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Cancer specialist confronts cancer

Doctor sold on steadiness of robotic hands for surgery

By Peggy Peck
MedPage Today Senior Editor

Dr. Jack Evjy speaks during his tenure as president of the Massachusetts Medical Society in 2000.
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BOSTON, Massachusetts -- In April 2004, cancer specialist Dr. Jack Evjy was congratulating himself on his good health and good fortune as he approached his 70th birthday:

"I was healthy and life was great," he recalled.

Unlike many men who battle high blood pressure and high cholesterol in their 60s, Evjy dodged those bullets. He kept his blood pressure and cholesterol under control. Moreover, Evjy had maintained his slim, athletic build. But Evjy knew there was a dark cloud in the otherwise sunny snapshot of his health. Prostate cancer ran in his family.

A younger brother had his prostate gland removed after cancer was discovered. So a part of Evjy's routine "health maintenance" was careful monitoring of his prostate specific antigen (PSA) levels.

PSA is measured in nanograms per milligrams. A PSA of zero to 4 ng/ml is considered normal.

"Mine never reached an abnormal level," Evjy said. "It was always less than 4."

So, Evjy was feeling pretty optimistic about his health and his future when he visited his family physician for a routine checkup. As part of that checkup, his physician examined Evjy's prostate gland manually, a process called digital (finger) examination -- and the doctor didn't like what he found: a ridge that was not present a year earlier.

"Even though my PSA was normal, he recommended a needle biopsy of the prostate," Evjy said.

Even then, Evjy wasn't concerned.

"Here's the deal: I had no evidence of a rising PSA, so I wasn't really concerned about the biopsy."

A urologist biopsied the prostate at 10 different sites. Nine came back normal. The tenth found prostate cancer.

At that point, the cancer doctor became a cancer patient.

The bad news was that he had prostate cancer. The good news was that it had not yet spread beyond the prostate. He faced a decision that thousands of patients faced every year.

Choice with a twist

Like any patient, there were certain things Evjy couldn't control. But unlike most patients Evjy, as a cancer doctor, could put his training and knowledge to work to make the key choices that lay immediately ahead of him. And Evjy took a route most patients would have never considered. He chose surgery, which was not unusual, but he added a robot to aid in the procedure.

At first, as he juggled his medical practice with Harvard/Pilgrim Health System and a move to a new house in suburban New Hampshire, a number of options "were swimming around in my mind." He considered the standard therapies like radiation, chemotherapy and surgery, as well as newer, high-tech options like implanting radioactive seeds in the prostate, a procedure called brachytherapy, or killing the cancer with superchilled probes, a technique called cryoablation.

Driving his decision process into high gear was a pathology report. Cancer specialists use the Gleason scoring system to differentiate aggressive, rapidly growing prostate cancers from slow-growing ones. Evjy's tumor had a Gleason score of 7, which meant it was moderately aggressive. Something had to be done. With a Gleason score of 7, so-called "watchful waiting" was out of the question.

As an oncologist, he knew that surgery "offered the best life-saving option" but it also carried the highest risk for nerve damage that could result in sexual dysfunction. Additionally, surgery increases the risk of urinary incontinence after surgery. "Still, it seemed to me that if I could get the prostate and some surrounding tissue out of my body, there was hope that I could cure the disease," he said.

As Evjy began to research treatment options, he learned that surgeons at Catholic Medical Center in Manchester, New Hampshire, were performing robot-assisted surgery and it was there that he met Dr. John Munoz, a Manchester, New Hampshire, urologist who learned the da Vinci System while in training at Dartmouth Medical Center in Hanover, New Hampshire.

The da Vinci System is a three-armed extension of the surgeon, who sits at a computer console and operates the arms using joysticks. Two of the arms are fitted with tiny "hands" that hold surgical tools. The third holds the scope that allows the surgeon to view the surgery under powerful magnification. Each arm enters the body through a quarter-sized hole or "port," Munoz said.

Tiny incisions mean less pain for the patient and magnification means that the surgeon can "see the tissue planes much better than with the naked eye or even with a regular endoscope," Munoz said. Sitting at the console, which is placed alongside the operating table, he has a full three-dimensional view of the prostate gland and the tumor. The robot's tiny metal hands operate "intuitively" so when Munoz moves the control stick to the left, the robot hand moves to the left.

What impressed Evjy most were the magnification and the steadiness of the robotic hand. He noted that in his experience even the best surgeon is at risk for a little "shake" in the hands.

"This device takes the 'shake' out of surgery," he said.

Steadiness of robotic hand

The surgery is not any faster than traditional methods, Munoz said, but recovery time is much less. "Using traditional prostate surgery we tell patients to expect a four- to six-week recovery; with robot-assisted surgery, patients are ready to return to their regular schedules in two to 2 1/2 weeks," he said.

By the day of his operation, Evjy was sure that he made the right decision by choosing robotic surgery, but he still worried as the preoperative anesthesia took effect.

"I knew I would wake up in recovery and would find out then if my lymph nodes were positive or negative," he recalled. If the lymph nodes were positive it would mean that the cancer had spread beyond the prostate and his prospects for long-term survival would be poor.

"They literally woke me up in the ICU to tell me the good news -- the nodes were negative," he said. "I was so relieved. That was one of the most emotional moments of my life."

But while he was relieved, he had an even more emotional experience still to come. At home, still recovering from surgery, he received the final pathology report. When pathologists examined the surgically removed prostate gland they found that "there was a spot on the prostate gland that was actually a Gleason 9," much worse than the Gleason 7 seen on the biopsy specimen. At that point, he said, "I felt a profound sense of despair and found it very hard to sleep for several days."

But again, he turned to old and familiar territory for a cancer specialist: research and consultation with other experts. He spoke to friends near and far -- at the Dana Farber Cancer Center in Boston and the M.D. Anderson Cancer Center in Houston, Texas.

Based on the advice he received, he underwent a six months of chemotherapy with Taxotere, a drug used to treat advanced breast or lung cancers. "I had some ankle swelling and problems with my fingernails while taking Taxotere for six months, but I got through it and it gave me hope," he said.

Additionally, he underwent a course of radiation therapy and is now taking hormone therapy to suppress testosterone, which feeds the growth of prostate tumors.

"I feel like I've done everything that I can to save my life," said Dr. Evjy, who also said he is now feeling "pretty good" as he approaches his 71st birthday. While he opted for a high-tech approach, he said "I haven't done anything that was nuts. I did the research and made my decisions based on the current evidence."

Asked if he would recommend robotic surgery for other men, Dr. Evjy didn't hesitate: "Absolutely."

The da Vinci System is FDA-approved for some heart procedures such as mitral valve repair, abdominal surgery and prostate cancer. U.S. surgeons used the da Vinci System to perform 2,700 prostate cancer operations last year.

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