NOTE: this is part of an ongoing series of posts about my journey with prostate cancer. So far the posts include:
1. January 30: “When Cancer Comes Calling”
2. February 16 – “Waiting in Mutual Ambush”
3. March 11 – “My Prostate is History” (on the surgery)
4. March 13 – “Letters Before Surgery” (saying goodbyes)
5. March 14 – “Cancer Prognosis: Uncertain Grace”
6. March 22 – “Post-Surgery Incontinence”

Cancer Prognosis: Uncertain Grace
David R. Weiss – March 14, 2025

I’m sitting out on the porch in 74-degree sunshine. Wearing pants!

I savor the sunshine with a certain melancholy delight. This is climate chaos bearing down on us. And while I can enjoy the warmth in mid-March—it is undeniably nice to recuperate in the sunshine—I know the long arc of this tale, and it does not end well for us.

But wearing pants—this is pure joy: because it means that, after nine days, I am catheter-free. For sheer tactile delight, nothing quite matches the mere stillness in my urethra. For the first time since surgery, my penis is not cowering, pulled back as though it could will itself to disappear from all the fuss going on around it. I have some amends to make with my manhood. But for today, the truce in my trousers in enough.

But Prognosis is the P-word that drew you in. Here it is in a single sentence: I am currently cancer-free although my prostate cancer will almost certainly make an encore appearance at some point and in some place down the road. Hence, uncertain grace. Let me explain.

Surgery went very well, says my urologist-surgeon. They were able to remove everything they went in to get, and without any complications. My incisions are healing well. My bowels have resumed their tides. And my urethra is putting down fresh roots at the lower neck of my bladder. (That’s surmised, of course, but backed by evidence in the form of the pale-yellow urine that it’s successfully delivering from bladder to toilet.)

I am cleared to bathe and to drive. My only real limitations are lifting (not more than ten pounds for another month—owing to the way my abdominal muscles were manhandled by Mr. Robot) and no bike riding for two more months (while the empty space my prostate once occupied above my perineum gets settled back down).

Now, for the nitty gritty. The pathology report on my whole prostate revealed cancer at a Gleason Grade 9 (where 10 is the worst). This matched exactly what my biopsy had shown. It had spread through 25-30% of my prostate (all on the left side) and was rated as a Stage T3 (on a scale of 1-4). Stage T3 signifies advanced cancer that has spread into surrounding tissue but has not yet metastasized to other organs or places in the body. That surrounding tissue was the seminal vesicle and neurovascular bundle on the prostate’s left side. Again, the MRI and PET scan had suggested this, so also, no surprise.

The only “surprise” was a very small “positive margin”: a place where the cancer had reached the surface (the capsule) of the prostate such that when the prostate was cut out, some cancer cells may have been left behind. (21% of all prostate cancers have positive margins.) This is typically bad news. (It is never good news.) However, two things put it in perspective in my case. First, the length of positive margin was very small (< 3mm or .1 inch). Second, because the cancer had already spread to the seminal vesicle and neurovascular bundle, it had already “left” the prostate in those places. So, my prognosis and plan of treatment will be the same as it would have been even with a clean/negative margin.

The good news is that the two lymph nodes removed were cancer-free. Lymph nodes are sort of like the ventilation system in a building: interconnected throughout the body. Once cancer accesses the lymph nodes in one part of the body, it can potentially move through “the ventilation system” and end up in another part of the body. That the lymph nodes nearest my prostate were cancer free is good news indeed.

What it all means. Today, with the cancerous prostate, seminal vesicle, neurovascular bundle all removed, I am currently “cancer free.” Emphasis on currently. But the combination of aggressive cancer (Gleason 9) and its actual spread into nearby tissue (Stage 3) and the very small but detectable positive margin, still puts me at “high risk” of recurrence. At some point. (Like 70% in the first two years and greater than 90% by year ten. My 15-year survival odds sit at 58%.) In other words, “cancer free” really just means that as of today, any cancer cells that may (likely) still be in my body are simply too few and too scattered to be registered by any imaging or even by a PSA score. There is no detectable cancer in my body today. Whew?

Of the few scattered cancer cells that may (likely) still be there, some will be attacked and killed by my immune system. Some will die of their own accord having not found a new host. And some handful may (likely) eventually set up shop somewhere as a “metastatic deposit” and start multiplying again. Ugh. There is no way to stop this. But there is a way to monitor it and intervene quickly if/when it happens.

In three months, I’ll have a new PSA test done. It should theoretically be ZERO (undetectable by the test), because my prostate is gone, and the PSA test measures a protein only produced by prostate cells. A normal PSA score is anywhere between 1.5 and 4.0 ng/ml (nanograms per milliliter). If mine registers even a negligible score of 0.1-0.2 ng/ml (that’s unimaginably low, but still detectable) that will tell us that some prostate cells have organized themselves in my body—and those would be cancer cells “born” in my prostate.

This is called a “biochemical recurrence” because it can be inferred from the blood test even though the cancer is far too small to be picked up by an MRI or PET scan. By the time it grows big enough to be “visually” caught by scan, the PSA is usually up to .5 ng/ml. But time matters, and we won’t wait for a determination of “clinical recurrence” on a PET scan. The moment a biochemical recurrence is shown (the earliest would be in three months, but it could be three years, or thirteen!), we begin treatment.

I would undergo a course of external beam radiation therapy targeted at the prostate bed (the space where the prostate used to be). Honestly, this is a bridge I’d rather not cross. But the cancer isn’t asking me. So, we’ll just have to wait and see. Following that course of radiation therapy, hopefully my PSA would again be undetectable. That would indicate we had killed off the cancer. Still, because the cancer at 0.2 ng/ml can’t yet be seen on a PET scan, we’d really just be guessing it was in the prostate bed. If it were located somewhere else, we’d have missed it; my PSA would continue to rise, and we might have to wait until it was picked up by a PET scan.

BUT—the “good” news is that research has shown that 80% of prostate cancer recurrences begin in the prostate bed (15% in the lymph nodes; 5% in bones). Even though we can’t see it there, we know there’s an 80% chance it’s in the bed. And the cure rate by radiation is best (as high as 80%!) if it’s used as early as possible. Pretty cool—well, for cancer. It’s sort of macabre yet fascinating that science has made huge strides in understanding the nature of cancer, allowing us to produce more promising treatments.

(Actually, what’s truly macabre is the Trump administration’s commitment to un-funding all manner of scientific and medical research. Honestly, the only “efficiency” gained by that, is that a whole BUNCH of us will die a whole lot sooner. I very much doubt anyone meant to vote for that. But that’s an essay about a whole other cancer …)

So, uncertain grace. Today I am well. In another essay I’ll explain how incontinence and erectile dysfunction are inevitable “party favors” that come with a radical prostatectomy. But today, in the sunshine—in my pants, no less!—it’s enough to discuss my cancer prognosis. I am surely “better” than I was last fall with the cancer growing undetected in me. And I am surely “better” than I was just two weeks before surgery. But “cured” is a word I may never wear again. And that’s okay. I may be “cancer free” the rest of my life. Or I may (more likely) find my life once again interrupted by unwanted company.

On June 16 when my first post-surgery PSA score is done my odds could improve. Or not. I’ll get a fresh PSA (and fresh odds) every 3 months for the first year, and every six months for the second year. Every year I remain cancer-free my odds get better. But the bottom line is I will live in this uncertainty. Probably forever. Which is why I choose to live in it with grace. Accepting each day as gift, each relationship as gift, each opportunity to weave words as gift. Each chance to do good in a troubled world as gift. Truth is, I never had a lock on certainty. None of us do. Now that I’m clear about the uncertainty, I can revel in uncertain grace.

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David Weiss is a theologian, writer, poet and hymnist, “writing into the whirlwind” of contemporary challenges, joys, and sorrows around climate crisis, sexuality, justice, peace, and family. Reach him at drw59mn@gmail.com. Read more at www.davidrweiss.com where he blogs under the theme, “Full Frontal Faith: Erring on the Edge of Honest.” Support him in Writing into the Whirlwind atwww.patreon.com/fullfrontalfaith.