Flocks would champion the use of Au198 and treat 1,585 patients in collaboration with his faculty colleagues. A prodigious surgeon, he would perform 1-6 gold procedures including radical prostatectomy in any given day! His surgical technique would change over time. Initially, he used a retropubic approach and changed to perineal prostatectomy, seeking to determine the appropriate volume and dose of the colloidal gold. He would ultimately come to use about 2cc of the colloidal material with a millicure dose of 100 mc.

Diagram from Flocks and Culp, radiation therapy of early CaP.

If the neoplasm was confined to the prostate without seminal vesicle involvement he removed the organ (radical prostatectomy) and instilled the gold into the fibro-lymphatic pedicles. He pioneered the staging of prostate cancer by pelvic lymphadenectomy. He related nodal spread to prostatic size and later related nodal spread to prostatic staging making his data transferable to present TNM staging.

If the neoplasm was locally extensive T-3,4 disease, he electrodessicated the prostatic tissue and seminal vesicles to decrease tumor mass and then instilled the colloidal solution into the tissue matrix. His surgical patients were never submitted to a double-blind controlled series. He liberally used orchiectomy and hormonal manipulations in selected patients based on the mass of prostatic neoplasm and local infiltration of the cancer.

Dr. Flocks wrote his last paper on his experience with colloidal gold in 1973, two years before his death. He reported on 384 clinical stage T4 node variable prostate cancers representing about 24 % of his total patient population. Among theses patients 69 were known to be T4, N0 and had 74% 5-year survival, 68% 10-year survival and 28% 15-year longevity.

The Flocks data demonstrates the detrimental effect of node positive staging and extensive disease. The Flocks data base is presently an area of study in the department. He had striking results among his patients with remarkably long term survivals which merit further study.

Flocks did not live to study his entire population. His local recurrence in the prostatic fossa was 4.5%, suggesting that his combined surgical and irradiation therapy affected tumor growth. These data compared to Belt who experienced a 12-20% local recurrence rate suggests a local beneficial effect. This patient population would be considered inoperable and would be treated hormonally in the present era.

Perhaps the definitive paper on prostatectomy and Au198 was the work of Kwon and Loening demonstrating the value of both modalities without orchiectomy in confined prostatic carcinoma. These patients now represent mature data and are the subject of reanalysis. This study differed from Flocks' experience since the treatment was modified to use gold seeds after the colloidal solution was removed from clinical use after Flocks' death by the manufacturing agency at Oak Ridge, Tenn.

The Loening/Kwon data revisited demonstrated parallel value in survival for organ confined disease prior to the use of PSA as a marker. The Mayo Clinic Data appears superior but are prostatic nodule lesions only and therefore a selected series. The Belt series demonstrates even more graphically the beneficial effect of gold on survival at 20 years. Of further interest the Loening data demonstrated 20% of patients lived longer than their Life Expectancy projection predicted for survival. This goal based on age at presentation was one of Dr. Flocks' expectations from therapy.