Prostate Cancer – Early Detection Keeps You Flying

    By John D. Hastings, M.D.

    Sport Aviation, December 1997

    In the late summer of 1996, my airplane passed its annual without a hitch. My mechanic found only the normal changes of aging along with a few minor items. In September, I was up for my annual, and since I had no squawks, I wasn't concerned.

    My exam was O.K. including the DRE (this stands for digital rectal examination - the words speak for themselves). I had some blood work done and left for a meeting. When I called home a day or two later my wife told me my PSA was elevated. PSA stands for prostatic specific antigen. This enzyme, produced by the prostate and normally present in the blood in small amounts, can become elevated in abnormal prostate conditions.

    Upon returning home, I visited a urologist who discerned "a little fullness" on one side of the prostate, but no nodules. He reassured me that at age 56 the chance of a cancer was only 20%. I then had an ultrasound guided biopsy. This was not a difficult or painful procedure, and I returned to seeing office patients twenty minutes later. My major problem was worry.

    When my biopsy report was positive for cancer, I readily admit that I was downright afraid. Though I am a physician, my specialty of neurology left me with no great knowledge of prostate cancer. I spent the next two weeks reading all the literature I could about prostate cancer. I found a book for layman called "The Prostate," by Walsh and Worthington, to be most helpful. Patrick Walsh is a urologist from Johns Hopkins who pioneered a nerve-sparing surgical procedure for the prostate, markedly lessening the complication rate. His book is excellent and readily available in bookstores. My urologist advised radical prostate surgery (a frightening term) and discussed all the possible outcomes and complications. The most worrisome complications are loss of bladder control and impaired or lost potency. With fear and uncertainty I decided to have surgery.

    My surgery in late October went well and I was home within three days. The surgery is major and I can state emphatically that I didn't like it, but I recovered well. The tumor had not spread beyond the prostate. I was pretty sore and "tied down" for two weeks, but then improved rapidly. While home recuperating I learned of Arnold Palmer's diagnosis of prostate cancer. Thankfully, I had no complications and was able to return to part-time work four weeks after surgery. Though grounded by my illness, I was able to fly to an aviation meeting in Dallas 39 days after surgery (my CFI son was pilot-in-command).

    My next step was to regain medical certification. The FAA wanted documentation that I had recovered from the surgery and a note from my urologist releasing me for normal activity. I was told a minimum of six weeks after surgery should pass before I would be considered. They asked for copies of history and physical, operative report, pathology report, and discharge summary from the hospital. They wanted to know if the tumor was confined to the gland or had spread. I was told that hormone therapy would not present a problem, but certification would not be granted during radiation therapy. Fortunately, I needed no treatment after surgery.

    I submitted all the documents to the FAA in December. On January 20, I received a special issuance third class airman medical certificate with the requirement of annual urologic reports and PSA determinations. My wife and I were able to fly south in late January to visit her brother. We had beautiful winter tailwinds. It had been 82 days since surgery, and it felt great to be flying again.

    I tell this tale to heighten awareness of prostate cancer and its frequency. Arnold Palmer has done the same. Within three months, two of my colleagues had the same diagnosis and have gone to surgery.

    The frequency of breast cancer in women is well publicized, but it is not generally appreciated that prostate cancer occurs with equal frequency in men. In 1994, about 20,000 men were diagnosed with prostate cancer, making it the second most common cancer in males. Dr. Walsh notes that a boy born today has a 13% chance of developing prostate cancer. Under 1% is diagnosed below age 50, and only 16% are diagnosed at age 65 or beyond, and the average age at diagnosis is 72. Thirteen percent (about one in eight) of males are eventually afflicted with clinically significant prostate cancer.

    Why all the fuss about prostate cancer if we can't prevent it? In earlier times, prostate cancer was discovered quite late, often after it had spread to bone and caused pain. Pain relief and slowing of tumor growth could be offered, but a cure was not possible. The diagnostic tools of digital rectal examination, PSA determinations, and prostate ultrasound have allowed for much earlier detection of prostate cancer, before it spreads beyond the gland. Ultrasound guided biopsy with a small spring loaded needle (not bad at all) also aids early diagnosis.

    With early detection prostrate cancer can be cured. If the tumor is confined to the gland and has not spread beyond the capsule to adjacent structures or to nearby lymph nodes there is a good chance of cure with surgery. In older age groups, surgery may not be needed because of slow growth of the tumor and the ability to treat with radiation and hormonal measures. Depending upon features such as grade of tumor and degree of spread, the chance of being free of disease 15 years after diagnosis can be as high as 85%. I, of course, want to be in this group.

    So what should you do? At age 50 or thereabouts, the DRE and PSA should be made part of your annual and kept in your medical logbook (the rate of change in PSA, called PSA velocity, is important also). The American Cancer Society recommends an annual PSA beyond age 50 (beyond age 40 in African-American males and those with a family history of prostate cancer).

    It is important to know what information the FAA requires and to gather the complete package for them. This will lead to early recertification. Misinformation can result in lengthy delays. At a recurrent flight training course in March, I spoke with a flight instructor who was erroneously told he would have to wait one year after an operation for benign prostate enlargement. He could not believe I was flying within 90 days of a cancer operation. Your EAA Pilot Advocate Program can help by giving you the proper scoop. They can help you assemble your file and guide it through FAA pathways. If you have a medical problem, call them. They are dedicated to help you avoid a holding pattern.

    Since surgery, I can't detect any decline in my flying skills. The left seat is just as comfortable. My ability to track outbound on an ADF bearing is no better. The prostate has been deleted from my minimum equipment list. There is no change in CG but I did gain about 30 grams of useful load. I think I can jog a little faster, but that's a subjective impression. I have offered my urologist an airplane ride. You can fly without your prostate.

    (Dr. John D. Hastings, EAA 451228, Tulsa, OK is a member of the EAA Aeromedical Council.)

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