternoon we sailed to Crocus Bay, which is part of Anguilla Marine
National Park, and protected. Taking a kayak and paddling along the cliff face
one can see many birds, which nest there and below the surface of the sea
there are many different fish to see. Eventually we have a barbecue off shore
after a most enjoyable day.

With all our activities taking up most of our day, one’s resolve to do some
writing and send post-cards is dissipated and somehow the time passes by,
having a cocktail, watching the sunset, chatting with fellow guests or the crew
and just relaxing. Some people tell me they get homesick when overseas and
yearn to return home. This has never really been a feature of any of our
sojourns overseas, even when we were away for two and a half years in the
nineteen sixties.

07.06.2005
If I don’t watch out I am going to put on weight, as at home I don’t eat
breakfast and on board so far, I have had a croissant, cheese, plenty of fruit
and a hot dish for breakfast.

Today we sailed around the Northern Tip of Anguilla and then on to Anse
Morceau Bay on the coast of St. Martin. There is a marina, and it was worth
exploring. The restaurants we were told about at, Grand Case, where we
sailed in the afternoon, are famous, particularly of course for their seafood.
Together with our new friends on board, we walked up and down, trying to
decide where to dine and eventually made our choice. We went through the
menu and a few bottles of French wine – good quality food, passable wine
and a hefty bill – but a good time was had by all, at what we thought was the
pick of the restaurants. Not a good place to go if you are a lobster. There are
said to be eighty restaurants there, and all the tourists I spoke to say it is the
best area to eat out, on the island.


08.06.2005
Creole Rock is just off the coast near Grand Case, and after breakfast we
went diving there, before sailing on to an uninhabited island for lunch. The
attractions here were the mud pools, with an enviable reputation for inducing
wonderful feelings, perhaps best described as a soothing feeling, as though
you have acquired a new skin. It was very popular. The girls especially,
plastered on the mud, let it dry then dashed into the sea and then washed it
off. After this, it was time to have a few cocktails, a habit we were getting to
enjoy, late each afternoon.

Finally we sailed down wind to Orient Bay, where we anchored close to a
small island, to watch the sunset before dinner, and this is where we spent the
night. There had been plenty to occupy us during the day, diving, snorkelling,
helping with the sails, sunbaking on beaches after mud baths and plenty of
socialising with our cocktails and enjoyable meals. It’s a very good life style,


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living on a sailing catamaran, in warm seas, reefs swarming with fish, with
seemingly endless new sights and experiences.

We were already looking forward to some exceptional diving the next day
when we retired for the night. The weather has been almost constantly fine
and sunny but there are a few clouds around now – though it is still balmy--
about                 the              perfect                temperature.



09.06.2005
First of all we went to the beach at Orient Bay for a swim, before weighing
anchor for Isle Fourche, which promised a dive site in the remains of the
mouth of an almost submerged extinct volcano.

Isle Fourche is to be found between St. Martin and our destination this
evening, Saint Barthelemy. The Captain anchored the cat in the volcano
crater and it was here that I enjoyed a memorable dive, almost an hour,
mostly around forty feet deep with a great range of sea life, including the
turtles, which I had heard so much about. Some of the reefs we had seen
previously were damaged, allegedly by recent hurricanes, though one
wondered whether there were other environmental adverse influences. Here
the reef was looking healthy, about what one expects around Antigua.

When we headed towards St. Barthelemy (also known as St. Barts or St.
Barth) we relied on one diesel plus sails, as the transmission on the other
motor had packed it in. Consequently we were too slow to reach Gustavia in
time to clear customs and had to anchor off shore, without a great deal of
shelter on a rather windy, rainy night. We plan to simply zoom into port in the
inflatable tender (RIB) tomorrow, to take in the sights of the capital. Never
mind, let us have another Jim Beam and Canada Dry and remember that
great dive today.


10.06.2005
Bright and early, we disembarked in the beautiful, chic port of Gustavia,
popular with the international cognoscente such as super models and film
stars allegedly – though we saw none. One can imagine why it is so popular.
It is architecturally different to what one expects in a Caribbean Island,
buildings all well painted and maintained, with designer boutiques and plenty
of interesting yachts moored stern to, along the waterfront, so I hope we shall
return, some day.

As we explored the waterfront area, we spied some classy looking bars and
restaurants, but the nearest beach was not to be seen. The island is small
and probably hiring a car or jeep is the way to go, though we didn’t have time.
We did have a look at some of the boutiques, and I bought some new blue
and gold designer swimming trunks to replace those unfortunately ripped
whilst diving yesterday.



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Elizabeth and I were so impressed with Gustavia that we resolved to enquire
about accommodation possibilities for the future. One can fly in to St. Martin
and catch a fast boat across to St. Barthelemy – with three return ‘voyages’
per day, as the local airport is pretty small. The locals do not approve of
cruise ships stopping there for a few hours and disgorging thousands of
‘round the Caribbean in a week’ tourists. They tried that in the past and
campaigned to have the big ships go elsewhere, and not inundate their little
port with day visitors.

We found a simple yet attractive hotel along the waterfront, handy to
everything, with rooms that have a big balcony facing the water. St. Barths is
said to be expensive, and certainly there are plenty of upmarket resorts and
villas to rent, but we are perfectly content to live simply and inexpensively in
attractive surroundings. In all honesty, I am very keen on returning here to
further explore the island – it all looks very promising. Anguilla has some
beautiful resorts according to travel brochures I have seen, but the
atmosphere in Anguilla and in parts of St. Martin does not really turn me on.
Whenever I travel I am on the look out for beautiful, interesting, friendly
environments, which are not quite as common as could be expected. Life is
far too short to waste time in places you hardly enjoy, so when one comes
across something exceptional, then it is worth noting and gathering
information, useful for a repeat visit. St. Barths is now on my list.

Soon we sailed to Philipsburg, but we did not stop – due to our late departure
from Gustavia – and continued back to Marigot after stopping for a swim on
the way. We strolled along the waterfront at Marina Royale and packed up
our luggage as we are to leave the catamaran in the morning – after an
interesting week. Tomorrow we fly to Antigua.

Only one problem has arisen, possibly due to my age! At the risk of boring
the reader I shall digress a little.

Thoughts on the effects of ageing on travel, stamina and health related QOL.
Many trips overseas, even those involving very long flights, have never
bothered me. Jet-lag is for others, tiredness is a minor nuisance and I always
plan to start work immediately on my return. When we arrive in Armidale on
Monday 18.07.05, my first patients arrive within the hour. This happy state of
affairs has even been a source of quiet pride, and has allowed my pleasure in
travel to remain undiminished until, perhaps now!

On arrival in New York my feet and ankles, as expected, (especially seeing I
had worn my surgical support compression stockings to prevent deep venous
thrombosis), were normal. By the time we arrived in St. Martin, the next day,
both feet and ankles were a little swollen and they got worse over the next
twenty-four hours.      Someone on the yacht even remarked on this
phenomenon. A born worrier, I started to think about possible causes. Maybe
I had pelvic blood clots, maybe I had heart failure, maybe I had some other
systemic cause, maybe I had hypoproteinemia; maybe……. This went on for
days! At the same time I seemed to be more tired than usual and after a few



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days on the boat, felt a little nauseated, though boats usually do not cause me
any problems.

My thoughts became a little more morbid. If this does not clear up, I shall
have to see someone about it – I thought. At the same time, I was going
diving, snorkelling, eating well and seemed to be otherwise unimpaired. At
night I rested with my feet elevated but this did not seem to make much
difference. My calves were not tender. A friend who still plays tennis
regularly has just been diagnosed with heart failure, suffered by hundreds of
thousands of Australians, and I thought of him.

After about four days of this, the oedema disappeared, to reveal my normally
skinny ankles and feet. No sign of any pitting -oedema – any more. No
tiredness! No nausea!

Looking back on this event, I am inclined to explain it as being due to
international flights totalling over twenty-four hours, within two days, plus
sitting around airports, being less active than usual and, unpalatable as it may
be, it could have something to do with ageing!

As we get older we may have to ease off a bit. Now, I only work about thirty-
five hours per week, with no nights or weekends – much less than a few years
ago. Instead of driving nearly 1200 kilometres overnight to Victoria after work,
for holidays, as before, we now take our time or travel by train, when we go on
trips there. A bit like travelling on a slowly sinking ship and gradually throwing
cargo overboard so that the ship stays afloat a little longer. To think that my
friends and I stayed up all night gambling at cards, before walking into our
final Pharmacology theory exam at Medical School, still all alert enough to
pass and get into fifth year. Ah! – the days of youth!


11.06.2005
My conscience is bothering me! I know quite a number of men with prostate
cancer, and remember a few who have died with bony metastases. As far as
I am aware, there has been a general focus on maintaining the lifestyle they
have previously enjoyed. Whether they are in the workforce or retired, they
seem, or seemed, in the case of those deceased, to want to continue to do
just as they did before, working, gardening, going out to social or sporting
fixtures and so on. Workers plan to go on working and I cannot think of
anyone who has made major changes, whilst ever their health has remained
largely unimpaired.

My situation is comparable. If I had not been diagnosed with cancer and
undergone a radical prostatectomy, then I would still be doing pretty well
exactly as I am. It is just that it may seem that I am going to great lengths to
experience the best of life and that is true, but for me that is the norm. There
are many people I know, who have the resources and energy to travel as
Elizabeth and I do, but predictably, travel little or rarely, enjoy their fishing or
golf or workaholic life style, well past retirement age – having no plans to



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retire. What they possess is their optimum QOL I suppose, or surely they
would do something else.

Among cancer chemotherapy patients, many of whom have a very limited life
expectancy, are those who tell me that they very much regret having
postponed trips and foregone pleasures in the past, which they now realise,
are unlikely to be possible in the future. They sometimes feel that they are
living in the land of missed opportunities. There are others who now turn
towards family and friends who they previously spent little time with, as they
realise that though they may survive for many years, there is a cloud over
their future, and they realise the importance of these relationships. I have
interviewed so many patients and know of friends and acquaintances, who
have suffered broken relationships with spouses, children and other people,
and seem to find it impossible to mend fences, apologise, rebuild
relationships, consequently suffering as a result. If their health is threatened
by cancer, sometimes a crisis is precipitated, which may be impossible to
resolve. My mother, now in a dementia centre, earlier in life talked, for many
years, of visiting her relatives in England. Gradually they died or migrated to
the United States. She never visited any of them, even when she could afford
the trip. An awareness of the importance of maintaining and strengthening
relationships is analogous to a ships captain checking on the lifeboats, life
rafts and emergency procedures, before there are any problems. Don’t be
like the captain of the Titanic.

Today we flew into Antigua and saw large British Midland, Virgin Atlantic and
British Airways aircraft on the tarmac – previously only American Airlines and
British of the big International carriers, called here. We hired a car as usual,
did some grocery shopping and drove ‘home’ to Antigua Village on Dickenson
Bay, where we were soon swimming in the warm sea.



12.06.05
Time marches on and one lives in hope of recovering sexual function. It is
tempting to be either too optimistic at some fancied improvement or, on the
other hand, too pessimistic. It will soon be nine months since my radical
prostatectomy, so about time for a review of any progress. There is nothing
dramatic to report, but a little progress.

My erections have improved marginally, enabling penetration with a little
manipulation manually.        Some careful thrusting is possible without
withdrawing too far! The lack of a hard erection appears to be the reason for
my continued inability to reach orgasm at intercourse as it is always possible,
with manually compressing the proximal penis and attaining and keeping
some distal rigidity, to masturbate to orgasm in a short time. Whether this
information is useful to other men post-radical prostatectomy I know not, but
this is my present situation. If the mood is right, my present ability is
adequate for Elizabeth to climax sometimes so it is worthwhile. I am still
considering the Caverject® injections when we get back to Australia. The
thought of explaining suspicious syringes and needles to suspicious customs


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officials, especially in the US, dissuaded me from bringing any Caverject®
overseas! So, apart from this loss of ability, all is right with the world.

Let me give you an idea of ‘our’ beach, where we spend so much time. It is
situated on the north east coast of Antigua, with Runaway Bay adjoining it to
the northwest and the other end is towards the Hodges Bay region. Antigua
claims to have a beach for every day of the year and this is rated the best,
though there are plenty of other world class beaches. Starting at the
Runaway Bay end is found Coconut Grove Restaurant on the point, part of a
small resort called Siboney. They serve a high quality menu, have a bar and
live music, often jazz, some nights, but it is not noisy. Next to this is Antigua
Village, with ninety five villa units set in a few acres of gardens extending to a
protective rock wall on the beachfront. This became necessary due to
repeated hurricane damage to the beachfront, and the front villas of the
resort. On the other side is another beach bar and restaurant, appropriately
called The Beach. Live music here, at weekends particularly, can be heard
from some apartments at our resort. The beachfront on the far side for a
couple of hundred meters is occupied by local purveyors of beach wear and
Art, dreadlock hair stylists and the like, The hinterland is covered by trees and
other vegetation without the otherwise ubiquitous coconut palms along the
beach. Soon it is destined to become an extension, horror of horrors, seven
floors high, of Sandals, the couples only resort next door, which is, to our way
of thinking, quite OK as it is, with frequent wedding ceremonies on the beach.
Finally there is a Rex Resort, Halcyon Cove, with its associated Warri Pier
Restaurant jutting into the sea. Then it’s all fine white clean sand (and a dive
shop) all the way to the headland.


13.06.05
Our Villa unit has dimensions of 10x6 metres, plus balcony 6x3 meters
overlooking the garden, with it’s fresh water pool. It is an open plan design,
with two single beds and a convertible double, plus table and chairs inside.
On the balcony are two deck chairs, and another table and chairs. There is a
full kitchen including a large fridge, a separate bathroom with shower, bath
and toilet. The floor has white tiles. We never use the air-conditioning, and
the TV, but rarely.

Looking around from the pool, one spies a dozen or more coconut palms,
seven or eight banana palms, breadfruit, pomegranate and mangos. A large
flame tree almost overhangs the pool and bougainvilleas shade one area of
the pool. A miscellany of shrubs, include cream and red hibiscus in formal
gardens interspersed with well tended lawns. A couple of tables with chairs,
complement a dozen or more colourful recliner/banana chairs around the
turquoise pool picked out with royal blue tiles.

We are seconds from the beach and the Caribbean sea, which means calm
water most of the time, with, frequently, colourful sunsets. When I studied
Biology for the Matriculation exams, prior to Medical School we spent time
learning about the marine rock platform. In fact this was how I really got to
know a beautiful blonde girl, C, who became my girlfriend for several years.


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Anyway, my interest in marine environments has remained and so I almost
always inspect any rocky shores for crabs and other life. A walk along the
beach is not only good exercise and good for the soul, this is where I see
God’s world. It is likely that the observer will see small fish, the occasional
sand shark, crabs and less frequent creatures. The other morning I watched
as another guest hooked a shark which was attacking a school of mullet along
our beach. Leaping out of the water, he or she quickly bit through the 40lb.
line and escaped.

Down here, fresh fish is cheap and more readily purchased than at home,
even nice snapper being about ($A) seven dollars per kilogram. Local
restaurants will charge you $US30 for a steak or lobster and not much less for
fish dishes, yet we see lots of visitors dining out. Yesterday morning I
microwaved a 1.5kg local fish for eight minutes and completed cooking it in
the frying pan with a little oil, onion, garlic and ginger for several more minutes
– quick and delicious with a salad!

At this time of the year, the temperature seems about 35C. during the
middle of the day, so it is siesta time then, for me. There have been a few
showers and a little overcast weather since our arrival and much more in the
last few weeks, so everything is green and the salt ponds are brimming over.


19.06.05
Over the last days, the opportunity to examine examples of some people’s
ideas of holiday reading has presented itself. Both in the Villa we had last
week and in our present one, previous occupants have left stacks of books,
possibly from the resort’s informal library.

There are over fifty, in fact fifty three, of these mostly plump and
overwhelmingly paper backed volumes. In my spare hours I have scanned
through this somewhat depressing collection of novels, many of which proudly
announce their claim to fame as #1 New York Times Bestseller. There are
books by such well known authors as Ruth Rendell, Tom Clancy, Dan Brown
and John le Carre. The vast majority focus on murder and other violent
crimes. Serial killers are an especially favoured topic. Female writers also
feature prominently and are not shy when it comes to the use of swear words,
graphic descriptions, and controversial topics. The central theme of Philippa
Gregory’s 648 page New York Times Bestseller ‘Wideacre’ is the long term
sado-masochistic incestuous relationship of a brother and sister, in which their
progeny feature prominently. It is claimed that ‘it is a saga as irresistible in its
singular magic as its heroine!’ Readers who enjoyed ‘Little Women’ may skip
this tome.

‘Slander’ is an altogether different offering. It is written by Ann Coulter, an
attorney and legal affairs correspondent. She honestly admits in the first
paragraph of her first chapter that ‘Political ‘debate’ in this country is
insufferable’. ‘Politics is a nasty sport’ and ’At the risk of giving away the
ending: Its all liberals’ fault.’ A dip into the book confirms her support of the
Right in the US. She supports her arguments with thirty-five pages of notes.


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Obviously the book is not going to please Democrats, but it has a lot of
interesting data and a few amusing quotes from politicians such as the quotes
of Bill Clinton saying ‘This is still the greatest country in the world, if we just
will steel our wills and lose our minds!’ and Al Gore ‘A zebra cannot change its
spots’.

The best of the books from my perspective is a smallish ‘National Bestseller’
titled Brunelleschi’s Dome- How a Renaissance genius reinvented
Architecture. His Dome, in Florence, at 143 feet in diameter is still the largest
in the world, designed and built – or rather supervised, over twenty-eight
years, by a gold smith and clockmaker, hoisting seventy million pounds of
stone, hundreds of feet into the air. We once visited friends at their home in
Florence, and from their bed they could probably hit the Dome with a cricket
ball, as it is so close. This is one book I am going to read.


23.06.05
Seemingly, one has been doing very little here in Antigua, apart from
spending a great deal of time around the beach and pool. Yet is has been a
time of reflection on my life, at first, of years rushing by, marked by
achievement of life goals and later, years and years of going to work. Have I
wasted my life in these latter years? Previous years seem to have fled
alarmingly quickly, viewed from my present perspective!

Elizabeth and I met and become engaged at the beginning of third year
medicine, married at the end of fourth year, on 1st December 1962, had our
first child, Stephen, 18 months later to the day, in my final year of Medicine,
Our second, Garry junior, was born on our 4th Wedding Anniversary and
finally Andrew, four years later, less a week, whilst I was a Registrar at Royal
Brisbane Hospital. Another four years later and I was Assistant Professor of
Anaesthesia at a Canadian University. And then, the decision to return to
Australia and thirty years of sitting in Armidale!

Once upon a time, I had the idea that I could end up as Head of a Department
of Anaesthesia, a professor, travelling the world, perhaps setting the world on
fire in some field of research. Observations of the career path of friends in
North America who were following this pathway, suggested that to have much
of a chance of success, one had to keep progressing in a department or move
to somewhere advantageous, elsewhere.

I spoke to a professor who left a son in Baltimore, where he once had an
appointment as Associate Professor, a daughter in London, where he spent a
few years in a more senior post, and now, their youngest is about to go to
college in Canada, whilst they contemplate yet another move towards
academic heaven. Of course it is not always like this, but family and personal
sacrifices are very commonly made, in the quest for academic position. And
guess what! Some of the people who succeed, are not my idea of nice
people, at least among those of my acquaintance.




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I thought, why not go out in to private practice, make some money (at least
more than as an academic), be independent, and spend my free time on
research. At least one wouldn’t have some ego-tripping bastard controlling
the whole department by not allocating work schedules until the last minute,
spending inordinate amounts of time out of the department, claiming work
done by others as his own and so on and so forth. That was my thinking,
justified or not, at the time. Most of the academics at my department left, at
that time, for pastures new in British Columbia, Alberta, Texas, Toronto,
Japan and I don’t know where else, whilst the University retained a
Department Head who hit a female anaesthetist resident (trainee) across the
face in the operating theatre – the very powerful old-boys network prevailed
for another few years until he left.


24.06.05
Where are all the people, I asked myself this morning, as I was walking my six
or seven kilometres along our beach and the next? According to my
calculations, knowing the size of the four resorts on the beach, there should
be at least 1000 holiday- makers on average, here at any one time – perhaps
15,000 per year, as most stay 1-2weeks and some live here, or stay for
months My morning starts typically about six o’clock or so. By the time my
walk is completed, plus a swim in the ocean and a dip in the freshwater pool, I
would have spent a couple of hours or more, around the beach.

There were three people in the water, including me. Another two, a young
couple, jogged as far as I walked and did some exercises at the Runaway Bay
end of the beach. A black man and, separately, a black woman, walked
determinedly, but not quickly, as seemed appropriate, for they were in their
fifties, most likely. Two other people sat, one on the sand, the other on a deck
chair. A grand total of nine souls, seen over several hours. It is now well
after 8 a.m, as I write, following a breakfast of savoury rice, (a very small
helping) and tomato juice. I am sipping the first of my two rum punches of the
day. We leave for Church with Andrew, at 9.30 a.m,, for we are being
collected by a church member and will enjoy a communal lunch after the 10
a.m. service at the Maranatha Baptist church.

If one observes the action, on a typical morning, there are few early birds and
only when divers are gathering at Sandals to go out, about 9 a.m. is there
much sign of action. Pop’s Water Sports is next to our resort, Antigua Village,
just before The Beach bar and restaurant, a most attractive venue, where
people gather to dine and meet friends as the sun sets over the Caribbean,
the sea lapping just a few metres away.

One day, a huge cruise ship came in sight early in the morning and docked at
the capital, St. Johns. When we walked down past The Beach, which was
closed at lunchtime, we saw hundreds of tourists, from this ship, in the water,
standing around, lying on sun lounges or the sand, enjoying the atmosphere
of Dickenson Bay. Further along, past Sandals, around Tony’s Beach Bar
and Grill, there was a crowd of cruise ship passengers buying rum punches
and pasta based meals to eat as they were served reclining on yet more


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plastic sun lounges. Tony spends a fair amount of time deep sea fishing, and
sometimes we buy fish from him.

Another day Andrew, who has provided us with two lobsters now from his
snorkelling expeditions, found a Danforth anchor with over a metre of good
chain and swapped it for about seven kilos of Wahoo steaks at Tony’s Bar
and most of it is in our freezer. Last night, well marinated Wahoo steaks were
baked by Elizabeth and enjoyed with fettuccini and eggplant. Delicious!

For those who equate a holiday with dining out and not cooking for
themselves when they stay here, they do not have to go far, for on one side of
Antigua Village is The Beach and on the other Coconut Grove.

At Coconut Grove, Chef Jean-Francois Bellanger enjoys producing dishes
such as tuna carpaccio and maki maki fish with honey roasted plantain and
banana chips. Diners appreciate the fine silver, good tableware and myriad
tiny lights around the restaurant, which is about three or four metres from the
sandy little beach in a prime position for all to watch the sunset. This
restaurant has been written up before, as one of the best in the Caribbean.

The Beach serves exotic Caiperinhas and Molutos Latin-American cocktails,
and for those who like to party, the resident DJ provides Friday Night
atmosphere until 2 a.m. For more serious diners, Mediterranean, Asian-Rim
and American dishes include freshly hand-made sushi and a range of lobster
dishes, perhaps served with the moon glowing on the Caribbean Sea. The
architecture features open archways, there is teak furniture and lush gardens.

Despite these temptations, we rarely avail ourselves of the pleasures offered
and dine well, in our villa.

Tomorrow, we check out after a wonderful fortnight, swimming for hours,
morning and evening and walking up and down the fine white sand. It is one
of our favourite places on earth!

26.06.05
Flight BA2602 is in the process of boarding now and we are in seats 14B and
C.

As for QOL – well it couldn’t be better, all things considered. The trip from
Antigua Village along the coast road to V.C .Bird International Airport proved
that Antiguan roads are improving and there are new houses by the roadside.
Our taxi driver was full of information on the new Government’s activities,
controversies about the as -yet- unopened hospital and various political
intrigues. All interesting to me, and a pleasant interlude before our seven and
a half hour flight to England on British Airways..

If you are not happy doing things like this, which are really an intrinsic part of
our annual routine, then, in my opinion, you are mighty hard to please. The
plane has taken off and reached cruising height, Elizabeth is asleep and I



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smell food as the trolley is wheeled past – in another minute the girls will be
offering me more food and drink – an early dinner perhaps – Bon appetit!

On arrival in London from Antigua we, as transit passengers to Pisa, did not
have to go through British immigration and customs, merely having to
negotiate a forest of perfume stands on the way to the British Airways
Executive Lounge. After a light breakfast (we avoided the calorie rich
breakfast box on board the last flight) Elizabeth went off to buy perfume for
our friend in Italy, together with some for herself. But first, to slow down the
growth of any prostate cancer cells, which may be reproducing silently, I
drank some tomato juice, to get my morning hit of lycopene, followed by my
Selemite B® tablets (I had my anti-hypertensives on the last flight) and finally,
eat an apple. A shave and sponge bath and I was ready to face the morning
British papers whilst I enjoyed smoked salmon sandwiches and a couple of
glasses of Chateau Le Sartre Graves – not a bad drop. That was actually
lunch, for we are in a difficult time zone and when we take off, in a minute or
two, it will be 1.40 p.m. A couple of hours and we shall be in Pisa, rescue
Liz’s case and board a train for La Spezia, then another for Pontremoli, by
nightfall.

The train from La Spezia winds up the valley of the Magra river, beside which,
in Pontremoli, some thirty kilometres up the valley, is our old Tower, which
can easily be seen from the train. The other day I left a message on Tino’s
phone answering machine, and he will have switched on our hot water service
and checked everything out, for our arrival. From the station it is an easy
walk, and I am looking forward to a hot shower, on our arrival. By now we
regard this as home and are looking forward to seeing our friends, doing
some shopping tomorrow, going for walks to mountain villages, doing all the
things we love to do there.

27.06.05
This morning, although she had a couple of hours sleep in the evening,
Elizabeth was still tired after the journey from the Caribbean and did not arise
until after 10.30 a.m. We left home later than we intended, with the need to
get money out of the Monte Paschi dei Siena bank, and get some groceries
before the shops closed for the ritual three hours until 3 p.m., for everyone’s
siesta.
Somehow, on the unevenly flag-stoned via Garibaldi, Elizabeth tripped and
fell and has possibly a fracture, either at the distal end of the ulna, one of the
bones between the elbow and the wrist, or possibly in one of the small carpal
bones at the wrist. It is painful and ‘clicks’ when she attempts to supinate or
pronate, (twist) her wrist, so I have bandaged it up firmly and we are learning
where to go to get it x-rayed and attended to. Unless there is an urgent need
for surgery we would prefer to wait, ideally until we get home, or, seeing we
shall soon be in Geneva, or soon after, Monaco, see an expert at one of those
cities, rather than here, in a town of 10,000 souls.

It has not become more painful but there is a little swelling, so Elizabeth has
taken off her engagement, eternity and wedding rings from the one finger. As



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things stand, we aim to go to the local hospital, which seems to be everyone’s
advice, tomorrow morning!

At 6 p.m, we visited friends who have just come over from near our home, to
stay five weeks. They have stayed at our place here in Via Garibaldi before
and are now just down the street, staying at a mutual friend’s apartment.
They are negotiating to buy the apartment on the floor above, which needs to
be refurbished. They regard this plan as a good move for them, as her
brother is a builder in Australia and will do it for them, or so they think. Things
are not the same in Italy. R is an Antiquarian, a former teacher at Eton and,
like us, he and his wife just love this part of Tuscany.

Slightly further away M, another person who has stayed at our place, has
moved into an apartment which she bought with a balcony, a luxury we lack,
and it is very difficult to get permission to alter the exterior of a historic
building here. M has sold her home in Australia and is living here
permanently.

When we finally retire and live here for a planned three months annually, we
shall have a tiny group of ex-pats to socialise with, over here. One wonders
whether the trend will continue!

Work has progressed on the under pass and bridge which will see traffic
crossing the river on the new bridge much further upstream and passing
under the railway line on the opposite side of the river. Another twelve
months and there will be no road traffic crossing the railway line nearby –
safer, and much quieter for us. Further progress, with more peace, all
ordered to comply with EU ordinances on level crossings.




28.06.05
One potential problem that may arise in later years after a radical
prostatectomy is, of course, a recurrence, locally, or more distantly. As well as
this possibility, older people are gradually more likely to need the services of
specialised medical services, so sometimes they move to somewhere where
there are excellent hospitals and staff.

In my case, living in a town of twenty thousand or a few more, one would have
to travel some hundreds of kilometres for radiotherapy, so if this is required
one would either have to stay in Sydney for daily treatment for perhaps seven
weeks or try and travel back and forth a few times per week if attempting to
still run a medical practice – if one felt well enough to do so – which is
uncertain.

In the event that some problem arises overseas, especially in a small
Caribbean island, where the nearest world class centre is 1300 miles away in
Miami, or in rural Tuscany 30km. from La Spezia (roughly the equivalent of
Newcastle in Australia) or an hour and a half drive from Milano, a top Italian


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centre, how would one be placed? Looking ahead, I guess one could make a
few enquiries concerning services and how one could arrange transfers and
so on if an emergency or urgent need arose.

Today, we experienced our local health service in the Tuscan countryside.
Pontremoli has a local population around the 10,000 mark and our hospital is
just one kilometre down the road. Elizabeth had a fall yesterday as you recall
and we suspected a possible fracture around the ulna side of her wrist. We
walked down to the rather unremarkable looking, oblong seven storey hospital
and pressed the buzzer at Pronto Siccorso (Italian for Accident and
Emergency) or Casualty Department. The door was electronically unlocked
from inside and we were met by a very pretty nurse and led to a row of seats,
at which site Elizabeth’s details were taken and she was soon seen by an
experienced doctor. Another was also working there, an x-ray was ordered
and we were escorted to the Diagnostic Radiology Department where x-rays
were taken. I told the Radiographer that I am a doctor and she showed us the
x-rays and fetched the on duty Radiologist. He was the first person we saw
sho spoke English and he confirmed that Elizabeth’s wrist was sprained,
‘distracted’ and not fractured.      He advised rest plus or minus some
nonsteroidal antiinflammatory gel and sent us happily on our way. There was
no charge for any part of this service.

Recently, so I read in the paper, an Australian couple living in New York
experienced a slightly worse incident when the wife fell and fractured a
metacarpal bone in her hand which required brief surgery and an overnight
stay in hospital. There the total cost exceeded $16,000. There are real
differences in medical and overseas hospital costs.

Downstairs, on the bank of the Magra river, all who dwell in buildings on this
bank have gardens, and we are no exception. This morning I decided to take
two white garden chairs down to ours, so we have a comfortable shaded
place under a banana palm close by the big old fig tree. On the way down the
stone steps, I noticed the vegetable garden of a neighbour replete with
tomatoes, basil, broccoli, zucchini, beans and pumpkins, with some other new
little plants recently watered. Our garden is shared with the other three
owners of homes in ‘our’ tower, built before the year 1100 AD. There are a
variety of different roses, succulents, a couple of olive trees, figs and bananas
and plenty of bright orange, soft pink, violet, yellow and red flowers there, so it
is a relaxing and beautiful area. Up the hill on the other side of the river I can
see grape vines, olives, and fruit trees, an old stone building and a villa, a little
further away and the sun is shining in on my desk. Everyone’s gardens are at
risk, for the occasional heavy storms up the valley cause the river to rise.
Once, about seven years ago, there was a flood, with big trees floating past
and the river just burst its banks, with the water almost reaching the tower,
which it has done in the past, causing basements to be flooded. Seeing that
this building has survived nearly a thousand years though, we are not overly
concerned about floods.

30.06.05



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We are on the train between Milano and Geneva, heading for my cancer
conference and we have just passed Stresa on Lake Maggiore, where we
went last year. There we took a ferry over to Isola Bella to visit a beautiful
Palace which occupies the whole island. From memory, it was built by a
Pope’s brother as a holiday home and is magnificent. Further along we shall
be reminded of other places close at hand, such as Leysin, in Switzerland,
where we enjoyed a skiing holiday and I thought I had fractured the scaphoid
bone in my wrist when a binding broke. Thank heavens it was OK. I might
have had my wrist in plaster for months – or surgery! Even further along is
the branch line to Gstaad, one of the most fabled ski villages anywhere and
definitely worth a visit. At home I have some black as ebony, very beautiful
coat hangers, purchased there.

I have just seen the first snow, on the top of the Alps ahead, as the train
climbs the tree covered mountain pass. It is not too far to French resorts,
further along on our left and I remember seeing a shop that specialised in
crepes and we bought a Grand Marnier crepe at Megeve. Another time we
had a memorable time skiing at Chamonix, which has some very challenging
and spectacular runs. Now I am contemplating a ski holiday, maybe in
August, but in Victoria, probably at Falls Creek.              Here we are, at
Dommodossola already! QOL is certainly being able to do what you want to
do when you want to do it, together with the associated happiness/satisfaction
in my opinion and we are enjoying every minute of this journey to the full!
Early this morning were busy getting ready to leave Sogni D’oro, as we call
our place in Pontremoli and this included me mopping all the floors, taking out
the garbage and cooking testaroli to have with ricotta, pesto sauce, olives,
tomato and lettuce for our breakfast. Doing a bit of necessary work is also
perfectly satisfying in its way and naturally we left everything ready for Andrew
to stay in a few weeks. He is going to take down the green shutters,
resurface and repaint them. Hopefully he will appreciate the five paintings we
have bought for our bedroom and see that we have put the former ones in the
foyer and stair area, to tone it up a little.

It is easier to write whilst we are stationary. It is 2.22 p.m. and we have
completed a light lunch of cheese, tomatoes, apples and mineral water.
Elizabeth is taking a nap, after having worked late to give our appartment a
spring clean and get rid of a few unnecessary items.

There is a reception at 7.30 p.m. This train takes us to Geneva Airport, close
to the Crowne Plaza Hotel, the conference venue where we hope to book in. If
they are full, there should be no problem finding a convenient alternative. You
have probably had enough of my scribbling by now – there is a goods train
coming the other way loaded with big trucks on flat tops – I wonder if they are
just doing that to avoid long steep climbs over the longer auto route through
the Alps!

01.07.05
Let me get more serious, now that we have settled happily into our suite at the
Crowne Plaza, all the lesser accommodations having been taken one
presumes by hundreds of registrants at the Multinational Association of


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Supportive Care in Cancer’s 17th International Symposium, “Supportive Care
in Cancer”.

Conferences, as I have indicated previously, tend to be held in the most
pleasant surroundings; so like the 16th Symposium, held last year at South
Beach, Miami, the Geneva venue is equipped with such niceties as two indoor
swimming pools, a hamman or steam room, which I have just enjoyed after a
lengthy spa, live music at the bar nearest the Conference Centre, currently
featuring Afro Soul with pianist, bass player, drummer and female vocalist –
you get the picture. Again I am starting to put on weight, being served
excellent food and wine, morning, noon and night. All this provides an ideal
background for all interested in learning more about complications and side
effects of cancer treatment, the more problematic late effects of the cancers
themselves, and the latest progress in the field.

Perhaps I can share with you a few snippets of information of relevance to
those with cancer.

In recent months at the Department of Palliative Medicine associated with
RWTH Aachen University in Germany, patients with prostate cancer featured
very prominently, only those patients with cervical cancer and pharyngeal
cancer being more likely on a percentage basis to need admission for
moderate/severe pain. Overall, of all pain problems seen in the unit, 85%
were caused by cancer; 17% were related to treatment; 9% associated with
cancer disease; 9% were unrelated to cancer or treatment; and 3% were of
unknown aetiology.

We were told that maybe 25% of all patients with cancer, throughout the
world, die without relief from severe pain, yet cancer pain can be effectively
treated in 85% to 95% of patients with an integrated program of systems,
pharmacologic and anticancer therapy.

Cancer induced Bone Disease – Prostate cancer has more of a tendency to
spread to the skeleton than many tumours, though women with breast cancer
are also particularly subject to this feared complication. Bone metastases are
in fact common with many cancers and are devastating to patients, nearly
always bringing them to the realisation that their cancer has spread and that
no cure is now possible. Their distress is compounded by the life – altering
morbidity and associated medical costs.

Pain is the symptom most likely to bring the reality of cancer in a bone to a
patient’s attention and metastatic bone pain reduces one’s capacity to
function, may impair mobility to the point of becoming bedridden, especially
with the occurrence of skeletal related events (SREs) and research is directed
to developing treatments which at best at present, offer a likely delay in the
onset and frequency of SREs. Fractures with cancer deposits in bones of
prostate cancer patients significantly reduce survival. When such an event
occurs, healing may be long and painful. If nerves or the spinal cord become
compressed then all the complications of loss of nerve function may follow –



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paralysis, pressure sores – you don’t want to hear any more – but there is
progress and newer treatments offer some hope.

Radiotherapy is often effective in palliating bone pain despite difficulties with
transport and disruption of daily life. Overall, a very significant change in QOL
is still likely.

In breast cancer, there is a relatively long survival with metastatic disease, as
in prostate cancer, - with a likely two to three years of survival after such
diagnosis and an ever-present risk of SREs threatens to worsen their distress.
The aim of modern treatment is to relieve symptoms as well as prevent
complications, restore mobility, optimise function and hopefully, reduce
treatment costs. What does the patient face? At the MASCC Symposium on
Cancer – induced Bone Disease the focus was on the potential role of
Zoledronic Acid and we were reminded by symposium speakers that
metastatic bone pain leads to poor QOL, of the need for radiotherapy to bone,
of reduced functional capacity and the need for opioid analgesics. Surgery for
spinal instability is not exactly fun and neurologic dysfunction can be a cause
of pressure sores, constipation, venous thrombosis, chest infection,
decreased bone integrity and not surprisingly, depression. Sarah Heatly
showed a slide, which indicated that the median survival in advanced prostate
cancer is about three years and the time of the first SRE, about one year.
Obviously, many men will live for years with the threat of SREs and all they
imply, so any treatment that can reduce that risk is of great interest to any of
us who may be affected in the future.

Rene Rizzoli, an expert on metabolic bone diseases, osteoporosis and
disorders of mineral metabolism, from Geneva, is of world renown. He told us
that the median survival in prostate cancer is long, with a high likelihood of
experiencing skeletal complications and high associated costs, then he
started to talk about the bisphosphonates, ‘which may significantly reduce and
delay the occurrence of skeletal complications in patients with metastatic
bone disease’ (Coleman RE, Bisphosphonates; clinical experience. The
Oncologist 2004; p (suff.4): 14-27.) He explained that Fleisch (2002) had
written that bisphosphonates preferentially bind to bone surfaces undergoing
active remodelling. They act by inhibiting osteoclast maturation, functions,
recruitment, and by reducing the production of bone-resorbing cytokines and
growth factor. This is how they interfere with bone destruction and restore
balance between the bone destroying osteoclasts and the bone building
osteoblasts in our bones. Early bisphosphonates were less potent and
clinically, less effective. They were administered orally, but many patients
failed to continue therapy.

Now there are more effective agents, particularly zoledronic acid, which is
given by intravenous infusion over a fifteen minute period every 3-4 weeks
when cancer has spread to bone. Previously, intravenous bisphosphonates
such as pamidronate, had to be given over one to two hours – so zoledronic
acid has this advantage.




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At this point, the message that I got was – zoledronic acid is the current
compound of choice, but one must be able to access a source of intravenous
therapy – how will that affect my future plans? As Rizzoli concluded ‘Effective
therapy for cancer induced bone disease is indispensable for both palliative
and health care reasons. With their high efficacy in preventing skeletal
complications and palliating bone pain, as well as a good safety profile,
bisphosphonates are the standard of care in this setting. A better efficacy
record of I.V. bisphosphonates and the low compliance observed with oral
bisphosphonates suggests that I.V. therapy is preferable, especially if it can
be administered through fifteen minute infusions every three to four weeks, as
is the case for zoledronic acid.’

Naturally, I was especially interested in what the speakers at the symposium
would say about prostate cancer. Zoledronic acid is the only bisphosphonate
with demonstrated efficacy in the treatment of patients with advanced prostate
cancer we were told. It significantly prolongs the time to a first skeletal related
event (SRE) compared with placebo, by some six months. It also decreases
the risk of a patient developing bony complications by 36% (p=0.002). In
addition, all types of SREs and pain scores are consistently reduced and
reach statistical significance at 9, 21 and 24 months. For instance the feared
complication of spinal cord compression in advanced prostate cancer is
reduced by treatment with zoledronic acid from an expected eight percent to
four percent and there is a gratifying diminution in other bone complications.

Prostate cancer patients with secondary spread have an eight percent risk of
suffering a neurological catastrophe within two years. Bisphosphonates
improve QOL. Reducing skeletal complications has a significant positive
impact on QOL because of the life – altering effect of these complications and
the resulting morbidity. In metastatic cancer, assessments have shown
bisphosphonates to reduce a decline in QOL during the course of therapy or
even to increase QOL (Roemer – Becume et al 2003) in breast cancer
patients.

It was claimed at the symposium that life expectancy with metastatic cancer in
bone may be as long as 7-10 years and certainly now, three years or more is
to be pretty well expected. Patients with bony metastases from advanced
prostate cancer should be routinely offered an effective bisphosphonate upon
diagnosis said Professor Costa, and that is zoledronic acid. He added that
bisphosphonates ‘are effective in controlling pain, preventing an increase from
baseline in Brief Pain Inventory score despite the progressive nature of
metastatic bone disease.’ There is also a significantly reduced incidence of
palliative radiation to bone, reflecting the better pain control. His talk made
me a little less pessimistic about the future of men with advanced prostate
cancer and its control.

Cancer Support Meeting.
Discussions of QOL in cancer patients have a tendency to affect one’s mood.
At a meeting like this, one is bound to become even more aware of the
plethora of unpleasant symptoms associated with advancing cancer.
Attendees at this conference were reminded by a group from The Cleveland


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Clinic Foundation that cancer related fatigue (CRF) is a major factor
determining QOL in more than 70% of cancer patients. On a personal level, if
my prostate cancer is not cured by my radical prostatectomy, or later
radiotherapy, in the event there is a rise in PSA at any time, then it will spread
and CRF will be a real possibility. I may as well learn something about it as
something to factor in, when contemplating possible future scenarios.

We are told that no one really knows much about where CRF arises, or its
pathophysiology. It may arise from the peripheral neuromuscular system or
from the central nervous system (CNS). Cleveland Clinic researchers studied
EEG and EMG signals of hand muscles and brachioradialis muscles during
sustained contraction in advanced cancer patients, compared with healthy
controls. At the onset of fatigue both groups performed similarly but the take
home message is that CRF is associated with reduced recruitment of motor
units at the onset of fatigue and CRF appears to be of central origin.

Another paper, from Denmark, by Monika Rucinsha and Sven Langkjer was
titled ‘Fatigue in Patients Receiving Radiotherapy After Breast-conserving
Surgery’. Their view is that fatigue may be associated with treatment or
caused by the cancer itself. Seeing that I might have to undergo radiotherapy
at short notice I was very interested in their study, which though it has breast
cancer patient participants and the dose of radiotherapy is a little less, (48
Gy/24 fractions/5 weeks) the study also included a group with an extra 10Gy/5
fractions/ 1 week) – than prostrate cancer patients might receive.

Before radiotherapy, 58% had no fatigue and overall, fatigue increased during
therapy gradually and seemingly fairly mildly on average. Mean VAS (0=no
fatigue to 10=fatigue as bad as it could possibly be) scores were: 1.18 at
onset of therapy, 2.42 at end of therapy, 1.46 at 14 days post radiotherapy
and 0.62 three months after radiotherapy had ended. Happily, 1 in 4 patients
reported no fatigue during therapy. More rest was required, as expected and
as fatigue increased, women who had pain were more fatigued. I'm not sure
of any relevance of this to prostate cancer patients. Those with acute skin
toxicity had higher fatigue levels. You should see some of the horrible scars
breast cancer radiotherapy patients have been left with – as I have! Older
patients, over sixty years, had less fatigue at the end of therapy.

Of course one cannot just say prostate cancer patient’s levels of fatigue will
mirror these results, but I have spoken to quite a few men who have had
radiotherapy for their prostate cancer. Nobody seemed to suffer severe
fatigue but generally it gets worse over the course of therapy. though the
onset may take some weeks and it can last a fair while – men are often vague
on this point.

A prominent urologist colleague, told me that following my radical
prostatectomy, I should just get on with my life and forget about it, as any
further therapy will just make me an old man. I rejected the advice, naturally,
but respect his appraisal that radiotherapy and hormone treatments may
negatively impact very significantly on QOL. One is very sympathetic
concerning the man who has unresolved psychosocial problems, lacks


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emotional support and financial resources or receives poor information and
advice from his medical advisors. In this regard I am privileged and wish to
share my experiences and probably controversial views with other men. Of
course I fear fatigue, pain, secondary spread, especially into my bones and all
the other morbid processes which may be my lot, but ignorance is no defence
for me. I treasure every minute of life.

Boris Zaidiner and his Russian colleagues report concerning Music Therapy
(MT) for 177 patients with a variety of malignancies who suffered fatigue
related to illness and/or treatment. One hundred and fourteen (97.4%) noted
a positive effect. Classical music by Albinoni, Bach, Tchaikovsky, Vivaldi,
Mozart and many others was used a great deal. For those who expressed
feelings of spirituality then spiritual music was played and composed mainly
by Russian Orthodox composers. Some listened to both. MT is claimed to be
an important part of the psychological support for patients with fatigue –
especially for those with fatigue believed to be aesthenodepressive in origin.

Earlier in this auto-ethnographic study, I spent a little time detailing my search
for a good sound system and television with a motor drive, so that even if I
were to be fatigued and disabled with advanced disease, then music and
films, which I enjoy, would be as close as the remote control. Equally,
attention to optimising one’s home situation with ease of access, non slip
floors, good lighting and a pleasant outlook is really just common sense, for
one is getting older by the day, anyway.

02.07.05
Longevity and Cancer prognosis.

Many men who have a radical prostatectomy for early localised cancer are
soon informed that all of the tumour was contained within the prostate, which
was removed, and that they should have regular PSA checks in case there
has been any distant spread, but that there is an excellent chance that they
will not suffer cancer recurrence. The higher the Gleason score for
malignancy, the greater chance of spread. Most of the people I know who
have had this surgery are in this position and I know nobody personally in this
category who has had a later problem with local recurrence             or any
secondary spread.

I keep thinking of those in my position, with a single positive margin, but no
detectable PSA following surgery, three months later. If they choose the early
radiotherapy option, aiming to wipe out any remaining cancer cells in the
prostatic region then they will likely still have negative PSA tests five years
later – about an 85 to 90% chance – and probably 100% chance of being
alive and kicking at that time, unless some unrelated event occurs. Of course,
ultimately their age at the time of diagnosis will affect their longevity and their
Gleason Score is important.

Radiotherapy, in some ways is the easy option.           Kill any remaining
malignancy right now. People tell me though that it has its downside. Many
weeks of daily therapy, except for weekends, hundreds of kilometres from


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home! At first one will probably feel quite OK, nevertheless, over the weeks,
tiredness is very common. I am not sure what prostate cancer patient’s
figures for radiotherapy related fatigue run at – but everyone I have asked,
says it affected them.


05.07.05
Another beautiful day on the Cote d’Azur, The weather promises to be hot,
after a shower yesterday. We have decided to devote most of the day to
visiting various museums, including the Monaco Naval Museum and the
Prince’s Automobile Museum with 100 vehicles in it. In a few minutes we
shall stroll the hundred metres or so to the ‘4 Chemins’ bus stop on Ligne 100,
which provides services approximately every twenty minutes, to serve the
coast from Menton to Nice. We are staying at Le Golf Bleu for a fortnight, in
an apartment big enough for four. This resort, in Roquebrune cap Martin, on
the border of Monaco, has a pool and its own beach, close to the railway
station and bus stop, and we have a sunny balcony. Our intention is to do our
shopping in supermarkets in Monaco, cooking for ourselves, as usual.

Elizabeth and I alight at the Place des Armes stop and cross the road to the
entrance to the Fontvielle area. Car museums naturally attract many
enthusiasts and we have our cameras ready to record any particularly
interesting vehicles. Prince Rainier III maintained that it is not a museum of
automobiles but a personal collection of ancient vehicles, of all ages and from
different countries. There is some truth in his claim, for the Collection de
Voitures Anciennes de S.A.S – The Prince de Monaco has some interesting
carriages and other horse drawn vehicles of the nineteenth century and a
number of American military vehicles from the 1940s to about 1960.

Even a non-car enthusiast will be interested to see the 1952 Austin London
taxi, with upgraded upholstery, favoured for years by Princess Grace. It is no
surprise to see Rolls Royces, from a Silver Ghost of 1921, through Phantoms
to a Silver Cloud of 1956 which like all of the vehicles in the collection are in
superb condition. There is a rare Ballenger Freres of 1921, a Delage D8/15, a
Delahaye 135MS, a Facel Vega HKII, a Hispano Suiza H6B, a Hotchkiss 411,
a lone Ferrari, (a red 250GT roadster) and the newest car in the collection is a
1986 Lamborghini Countach, in black. To me, the most interesting car in the
collection is a 1950 Cisitalia 202SC. In 1951 a Cisitalia 202 was displayed in
the museum of Modern Art in New York, as a symbol of Automotive art. This
beautiful little four cylinder car of 1089cc could reach 160km/h – in 1950,
when the average large car was lucky to reach 135kmh and small cars
perhaps 100km/h.

Another car that took my eye was a Maserati 4000 Coupe Mistral, from 1968,
in metallic blue, rather similar to my Jensen Interceptor Mark II 1970 in both
colour and style with a big rear window. Whereas the Jensen was styled by
Touring, this has a Frua body and their performances are similar. They each
also rely on rear semi-elliptic suspension, cheaper, simpler and inferior to fully
independent set ups. The Jensen is an example of a hybrid, with Italian
styling, an American 383 or 6.3 litre Chrysler, a simple, big, heavy, slow


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revving but powerful motor, and Torqueflite® transmission. It is however,
rescued from the common herd by English built coachwork over two huge
longitudinal tubular chassis members and is heavy, supremely comfortable,
has a perfect driving position, top quality leather interior and every luxury of
the period. The downside was, or rather still is, heavy fuel consumption, a
tendency to overheat when idling in traffic and by nature a GT or Grand
Touring car, not to be thrown around on tight secondary roads. The Mistral
relies on more sophisticated mechanicals with engine options of three
specifications 3.5, 3.7 and 4 litres, of 6 cylinders with double overhead
camshafts. A ZF 5 speed manual or Borg Warner automatic were available.
Jensens were popular with golfers, film stars and other people who wanted
the looks, performance and luxury of a thoroughbred like the Maserati, without
the complexity and service costs. Jack Niklaus, Bing Crosby, Cliff Richard,
Lulu and Frank Sinatra for example, bought Jensen Interceptors.

After several hours admiring the vehicles, which included a good range of
early Renaults and Citroens, we reluctantly left and headed for the Naval
Museum. This is another worthwhile collection. Even visitors with little
interest in ships will be fascinated to see the hundreds of painstakingly built
models. Everything from Viking ships to submarines and huge oil tankers are
featured. Over on one side, was a model of the Titanic, which we found
fascinating. There certainly seemed to be a great shortage of lifeboats, as
was tragically proven all too soon.

We learned some interesting facts about the history of submarines. The first
practical submarine was built by Bushnell in 1776 who the first to apply the
principle of the propeller. Cyclists will not be surprised to learn that the
propeller was turned by arm and foot power. A pity Lance Armstrong was not
around!

Jules Verne knew that Robert Fulton built his submarine in 1798, still
manually propelled by propeller but with a double hull. By 1886 Dupuy de
Lome built the Gymnote which relied on accumulator batteries and a very
heavy engine, enabling it to reach the dizzy speed of 3-4 knots. This was the
first submarine to use a periscope. Progress came quickly and Laubeuf in
1896 used a double hull, which increased buoyancy. The space between
could be filled with water when diving and when it was time to surface, the
water was pumped out and air filled the space. Unbelievably, to me, it had a
steam engine (used on the surface) and an electric motor for when
submerged. The steam engine also recharged the batteries with a dynamo.
Petrol engines were tried, proved dangerous and in time diesels came to be
the standard, until those nations with nuclear power were able to use a
Uranium battery to heat water, turning it into steam for turbines and stay
underwater for months.

At the start of World War II there were about 500 submarines and of course it
was most important that one remained undetected, as depth charges were
pretty lethal. Submarines could reach 20 knots on the surface and 10 knots
when submerged so could sneak up, torpedo enemy shipping and ‘speed’
away. Unfortunately for the submariners, electronic devices were developed


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which could detect their presence. Asdic, or sonar, emits sound waves –
ultrasonic sound waves – which bounce off obstacles in the water, such as
submarines and the transmitter can locate them. Radar is very effective when
submarines are on the surface. We have all seen films of submarines under
attack going deep and keeping as silent as possible to reduce the chances of
detection, as surface ships race about with their sonar equipment, trying to
pinpoint them. From all accounts and an inspection of a couple of navy
submarines, life aboard is claustrophobic and unpleasant, to say the least.
Our son Garry almost became a submariner once and I am glad he is working
at Naval Headquarters instead! No wonder the crew are paid at a higher rate
than land based sailors.

A couple of years ago we had wandered around, trying to find the Columbus
Hotel, partially owned by the Scottish Formula I driver David Coulthard, but
we never succeeded. Today with a little advice, we found it, near the Monaco
Heliport and opposite the Rose Garden built by Prince Rainier as a memorial
to Princess Grace. This garden is also a beautiful place to visit, and I, for one,
have never seen such an extensive rose garden; all of the roses have the
names of the varieties included. Earlier, we had eaten a luncheon of French
bread, prawns and Perrier water in another exceptional garden in the
Fontvielle area.

We were slowly making our way around the port area admiring some of the
yachts, which included a magnificent two masted small wooden ship,
complimented by fine traditional fittings, when we spied a prestige car
showroom, where I saw a competition Can-Am McLaren several years ago.
This time, the piece- de- resistance was a new Porsche Carrera GT, another
of which I noticed on the road here yesterday as it flashed past. Like the new
Phantom Rolls Royces seen in Monaco yesterday, these are dream
machines, far beyond my means, but gorgeous. It is a joy just to see what
manufacturers can produce – art on wheels!

More practically, Elizabeth bought fresh salmon for seven Euros per kilo -on
special- which we plan to have this evening, with a fresh salad, out on our
balcony – where I am now sitting at 9.30 p.m, in my Speedos, writing in the
remaining natural light. Elizabeth has just brought out some fresh grapes,
given me a kiss and together we have admired the Mediterranean coast, with
the villas dotting hilly Cap Martin. QOL par excellence!


07.07.05
Elizabeth is still suffering from what seems to be right sacroiliac joint pain and
is going to rest and hopefully improve today. If there is no progress then we
shall have to call one of the resort doctors, who speaks English. Today,
therefore, I left alone for Beaulieu sur Mer on the bus, and alighted at Little
Africa stop, curiously named, unless one is aware that this is the name of a
local beach. Next to the beach, behind which towers the high and rocky
hinterland, is a flat area of fairly rough ground where a group of old men (at
sixty eight I am some years younger than their mean age, I believe) were
playing petanque or boule, with their steel balls. For my record of the trip, I


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took some photos of the beach and boule’s players before heading, under the
shade of some palms, to the attractive marina to look at the yachts. There is
a make called Apreamare, of which I have only seen examples in magazines.
I saw two, and photographed one. They are what I would call modern- retro
and seem really suited to transporting well heeled Riviera holiday makers in
supreme comfort from Beaulieu, to Villefranche sur Mer, to Nice, to Antibes, to
Cannes and Saint Tropez. Fantasyland is one my favourite destinations and
St Tropez is one of its suburbs. Never in my life have I actually been there,
though I know that trains do not go there, but the fabled rich and famous, from
Brigitte Bardot onwards, regard it very highly. I am curious to know why.

In the marina, most of the yachts are from twenty five to fifty feet long,
constructed of fibreglass and motorboats outnumber sailing craft, by far.
There they float, depreciating in the strong sun light, in front of a row of rather
classy waterfront restaurants and further along, a few designer shops
including Hermes and Valentino, where I ended up buying a beautiful red
Italian leather handbag for Elizabeth. At about that time I noticed a Ferrari,
not just another Maranello, 360 Modena, 288 GTO, 456GT, 355 Spider or
even a Daytona, but a new, silver 612 Scaglietti 2 plus 2. All of the above I
have seen in the last few days. Lamborghini’s are scare, for the factory
usually only produced a few hundred annually, prior to the Gallardo -- but I
have seen a rapidly disappearing Diablo and Prince Rainier’s Countach. A
couple of new Porsche Carrera GTs, which I have never seen before this
holiday, were a real treat, for you are never going to see a lot anywhere. The
Monaco region is the promised land, when it comes to seeing the very latest
exotic automobiles.

From the waterfront at Beaulieu sur Mer, if you continue towards Cap Ferrat,
there is an exceedingly good footpath around the coast, a few metres above
the seashore. This is one of my favourite passegatas, to use the Italian term
for a pleasant walk, and leads to the village at St. Jean- Cap Ferrat. Moored
offshore were ten super- yachts in the bay, including an old, presumably
restored steam yacht, all over 100 feet long and worth another photo. Whilst
in the area I took the opportunity to visit some local art museums which
impressed me with the quality of the art displayed and the prices -- which
were not unreasonable. I was tempted!

Cap Ferrat is well worth a visit, for it has a village atmosphere, a coarse sand
beach, where a few unfortunate girls seemed to have lost their bikini tops, a
marina, beautiful gardens and Villas, too often barely glimpsed behind high
walls. There is a zoo, plenty of waterfront restaurants and plenty of
atmosphere.

Eventually I retraced my steps in the hot, afternoon sun, caught the bus back
to Carnoles, close to Roquebrune, did some necessary shopping and walked
home to the resort by about 5 p.m. After a cold bath I felt human again,
cooked some fresh salmon fillets for dinner, as Elizabeth is still in a lot of pain,
and resolved to get the English speaking resort doctor in the morning.




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Here I am now, Elizabeth is asleep prone and I am sitting at the kitchen table,
writing, consuming cheese and Sandeman’s Port, which is good enough to
tempt me to have a second glass. It is twenty five past eleven, the
temperature about 25C. or whatever ranks as perfect and I am in a pair of
swimming trunks – which I shall likely wear again for my morning swim. We
are expecting our son Andrew to arrive sometime tomorrow and we spoke to
Stephen tonight.

The French know how to make cheese, the Portuguese how to make Port and
apart from Elizabeth’s right sacroiliac pain, all is ideal in regards to QOL. And
yes, I am sorry for the London people, and the terrorist bombings. If I worry
about everything though, I’ll never be happy!

QOL assessments appear to focus on a sub-optimal level of functioning, if
one accepts that QOL is intrinsically related to life, living, or what you actually
do and experience. Let us get down to the nitty-gritty! Whilst I was training to
be an anaesthetist I used to ask surgical trainees why they wanted to be
surgeons. Was it the challenge of diagnosis in the outpatient clinic? Well –
not exactly! Then was it the satisfaction of telling the patient that the
operation was successful, that perhaps she or he would no longer have
problems with gallstones? – Again, no! Then was it the actual operating,
wielding the scalpel? Yes – actually – Yes! That is what a surgeon does.

Aim for the exceptional in QOL. When an athlete wins Olympic gold! When a
violinist gets a standing ovation! When you win at the local show for the best
tomatoes! When you have an exceptional day or make an exceptional
presentation or make the best product in the market! On holiday, experience
the best! Enjoy the best family life! See your kids and grand kids! What do I
remember best? Falling in love, graduating, simultaneous orgasms, the birth
of children and grand children, professional success and research
discoveries, high speed mountain driving like being on a roller coaster, skiing
at the limit – there are more – that real QOL high is remembered and enriches
your subsequent existence. Enhance your overall QOL loving your family,
your work, the world around you. Try and make each day exceptional –
appreciate the sun, the clouds, the rain and all that is good in life.


11.07.05
The Cote d’Azur or French Riviera is much more extensive than is commonly
imagined, for it starts at the Italian border if one is coming from the east and
ends at Toulon in the west. Though it is thought of as part of Provence, it
includes a lot of Var and Alpes – Maritimes departments. Nice is really the
capital and surrounded on all sides by France except for the sea, is the
Principality of Monaco, almost at the eastern end, between Menton (or even
closer Roquebrune cap Martin, where we are staying) and Cap d’Ail on the
other, western, border of Monaco. It is worth getting a detailed map of the
area, if this sort of thing interests you, so that you can follow the path we
travelled today.




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Andrew, Elizabeth, a friend from Victoria-- Colin, and I all piled into a hired
Ford Ka, almost new, with front airbags and forty one Euros for the day, at
about 9 a.m. this morning. We headed from Roquebrune cap Martin to the A8
Autoroute and an hour and a half later arrived at Sainte Maxime, down the
other side of Frejus past Cannes and Massif de L’Esterel, close to Port
Greinand. St Maxime is a busy holiday resort at this time of the year with good
and very popular sandy beaches, lots of yachts, both around the harbour and
off the coast sailing and altogether a most attractive town.

We boarded a ferry and in twenty minutes or less arrived on the other side of
the wide bay, at the famous resort of St Tropez. The film ‘And God Created
Woman’ starring a young Bridgitte Bardot really put the former fishing village
on the map. We were initially vaguely disappointed. The harbour is bigger
than I had imagined, The Old Harbour that is, for there is a newer harbour and
marina further along, together with a larger car park and we decided not to
explore this area. The waterfront is crowded with shops with appeal to family
day-trippers, though we spied a few up market establishments and believe
that there are some notable villas in the area. Plenty of yachts, including a
row of beautiful classic wooden Rivas, another of “Cigarette” boats and some
super-yachts, are a pleasure to see.

Further around, hidden from view and quite different from the pastel coloured
multi-storeyed waterfront, rather reminiscent of an overgrown Portofino, is a
small beach and some more interesting buildings – and not a shop in sight.
This is where Andrew went swimming. We did not try and find the Plage de
Tahiti, a few kilometres away or Plage de Pampelome, which is said to run for
miles. Further to the west is less famous. In the area are many walks and
there are nudist beaches – but even later in the day on the Croisette in
Cannes, there were plenty of topless girls and one who was on the beach
completely nude – though this is unusual in Cannes from my observations.

Back in St. Maxime, we decided to drive along the coast road through Frejus,
St.-Raphael, Theoule sur Mer, Mandelieu, Cannes and Antibes and this was
really most enjoyable. The coastal scenery is magnificent, happy people were
out in force on the many sandy beaches – and the water can reach 25C. at
this time of the year. There were simply thousands and thousands of yachts in
the harbours and many out sailing. Old castles were spectacular, the
gardens beautiful everywhere we looked and attractive villas were dotted
along the hillsides and on the coast. Words fail to do justice to this coastline.
No wonder people flock to the Cote d’Azur.

Time was passing quickly so after viewing the huge number of yachts in
Antibes and having stopped in Cannes close to the site of the annual Cannes
Film Festival (which is held in May, the week prior to the Monaco Grand Prix)
for an impromptu meal at the Croisette – beach front area, we headed back to
the A8 and thence to Menton.

The Croisette in Cannes is worth mentioning for it is a most attractive area
with its gardens, designer shops, magnificent hotels and atmosphere and
some year soon, we intend to visit the Film Festival and experience Cannes at


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that time. It was easy for us, when we stayed in Cannes a couple of years
ago, to commute each morning to Monaco for the Grand Prix practice and
race on the frequent trains running along the coast. The town is really a
delight.

When we arrived in Menton we drove through this holiday resort area on the
coast, then headed up through a spectacular area of immaculate villas in
Roquebrune cap Martin as we made our way back to our resort.

By the time we arrived home we had spent twelve hours exploring some very
interesting places and have just resolved to keep visiting this part of France
regularly. It is now nearly midnight and tomorrow we intend to travel into
Monaco for the ceremony which is to mark the official start of Prince Albert’s
Inauguration as ruling Prince of Monaco. It is time for bed, though I am not
tired. As a matter of interest, as far as my bladder control goes, I did not need
to go near a toilet from the time we left home until when we arrived back at
the end of the day so I cannot say that I have the slightest problem with
incontinence – praise be! My energy levels are high. I walk for miles, swim
and feel on top of the world. Do I miss work? – No. Do I miss Australia? No!
Only my impotence still concerns me, no matter how I try and rationalise or try
to forget about it and of course, I am due to have another PSA as soon as I
get home!


12.07.05
The ceremony celebrating the accession of Prince Albert commences at 3
p.m. this afternoon and is to be followed by an open air evening of music by a
Symphony Orchestra. There is time this morning therefore, for a little writing.

Some days ago I rang a friend in Armidale who told me that our mutual friend,
who recently had a stroke and was in palliative care, had died on the fifth of
this month. He knew that he had been getting weaker in recent months, was
getting up later in the day but still had enough energy about two months or so
ago, to take me for a ride in his Chevrolet Corvette. It is a 2002 model with
outstanding performance and he was selling it, apparently aware that the
future held little more for him. He also disposed of his rare Ford open wheeler
V8 racing car and handed in his extensive and valuable collection of revolvers
and automatic pistols to the police – for he said he would no longer be
competing in shooting competitions. Until several months ago he still took an
interest in model aeroplanes, which he had a great interest in constructing
and flying. His wife and daughter share a great interest in horses and his
daughter is married to another horse enthusiast. He did his best to maintain
the trucks they use to transport horses to events. Since he was formerly I
believe President of the Porsche Club, with six Porsches, life had radically
changed with the diagnosis of medically acquired HIV, then later AIDS. He
was gifted with things mechanical and able to do intricate work beyond the
skills of others.

Our friend knew he had cancer of the liver as a complication of his illness yet
made the best of a situation where many others with AIDS abandon hope. I


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am convinced that his adherence to a diet of natural rather than chemically
treated foods, staying away from adverse influences on his health, such as
cigarettes and alcohol, contributed to his survival with this dreadful disease
plus haemophilia, for well over twenty years. Has anyone else in his situation
lived so long? Through all this he remained, remarkably, able to see a
humerous side to life and he was even able to be cheerful after his recent
stroke and progressive deterioration, at least for the first days. Who can
measure his suffering and distress over the years, as relatively healthy
periods were interspersed with events such as life threatening pneumonia and
adverse reactions to treatments, for which he journeyed quite often to
Queensland, How do we measure bravery and endurance?

And now I have to write a letter to J, the widow of my Canadian- then- U.S. –
friend. Though born in the UK he migrated to Canada and spent his life as a
Professor of Anaesthesia specialising in paediatric cardiac anaesthesia, until
he acquired Hepatitis C from a patient and as his wife said, he just ‘faded
away’.


13.07.05
Well! We are on our way back to Roquebrune cap Martin after a day in which
the French train drivers surprised us with one of their strikes or disruptions –
with very limited local services. Our plan to travel to Bordeaux which would
take us all day, then return on a sleeper train tonight was just impossible to
attain. Fortunately we managed Plan C. Plan B was just to travel to Aix en
Provence which was also not possible as there are very, very few trains
anywhere in this region.

Plan C was simply to catch trains, after a long wait, to Nice, then after another
wait, just to Cannes. Here, having stocked up on bread, ham, cheese, wine
and other essentials at a supermarket, we strolled past the Old Port to the pier
where ferries to Saint Marguerite, an island close to the coast – one of the
Isles of Lerins – leave at regular intervals.

The old fort – Fort Royal on Saint Marguerite – is the prison where the Man in
the Iron Mask featured in a couple of films, the latter starring Leonardo di
Caprio. It is vast and we inspected a few surprisingly large cells with tiled
floors which I suspect are modern replacements, not the originals. There
were three separate grills at the windows in the very thick walls – no glass of
course – in each cell. It looked pretty impregnable and suitably unfriendly to
the marauding Saracens of long ago, one imagines!

We joined the many family holiday makers at a little beach area and took
refuge from the hot sun under the trees for our impromptu picnic. All- in –all, a
most enjoyable day.

It is a small world really. In the side street in Cannes where we shopped in
the supermarket, is the Hotel where we last stayed, the year before last, when
we commuted from Cannes to the Monaco Grand Prix. I enquired about their



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latest rates and they go sky high during the Cannes Film Festival. A couple of
minutes walk down the road is the Croisette and Festival site.

Whilst I have been writing, we have stopped at Juan les Pins, Antibes and a
few other stops which I did not observe, but now they are announcing, in
French naturally, our imminent arrival in Nice. The train is late. It is eight
o’clock and it is still daylight. When packing for this trip I left out sweaters and
cardigans. I have not needed any warm clothing and somewhat regret
bringing the one light jacket I wore on leaving home, as it is just excess
baggage. Probably just one pair of jeans and one pair of shorts is enough
and certainly the pair of joggers, which are my footwear for the trip, are quite
enough. The less one has to carry, the better. I must confess that I have
bought one T-shirt today!




16.07.05
(On board flight BA349 from Nice to London, thence to Australia.)

It is Saturday here in Nice and I start work on Monday morning. This last
week has been problematic in regard to changing traveller’s cheques and it
was crisis day today. Le Golfe Bleu, where we have been staying, does not
exchange them for cash and it has been difficult to find anyone who can help
us. Yesterday we went East, to Italy, to Ventimiglia, to no avail – the banks
had closed by about 3.30 p.m. and not a money exchange was open either.
Local traders at the huge outdoor Friday Markets would not accept Credit
Cards, Australian Dollars or Swiss Francs – Euros in cash please! This
morning we checked out, left our luggage and went into the wilds of Monaco,
in search of money – we did not have enough in cash to reach Nice Airport
and nothing else was acceptable!

Elizabeth tried here and there, including exclusive Hotels and at last found
that the Cafe de Paris, a gaming Casino, would open their Caisse, exchange,
at 2 p.m. After some waiting around, during which time I saw countless
exotic cars, especially Ferraris, including a new F430 outside the Hotel de
Paris, plus numerous Bentleys, SL55 AMG and SL500 Mercedes, Porsches
by the score, Aston Martins and a Lamborghini Gallardo – Elizabeth
succeeded. We rescued our luggage and after journeying to Nice, enjoyed
drinks and nibbles at the Airport executive lounge before catching this flight.
Seats are so overbooked that they can’t find a Business class seat for an
Australian lady who paid $A8,300 for her ticket – she is in the front row of the
next best, World Traveller Plus and will no doubt have a word with her travel
agent and British Airways later on.
The weather has been fine and hot for just about all of our holiday from start
to finish. My fairly decent suntan will soon fade when we start to experience
winter at home though.

On Bastille Day, July the fourteenth, we went to Menton, as we knew there
would be fireworks that evening. We caught the train and meandered down to


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the waterfront area. There we saw rows of yellow umbrellas shading tables
along the beachfront across the road along the beach, in front of La
Mandibale – what a strange name! Soon we were seated at a table enjoying
an evening of Creole music and dance. The Brazilian music and the girls,
dressed in colourful plumes and very little else, were just fabulous. After a
most enjoyable supper we watched the fireworks further along the beachfront
before catching the train home. As we walked slowly along towards the
fireworks we were constantly entertained by Jazz bands and other musicians
from live shows at the restaurants facing the sea. A memorable night!

Yesterday, Elizabeth wanted to see the Changing of the Guard at the Prince’s
Palace, so we went, took some photos, bought some souvenirs, bought fresh
prawns and salmon for dinner, walked in beautiful gardens typical of Monaco
and generally lived the tourist life. No wonder we return each year to this
region!

18.07.05
Sitting in seat 9D of the Dash 8 to Armidale this morning, it is a crisp 10-
12C. but beautifully sunny. Elizabeth and I boarded the first of our return
flights on British Airways from Nice to London on Saturday evening and it is
now 8.40 a.m. on Monday here.

Our flights were pleasant and uneventful with time to read and reflect. This
last Weekend Australia magazine, of July 16-17, 2005 has a short report of
interest on page 3. In the latest British Medical Journal, it is reported that
‘researchers say clever people are no more likely to be happy in their old age
than anybody else’.

Study subjects all came from Lothian, Scotland and were born in 1921,
making them 84-85 years of age. All had undergone Mental Testing at the
age of 11 years and amazingly, all the records were preserved. In recent
years they were tested again and this time, in addition, they ranked their
happiness on a scientifically validated scale of satisfaction. There was no
relationship between cleverness and happiness, either when young or later, it
was concluded. The newspaper commented that not only can money not
bring happiness, but neither can brains. A more scientific comment came
from the Director of Brain and Mind Research at Sydney University, Ian
Hickie. He remarked that it is fashionable to think that individual brain
characteristics could affect happiness but the quality of social networks was
more likely to have an influence ‘People value you more for your contribution,
rather than whether you are smart’.

Whilst this may make those of us who have been less intellectually gifted,
take heart, I think that we all know people in all walks of life who have a sunny
disposition, a pleasant personality and are happy despite family, career or
health problems whilst others are unhappy whilst appearing to have every
advantage. I recall a report of a German fifth year medical student, who had
come top in every exam he had ever attempted until, at last at the end of fifth
year he was ‘beaten’ in one subject by one person – he suicided!



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We have just flown over the city of Sydney and are now passing Palm Beach.
One must emphasise that Australia has superb beaches, as we all know. I
am viewing beach after beach now as we fly up the coast. The last beach I
saw on the Riviera was at Nice, which, like many another along the Cote
d’Azur, is a ‘pebble’ beach and would be shunned here. It was lovely warm to
hot weather day after day there though, whilst I hear it has been cold and
miserable at home where I shall be starting work in an hour. Elizabeth is
staying in Sydney to meet our Thai student friend at the Radisson.


19.07.05
First thing this morning I have to have some blood taken for my PSA screen,
then wait for the results, thinking about the possible scenarios until the
afternoon! Perhaps I am becoming used to having PSA tests every six
weeks, for as the date approaches I try and plan in advance what course of
action to take if the result changes from the <0.01mg/ml that it has steadfastly
remained ,so far.

[Later] Good news again – my PSA remains undetectable and this means it is
now over nine months since surgery, with no sign of cancer. Having finished
at the hospital, I had a little time to spare before the regular Department of
Anaesthesia Meeting at 5.30 p.m, so I went down to a popular market to buy
vegetables. There I met a colleague, who was on the point of leaving the
market, and told him my good news. Many years ago we were Registrars
(trainee specialists) at Royal Brisbane Hospital, though in different fields.

He told me that he is about to go to have prostatic biopsies done as his PSA
has been ‘slowly rising.’ I asked more details! ‘Oh-- it went from 6 to 7 and
now it is 9.’ Really, I did not know what to say. On my pathology result form,
which details my PSA, it gives information on PSA levels, including the fateful
words - at a PSA level of 6.5 ng/ml approximately 50% of men will be found
to have cancer. At a level of 8.0 ng/ml, 90% of men will be found to have
prostate cancer. Many questions ran through my head. One keeps on
hearing the word ‘slowly’ used again and again in relation to prostate cancer.
One could say the “sun slowly rises and slowly sets” – it all depends on your
point of view.


21.07.05
For the second time this week I am the bearer of bad tidings. As you recall.
One man has been waiting while his PSA rose to 9 before booking in for some
biopsies. Now for the second piece of information. I have been told that a
friend’s brother had a radical prostatectomy three years ago. Now he has just
gone along to his doctor, one supposes for good reason, to find that his
present PSA is 19 nanograms/ml. Without knowing any more than this, all
one can say is that it does not sound good. Perhaps he believed that the
radical prostatectomy had cured him and has not been having follow up PSA
tests and examinations. This is what one thinks of as Option C – opting to go
away and forget about the possibility that there are still some prostate cancer



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cells in one’s body –‘I may be OK, everything will be alright and I just don’t
want to think about anything nasty.’

What is to be done? This is not my area of expertise and I have no
knowledge of the problem he presented with – but the cancer may have
spread locally or more distantly. The chance of any curative treatment –
potentially curative to be more precise – is probably long past. Perhaps if he
had attained a non-detectable level of PSA, <0.01 nanogram/ml, and it had
slowly started to rise and been detected early, then he could have been a
candidate for radiotherapy – but I am speculating – all I know is that for me,
going off and not having regular PSA tests would be tempting fate and idiotic!



22.07.05
Yesterday, after a morning clinic I drove to Inverell to ‘exercise’ my cars at the
Transport Museum as it is nearly seven weeks since they had a run to
recharge their batteries. Whilst over there I finally went to a pharmacy to fill a
script for Caverject®, which I had written in March.

Caverject Impulse® is a preparation of Alprostadil or Prostaglandin E1
(PGE1) and comes in 10 microgram and 20 microgram packs. Each pack
contains a dual chamber glass cartridge in a disposable syringe device. The
front chamber contains the PGE1 powder and the diluent is in the rear
chamber. These are mixed just prior to use and there is a device, which
allows the user to program the syringe to deliver the dose, decided upon
beforehand. There are a few pages of instructions which are meant to be
supplemented by information and instruction by the patient’s own doctor prior
to use.

The idea of injecting some drug into my penis, especially when there are a list
of contra-indications, a very long list of complications and the realisation that it
will probably hurt a bit and bleed a little – has not made me too enthusiastic.
Too small a dose and no effective erection! Too large a dose and one can
end up with an erection which will not disappear, fade away or settle down
and you may end up in hospital, explaining it all to the nice nurse, who will call
the doctor at the Accident and Emergency Department, who may call a
Surgeon etc, etc!

There is plenty to read about it, and yes you may get some penile damage,
especially if you are not very careful. But heck, the darn thing is not exactly
useful in the bedroom now – so after trying the Viagra®, Cialis® and the
Vacuum Erection Device, plus waiting hopefully for something worthwhile to
happen – it was time to give it a trial.

I never really considered going to my doctor to have it all explained as I have
given countless tens of thousands of injections. This does not mean that you
should be cavalier about it – go and get good instruction. I read that for
people with problems like mine, a reasonable starting dose of PGE1, for
injection is 5 micrograms – the maximum, by the way is 60 micrograms but


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the bigger syringe is only a 20 microgram shot so I’m not sure how you would
manage 60 micrograms. If you get some response, but not enough, they
suggest trying increases of 5 micrograms (at a later date) at a time until you
get a useful erection which lasts 30-60 minutes – it is dose dependent in
terms of duration of effect and most men require 10-20 micrograms.

I followed the instructions and gave myself a 5 microgram injection (only 3 per
week allowable at maximum) and applied the alcohol swab to the slightly
bleeding injection site for 5 minutes as suggested (no bruise resulted and you
can barely detect the site afterwards). A little massaging is suggested so I
did. In five minutes I was getting a decent response – not as rigid as a rock
but ready enough and we headed to bed. Penetration was the best that I
have experienced since the radical prostatectomy but I was wondering if the
erection was hard enough for orgasm and thought that within minutes it was
starting to fade away. A bit of persistence and guess what – we both were
able to have an orgasm – my first vaginal orgasm since the operation. This
was probably about 15-20 minutes after the injection and the erection was
diminishing so I resolved the next time I would increase the dose but maybe
get a 10 micrograms syringe, which can be programmed to deliver 2.5
micrograms increments, which may be more appropriate. Anyway a total of
7.5 or 10 micrograms may be just about right.

Talk about happy, pleased and optimistic about future QOL! After our
experience we lay awake talking until 2.30 a.m. Then we decided to ring
Andrew in Pontremoli as their time is 9 hours behind us. I must admit I was a
bit tired as I was getting ready to go to work but more nights like last night are
something I look forward to – everything is not going to be quite as good as in
the past – but lets face it – its pretty well as good as its going to get –
especially with a bit of an increase in PGE1 dosage – something to anticipate
in the near future. By the way, one shot of Caverject® costs about the same
as a Viagra pill, not cheap but about the cost of an average bottle of wine.

24.07.05
 Prostate Cancer in Perspective
It is easy to focus on one’s own situation and forget the big picture concerning
prostate cancer in our society. In order to inform the reader of some
background data on this subject I am going to quote some facts and figures
from an article used as a reference at an educational meeting for doctors in
Armidale at a one-day seminar yesterday. If appeared in Medicine Today in
July 2001, was written by Associate Professor Phillip Stricker and titled
Prostate Cancer Part 1. Issues in screening and diagnosis.

First of all, what is a man’s chance of developing prostate cancer and worse
still, dying of it? The lifetime risk is about 13% and only 2% of men die of it.
After skin cancer, prostate cancer is Australian men’s most common
malignancy. Twelve thousand cases were reported in 1995 and it caused
13.3% of all cancer deaths in men. That meant about 50 men died every
week or 7 every day of the year – a total of 2564 men. There is a
recommendation that if screening is chosen then it should commence at the
age of 50, with a digital rectal examination and a PSA. If there is a family


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history of prostate cancer, screening should be done annually from the age of
40 and continue until life expectancy falls below 10 years.

In our family we have three sons, but no one else among our relatives is
known to have had a prostate cancer diagnosis. All my sons have double the
risk that I have had of cancer and if there was a second relative the risk might
be raised by 5 to 8 times. If you get prostate cancer before the age of 55
years, the figures show that 43% of others in that situation have a family
history.

Who is going to have problems? Basically, the younger you are and the more
aggressive the cancer, the more likely you are to get problems with it. It is
true that older men with cancer often have very low grade, less aggressive,
slow growing tumours and may die without their prostate cancer ever causing
problems.

What is the situation if your PSA is found to be elevated? Stricker says 25%
of men with PSA’s between 4 and 10 ng/ml have prostate cancer. There is a
doctor in Armidale who is the general practitioner of two of my friends and
conscientiously monitored their PSA levels annually and the levels gradually
and relentlessly rose. By the time their PSA’s were heading towards 4 ng/ml
he referred them to a urologist, they had positive prostatic biopsies, each
cancer had a Gleason score of 7, in the mid range of aggression and they
elected to have radical prostatectomies. In each case the tumour was
contained within the specimen. One is two years post-operation and the other
three years post surgery. Both men have unrecordable PSA’s and an
excellent chance of cure.

The Pathology Laboratory where I have my PSA done states that 50% of men
with a PSA of 6.5 ng/ml will be found to have prostate cancer and 90% of men
with a PSA of 8 ng/ml will have cancer. What else could cause an elevation of
PSA? The range of ‘normal’ PSA values rises in any case with age, but a rate
of rise of 0.75 ng/ml/year or more is very suspicious.
PSA levels may be raised in conditions other than cancer, such as benign
prostatic hypertrophy (enlargement), after exercise or sexual activity or with
prostatitis.

What might the Urologist do next? If cancer is suspected a transrectal
ultrasound – guided biopsy, or rather biopsies (I had 29) is recommended.
Positive biopsies can be given a Gleason score, which is calculated using a
histological grading system. One hopes for a low, low score for a high score
is equated with more chance of rapid spread and invasion of tissues. There is
also a system of clinical staging to describe the extent of the primary tumour,
the presence of metastases to nearby glands or lymph nodes and the
presence of distant metastases.

Stricker writes that ‘histological evidence of prostate cancer is present in 30-
40% of men over the age of 50 years but only half of these cancers become
clinically evident’. Of the many tumours found at autopsy very few would



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have resulted in an elevated PSA level, so are rarely picked up in screening
programs. It is not a simple world we live in!




25.07.05
It has been concerning me that in the literature there is a great deal of
discussion regarding subjective well-being and objective well-being as the two
components of QOL in the minds of some authors. In the patient – generated
definition of QOL that has arisen in my interviews with cancer patients,
chronic pain patients and joint replacement surgery patients, the term
subjective well-being (SWB) is notable by its absence. What is the
relationship between QOL and SWB in the patients under consideration?

A 64 year old patient who was diagnosed with cancer of his left parotid
salivary gland last year presented for an unrelated problem today. In 2004 he
underwent a five hour surgical resection of the gland, including removal of his
left facial nerve, which has unbalanced his appearance markedly. This was
followed by a course of radiotherapy, which made him fatigued, and he
became depressed. He said it took some six weeks after his radiotherapy
treatments were completed before his marked fatigue resolved.

I asked him how he would define SWB. Again, as patients have told me
previously, I was told that it was a term with which he was not really familiar.
His definition is ’Something that a person has to stop and listen to his/her own
body, and report back to themselves, in the case of optimal SWB, that they
are feeling good, have adequate levels of energy – and they have to feel that
they have no emotional or mental stress”. How is this achieved? “You
achieve this not only by diet and right living but by a right attitude of mind”.

How was his SWB affected by his cancer? ‘The cancer did not affect me
physiologically at all, but it caused a negative mental state in which I would
beat-up on myself, criticise myself and get angry with myself. The solution to
that was to deal with all the emotional baggage of my past life and live in the
present moment.’

And what is the relationship of SWB to QOL? ‘It is not part of what I think of as
QOL. I agree with the definition of QOL as being able to do what you want to
do, when you want to do it – but it depends on your attitude of mind and if you
have afflictions – for example arthritis, and loss of a facial nerve. [He suffers
both afflictions]. Then you have to be accepting of them and accept also that
you can still have a good life.’

When I spoke to the nurse in charge of our cancer chemotherapy unit in
regard to SWB – she said on reflection, that she believes that many patients
receiving chemotherapy tend to rationalise, saying, for instance, things like ‘I
am so blessed to be alive and to be able to do what I am able to’ or ‘I value
every day that I am as well as I am’. They are seemingly grateful for what
they currently possess, despite an uncertain future, regard the moments they


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have as precious and appreciate being able to live as well as they do, despite
an existence which others would regard as certainly sub-optimal. Yet one can
appreciate that for some whose treatment is problematic and future more
under a cloud than others, that the above rather gratifying level of adjustment
will not be attained. A past history of depression is not a good omen. More
exploration of patient views on SWB will be undertaken – especially in regard
to its relationship to QOL.

Today I was chatting with a busy senior GP in the corridor (alone) and learnt
that he has just seen a patient of his who has a PSA of 9 and refuses to have
any further investigations. The man is very active, loves riding horses and is
so far, unwilling to face having biopsies or having any interference with his
lifestyle!

How about Happiness? Whilst in Geneva I jotted down a few thoughts on the
concept of a Super QOL/Idealised QOL/Gold Standard QOL/Optimised QOL.
Aiming to specifically and consciously weed out any remediable negative
aspects of QOL and maximise life satisfaction with QOL. Perhaps it is
possible to attain a higher state of QOL more frequently. Initially my focus
has been on optimising one’s social and physical environment and planning
for the future.

Peterson, Park and Seligman (2005) have recently published a most
interesting paper titled ‘Orientations to Happiness and Life Satisfaction; The
Full Life Versus The Empty Life!’ The authors examined three different
orientations to happiness, defined ‘in its broadest sense to include hedonic
features but also fulfilment and contentment’ (Seligman 2002) and life
satisfaction, defined (Diener 1984) as a ‘summary appraisal of the quality of
one’s life regardless of how it is achieved.’

In my current research on clinic patients, routine assessments include two
measures of happiness, measures of QOL and self assessment of life
satisfaction, so naturally this is of great interest to me. We are all familiar with
the two historic pathways to happiness enunciated by ancient Greek
philosophers, but a third has only come to prominence in recent times, so it is
valuable to outline these three paths.

Aristuppus (435-366 BCE) is famous as the man who described the doctrine
of hedonism, the maximising of pleasure and minimising of pain – he was the
champion of immediate sensory gratification. Epicurus (342-270 BCE) went
further, claiming that it is our fundamental moral obligation to maximise our
pleasure – the doctrine of ethical hedonism, which, as expected, was met with
objections by some Christian Philosophers, until Erasmus (1466-1536) and
Thomas Moore (1478-1535). As we are aware, this doctrine still flourishes
today despite many detractors.

Aristotle (384-322 BCE) taught that we should be true to our inner selves, the
doctrine of eudemonia. One should cultivate virtues and live appropriately
and be the best that one can be, serving others, focusing on the good that
one has the obligation to strive for. The search for a meaningful life should


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enhance life satisfaction and happiness. Aristotle thought hedonists vulgar.
People still argue one view against the other sometimes forgetting that they
are not necessarily mutually exclusive paths (Ryan and Deci 2000)

Csikszentmihalyi (1990) described “the psychological state that accompanies
highly engaging activities” as flow. One may become so absorbed in an
activity that the sense of self is suspended. The activity is everything and
later one may feel invigorated, though at the time there may not be a feeling
of pleasure. Having anaesthetised tens of thousands of patients for surgical
procedures I have observed surgeons at work. At times, when they need to
fully concentrate on the procedure, they become extremely focused on the job
at hand and only start to emerge from this flow or engagement (as Seligman
(2002) has described it) when starting to ‘sew up’, when normal conversation
recommences – and make no mistake, the reason young doctors train to be
surgeons is because they love actually operating, all their other activities are
purely subsidiary to their focus on performing surgery. Personally, when I
start reading, I switch off to all around me, hearing nothing and becoming
‘engaged’ with my absorbing concentration on the printed word.

The authors of this paper (Petersen, Park and Seligman 2005) developed an
Orientation to Happiness instrument and 845 participants answered 18
questions, 6 each on a Life of Meaning, on a Life of Pleasures and on a Life of
Engagement.

My bet is, that most of you readers are interested in enhancing your
happiness and life satisfaction, at least enough to be curious to learn the
details of the questions asked. You may wish to answer them yourselves for
your own edification. The respondents were asked to answer on a five point
scale, so do the same and we shall discuss their results later on.

Instruction (- circle 1, 2, 3, 4 or 5) (from- disagree very much, disagree,
neither agree nor disagree, agree, agree very much)
Firstly, we have the six statements related to a Life of Meaning
•       My life serves a higher purpose
•       In choosing what to do, I always take into account whether it will benefit
other people.
•       I have a responsibility to make the world a better place.
•       My life has a lasting meaning.
•       What I do matters to society.
•       I have spent a lot of time thinking about what life means and how I fit
into its big picture.

Secondly, here are the six statements on a Life of Pleasure
•     Life to too short to postpone the pleasures it can provide.
•     I go out of my way to feel euphoric.
•     In choosing what to do, I always take into account whether it will be
pleasurable.
•     I agree with this statement ‘Life is short – eat dessert first.’
•     I love to do things that excite my senses.
•     For me, the good life is the pleasurable life.


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Finally, here are the six statements on a Life of Engagement
•      Regardless of what I am doing, time passes very quickly.
•      I seek out situations that challenge my skills and abilities.
•      Whether at work or play, I am usually ‘in a zone’ and not conscious of
myself.
•      I am always very absorbed in what I do.
•      In choosing what to do, I always take into account whether I can lose
myself in it.
•      I am rarely distracted by what is going on around me.

Well! That’s it! How did you go?

The authors report that no matter how they grouped the (internet)
respondents the same pattern emerged – and it was statistically significant.
(a) There were ‘somewhat higher life satisfaction scores for respondents
simultaneously near the top of all three Orientations to Happiness subscales;
and (b) notably lower life satisfaction scores for the respondents
simultaneously near the bottom of all three subscales.’ Individually, you may
be surprised to learn that the pleasure orientation was not as strong a
contributor as engagement or meaning orientations.

Those low on all three subscales were dubbed as having an ‘Empty Life’ with
the least life satisfaction and those at the top end – as having a ‘Full Life’.

We can see that the three orientations are not incompatible with each other.
Later on, the authors wish to explore the question of whether those with
particularly strong orientations actually succeeded in attaining what they set
out to achieve and have more gratifying experiences.

It is reassuring to older readers to learn that those with the ‘fullest lives’ were
more likely to be older, married and more highly educated. In the past it has
been argued that one’s pleasure has a ‘set-point- to which level one tends to
return after good or bad experiences and some hold that the pursuit of
pleasure is futile. The authors suggested a possible strategy, ‘savouring’ be
applied, particularly to engagement and meaning to increase pleasure and life
satisfaction. It is noted that it was suspected that those at the lower end with
‘Empty Lives’ were probably ‘depressed, anxious or otherwise distressed.’ I
shall examine my data on hospital outpatients, whom I have assessed for
anxiety, depression and distress from a plethora of causes and see how their
results correlate with their self assessed levels of happiness and life
satisfaction. As I possess their identification codes, it may be possible to
assess their Orientations to Happiness in a future study, to learn if there is
any relationship between patient orientation patterns and levels of life
satisfaction under adverse circumstances.

 I have observed that those individuals with a strong bias towards
engagement or flow in their occupation, tend to bury themselves in their ‘flow’
activity, almost to the exclusion of other aspects of their lives when subjected
to negative circumstances and events in their lives. Perhaps this is a form of


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coping, akin to denial, which protects them from the conscious sequelae of a
distressing occurrence. Patients awaiting joint replacement surgery who only
have one or two meaningful, possibly flow inducing, occupations, frequently
suffer rapid psychosocial deterioration if their disability becomes so severe
that they must abandon their ‘flow’ inducing activity. An operation, which
allows recommencement of their activity, for example, bowling, results in rapid
recovery. We need to explore these implications as they affect work and
retirement.


12.08.05
It is Friday and for me, a day off. This morning one of my friends rang and we
talked for two hours. He is a retired professor and had his radical
prostatectomy over four months ago. Our conversation ranged over many
things, including our common problem of impotence. We should form a
support group or society here, for there is quite a little clan of men in Armidale
with post radical prostatectomy impotence. None of those that I know have
any other residual complications. Some have taken longer than others to
recover from initial urinary incontinence and all had their cancer contained
within their prostate and have undetectable PSA readings. With this generally
positive news, they are fairly philosophical about their continuing impotence
and nobody has quite given up hope of recovery. Despite this, they are all
happy with their decision to have surgery, bearing in mind the potential
problems associated with radiotherapy. They were also convinced that
surgery offered the best chance of a cure.

 Loss of sexual function in all of our little band has not been helped by
Viagra® and this morning my friend and I decided to have a private trial of
transdermal glyceryl trinitrate. A Transiderm Nitro® patch on the back of your
hand will increase the diameter of the veins in the vicinity by 50% in 15
minutes, so why not elsewhere. I published papers with my colleagues, John
Hecker and Helen Stanley, demonstrating the efficacy of locally applied nitro-
glycerine for dilating veins for intravenous cannulation and preventing
superficial thrombophlebitis twenty years ago and more in the Lancet
(1983,1985).The only small problem really was that maybe 9-12% patients
suffered a headache which responded to the removal of the patch. Tomorrow
I shall get a patch from the hospital and see what happens. Strangely
enough, most pills and the Caverject® seem to cost around $15-20 a time -
so- if it is effective in attaining an erection it might be worth pursuing further.
One cannot, I assure you, obtain a patent on this readily available treatment
for chest pain (angina) due to coronary artery disease just because you find
another use for it – as we did by using it to make venous cannulation easy.
No doubt other people have tried it before, but I have not read of any reports,
so the easiest thing is to give it a go! It is said that God gave men a brain and
a penis, but not an adequate blood supply for both to function simultaneously!

After dealing with this topic we discussed subjects as diverse as
superannuation and other investment strategies, the hotels we have stayed
at, from Athens to Cairo, the advantages to be gained by seeking out
restaurants a little off the main streets in cities and the origins and current


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problems of the Israelis and Palestinians, particularly relating to their
respective leaderships. It doesn’t really matter what we talked about, other
than our impotence – the important point is that we can talk without
embarrassment. Men have a reputation for not talking about their problems
but I hope that more men will find it possible to be frank with others in the
same situation, instead of being so notoriously inhibited.

What else has happened this week?
I have learnt of two more cancer cases in the last two days in our community
– both in their middle years. One has breast cancer with spread to her liver
and the other, a man whom I know well, has been given six months to live
with cancer that has spread to his lungs and liver, from where I know not.
Originally the lady believed that she had a problem in one breast but nothing
was found on examination and a mammagram was reported, mistakenly as it
turned out when reviewed much later, as normal. She was repeatedly
reassured for a year until a lump was found in her breast. At the same time,
further investigations showed ‘a shadow’ in her liver which has now extended.
She underwent a ‘lumpectomy’ of her breast lump and radiotherapy-- without
any promise for the future. On review the mammogram was suggestive of a
malignancy – what a sad story. 13% of claims against GPs by patients relate
to failed or delayed diagnosis of cancer in the last 5 years. (United Medical
Protection).

My friend with the cancer beyond cure has worked hard in a small business
building it up all his life. It is a real credit to him. And now…….. what can I
say? He has lived. Always obliging and cheerful, a contributor to his
community and a family man who has a flourishing enterprise. My guess is
that he would do it all over again if he had his time over – happiness and life
satisfaction-- whilst the years race by, as they do.


19.08.05
Today I met another pain specialist whose story is in many ways similar to
mine. It would not have happened if I had not been asking a question of the
lecturer on Narrative Writing about the differences between Auto-ethnography
and Narrative and mentioned this study in front of the large audience at a
world pain congress in Sydney. Later, this person, whom I have met at
conferences before, came up to me and quietly told me his story. He is co-
incidentally a pilot and knew I owned a little Cessna before. Anyway, he had
a routine medical check each year for his pilot’s licence and this included
routine PSA’s. Gradually his PSA rose from 2 to 3 to 4 to 6 and his GP kept
observing the increase. Last year-- when he was fifty-four-- his PSA was 9
ng/ml, but his GP was still willing to observe it a while longer as he said the
prostate felt normal.

My colleague asked for a referral to a urologist, who repeated the PSA
months later-- as it took a long time to get an appointment. The PSA was
15ng/ml. Ten prostate biopsies were taken and 9 out of 10 showed cancer up
to the capsule of Gleason score 6 (just less than my 7). The month before I
had my radical prostatectomy with nerve-sparing, he had the same procedure.


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Post-operatively he was told that his cancer had penetrated the capsule in
one place and extended up to the margin of the specimen, but, seemingly the
tumour, though right at the edge, appeared to be just contained.

Since surgery his PSA has dropped to undetectable levels and he has three
monthly PSA tests, which remain negative. He suffered urinary incontinence
for six months and now is dry. He has been quite impotent ever since his
operation, a year ago next month, but remains optimistic that things will
improve. His knowledge of treatments for impotence is encyclopaedic but he
does not seem to have resorted to vacuum erection devices or injections.
Unlike me, he is rather shy about his predicament and certainly not prone to
talk about it to others. We swapped e-mail addresses and will keep each
other informed of any changes related to our situation. How many other GPs
are sitting and watching PSA’s rise or recommending that PSA’s not be
screened. If he had not insisted on referral one can safely predict that his
cancer would have spread further outside the capsule and been beyond
potential surgical or even perhaps radiotherapeutic treatment before action
was taken.


21.08.05
It is a cold but sunny day here at the Convention Centre at Darling Harbour in
Sydney. I was out on a balcony overlooking the water before our first lecture
this morning and met a pain specialist about my vintage. He had worked at
Armidale Hospital as a Resident Medical Officer on secondment from Sydney,
became an Anaesthetist and now has given up Anaesthetics. He always had
an interest in pain management and palliative care and now practices solely in
these areas. We agreed that our QOL has improved with freedom from being
on call for emergencies at nights and weekends. We have altered and fine
tuned our lives to achieve optimum QOL, bearing in mind our advancing age.


The idea of a Super QOL or something above and beyond the upper range of
QOL usually contemplated, is very attractive. One suspects that there are
many, many people who carefully craft their lives to optimize positivity, and
eliminate all those elements which are predictably frustrating. Whether they
are able to achieve a truly heightened QOL is arguable, but they surely try.

My two sisters provide some pointers to ponder. P is two and a half years
younger than I and after a career in psychology and teaching suffered a
decline in health. She resigned from her position and for years has focused
on coaching school children, before and after school hours and formerly at
weekends. When I asked her what she would do if money were no object,
she replied that she would do exactly as she is doing. Last month she
journeyed to China and plans other trips in the future. She takes a keen
interest in her grown up children, grandchildren and animal welfare. There is
really nothing she would change. I know she used to be more stressed in the
many years she worked for the Education Department. Now she has a life of
peace and contentment and is probably happier than she has even been,
doing exactly as she wishes.


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Our sister H is younger and is still a teacher at a large private school. She
has hived off all administrative responsibilities, which she finds onerous and
focuses on teaching special pupils, three days one week and two days the
next. Frequently she and her husband journey to their houses in Indonesia
and her grown children also often fly there and have close ties with local
people there. She is selling her home on a busy road in Sydney and
purchasing another in a quieter district. These and other changes are
enhancing her life, fine tuning it if you like, in an effort to optimize her QOL,
maintaining her interests and deriving a great deal of pleasure from her
recently acquired love of Indonesian life.

It is easy to assume that people just give up work and retire into a diminishing
world. There is plenty of evidence to the contrary, if you look around.


23.08.05
Today marks my transition from Anaesthesia to Pain Medicine if anything
does. It is the first day that I spent in Inverell seeing patients all day at my
new Private Pain Clinic. The arrangement is pretty simple. Inverell Health
Service provides rooms for the clinic in their Doctors Clinic Building, where
other specialists see patients, for a facility fee. Appointments and secretarial
services are catered for. Gratifyingly, this first clinic is booked out and I have
a busy day –only leaving at 4pm to avoid risking having my car hit by
kangaroos, which start to cross the road as afternoon turns to evening.

The reasons for this change are many. Another doctor is now available to do
my anaesthetic lists so I am not leaving a gap in the anaesthetic services. My
public hospital pain clinics in Armidale are completely booked out and even at
my official morning teatime I have patients booked. Patients from the North-
West have to travel hundreds of kilometres to see me, which is very hard on
many with chronic pain syndromes. At Inverell, access will be very much
easier for them. I wish to provide an increased service and there is no
opportunity to start a public ‘free’ clinic, so I bulk-bill all patients, the vast
majority, who are on a disability, age or other pension so they are not out of
pocket. At lunchtime I can get my cars out of the Transport Museum and give
them a run to keep their batteries charged and I enjoy driving over to Inverell.
This morning the temperature was seven below zero in Armidale and Glen
Innes, the coldest in NSW, yet by the time I reached Inverell it was a brilliant
sunny day and a joy to be alive. I am sure, for many reasons, that this new
venture-- though a retirement in a way-- is going to be a pleasant form of
retirement. Quite frankly I feel that I am now retired, despite formally ‘working’
around thirty five hours a week or more with patients.


25.08.05
Today provides me with a good opportunity to describe an experience of
engagement or flow, the process described by Czikszentmihalyi, which
provides one of the mechanisms by which we generate happiness, besides
our old favourites hedonism and meaning.


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This morning at my private pre-anaesthetic clinic I was so busy that there was
no time to think of anything else. My first patient is a candidate for major
surgery and is seemingly a fairly fit middle aged man, with no health
complaints. However, on examining his electrocardiograph (ECG) I noted
widespread abnormalities suggesting that he had suffered a heart attack, a
myocardial infarction, so I found a friendly specialist physician in one of the
wards, to seek a more expert opinion. Yes, it seems this man has had a
myocardial infarction, despite no history of illness or chest pain and he needs
further investigation by the physician to check for any serious damage, before
surgery, which must be postponed.

By the time letters were written and everyone informed, there were a few
patients waiting to be seen. An old lady in her eighties was next, scheduled
for a routine procedure. Some years ago she had suffered ischaemic heart
disease and underwent a coronary artery bypass procedure, with grafting to
the damaged vessels. Now, on close questioning, she admits that she has
chest pain -angina- on exercising a little – and it is getting worse. She takes
nothing to relieve the pain. When I told her she needed a stress test to
assess her function, she told me that she is already booked in to see a
physician to have this procedure, but not until after her operation. A case of
putting the cart before the horse. More phone calls, negotiations aimed to
postpone her surgery (which is fairly urgent and may reveal cancer) until she
has had her heart problem investigated, more expeditiously. Her GP is not in
her rooms, so a referral and appointment is organised.

Later in the morning, I saw a lady with undiagnosed hypertension – her blood
pressure too high for her to be admitted for surgery, until she is more fully
assessed and her blood pressure controlled – more phone calls and letter
writing.

You can imagine that with all the activities involved in assessing patients,
such as I have described, there was no time to think of anything else or stop
for a cup of tea. I was ‘engaged’ with my patients in a ‘flow’ situation, very
busy, yet not unpleasantly pressured, in no way distressed and at the end of
the clinic, together with my clinic nurse, pleasantly satisfied – happy if you will,
that we had detected and appropriately handled the problems that presented
so that our patients will be first fully assessed and their health optimised
before they face the physiological challenges of anaesthesia and surgery.
Nothing really heroic, or awe-inspiring in clinic work, nothing to encourage a
TV series to be written, just the every day but absorbing engagement or flow
which enhances my happiness – isn’t this enough of a retirement for now? If I
do end up with an elevation of PSA and consequently radiotherapy – as soon
as I recover from any associated fatigue, which seems to be a very common
accompaniment, I plan to re-commence these clinics, for there doesn’t seem
to be anything better for an ageing doctor to do – whilst one is still able. Old
farmers notoriously wish to keep on doing some form of work around their
farms, with no wish to relinquish what makes them happy. Think of the old
adage ‘find what you love to do and you never have to work again’!



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26.08.05
 Cancer Pain
Since I have attended a refresher course as part of the 11th World Congress
on Pain in Sydney this month, it seems an appropriate time to share with you
some of the material presented at this Congress, attended by over 5000
workers in the field.

What is the current situation in regard to cancer pain? This is possibly
relevant to any of us who have had radical prostatectomies for prostate
cancer in recent years. We know that there is a chance of spread to distant
places in the body, especially to our bones. Every time I go to have a PSA
test I wonder if there is any evidence of a local or distant cancer focus. Whilst
it remains localised there is an opportunity to treat it with the aim of cure in the
early stage when the PSA starts to rise. More extensive local disease or
distant spread is liable to eventually result in cancer pain and as the disease
progresses fatigue, weakness, shortness of breath, nausea, constipation and
impaired cognition may complicate the assessment of pain further.

How many patients world wide die from cancer annually? In 1996 the World
Health Organisation estimated the number at 6.6 million people. Cancer
deaths from prostate cancer and breast cancer in Australia each year are
approximately 2500 to 3000 for each cancer. In palliative care patients, pain
occurs in 65-85% but it is possible, using the World Heath Organisation
(WHO) Guidelines for Cancer Pain Relief (1986) to achieve effective pain
relief in 85% - 95% of these patients (Goh 2005). Analgesic drugs are most
frequently used for managing cancer pain, but in order to obtain the best
results a number of factors must be addressed. Both the patient and the pain
must be comprehensively assessed.
  The WHO guidelines should be followed, in a simple logical approach to
analgesia. There must be adequate knowledge of causes of pain which are
remediable. Tumour killing treatment (tumoricidal) such chemotherapy,
radiotherapy and hormone therapy have to be appropriately used. More
generalised methods of relief such as acupuncture, transcutaneous electrical
nerve stimulation (TENS), relaxation therapy, music therapy, and various
other physical therapies may be indicated. Finally there is a spectrum of
adjuvant pharmacological therapies and interventional methods used by
surgeons and anaesthetists.

It must be emphasised that pain relieving drugs, particularly the opioids,
provide effective relief of cancer pain in the vast majority of cancer pain
patients. Typically these drugs, such as morphine, are supplied as sustained
release capsules or tablets, which provide sustained steady relief. But there
are other methods of administration, such as by the application of sustained
release patches, rather like a band-aid, which may last for three days before
they need changing; others are applied weekly. For break-through pain,
which is an exacerbation of pain above the steady background level of pain –
there are short acting preparations, for this episodic or transient pain, which is
very common in advanced cancer. Pain relieving drugs can be given before
starting known painful procedures. Every effort is made to control pain, for we


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know that if pain is uncontrolled, cancer patients. like the chronic pain patients
that I see at my clinics, are prone to suffer increased anxiety, depression,
somatisation (the tendency to focus on bodily symptoms) and hostility. They
may become emotionally disturbed, respond poorly to treatment and die
sooner and it is the pain which typically induces psychological distress
(Spiegel et al 1994). Besides the analgesics given specifically for pain, we
have what are called adjuvant analgesics, those with primary indications other
than pain but which relieve pain in certain conditions. You will have heard of
the non-steroidal anti-inflammatory drugs, steroids, tricyclic antidepressants,
anticonvulsants such as Epilim®, used primarily in epilepsy, and some drugs
used for heart arrhythmias.

Some medications used for depression are effective in relieving neuropathic
pain, but not all. Traditionally the tricyclic antidepressants have been thought
best and are all much of a muchness in terms of effect on pain. Names like
Endep ® and Tryptanol ® come to mind. Of the newer antidepressants
Venlafaxine, which is a serotonin and noradrenaline reuptake inhibitor, has a
place in the treatment of neuropathic pain in a patient with low mood. There
is not much good evidence that other antidepressants work in this situation.

There are anticonvulsants which have an effect on neuropathic (nerve-
damage) pain, the current favourite being gabapentin (Neurontin®) and there
is a new one called Lyrica® (pregabalin), which I have used successfully in
pain patients.

Minor and major side effects may occur with any of the drugs mentioned and
may limit or prevent their use. A common fear with the narcotics is that the
cancer patient will become tolerant to the drug, but this is rarely a problem.
People worry that they will become addicted to their morphine – but again,
apart from those with a history of addiction it is not often a problem in terms of
psychological dependence. Toxicity can be a problem and must be watched
for.

It is suggested that 40% of patients with cancer pain have neuropathic pain
and in the majority there are mixed pain mechanisms, so many people need
opioids with adjuvant analgesics.

I have formerly talked about the use of bisphosphonates, particularly
zoledronic acid, for metastatic bone pain, for it can be very effective for men
with severe bone pain. Here, it is interesting to note that normal prostate cells
and also prostate cancer cells produce prostate-specific antigen – the PSA we
are always testing for at the laboratory and this, if you are interested, is a
kallikrein serine protease that can cleave parathyroid hormone-related
peptide, thereby blocking bone resorption. There is normally a balance
between the growth of bone, mediated by osteoblast cells and resorption of
bone, mediated by osteoclasts. In breast cancer the metastases in bone are
osteolytic or bone destroying or resorbing, but in prostate cancer the
metastases are osteoblastic in nature. The osteoblasts also release growth
factors such as a platelet-derived growth factor that encourage tumour



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growth. So now you know! But what can you do about it except administer
bisphosphonates?

You probably guessed correctly. Yes, radiotherapy given by external beam
radiation to the localised area of pain, shrinks the tumour and inhibits the
release of chemical mediators of pain – so there is pain relief, which may be
complete for months. Larger areas of the body may be irradiated in advanced
prostate cancer with rapid relief in 24-48 hours, however a lot of patients may
get toxic side effects such as nausea, vomiting, and diarrhoea. Injection of
radio-isotopes is another alternative treatment for widespread bone
metastases. This is an outpatient procedure and all the osteoblastic sites are
zapped in two or three minutes with pain relief following in a few days, which
lasts commonly for months. Treatment may be repeated, but it may be costly
or difficult to access in some places. There are surgical approaches and
major blocks, which can provide relief in suitable patients.

Well may you ask, what are these surgical approaches and what can
anaesthetists achieve with blocks of the nervous system when ordinary
medication regimes prove inadequate?

Firstly, orthopaedic surgeons are often asked to intervene when prostate
cancer metastases in bones cause fractures.             Most men with bony
‘secondaries’ in the ‘long bones’ of the skeleton do not suffer fractures there,
however somewhere between 10% and 30% do, most commonly affected
being the femur or thigh bone. Even when there is a high risk of fracture,
orthopods can pin the femur prophylactically and this may be followed by
irradiation. If a fracture does occur then this is a strong reason to have
surgery to stabilise the fracture. Otherwise severe pain is likely to occur on
movement, as with anyone else with a fractured femur or other long bone.
Internal fixation and more radical procedures may be indicated, including joint
replacement. Urgent investigations and surgery may also be required for
fractures of the spine, which may cause damage to the spinal cord and nerves
unless decompression and stabilisation is carried out, if this is possible.
There are all manner of techniques used by surgeons including bone grafting,
plating, cementing and titanium cages. After healing, radiation may be
advised. Even if surgery is not possible there is often a place for radiotherapy
to protect the nerves, but things are getting far advanced by this stage, if it is
to happen. More positively, there are new interventions to treat compression
fractures of the spine which are termed minimally invasive, such as the
injection of cement into problem areas of bone and there is hope that such
measures will control pain.

Secondly, what have anaesthetists to offer? Anaesthetists, in every day
practice, often choose to administer what are commonly called spinals,
epidurals and nerve blocks for surgery. Common operations for which such
procedures may be the method of choice include total hip and knee
replacements, major shoulder surgery, and gynaecological, urological and
general surgical operations, particularly below the waist. Tiny amounts of
opioids, local anaesthetics and other drugs may be administered right where



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you need them, either via needles or fine catheters, tubes often inserted
through needles.

When typical analgesics such as morphine are given orally for cancer pain
they usually work very effectively in advanced disease. If has been reported
though, that 2-10% of patients still experience severe pain (Chery et al 1990;
Mercadente 1999). Anaesthetists are able to offer effective and long lasting
pain relief with a range of procedures. Sometimes the dose of morphine for
example, which is needed to control pain orally, produces unacceptable side
effects such as over sedation, constipation, or toxic reactions. An epidural
route allows the dose to be reduced to a fraction of the oral dose and a
‘spinal’ catheter requires only one tenth of the epidural dose – so we are
talking of really tiny doses, which are usually free of the troublesome side
effects of oral medications. It is possible to even insert a fully closed system
under the skin, an implantation pump which lasts for months. This can of
course be done for certain patients with unrelieved non- malignant pain too,
and the chance of infection is less than when regular injections have to be
given into catheters. The patient can return home and live a fairly unrestricted
life.

In terms of the effectiveness of epidural or spinal techniques I recall a patient
of mine who wanted to watch the midday television program whilst she
underwent a total hip replacement. I put in a ‘spinal’ and she, aged 80 years,
watched the show happily whilst the orthopaedic surgeon replaced her hip.
The only modification I used was to provide her with a set of earphones so the
TV would not disturb the operative team. In surgery we use strong
concentrations of local anaesthetics and patients are not able to move, but
low doses of morphine plus small doses of local anaesthetics provide pain
relief without preventing the patient ambulating – this is often done for
obstetric patients with epidurals during labour too!


29.08.05
A time to live and a time to die! I have just been talking about this topic with
the wife of a friend. She helped to nurse a mutual friend, in the final months of
his life. He had been ill with prostate cancer metastases in his bones. She
arrived one day, to minister to him, as a member of a group of his friends who
used to cook, clean, wash his clothes and care for him. This particular day,
he was suffering from a rattly cough, and she suspected pneumonia. She
offered to call an ambulance and supervise his transfer to hospital. He asked
that she not do this, as he did not wish to live any longer, and spoke of his
wife, who had predeceased him, for a couple of hours. Then his son arrived
home and despite his protests, organised his father’s transport to hospital,
where he later recovered from pneumonia. Eventually a team of twenty
volunteers, all friends of his, were involved in caring for him in the ensuing
months at his home, but eventually, after five months, his condition
deteriorated so much, that he spent his last month in palliative care.

She had initially been criticised for not calling the ambulance at once, yet later
on, after he died what she calls a horrible death – his son admitted to her that


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he was sorry that he had overridden his father’s objections, in transferring him
to hospital. Not for nothing has pneumonia been called –the old man’s friend!

This story reminds me of the slow and painful death of our former next-door
neighbour, with bony secondaries from prostate cancer. What causes fear is
the thought of an agonising, slow death. A quick end is not nearly so
threatening, at least to me.        Last week I saw an article in a newspaper
warning of the mental anguish that might be caused if men were urged to be
screened for prostate cancer with PSA tests, when any elevation could make
them distressed about an abnormality, which in many cases could turn out
not to be due to cancer or due to a very slow growing cancer which is unlikely
to reduce life expectancy-- and investigation could have its risks. Compared
with a delayed diagnosis of life threatening cancer, and a possible miserable,
slow, drawn- out end, these well meaning warnings are to my mind, a
dangerous impediment and dis-incentive to the diagnosis of a major cancer
which is potentially curable, if diagnosed early. Every time I check on my PSA
I realise that the result may show evidence of a recurrence, necessitating
radiotherapy and possibly, later, death, if that is not effective. To fail to have
the test regularly would be crazy, for to wait too long, might mean—little or no
hope of a cure. The admitted anxiety, whilst waiting for the results every six
weeks (which is twice as frequently as recommended –I wish to be warned as
early as possible) has simply to be accepted, just like the risks of being
screened, in the first place. PSA results are available the same day, so it is no
big deal, like waiting for exam results, as a student!



31.08.05
About a year ago, a friend of mine learnt that his PSA was elevated and that
he also had a heart valve abnormality, which needed surgical correction. His
urologist told him to have his heart fixed up and think about his possible
prostate pathology later on.

In February he underwent major heart surgery and has made an uneventful
recovery. He is back working on the land with his cattle, and his PSA, which
was 7 previously, has remained curiously stable, so he thought that he had no
great cause to worry!

Two weeks ago, he had prostatic biopsies taken, and yesterday visited his
urologist to learn the results, fairly confident that he would have been rung if
there was any adverse finding. Today he rang me and told me the outcome.
He has prostate cancer and the Gleason score is 7, the same as mine. It is,
according to the biopsies taken, restricted to one side. He has been advised
to make an appointment with a radiotherapist, for an opinion, before making
up his mind about whether to have a radical prostatectomy or radiotherapy.
The earliest appointment he can get is a month away. He has read up quite a
bit about radiotherapy and is not very enthusiastic about the likely
complications, particularly fatigue, which may adversely affect his ability to
function, running a cattle property. In addition, he thinks that if he has a



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radical prostatectomy he can have radiotherapy as a follow up if needed,
whereas radiotherapy first wipes out the option of a surgical intervention later.

The upshot of all this is, he is going to ring up the radiotherapist tomorrow and
see if he can get an appointment sooner. He knows the radiotherapist
personally and wants to be able to get all relevant information quickly and get
on with whatever therapy, probably a radical prostatectomy, is decided upon.
Otherwise he says it will be Christmas and he feels he has had cancer for a
year already and he had best have treatment very soon!

Great news-- to change the subject-- about my latest PSA. Yesterday I had
blood taken as it is now ten and a half months since my surgery. My PSA is
still less than 0.01ng/ml. My next appointment to see my surgeon, for an
annual follow up, is on 21.10.05, as he is unavailable on the anniversary, a
week before.

Somehow, one feels one is under some pressure from the press of the
environment, as Kielhofner might phrase it, to live as wisely and fully as
circumstances allow, when there is the ever present risk of a recurrence,
which will be followed by radiotherapy and all that it implies. The other night
on the television show Enough Rope, Andrew Denton interviewed a youngish
woman who was diagnosed with breast cancer when she was pregnant.
Things have not gone well for her and she has had treatment for metastases
in various parts of her body. She is practical, vivacious, in control of her
emotions and living life to the full despite her secondary-cancer, aware that
her future is very much under a cloud. She feels the urge to do the things that
are important to her, sooner rather than later, appraising her priorities very
carefully.

It is all too common for one to catch oneself viewing people who seem to be
aimlessly drifting through life, as frittering away their precious time without
realising it. Without knowing the true situation this impression is probably
unwarranted. Faced with a real threat that may end up curtailing one’s
capacities and life within the next few years, there is every reason to plan and
optimise one’s QOL, making every day as happy, fulfilling and worthwhile as
possible. Why would one do otherwise? I see many cancer patients draw
closer to their families. My friends who have had radical prostatectomies all
intend to live life to the full and to do all the things that they enjoy most.

01.09.05
Skiing is an integral part of our family’s activities. Elizabeth is flying down to
Sydney on Saturday to join young Garry and his family and drive down to
Charlotte Pass. A major ski race is on and Garry and his wife Lisa-Jane are
competing – only a couple of weeks after Lisa-Jane’s cholecystectomy. Last
weekend Garry competed in the Kangaroo Hoppet 42 kilometre cross-country
ski race against a thousand odd others from 28 countries. He came 64th
overall, 8th in his age division (38) and young Sophie came second in her age
group aged 8!




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Next week Elizabeth and I shall drive down to the snow and ski at Perisher.
Yesterday evening before starting our regular walk around the University
Ovals, under the floodlights, Elizabeth asked me to take a look at her
troublesome knee. There are signs of significant osteoarthritis, accounting for
her increasing disability. Over the last seventeen years we have had many
happy and sometimes exciting ski trips and for some time I have been
pondering the future for our skiing. Elizabeth has had her fair share of
injuries, including a fractured ankle in the Canadian Rockies and it might be
prudent to call it a day, after this trip. We have already sold a couple of
properties down at the snow, another is rented out for the whole season and
the final one, we have rented out to a fellow anaesthetist and his family, who
will be travelling down there to ski at Falls Creek, tomorrow.

In the future, what we shall have given up, if we are to relinquish our downhill
skiing, we shall compensate for by spending more time at the beach, on the
catamaran, diving and swimming, which Elizabeth thoroughly enjoys and will
be at less risk of injuries. With increasing age falls become more dangerous
and for elderly people fractures of the neck of the femur are bad news.
Swimming is an excellent sport or pastime – it is all up to you and part of the
Australian way of life. This has implications for me too, if I ever, God forbid,
end up with bony metastases! I think I have said enough.



02.09.05
On 31.08.05 I was alluding to the desirability of doing what one dreams of
achieving, whilst there is yet time. Many of us have unspoken ambitions
concerning things to do, places to visit, courses to enrol in, achievement of a
degree of competence in a skilled activity, art, music, photography – the
possibilities are endless. If possible, it is worth planning to achieve at least a
few of these desires and this leads me to discuss something I have been
doing this week.

Elizabeth and I have never been to South America, though it is relatively close
to Antigua, where we venture every year. For many years I have been
dreaming about it, but it is a bit off the beaten track for us and my thought has
been to wait until there is a worthwhile conference to attend, rather than
simply going there for a holiday. There is a conference, the Second World
Congress on Regional Anaesthesia and Pain therapy, to be held in Rio de
Janeiro, Brazil, next February. Most appropriate for me!

In South America there are many, many fascinating areas to visit, among
them we have been particularly interested in seeing the Iguazu Falls, at the
junction of Argentina, Brazil and Paraguay. If we fly to Santiago, Chile, we
can enjoy a couple of days thereabouts before flying on to Rio de Janeiro and
hence to the Iguazu Falls. We plan to stay there for two nights, enough time
to explore a little of the area, we hope. By then it will be time to return to Rio
for the conference, for five or six days.




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Initially, on viewing a map of South America, it seemed temping to venture
south to Patagonia, about as far south as the Falkland Islands are to the east
(-where a colleague has applied to work as an anaesthetist for six months!)
Friends who have holidayed in Patagonia assure us that hiking and trekking
are the favoured ways of exploring Patagonia, so perhaps it would have been
better if we had travelled the area many years ago – when of course, we
didn’t have the time or money with three young sons to bring up.

How about flying up to Cuzco in Peru and visiting fabled Machu Picchu to the
North. A good thought, but the airline routes would mean flying back a long
way to Santiago, so that is not ideal. We thought of the Matto Grosso, but
when you see the size of Brazil and realise that to visit a fraction of the places
we want to see we would need months, probably, we were forced to face
reality and plan to see less, but thoroughly.

Probably we shall fly from Rio to Miami and the Caribbean but we shall have
to do a bit more homework before finally booking our trip in the next day or
two. Already we are taking up the last two seats available on our favoured
flight from Sydney to Santiago in February – all 15 hours and 55 minutes of it!

The Iguazu Falls are 3 kilometres wide and plunge 20 metres into the gorge
dividing Brazil and Argentina. They are in a tropical rainforest area famous for
a wide variety of fauna and flora, perhaps best known being the many
beautiful butterflies. In terms of water volume these falls are the largest in the
world. Actually there are really 275 different falls of differing heights in a huge
semicircle and the whole area is a national park. One really needs to view the
falls from both Argentina and Brazil to appreciate the immensity of it all,
according to what I have heard and read. Many years ago we visited Niagara
Falls, so it will be interesting to compare them. Obviously Niagara is set in a
very touristy area today, which tends to detract from the natural spectacle.

Santiago is pretty well half way down the coast of Chile, which adjoins Peru
and Bolivia to the north and hugs the coastline for some 4,290 kilometres
down to the Straits of Magellan and to Tierra del Fuego. We shall restrict our
touring from the city, which is actually inland, to a trip to Valparaiso on the
Pacific coast. This has always sounded a romantic destination to me, for I
read about its spectacular setting with surrounding steep hillsides and
interesting architecture. In reality it is billed as Chile’s main seaport so it may
have a seamier side, as port cities often do. It is our intention to then venture
up the coast past Vind del Mar, a coastal resort, which may be in an area
equivalent to the Great Ocean Road, west of Melbourne. We shall see!
Another option would be to explore Chile’s extensive vineyard region, but we
haven’t time to see everything.

Whatever our route, we shall have achieved a long nurtured dream and not
die regretting that we did not make the journey. Perhaps it will awaken desires
to explore that continent further, if our circumstances allow. Whilst it is
possible, I wish to ‘engage’ with our beautiful world and experience more of its
wonders. Life is so short and there are just so many things to see. QOL
enhancement is a vital ingredient in a life management strategy, to my mind.


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Now that I know my PSA is still negative I am more than ever convinced that if
I were to have to have radiotherapy, I would endeavour to keep working or
living life to the full despite a fair level of fatigue – my schedule is not so
onerous that I should have to abandon my clinics, though they might have to
be shortened for a while. Sitting around at home doing nothing is not an
attractive option. One hopes that one never has to consider the whole
question!


03.09.05
As you have doubtless observed, sometimes little happens to write about and
at other times, as at present, all sorts of events are occurring.

On 31.08.05 I wrote a little about my friend with the elevated PSA, whom I
urged to personally contact the radiotherapist he was to see in a month’s time.
He did! On Wednesday he will be seen in Sydney. In the meantime he is
more and more inclined to opt for a radical prostatectomy and the sooner the
better. This may be due to the fact that a mutual friend, who opted for
radiotherapy for his prostate cancer a few years ago – suffered greatly from
his treatment.     Within two weeks of completing over six weeks of
radiotherapy, he began to suffer faecal incontinence and this did not improve
over time. He was a pretty stoic sort of chap and a committed Christian. I
never heard him complain. Time passed and his cancer spread. His last
days were spent in palliative care with bony secondaries – and of course his
ever present faecal incontinence. No wonder my friend is not very favourably
disposed to radiotherapy as a first line treatment if surgery is the alternative.
Before you start thinking -hey- this is a pretty unusual story and not at all
typical of the expected profile of complications – I would agree, but very much
sympathise with his view.

By the way, only this morning I learnt that yet another guy, about 60, whom I
knew well, but lost contact with when he moved away to Sydney several years
ago – had a radical prostatectomy last June and is making a good recovery –
apparently the cancer was contained within his (removed) prostate so he
should do well. Again and again I think - what if his doctor had not ordered a
routine PSA – and this is another case in point. Look at the figures.
Americans are justifiably greatly upset about the present hurricane disasters
in New Orleans. Have they mentioned in the media lately that a hundred or
so Americans die of prostate cancer every day of the year? That’s hardly
newsworthy!

Let us move on to more positive matters. How is life for me now? How is my
QOL? Really, and I kid you not, it is, apart from my continued failure to
achieve a decent spontaneous erection, about maximal, for which I am truly
grateful. I am really blessed and thank God.

Here am I, sitting up in singlet and jeans, with a rum punch to sip, writing and
waiting for the chicken and vegetables, pumpkin, sweet potatoes, potatoes
and onions, to finish baking. This morning I took my lycopene, as tomato


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juice, with my vitamins, zinc, selenium and blood pressure tablets, had my
shower with Elizabeth – a really good habit, and drove her to the airport so
she can go off to Charlotte Pass and look after Sophie whilst young Garry and
Lisa-Jane compete in the cross country race. Andrew rang last night from
Bangalore, India, where he had just finished lecturing to 600 bible college
students and the lectures were very favourably received. He is keen to return
to Israel later to learn Hebrew and Greek and life is as good as it gets for him
too.

How was work yesterday? Very fulfilling! All day long I ran a pre-anaesthetic
clinic. Pretty routine? One guy, a candidate for a major joint replacement
was initially assessed at my Early Joint Clinic only a month ago and was
placed on the waiting list, as fit enough then for the surgery. Now he is
scheduled to have surgery on 16.09.05 and still feels well. He is a hard
worker and 48 years old. We repeated his electrocardiograph and guess
what? He is in atrial fibrillation and must have a lot of investigations prior to
surgery plus probable treatment with anticoagulants so, having spoken to two
physicians to see if they can sort him out prior to his scheduled surgery date –
I have had to postpone him – probably for a couple of months – there are no
appointment times earlier for him to be fully assessed. At least he did not get
to the operating theatre ill prepared.

Another patient was very anxious about surgery and had experienced
problems with hospital staff previously. I became even more cautious in my
assessment of her, when I learned that her husband, who accompanied her,
was a surgeon and she is a lawyer. I explained the risks of surgery, as one
does, to someone even more alert to the possibilities of medico-legal
complications than most.

A third patient, a man of 47 years, had a carer with him. He is in a nursing
home, spoke not a word to me and has been suffering a progressive dementia
since the age of 41 years. It certainly makes one count one’s blessings.

After a number of reasonably routine assessments I saw my last patient but
one, a seventy-nine year old who seems to be in heart failure, so I ordered
blood tests and an x-ray which confirm her unfitness for surgery, and again,
our clinic’s purpose is achieved.

 Lastly, a woman in her forties came in to see me, visibly upset. She is very
worried about having her operation. An in-depth interview reveals that people
are able to track her and everything that is occurring to her is not merely
coincidental. She is reluctant for me to ask a psychiatrist to see her but finally
agrees. Our sole available psychiatrist in town is about to fly back to Sydney.
I appraise him of her paranoid delusions and of her consequent distress. He
sees her and she agrees to be admitted to the psychiatric unit. She will not
be undergoing surgery until he is satisfied with her mental state. She agrees
to treatment.

Our little team, at our little country hospital, has done its bit for our community.
My guess is that everyone involved with our day’s activities will go home, as I


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did, with a sense of fulfilment. Why would I give this up? This is life, indeed
QOL!

The other interesting thing I did yesterday was to call in and see my friend
Craig at his travel agency. We needed to complete booking our tickets for our
overseas trip to the Rio Conference in February. My plan depended on being
able to use our Frequent Flyer points instead of paying for our airfares. It
seems that there is no allocation for Frequent Flyer tickets. Two hours work
for Craig and I and all is sweet. Except that our trip is very different. In
February, we fly not to Santiago, Chile, but to Los Angeles. Obviously, we are
not going to journey up the coast north of Valparaiso. Instead we shall
probably indulge in what is known as retail therapy – exploring the shops in
Rodeo Drive, which Elizabeth has never seen previously. I assured her that
she will enjoy it, for she loves looking in shops. I would also love to visit the J.
Paul Getty Art Museum whilst in L.A. To get to Rio we shall fly, after a
needed sleep at the Hilton Los Angeles International Airport Hotel, to Miami
for six hours then on to Rio, then change planes for the two hour flight to
Iguazu as planned.

The other change is that we fly out of Rio after the conference to Madrid then
on to Tenerife, for two weeks, before flying home via London and Hong Kong.
Altogether, five continents, twelve flights and nine different airlines.

Why Tenerife? It is an island in the middle of the Spanish Canary Islands, a
little over 100km off the west coast of Saharan Africa opposite Morocco.
Craig kindly reminded me about the two 747s crashing into each other whilst
trying to land there in bad weather some years ago. Never mind, such stories
do nothing to put me off travel – flying really is very safe.

In February – March, Europe is pretty cold overall and a lot of people there
head to the Canaries as the weather then averages 15C. minimum and
22C. maximum with possibly 25 mm. of rain in a month. Averages aren’t
everything but in Tenerife, which is 80km. long, it is wetter and more luxuriant
in the North and more typically African and drier, to the South. Why? I
suppose it could be due to the highest mountain in Spain, really an almost
extinct, (they believe) volcano, some 10,000 odd feet high and snow covered
and is the main feature of the island. We shall hire a little car and explore this
fascinating area, where so many others have made their home, besides the
Spaniards who dispossessed or disposed of, the original population. A bit like
their actions in the Caribbean when faced with the warlike Carib Indians.

 Of course times change, and now pickpockets and other thieves flourish in
such holiday resorts and visitors are warned to take every precaution. It was
different when General Franco ruled. Now I can make use of one of the very
few advantages of being what I must accept - yes- Old! I remember visiting
Spain in his day. Any one was safe to wander the streets of Madrid alone at
night, yes, even young girls. If you dropped your purse or wallet there was a
good chance it would still be there if you came back later, for General Franco
liked peace, quiet and happy pedestrians. Of course one often saw military
trucks rumbling past with armed soldiers keeping an eye on things. Whilst


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neighbouring Portugal had graffiti everywhere, the Spaniards did not seem
keen to deface the city buildings. One cannot imagine the old dictator
approving of any illegal drugs either, come to think of it. Since his day things
are very different.

After farewelling Craig, I walked to the car in a jubilant mood, my QOL buoyed
by fulfilling work and with a stimulating trip to look forward to in February. In
the evening Elizabeth and I went to a crowded lecture by a visiting Anglican
clergyman who was formerly an Orthodox Jew from the Eastern Suburbs of
Sydney. He was a medical student when he became a Christian. Living in a
University town, as we do, we are privileged to be able to attend many
interesting lectures and access many University facilities, besides doing post-
graduate degrees and research. What a pity our time on earth is so brief, with
so much to see, do and learn.


05.09.05
The latest issue of the Journal of Happiness Studies has an interesting article
by Adam Crossley and Darren Longridge ‘Received Sources of Happiness: A
Network Analysis.’ Reasons for happiness were ranked by young men and
young women and compared..

For our purposes it is appropriate to focus on young men’s perceived ranking
of causes of happiness and then to se how relevant this might be for older
men.

The order from 1 to 32 is –
(1)          being loved by loved ones
(2)          enjoying a good social life
(3)          being part of a close/intimate relationship
(4)          being healthy/well
(5)          being liked by others
(6)          having self confidence
(7)          having self respect
(8)          being able to spend time playing sports
(9)          regularly having sexual activity
(10) being part of a close network of friends
(11) being successful in my choices/career
(12) being comfortable financially
(13) being physically fit
(14) being free of stress
(15) being part of a close family
(16) having meaning in my life
(17) being in romantic love
(18) being satisfied with daily occupation
(19) being found physically attractive by others
(20) being free of family/home problems
(21) to be content in my religion
(22) helping others
(23) being able to spend time on hobbies


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(24)   not being subjected to bereavement
(25)   being constantly challenged
(26)   being rich
(27)   being able to travel and see the world
(28)   always improving myself
(29)   being well fed
(30)   being able to use alcohol/drugs
(31)   to live a long time
(32)   weather

There were many similarities in the rankings of women but men ranked sexual
activity, sports, being liked and having a good social life significantly higher
than women did. Everyone focused on self confidence, being free of stress,
social and occupational factors, personal relationships and family support The
authors suggest that the similarities form, ‘the core elements of a shared
social representation of happiness.’

You will quickly see that prostate cancer may negatively impact on a number
of factors but a number of other factors may be strengthened, such as being
loved by loved ones and being part of close/intimate relationships. Your
ranking of some factors has probably altered over the years; sport may be
less important and adverse weather may affect you more. It may be
interesting to self-rank yourself. It has been my experience that many
patients receiving chemotherapy for cancer (not part of the standard
armamentarium for prostate cancer) focus very much on being loved by love
ones, close relationships, a close family- and other elements mentioned by
the authors. No change over the years would be expected until age impacts
on many patient’s social reality.

 If there have been family problems which are unresolved, then a diagnosis of
cancer in the family may encourage family members to mend-fences and
become closer.         Fractured relationships may be a serious cause of
unhappiness. Strains within families may become worse. Counselling may
be required and it is well known that women with breast cancer are at greater
risk of a marriage break-up unless there is appropriate counselling. With
prostate cancer, spouses are often more distressed than patients, and there is
often poor communication about the cancer and its effects. Professional
support and advice, cancer support groups and close family ties are often
instrumental in helping men adjust to their new situation, if they have
difficulties facing their new reality.

Returning to the ranking of happiness factors by the young - the ‘weather’
ranked last of thirty-two factors contributing to happiness in the study of young
men. From what I understand, in Northern Europe and Japan in winter, in
times of bad weather the incidence of suicide is increased. Close to home,
Armidale quite often records the lowest temperatures of the day in the whole
state of New South Wales. It did so one day this week, accompanied by
bitterly cold wind. That day, I did not go for my regular walk. The next day
was sunny instead of overcast and considerably warmer. Making up for the
miserable weather of the day before, I walked a good nine kilometres, happy


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and at peace with the world. My long term planning for retirement takes the
weather into consideration. Why would I hang about Armidale in the often
unpleasant winter weather when I can spend from May to September
inclusive overseas in glorious sunshine, returning when spring is well under
way in October. Surely there are many who move to a new more pleasant
environment in retirement when their work days in a cold climate are over.
Canadians from the prairies, used to sub-zero temperatures, sometimes
reaching 40-50C. below freezing, flock to Victoria Island in British Columbia.
Others head south, even to Texas, where the weather is much warmer.
Australians purchased over a million air-conditioning units for their homes last
year. They wouldn’t do so unless that made them happier. Are young people
different?

‘To live a long time’ was another factor influencing happiness, which ranked
very low with young people. Second last in fact! This is a complicated matter
with many influences at work. For a start, when you are young you feel you
are ‘bullet-proof’. You are going to live ‘forever’ or at least for so long that the
potential years seem to stretch beyond any horizon contemplated. Tell a
young person that smoking may shorten his/her life. It is likely that he/she will
feel that any curtailing of life will occur so far into the future that, in their
present context it is meaningless.

There are many, many possible disasters that can occur, which we all realise,
but generally discount, whilst we remain positive, healthy, and seemingly in
control of our lives. The other day it was reported that the pregnant Princess
Mary of Denmark was, in her official car, clocked at a good 200 kilometres per
hour. If you read the article in the press you would recall the tremendous fuss
made about this happening. What if this – what if that! I am positive Mary
was not contemplating any disaster and neither do I when I do the same thing,
for we factor in all the risks that we can foresee, before we push the
accelerator down further, then simply enjoy ourselves – thinking nothing bad
will happen.      We are not really thinking of our potential long lives.


Until my PSA level rose pathologically, I believed that barring accidents, I
would live until my eighties, basically free of debilitating degenerative
diseases. There is no family history of any form of cancer. My relatives died
like flies, often at an early age, from the complications of familial
hypercholesterolemia. A first cousin died of a coronary occlusion at 39 years.
A sister has had coronary bypass surgery, two carotid artery
endarterectomies, to clean these essential blood vessels of atheromatous
plaques and now has an aortic aneurysm. She has inherited the familial
hypercholesterolemia and so have all her children. My other sister and I have
not. Still being active, swimming, diving, skiing, bush walking and routinely
avoiding lifts in buildings, I thought my chances of a long life were excellent.

The diagnosis of prostate cancer, a nerve sparing radical prostatectomy with
a positive margin at pathology – and my ‘long life’ expectancy is very much in
doubt. Firstly, I was warned when I had prostatic biopsies done that I could
get septicaemia and die if I was unlucky. That did not put me off for a


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moment. Then when I had my surgery I was warned there is a small chance
of death at surgery. Again I dismissed the thought – it would be unknown to
me if I succumbed at operation. If it is a quick, unexpected death, what is the
worry? It is the long term risk of local or distant spread of cancer which
engenders fear. What wouldn’t you do to avoid a scenario like this narrative
told to me, by a patient this week, from another area?

‘In 1999, my 65 year old husband started having trouble passing his urine. He
had a PSA test and the reading was 36. He had a TUR operation to clear the
passage from his bladder, then radiotherapy in Brisbane for eight weeks. He
was feeling tired even before the radiotherapy and his PSA never went down
completely.’

‘He didn’t have hormone tablets for a start but they started him on them in
2001. Later on, in 2002 his kidneys failed due to a blockage, which was an
emergency, but they managed to unblock one, clogged by prostate cancer
spread. The next year they operated to drain his bladder through his
abdomen – he lived with this for a year before he died in 2004. The cancer
had spread to his bones. They treated him with Capadex® plus Panadeine
Forte®, which didn’t work, then finally morphine which didn’t help his pain until
they had to give him so much he became unconscious. He was in hospital
that last three weeks and then died.’

She is very bitter! ‘Right from the start, I kept on being assured by the
urologist that he was alright, and doing well’. ‘He’s doing well’ ’He’s fine.’ ‘I
believed – if I could get away with it-- I’d kill that urologist. Why can’t people
be honest?’ To live a long time, does not necessarily equate with QOL.

I asked my patient about her husband’s history, in relationship to prostate
cancer. He was one of seven brothers – four of whom have now been
diagnosed with prostate cancer. As we know, he died. Another brother has
had a radical prostatectomy and, she says, is doing very well. The other two
are still alive, both are on hormone treatment and are sick men. What a
history! One can only suppose that the other three are having regular
examinations and frequent PSAs. What a pity that her husband and his
brothers had not been having annual PSAs from the age of fifty – as once
proposed by American urologists. My guess is that their cancer would have
been detected much, much earlier, when there was a real chance of a
potentially curative radical prostatectomy.




08.09.05
After returning from work this morning at the Private Hospital, I packed my
bag. We loaded up the little Mercedes and drove towards the ski fields,
arriving in Queanbeyan at 10.30 at night. This means that if we start early, we
will be skiing at Perisher and Blue Cow tomorrow, and checking in to the ski
lodge before dark.



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Elizabeth has decided to learn to cross-country ski so she can accompany our
grandchildren when they go to the snow each season. On my last serious ski-
trip, after two weeks of enjoying myself downhill skiing on challenging runs – it
took my knees and right arm many weeks to recover. This was a new
experience and it made me reconsider the wisdom of continuing to go down
hill skiing. This short trip I shall simply go cross-country skiing and probably
try snowshoeing which is as easy as you make it. Pessimistically, even with
bony cancer secondaries one could probably quietly move around admiring
the vista of snow gums, rocks and interesting terrain, without much chance of
coming to grief. If this is not enjoyable enough to be worth the effort, maybe
our skiing days are numbered.


09.09.05
Elizabeth and I parked the car at Perisher, hired some snowshoes, caught the
ski-tube train up to Blue Cow and explored the area on foot. The temperature
was warm and the snow was melting. Clouds threatened rain which is
forecast and everyone is hoping it cools down. There is enough snow cover
for most lifts to be open and as always on the snow it is a colourful
environment.

We are staying in Jindabyne, which is a popular little ski-town within easy
reach of Thredbo, Perisher Blue – Guthega and Mount Selwyn fields. It is
well serviced with shops, restaurants, lodges and apartments, for the winter
crowds not willing or able to pay the high prices charged for ski-in-ski out
accommodation right near the lifts. In the past we have enjoyed staying right
on the mountains in our own appartment at Mt Hotham surrounded by snow –
but we sold it a couple of years ago. It is not really a big hassle driving to the
actual resort – you just leave a bit earlier in the morning.


10.09.05
Elizabeth had a cross-country ski lesson, during which it started raining, then
there was hail, this afternoon. The promised snow is still to come – but first
the temperature must fall. I did a bit of cross-country skiing, but conditions
are not ideal. Never mind – you can’t expect ideal conditions always – and
that applies to life generally. My QOL is at a high level and we are having a
good time.


11.09.05
No more skiing now – it is time to drive home today, about 1000 kilometres.
We shall call in and visit friends at lunchtime and get home tonight – in time to
watch the Belgian Grand Prix and some of the Ashes cricket – after a fun few
days. Nearly all the people on the snow seemed about a quarter to a third of
my age. Where are all the other oldies? My energy levels are unimpaired
and I am keen to live life to the full whilst I can.




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12.09.05
Good news! Bad News! And finally – a surprise! The old soldier can’t
remember when he had his transurethral resection (TUR) for urinary
obstruction, but it was many years ago and there was no evidence of cancer
he is sure. A check up in 1997 included a PSA test, which was 10 ng/ml. This
time he did have cancer. Hormone medication was given, to shrink the
tumour, then he underwent radiotherapy.

Good News! Eight years later his PSA tests remain negative. The last one
was two weeks ago. No sign of prostate cancer. He does not recall suffering
any fatigue during his treatment and today is fit, happy and alert, regularly
walking for 4 or 5 kilometres.

Bad News! Radiation proctitis is bad news. Sometimes radiotherapy causes
serious damage to the lower end of the bowel with scarring and over growth
of fine blood vessels, pain, possible bleeding and in this man’s case faecal
incontinence. It has slowly improved but he still gets bowel leakage mildly,
every few weeks. He is philosophical about it.

And finally a surprise! After hormone treatment and radiotherapy he became
impotent straight away and remained so until a few months ago when he
noticed that his capacity to have erections has returned. Now that is a
surprise. Let there be more such occurrences. He is now 82 years old.


13.09.05
Another hormone treatment and radiotherapy story.

I have only just learned from a mutual friend that a man that I have known for
many years, has prostate cancer. Some two years ago Fred learned that he
had an elevated PSA. It was 15 ng/ml and cancer was diagnosed. Fred was
given injections to lower his testosterone levels, just like the man whose story
I have told above. Radiotherapy followed subsequently for seven weeks.
Fred lost his vim and vigour and became lethargic. He is still fatigued,
receiving injections and his PSA is mildly elevated.

Most of the cancer patients that I have questioned, who have undergone
radiotherapy and/or hormone therapy, have described a period of loss of
energy or fatigue. Commonly, with radiotherapy this seems to begin about
the middle of therapy and often lasts for maybe six weeks, sometimes much
longer.

Well maybe yes, but maybe no! Some men do not get fatigue!




14.09.05


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A week ago, my friend newly diagnosed with prostate cancer, saw a
radiotherapist in Sydney at his urologist’s request. He learned that the
alternatives to radical prostatectomy were Iridium needle insertions for three
days followed by a reduced dose of external beam radiotherapy or the
standard full dose external beam regime. The Iridium modification aims to
reduce the radiation dose and potential damage to the rectum – but radiation
proctitis is still a possibility. He has thought about his options and wants to
have a radical prostatectomy – still. One reason is that the chances of a cure
are a little higher with surgery and he is fit enough for the procedure. We
spent some time on the phone discussing his situation. Now he has to wait
until the end of next month to have surgery, unless his own doctor can
suggest another path to the operating theatre. I sometimes talk to his wife
about his prostate cancer as well. I spent a pleasant hour talking to another
friend who had his radical prostatectomy earlier this year, mainly discussing
future possible therapies. We never even got around to discussing share
prices, which we commonly do!


15.09.05
Crossley and Langdridge (2005) in their article ‘Perceived Sources of
Happiness: A Network Analysis’ point out that a number of variables have
been found to be significantly associated with happiness including social
relationships, work and leisure activities. In fact Argyle (2001) states that
these three variables are the main reasons for happiness. This sounds very
consistent with my patient generated definition of QOL. A number of
researchers have argued that the most important reason for happiness is
social relationships (Larsen 1978, Inglehart 1990 and Myers 2000).
Meaningful social relationships such as those between men who have
prostate cancer surgery or radiotherapy provide an important Network. We
can tell our stories, listen to others, discuss areas of common concern, pass
on newsworthy information or research reports and generally support each
other. None of the men that I know here have ever had anything to do with
organised cancer support groups. To my knowledge none of us have any
psychosocial problems of significance and I believe we all benefit from our
supportive network and friendship. There are those of course who retain their
privacy and the many who never have a PSA to learn if they have a problem.
Let us hope education soon reduces ignorance and increases communication.

16.09.05
Two of my medical colleagues, both of whom I have known for over thirty
years are awaiting radical prostatectomies as I write. There is one man I
learned about on Wednesday, two days ago, and now yet another that my
own doctor told me of yesterday. This guy frequently referred patients to me
until he decided to move to the city a few months ago.

Everywhere I turn, there is news of prostate cancer, PSAs, biopsies,
radiotherapy and surgery.

Some time ago I examined a man of my age, who was scheduled to be
admitted next week for TRUS (transrectal ultrasound) and biopsies of his


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prostate. In the last few years his PSA has been rising from normal levels,
until now it is 6.4ng/ml. He is overweight and has had two documented heart
attacks This brings up the question of fitness for major surgery, if men need
a radical prostatectomy. Not all men who would otherwise be suitable for
surgery are healthy enough and this can be a reason for having radiotherapy
with an almost comparable chance of cure.


17.09.05
What are doctors and dentists of my age, or at least in their senior years,
doing around here? Four have farms and still work part-time. One, younger,
in his late fifties, is a part time officer in the Army, currently in Iraq, but
formerly in a lot of trouble spots, such as East Timor and Somalia, and the
rest of the time is a specialist here. One has moved to the coast but works
part time. An eighty year old lady now works in north Queensland, would you
believe – it is warmer. A few still work full time, two work only as locums and
as for me I feel as if I have retired, with no nights or weekends to work, and
Thursday afternoons off.


18.09.05
Retired academics and University of New England former technical staff living
in Armidale very frequently change their routines very little in the years that
follow. Freed of restrictions and responsibilities they very much enjoy
pursuing their research interests or maintaining meaningful relationships at
the University.. Sadly, some have been frustrated whilst employed at the
University and opt to take an early retirement; not to leave their environment
but to continue doing what they enjoy at peace and at their own pace, namely
continuing their research.


19.09.05
Last Friday, 16.09.05, was an exceptionally rewarding day. Part of my
research on patient QOL involves asking them to define QOL, Happiness and
Distress. Typically, participants read and sign their information sheet and
consent form respectively, then proceed to tell me about their QOL and so on.
Let us examine the definitions given by the four participants interviewed this
morning on the definition of QOL.

Participant 1 – an eighty year old married lady ‘QOL is love, family, give and
take a little, enjoy day by day – visiting, eating, doing what I like to do’.

Participant 2 – a fifty two year old married lady ‘QOL has it ups and downs –
ideally-- good health, enough money, lovely well earned holidays. I have a
wonderful husband, four daughters and eight grandchildren. I spend lots of
time with them’.

Participant 3 – a sixty year old male clinical psychologist with a PhD ‘My QOL
would be what I am doing now – not overindulging in anything – that is – in
the way of food, exercise and drink. I make sure I stay in touch with my


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family, especially my son. Family concerns are part of my QOL. They are
concerned about me and I notify them of any problems in my life’.

Participant 4 – a sixty eight year old retired Science Professor. I shall give
you his definitions of QOL, Happiness and Distress – and remember – no one
is asked to describe their personal QOL but to simply define QOL. ‘QOL is
being able to do the things you want to do’. ‘Happiness is feeling well and at
ease with the environment and one’s associates’. ‘Distress is coping with
some problem that arises with the above’.

He declined to add anything further to his replies. He did agree without
comment with the patient generated definition of QOL as ‘QOL is being able
to do what you want to do, when you want to do it, together with the
satisfaction/happiness that accompanies it’ (when it was later presented to
him for his views.)

It is unusual for a participant to define the terms presented to them. The last
person to do so was another man who is a professor in biological science. Is
this a coincidence? I wonder! Some humans seem to have a marked
tendency to take scenarios personally. If told of another individual’s
experiences, journey or achievements, all too frequently their comment runs
along the lines of ‘I couldn’t do that’, ‘I couldn’t afford that’, or ‘I wouldn’t
attempt that’. Is this a fair comment? If the activity seems beyond them for
any reason they react negatively, even resentfully. Tall poppies need to be
cut down! If I cannot have one, then neither should you or anyone else---who
do you think you are!


21.09.05
Every day I feel that I am a retiree. I have not given an anaesthetic since we
went overseas at the beginning of June. Surely I should be used to the idea
of always starting work at 8.30 a.m. or 9 a.m, only leaving home at 7a.m.
when I work at Inverell. So many years of arising at 6.30 a.m. and leaving for
work at 7.15 a.m. to see surgical patients, prior to changing and starting the
day’s operating list and often arriving home after dark. No more! It really is
strange after so many years. Every day is a pleasure. Interviewing patients is
always enjoyable, everything is organised and emergencies are a thing of the
past.

Perhaps if I had become a psychiatrist, as I nearly opted for, at an early stage,
it would have been a very reasonable choice. Now that I spend most of my
time seeing chronic pain patients, I see quite a number of patients with a
psychiatric history complicating their chronic pain. The work, if it can be
called that, is challenging and fulfilling. Never, never do I bring their problems
home or get depressed after seeing patients, which is a problem for some
practitioners. Being a doctor has never been better. Sure, I enjoyed my life as
an anaesthetist, with all the challenges and satisfaction, but for the last twenty
years I have run pain clinics too, so it is a simple transition now.




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22.09.05
Yesterday was a big day for a guy I met on Monday. He had a transrectal
ultrasound and prostatic biopsies, though he wasn’t the only one to have such
a procedure. Over the last five years his PSA has been rising, and let me
repeat it, rising. In 2003 it was still within the normal range, at 3.5 ng/ml. Last
year ti was ‘a bit over six’! Now, over a year later it is 9.0 ng/ml and not
surprisingly, he is worried. In the hospital laboratory a PSA of 8 equates to a
90% chance of prostate cancer. His case is a little different. He has an
enlarged prostate and has been receiving treatment with prazosin. Prostatic
hypertrophy or enlargement is typically benign and is a common cause of a
raised PSA. Then again he could have prostatitis or something else – like
what? Maybe, as PSAs can be raised after exercise or sex, it could be that!

Now he will have to wait until he learns whether he has prostate cancer and if
so, whether it still confined to the prostate? Is it operable? Has it spread?
Maybe he will be thinking why didn’t I have biopsies last year? He is about
my age. He is going to tell me the outcome and I sure hope there is no
evidence of cancer. I shall let you know in due course.

23.09.05
Landis et al (1998) reported that prostate cancer is common and 1 in 5 men in
the United States have this disease during their lifetime. The figures for
Australia should be comparable, so we are looking at a very serious situation.
In the last months, since my radical prostatectomy, I have tried to give you a
picture of the reality experienced by one man, in one small town, in one state,
as it has touched him, in one way or another. Certainly, I am in a privileged
position, working as I do in hospital clinics where I interview men (and
women) and take their histories. Also I have lived here for over thirty years,
know a lot of men, some of whom know I have had prostate cancer and hence
are willing to tell me of their experiences.

In the next few weeks I shall attempt to focus more on the problems that I see
for men, as they age and face the very real risk of prostate cancer. Seven or
eight Australian men die from prostate cancer every day, yet there is much
ignorance among the population and regrettably, among some doctors and
health policy gurus on prostate cancer.




25.09.05
One of my Anaesthetist colleagues came to lunch today and Elizabeth cooked
a superb meal which we enjoyed whilst J described her forth coming
retirement.

She is a medical missionary and spends her vacations working in West Africa
teaching Anaesthetics. Soon she will leave us permanently and journey to
Niger, one of the poorest nations on earth, where she will work in
temperatures in the 40’s bordering on the Sahara Desert. Over the years her
French has improved. Our Department will give her a farewell party next


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Sunday. There are only four Anaesthetists in Niger so nurses give by far the
most anaesthetics.



26.09.05
For some reason I have been feeling somewhat depressed all day. Mild
euphoria and high levels of positive affect characterise my usual outlook, so
this is a little disconcerting for me. It is hard for me to imagine the misery of
those suffering from clinical depression, which is so very common. One of my
routine assessments for all new pain patients is to screen them for
depression, for it is known that frequently, chronic pain is associated with
elevated levels of depression, anxiety and somatization. Only two of my
many pain patients have actually suicided to my knowledge, both coming
unexpectedly, when they seemed to be doing well. More have taken non-fatal
overdoses of prescribed medications, for one is careful to assess the risks of
the powerful drugs used for chronic pain at all times and so many patients
have had at least some suicidal thoughts at times. I am always surprised at
how quickly suicidal patients admitted to psychiatric facilities are discharged
home.

A quick count has revealed that 331 clinic patients have now been questioned
concerning QOL in my study.


27.09.05
Today I am still feeling rather negative and reflect that since I first determined
that patients seemed to believe that-- QOL is doing what you want to do,
when you want to do it, together with the happiness/satisfaction that
accompanies it --nothing has arisen in questioning of more and more patients
from cancer, pain and pre-anaesthetic clinics, to cause me to doubt that this
definition has overwhelming support among our clinic population. The twenty-
five hospital staff I surveyed in 100 minutes one morning, early on, in the
hospital all agree with the definition with a few additional comments, as one
would expect. This being the case, all one has to do then is to conduct a
short qualitative interview with any person to gain further information on their
individual QOL, for we are all different. I believe that when people answer the
Bowling and Windsor global QOL question (How is your overall QOL – As
good as can be? Very good? Good? Alright? Bad? Very bad? As bad as
can Be?), they compare their present QOL with their personal ideal. They
have no difficulty answering within seconds and I have questioned several
thousands over the years. Simple, simple, simple! We know community
sample results and this allows comparisons to be made for individuals.


28.09.05
This week I have met two men in the course of my work, who have prostate
cancer and are being treated with hormone therapy.




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Mister A is seventy-one years of age and was diagnosed over two years ago.
His PSA was 35 ng/ml, he commenced hormone therapy, then underwent
radiotherapy and still receives hormone injections every three months. He
works on the land, feels generally well and has a low but detectable level of
PSA. He has a sense of humour. When I asked him about his sexual
function he said ‘Well, they have put me out with the wethers these days’. For
those without a knowledge of sheep – most male sheep are castrated and
spend quiet lives, as wethers, concentrating on eating grass and growing
wool.

Mister B is eighty-three and was found to have prostate cancer some five
years ago, when he had obstruction of his urinary flow and had a TURP
(transurethral resection of prostate operation). He was told that he would live
with prostate cancer but would not die from it. He is receiving hormone
tablets now, is impotent but not concerned about it and is active for a man of
his age.

Neither of these men complain of significant fatigue.


29.09.05
Remember my experiments with Caverject ® alprostadil or prostaglandin E1?
I had tried 5 microgram injections, then 10, 15 and finally the full 20
micrograms, in an effort to achieve the best erection possible. Even the 5
microgram dose was enough to achieve a more or less usable erection! This
minimal dose enabled me to successfully perform and climax.

Further experiments, injecting 10 and 15 micrograms were really not
significantly more successful and erection barely lasted long enough to have
sex, but yes, I could climax. Finally I tried 20 micrograms of Caverject®,
knowing most men require 10-20 micrograms for success, but was wary of the
risk of priapism, a long lasting painful erection probably requiring a trip to the
hospital! Well, 20 micrograms worked all right for bedtime success after
lunch. My erection lasted a good hour, far more time than I needed and
slowly subsided, but I had significant discomfort for an hour and a half after
this, so a little too much of a good thing. If you are trying this method, try only
5 micrograms for a start and increase the doses stepwise. Perhaps one could
develop a Quality of Sex Index (QOSI). Sadly, nothing is as good as it was,
since the operation, yet!


30.09.05
Why am I so committed to having PSA tests every six weeks? This is
certainly not recommended and I know of no one else who does this. After a
radical prostatectomy, three monthly PSAs are recommended if one has an
undetectable post operative level and is ‘watching and waiting’ to see if there
is a change – for if PSA is detected, salvage radiotherapy is indicated, and
soon-- If it reaches 1.0 ng/ml-- your chance of a five year ‘biochemical’ cure
drops to 30% from more like 80%.



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Stephenson et al (2004) in their paper-- Salvage Radiotherapy for Recurrent
Prostate Cancer After Radical Prostatectomy-- found that patients ‘with a pre-
radiotherapy PSA level of 0.6ng/ml or less, had a better prognosis than those
with a level between 0.61 and 2.0ng/ml (hazard ratio 1.0; 95% C1 1.2-202)
Bonferroni corrected P=.006 or a PSA greater than 2.0ng/ml (hazard ratio
2.8:95% C1 2.0-4.0 Bonferroni corrected P<0.001) when other variables were
considered and when adjusted for multiple hypothesis testing.’ Katz et al
(2003) had suggested that a PSA level of ≤ 0.6ng/ml could be associated with
a better chance of cure with radiotherapy, than higher levels. The longer one
waits once PSA become detectable after a zero level following surgery the
less chance of a cure from salvage radiotherapy. Naturally, I want the best
chance of survival. I believe that these findings are of real importance.


01.10.05
By the way, Stephenson et al (2004) reported that-- (and this is important if
their findings are generalisable to the wider population)-- if one waits post-
operatively until one’s PSA is over 2.0ng/ml, one only has a 21% chance of
being free of progressive cancer after radiotherapy, in four years time. They
add, that less than 50% of men receiving secondary treatment after radical
prostatectomy receive salvage radiotherapy – the others, a majority, receive
hormone treatment, which offers no hope of cure. Some men don’t take PSA
testing seriously, and forget to be tested regularly, dicing with death.


02.10.05
Let us be a bit more cheerful today. It is a beautiful warm spring day. I
finished mowing the lawn. Elizabeth and I had a good walk in the
neighbourhood, admiring all the flowers and of course I am now doing a little
writing before we jump in the Mercedes to go out for J’s farewell luncheon,
held by our department at Petersons Winery. There we shall sit out among
the trees on the lawn, in the shade, and enjoy a little local wine with our
friends, and wish J a pleasant retirement and of course optimal QOL, as she
works in West Africa.


03.10.05
I am keen to detect any evidence of PSA as early as possible by having six
weekly blood tests. However, a single positive reading is not considered
grounds for rushing off to have salvage radiotherapy. Our friends Stephenson
et al (2004) point out that numerous studies have demonstrated better
outcomes with salvage radiotherapy when it is administered at the earliest
evidence of disease progression, that is, when PSA has just begun to
increase above detectable levels. Patients receiving treatment at very low
PSA levels (≤ 0.6ng/ml) had an improved outcome compared with patients
with higher pre-radiotherapy PSA levels. This cannot be emphasised enough,
in my opinion.

Nevertheless the use of very low PSA levels as thresholds for radiotherapy,
risks over- treatment, as these low levels may be due to residual benign


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prostatic tissue. One report found that a single PSA elevation of less than
0.4ng/ml after radical prostatectomy is associated with subsequent stable,
non progressing disease in up to 50% of patients. One should confirm the
rise by repeating the PSA test, and I would consult my therapist before
rushing off to Sydney for radiotherapy. How soon would I repeat the test? I’m
undecided, but it would not be long – even doing frequent tests and graphing
the results doesn’t seem a bad idea – weekly perhaps! Is that so ridiculous?


04.10.05
Let us examine another study also published in 2004, which compared
adjuvant versus salvage radiotherapy policies for post prostatectomy
radiotherapy. Hagan et al (2004) found that biochemical recurrence free
survival (BRFS) – with an undetectable post-operative PSA level – depended
on pre-radiotherapy PSA level, not whether radiotherapy was commenced
routinely post-operatively or for salvage (when a previous zero reading was
succeeded by a rising PSA). For salvage radiotherapy patients (the group I
shall be in if my PSA rises and I have radiotherapy) the BRFS for those with a
PSA before therapy <1ng/ml was 81% five years from the date of
radiotherapy. If PSA was ≥1ng/ml the rate was 31% - a drastic difference. I
conclude that one must have frequent PSA tests.

On these figures, and accepting that someone with a positive margin after
prostatectomy has a 35% chance of no recurrence after 10 years, then if one
develops a detectable PSA and has radiotherapy before the PSA reaches
1ng/ml there is a about an 80% or more chance of a five year BRFS which
equates to 80% x 65 (100-35) = 52 + 35 (the percentage chance of no
recurrence with a positive margin) = 87% BRFS from the date of radiotherapy
– and I am free of disease so far after almost a year from surgery. That
makes one’s chances about the same as if one had adjuvant radiotherapy 3
months after surgery, without a 35% chance of having radiotherapy when
there is no residual cancer!



05.10.05
‘Life wasn’t meant to be easy’, said our then Prime Minister Malcolm Fraser,
and this is true for a man I saw today, who is to have a total hip replacement.
He has looked after his disabled wife for the last five years as his arthritis
worsens. Earlier this year he had a health check and his PSA was 28 ng/ml.
It was possibly not done in 1996 when he had a TUR – he is not sure.
Anyway, he was given two anti-androgen injections prior to radiotherapy after
biopsies proved prostatic cancer. He does not know his Gleason score, but
certainly knows that since his radiotherapy in May finished his PSAs
subsequently have both been 0.10 ng/ml.             Another month after his
radiotherapy finished, he started getting angina, had a stress test, then off he
went to Sydney for a coronary angiogram, a stent and balloon angioplasty.
He is seventy-seven years old and is now about as fit as he is likely to be, for
his hip surgery. Has he any other joint problems? Unfortunately yes!



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At present, his prostate cancer is about the least of his problems and the
radiotherapy program did not cause him problems or worries. He is doing well
in this regard.

06.10.05
On 4.10.05 we considered Hagan’s (2004) paper in regard to percentage
chances of disease free survival over time. Today let us document the
complications from radiotherapy suffered by men in that study.

Of all the men studied, 63% suffered mild diarrhoea and 5% suffered more
diarrhoea--perhaps we should call it moderate (Grade 2). Later on 1%
suffered Grade 2 rectal bleeding. 55% developed dysuria – or pain on
passing urine and 84% had urinary frequency, which was Grade 1. In another
13% it was more severe – Grade 2.Two percent later suffered hematuria or
bleeding from the bladder. 1% of patients who previously had mild urinary
incontinence were worse off. Impotence was not mentioned, but in other
studies, it is reported to be at least unhelpful and likely to increase difficulty
with erections for some. Bleeding from the bladder rarely can be severe –
even requiring cystectomy (the surgical removal of the bladder). For all these
reasons I am keen to avoid radiotherapy, though as all these PSA studies are
in small series, it is hard to be sure of the significance. I am just trying to
balance optimum QOL with long- term survival.


07.10.05
Frazier et al (1993) reported a series of prostatectomy patients with clinically
organ confined prostate cancer who had positive surgical margins and they
had only a 34% freedom from biochemical relapse at 10 years with a local
recurrence of 32%. This is probably typical. Others have found about 35%
free of disease after 10 years. One of the options given to me was to go away
and forget about it. If I suffered a recurrence, presumably with symptoms
such as urinary obstruction or pain, I could then have anti-androgen palliative
care. To me this is denial. Let us consider denial – a completely
unacceptable alternative to me.

Denial is a common defence mechanism, by which people act as if unaware
of something that it would seem they should be aware of. A common coping
style characterising numerous people is the Repressive style. They rely on
denial and repression, denying negative feelings and being unwilling to think
about things very much, repressing feelings and thoughts. They do not want
to admit that anything is wrong. Such individuals are prone to deny
uncomfortable feelings like anger and do not appropriately and consciously
address conflict or physical changes. Unfortunately they may meet an early,
perhaps avoidable, unpleasant death!



08.10.05
On 04.10.05 I detailed Hagan’s (2004) figures for complications/toxicity
following post-prostatectomy radiotherapy. A further search reveals that in


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Zelefsky et al’s (1997) study the risk of genito-urinary toxicity above mild was
5% and bowel complications 9%, two years post-treatment. Choo et al (2002)
claimed there was a ‘minimal’ risk of serious radiotherapy morbidity including
increased impotence, moderate urinary problems (2.7%) and no serious
bowel toxicity. Leibovich et al (2000) quoted figures from other series of up to
14% of mild to moderate bowel or urinary problems. Morris et al (1997)
reported rare and mild complications – an increase in impotence and increase
in incontinence (6.4%) hematuria (12.5%) including one who developed
intractable bleeding from the bladder and had his bladder removed
(cystectomy). This is the picture.


09.10.05
What are the chances of still being alive five years after a radical
prostatectomy with one positive margin, as I have had, whether treated with
follow up radiotherapy or just doing nothing further! In Liebovich et al’s (2000)
series nobody died of prostate cancer within 5 years though a few guys died
of other things, as one would expected in this age group. I note in the series
of Choo et al (2002) one chap died of prostatic metastatic disease in the
untreated (no radiotherapy group) whereas none in the radiotherapy group
died from prostate cancer and about 5% of other causes. Could be worse!


10.10.05
In the almost one year since my radical prostatectomy, there has been some
fine tuning of my future plans, a more intense focus on the attainment of super
or superior QOL and an inevitable confrontation with the reality that one’s
days are numbered on this earth, whether due to prostate cancer or
something else. I have given up Anaesthesia to work as a pain specialist.
There has been progress on my studies of QOL, a growing realisation of the
situation that exists in regard to prostate cancer in our community and an
adjustment precipitated by my surgery. One is even more aware of the
blessing of a happy marriage and close family ties. Friends abound and for
that I am truly grateful and give thanks daily. I know many have prayed for
me and people frequently enquire after my health. No one could wish for
more support. Sadly, there are many men without a partner, family or a
supportive environment. Others there are, with poor health, psychological
problems, with unresolved conflicts and poor access to services, whether due
to geographic isolation or other reasons. It may interest readers to know that I
have surveyed literally thousands of patients in regard to perceived distress,
including financial distress. Hardly a soul has intimated that financial
problems have been a source of distress or limited their access to medical
services. This is not true in all countries.


11.10.05
On 22.09.05 I recounted the story of a man with a rising PSA – now 9ng/ml
who was to learn the results of his biopsies today. Well, I rang him this
evening and there was no evidence of prostate cancer, which is a great relief
to him. He is to have his PSA repeated in the future and a further review. It


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seems so far that his enlarged prostate, for which he is receiving treatment,
accounts for a PSA double the value to be expected as a maximum for his
age. My biopsies were normal too when my PSA was 6!

It is only a few days until l call a halt to my year of recording my thoughts
following my surgery and get another PSA done and a review by my urologist.
My QOL continues to be top-notch, apart from the need to give myself a shot
of prostaglandin to get a really good erection.

Today I finished repainting the last of the barbecue furniture and Andrew and
a couple of his friends arrive tomorrow morning after I have left for work. We
are looking forward to hearing of his overseas experiences.

I hope to find out when the two friends who have been diagnosed with
prostate cancer are to have their radical prostatectomies – soon – they hope.
I mentioned them on 16.09.05 – it can’t be long now!


14.10.05
This morning I interviewed a sixty-four year old man who was diagnosed with
prostate cancer last year. He had a rising PSA, his last two readings being
5.1 and 6.1ng/ml prior to having positive biopsies. The pathologist reported
that his Gleason score was 3 + 2 total 5, which is regarded as a fairly low level
of malignancy. It was considered that he was suitable for Brachytherapy, a
specialised form of radiotherapy/implant treatment. Firstly he underwent
androgen suppression therapy with Zoladex for six months then the treatment
was undertaken under a spinal anaesthetic at a Sydney hospital. He went in,
had his treatment and was discharged the same day. Later he developed
urinary obstruction and required awake catheterisation, but only once.
Brachytherapy was performed in May 2004 and his PSA has varied with
values of 0.26, 1.02, 1.16 and most recently 0.08ng/ml. He is well and has
been told that he has a 10% chance of a recurrence which does not worry him
one iota. He has been a bookmaker and still takes an active interest in
bookmaking. The odds are so much in his favour that he dismisses the risk.

Most interestingly, he has been impotent for over fifteen years and was
already using Caverject® 10 microgram injections to obtain erections before
he had Brachytherapy and nothing has changed – this erection therapy works
satisfactorily for him. He told me that in previous years before Viagra and
other pills were on the market, Caverject® was on the list of drugs one could
get for a nominal sum. Now he pays $15 a shot!

My patient has two brothers who have had radical prostatectomies for cancer
and so far both have no evidence of any recurrence. One must accept that
with such a strong family history the sons of these three men have a very
significant risk of developing prostate cancer too.

Today is the first anniversary of my radical prostatectomy and my PSA level is
reported as 0.01ng/ml – not ‘less than 0.01mg/ml’ – so I spoke to the
laboratory manager and was assured that this is really within the error range


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of this laboratory and that I should not worry about it. It is not likely to be
meaningful. He advised that I should just have my PSA test repeated in 6
weeks and if there is a difference then treat it on its merits. As a natural born
worrier I am only partially reassured. It is always a time of increased anxiety,
waiting for test results – at least for me!

When I reflect on the past year and count my blessings there seem to be
many reasons to rejoice. I went to a good surgeon, had a good anaesthetist,
a good pathologist and if you have to have an operation, St Vincent’s Private
Hospital in Sydney is a good choice, if you belong to a health fund. My post
operative course was smooth, I had no urinary incontinence, walking up and
down the corridor 5km daily after the first 24 hours and started work again
twelve days postoperatively. Of course the big down side was having a
positive margin, with a very significant likelihood of a rising PSA in the coming
years and then radiotherapy will be needed whilst my PSA is ideally less than
0.6ng/ml. In the mean time I have had a year of excellent QOL. Many, many
people have given me support as well as Elizabeth, who of course always
waits on me hand and foot, and my three sons and our grandchildren.

There have been changes. Now I have ceased giving anaesthetics and
increased my pain medicine practice instead, life is more predictable. We
have still travelled a lot, as usual. It is impossible to remember how many
interstate trips we have made, plus trips to Sydney and to the snowfields. Our
annual trip to the Caribbean was enhanced by our time on the catamaran,
sailing and diving, visiting St Martin, Anguilla and St Barthelemy. We loved
returning to our home in Tuscany, then on to Geneva, where I leaned about
cancer therapies, and finally Monaco for a fortnight. On my return to Armidale
at the end of the trip I started work ten minutes after the plane landed, worked
all day and did not go to bed until 11pm, as I had to work the next day. Our
plans to go to Rio and other interesting places next February – March are all
confirmed. Is there a down side? Impotence is it. I have tried most things,
Viagra and Cialis were pretty useless. Another guy and I with post-radical
prostatectomy problems tried using Nitro glycerine patches, - used for angina
– but they were not better really than Viagra, which is still beside our bed –
but I could never achieve orgasm. The erection device certainly works but is
far from natural! Caverject is aesthetically not the best! Who wants to fiddle
around and inject one’s penis with prostaglandin? Only those who need to, I
suppose – and in a few minutes one is ready for action. Not exactly romantic,
like the good old days. As time passes, a lot of things are really not as
exciting, brilliant, stimulating and fulfilling as they were a generation earlier –
so don’t be too unrealistic. Life is just so good – this world is a fantastic place
and I strive to attain a ‘super’ QOL, savouring every moment offered in God’s
creation.

While I was waiting to speak to a GP at her surgery this morning, I was
listening to a recorded message on health which included a suggestion that
one should ask one’s practice doctor for a prostate cancer test. I sense that
more and more doctors are recommending PSA tests. In time there may be a
change in health policy re PSA testing. Colonoscopies are done very
frequently too, for the very good reason that bowel cancer can be detected at


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an early stage and this too may be at some time be done as a routine
procedure. Of course there are risks with colonoscopies and prostatic
biopsies but honestly, I see little evidence that the risks put people off these
procedures!

Further down the track I believe more effective therapy for prostate cancer will
be developed and very frequently we hear of significant scientific advances in
other fields of cancer research, so who knows when a breakthrough will
happen.

When I saw a girl (well she is actually 49 years old) at a clinic the other day, I
was reminded of the importance of personality. Several years ago she had a
left breast biopsy, followed by mastectomy and clearance of all her lymph
glands in her axilla (under her arm). A year of so later, after she had
recovered from her course of radiotherapy, she presented with cancer in her
right breast and had the same procedure carried out. The cancer is hormone
dependent and so she later had both her ovaries removed.

She was subsequently unable to continue with her previous job and she now
works as a “gardener and handyman” as she terms it, at a nursing home. She
loves the work and presented as a happy, vivacious person. Though well
aware of her uncertain future she is not distressed and enjoys her full and
active life, remarking that her QOL is ‘as good as can be’. She is single and
very independent.

I spoke to a friend at a gathering the other day who is about to travel to
Newcastle for his regular injections that keep his prostate cancer under
control. He is 73 years old and has known of his cancer for three years or so.
His PSAs remain low and he is enjoying an active retirement.

Another two friends, both doctors, are awaiting their radical prostatectomy
operations, one on the 24th of this month, and another in four weeks time.
Aren’t they glad that they were screened for prostate cancer in time to have a
good chance of cure. All my other friends and acquaintances who have had
surgery in the last year or so are still doing well – apart from their erectile
dysfunction. After so very many years of waking up in the morning with an
erection and just being able to have sex before my morning shower and going
to work – even after a year of waiting for a return to my former capacity I still
have not really adjusted to it. Sex is possible - sure, with the Caverject®, but
all spontaneity is gone and I still look back, remembering what fantastic times
we have had for the last forty odd years. Still, we lie in bed together for hours
any time we don’t have to get up early, shower together and share so much –
we keep optimistic that one morning I shall wake up with a decent erection
again! The time we spend together is of great importance.

 There was a television coverage of some interesting aspects of distress and
pain, on the ABC Catalyst program of 9th September last year. Researchers
developed a computer game which could provoke feelings of rejection in a
targeted subject and, monitoring brain function, this stimulated an area of the
anterior cingulate – as does physical pain and rather similar feelings result.


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There is another area in the right prefrontal cortex, which can be activated by
socialising and by small amounts of alcohol. This activation affects the
anterior cingulate feelings to modify and reduce the ‘pain’ of rejection with its
emotional distress. Humans, it was suggested, are acutely aware of social
rejection so that personal action can be taken to behave in a more socially
acceptable manner to the tribal community and this has survival value.
Stimulation of the modifying prefrontal cortical region by social interactions
soothes the distressed individual. By inference a close family and marriage
should reduce distress by this process. Interestingly, if one is in a group of
individuals who really are different (the ugly duckling syndrome) then the
irreconcilable differences will tend to cause the outsider to seek out social (or
genetic!) equals.

Among my patients there are those who view the pain of crippling arthritis as
only ‘discomfort’ which has no emotional component. For others with similar
pathology there is pain, suffering and emotional distress. What is the range of
triggering stimuli which can ‘turn on’ the anterior cingulate of the brain? Why
is there such a difference in pain thresholds among individuals any way?
Some people that I have questioned about distress deny that they ever suffer
distress. Negative situations are seemingly addressed very effectively at an
early stage. Perhaps the lady with the breast cancer just mentioned, has this
ability – perhaps we can learn more about this and diminish much suffering. In
the meantime we can aim simply to optimise our QOL and happiness.

As an illustration of how I see people living in happiness with optimum QOL
despite health problems, I shall tell you about a man I saw today. R is my
age and is a retired shearer, about to have a total hip replacement, so I
interviewed him as part of my QOL study. He defined QOL in the following
words “ A comfortable life stye – not to want for too much – three feeds and a
bed. I like to play bowls and enjoy a couple of beers. I’m not a greedy person
– we own our own home. That’s what I want out of life and a bit of social life”.

When asked his definition of Happiness, he replied simply ‘contentment.’
Distress, he said, can be caused by various things – ‘a death in the family –
having a dog put down – undue cruelty to animals or people distresses me.
Personal hardship in life – I have never had any really, apart from back pain
[he had a total of three lumbar laminectomies – after the second he returned
to shearing for four years before further injury and a third failed laminectomy
left him unable to work]. Sheer agony – I couldn’t walk on three occasions.
The thought of having a total hip replacement is not causing me any distress
at all [he has pain and difficulty getting around though] Maybe a bit of
apprehension – what sort of ordeal it is going to be – but I am not unduly
concerned about it.’

Then I showed him the patient generated definitions of QOL (QOL is being
able to do what you want to do, when you want to do it, together with the
satisfaction/happiness that accompanies it) and he agreed with this definition,
commenting ‘I guess that says it all – that’s ideal QOL – not everyone would
be that fortunate.’



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Another patient, for a knee replacement, today defined QOL, as ‘To be able to
do what you want to do when you want to do it,’ basically exactly following the
patient generated definition, but adding “and to try and help other people
when you can and to be a good mum and grandma.’

She defined Happiness as ‘The same.’ I will not continue, or I shall never
complete this book – for I have interviewed nearly 400 patients now. Despite
pain and problems getting around, this lady, a year younger than I, has many
interests, no distress, assess her happiness at 8.5 out of 10 and her QOL as
‘as good as can be.’ Distress to her would be ‘something that you cannot
solve – that plays on your mind.’ She told me that she doesn’t let things get
her down. When she was young she wanted a lot of children and five great
grandchildren! She has achieved her goals.

I see so many patients who have happy lives, with no distress and excellent
QOL despite what other people would regard as serious health problems.
Those for joint replacement surgery are asked about what they do in fine
detail. Almost universally they enjoy what they do, think they do it well or very
well and regard it as important. They typically believe that in fact they are
happier and rate their QOL higher than do the members of the population
surveyed in polls!

My year is up! With no evidence of a recurrence so far and an optimistic
outlook, one can expect no more in my circumstances. I shall see my
surgeon in a week’s time and ask him about any advances in the treatment of
prostate cancer. My QOL study has been very fruitful and I shall complete all
my data gathering before Christmas then set about analysing my files of
interviews and get my thesis writing started. My aim is to fully retire when I
turn seventy on April 5th 2007 and to have my thesis ready for submission by
then.

Already my plans for future travel with Elizabeth are made, including plenty of
time to be spent in the Caribbean, France and of course Italy. We shall have
to work on our French and Italian to get the absolute best QOL in those
countries.
I shall write up any worthwhile information on prostate cancer treatments and
what the future promises when I have seen my surgeon. Somehow, I feel a
reluctance to sign off and say good bye to all you readers out there – keen
enough to stick it out to the end, reading my amateur ramblings on the off
chance of learning a little of interest about radical prostatectomy experiences
from a patient point of view. May God be with you.


                                  POST—SCRIPT

On Friday 21st October, my surgeon told me that he has been using high –
intensity focused ultrasound for the treatment of localised prostate cancer in
selected patients. Radical prostatectomy is still the standard treatment for
patients with organ-confined prostate cancer and a life expectancy exceeding
ten years when their prostate cancer is diagnosed. Some men who would be


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suitable for radical prostatectomy fear that they may end up with significant
urinary incontinence, loss of erectile function or other rarer nasty
complications. Even if death is fairly rare with a radical prostatectomy, it is a
major procedure and naturally, if there is a reasonable alternative then some
men will take the option.

Up until very recently, the options to be considered for such men and others
with a shorter life expectancy, depending on their cancer, were three-
dimensional radiotherapy, Brachytherapy and cryotherapy. The first downside
with all of these is that if treatment fails you have pretty well burnt your
bridges. Salvage radical prostatectomy has a high morbidity rate and these
original treatments cannot be repeated.

When we talk about organ-confined prostate cancer, we really mean localised
prostate cancer in which the cancer is intracapsular, that is, confined to the
prostate within a surrounding capsule or layer of muscle fibres. By definition
there is no extracapsular extension.

Stage 1 cancer (T1) is non palpable, so digital rectal examination is absolutely
normal. If the doctor can palpate any irregularity or nodule in the prostate on
digital rectal examination (DRE) then the tumour is labelled or classified T2.
All this sounds simple, but in my case the tumour was thought to be T2 prior
to surgery but in reality it had penetrated the capsule in one place and a little
‘finger’ of cells had started to spread outside the prostate, though almost
certainly not reaching the adjacent organs. At operation this extracapsular
extension was cut through, possibly right at the far limit of the ‘finger’ of cells,
with the diathermy knife, which may have killed the cancer cells there. Has it
got away, to spread locally or further in my body, as one of more metastases?
There was no invasion of my seminal vesicles or glands. Time will tell. Any
way, back to the story! Once the cancer becomes extracapsular and spreads,
it tends to invade the seminal vesicles, lymph glands and anything in its path.
If a colony of cells is dislodged, as when invading a blood vessel or lymph
gland it may be carried anywhere to grow especially in your skeleton and give
you a nasty surprise later on. Stage 3 cancers have crossed the capsule, like
mine, or reached the seminal vesicles. A Stage 4 cancer has spread further
locally, perhaps into the bladder or rectum. Without a DRE and a PSA this
may be the first time it actually causes any symptoms and causes the man to
seek medical attention.
The tumours we are talking about treatment options for here are those
thought initially to be T1 and T2 cancers.

The first option to radical prostatectomy is external radiotherapy, which
involves treatment for seven or eight weeks, five days per week. Each
treatment with very high energy rays focuses extremely accurately on the
prostate gland, only lasts a few minutes, and does not require an anaesthetic.
Time consuming, but not a risk to ones life, so tolerated by men in poor
general health.

Option two is Brachytherapy, but it is only suitable for certain categories of
malignancy. It requires a spinal or general anaesthetic whilst 50-150


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radioactive seeds are strategically implanted in the prostate, utilising 20-40
needles. It was not considered an option for me.

A third option is cryotherapy, which really just means freezing the cancer cells
to death. It might sound like cold comfort but it requires an anaesthetic and a
day or two in hospital. The prostate is frozen solid under ultrasound
guidance. I think that is enough detail!

Finally, we now have a fourth option called ABLATHERM ®. If you want to
look it up on the internet then run along and type in www.edap-hifu,com. For
the rest of you – and I took this information from the Ablatherm ® booklet;-
The treatment of localised prostate cancer with High Intensity Focused
Ultrasound is a new treatment with many advantages!
•       Destruction of the cancerous tissue with minimal risk of lesions of the
surrounding organs.
•       Absence of irradiation.
•       Short hospital stay.
•       Treatment performed, under spinal anaesthesia in one session.
•       Treatment can be repeated
•       Other therapeutic alternative
•       The treatment can be used for the treatment of local recurrences ie.
after external radiotherapy.
[This is important considering the last three]

When I read this, I really sat up and took a lot of notice. In the last twelve
months, I have been thinking that if my PSA rises, then I will have to go to
Sydney -or somewhere- and undergo radiotherapy, with further follow up PSA
testing. Then if I get a local recurrence following that, I was thinking my
options were pretty limited. In this booklet, it states that this Ablatherm
therapy is recommended for patients with localised cancer of T1 – T2 status
who, because of age, health or inclination are not candidates for
prostatectomy. It is good news that men who have a local recurrence
following surgery or external radiotherapy can also have this treatment. If
anyone with a positive margin at surgery is unfortunate enough to have a local
recurrence this is a possible “salvage” treatment. It is non invasive, a local,
one session treatment, with a low complication rate and if necessary
repeatable. And one still has other options open later. It sounds almost too
good to be true? Well, what do they actually do to you.
Mostly the patient will have a spinal anaesthetic, and first things first, a probe
is placed in the rectum. A beam of high intensity convergent ultrasound is
emitted from the probe. At the focal point of the ultrasound beam there is
created a sudden rise in temperature to 85-100c destroying the cells in the
target area. This zone is about 19 to 24 millimetres high by 2 millimetres in
diameter, of an oval shape. One shot after another is carried out after moving
the focal point between shots until the whole planned target volume is treated.
This may take in some cases the best part of three hours. There you are lying
in the right lateral position, strictly immobilised of course to ensure the beam
is hitting the targeted area and the treatment may involve 400 to 600 shots. I
bet the surgeon is ready for a cup of coffee after that!



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As one might expect, the poor old prostate will swell up straight away and
block off the urethra, so they have to put a temporary urinary catheter in
place. When the swelling (oedema) settles down in some days – up to 8 – the
catheter is removed. All is not as bad as it sounds. From the patient’s point
of view the anaesthetist sets up a ‘drip’ and besides putting in a spinal block
administers sedation whilst the procedure -well- proceeds. There will be an
awakening later and then return to a normal diet is probable later in the day.
One may be discharged from hospital the next day or when the catheter is
removed, usually in a few days. Infection is a real possibility and antibiotics
will probably be given prophylactically. Later, routine urine tests for infection
and regular PSAs are routine. Mild bleeding on passing urine and urinary
stress incontinence are other possibilities. If on follow up in some months, to
have control biopsies to see if there are still signs of any cancer, a chance of
about 10 to 15%, - there is any cancer found, then a second Ablatherm
treatment is carried out. Of course the treatment is not always successful and
PSAs may show a rise despite negative biopsies and spread may have
occurred to other parts of the body.

Okay, there is the scenario – what have actual series of patient treatments
shown? Blana et al (2004) reported on their 5 year results with transrectal
high intensity focused ultrasound (HIFU) in a series of 146 men with biopsy-
proven Stage T1-T2 prostate cancer using the Ablatherm device.

Their patients all had a PSA of less than 15ng/ml and a Gleason score of 7 or
less.    They were all unwilling or unsuitable candidates for radical
prostatectomy. Neo-adjuvant hormone therapy had been given to 63 of them
before treatment – but none received any post treatment cancer therapy.

They ended up with 137 patients with complete follow up and three months
later after therapy their PSAs averaged 0.07ng/ml (range 0-5.67). After a
follow up in an average of 22 months it was 0.15ng/m (range 0-12.11. 87% of
all patients had a PSA level of <1ng.ml.

Suprapubic catheters were removed on average after 12.7 days (range 1-59
days) a bit longer than the Ablatherm brochure indicated. At last follow up
5.8% of men still had low grade urinary incontinence – not more than one pad
per day. Six developed urinary infections and two experienced perineal
discomfort. A TURP or bladder neck incision was required for urinary
obstruction in a lot of men, I think – 11.7% in all. Finally 52.7% of men
suffered postoperative impotence – of those who were potent before. Follow
up is too short yet to make comments on longer term results, but the authors
are optimistic that this is going to be a ‘true alternative for patients who are not
eligible for radical prostatectomy or who do not want to experience the
potential side effects of the operation’. Time will tell! The side effects may
diminish further in time too. The treatment is repeatable and may turn out to
be an effective ‘salvage’ procedure for men with local recurrence.

Finally, there has been a lot of attention paid to the rapidly emerging new field
of immune based therapy. The idea is to attack disease indirectly, by
stimulating the body’s own immune system to attack, traditionally, infectious


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                                A Positive Margin

diseases but also cancers. Glaxo Smith Kline, through GSK Vaccines is
developing therapeutic cancer vaccines – cancer immunotherapeutics.
Transgene, a French company has been getting encouraging results with a
therapy for non small cell lung cancer (NSCLC) with their vaccine MVA-MUCI-
IL2. It co-expresses an antigen and a cytokine, so slowing the progression of
NSCLC and lengthening the duration of remission.

There is a US company, Dendreon, which is developing a vaccine which,
requires manufacture of a vaccine tailored to the individual patient’s own
immune system and their target is prostate cancer. If this therapy proves as
effective as it is hoped it may be another useful technique to fight cancer and
prolong life. Many other teams are working in this area to produce off the
shelf vaccines. Therion Biologic Corporation has had success with a vaccine
for the treatment of advanced pancreatic cancer, which doubled survival time
in a small study and work is continuing. We live in exciting times for cancer
research and already many more patients are living with cancer for prolonged
periods.


 Late October 2005
Whilst I was interviewing a patient today, on the meaning of Distress, she
mentioned her brother’s illness and the distress it has caused. Five months
ago, at the age of 57, her brother presented to his doctor with difficulty
passing urine, which was blood stained. His sister was not aware of the fine
details but was told his PSA was very high and he was diagnosed with
prostate cancer and underwent extensive surgery in Sydney due to his urinary
obstruction from cancer. He was given tablets which reduced his PSA and
three months after his operation he commenced a course of radiotherapy
which is now almost finished. He has lost a lot of weight, she added, and has
not been very well all the time he has been in Sydney but he is looking
forward to coming home. One can imagine this poor man’s distress and that
of his family, relatives and friends. What a pity he had not been having
annual PSAs as part of his preventative health check-ups. He may have had
an earlier diagnosis and potentially curative treatment with a radical
prostatectomy. I don’t like to even think about it.

A week after my doctor friend had his radical prostatectomy operation last
week, he rang me. He had a rising PSA last year and seven biopsy
specimens were taken. Why seven? I don’t know. They were all pronounced
normal. He was told to have more biopsies this year so in September 2005
when his PSA was 5.5ng/mL he had fourteen biopsies taken. Why fourteen?
I don’t know. I had ten the first time and twenty-nine the next. Anyway, three
of his were positive for adenocarcinoma of the prostate and his Gleason score
was 7. He was advised to have a radical prostatectomy and, of course, did so.
Guess what? He did not need a blood transfusion. Nor did I. His cancer had
penetrated the capsule and was cut through at the margin of the specimen i.e.
Prostate – removed. The same as mine, – a single positive margin. And
what did his surgeon advise? ‘Wait and see’ – get three monthly PSAs after
an initial one in a month’s time, and a check with the urologist, two months
later. If the PSA goes down to zero and then starts to rise, he was advised to


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                                 A Positive Margin

start radiotherapy. In other words, his situation is approximately the same as
mine, yet he was not asked to have early radiotherapy, three months after
surgery, nor was he given the option of’ “going away and forgetting about It’
and having hormone suppression therapy if it returned later, in other words,
palliative therapy.

 Maybe, there is a change in advice given over the last twelve months, to men
with one positive margin. Maybe, there is just a variation in advice, that
depends on the whim or opinion or whatever of the patient’s urologist. One
urologist that is well known and a friend of mine told me to just go away and
forget about it when I had my prostatectomy with a positive margin. I feel
vindicated in my decision to just watch and wait carefully. My surgeon has
actually told me not to have my PSAs done every six weeks as I do but of
course I shall continue to do so, being an independent spirit. My other doctor
friend, who is to have his prostatectomy soon, has been told that there is a
50% chance of him needing a blood transfusion, that the operation will take 4-
6 hours and that he will have an epidural block, for two days after surgery. I
checked with other friends who have gone to the same surgeon and
anaesthetist and they tell me that this was their experience and advice. The
other guy mentioned, had his surgery in a large private hospital in Sydney
under general anaesthetic without a block and no transfusion. It varies from
place to place and surgeon and anaesthetist.

 The doctor who had his operation in Sydney is fifteen days younger than I,
and is a Radiologist. A group of us, who have all had our prostatectomy
within the last few years and have known each other for many years are
thinking about forming a mutual support group – to meet, have a dinner or a
few drinks and discuss our experiences and any concerns – most are doctors
or academics – retired professors, pathologists, scientists and so on – and so
all ring each other up when we feel like it, already – why not formalise it a bit
more – we all have a similar outlook and benefit from our communications.
Other men may join us for there is probably some potential to extend our
network. Only yesterday I was told of a man who lives locally and is now
receiving treatment for his bony secondary cancer – a friend of one of our little
group. Knowledge is power and we help each other.

I now face my second year since radical prostatectomy with a fair degree of
optimism that I shall be a long term survivor, maybe with no recurrence ever,
but more likely with a course of radiotherapy following detection of PSA on
regular blood testing. The longer I go without a problem, the greater the
chance that one or other developments, now in the pipeline, will come to
fruition and prove effective in prostate cancer therapy for the countless
thousands of men who will need further treatment. I do not regret my decision
to turn down the offer of early radiotherapy following surgery. I have not
risked the complications of radiotherapy, which can very much affect one’s
QOL and believe if the need for it arises, my prognosis will be comparable to
those opting for it 3 months after surgery with a positive margin indication.

QOL is so important that men should spend significant time and effort to
maintain their health with regular exercise, sensible dieting, check ups with


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                                 Dr G B H Lewis
                                A Positive Margin

their doctors and in my opinion have regular annual PSAs and five yearly,
colonoscopies unless indicated more frequently.     Early diagnosis and
treatment of prostate cancer and bowel cancer can thereby be expected. I
assure you that they are not a good way to die.

 Yesterday I interviewed a sixty one year old man who is to have a total hip
replacement. His wife was present. He and his wife both smoke 30
cigarettes daily. Besides the effect of this on their health, it costs them nine
thousand dollars annually in cash. They have often thought of having a trip
around the world, but don’t have the money! Surprise! Surprise! I spent
some time counselling them and they agreed to have a pact to stop and put
$13 each per day into a large jar, towards their desired trip and support each
other in their goal. A lot of Australians have given up smoking yet lung cancer
still kills more men than prostate cancer and the great majority of victims are
smokers, I wish them well in their endeavour. From the 28th August 1953 until
20th June 1965 I was a smoker – even up to 50 cigarettes/day when I was
working double shifts as a cab driver. It was really enjoyable too, but I wonder
whether I would still be alive, if I had continued.

Life is just so unbelievably good that it is worth taking time to look after
yourself – which reminds me of the story of the old man at his 100th birthday
celebration saying ‘If I knew I was going to live so long – I would have looked
after myself better.’

PSALM 150
 1 Praise the Lord.

                          Praise God in his sanctuary;
                       praise him in his mighty heavens.
                      2 Praise him for his acts of power;
                   praise him for his surpassing greatness.
                3 Praise him with the sounding of the trumpet,
                       praise him with the harp and lyre,
                  4 praise him with tambourine and dancing,
                     praise him with the strings and flute,
                    5 praise him with the clash of cymbals,
                     praise him with resounding cymbals.
                        6 Let everything that has breath
                                praise the Lord.

                               Praise the Lord.

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London.



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                               A Positive Margin

ARISTOTLE (384—322 BCE) Ethica Nichomachea (translated by R.Crisp
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FRAZIER, R, ROBERTSON, J., HUMPHRIES, P. et al, 1998. Is Prostate
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