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Current Work - Radiotherapy Sketchbook

  Radiotherapy for prostate cancer
 Day 1: Time to Start!
(3:00 pm on 1st November 2021)

I might be wrong but I view this radiotherapy as a bit of maintenance rather than something for a life threatening condition. I had a specialised form of radiotherapy for prostate cancer 8 years ago and now some vestiges of it have turned up in a couple of lymph nodes, which is what they're zapping. Might keep me going for another 8 years!
  Radiotherapy for Prostate Cancer Day 2: In the Waiting Room
  Radiotherapy for Prostate Cancer Day 3: View During Treatment.
A rough representation of the view while I lie on my back for treatment.
So far I've been in a (£2.3 million) machine called "Acer'. Some of the ceiling tiles have been replaced with screens showing views of sun-lit acer trees against a blue sky. Lovely. As I gaze at them as bits of machinery emerge and disappear in the foreground.
I'm going to be in "Beech" tomorrow
  Radiotherapy for Prostate Cancer Day 4: The Oncology Waiting Room.

I was told that the radiotherapy might make me feel tired but so far so good - even went for a "run" (jog) this morning.

The "Beech" radiotherapy machine (see yesterday's post) also has screens in the ceiling but the trees look as though they're a mixture of pine (no blossom), cherry and possibly magnolia.
The treatment is totally painless so laying there gazing at the trees and the blue sky is quite enjoyable - almost looking forward to more sessions!
  Radiotherapy for Prostate Cancer Day 5: The Procedure.
Shoes off. Trousers off. Get on the machine's "bed" so that my feet touch a positioning device indicating that I'm roughly in the right place.
A "modesty" sheet of paper is placed over my pelvis and I'm asked to pull down my pants and pull up my top garments to expose my abdomen. I'm asked to put my hands on my chest to get my arms out of the way.
In preparation for radiotherapy I had a CT scan during which some tiny marks were tattooed on my abdomen as reference points. My body is moved around slightly (by me and nurses) to line up the marks with laser guides from the machine. This enables it to lock on to the 2 cancerous lymph nodes that need treatment.
The nurses leave the room. The machine starts whirring and moving. The ceiling comes into view - the screens with trees and blue skies - and I gaze at them for what feels like about 10 minutes. It's quite soothing.
Click here for more details
  Radiotherapy for Prostate Cancer Day 6: Art in the Waiting Area.

I get called in to a small waiting area a few minutes before my treatment. There's some art on the wall - nine boards that combine poetry (by John Fairfax), holograms (by Jonathan Fairfax) and carving (by Michael Fairfax).

Here's the first three. I had to draw them from a photograph - not there long enough to draw them in situ
  Radiotherapy for Prostate Cancer Day 7: Still Life!
Items for my "prep" - emptying my guts and filling my bladder to push them out of the way. I administer the micro-enema as soon as I arrive and drink the water when there's 30 minutes to go. It gets a bit tricky if there's a delay and I'm busting for a pee!
  Radiotherapy for Prostate Cancer Day 8: Not Alone
Beryl came with me today - we had an appointment in Plymouth afterwards. This is her in the Oncology waiting room.
  Radiotherapy for Prostate Cancer Day 9: Selfie
People are asking how I'm feeling so here's a "selfie" of me in the Oncology waiting room. I feel my normal self. The tiredness I was expecting hasn't happened yet.
My next radiotherapy session is on Monday. I've got tomorrow off because they're carrying out maintenance on one of the machines.
  Radiotherapy for Prostate Cancer Day 10: My "Indolent" Cancer.
Today's sketch of a ship's telegraph is my way of introducing the topic of the speed at which prostate cancers develop.
It's been on my mind since a friend of mine announced last week that he'd been diagnosed with prostate cancer, that it had already spread to his pelvis and he'd only got another 6-12 months left to live.
Pathologists grade prostate cancers in terms of a "Gleason Score", which is sometimes simplified to a "Grade Group". Click here for more info.
I have a Gleason Score of 7 out of 10, which sounds pretty bad but in fact hardly anybody has a score of less than 6 and 7 is considered "intermediate." From what I can make out, I'm in Grade Group 3 out of 5. My consultant says my cancer has a "fairly indolent nature".
I wonder whether I've had prostate cancer for a long time. Blood was found in my urine when I had a medical for life insurance in 2001 but I wasn't tested for prostate cancer ( a PSA test) until 2012. I had radiotherapy in 2013 and now I'm having it again, 8 years later.
Bearing all this in mind, I think there's a reasonable chance that my current treatment will keep me going for several more years. Then I can have some more radiotherapy.
  Radiotherapy for Prostate Cancer Day 11: My Battlefield?
Earlier this year I had a PET scan that suggested that prostate cancer might have got into my sacrum, the bone above the coccyx (tail bone) in this picture.
Bad news - survival statistics aren't great.
Luckily, a subsequent MRI scan convinced my consultant that this was incorrect - the cancer was limited to two tiny lymph nodes.
I hope he's right!
  Radiotherapy for Prostate Cancer Day 12: Hormone Treatment
I've been taking 50mg of Bicalutamide every day for the past six months to make the tumours more susceptible to radiotherapy. They stop me producing testosterone, which is what prostate cancer "feeds" on.
The absence of testosterone in my body means that the female hormone, estrogen, is in charge. I have menopause-like hot flushes.
The plan is to keep me on Bicalutamide for at least another year. In the end it stops working - prostate cancer finds a way around the problem.
  Radiotherapy for Prostate Cancer Day 13: In the Waiting Room.
Giving the medical stuff a rest for today. This is an antique "private mailing box" and stamp vending machine in the Oncology waiting room.
Click here for some background.

  Radiotherapy for Prostate Cancer Day 14: In there Machine
This is me being prepared for radiotherapy in "Acer", one of the external beam radiation machines at Derriford.
I got a nurse to take this photo yesterday. I didn't like the drawing I tried to create from it so, once I got home, I used an image transfer technique I learned from Richard Sunderland to create this.
In this picture the nurses are lining me up with laser guides from the machine. They then leave the room, the bed is raised and the whole front of the machine rotates around me.
It starts by doing some 3D scans to identify the target. Then it adjusts the bed slightly to line up the radiation beam on the target and the treatment starts - there's a high pitch buzzing sound as the machine rotates around me twice.
And that's it. The nurses come in, I pull up my underpants, they lower the bed and I hop off, put my trousers and shoes back on and go home.
I'm having image guided radiation therapy- IGRT. Click here for more about the technology.
  Radiotherapy for Prostate Cancer Day 15: Part 1 of my Typical Day
I've decided to spend this week illustrating a typical day for me while I'm having radiotherapy.
Today's sketch starts with a cup of tea in bed and gets as far as me driving to Derriford Hospital. Tomorrow will be arriving at Derriford and what goes on in the Oncology waiting room. And so on.
My times of treatment vary but for the purposes of these sketches I'm going to use a start time of 12:45 to keep things consistent.
The treatment only takes 10-15 minutes but it takes me almost 3 hours to drive to Derriford, carry out preparations, have my treatment and drive back home.
Time flies while I'm drawing these sketches!
  Radiotherapy for Prostate Cancer Day 16: Part 2 of 5 of my Typical Day
In case this gets read by someone else about to have radiotherapy:
There are occasions when Car Park C is full and there's a queue to get in. I've discovered that it pays to queue. The car park has a high turnover and I've rarely had to wait more than 5 or 10 minutes to get in.
Not all car parks at the hospital use chip coins, which is what you need to get free parking. The multi-storey car park, on the other side of the hospital, uses chip coins but it's often so busy that it takes a long time to find a space and it's a heck of a long way from Oncology.
  Radiotherapy for Prostate Cancer Day 17: Part 3 of 5 of my Typical Day.
I get to the Oncology waiting room an hour before my treatment time so I can empty my intestines and push them out of the way by filling my bladder.
When I checked in yesterday there was a sign on the reception desk which read: "Acer - 20 minutes". I asked whether that meant a delay of 20 minutes and the receptionist simply shrugged her shoulders. Some time later a nurse came out and announced a 30-35 minute delay for something. I asked the receptionist whether this was Acer - more shrugging of shoulders.
It put me in a quandary: I didn't know when to drink the water.
In the end I stuck to the timetable, I was treated on time and I didn't end up in the machine busting for a pee. But it was a bit of a stressful visit.
  Radiotherapy for Prostate Cancer Day 18: Part 4 of 5 of a my Typical Day.
In preparation for radiotherapy I had a CT scan during which reference points were tattooed on the front and sides of my abdomen and their position relative to my cancerous lymph nodes was recorded in 3D.
Once I’m on the radiation machine's table my position is adjusted to line up these reference points with laser guides. I start off in an approximate position based on my feet touching a couple of blocks, then I’m asked to move myself a bit, then I’m asked to relax while the nurses do some fine-tuning by pushing, pulling and rolling my body.
I think this is just so the lymph nodes are in the right ball park for the machine to find them, which is what happens next. The nurses leave the room and the whole, huge front of the machine rotates, scanning me in 3D. After a while this stops and there’s a pause, possibly while the scanning data is processed to find the exact location of the lymph nodes.
After this the machine moves the bed slightly, with a bit of a jerk. My guess is this is so the lymph nodes are in the exact line of fire of the radiation beam.
There’s another pause and then the machine starts making a buzzing sound as it rotates around me. This is the actual radiation therapy. It does a complete revolution in one direction and then another complete revolution in the opposite direction.
Here's a video of an identical machine being used elsewhere:
Impressive, isn't it?
  Radiotherapy for Prostate Cancer Day 19: Part 5 of 5 of my Typical Day.

As you've probably seen, when I had radiotherapy 8 years ago external beam technology was considered too risky for me because my prostate was surrounded by scar tissue from my bowel cancer op. This machine has made it okay. I'm tempted to say "more than okay" because I've had absolutely no side effects, I'm not even tired.
As I've mentioned in previous posts I think this treatment will keep me going for several more years. And who knows - by then there may be some big advances in cancer treatment.
At present I'm reading "The Code Breaker" by Walter Isaacson, which goes into incredible detail on current advances in gene editing which is behind a lot of the amazingly fast development of Covid testing and Covid vaccines as well as a lot of other stuff. The need for speed on Covid has resulted in academia speeding up peer review processes, universities and industries working much more closely together, and lots of startup activity. What happened in the computer and communications industry, the tech revolution, seems to be repeating itself in health. There's going to be some breakthroughs, I think/hope. And I think/hope I will be alive to benefit from it!
  Radiotherapy for Prostate Cancer Day 20: History of my prostate cancer, Part 1. Today is up until my first round of radiotherapy treatment in 2013.
In hindsight I think I might have had prostate cancer 20 years ago when blood was found in my urine (a symptom of it). At the time it was put down to a restriction in my urethra and I wasn't tested for cancer.
Ten years later I was diagnosed with bowel cancer and had a section of my colon/rectum removed. It was next to my prostate (not as shown in my diagram) and the operation resulted in it being surrounded with scar tissue.
The following year I noticed blood in my semen(another symptom of prostate cancer) and had a PSA test. PSA results are unreliable - you can have very high readings and not have cancer. Mine was 11 and medics start taking an interest when it gets over 4.
A biopsy and various scans confirmed that I had indeed got prostate cancer so I was put on hormone therapy (tablets and injections) to starve and shrink the tumours while solutions were investigated.
Removing the prostate gland or having external beam radiotherapy were ruled out because of the danger of damaging my nearby colon surrounded by scar tissue. So I ended up having "High Dose Rate Brachytherapy" in Mount Vernon hospital north of London. This involved inserting a lot of hollow needles up between my legs into the tumour and then using software to move highly radioactive beads through the needles very precisely so that it killed off the cancer without damaging the surrounding tissue.
The needles were installed under a general anaesthetic so that and the first session were pain free. However, I then had to lie still on my back, trying not to move the needles, right through the night for a second session the following morning. It was torture. And it got worse: I had a scan and then had the position of the needles adjusted without anaesthetic. It hurt like hell.
Some of the photos of this process are really gruesome! I guess the plus was that two 15 minutes sessions and a couple of days in hospital did the trick - or at least, it did for several years.
  Radiotherapy for Prostate Cancer Day 21: History of my prostate cancer, part 2

After my 2013 session of radiotherapy my PSA was monitored regularly. It crept up and was eventually dubbed a "relapse" in 2019 when it went over 3. I agreed a strategy of waiting until my PSA got to 5 and then having CT and bone scans to assess the situation.
My PSA got to 5 towards the end of 2020 but the CT and bone scans were inconclusive. I went on to have a PET scan to get a more detailed look, which turned into a palaver: Three scans were postponed because of technical problems so the whole thing took more than a month.
There was a further delay of more than a month in giving me the results. In the end my consultant phoned and apologised profusely. I’d assumed no news was good news but that wasn’t the case - the scan indicated that the cancer had probably got into my sacrum (see diagram). Bad news indeed - click here to see some life expectancy statistics.
I was fast-tracked for an MRI scan to validate this and was soon told that the results of the PET scan were “spurious” and cancer probably hadn’t got into my bones. Phew!
I was put on hormone therapy - a tablet a day and an injection every 3 months. It gives me hot flushes that wake me up at night.
Preparations for radiotherapy also turned into a palaver. Ostensibly it’s to tattoo reference points on my abdomen for the radiation beam machines. That required a CT scanner getting a clear view of my 2 cancerous lymph nodes and I wasn’t able to empty my guts sufficiently to make this possible. I ended up going to the hospital 4 times as various solutions were tried. As you may have seen, I have to take Laxido at home and self administer a “micro-enema” when I arrive at the hospital. I drink 500ml of water 30 minutes before treatment to fill my bladder to push my guts out of the way.
Judging by the number of empty micro-enemas in the Oncology waiting room toilets, I am not alone!
  Radiotherapy for Prostate Cancer Day 22: The Unsung Heros
Up until now I haven't managed to give proper credit to the radiologists that have looked after me so well for the past month. They are a lovely bunch, so kind, caring, and knowledgable.
I've called them nurses in previous posts - they are radiologists! There's 20-plus of them, plus various specialists, in Derriford's Oncology department. Two or three typically look after me - not the same ones every day.
  Radiotherapy for Prostate Cancer Day 23: Last Day of Radiotherapy.
(2nd December 2021 - my birthday!)

I know this is weird but I will miss some aspects of the radiotherapy.
I enjoyed the time (a total of 23 hours!) I spent in the Oncology waiting room because I was busy dreaming up ideas, figuring out how to express some things visually and getting on and doing the actual drawing.
I also enjoyed the actual treatment (15 minutes max each day). The radiologists were so caring, it was totally painless, it was quite restful staring up at the sky and trees in the screens on the ceiling, and I had none of the expected side effects such as tiredness.
Driving to and from Plymouth (a total of about 1,000 miles) was a bit of a drag but for a lot of people that's their daily commute.
I didn't enjoy having to take Laxido and self-administer micro-enemas but all of this needs to be put into perspective: basically, the NHS has saved my life (again!)

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