The Ides of March Judgment Day #10 - March 15, 2012

Julius Caesar's bloody assassination on March 15, 44 B.C., forever marked March 15, or the Ides of March, as a day of infamy. And the character of the Soothsayer created by William Shakespeare for his play Julius Caesar has given English-speakers a famous line:

CAESAR Who is it in the press that calls on me? I hear a tongue, shriller than all the music, Cry 'Caesar!' Speak; Caesar is turn'd to hear.  
Soothsayer Beware the ides of March. 
CAESAR What man is that?  
BRUTUS A soothsayer bids you beware the ides of March.  
CAESAR Set him before me; let me see his face.  
CASSIUS Fellow, come from the throng; look upon Caesar.  
CAESAR What say'st thou to me now? speak once again.  
Soothsayer Beware the ides of March.  
CAESAR He is a dreamer; let us leave him: pass.

While Shakespeare's Caesar was ill-advised to ignore the Soothsayer's advice, I fared well today.  Although the day retains a certain air of destiny that seemed appropriate when I scheduled my cystoscopy six months ago.  Flirting with danger?  Hardly. The news was all good - ALL CLEAR now marking over 45 months cancer free! 

Many of you have sent notes of encouragement, well-wishes, reports of prayers and  other helpful things, and I thank you all for them.  For some reason I had less trepidation this time than in the past - perhaps the success of diet and improvement in various blood test variables has re-enforced my belief that I am doing all I can to stay cancer free.  That coupled with the ever-present and simple fact that GOD IS GOOD, ALL THE TIME!

Most of our small "fraternity" here have had similarly good results, so the pressure was on for me to continue the trend.  I was happy to continue it.  We arrived ten minutes before the appointed 9AM time-frame, did the paperwork, urine sample, etc. and were shown to the exam room.  I was pleased to see the Storz scope stationed there, a much nicer instrument that had produced no side effects from the exam last time.   I had taken the liberty to call in advance to try to negotiate, persuade, incentivize, bribe, or whatever to make sure this happened.  I even metaphorically twisted the arm of Gloria, our favorite medical assistant, to make it happen.  On all fronts I was assured of two things:

1) All three scopes (optical, low-def video, and high-def video) are exactly the same diameter, and
2) The assignment of scopes to exam rooms is purely random and not subject to my influence

So call it coincidence, karma, destiny, fate, or providence - whatever.  The scope was there.  Only one thing differed.  Last time they had given me a Lidocaine prep, an unpleasant extra that I declined for BCGs in the past.  This time there was none.  I decided to go with the setup as presented to serve as a new data point for all.  Was it the scope or the Lidocaine that made the difference last time.  While there was some discomfort, it was still less than either of the other two scopes, and certainly less than experienced initially when the Lidocaine prep is applied.  So I do prefer to do without the prep, and the Storz scope is still better for me than the other two.  Could it all be in my mind, or a more flexible probe, or some other factor?  All I can rule out was the video quality, since I could hardly see the monitor at all due to its strange angle today.

The Doctor was pleasant, quick, and efficient and the entire exam from when he entered the room until he left was less than 5 minutes.  Good news on all fronts.  Return as planned in September for another scope to be followed by 3 more BCGs, at which point the scope inspections move to annually.


Having the good news assimilated, and after cleanup and re-dressing, we scheduled the September events and received a prophylactic dosage of antibiotic (Cipro) to ward off anything incidentally induced by the procedure. The next order of business was to celebrate the good news.  With somewhat less trepidation, there was less stress-relief exhaustion and perhaps a tad of euphoria.  My wife suggested an Irish jig, but I need to lose a few more pounds before subjecting the world to that!  And we were hungry - as I chose to skip breakfast (my usual practice) to avoid giving my stomach any reason for upset prior to or during the procedure.  Temptation was to go have a celebratory breakfast, but my diet dictates strict limits on what is eaten until Saturday.  So we had a high protein breakfast and returned home for a day of March Madness basketball.  We will have some cookies and other goodies plus Italian food for dinner on Saturday. Maybe even some green beer, corned beef, and cabbage.  It will certainly be a happy St. Patrick's Day here.  As for today, red wine is allowed, so we indulged in a bottle of EIEIO Pinot Noir.  It was fantastic!

Bladder Cancer WAY South of the Equator! - March 3, 2012

In a few previous posts I have mentioned "El Caligrafo" which may be translated "The Calligrapher," or perhaps more accurately "The Scribbler."  Despite the appearances he is not actually Batman's latest Latin nemesis, but rather a really great fellow named Sebastián B. from Argentina. His nickname comes from his hobby as an amateur writer of fiction.  He and I have a lot in common: married (over 20 years), no children, loves dogs, loves travel, works in engineering (civil), has a great sense of humor, and bladder cancer.  His wife, Marisa, is also an engineer (systems).  He also used to refer to himself as Oldman, but at only 45 he is a bit younger than me, so there will be no further reference to that!

Sebastián and Marisa live in Rosario, the second largest city in Argentina with over a million population, located about 300km (188 miles) from the capital city of Buenos Aires.  He sent me a few official photos of the city:

They are in the middle of summer now in the Southern Hemisphere, and the family has just completed a nice Carnival holiday at nearby Victoria.  Even their dog, Chiche was able to go with them.  According to Sebastián, Chiche (pictured below) is "not precisely a Rottweiler," and he loves to ride in the car!

The protocol for bladder cancer treatment in Argentina is quite similar to the US standard of care.  Diagnosis with urine test, ultrasound, x-ray, and cystoscopy, then TURBT surgery (one or more), and then BCG treatments with cystoscopy inspection for life.  One difference is that routine bladder biopsies are performed after BCG - 15 samples!  Sebastián initially contacted me with a few suggestions.  He has independently adopted a similar attitude to mine regarding diet and lifestyle changes.  Sebastian's diet is covered in this post.  Another suggestion concerned relaxation before scopes and other procedures.  Sebastián has found daily, low-dose (75mg) pregabalin (sold in the US under the brand name Lyrica) to be quite effective in taking the "edge" off pre-procedure anxiety.  He has found no side-effects, drowsiness, or difficulty concentrating,and he offers this following item from Medscape Medical News as support:

Pregabalin Safe, Effective in Generalized Anxiety Disorder 
Laurie Barclay, MD March 7, 2003

Pregabalin was safe and effective in treating generalized anxiety disorder, according to the results of a placebo-controlled trial reported in the March issue of the American Journal of Psychiatry. This drug was almost as effective as benzodiazepines without withdrawal symptoms, making it a potentially good alternative. It may also be beneficial in a number of other neuropsychiatric disorders. "Recent attempts to develop nonbenzodiazepine anxiolytic agents with novel mechanisms have been mostly unsuccessful," write Atul C. Pande, MD, FRCPC, from Pfizer Global Research and Development at Ann Arbor Laboratories in Michigan, and colleagues. "One novel agent, pregabalin, a structural analogue of gamma-aminobutyric acid (GABA), is currently in development as an anxiolytic on the basis of its profile of pharmacologic activity in animal behavioral models." In this double-blind study, 276 patients meeting DSM-IV criteria for generalized anxiety disorder were randomized to treatment with pregabalin (150 mg/day or 600 mg/day), lorazepam (6 mg/day), or placebo. Some subjects had mild depressive symptoms, but patients with other comorbid psychiatric disorders were excluded. After a one-week placebo lead-in, subjects received four weeks of treatment followed by a one-week dose taper. Mean decreases in total Hamilton anxiety scale score from baseline to endpoint for each group were –9.2 for pregabalin 150 mg/day, –10.3 for pregabalin 600 mg/day, and –12.0 for lorazepam, which were significantly greater than –6.8 for placebo. Pregabalin's effect on the total Hamilton anxiety scale score began as early as week 1. Compared with the other groups, fewer patients in the lorazepam group completed the trial (59% vs. 73% for placebo, 71% for 600 mg/day pregabalin, and 90% for 150 mg/day pregabalin.) Somnolence and dizziness were the most frequent adverse events reported for pregabalin and lorazepam. No patients receiving pregabalin reported serious adverse events or had evidence of withdrawal syndrome. "These results indicate that pregabalin is an effective, rapidly acting, and safe treatment for generalized anxiety disorder," the authors write. "In short-term treatment, pregabalin does not appear to have the withdrawal symptoms associated with the benzodiazepines.... Pregabalin is also currently under study for treatment of seizure disorders and neuropathic pain [and it] may have activity in several nervous system disorders other than anxiety." 

Am J Psych. 2003;2160:533-540 Reviewed by Gary D. Vogin, MD 

 I have not tried it, as I tend to be on-edge pretty much all the time, so for me the pre-procedure times are simply a matter of degree.  Ever the creative optimist, Sebastián suggests a slightly more complex alternative which I can wholeheartedly endorse, involving a tropical island, beach, good weather, and perhaps some ethanol.  The photo below shows Sebastián demonstrating this alternate relaxation technique:

Sebastián has also had some benefit from adding ultrasound checks between cystoscopy, just to add peace of mind.  I shared that ultrasound had not detected anything in my case, but perhaps it cannot hurt to check.  On the other hand, about 3 months after cystoscopy and biopsies came back all clear, Sebastián went in for a precautionary ultrasound that detected a large (8mm) spherical intrusion into the bladder.  Look at the center right side of each photo below - this thing looks huge!

Rather than adding peace of mind, the effect was opposite.  Can you imagine the growth rate of something that size forming after only 3 months?   The doctors told him it could be a "blister," a harmless byproduct of the biopsies, or it could be a tumor.  A TURBT was scheduled for the day after Christmas last year.  On January 3 he got the good news.  The "tumor" was an inflammation of the bladder wall caused by the previous TUR surgery and biopsy.  Supposedly a rare phenomenon, it is completely benign.  God is indeed good, ALL THE TIME.  Sebastián wanted me to post the details here so that others may know that not everything detected after surgery is a problem.

Other advice from Sebastián concerns post-TURBT recovery.  Super-hydration (4+ litres/day), avoid spicy foods or other dietary irritants (citrus and other things high in vitamin C), and chamomile tea.

I want to thank Sebastián and Marisa for sharing his information with us all, and I hope that he can remain cancer-free.  Perhaps we can meet on some tropical island some time to practice our relaxation techniques!