The Road Not Taken

On the way to work Wednesday morning, I had my car stereo set on “play all.” That is a random play function like the iTunes DJ; the system picks tracks off the hard disk in random order. It began to play “Dragons are Too Seldom,” a song written by my friend William Weinacht about loss of childhood innocence. As I turned the lyrics over in my mind it made me think about a Longfellow poem I had set to music back before Linda and I married. Since Longfellow and so many other poets from that era were New Englanders, that made me think about my old navy buddy, David Woodman — Woody. He was from Bristol, New Hampshire near Laconia and Lake Winnipesaukee.

Funny how memory works. It is a lot like those demonstrations using dominoes that you see on TV. They set them all up and then knock over the first and it knocks over the second, and so forth. Fancy trails are made out of the dominoes as they fall one by one. Beautiful patterns are produced as the dominoes cascade into each other and appear to walk across the room. That is what happened to me. I thought about cold and snow — it has been below freezing here all week — and the fireside poets of New England, so named because they often included fires in their poems. Longfellow is such a poet as are Lowell, Whittier, Bryant and Holmes. Oddly, they are not held in as great esteem as other American poets such as Robert Frost or Edgar Allen Poe. I had set Longfellow’s “Fire of Driftwood” to music long ago, and it always makes me think of Linda’s brother, Chuck, and the times we would play guitar and sing before the fireplace in our house on Sherman street.

Ah…, Frost, “Stopping by the Woods on a Snowy Evening.” That poem popped into my head. It was a snowy Wednesday morning rather than evening, still that is how the dominoes fell. And then I thought of “The Road Not Taken.” Nothing to do with snow; nothing to do with fireplaces; it is a poem about decisions. That idea took root in my conscious and this essay is the result.

I’ve made some important decisions lately and there are more to be made. Of course, life is about decisions, some big some small. I often ponder how I reached this point in my life and trace back the key decisions that led me down one path or another. That is why Frost’s poem has always resonated with me. Lately the decisions have been big ones.

In May I was diagnosed with prostate cancer. The results of a blood test had shown my prostate specific antigen (PSA) had increased so a biopsy of my prostate was performed in the doctor’s office. The tiny needles found that 60-70% of my prostate on both sides was cancerous.

With prostate cancer, there are several courses of treatment to choose from. You can select surgery and have the prostate removed. There are different types such as open surgery or laparoscopic or robotic. There are radiation treatments including external beam and brachytherapy using radioactive seeds. There are also chemical and hormonal treatments or a non-treatment called “watchful waiting.” There are other new and experimental methods too that involve freezing the prostate.

After considering the decision carefully, doing a lot of internet information review, talking to my insurance company, and seeking several doctors’ opinions, I was ready to decide. I even met with Chuck’s doctor and family friend in Alaska to get a general opinion of proposed treatments. When you ask a specialist such as a surgeon for an opinion, it will often be “to have the surgery.” That is why I sought out advice from other area specialist and generalists and spoke with many patients who had gone through the process I decided to have the surgery using the new daVinci robot. This is a procedure done through several small incisions in the belly. The doctor sits at the machine viewing through a stereo TV camera inserted into one of the incisions. He uses “waldos” which are hand manipulation devices to remotely control the miniature tools inserted into other incisions and removes your prostate.

An advantage of using the robot is the quick recovery since there is very little blood loss and the incisions are all less than one inch except for a single two inch cut. There are always dangers with surgery ranging from infection and reaction to anesthesia to very serious problems with blood loss or blood clots. There are also several nasty side-effects including loss of continence and loss of sexual function. One big advantage of surgery is that, if the cancer does reappear later (indicated by the continuing PSA blood tests), then you can do follow up treatment with radiation. If you do radiation first, you can’t do surgery later.

In Frost’s poem “The Road Not Taken,” the dilemma is less dramatic.

Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth

A simple decision, which road to take? The poet peers down one road as far as he can see until it disappears around a bend. Being one traveler, he can’t send out scouts to track both trails. That might have been what Lewis and Clark would have done when exploring the great American Northwest. Again, not so serious a decision in this case, still the poet takes the time to consider the choices.

So I chose the surgery. I sought out one of the best surgeons in Colorado. Some recommended a visit to Mayo Clinic or even better would be the university hospital in Cleveland, Ohio, home of the greatest expertise in Urology and Prostate surgery. I consulted with a professor at University of California. He is a leading expert on the robot surgery and charged $500 for a 30 minute telephone consultation. I ended up following the advice of my family doctor and my urologist to have the surgery done locally. This was both because it is a common procedure, and you can recover locally and that simplifies post operative treatment.

I chose a doctor with the large Urology Center of the Rockies based in Ft. Collins and had the operation at the new Medical Center of the Rockies located near Loveland. One factor in my decision was that this doctor and his assistant had done hundreds of these procedures with the robot and that experience is key to success.

MCR is a modern facility with wonderful staff, and I was home the day after the surgery and recovering quickly. Although the daVinci Robot is new technology, over 2,000 operations using it have been performed at MCR, so they were experienced. There was so little pain I was quite amazed at how quickly I recovered. I did not take any strong pain pills at all after the surgery. They gave me a spinal block prior to the surgery similar to what women get when delivering a baby, and afterword I only took simple aspirin like pain relievers for a few days. It was really amazing how little pain there was.

However, I was pretty uncomfortable for a while with a catheter and had to sleep on my back all night long. I got the catheter removed at ten days, and things got a lot better after that. I did not suffer the loss of continence, and for that I’m very grateful.

I made my decision, and it seemed that it was the right decision. At least things went well so far.

Then took the other, as just as fair
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that, the passing there
Had worn them really about the same,

So the poet decides to take the road less traveled, hence the way most people remember this poem. However, this poem can be misleading. Robert Frost himself stated, "You have to be careful of that one; it's a tricky poem — very tricky." Yes, the poet says the path he took was grassy and not worn, yet he says at the end of the stanza that, really, both were worn about the same. It is not the road less traveled, it is simply the road taken — a choice.

It was not an easy decision for me. I have over half a dozen friends that were in the same situation. Two old friends from the navy have recently had prostate surgery, the father of another friend chose surgery some five years ago, and I know two people at work, one who went with the surgery and one who had the radioactive seeds implanted in the prostate. There are different paths to choose.

Prostate cancer is the most common cancer in men with about one in seven affected. Doctors say that, if we lived long enough, all men would develop prostate cancer. Fortunately it is a slow growing cancer with effective cures, and, if discovered in a person in their seventies or eighties, it is possible that no treatment or “watchful waiting” would be the recommended path.

I chose the surgery since I was healthy and able to withstand the assault on my body and it seemed the choice with the best outcome. Key was the fact that you held in reserve radiation treatments in case of a recurrence. The trouble is that you don’t have a crystal ball to gaze into the future and determine the result. A nasty side effect that occurs in only 5% of all patients is a 100% probability if it happens to you. The odds can guide the decision, but they don’t guarantee the outcome.

That is something I understood clearly. My current job is to analyze data statistically and predict outcomes and identify trends. So I know how to do the math, and I’m aware of the gambler’s paradox and other limitations of statistics. Statistics are a way to analyze outcomes with a large group. If 1,000 patients have surgery, then typically, 50 will have a particular side effect. That tells you the likelihood that this will occur in an individual case, but you can be one of the 50. Rare events do occur; they just occur rarely.

And both that morning equally lay
In leaves no step had trodden black
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.

Again the poet states that the two choices were about equal. In fact, no-one had taken either road recently as the leaves were not disturbed on either path. In life we can sometimes chose one choice, and then get a second chance to take the other path. For example, although I’m disturbed by the high level of divorce in modern society, I recognize that many second marriages turn out to be much wiser choices with happier results. Still Frost knows that, with the twists and turns of life — or a path chosen — it is unlikely he’ll be back to try the second way.

Another advantage to prostate surgery over radiation is that the removed tissue can be examined. This is called a pathology report. The prostate is frozen and then sliced into tiny slivers. Each of these is then examined under the microscope by a specialist. The biopsy is done with twelve little needles and only samples small areas of the gland. The pathology examines everything.

When my surgeon gave me the pathology report, it was not good. It showed that the cancer had spread beyond the “capsule” of the prostate. There was good news in that it appeared that the surgeons had gotten all the cancer since they routinely remove a little more tissue around the gland called “margins.” The pathology report indicated the cancer had been completely contained in the margins. However, due to the fact the cancer had escaped the prostate, my diagnosis was elevated from stage one cancer to stage three. That moves me into a different statistical group which does not have as positive of results as the stage one group.

Based on these results, my surgeon recommended I have external beam radiation treatments focused on the area where the prostate was removed. He planned that treatment for April to give my body the opportunity to heal from the surgery, so I had time to examine the options. My research verified the reason for his recommendation and indicated that the final results and probability of no recurrence of the cancer was statistically higher in men who had immediate follow-up radiation treatment.

However, the radiation treatment itself has several disadvantages. First are side effects of incontinence and impotence — same as the surgery although these problems don’t usually appear until 12 months after the radiation treatment. If they do occur, they can be more severe than the effects of the surgery. Further there is a danger of the radiation actually causing cancer as well as other undesirable side effects. Another decision to be made.

I shall be telling this with a sigh
Somewhere ages and ages hence:
two roads diverged in a wood, and I --
I took the one less traveled by,
And that has made all the difference.

This is the tricky part of Frost’s poem. Most recall the final two lines which would seem to indicate that the author chose the path less traveled, an analogy for choosing a life of some eccentricity instead of following the beaten path, and that had made all the difference which assumes a positive outcome. Most think Frost is saying to take the less traveled path in life for greater satisfaction.

But read more carefully. He switches to the future tense. At some point in the future he will be telling this tale with a sigh. Ages and ages will pass before he’ll know the outcome of his decision. And what about the “sigh?” Is it a sigh of regret or a sigh of contentment? That is what is tricky about this poem. Robert Frost is really saying that we make choices in our lives, chose this path or that, and we may not know the result until ages and ages hence.

I have to tell you frankly, I didn’t want to do the radiation treatment. It is lengthy, every day for four to eight weeks, although the individual treatments are less than 30 minutes. Near the end of such treatment regime you are fatigued. Plus there are all the side effects. Finally, you can only perform radiation treatment once. If I have the treatment now, and the cancer still reoccurs, I am left with fewer options.

So I again did my research and sought out one of the most experienced Urological Oncologist in Colorado. He is a professor at the University Hospital and is author of 38 articles and books on prostate cancer. I met with him in December and he took all my medical and surgical records and a CD with the pictures from the pathology and a team of doctor’s reviewed the information. I met with him this Monday and he stated that the odds are better if you do the radiation treatment now, but only a little bit better. He said that, in my case, it would be acceptable to do “watchful waiting.” That means that I’ll have the PSA blood test several times a year and we’ll use a very sensitive version of the test. If my PSA starts to increase (it is near zero now since my prostate has been removed) even a little bit, then I’ll have the radiation treatment and possibly chemo too.

I’ve check the statistics. Here is the data. Even with a clean pathology report that the cancer had not escaped there is a 10 – 30% chance of recurrence, and in my case with the large tumor size, I’m at the higher end of that number. So as many as 30% of men with my surgery suffer a recurrence. Of those, about 50% have the recurrence in the first three years and 19% after year five. So the odds are that I’ll be having radiation in any case. As Frost so correctly noted, it will be with a “sigh” somewhere in ages hence that I’ll know if I took the correct path. Meanwhile I’ll be watching and waiting and having regular blood tests.

Did I make the right decisions? Time will tell.

Originally written on Jan. 13, 2011.