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August 12, 2019

Midlife and prostate cancer with James A Hill

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Cancer is the scariest word for many of us. James Hill takes us through his journey with prostate cancer and by doing so gives us a solid approach for dealing with the disease and the thoughts and fears we'll face after diagnosis.

Allan: 02:28 Jim, welcome to 40+ Fitness.

James: 02:30 Thank you Allan. Glad to be here.

Allan: 02:33 Now your book, Midpoint, aptly named. You know, I'm sitting here at 53 and I'm thinking, okay all those things that I did as a kid, you talked about some of them in part of your book where you're riding your skateboard and then that happens and there's an accident and blood and scars and this happens in blood and scars. And I'm thinking, you know, when we get this age, blood and scars are actually really scary.

James: 02:59 Yeah. It's a remarkable a for me that this is the point in life for a lot of men, that really marks an inflection where we, where any kind of a, um, a brush with health can be more than just important, more than just a scar on your under elbow. It can be something a lot scarier. So, um, it is an important point for me to explore in the book.

Allan: 03:21 Yeah. But beyond the being scared part. I, you know, I think, I think what the purpose of this show and then when you're listening to this show, I want you to know why we're here. We're here because men tend to have this trait of pride and obstinance and wanting to be the provider, wanting to be that man that's out there doing these things. And many times, you know, we neglect those little things. We neglect doing the things that we shouldn't be doing to manage our health. Fortunately, even though you said you, you may have avoided screenings, not, not completely avoided them, but delayed them somewhat, you did make a point of making health screenings a part of your regimen.

James: 04:03 Very much so. Yeah. I mean I would describe myself overall as being a pretty earnest health care consumer. I always took my health pretty seriously. I work out, I've always been very focused on taking care of myself, but like, like so many guys there certain things I just don't want to be, you know, physical as being one of them. I talked about this in my book. I just never much cared for physicals cause I felt like they marked at least once I hit my forties and fifties, they started to mark a decline in my, in my physical strength and my, in my physical being. So I was probably not as earnest as I should have been on certain screenings. And then of course the PSA test, which my doctor eventually had me take, I should have taken more ownership and asking for it rather than just being a passive recipient of his recommendation to get it done. Because I was at an age where depending upon who you talk to, typically over 50 men should be getting their PSA.

Allan: 04:59 Yeah, it's part of my wellness testing, my, my PSA and so far I haven't had any, any issues, always less than that. And that's always been, that's been the case. It's always, it's always been below two well below two, well below one actually. So I feel pretty good there. But it was funny because for a long time as we looked at these tests, doctors were actually starting to pull away from them and saying, we don't need diagnostic tests because we get false positives and we ended up with people freaking out. We may even end up with procedures that we didn't need to do. But the thinking's turning around on that a little bit, isn't it?

James: 05:36 Yeah, it is. It's, you know, as I mentioned in the book, the, the subject of whether to get PSA testing is an enormous point of controversy in men's health. And it's one that I think has done men in general a disservice. You know when PSA testing kind of came on, the scenes became popular in the 90s. Everybody was recommending it to gives, it seemed like you're her first really reliable or, or reasonably reliable diagnostic for, um, screening methods available to men to catch, to catch a prostate cancer. And it does, it does. What a lot of people didn't come to terms with at the time is that there are multiple reasons why your PSA, your prostate specific antigen might be elevated if cancer is only one reason. And so what ended up happening is men who had BPH, benign prostate hyperplasia or prostititus, which is an infection of the prostate or other things that might cause their PSA to be elevated. They were rushing out and getting a, getting a biopsy which can, which can result in an infection and complications. And they had a lot of general adjuncts around the fear of cancer only to find out that they, they never had cancer in the first place.

So then the medical community pulled back from PSA testing and said, you know, if you look at it statistically, it's not saving enough lives. Well, I'm not a believer that any guy wants to be a statistic and I'm one of those people who had I not gotten my PSA tested, could have ended up very easily with metastatic prostate disease. So yes, the view has changed back and forth. I think that's why any man, I think over 50 and certainly over 55 needs to own that process, needs to understand what prostate screening or PSA screening is all about. Needs to consult with either his urologist or his physician about whether he thinks at a digital rectal exam is sufficient or whether he wants to get a baseline PSA and continue testing. But it's the one thing you shouldn't ever do is not have the discussion with your doctor needs to be something that you do in a methodical, calculated way. And at least if you make a decision not to be tested, at least you're owning the decision.

Allan: 07:54 Yeah. So for the first several years, you know, when your doctor was going through the standard of care, he was using the old rectal means of testing to see if there's any abnormal swelling or growths or anything like that. And you were checking out just fine.

James: 08:11 Yes. Every time. Yeah. We, we've been checking, I think since I was 50 and I was diagnosed when I was, I want to say 50, 56, almost 57 so yeah, the nature of that exam of course is that a digital rectal exam only has access to part of the prostate and it's a pretty good screening test if you have a capable physician or pa or nurse Practitioner who really understands what a prostate should feel like and can recognize a nodule or some irregularity. But again, if you've got a, if you've got a lesion on the, on the far side of the prostate that's not accessible through the rectum, that's not going to be detected through a DRE is as they're called. And that was the case with mind and why mine was, was had reached all the way to stage three before they ever found it.

And it also that very fact, even when I had my biopsy, they typically they take 12 cores, tissue cores in a biopsy, only two of mine, showed, showed cancer, which led them to a very reassuring diagnosis of stage one prostate cancer with a Gleason score of six, which is a, which is a very low grade cancer. Well, by the time we got through MRIs and everything else, we found out that I was actually stage three with a, with a high seven in which we can talk about it to like, but so I had to go all the way through MRI and eventually through the surgery to really understand the nature of the disease. So, you know, it's a process of understanding what you have is very much a process of choosing the right procedure and getting a more complete picture of what's going on down there.

Allan: 09:50 Yeah. Now as you went through the book and it was Kinda like you're walking us through some of the learnings that you had as you went through here, because prior to this you had no reason to know a PSA relative. You know, it just, if it's better or bigger than two or lighter than two, but you know what it means when it's excessively at higher than two. You learned what the Gleason score was and how almost somewhat, I'm not gonna say subjective, but there's a little bit of, we learn as we go because we, we probe further and you know, biopsies will do something MRI's will do something. But, even after the surgery, they're there, they're still coming back and trying to look at that data to say how aggressive was this? Do you mean because going to the Internet for some of this stuff, I guess you can be, should be scary as hell reading stories. But how does someone swim through all that information and get their head clear on, on the, the treatment that's right for them.

James: 10:47 That's a great question. And it's such a personal process, Allan. I mean, that's a remark. I get a lot from a lot of guys because maybe it was how I presented the process I went through in the book that made men thing. Geez, I don't know if I would have the desire or the or the staying power to do the kind of research I needed to do to make an intelligent decision. And a lot of guys don't. Honestly, you know, I've spoken to a lot of men who kind of went the, from the moment they met with their primary care physician, whatever that primary care physician recommended they did. And in some cases they have good outcomes. In some cases they don't. I'm a great believer in the whole model of the empowered healthcare consumer. I think it's critical that a man, as I said earlier, own his health and particularly in an area that is so fraught with controversy.

So what I did is I simply didn't believe everything I was told at first blush. Acknowledging that everybody in the healthcare system and all of the information on the Internet is to a certain sense. It's, you know, there's some subjectivity to it. There's certainly some controversy there. So I made it my job to talk to people. First of all, I knew who had been through prostate cancer themselves, what their processes were. I tried to find out where they went for information and what they had learned so I could kind of leapfrog or, or piggyback off of what they had they had done and if I could of saved myself some time by using their research I did. But I also, I very much guided myself by going to the best, the best resources online. So I was in my career, uh, prior to having cancer had been in content marketing where we published good clinical information on behalf of some major hospitals and hospital systems.

And so I knew who the, who the great cancer centers for example, were. So I tended to go either to.org or.edu sources online and you know, so names like Sloan Kettering or Mayo Clinic or Harvard health. And the more scientifically sound that information was, I found the more tended to align well. And the theme that I kept hearing over and over again is your situation's unique. You need to interact very proactively with your caregivers and be picky. And so I did a ton of research. I read up everything I could on PSA at Gleason scores, on staging, on radio radiation versus surgery versus what they call cocoa therapies, which are for early stage cancers. And I kept asking a lot of questions. I also happened to be very fortunate. My wife is a very smart and very capable partner and so she at the same time was challenging me and challenging doctors that I was meeting with and we just kept asking questions and challenging the kind of the prevailing wisdom until we felt like we had enough information to make a decision.

And I want to credit some of the doctors I met with for, for having said early on, look, because treatment plans and treatment decisions aren't always clear for a man because there are so many variables and there's so much unknown about prostate cancer. It's a, it has to be a collaborative process between the doctor and the patient. And I've even seen that taken to some ridiculous levels where some doctors will say, it's your decision, just tell me which one to do. The doctors that I dealt with were much more collaborative and said, look, here are your options. You know, here's what I would recommend, but you should go out and meet with people that you, uh, that you think and kind of eliminate the matter for you. So for example, I met both with a radiation oncologist and a surgeon and then of course a number of urologists and positions and PA's along the way. And my thought process eventually took me to surgery, but um, you know, for it, had I been 10 years older, I might've gone with radiation. It just depends on your, your particular situation. So it's, for me, it's all about ownership of the healthcare process and decision making process.

Allan: 14:49 Yeah. And, and beyond, you did something that I think a lot of us would actually find very difficult. You fired your first position effectively.

James: 14:58 I did, yeah.

Allan: 14:58 He wasn't supporting you in a way that, you know, we're not talking about a diagnosis or work. I mean, but the two of you just were not connecting on an emotional level where you felt comfortable with him. Can you talk about that a little bit? We're not going to name him cause he wasn't named in the book, but could you talk a little bit about that, that process of, okay, I've got a doctor that I'm asking him a question and he's sarcastic or belittling me in a way that I just don't feel like he has my best interest at heart.

James: 15:30 Yeah. And, and um, he, you know, he was, this doctor was, was honestly, I think a good guy and an excellent physician. But like anything in life, certainly in healthcare, which is such a, it's such a human interaction. I just believe that you need more than your expertise. You need somebody who respects you as a human being who understands that your approach to making decisions about your health care might be different from the other patient who doesn't. You know who, I don't care for sarcasm. You know, if somebody sitting with cancer, the last thing they need sarcasm. So this particular doctrine I simply weren't clicking. You know, as I mentioned earlier in the book, I had been advised early on to get an MRI before I had a biopsy and I push really hard with this doctor to do that because the idea is that an MRI gives you a visual picture of the entire prostate before you go in there and start poking needles because if you, if you don't have that visual picture of what you might end up getting is an incomplete diagnostic perspective, which is what in fact happened with me.

We only got two cores when in fact I had quite a large tumor. So I pressed this particular doctor for an MRI and he responded largely by saying he didn't think it was necessary, it wasn't the best practice and made me feel a little bit like a hypochondriac for asking. Well later when I was still considering using him as my surgeon, I subsequently went to Sloan Kettering and the first thing they asked me was, did you do an MRI before your biopsy? And I said, no, I, my doctor divided against you. They said, well here we wouldn't consider doing a biopsy or MRI. So you know, that entire view that I had taken was very much validated. And it was also just a manner in which he opposed me on that decision. It just felt like he was asserting his medical, I don't want to say supremacy but, superiority and I you're a patient, I'm a doctor. You need to listen to me and not acknowledging the fact that I had done my homework.

Allan: 17:39 Yeah. Well and, and realities, you know, are the generation before us and before that and then the white coat walked in and said, do this. We just did it. But now with the advancements in medicine and what's going on in the world, standard of care changes all the time and for the doctor gets you up to speed and say, no, this is, there is a standard of care. And if there's no reason to believe that doing an extra step is going to give you a better outcome. I was just surprised that when you said you were willing to pay out of pocket for this because you weren't, you know, you were told you would probably have to do that, that he just said no. Whereas it would just been a data point. And you know, again, I'm a big fan of the more data points you have, the clearer things can be as long as you just don't get overrun with it. But I think it would have been a point that you've obviously now hindsight definitely should've had.

James: 18:31 Absolutely. And the fact that it was validated the way it was and validated with really good information in the sense that the folks at Sloan Kettering explained that, you know, biopsies first of all, it not that you want to go back in and do, but also it causes bleeding because you're poking all these holes in the prostate. It causes bleeding, which obscures any subsequent MRI image for several weeks after that. So it actually impede the ability to get it to get a good perspective. So there's really a very practical reason to do an MRI beforehand. Now that you know, you mentioned standards of care. The problem with, I think with dealing with with prostate cancer is that standards of care are, they're changing, they're shifting back and forth as, as new data comes in and as doctors debate what to do. Another example of that would be the level of sedative or anesthesia they give you for biopsy and a biopsy is pretty painful. Either I'm a whimp or biopsys are pretty painful.

Allan: 19:30 No, I think 12 holes in the human body.

James: 19:37 Yeah, yeah. Particularly that area. Yeah. It's not, it doesn't feel good and the standard of care is to give you at most of a valium to calm you down and a local anesthetic. Well, when I asked the doctor after the biopsy was over, I said, wow, that really hurt. Has there been any discussion of putting guys under under general anesthesia? He said, yeah, I actually missed his credit. He said, I've been proposing that for a while, but it hasn't been adopted as a standard of care. And so that's one of those examples where it's an evolving thing and I think to a certain degree, medicine is always kinda catch up with what it's learning from patients. And frankly, part of my objective in writing the book was to educate doctors as much as patients about what the process is like so that when they realize, Oh gee, you know, these biopsies really hurt, or Oh gee, it makes it more complicated for a patient if we don't let them do an MRI beforehand. Maybe that's something we can revisit, whether it's on an individual level or on the standard of care level.

Allan: 20:36 Now you mentioned earlier three, three different approaches to treatment. You were passed one of those by already being a six, but do you mind going through those three and then in particular the surgery and the radiation. Spending a little bit of time talking about the pros and cons.

James: 20:53 Sure, absolutely. So the two most common forms of treatment for prostate cancer are either a prostatectomy, which is surgical removal of the prostate or, and by the way, it's always the entire prostate. There is no such thing as taking out part of our prostate, which was illuminating for me at the time. You had to take it all out or you're leave it in. The other option is is radiation therapy, which irradiates the prostate gland and potentially some of the areas around the prostate with radiation to destroy the the cancer cells. They've also developed for men who are very early in their, in it with a very localized cancer or small low grade cancer, have what they call a focal therapies, which are, they use all kinds of exotic things like cryoablation, where they go in and they actually freeze the cancer cell with a, with a needle.

Those focal therapies, as the name suggests, are very focused, therefore very well located small, early cancer. By the time they found my cancer, I was a stage three that the malignancy had moved out beyond what they call the prosthetic capsule or the envelope that is basically the membrane that whole step that surrounds the prostate. So I was by virtue of that the end, it was I think a two centimeter tumor. I was not a candidate for focal therapy. So for me it came down to either radiation or surgery. I should also add that for many men, particularly men who are potentially in their seventies or and who have a slow growing low grade cancer, they have what they call watchful waiting, which is simply to do nothing and to go and maybe every six months or so to get your PSA checked.

And if it's really not growing quickly, there's a great likelihood that men like that will die from some other natural causes before the cancer ever presents a real problem. And that is very much something that's being recommended for men who are older. I was not a candidate for that because I had a very high PSA and it was changing. In fact, it changed from about 15 to about almost 20 in the space of six weeks. So they immediately ruled out watchful waiting. And the fact that I was in my fifties so the decision for me came down to surgery or radiation. And surgery, I think I'd have to check this thing, but surgeries are more common. There's been a lot of push back among some doctors against surgery because they think it's too often proposed for people who could have avoided it.

And I think that probably was the case. It's less so now. But there are, there are various types of surgery that's performed. The most common now I think is a laparoscopic radical prostatectomy, which is the doctor uses a laparoscope that, that goes in basically through five small incisions in, in your abdomen. You know, they use laparoscopes on you know, for example, to repair damaged knees. It's a way of having a smaller incision and cutting less tissue to make repairs. So you get five small incisions into your abdomen. They go in with these kind of like robot arms and they with a doctor looking through, uh, through a video monitor, they removed the prostate that way and, and uh, fix things up and send you on your way. Radiation on the other hand is a process of going in I think typically for about six weeks, five times a day and lying under the beam and the pros and cons are with radiation.

They don't remove the prostate. So some of the side effects of not having a prostate are entirely avoided. So there typically is less with radiation, they are less issues with, with continents, less issues with, uh, post treatment potency. And a man still has his prostate. So physiologically he can still produce semen, which a man cannot live without his prostate. So for a lot of men who, who can, for whom radiation is an option, it's a good choice to give. They can, it has less of an impact on their sex lives. As an example, and my, my own brother-in-law went that route and was, was very pleased with it. The trick is, and this is what helped me form my decision with surgery, my, by the time we had my MRI results and they had, they kind of accurately stage my cancer.

They knew that I was stage three. They knew that it was aggressive and they knew that it had moved outside of the prosthetic capsule. It was likely, in fact, I was told I had about a 50/50 chance. My radiation oncologist explained I had a 50/50 chance of needing radiation after surgery as well. So if you have radiation as your first line of defense, the tissue is so substantially changed by the radiation that it really can't handle surgery Afterwards. Now Sloan Kettering is developing what they call a salvage radical prostatectomy where they will go in if necessary and remove the prostate. That's already gone through radiation, but it's very tricky and recovery is tough and there are a lot of side effects to it. So generally speaking, if you think you're going to need radiation later on as a followup, because maybe the surgery couldn't get all the cancer guys will go prostatectomy first radiation second. It's worth noting too that the cure rates are about the same for radiation and surgery. So making the final decision very much comes down to how bad is the cancer, how fast is it moving, how old are you, what's your life expectancy? All these variables that are unique from man to man. And it was that process for me that was really kind of essential kind of core to my experience with cancer, which was realizing that just because my brother-in-law got radiation and it worked for him and just because my best friend got surgery and I work for him, everybody's different and you cannot just make a decision based on kind of generalized views of these treatments. You really need to dig in deeply and understand your own cancer.

Allan: 27:10 Yeah. And I think that was, that was kind of the core because you had done some research and found surgery's gone really bad. And um, that like you said, the radiation could have done something and then it would've been much more difficult if there was a Reoccurrence. So it is something I strongly considered as far as you know, which you feel good about and you know, what the facts in your particular case are saying. I guess one of the parts of treatment that kind of, I guess I didn't really think a whole lot about, you know, I thought okay, well you have the surgery, they remove it, you know, you heal up from the sutures and you're on your way. That's not the case with prostate cancer. There's, there's a lot of uh, post treatment that needs to occur. Without going into all the gory details. I can kind of talk about cause you need, yeah, you need to buy this book if nothing else to read that story. But um, uh, can you go through some of the details, you know, some of the things that you have to do just to get yourself back to normal.

James: 28:07 Yeah, the main, and of course my experience is specific to the surgery. I can't speak to, to radiation, which does have it have its own side effects. What I didn't mention is that radiation can have side effects affecting potency. And, and I'm from continent, but they tend to be deferred by six months to a year. Whereas with surgery, those side effects of course are immediate coming out of surgery. But the typical things that, that a man needs to worry about coming out of surgery of course, is potency, which is, which requires obviously intact of nerves and in tact blood flow to that part of the body. And sometimes the two nerve bundles that make an erection possible are affected by the cancer and one or both have to be, have to be removed. Now you only need one, but if even one is removed, that's gonna require some post-surgery work, which we can talk about.

But under any circumstances, the trauma that's done to the body during the surgery, particularly the nerves and a man's groin send those nerves into what they call hibernation mode, which can last for one to two years where the nerves simply don't work properly, their healing and they just kind of let like a bear going into a cave. They just stop physiologically functioning during that time. The tissue down there that's required for an erection literally it needs to be regularly stretched in troll with blood. And if it's not, if that doesn't happen, there can be term long term effects on a man's potency. So, and then the other issue is incontinence, which is a very significant problem for man because during a prostatectomy, the urethra is surgically detached momentarily from the bladder to do the surgery.

Then it's reattached and that affects all the muscles down there and the ability to control urine flow. So the two things that are typically one thing certainly has done most commonly coming out of prostate surgery is they're going to recommend that men do with they call Kegel exercises. That's very well known to women who are advised to do with these after they have have a child because the muscles down, they're affected by childbirth. Same thing goes for men after a prostatectomy is literally just like clenching, clenching the muscles of the pelvic bed over and over again, like a workout. Honestly what it is. And in my case, I was advised to do these exercises before surgery and then to do them right after surgery to to just like anything else, you want to have strong muscles. So that's a big part of, of regaining continents.

And then in my case, Sloan Kettering has a group called the sexual health clinic, which is really pioneering ways to keep men functioning from a, from a, from a potency perspective, functioning well, while those nerves recover come out of hibernation mode and that's they, they have various ways of dealing with it. But the most, the way that they use most is an injection therapy where a man gives himself a shot that actually physiologically reproduces, creates an erection, which allows the tissue to be stretched and so forth and, and oxygenated until they heal on your own. So, unfortunately, that is not a therapy that is widely known about known by men, and it's not as widely recommended as, as it should be in the result of a lot of men. Too many men end up having potency issues when they didn't need to. They could have actually recovered normal, normal functioning.

Sloan Kettering is fabulous about that and I was actually part of a study, a 2-year study and following up with men on that and comparing the results of that therapy with men who didn't go through it. And the results are dramatic. I mean dramatic, the kind of improvement in that they see when you're on kind of therapy. And then of course the only other thing I would add, Allan, is that both going into a prostate surgery and coming out of it, the more you can be in good shape, eat well, not be carrying any extra weight, have good muscle tone, all of that prepares you for the what is a pretty significant assault on your body. I mean the prostatectomy takes four to six hours, it's a big deal and a lot of men don't realize it's one of the most complicated cancer surgeries out there.

It messes up the body in a pretty significant way for a while. And it takes a long time to do all the healing that's necessary. The more fit you are both before and after the surgery, you know the better you're going to handle it, the more quickly recover. Some of big proponent of be fit all the time, follow it, have a good diet so that you're not inadvertently helping the cancer or the cancer recur by eating the wrong kinds of foods. All those things. The same things that we're told anyway about being fit and healthy very much affect the outcomes of a prostate surgery.

Allan: 33:04 Yeah. And you know, as you were talking through that and you're getting yourself physically fit. I was, I was thinking about a quote that you had in the book, you talked a lot about how you didn't really see cancer as a battle or at least you didn't like that kind of that phrase of encouragement battles. But you did say this in the book. You said cancer cells are the terrorists of the human body, the weaponized bundles of angry, twisted cellular matter that have come unmoored in their restraints. And, and I thought about that in the basic ways of saying, you know, if we prepare ourselves generally for life, we're going to be strong, we're going to be generally healthy and that's going to put us in a better place. So it's not necessarily a battle so much as knowing, okay, we have this insurgency that uh, we now have to deal with and if we're physically fit and generally healthy, our bodies are going to be more resilient. And then there's always the mental side of this of, you know, terrorism is scary, not knowing when this could happen or if this will happen is scary. And in a sense it kinda changes the way we think about life when those scary moments happen.

James: 34:15 Yeah, yeah, very much so. I'm fortunate that I was always somebody who just was interested in staying healthy as much because I wanted to look good and feel good. But you know, it turns out that healthy has a lot of dimensions to it and you just don't want to go into a scary diagnosis like cancer with anything already compromising your health or that makes it just much more of an uphill battle. And I joked about it in the book about doing, you know, following that was so earnest about following the, the physician's advice for, or being prepared to physically put surgery. I followed advice they didn't even give me, but that's how seriously I took it. And you know, one of the things also that they push you to do, which I talked about quite a bit in the book, is walking right after surgery.

I mean they have you up walking down the hallway within four or five hours of the surgery and then walking subsequent to that while your catheters in and during that, that first 10 days or two weeks of recovery, physical activities so important and the more fit you are going into that process, the more quickly you're going to be able to resume that physical activity that is so central to your healing. The human body was made to move and we're not, certainly after a surgery like that, you might have fluid in your, in your lungs that you need to be able to call from. The stronger your body is, as soon as that can happen, the stronger your circulatory system, the more likely you are to replenish the blood flow to your groin. All of that benefits from being in a generally good state of health. I can't say enough about the importance of that and you know I honestly, I as hard as I've worked at it, there are even things I could have done a lot better. It's just a matter of doing everything you possibly can.

Allan: 36:03 Yeah. Now I define wellness as being the healthiest, fittest and happiest you can be. What are three strategies or tactics to get in stay well?

James: 36:14 That's a great question. I would say from my perspective and within the very specific context of prostate cancer treatment, it's leading a fit lifestyle. Not when I say a lifestyle, it's not just, it's not just going to the gym, but it's maintaining good physical and mental health. So eating right, getting exercise, managing stress, making it an approach to life rather than something that you do when you're not stressed out about work. So I'm all about just making health and matter of lifestyle coming out of surgery also, I believe that the best thing you can do to, to regain that sense of wellness, just to be a model patient, doctors know what's required to, to return to a good state of health. And so I'm a big believer in follow exactly what they, don't be a c student, do everything they say you're supposed to do, ask questions and they know how to get you healthy.

And they're going to push you to do that and don't subvert that process and you know, something. The third thing I would say, Allan, is that a lot of men overlook, particularly in this context, the importance of psychological changes that happen during middle age and particularly during treatments for prostate cancer. It's a disease of the male reproductive system, which is central to our sense of wellbeing. And men need to, who go through this need to prepare themselves for those psychological shifts. How they see themselves, their relationships with the partners, uh, how they see the world around them now as they are some in some ways altered. So surrounding oneself with support, with loved ones who can, we can be there for you if you start to stumble or you feel down or if you're not pushing yourself as hard to recover. That's just as much about wellness as is staying physically healthy. And it's something I end on that point. Particularly think of the thing. It's something that too many men, particularly in the context of prostate cancer, come to, uh, not pay close enough attention to.

Allan: 38:12 Thank you for sharing those. Uh, I do want to kind of close this a little different because there was a quote, some advice that your father gave you that I want to share here because I think this is really important. And he basically told you, he said, make sure you live your life before the hard times come. And I think that's some advice we should take to heart and realize that you know, we should be living the fullest life we can possibly live because this type of stuff can to us. Stay healthy, stay fit and enjoy the life that we have while you can. And so I appreciated your father's advice and I appreciate you sharing that along with your entire story in this book, Midpoint. If someone wanted to get in touch with you, learn more about the book and the things that you're doing, where would you like for me to send them?

James: 38:57 Well thanks for asking. I have my website is www.jamesahill.com and that is both a place where there's more information on me, my book and I also blog regularly on issues related to this. And um, and also of course the book is, is uh, going to be released in a few days on July 30th on Amazon. Barnes and Noble is all the, uh, all the major booksellers online. So anybody who wants to reach me can certainly reach out to me through my, through my website contact page there.

Allan: 39:29 Cool. You can go to 40plusfitnesspodcast.com/394 and I'll be sure to have links there to the book and to Jim's website and all of that. So Jim, thank you so much for being a part of 40+ Fitness.

James: 39:43 Thank you for having me on. I enjoyed the conversation.

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