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A Primer on Prostate Cancer
Written and Compiled by Donna Pogliano

The Primer has evolved into a book called "A Primer on Prostate Cancer, The Empowered Patient's Guide", by Stephen B. Strum, MD, FACP and Donna Pogliano, available through web booksellers, at local libraries and bookstores and at the website of the publisher.


TREATMENT OPTIONS

SURGERY


Radical prostatectomy (RP) is the surgical removal of the prostate. It has a long track record. It is not effective as curative therapy if there is spread of the cancer beyond the borders of the surgically removed specimen. Most commonly, lymph node biopsy is done early during the radical prostatectomy procedure, and if evidence of spread to the lymph nodes is detected, the surgery may be aborted in favor of other treatment options, since the procedure is not curative. However, there are convincing studies from the Mayo clinic showing that patients undergoing radical prostatectomy with diploid tumor do exceptionally well with androgen deprivation therapy despite lymph node metastases and the RP affords significant benefit in such patients. There are also studies from Duke University that indicate that RP in the setting of no more than two lymph nodes involved confers a significant survival advantage.

Surgery affords the benefit of allowing assessment of the size, distribution and aggressiveness of the cancer by doing a full pathological exam of the removed gland and seminal vesicles along with lymph node sampling, as opposed to the tiny samples obtained by biopsy. Although this doesn't give a full representation of the extent of the disease (distant metastases, for example) it does provide more complete information than other treatments can.

Surgery may result in temporary or permanent incontinence and impotence, but some patients accept that risk in the belief that the procedure will result in the most favorable cure rate and thus, they will have peace of mind for their future. RP is technically difficult surgery and requires the selection of an artist to achieve outstanding results and to minimize adverse effects.

Both surgery and radiation therapy destroy the prostate gland resulting in dry orgasms. There is no ejaculate because the prostate can no longer produce the fluid that it produced when it was intact.

Nerve-sparing surgery is possible in some, but not all cases and cannot be determined prior to the procedure. The doctor's goal in surgery is to remove all the cancer, not to preserve erectile ability. If one or more nerves are spared, some men are able to achieve erections unassisted or by use of Viagra or other similar drugs being tested and approved for treatment of erectile dysfunction. Probability of regaining erectile ability with or without Viagra after surgery increases if the patient is relatively young (50 and under), if he had no erectile difficulties prior to his surgery, and if he was sexually active before the surgery.

If Viagra doesn't work or both nerves responsible for conducting the impulses from the brain resulting in erections are removed, options include injections of drugs into the penis (again, not as bad as it sounds and favored by many over other options), and vacuum erectile devices (VED's) which manually draw blood into the penis resulting in an erection. Some men have surgery to install penile implants if they are not comfortable with the other options.

Incontinence is due to surgical involvement of the muscles that control urination. Urinary incontinence may be temporary or permanent. In general, younger patients recover full continence faster, while older patients need to be just that-patient. Stress incontinence, releasing urine involuntarily while lifting, coughing or sneezing, can be a lingering side effect, particularly in older men. Incontinence as a result of RP is related to the skill of the urologist doing the surgery.

Exercises, called Kegel exercises, are done to help retrain the muscles responsible for containing and releasing urine at will. Other options for long-term incontinence include drug therapies, physical therapy, biofeedback and other options, including surgical implantation of an artificial urinary sphincter or AUS.

In general, whatever the problem, there is usually some treatment option available to you. And in the event of recurrence, you have radiation treatment and/or hormone treatment to fall back on. However, the fewer the intrusions into the human body the better. Therefore, it is important to try to properly select the patient for a treatment that is most appropriate to him and to prepare the patient for the therapy while always choosing an artist to perform the procedure.

RADIATION THERAPY

Radiation therapy (RT) is another commonly used treatment for prostate cancer. There are several commonly used forms.

Brachytherapy

The word "brachytherapy" comes from the Greek words "brachy" meaning "close by" and "therapia", in this instance, referring to a radioactive source applied in or near the tumor.

Permanent Seed Implants (SI) or High Dose Rate Temporary Brachytherapy (HDR)

Brachytherapy is available in the two forms mentioned above. Treatment by permanent seed implant (SI) involves injecting a number of radioactive seeds into the prostate gland. The seeds consist of radioactive material encased in a titanium shell smaller than a grain of rice. The radioactive material can be iodine, with a half-life of two months, or palladium, with a half-life of two weeks. Your doctor will help make the determination as to which is most appropriate for your cancer and will determine how many seeds you need to adequately treat the size of your prostate gland. The smaller the gland size, the fewer seeds you will need to adequately treat the entire gland.

The seeds are inserted through hollow needles, under anesthesia, through the perineum (the space between the scrotum and the anus). This is usually "day surgery" or done as an outpatient procedure and normally does not require an overnight hospital stay. Some doctors place seeds in areas outside the prostate, such as the seminal vesicles, if they are considered to be at high risk for cancer spread. Sometimes external beam radiation in addition to seeding is necessary to kill any cancer thought to have escaped the capsule and still be contained within the pelvic region.

A major disadvantage of this form of treatment is inability through the procedure itself to obtain evidence as to whether the cancer has spread beyond the capsule to an area that the radiation from the seeds cannot reach. Proper testing prior to the procedure is therefore very important. In addition, patients considering either form of brachytherapy or considering surgery need to refer to the Partin Tables and Bluestein predictions to obtain their percentage for risk of extra-capsular penetration and lymph node involvement. You or your doctor can determine these figures. The Partin Tables are also available on the Internet. See the Resource List later in this primer under "Quick Reference." The Partin Tables were compiled by analyzing prostate glands removed during surgery to determine the spread to lymph nodes and seminal vesicles.

Treatment by seed implantion can result in bowel and bladder problems, usually temporary and treatable with medication. The urethra goes through the prostate gland and the insertion of the seeds or wires can cause the prostate gland to swell, which can cause in varying degrees, restriction of the urine flow from the bladder. In severe cases a catheter may be used to overcome difficulties in urination that arise as a result of brachytherapy. Self-catheterization kits are available for home use if urinary retention problems persist for an extended period of time.

The procedure has the advantage of being inherently nerve-sparing, which means that Viagra or new medications that act similarly will produce erections in most patients. Incidence of at least partial impotence seems higher than usually disclosed, especially in patients 70 and older. Longer term follow-up of patients having brachytherapy and its effect on erectile function is needed.

Many patients experience a rising PSA at some time after having brachytherapy. The average time to this PSA "bump" is 18 months. This phenomenon is thought to be the result of radiation-induced prostatitis, a reasonable explanation for this bump in PSA. This stressful event can be avoided if patients know that a rise in PSA may not necessarily indicate a recurrence of the cancer, pending the timing of the PSA rise and the history of having received brachytherapy.

If however, testing indicates the treatment has failed, traditionally the salvage treatment is hormone therapy, but High Dose Rate (HDR) temporary brachytherapy is now also being used for failed treatment by permanent seed implants. Surgery after radiation is seldom done because of the high incidence of severe complications. Many men prefer to avoid the increased risk of complications and elect hormonal therapy instead. Cryotherapy (freezing the prostate) is now being used by some as a salvage therapy after failure of primary treatment.

High Dose Rate Temporary Brachytherapy (HDR)

High dose rate (HDR) brachytherapy is the other form of brachytherapy. Unlike permanent seed implants, no "seeds" remain in the prostate after treatment. The procedure usually involves an inpatient hospital stay of about two days. Tiny plastic catheters (hollow tubes) are inserted into the prostate gland and the tumor. The patient is then placed on a very high powered CAT scan to aid in refining the position of the catheters to ensure there are no cold spots. A computer-controlled machine then pushes a single highly radioactive iridium wire into the catheters one by one. The wires are left there for a few seconds, then removed.

The computer can control the length of time a single wire remains in the catheter and therefore precise dosages to different areas of the prostate and the tumor are possible. The tumor itself can be treated with a higher dose of radiation, while sparing healthy tissue and surrounding organs, thus bowel and bladder complications are more likely to be minimized. Patients report that no urinary catheter was necessary after this treatment.

The goal of this procedure is to destroy the cancer quickly, with higher doses of radiation than could be permanently implanted. Ideally, placement of the radiation is very precise, leaving no cold spots. HDR, in use for over ten years, is gaining acceptance as a highly effective alternative to conventional permanent seed implants. It is presently done in just over a dozen places in the United States. (See the Resource List.) The equipment and training are very expensive, but the cost of treatment is competitive.

HDR is usually combined with external beam radiation therapy to destroy cancer that may have escaped the capsule yet still remains within the pelvic region.

External Beam Radiation Therapy

Another type of radiation is external beam radiation therapy (EBRT). Some radiation oncologists use EBRT in conjunction with treatments to the pelvis in an attempt to cure prostate cancer that is not organ confined. Full pelvis EBRT seems ineffective in curing the cancer and may result in bowel and bladder problems due to radiation being poorly directed and affecting healthy tissue.

However, there is new technology in the field of external beam radiation. 3-D conformal beam radiation therapy (3D CRT) comes highly recommended and is widely used, particularly in conjunction with brachytherapy to be sure any cancer which has spread to the immediate area surrounding the gland is also killed. In this procedure, marks are made on the body, or a custom-made body mold is made for positioning the patient during the treatments to help insure that the radiation is delivered precisely to the intended area. Various other techniques are employed in modern beam radiation treatment to control for such factors as the movement of the prostate and variations caused by fullness of the bladder or bowel.

Intensity Modulated Radiation Therapy (IMRT) is another major advance in treating prostate cancer that minimizes radiation to the normal tissues. IMRT uses sophisticated computer planning that allows the radiation oncologist to designate how much RT he wants administered to both malignant and normal tissues. The IMRT hardware allows variation of the dose of RT while the equipment moves around the patient to fulfill the equation determined by the computer. This is a serious advance in the technology of RT and should be the basis for all radiation in the near future. See the July, 2000 issue of Insights (PCRI) for a full discussion of IMRT. (See the Resource List under General Information.)

Proton Beam Therapy

Proton beam therapy is a lesser-known radiation therapy done at only a few centers in the United States. It does not currently have a long track record, so long-term cure rates are uncertain. It uses the proton instead of the photon for the treating particle. Protons have the ability to be more sharply focused and their energies fall more within the target tissue (the prostate and seminal vesicles) than outside the gland. Comparison studies of proton beam vs. 3D CRT or IMRT have not yet been done.

ANDROGEN DEPRIVATION THERAPY (Hormone Therapy)

Hormone therapy is recommended for patients whose prostate gland is too large to be effectively treated with EBRT, brachytherapy or cryosurgery, and needs to be reduced in size before these procedures can be performed. Hormone therapy can thus make these local therapies more effective and reduce their side effects.

Hormone therapy is sometimes used in conjunction with various radiation therapies for the purpose of limiting testosterone production and reducing tumor volume, since this will increase the effectiveness of RT and yield a higher disease-free rate. EBRT of any kind, brachytherapy and cryotherapy are all volume-dependent treatment modalities. If there is too much tumor volume, they will not be effective.

Some patients who feel the need to buy time for one reason or another-to research their options for treatment or because of some other pressing life issue that prevents immediate treatment may initiate ADT. ADT is sometimes used for this purpose, but it may not be necessary and may preclude treatment at some centers.

For men with advanced prostate cancer, ADT is the only currently recognized effective treatment option. For some men with distant metastases, this therapy can work for many years. Intermittent androgen deprivation therapy can have a positive impact on quality of life because in off cycles, the patient gets a break from the side effects of treatment.

This therapy typically uses drugs to eliminate the production of testosterone by the testes, thus removing the nourishment to the cancer. Some patients choose this therapy as primary treatment because they are unwilling to undergo a more invasive treatment for health reasons, due to advanced age, or other factors. However, be aware that the side effects of ADT are many and varied, although not all patients experience all of the possible side effects. One common side effect of long-term ADT is osteoporosis, which compromises the integrity of the bones and can result in fractures, bone pain and shortening of height due to compression fractures of the spinal vertebral bodies.

Younger men typically wish to avoid ADT because it results in decreased libido (sex drive). However, some informed younger men are using hormone therapy as primary treatment, with the idea that there are many fall-back options if it is not effective. If the disease is brought under control, a patient may be able to stop the medication intermittently for long periods and would still have his prostate. Once the prostate is destroyed, orgasms are "dry", that is, without ejaculate. Some men report that the sexual experience is thus permanently diminished for them.

Effects of temporary ADT for a short term (less than two years) are typically reversible once testosterone production is naturally resumed by the body, or resumed by introduction of testosterone drug therapies.

Cancers that have spread to the bone can be dramatically halted or slowed by ADT resulting in almost immediate pain relief. Testosterone production can also be halted by surgical removal of the testicles (orchiectomy) and by drug intervention to block male hormones (androgens) produced by the adrenal glands as well as the testicles. Agents like Ketoconazole (Nizoral) have this ability.

Orchiectomy is a surgical procedure in which the testes are removed from the scrotum surgically, so the testosterone they produce is unavailable. This is an irreversible method of depriving the body of testosterone. It is sometimes done for reasons of economy, because the drugs involved in hormone therapy are very expensive. Both orchiectomy and drug ADT are capable of reducing the testosterone to castrate level.

The use of ADT is complex and controversial. The options for specific drugs to be used alone or in combination need to be thoroughly discussed with your doctor. If you are a candidate for this therapy, it is recommended that you research all of your options very carefully.

WATCHFUL WAITING

Watchful Waiting (WW) is an option for some cancers. A cancer that appears to be slow growing and organ confined may require no local treatment for some time, if ever.

Some patients feel that they can preserve their quality of life by avoiding more aggressive treatment and proper testing can help determine if this is an option for any specific case.

Watchful waiting does not mean doing nothing. It implies that the patient is embarking on a regimen of diet and exercise best suited to his condition in consultation with his doctor. See the Resource List later in this primer under "Diet & Lifestyle" for specific information on what the experts recommend in this regard and what current research indicates. Some patients using watchful waiting are using herbal supplements, meditation, exercise, prayer, humor and a variety of other methods in concert, in an attempt to control the disease. It is wise to closely monitor the cancer in the event that more aggressive treatment seems indicated.

CRYOTHERAPY

Cryotherapy is a lesser-known therapy that is gaining some acceptance. Hollow needles are inserted through the perineum and liquid nitrogen is used to freeze the prostate and destroy the cancer. This therapy is being used as a salvage procedure in the event of recurrent cancer after EBRT or brachytherapy has failed. However, it is a reasonable primary therapy for prostate cancer that is organ confined or that is associated with minimal disease extension into the capsule. This therapy mandates the choice of an artist.

MICROWAVE THERMOTHERAPY

New on the horizon is microwave thermotherapy, just recently approved by the Federal Drug Administration for use in the U.S., offering an alternative for those men who are not good candidates for surgery. This therapy heats the gland, thus killing the cancer. There are also no established cure rates as yet for this relatively new treatment.

TREATMENTS ON THE HORIZON

There is currently no "magic bullet" to cure prostate cancer. However, research and clinical trials are proceeding to develop medications that will search out and destroy cancer cells in the body by various methods. In the future, some of these therapies may gain approval by the Federal Drug Administration and be put into use by the general public.

Aptosyn (Exisulind) is a drug that has been successfully used in clinical trials and is undergoing further testing. It theoretically directs precancerous and cancerous tissue to self-destruct without harming healthy tissue. This is one of a number of "smart bomb" drugs in clinical trials. The FDA is expected to give approval on this drug manufactured by Cell Pathways, Inc.

There are also numerous other drugs under clinical testing that may hold promise for future treatment. Anti-angiogenesis drugs (Endostatin, for example) may eventually be available to "turn off the switch" in molecules that signal blood vessels to develop and nourish tumors. Without nutrients, the tumor shrinks.

Vaccines are also being tested which use the body's own immune system to cause death of cancer cells.

Chemotherapy is used in the treatment of prostate cancer in advanced stage disease in the hope of slowing the growth of the cancer and prolonging life. There is an experimental treatment currently being investigated, using imaging with vitamin B-12 to detect tumors. This could be used as a vehicle to destroy tumors by attaching a lethal anti-tumor agent to vitamin B-12, which tumors use to build their network of cells and blood vessels. Tumors are detected by use of vitamin B-12 because of higher B-12 concentrations than in normal tissue, since tumors require more of this vitamin than normal tissues require.

CLINICAL TRIALS

Drugs being tested and other experimental therapies are the subject of clinical trials. Clinical trials are not usually a preferred primary treatment option. But for patients who feel they have few options left, clinical trials may be appropriate.

These trials are done in Phases, with Phase I being the most experimental, to determine proper dosages. Phase II is usually a trial done on a limited number of patients, once optimum dosage is determined. Phase III is usually a widespread test population which precedes the application for approval by the Federal Drug Administration to make the drug or treatment available to the general public.

If you are considering becoming involved in a clinical trial, you need to research thoroughly and ask questions. Will you get the drug or will you be part of a double-blind study in which a control group does not get the medication or treatment? What will the side-effects likely be? Will you be able to leave the test at any time if you choose? Will you be eliminated from the test under certain conditions? Do you fit the criteria for involvement in the test you are considering?

The costs of clinical trials are not currently covered by most insurance plans, but new legislation may bring changes in this policy, making participation in clinical trials possible for more patients, resulting in faster progress in developing new medications and treatments.

RESOURCE LIST

Books, Web sites and e-mail mailing lists

The information provided in this Resource List is included in an attempt to provide prostate cancer patients and those who love them with help in their search for information about their disease. This list in no way is intended to be all-inclusive and it certainly could never exhaust all the information available on any particular topic. Some of the resources included are commercial sources, since the profit motive in many cases has provided the impetus for the existence of the material.

It must be recognized that the people responsible for providing this Primer on Prostate Cancer and its informational content have no financial interest or connection with any person, product or institution included in the Resource List, nor are they endorsing any particular product, institution, person or treatment modality. Inclusion of a resource does not imply or constitute any endorsement, and conversely, omission of any product, institution, person or other resource does not imply or constitute a negative endorsement.

BASIC INFORMATION:

"Prostate & Cancer, A Family Guide to Diagnosis, Treatment and Survival" by Sheldon Marks, M.D., specifically recommended for it's good organization and completeness. This book may be a little outdated in terms of newer treatments such as high dose temporary radiation therapy and cryotherapy, since these procedures are in more widespread use since the book came out, but it is still a valuable resource.

A book that can be read on line A Revolutionary Approach To Prostate Cancer by cancer survivor Aubrey Pilgrim

QUICK REFERENCE

Full description of TNM Staging designations

A discussion of Clinical Stage with color illustrations is to be found in the July, 2000 issue of INSIGHTS, published by the Prostate Cancer Research Institute (PCRI) with the financial support of the Life Extension Foundation. Call to be placed on the mailing list at (310) 743-2116, or Fax your request to (310) 743-2113. Or look for Newsletter at the PCRI home page.

Information on Markers and Tests for prostate cancer.

The Partin Tables

Expert pathologists to confirm Gleason score.

Questions to ask your doctor.

HIGH DOSE RATE TEMPORARY BRACHYTHERAPY (HDR)

Listed below are some of the links and web sites relating to HDR. This is not intended to be a complete listing of all manufacturers, hospitals and centers involved with HDR, nor is it to be construed as an endorsement of any product or treatment center. These resources are listed to provide an overview of HDR and how it is performed.


These Cancer Treatment Centers of America at Tulsa (CTCA) Web sites have explanations of HDR while the web site of the California Endocurietherapy Cancer Center in Oakland, California also gives good information and Brachytherapy/Seed Implants provides some thought provokong material.

DIET & LIFESTYLE

The Prostate Cancer Protection Plan - The Food, Supplements, and Drugs that Could Save Your Life by Dr. Bob Arnot. This is a new book that includes nutritional and lifestyle recommendations for use in preventing and controlling prostate cancer.

Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer by Michael Lerner. Available on line.

Eating Your Way to Better Health: The Prostate Forum Nutrition Guide, by Charles E. Myers, Jr., M.D., Sara Sgarlat Steck, RT, and Rose Sgarlat Myers, PT, PhD.

Dietary advice is available through the Prostate Cancer Foundation.

GENERAL INFORMATION

The American Cancer Society phone number is 1-800-227-2345. The American Cancer Society has a free program called "Man to Man" where survivors offer support to the newly diagnosed. There is also an interactive section in which people can e-mail oncology nurses with questions and obtain referrals.

Prostate Cancer Research Institute (PCRI) is a non-profit educational and research organization with valuable information regarding prostate cancer. PCRI publishes Insights, a newsletter covering in-depth areas of key science and key concepts in prostate cancer. PCRI is at: Helpline number is 800-641-PCRI or 310-743-2110 EMail address is help@pcri.org

TREATMENT DECISIONS

A helpful guide to determining appropriate treatment options (a Decision Tree) is at the National Comprehensive Cancer Network site

Also consult: National Cancer Institute at 1-800-4-CANCER.

RADICAL RETROPUBIC PROSTATECTOMY SURGERY

The Prostate: A Guide for Men and the Women Who Love Them, by Patrick C. Walsh, M.D. and Janet Farrar Worthington.

PERSONAL ACCOUNTS

Surgery:

Man to Man: Surviving Prostate Cancer by Michael Korda. This is a book specifically dealing with a patient's experience with surgery. People report that it frightened them, but they were glad they read it. Your library may also have this book on cassette tape.

Prostate Cancer, A Survivor's Guide by Don Kaltenbach

My Prostate and Me by William Martin

Brachytherapy:

Seeds of Hope by Michael Dorso, M.D. may be available on line, but is now available as a paperback. This is a personal account by a doctor who had permanent seed implants (brachytherapy), hormone therapy and conformal beam radiation. Cost was $6 to obtain it on line.

DISCUSSION GROUPS

If you have e-mail access, there are a number of discussion groups available to you for support and technical information, sharing experiences and asking and answering questions. All are free of charge.

Prostatepointers offers mailing lists specific to various treatment modalities and a support list called "Circle." Address an e-mail to: Majordomo@www.prostatepointers.org leaving the subject line blank, and write "subscribe" in the body of the message. In a few minutes, you will be sent information on which discussion lists are on the system and how to subscribe to them.

An extensive network of discussion groups, archives, encyclopedia of information, practitioner lists for various therapies, lab recommendations for second opinions, Partin Tables, you name it, its there, at Patients Helping Patients.

SUPPORT GROUPS

You may or may not wish to join a formal support group and attend their meetings. If you have the need or the curiosity, or just want to go to see what help you can be to others, your local hospital can probably put you in touch with your local chapter of US TOO! International, Inc.

A support group affiliated with the American Cancer Society is "Man to Man." Contact your local hospital or the National Cancer Information Center at 1-800-ACS-2345 to get information about your local chapter.

SHARING AND CARING

A website dedicated to helping men and their companions with the deeply personal issues created by prostate cancer is Phoenix5. This site also features an excellent interactive glossary of terms.

Another excellent and highly recommended support and information network is called "You Are Not Alone" (YANA) with a wealth of good advice and information


HELPLINES

Physician to Patient (p2p) is a mailing list which allows patients to ask specific questions related to their case of doctors who volunteer their time to write answers which are posted to the for the education of all. It can be accessed through: Majordomo@www.prostatepointers.org Address an e-mail as shown above, leaving the subject line blank, or show a dash (-) if required, and write "subscribe p2p" in the body of the message, and under it, write "end." In a few minutes, you will receive a welcome memo and instructions on how to present your prostate cancer digest.

Prostate Cancer Research Institute (PCRI) has a telephone Helpline at (310) 743-2110.

PRACTITIONERS

The Prostate Cancer Address Book (PCAB) lists outstanding people in the world of prostate cancer.


SO...

You will change as a result of having prostate cancer touch your life. It's not ALL bad. You are a member of the fraternity now. And you have opportunities born of adversity to change the lives of others.

Many people report oddly incongruent benefits of having been diagnosed with cancer as they progress down this road. Some say that life seems more precious, their relationships improve, they find new joy in simple pleasures, they become more spiritual, they live each day as if it were their last, they appreciate everything more, they have found a new intimacy with their partners, they define sexuality in a more mature fashion, they have found new friends, formed new attitudes, embarked on healthier lifestyles...the list goes on and on.

We hope the information contained in this prostate cancer primer will be helpful to you and that you will discover additional information through your further research. Your first task is to educate yourself about your own condition, then hopefully, you will be in a position to educate other men and their families about prostate cancer and to urge them to have regular annual screening in the form of PSA testing and digital rectal exams.

We wish you low PSA's, and may your days be good, and long upon the earth.

-------------------------------

Compiled and written by: Donna Pogliano Partner of a warrior in the battle against prostate cancer. E-mail address: dpogliano@core.com

You may print one copy of A Primer on Prostate Cancer for your own personal use. The entire document is available for easy printing as a Word.doc file (98 KB) or in Adobe.pdf (150 KB)

My special thanks to Georann Whitman and her family who provided the inspiration for the primer.

My thanks to the following men and women who reviewed the document, contributed material or provided moral support:

Grayson S. Young
Terry Herbert
Aubrey Pilgim
Michael Dorso, M.D.
Jim Lamberth
Joe Armon
LaVonda Hurlbut
Esther Kutnick
Howard Waage
Ann Salvato
Rip Rinehart
Ramon Henkel
Stephen Strum, M.D.
Robert Vaughn Young


Copyright Donna Pogliano 2000. All rights reserved.