A DELICATE OPERATION

Prostate2_0

When it comes to fighting prostate cancer, nobody in Britain has done more than Professor Roger Kirby. So what happened when he got it himself? Simon Garfield reports from the operating theatre

THE SCENERY WAS like nothing they had ever seen before. Last March, 47 cyclists had negotiated a 27km climb to the Puyehue Pass on the border of Chile and Argentina, passing forests and mountains, hot springs and glacial melt-water. At the summit one of them noticed a circling Andean vulture, and they joked that it might be a grim omen. Others noticed that one of their most experienced riders was looking distinctly grey. Roger Kirby, a 62-year-old professor of urology, was taking part to raise money for the Urology Foundation. He had been on similar rides in Malawi and Madagascar and prided himself on his ability to keep up with younger riders, but now he felt severely breathless. His father had died of a stroke following heart failure at the age of 49, and ever since he had been wary of the weight of genetics. So he resolved to have a cardiac check and some blood tests as soon as he returned to England.

The heart exam showed a little calcifying in the arteries, something fairly typical in men of his age, and the blood tests showed another common male attribute: a raised level of prostate-specific antigen (PSA). PSA produces the liquefying component of semen, and may ease the passage of male sperm within the uterus. It is a vital protein for conception, but when it enters the bloodstream in increasing amounts it may also indicate the growth of prostate cancer.

Roger Kirby had monitored his PSA level for more than a decade. At 50, it stood at 0.5, which was negligible. But it had risen gradually over the years, to 1.5 and then 3.3, which he regarded as a light flashing on the dashboard. Two weeks after getting back from South America, he took a second PSA test, and found it had gone down a little, which reassured him. Six months later, in September, he had another test and his PSA was 4.3, the highest it had ever been, so he underwent a high-resolution localised MRI scan.

The news wasn’t good. There was a definite lesion on the right side, which his radiologist thought could be one of two things: prostatitis, an inflammation treatable with antibiotics, or a tumour. And so a biopsy was ordered, involving a local anaesthetic and a rectal probe, and the removal of 12 samples from the suspicious area.

The following day Kirby received a phone call from his pathologist. “Are you sitting down?” He was. “I’m afraid that three of the biopsies show Gleason 7.” The Gleason scale is a grading system particular to prostate cancer, made up of two scores, each defining the advancement of a tumour and the risk of spread to other organs, with 10 as the worst prognosis. A combined score of 4 or 5 would prompt concern, and perhaps a policy of watchful waiting. But with a score of 7, Professor Kirby had a decision to make.

He looks boyish for his age, with a full mop of greying hair and a slightly Bunterish face, and he is not averse to wearing a rugby shirt in his leisure time. He likes to think of himself as a rather stoical, stiff-upper-lip type of Brit. But in the case of his illness his stoicism had both cause and irony: Kirby is one of the leading prostate surgeons in the world.

Prostate cancer—its prevalence and diagnosis, its virulence and treatment—has not been short of publicity recently, and Kirby is one of the reasons why. The fact that the disease is now regarded as both common and a common topic of conversation is partly thanks to Kirby’s proselytising and fund-raising. He has written more than 200 research papers on the prostate and several books, including one called “The Prostate: Small Gland Big Problem”. He estimates that he has removed more than 2,500 prostates since the mid-1980s.

As well as being Mr Prostate UK, Kirby has one other claim to fame: he was briefly Mr Viagra UK. As Viagra was being developed at the old Pfizer laboratories in Kent, Kirby conducted many of its safety trials (particularly on cardiovascular patients) from his base at St George’s Hospital in Tooting, south London. When Viagra was announced to an excited media in 1998, Kirby was on hand as an expert, dismissing claims that it would lead to the world’s adult male population spending the rest of their lives walking around like tent poles.

Picture: Professor Roger Kirby

There’s a certain symmetry in this too: one of the symptoms of prostate cancer, and one of the side-effects of a prostate gland removal, may be erectile dysfunction. When I ask Kirby about the emotional impact of his cancer, and the irony of contracting the disease on which he has built a career, he is nonchalant to the point of perversity. “I thought we’d better just get on with it,” he says. He is in the living room of his large house in Wimbledon, and has half an eye on the television as Chelsea, his football team, compete in Japan. “One of my heroes is James Bond, so I was hardly going to go around weeping. And there was no doubt in my mind that I should just have it taken out.”

He told his colleagues during a weekly team meeting the day after his biopsy results. “They were interested,” he says. “Nobody was emotional. It was just another case, although it was a bit weird that it was me.” His wife Jane, who works as the chief business manager at her husband’s clinic, was only slightly less blasé. “It was a bit different for us,” she says. “Most people would find out if they had a lesion from their surgeon face-to-face, but ours came through when we were in a street in Marylebone at about 10.30 at night—a text message on Roger’s phone.”

How did she feel? “Yes, a bit of a shock but I just thought, ‘OK, now we have to get on to the next stage’.”

When the next stage—the biopsy—brought the grim confirmation a few days later, the only question in Kirby’s mind (apart from which of his colleagues should perform the operation) was whether to have his prostate removed immediately, or complete another fund-raising expedition first, trekking in Morocco. He decided to go on the trip, and to use the time to get as fit as possible. He set a surgery date for December 3rd, and asked me whether I’d like to attend the operation.

IN ITS HEALTHY state, the prostate is a 12-gram walnut-sized gland that sits at the base of the bladder and surrounds the urethra (the tube that carries urine out of the body) before it connects to the base of the penis. Its principal function—the liquefaction of semen—helps create life: without it a man becomes infertile. But its extreme malfunction may also hasten death. The incidence of prostate cancer has increased markedly over the past 20 years, although this may be partly down to greater vigilance and earlier detection.

Nearly two-thirds of cases are diagnosed in men of 65 or more, and it is extremely rare before the age of 40. In the United States, about one man in six will be diagnosed with prostate cancer, but only one in 34 will die of it. The American Cancer Society (ACS) estimates that in 2012 there were about 241,000 new cases of prostate cancer diagnosed, which will lead to about 28,170 deaths; it is the second most fatal cancer for American men, behind lung cancer. In Britain, prostate cancer accounts for around 7% of all cancer deaths—some 10,721 in 2010. Figures from 2008 suggest that prostate-cancer mortality rates are highest in the Caribbean and lowest in Eastern and South-Central Asia, with Europe and North America sitting somewhere in the middle.

Kirby knows of four other urologists afflicted with prostate cancer, three of them advanced, one with little hope of survival. He says many of his colleagues remain dubious about the value of PSA screening and surgical intervention to remove a gland that, even if cancerous, may not kill you. “Many are just frightened. It’s easier not to know, just as it’s easier not to screen for heart disease. Or breast cancer in women. But when I began in the 1970s, before all these tests became available and refined, I only saw patients whose cancer had already metastasised, and many lived only a few weeks.”

In 2013 this is still the big controversy: whether to test and when to intervene. It is a debate peppered with issues of priorities, medical expertise, money and robotic technology, and complicated by the fact that we are still in the early days of a new science. PSA has only existed as a debatable marker of health since the 1970s, and has only been widely available since the late 1980s. Charities dedicated to prostate research and education have been campaigning since the mid-1990s.

Picture: Roger Kirby with Professor Prokar Dasgupta, the colleague who became his surgeon

In January 2013 Britain’s leading charity in the field, Prostate Cancer UK, still claimed that the disease was getting less attention than other illnesses with a lower mortality rate. Education and awareness were still vital, it argued, and it set about launching what it called the Sledgehammer Fund as “a call to arms”. Its celebrity patron was the comedian Bill Bailey, whose father-in-law had suffered from prostate cancer, but the most prominent name on the roster of medical experts was another one: Roger Kirby.

In a recent e-mail, Kirby joked that he was happy to help me with this article, even if it did mean the removal of his prostate to heighten the drama. He attached a set of articles from medical journals that laid out the arguments for and against the procedure he was about to undergo. The debate is fairly simple, and exists primarily because prostate cancer lacks the historical pathology of other diseases, and thus the near-certainties that permit a relatively unchallenged course of medical action. Instead, we still have an unsatisfactory and incomplete set of evidence from small-scale trials, anecdotal observations from doctors, and a subjective collection of hunches and gut-instincts. And there is another difficulty: prostate cancer—unlike breast or lung cancer—is frequently a natural disease of ageing. Many men in their 70s and 80s will develop it with only minor symptoms; it may not present a threat to life, and is likely to be overtaken as a cause of death by something else. But how long should you wait to find out? This partly depends on the virulence of any one patient’s particular cancer: the higher the number on the Gleason scale, the greater the chance it will spread beyond the prostate. But of course this was the dilemma: even to get to this stage one needed an indicator of early trouble, and the PSA screening was still the most consistent method, if not wholly reliable.

The debate has polarised into two horn-locked camps. In one, Roger Kirby and his supporters advocate careful surveillance and, if the surveillance prompts it, medical intervention. They are an increasingly vocal unit, and their most visible campaign, gathering momentum each year since its founding in Australia in 2003, is Movember, the month-long festival in which men are urged to grow a jokey moustache. The charity, which raises money for other male-health causes as well as prostate cancer, has helped remove some of the stigma from urological disorders. With a buoyant social-media presence (“Knowledge is Power, Moustache is King”), Movember 2012 raised in the region of $20m in America, $40m in Canada, $33m in Britain and $26m in Australia. In all it raised almost $130m from around 1.25m registered participants.

In the other camp sit those who argue that prostate problems are being over-publicised, over-diagnosed and over-treated, causing men to be unduly alarmed by an illness they never worried about much before. They argue that PSA scores ought to stand for Producer of Stress and Anxiety as they are not a sufficiently accurate indicator of disease to be helpful, and that making tests more available not only places an unnecessary strain on health providers’ funds, but may put overly worried patients in conflict with their doctors.

One of the most vocal objectors is Margaret McCartney, a GP in Glasgow with a popular and outspoken blog, who wrote a lucid article in the British Medical Journal at the end of last year criticising the Movember campaign for biased and misleading information. She claimed that the advice on the Movember website that men over 50 should undergo screening for PSA made no mention of the fact that this advice was contentious, nor that the National Health Service and the World Health Organisation argue that there is no evidence that universal non-symptomatic screening saves lives. Following her intervention, the Movember site has amended its advice to include the line, “discuss your situation with your doctor to decide if PSA testing is right for you.”

The arguments are one thing, the personal dilemma another. In one sense, macabre as it sounds, Roger Kirby’s prostate cancer could only be good for business. “I could hardly advise so many patients to have their prostates removed and then sit back and do nothing,” he told me a few days before his operation. He was in his office at the Prostate Centre in Wimpole Street, a gleaming modern edifice to hi-tech male well-being. With its neighbours Harley Street and Devonshire Place, Wimpole Street has long been established as a centre of excellence for private medicine. In a booklet given to new patients, one satisfied client compares the ambience to “a gentleman’s club”, albeit one with a less fuggy atmosphere than you might find in Pall Mall.

Kirby practised urology within the NHS for 20 years—”longer”, he points out, “than you get for murdering your wife”. Many of his colleagues at the Prostate Centre, including the surgeon to whom he will entrust his own prostate, split their time between NHS work and private care, but a patient who chooses the Prostate Centre will be landed with a final bill of £20,000 or more. The list of clients who have benefited from the centre’s care includes many famous and wealthy names, most of whom wish to keep their medical history to themselves. One notable exception is Andrew Lloyd Webber, who underwent a prostatectomy in 2009 and has since become a champion of both the centre and early testing.

Picture: The da Vinci robot in action: each one costs $2m

In America, men tend to bandy about PSA scores as if they were sports results. About 70% of American men over 50 are reported to know their PSA score; Kirby thinks the equivalent figure in Britain would be 7%. In America, the list of well-known men treated for prostate cancer is far longer. Robert de Niro, Rudy Giuliani, Rupert Murdoch, Harry Belafonte and Colin Powell are all survivors, and most have lent their names to education campaigns. The list of famous fatalities, from whatever country, is longer still: Robert Frost, Telly Savalas, Frank Zappa, François Mitterrand, Sir Harry Secombe, George Carman QC, Johnny Ramone, Corin Redgrave.

KIRBY AND I first met in 2005, when he was due to operate on a friend and former boss of mine, Tony Elliott, the founder of Time Out magazine. At 58, Elliott had begun to feel dizzy. A battery of blood tests revealed a PSA score of 5.8, leading to a biopsy that showed signs of a tumour. Within a week of the biopsy he found himself sitting opposite Kirby, discussing his options. These were manifold, and they hold true today. Watchful waiting; external radiotherapy, involving a 40-day course in which beams are directed at the cancerous cells; brachytherapy, a newer treatment in which pellets are inserted strategically into the prostate with the aim of killing the tumour from within; cryotherapy, which involves freezing tissue by inserting liquid nitrogen through probes; high-intensity focused ultrasound, whereby a rectal probe delivers a localised beam; hormone treatment, most often deployed if the cancer has spread or recurs after treatment. And then there is radical prostatectomy, whereby the entire gland is cut out—something that has the slashing air of the Victorian operating theatre about it but may still be the most thorough and containing treatment.

“I don’t advocate that everyone should have their prostate removed—we use radiotherapy a lot,” Kirby told me at that first meeting, at a café near his work (the Prostate Centre was still at the planning stage). “In a case like Tony’s, [the cancer] may not have done any harm, but there was also the chance that we may not have removed it early enough. His tumour was quite large and quite close to the edge of the prostate by the time he was diagnosed.”

Kirby said that Elliott struck him as “a great example of a highly intelligent, highly successful man who has ignored his health until this bolt from the blue comes along. Men can delude themselves by doing 20 minutes in the gym and saying ‘I do exercise, I’m OK,’ but unless you also have the blood tests done to detect diseases, these things grow inside you.”

So Elliott opted for the prostatectomy, and Kirby performed the operation by a transverse lower abdominal incision. This was his speciality, and he demonstrated it to me with his pen, a vertical line of about 10cm just below what he called the bikini line. “A lot of surgeons do it up and down, a bloody great hole,” he said. Today, Tony Elliott is thriving, occasionally boosting his resistance with hormone therapy. It was Elliott who first told me about Roger Kirby’s own cancer. In that seven-year gap another option had been introduced, and it was transformative: the da Vinci robot.

This is a machine that has brought a far less invasive and more refined method of performing a prostatectomy, and has rapidly come to define the gold-standard of treatment for a multitude of cancers. Despite its name, it is far from being an automated procedure, requiring many months of specialist training to master, something Kirby and several colleagues did through a series of trips to America. The da Vinci method involves making six 10mm keyhole incisions in the abdomen, into which thin steel arms, known as ports, are inserted. This is the robotic element: the arms are fitted at their tips with a variety of instruments for cutting, sewing and sealing, as well as a camera that allows the surgeon to operate the ports remotely from a console a few yards from the patient while looking at an enlarged 3D image on a screen. In skilled hands, the machine will enable not only a cleaner excision through greater dexterity, but also a quicker recovery, as there is less bleeding and trauma. There are now 30 such units in Britain, the majority in NHS hospitals (as well as prostate operations, the da Vinci is used predominantly for hysterectomies and cardiac work; the cost, some $2m per machine, inhibits wider adoption). Worldwide, the manufacturer, Intuitive Surgical of California, claims to have sold almost 2,500 robotic systems to more than 1,900 hospitals in 44 countries.

Which brings us to the fifth floor of the London Clinic in Devonshire Place at the beginning of December 2012, and a 62-year-old patient awaiting a trip to the basement. Roger Kirby, already in his gown when I arrive, is busy maintaining the air of a man about to take a stroll in the park. We talk about Chelsea’s chances in the league and how he broke the news of his cancer to his three adult children: “They felt that if I had to have any cancer, this was probably the best one.”

Picture: The da Vinci robot’s steel arms, known as ports

At 1pm a chief nurse arrives to accompany us to the operating theatre. We all scrub up. The anaesthetist, Richard Morey, puts a large needle into the base of Kirby’s back and injects slowly. Pads and wires are applied to monitor his heartbeat and blood pressure. A nurse shaves his stomach. In a standard routine, everyone in the room introduces themselves, and their reason for being there. The precise nature of the procedure is announced.

The abdominal cavity is distended with carbon dioxide to lift the walls from organs and create more space, X-marks are applied to the points where the ports will be inserted, the robot is pulled into position, and the first incisions are made. The process of delicately slicing the prostate away from the bladder, urethra and fatty lining begins, and a mixture of pumping and hissing reds and yellows flood the screen as metal pincers pull and cut and seal. We joke that Kirby could have performed this operation in his sleep. Instead, his team is led by Professor Prokar Dasgupta, who learned robotic techniques with him in America. He will repeat the procedure on several other men later in the week.

Kirby’s operation, which lasts about 90 minutes, proceeds amid an atmosphere of gentle instruction and good humour. “It’s not exactly giving itself up, the professor’s very attached to it,” someone says as surrounding muscle and fat are snipped away. Ben Challacombe, another of the surgeons present, tells me that the priorities are, in order: the removal of the cancer; the resumption of continence following the removal of the catheter; and the resumption of erectile function. It is the third of these that produces the backchat. When it comes to detaching the side of the prostate from the nerves that control erections, someone says: “Mrs Kirby expects us to be absolutely on top of our game here.”

The whole procedure is like the mechanised teddy-picker at a fairground, albeit with more chance of a prize at the end. Once cut away, with the catheter inserted and the urethra and bladder tied together, Kirby’s prostate—still in his abdomen—is tweezered inside a plastic bag and set aside by his bladder. One of the port holes is then cut a little larger, and the plastic bag is removed, to light applause. Professor Dasgupta places his colleague’s gland on a piece of gauze and prods and stretches it. It is dark-reddish, grainy and meaty, and if I hadn’t just seen it functioning inside a human being I would have thought it as benign as a piece of chicken tikka. Its previous owner is pulled out of his anaesthetic ten minutes after being sewn up. Colour returns to his face. Kirby is groggy, but his first words are reassuring. “I think, gentlemen, I need a gin and tonic.”

SIX WEEKS LATER, in mid-January, Kirby sent me an e-mail. “Just received the news that my PSA is undetectable at <0.03ng/ml,” he wrote. “That means the operation has been a complete success. As ever, Roger.”

He was back at work, and when I called on him at his office the day after his results he was discussing treatment options with a man in his early 80s. “I can now tell people what the operation is really like from the inside. It’s like Joni Mitchell sang in ‘Both Sides Now’,” he said, before acknowledging that the song was predominantly about the arcane mysteries of love.

“I think I’ll be much more careful about explaining things to patients now. Dealing with the catheter can be pretty uncomfortable, and that leg one you have at night—you get anxious that you’re going to disconnect it and have urine all over the bed. And then waiting for the pathology, and for this PSA result—these are proper anxieties. I was really pleased to see my PSA. When you have any cancer, even though they get the primary out, there’s still that lurking worry that it’s too late and things have spread. It doesn’t mean to say there won’t be some lurking cells somewhere, but the chances are less than 5%.”

It was good to see him looking so well. He told me that his prostate was now in the pathology department at St George’s, Tooting, and that the biopsy also suggested the cancer had been contained within it. He was planning another charity cycle ride for November 2013, this time in South Africa.

And how was everything else? “My erections are not as rigid as they used to be,” he said. “But they’re still there. You expect three, six, nine, 12 months until you get restoration of those.” He is taking small doses of Cialis, a Viagra-style blood-flow booster, and says it helps a bit.

“I did wonder about whether I should go public on all this,” he concedes as I leave. “Some professional people advised me to keep it quiet, because of the negative connotations that cancer confers. Agents of famous people tell them it’s ‘game over’ for their image, which is one reason a lot of my patients aren’t keen to talk about it. Personally, I thought it would only be worthwhile.”

Picture: Roger Kirby’s prostate, snapped by the author

For further information, visit prostatecanceruk.org or, in America, pcf.org

Photographs Nick Ballon

Simon Garfield is the author of “On the Map”
From INTELLIGENT LIFE magazine, March/April 2013

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