Lessons from a Prostate Cancer Survivor

Ric Siler fought prostate cancer twice, both times with doctors who were going for a cure. Today, five years out, he’s cancer-free and sharing his message of hope with other men and their families.

            You’re minding your own business and happily living your life, as most of us are when there is a diagnosis of cancer.  What do you do now?

            This is what happened to Ric Siler, an actor and writer, who was diagnosed with prostate cancer at age 64.  He’s 71 now, and cancer-free.  How did he get from there to here?  Ric shares several important lessons – things that helped him get through cancer treatment and on to the other side, where cancer is an increasingly smaller picture in the rear-view mirror.

Attitude Matters a Lot

            First and throughout, Ric did what many doctors believe is the most important thing you can do in a medical crisis:  he remained upbeat.  He practiced gratitude – for his wife and daughter, for a chance conversation that resulted in finding just the right surgeon, for the kindness and support of friends and the many medical professionals he would soon come to know, and especially for the beauty of nature and art, which he began noticing all the time.  He also kept his sense of humor.

            Why does attitude matter?  Nobody understands the mind-body connection completely, but University of Texas-Southwestern scientist Suzanne Conzen, M.D., and others have shown that stress involves the same pathways as cancer.  The stress hormone is cortisol, and just about every single cell in our bodies has a receptor for cortisol (this is called the glucocorticoid receptor, or GR).  Conzen has shown that decreasing stress lowers cortisol, and this can slow the growth of cancer.  (This is no substitute for treatment, but I firmly believe that every little bit helps, and there are other lifestyle changes that can help slow cancer and make treatment more effective, including changing your diet, reducing your caloric intake, exercising, losing weight and stopping smoking.)

            Out of the blue:  When Ric’s prostate cancer was diagnosed, in June 2018, “I had no symptoms,” Ric says, “no idea that anything was wrong.  I had gone to my doctor for something completely unrelated, and he said, ‘We haven’t taken your blood for a while.  Maybe we should.’”  It turns out that in a year and a half, Ric’s PSA had doubled, from 4 to 8.

            He went to a urologist near his home, in Rockland County, New York, and didn’t much care for him.  “He did nothing to instill confidence; I didn’t feel right about him.  There were four doctors at the practice, so I picked the one who was, available.  Funny how that works.”  (Note:  In my experience, this can be a red flag.  The doctor who can see you right away may not be the one you want to see.  Due diligence in finding the best doctor you can is really important.)  The biopsy came back: cancer was present in all 12 tissue samples, and his Gleason score was initially thought to be 8; it later turned out to be 9. 

A Second Opinion: Ask Around!

            Ric’s daughter, Laurette, suggested that he get a second opinion.  “I hadn’t even thought of that,” says Ric.  But he didn’t know what to do, or how to find a good urologist.  “The next morning, I was working out at the Y,” and without realizing it, he networked.  This is a good thing for every patient to do.  It is very important to find a doctor in whose clinical abilities you feel confident.  And networking – to find the right doctor, or to talk to men who are or have been in your same boat – can make a huge difference in how you approach your cancer treatment and look forward to your life after cancer.

            Ric talked to his friends, Peter and Steve.  Steve said he knew men who had survived prostate cancer, and offered to ask around for a good surgeon.  And “Peter said, ‘Talk to Jerry.’  Jerry is the founder and CEO of the company Peter and I work for, and is a prostate cancer survivor.”  Ric talked to Jerry that same day.  “I saw Jerry in his office with the door open.  I asked if he had a minute,” and explained the situation.  “It just came out in a flood.  I hadn’t planned to be emotional;” in fact, “a sort of stoic resolve is usually my default mode.”  But Jerry understood, and said had felt the same way with his own diagnosis of prostate cancer.  “He said, ‘When I heard the news, I thought my life was over.’  And then he said, ‘A year from now, we’ll be laughing about it.’  It was great to talk to someone who had been in my shoes and come out the other side.  He offered any help, any time I needed to talk, and said, ‘You’ll do the same for people someday.’  Yes, I will.” (And he does.)

            The next day, Steve texted Ric with a referral from one of his buddies to urologist Ash Tewari, M.D., at Mount Sinai.  “Time for a second opinion!  I was reading Don Quixote at the time, and I saw this quote the same day, a Latin phrase that translates into, ‘After the darkness, I hope for light.’”   

            While he waited to see Tewari, Ric, who had started to keep a written record about his experience, made a note of how he was feeling:  “Keeping it as normal and real as possible.  Not dwelling on it.  Staying positive, or trying my best to.  I never completely lose sight of what’s happening, but I am not letting it get me down.”

             The date for the operation was September 17.  “I asked about the hospital stay, and he said that he did three surgeries yesterday, and they were all going home today!”  Ric recalls.  He mentioned the big trip to Italy, scheduled for November, that he and his wife, Bette, had been planning for years.   Tewari said it should be fine, and this turned out to be the case.

            A one-act play Ric wrote, “How Do You Say Prostate in Italian?” covers what happened next in some detail:  the MRI, which had radio music piped in, including ad for Dunkin’ Donuts in between soothing classical music pieces; the hospital, where he was delighted to have a private room (“It could spoil a guy!”); walking the hospital floors after surgery, with his catheter, “pee bag,” and abdominal drain; important milestones, from passing gas after surgery to getting the catheter removed, to buying pads, getting biofeedback and learning to do Kegel exercises while he dealt with temporary urinary incontinence.  And it’s funny!  And enthusiastic, and full of gratitude.

            Not so fast:  But wait – there’s more.  Ric’s PSA started to go up again after his surgery.  “I had thought I was out of the woods… not so fast, Kimosabe!  I had thought the PSA being elevated post-surgery meant that maybe there is cancer… nope.  It means yep, there’s cancer, and we have to deal with it.’”

            Christmas of 2018 was a time for reflection.  Ric made a note:  “I’ve lived my life mostly feeling kind of indestructible, so it’s sobering to feel, well, destructible.  One thing that I know for sure as I sit here quietly with the dog and a beautiful tree with presents arrayed around it, under it and on it, and my wife and daughter sleeping peacefully upstairs, is that I want to be here next year to do it again, and the next and the next… and I’ll do whatever it takes to make that happen.”

            Under the care of medical oncologist William Oh, M.D., and with the goal of “total eradication of the cancer,”Ric had a short course of hormonal therapy and eight weeks of external-beam radiation therapy, which had its own challenges.  When the eight weeks ended, Ric was surprised to find he had mixed feelings.  He wrote: “While the treatments have been happening, there has been a sense of rock-solid purpose.  We’re working together to eradicate this cancer.  I do my part by coming in with a full bladder, no gas and on time, and I get really good at it.  Now that it’s over, we have to wait six weeks – only then will we know for sure.  It’s all about PSA levels at this point.”  Laurette surprised him on his last day of treatment by showing up to ring the official bell – a rite of passage at many radiation therapy centers to say, “I made it through!”

            Ric is cancer-free now, and getting on with the rest of his life.  “I was so fortunate,” he says.  “If I hadn’t mentioned my cancer to these guys at the Y, I wouldn’t have met Dr. Tewari,” and through Tewari, Dr. Oh.  “Everything fell together beautifully for me.  If I hadn’t gotten that blood test done, I’d be sitting here a year and a half later none the wiser, and the cancer would have continued to grow.

“Silence is Not Golden When it Comes to the Prostate.”

            “The whole point of my play, aside from the personal reflections on living to see the art in Italy, and what it meant to me, and being here after this brush with cancer, is that early detection is really important.  You’ve got to get checkups regularly, and if something’s not right, you have to take the steps to see what’s wrong, go to the best people you can.  I wasn’t really going into this with any great message; I didn’t know what would come out of it, or what the next step would be.  It is a cautionary tale for doing what you need to do, as soon as you can.  Silence is not golden when it comes to the prostate.”

            Ric has not been silent; one man he spoke to about his experience said, ‘Wow, my wife wanted me to make an appointment with the doctor.  I didn’t go.  I’m going to do it right now.”  He hopes such encounters will be like “ripples in the pool,” men helping each other to be healthy.  When Jerry first told him that one day, he would laugh about his experiences, Ric didn’t believe him.  “I hoped he was right – and he is!  But it’s been quite a ride.”

             Several years ago, Ric did a reading of his play in New York.  Afterward, a woman came up to him; her husband is a prostate cancer survivor.  “She took me aside and said, ‘This is very important, because men don’t talk about this stuff except in whispers.’”

            Ric continues to act and write, to help raise awareness about prostate cancer and to encourage men to get screened, and to take action if treatment is needed – so that they, like him, can move past cancer and get on with life.  Recently, he said:  “It’s great to be 71 and feel the best is yet to come!”

 

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

Roadblocks to Combination Therapy, and Paving the Way for Success

            As we discussed in Part 1, the year 2015 was a milestone in treatment of early metastasis (metastatic hormone-sensitive prostate cancer, or mHSPC).  For the first time, the CHAARTED study showed that men with mHSPC who began ADT (androgen deprivation therapy, which shuts down testosterone) plus chemotherapy (docetaxel) lived significantly longer than men who started treatment with ADT alone.

This study was the first of several that changed the standard of treatment for early metastatic prostate cancer to combination therapy:  ADT plus docetaxel or ADT plus an androgen-receptor pathway inhibitor (ARPI; these drugs include enzalutamide, abiraterone, apalutamide, and darolutamide) or ADT plus chemo plus an ARPI.

With combination therapy, median survival – again, some men live much longer – is now about five years, compared to around three years a decade ago.  The results continue to improve as new drugs are developed and doctors keep pushing the treatment envelope.  This improvement is monumental, says medical oncologist Neeraj Agarwal, M.D., of the University of Utah’s Huntsman Cancer Institute.  I recently interviewed him for the Prosate Cancer Foundation’s website.   It’s particularly so, he continues, “when you consider that some anticancer drugs get approved based on a three-month survival benefit.  There is no doubt that ADT alone is not sufficient.  It works so much better when it is combined with one of these ARPIs.”

And yet.  This is not the case for thousands of American men with mHSPC, Agarwal states:  “A lot of patients in the U.S. – the richest country in the world – are not getting ADT plus ARPI  or ADT plus ARPI plus docetaxel, up front.  That is unacceptable in our view, because of the significant survival advantage and quality-of-life benefits associated with combination therapy.”

 What is the problem?  Unfortunately, there are several.

“There is no shortage of evidence that combination therapy works,” says Agarwal.  However, “the number one reason that combination therapy is not being used up front in patients with mHSPC is lack of awareness of the data.”  A lot of clinicians have a pre-2015 mindset about mHSPC.  “They fear that if you use everything up front, what will you use later?  They want to keep these therapies for the time when ADT fails.”

But here’s the thing:  using both therapies up front may significantly delay or even change the course of mHSPC. Nobody really knows; there have been no long-term studies because this standard of care is still too new.  However, in my experience of studying and writing about prostate cancer over the last 30 years, I will tell you that all of the things that used to be done as a last resort have done much better when used as weapons against prostate cancer sooner rather than later, when cancer is more vulnerable.  We’re not there yet, in terms of being able to put all men with prostate cancer into a durable remission, but that is the goal.

Agarwal is the senior author of a striking study published in 2023 in the Journal of Urology, looking at how physicians in different specialties treat men with mHSPC.  “We found that combination therapy was underused as a first line of therapy across urology and oncology specialties despite evidence of improved survival,” he says. “In subsequent lines of therapy, ADT plus ARPI was prescribed more frequently across specialties,” but these men would have been better off if they had hit mHSPC with both barrels from the start. 

“We found that many physicians are worried about the side effects of these medicines,” says Agarwal.  “In a lot of medical oncology practices, doctors are dealing with many different types of cancer in a given clinic, so do they have enough time to delve into prostate cancer only?  On the other side, many urologists are very busy surgeons.  How much time do they have to spend on learning about the latest data?  Misconceptions happen because of lack of awareness.  They think, ‘these drugs have toxicities; we need to keep them for later.’  They’re not aware of the data; that’s why they have these misconceptions.”

But it gets more complicated.  There are financial roadblocks, as well.  In our  country, medical care in general is expensive and complicated, and many medical practices rely heavily on a small team of people whose job is simply to be on the phone with insurance companies every single day, advocating for patients.

“Using combination therapy is associated with more workload for clinicians and their practices,” says Agarwal, “especially if you don’t have enough support staff.  Many solo oncology practices don’t have the support of an in-house nurse practitioner, pharmacist, or big team of financial people who can write letters or talk on the phone with insurance companies.”  There are copay issues with combination therapy, he continues, and also issues arising from comorbidities – other health problems requiring other drugs that may interact with one ARPI versus another.

Here’s an example:  “Eliquis (a blood-thinning drug) is quite common.  But it has an interaction with enzalutamide.  You either have to talk with a primary care doctor or cardiologist to see if you can have Eliquis switched to something else, or you have to fight with an insurance company to switch to abiraterone or darolutamide if they have enzalutamide as their preferred agent.”

With insurance and also with Medicare, out-of-pocket copays are a big problem for many patients.  One option for the man on Eliquis might be abiraterone, which has another major benefit:  Abiraterone has been around long enough that it has “gone generic,” and is much less expensive than other ARPIs.  “This man could get abiraterone for $170 a month.  But many patients have zero copay for enzalutamide; it’s $15,000 per month, but their copay is zero.”  If this man only has Medicare, “and he doesn’t have a backup insurance plan to help with the out-of-pocket costs, it can be very challenging to afford that monthly copay,” which could run into the thousands each month, depending on a patient’s insurance plan, and whether he – not to mention his spouse or partner – is on any other expensive medications.

What about a coupon?  Unfortunately, coupons don’t always help, Agarwal continues.  “Say you have a coupon from a pharmaceutical company for $200 for your copay.  That is not considered by the insurance company as support for the copay.  Instead, it’s considered as a contribution toward the base price of the drug, which is wrong.”

It sure is.  Agarwal has been advocating on Capitol Hill for legislation to help relieve the financial burden for patients with cancer.  The recent Inflation Reduction Act contains a provision that allows Medicare to negotiate the price of some prescription drugs.  Additionally, “patients on Medicare will have a $2,000 yearly cap on out-of-pocket prescription drug costs, starting this year,” says Agarwal, “so that should help.”

Maximize Your Odds for Success

Here’s something Agarwal always tells his patients before they start combination therapy:  “Yes, you will feel overwhelmed, because your life has changed.  But I have a lot of patients who are living for years – beyond a decade  – and I give them this hope:  You could be one of them.”

            Just as the best way to target early metastasis is to hit it hard, right from the beginning, the best way to approach combination therapy is to address all of its potential side effects right up front.

The drugs can take a toll, says Agarwal.  “There’s fatigue, loss of muscle mass, the risk of metabolic syndrome, increased fat around the midsection, increased cardiovascular risk, increased risk of stroke, quality of life issues – hot flashes, inability to perform your daily duties to the max, and the effect of treatment on your marriage and romantic life.  But there are ways to handle all of this.”

            Here are some key points for doctors and patients to consider:

            Exercise:  cardiovascular exercise with resistance training “is more important than ever.”  Agarwal is principal investigator of a NCI-funded study that starts combination therapy patients on a yearlong exercise program.  As we have discussed, for men with mHSPC, any exercise is better than none, and even light weights and short bursts of exercise can make a big difference.

            Taking care of the heart:  “Screening for cardiac issues is more important than ever, too, says Agarwal.  When he starts patients on ADT plus an ARPI, “it’s routine for me to do EKGs in my clinic, especially in those patients who seem to be prone to cardiac disease.”  These include men who have a history of smoking, or who are overweight or who don’t have a very active lifestyle, or who feel short of breath.  He works with cardiologists and family physicians to make sure the patients get a stress test, cholesterol and other blood tests, or other workups if needed.

             Taking care of the bones:  “So many times this is missed,” Agarwal says.  “If somebody already has low bone density and then starts on ADT and an ARPI, he will start having fractures.  Vitamin D, and calcium plus exercise really go a long way to help strengthen the bones. We recommend bone-modifying agents to those who have thin bones to start with.”  Diet can help here, as well:  leafy green vegetables are really good for the bones.

             Social help can be huge:  “It takes a village, especially in the early days,” says Agarwal.  “I tell my patients, ‘You need to get over this immediate barrier, these seemingly insurmountable barriers of tests, medications, and insurance – so let’s work together.’  That’s why a social worker and financial counselor play such big roles in the beginning.”

            And then… “These same patients, their insurance resolved, all the screening done, the combination therapy begun – their PSA has dropped.  They are feeling great.  They don’t have pain, they’re feeling much better.  They come back and say ‘Thank you very much.’  After six months, their whole family has a sense of relief.  Those first three to four months are crucial.  And then, after six months, I really hope we can say we did it together.”

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.  Note: I am an Amazon affiliate, so if you do click the link and buy a book, I will theoretically make a small amount of money.  

© Janet Farrar Worthington

PSA Numbers and How to Make Sense of Them

What should the PSA level be?  Before we look at some numbers, please note:  if a man’s PSA is higher than these numbers, that doesn’t necessarily mean that he has prostate cancer; there are other factors that can raise PSA, which we will cover briefly.  I have much more about PSA here, and of course, in the book. 

• For men in their 40s and 50s: A PSA score greater than 2.5 ng/ml is considered abnormal. The median PSA for this age range is 0.6 to 0.7 ng/ml.
• For men in their 60s: A PSA score greater than 4.0 ng/ml is considered abnormal. The normal range is between 1.0 and 1.5 ng/ml.
• An abnormal rise (the rate and speed of change in PSA is called PSA velocity): A PSA score may also be considered abnormal if it rises a certain amount in a single year. For example, if a man’s PSA score rises more than 0.4 ng/ml in a single year, he needs to find out why.  If his PSA is going up and down but is still higher than it should be, he needs to find out why.

Men: If you are in your 40s and your PSA level is greater than 0.6 ng/ml, or if you are in your 50s and your PSA is greater than 0.7, you should have your PSA measured at least every two years.  If your PSA is below this, you may be able to wait as long as five years for the next test.

In older men, benign enlargement of the prostate (called BPH) can also raise the PSA number.  BPH is very common: it’s in 50 percent of men in their 50s, 60 percent of men in their 60s, 70 percent of men in their seventies, etc.  Note:  Drugs to treat BPH can artificially lower PSA by as much as half.  Taking a 5-alpha-reductase inhibitor, such as finasteride (Proscar) or dutasteride (Avodart) to treat BPH, or the drug Propecia, used to deter hair loss (a low-dose form of finasteride) can artificially lower PSA.  If a man has been taking one of these drugs for a short period of time, his PSA number should be doubled.  If he has been taking it for five years or longer, his PSA should be multiplied by 2.5.  Don’t just take that low score at face value.

Here are more PSA numbers from the book,, adapted from the Journal of the American Medical Association:

How many men my age have this PSA level?

2.5 or lower:  88 percent of men in their 50s, 75 percent of men in their 60s, and 61 percent of men age 70 or above.

2.6-4.0:  8 percent of men in their 50s. 14 percent of men in their 60s, and 18 percent of men age 70 or above.

4.1-9.8: 3 percent of men in their 50s.  9 percent of men in their 60s, and 16 percent of men age 70 or above.

10 or higher:  1 percent of men in their 50s.  2 percent of men in their 60s, and 5 percent of men age 70 or above.

All of this said, a PSA score on its own is not enough, because other things can raise PSA.  This is why getting that baseline and then watching what PSA does over time is so important.  This is PSA velocity:  watching what PSA does.

What else can raise PSA?

             Here’s a tip:  Get the PSA blood test done before the rectal exam at the annual physical.  The rectal exam, when the doctor pokes the prostate to check for any signs of hardness or lumps, can cause PSA to be released into the bloodstream – artificially raising the PSA number.  (Fun fact: what’s the prostate supposed to feel like?  Feel the pad at the base of your thumb.  The prostate should feel kind of squishy like that.)

            Similarly, so can having sex.  Therefore, a man should avoid sexual activity for three days before the blood test.  

Prostatitis can also raise PSA, sometimes to high levels.  This is not cancer; it’s inflammation in the prostate and it is treatable.  I have good information about prostatitis and pelvic pain syndrome here.

Second-Line Tests Shed Light in the Darkness!

Fortunately, there are “second-line” blood and urine tests that can help figure out if a raised PSA number is coming from BPH or prostate cancer.

I’ve got much more about these tests here, but briefly:  Nuanced tests such as the 4K score or Prostate Health Index (PHI) look at “free PSA.”  PSA comes in several different forms.  Free PSA measures whatever PSA in the blood that is not bound to proteins.  As Johns Hopkins urologist H. Ballentine Carter, M.D., was fond of saying, the higher percentage of PSA that is free, the more likely you are to be free from cancer.  This test provides context:  If the percentage of free PSA is higher than 25, then the elevated PSA is more likely to be caused by BPH, benign enlargement of the prostate.  If it’s lower than 25 percent, this doesn’t automatically mean that there’s cancer, but it does raise the likelihood that cancer may be present.  The 4K and PHI tests are even more helpful than the free PSA test, because they also look for biomarkers of aggressive cancer, and put it all together into a score.

What if these things point to cancer?  Is the next step biopsy?  No, it’s prostate MRI.

I’ve written about that here, but basically, the result of prostate MRI is called a PI-RADS score, ranging from 1 to 5.  A PI-RADS score of 3 or higher is the trigger for a biopsy.

That biopsy should be an MRI fusion biopsy, where the MRI image is combined with transrectal ultrasound to give the doctor the best view of any suspicious areas that really need to be checked.  In the biopsy, 12-14 hollow-core needles are used to get samples, or cores, of tissue.  Note:  a biopsy is not perfect; each needle only samples 1/10,000^th of the prostate!  In the book I’ve said it’s like looking with a needle in a haystack.  That’s why the second-line tests can help paint a more complete picture of what’s going on in the prostate.

            There are two ways to have the biopsy done:  through the rectum (transrectal) and through the perineum, the area of skin between the rectum and the scrotum.  If you think of the prostate as about the size of a golf ball, the transrectal approach basically goes from south to north.  The transperineal approach goes from east to west, and it does a much better job of finding out-of-the-way cancer.  I’ve written about that here.  Not only is it more effective:  there is zero risk of infection.  No need for antibiotics!  It’s also better for diabetic men, who are at higher risk of getting an infection.  The transrectal approach, because it goes through the rectum, involves antibiotics.  There’s no getting around it; the rectum is chock full of bacteria.  Transperineal is the better way to go.

Since this series is about screening and detecting cancer, I’m going to leave it here and not get into treatment.  That is covered throughout this website, and if there’s interest, will be the subject of another series.  Very briefly, if cancer is found, you will be given a Gleason score, or Gleason grade group.  The cancer can range from very low, low, and favorable intermediate risk – which may not ever need treatment – to unfavorable intermediate, high, and very high risk.  You will also be given a clinical stage, which is the estimate of how much cancer there is – whether it is confined to the prostate (the most common scenario in the U.S. today because of screening); whether it has spread locally but does not appear to be present at distant sites (seen with imaging); or rarely, less than 10 percent of the time, whether the cancer has spread to either the lymph nodes or bone.  Whatever the finding, don’t become discouraged!  There is more hope now than ever before.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.  Note: I am an Amazon affiliate, so if you do click the link and buy a book, I will theoretically make a small amount of money.  

© Janet Farrar Worthington