14 Years Cancer Free - New Procedures - June 25, 2022

New country, new doctor, new protocol, new (to me) procedures, same old VERY GOOD result - ALL CLEAR now 14 years and counting!  This all happened a couple of weeks ago, and the process was unusual and anticlimactic and did not really feel "real" at the time. But now it does, and I'm pleased to have something unusual to report.

From my last post you will have learned that we decided to retire and have now relocated permanently to Bodrum, Türkiye. That makes chasing Dr. Hopkins (who has moved back to Salt Lake City from Oregon) a bit more expensive and troublesome. Medical and dental care in Türkiye are world class. It is the number one international medical tourism for male hair implants, top 5 for elective cosmetic surgeries, and top 10 for dentistry - the latter being very popular for folks from the UK, who vacation here often. We live in the cosmopolitan area of Bodrum with an enormous summer tourist presence and a very strong year-round international presence, so the demand for excellent healthcare (and other consumer items) is supplied in surplus by enterprising Turkish and international businesses. 

The best all-round healthcare center in the area is Acibadem (pronounced Ah Jee BAH dem).  It is a combination hospital and medical center about 25 minutes from our villa. We had visited there last year for a nuisance inner ear problem my wife had and were treated very well. Based on that and some communication with a couple of Turkish urologists in other cities, I decided to just go for it and schedule an exam and cysto. Of course you can only schedule the exam - the doctor decides about ordering the cystoscopy.  So in I went on Friday afternoon. I was met in the lobby by Becky, the head of international patient relations, who escorted me to Urology, translated for me to the check-in personnel, and then 30 seconds later we were ushered to the doctor's private office.  Becky introduced me to Dr. Mirze Bayandir, and explained that he could read and understand written English, but not conversations, and she remained with us throughout to translate both ways.

I should mention in passing that the facility here is an architectural marvel - stunning, open, airy, and radiating an air of cleanliness, modernity, and professionalism that ALMOST convinces you that you aren't in a medical facility. While we thankfully have not had the occasion to see for ourselves, we've been told the hospital rooms resemble Ritz-Carlton rooms much more than they look like American hospital rooms. Based on the exterior and interior spaces I have seen, I tend to believe it.

Dr. Mirze (in Turkey the docs go by first names) was very interested in the history and documentation I had brought with me, all in English. We started with the date of diagnosis and staging, and he expressed deep concern at the grade of my cancer (T1G3).  He asked about follow-up BCG, and I told him first about the Mytomycin chemo-bake following my second TURBT, which he understood. Then I gave him a copy of my spreadsheet that showed every exam, DRE, CT-Scan, and BCG series for the past 13 years. He asked several questions about BCG and was surprised that I had consulted with Dr. Lamm himself.  I also gave him the summary of my CT scan last year, 10 years of blood work history, and some recent weight and blood pressure data. He was pleased to have all of it, and even more pleased that I had made copies he could keep.  He asked (via Becky) if my PSA values were Total PSA or Free PSA, and was surprised they were Total.  I added they are low, and he agreed VERY low. After perusing everything in depth, he said something very excitedly to Becky and showed her a paperback large-format book, all in Turkish.  Becky explained, "Dr. Mirze is extremely impressed with the history and level of care your case has been given. He described it as extraordinary, and he also wanted you to know that he is both and expert and advocate of maintenance BCG. The book he showed us was his Doctoral thesis on BCG treatments."  I mentioned also the Mytomycin bake, and he agreed, saying it was his standard protocol.  

Becky went on to explain that in Türkiye, after 10 years cancer free, the standard of care for bladder cancer is not cystoscopy, but rather urine cytology, blood tests (including PSA), and ultrasound of the bladder and kidneys. But he would gladly do a cysto if I wanted.  Since I had been conditioned to annual cysto for life, I felt like I should, so he scheduled it for Monday morning, ordered urine and blood tests,  Then behind a curtain for a quick physical poke around, after which we all went to a side room for the ultrasound.  It was just like a pre-natal ultrasound, with messy goop on each kidney and over the bladder, the doc pressing the ultrasound probe and moving it around, all while looking at a big screen with nothing evident to me except blobs in shades of black, grey, and white.  The doc asked a question which Becky translated, "Have you ever had prostate surgery?" and seemed surprised (and disbelieving) my NO answer.  He remarked that my prostate was extremely small for someone of my age.  I told him I was happy to have that situation. Finally the doc told Becky he saw nothing on the ultrasounds, and if blood and urine tests were clear, I was good to go.  But no harm in doing cysto on Monday. 

Cooler than Sickbay on Starship Enterprise!

Becky and I went back to the Urology check-in and she asked them to prepare my bill. The good news is that we are now permanent residents of Türkiye, and therefore entitled to a substantial discount - last year we were "tourists" and paid full retail - still well below USA pricing.  Becky had told me in advance that the doctor's exam (including ultrasound) would be US$55, and I was a bit surprised that the labs were US$140 more - still the total bill was under $200 with no insurance at all. The only downside was that Acibadem's payment processor detected my foreign credit card and auto-converted the bill to US$ at a very poor rate, adding about 12% to the bill, while my credit company would have converted at spot rate with no fees if they had just charged in local currency.  Lesson learned - next time I will put the cash in the bank and use a Turkish card at Acibadem.  Lastly I asked Becky to check on the cost of the cystoscopy, and she said she would give me a call after checking.  

Then she sent me on my own to the lab to have blood drawn and urine collected, which went very smoothly, after which I was free to go, and so I departed to my car. On the drive back home Becky did call and told me the cysto would cost just over US$3000.  Shocked, I told her to cancel it. She was surprised and asked how much it was in the US. I explained that it was probably more, but that after insurance I paid around US$1000.  She said she would double check with the doctor.  A few minutes later she called to let me know that the $3k price was given to her by the admin department for a full operating room, general anesthesia, an anesthesiologist, surgical intern, both hard and flexible cystoscopy, and ability to do biopsies.  But as the doc told her I needed only a flexible scope, most of that did not apply - but it would still be done in the surgical theater, and the real price would be around US$1300.

By this time I had already decided the doc's exam was good enough, and I was cancer free, and so spending as much as I would in the US or more seemed like a waste of vacationing money. And let's face it - once you decide NOT to do a scope, it's really hard to reverse that decision. I told her to cancel anyway and thanked he for her help. She was quite surprised, but accepted my decision.  If the price had come in at the $300-$600 I had expected, I probably would have done it. But now I think I can accept going to every second year for cysto, and that gives me time to see if alternative providers can do cystos in the office rather than in a surgical theater, perhaps bringing the cost way down.  

Upon arriving home, I was a bit surprised to see my blood work and urine cytology reports, along with the doctor's full report, were live online for me to see and download - all in English. And the urine culture results arrived 24 hours later. All results were negative or within limits, and PSA still below 1.0.  Good news all around. But the bottom line is my logic told me all was good and I am Cancer Free, but not having the experience of SEEING it real-time in living color on a big TV made the entire thing anticlimactic. Now 2 weeks later it feels more real, and I guess I can live without the excitement. Life is good, God is good, and I am super happy with this year's adventure.