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The Prostate Saga, Part 2

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It’s a good thing Dr. Fine’s reputation preceded him, or I might not have stayed long enough to meet him. But first, a segue into the genesis of my ire.

When Corporate America took over health care administration, it decided physicians had wasted too much time taking care of patients instead of generating revenue. Large health care organizations began buying up individual physician practices and, in some cases, taking over hospitals. Younger physicians loved this idea: they got a salary, paid vacation and none of the administrative hassles of running a private practice. (I plead guilty, as I joined an HMO for those reasons. I was a poor businessman and I admitted it. The problem was, in many cases, I knew more about business principles than the people signing my paychecks.)

Older physicians balked at being controlled and some of them resisted as long as they could. If you didn’t play ball, The Corporation would find ways to shut you out. If you didn’t contract with the predominant insurers, you became “out of network” and a lot more costly to patients. Other older physicians saw the handwriting on the wall and retired early, the lucky bastards, to stay at home, engage in hobbies, travel or annoy the wife full-time.

We traded autonomy for financial security and ended up with neither.

The Corporation now controlled everything, including your ass, so it could dictate how you did your job. One physician I knew 25 years ago, a hospital employee, said, “I have guys in three-piece suits telling me what to do. And I do it.” Thus, the standard 10-minute appointment was created. No matter how complex the patient, physicians were expected interview, examine, diagnose and treat a patient in the allotted time before moving onto the next one. Or should I say “mooving on”, since patients were now herded through like cattle. (I often threatened to play the Rawhide theme in the hallway during my HMO days. “Head ‘em up! Move ‘em out!”)

If you were a specialist, you got 20 or 30 minutes for consults, even if the patient had cancer. No “wasting time,” like my gyn oncology professor during residency, who spent an hour discussing ovarian, uterine or cervical cancer with women who were still in shock from the diagnosis.

And now, back to our regularly scheduled blog post.

Dr. Fine’s office booked a 30-minute visit at 2:50 p.m. Peg and I arrived about 15 minutes early; she was still in a wheelchair after having foot surgery.  I checked in, sat down and waited. And waited. And waited.

About 40 minutes later a nurse, nursing assistant or whatever, appeared in the door to the inner sanctum and bellowed, “David.”  I got up and wheeled Peg through the open door.

Halfway down the hall, the nurse said, “David, what is your date of birth.”

I told her and she said, “Oh, wrong David.” So, I wheeled Peg back to the waiting room while the correct David was whisked away.

Twenty minutes later she reappeared. “David.” Once again, I wheeled Peg down the hallway, but not as far this time before she realized my date of birth didn’t match what was on her tablet. And, once again, I wheeled a now pissed-off Peg back to the waiting room.

Different women appeared at the magic door, calling names as if they worked in a cheap restaurant, and patients disappeared.

It was now 4:15 pm. I’m normally a quiet, patient type (you shaddap and stop laughing!), but even my patience was wearing thin. The first woman we saw opened the door and called, “David.”
“Which one?”
“Last name Rivera?”
“Yeah, that’s me.”

We were herded into a pen patient room and a few minutes later a very sweet assistant came in to verify my information on the computer terminal (paper charts have all but disappeared). She apologized for the wait and said Dr. Fine would see us soon, but he was running behind.

Peg smiled but said, “We’ve been waiting a long time. Dr. Fine better be a rock star!”

The SYT swallowed and assured us Dr. Fine was indeed was, figuratively speaking, on par with Jimmy Page.

We could hear snippets of Dr. Fine’s conversation with another patient. Another 15 minutes elapsed, then yet another nurse/assistant came in with two books. I don’t recall the titles, but they could be titled, “You and Your Prostate,” and “What You Need to Know about Prostate Cancer.”

“The doctor will be in shortly to discuss your diagnosis.”

Now I was pissed! “I’m a physician! I KNOW my diagnosis; Dr. Ky and I have talked about it and I’m here to talk about getting a surgery date scheduled!” I thought If you’d looked at the record before barging in here, you’d know what’s happened and why I’m here.”

Finally, Dr. Fine entered the room and I understood why he was running late. He greeted us and apologized for running late. “Discussing a new diagnosis of cancer with a patient takes some time and I don’t want them to feel rushed.”

Ok, you earned your rock star status.

He talked at length about Gleason scoring in general. A Gleason score of 6 suggests one’s cancer is likely to grow slowly while a score of 8 and above is likely to be more aggressive and spread quickly. My score of 7 (4+3) put me at intermediate risk and was more concerning than a score of 3+4.  Then he talked about Tumor, Node and Metastasis (TNM) staging and how that relates to overall survival; my cancer stage was T-IIa, meaning no metastases or node involvement. (For more information, go to the Urology Care Foundation educational materials page and download the Localized Prostate Cancer guide.)

Notes from our discussion of prostate cancer and treatment options

We then discussed treatment approaches. I talked about the risks of radiation in my previous post, but the biggest drawback is it turns the prostate to mush. If the cancer recurs, taking out the prostate is next to impossible. Doing surgery first leaves radiation as an option for recurrence.

Surgery removes the prostate completely and, potentially, all of the cancer, but has its own set of risks. Immediate problems include recovering from surgery, including having a catheter in one’s bladder for a week. The surgeon has to cut the urethra (that tube from the bladder to the outside) to remove the prostate, and then sew it back together. One is likely experience some degree of urinary incontinence once the catheter comes out; they recommended getting a large supply of “adult incontinence underwear” along with pads that look like what women wear after delivering a baby.

Surgery removes the seminal vesicles and potentially some nerves along with the prostate, guaranteeing temporary or permanent erectile dysfunction. I would be taking a low dose of the “little blue pill” (sildenafil) every day to “promote blood flow” back into a limp penis. I’d have a checkup six weeks after surgery and then go to the Austin Powers Swedish Penis Enlarger clinic to learn how to use a $300 “medical grade” acrylic cylinder and vacuum pump. For some reason they discourage procuring the much cheaper products available at your friendly neighborhood adult toy store as it could “result in injury.” (Like Ralphie getting his tongue stuck to the frozen flagpole in “A Christmas Story?”)

We agreed to a surgery date right after Thanksgiving. He gave me a card for the Patient Navigator, someone who is supposed to “guide you through the process.” I talked with her once; she told me someone from the hospital “will call you with a surgery date within a couple of weeks. Then someone will call you a week before surgery with questions and instructions.” I used to impart that information to my patients at the end of our visit and didn’t need someone to do it for me.

I saw one of the Urology Department P.A.s (physician assistant) to teach me Kegel exercises, which help control the inevitable leaking bladder after surgery. Women learn Kegels when they are far younger, since they have only one urethral sphincter to men’s three.  I told her I’d been wearing protection for months to which she replied, “Welcome to our world.” The visit lasted only a few minutes. Peg had taught me abdominal core and Kegel exercises to do while driving to client’s houses. She did a better job and for free.

About a week later someone from the hospital’s scheduling department called me while I was driving to a client’s house. My surgery would be on December 2 at 7:30 a.m., a wretched time, as I’d have to be there about 2 hours earlier for preparation (which often takes about 30 minutes). 

“I’m wandering around the Chicago suburbs so now isn’t a great time to talk. How about you give me a call next Monday when I’m home?”

“Ok, that would be fine. In the meantime, I’ll send you preoperative instructions through our website and we can go over them next week.”

 She called and went over my medical history – current and past illnesses; the medications I took; allergies to medications – before going over the same instructions she’d sent the week before. I realize it may seem redundant, but there are people handicapped by a Y chromosome who don’t read or listen and need all the reinforcement they can get.

“Back in the good old days, I used to do all this myself.” 
She replied, “You probably weren’t that busy back then.”

Bullshit. I routinely saw 25-30 patients a day in the office and worked in women with acute problems. I did my own preop H&Ps (history and physical) and dictated it on the hospital’s transcription line. Years later, wrote my reports in MS Word and hand delivered them to avoid hearing, “We can’t find your H&P. Did you forget to dictate it?”

Preparing for surgery

Physicians go through “informed consent” with a patient before surgery or a significant treatment. Ideally, a physician explains what s/he proposes doing, what it is meant to accomplish, the risks and benefits of the procedure (including risk of death, if appropriate), and what might happen if the patient refuses. Then the physician gives the patient time to ask questions, have those questioned answered and, often at the end, sign a permit for said treatment or surgery.

This ritual is supposed to ensure the patient makes a well-informed, intelligent decision while also minimizing the risk of litigation in the event of an adverse occurrence or outcome. In reality, a pissed-off patient can always claim “I didn’t know what I was agreeing to” and some lawyer will take the case. So, many of us believe there is no such thing as truly “informed consent.”

My approach to informed consent for surgery went something like this:

“You need to be at the hospital two hours before your surgery time. They will get you ready for surgery (but it doesn’t take two hours, so you’ll spend a lot of time picking your butt). When everyone is ready, one of the nurses will take you to the operating room, put you on the table, hook up EKG leads and strap you down, so you don’t roll off. (Sometimes we will pick our butts waiting for anesthesia to stroll in.) I will be there before you go to sleep. This procedure is going to take about x hours. You’ll go to the recovery room for about an hour and then sent to your room (inpatient) or sent home (outpatient).

“All surgery comes with some risks: risk of bleeding, infection and injury to something inside. You also have a 1 in 60,000 risk of dying from anesthesia, but you are much more likely to die driving your car, especially in the winter when there are a lot of idiot drivers around.” (For the curious among you, the risk of death from a motor vehicle accident is 1 in 103. I can’t find the odds of dying from stupidity, but the Darwin Award people keep a nice tally.)

If I was tying a woman’s tubes (tubal ligation), I added this:

“You also need to understand nothing is perfect, including tubal ligations. About three out of every 1000 women getting their tubes tied get pregnant, sometimes many years later. A few of those pregnancies will end up in the uterus, but many get stuck in the tube, causing an ectopic pregnancy which can kill you  if not treated. So, if you ever think you are pregnant, you need to see a physician right away.” (I met a woman in Tennessee who had an ectopic pregnancy 13 years after her tubal ligation. She had been bleeding vaginally (and internally) for a few days, not realizing she was pregnant. I found 1300cc of blood in her abdomen.)

Now, that approach was too vague and informal for Ms. “Expectation Management” who thought researching every possible surgical complication was a fine idea, and then expected ME to grill my surgeon on how the team was prepared to avoid them.

I know a lot of the possible complications, which is why I hated gyn surgery! I’m more like Peg’s sister, Michele: Ignorance is bliss.

The day before surgery I had to drink only clear liquids and do a bowel prep. I drank a bottle of magnesium citrate, which is far easier to take than the gallon of NuLYTELY® I had for my colonoscopy prep. But, because a bowel prep can screw up one’s electrolytes, they told me to drink a 20oz bottle of Gatorade four hours before surgery. Yep, 3:30 a.m. Sleep is overrated.

We arrived at the hospital parking lot about 5:30 a.m. and trekked what seemed like a couple of miles to Surgical Registration. I checked in with a woman who was too alert for such an abysmal time. We waited for about 20 minutes, then someone led us on another trek to Pre-Op where I changed into a hospital gown and hopped onto the gurney.

My nurse was an adorable, diminutive redhead with freckles and a pixie cut, too alert and too cheery. She put EKG leads on my chest, a blood pressure cuff on my arm, and poked my finger to check my blood sugar, and started an IV, all while telling me what I needed to do.

“You remind me of my wife.”
“Hey, you brought her here, I didn’t.”

I started laughing so hard she had to retake my blood pressure after I calmed down.

I talked with Dr. Pierce, the anesthesiologist, and reminded him of my paradoxical reaction to Versed (midazolam), a drug used for anesthesia induction and conscious sedation. Dr. Fine appeared a little after 7:00 am for some last-minute discussion and reminders. Surgery would take about two or three hours and I would go home in the afternoon if everything went well.  Then the OR nurse put a bonnet on me, had me kiss Peg and rolled me down to the room. I slid onto the table while the anesthesiologist and the scrub tech introduced themselves and got me ready.
The last thing I remember hearing was, “This might sting a little as it goes into your vein.” Click here if you want to see Robotic Assisted Laparoscopic Radical Prostatectomy .

When I woke up 3½ hours later, it seemed as if only ten minutes had passed. I felt pretty good in large part to the local anesthetic injected around the trocar sites. Even the catheter wasn’t uncomfortable.  I had something to drink and the recovery room nurse had me walk down the hall.  I was home by 3:00 and really happy I didn’t have to stay in the hospital.

The following week wasn’t bad, either. I didn’t have to get up at night because of the catheter. Peg got up at 1 a.m. that first night to empty the bag, but I cut my liquid intake in the evening and emptied it about 11 p.m. which got me through the night. I had six stab wounds for the trocars but only one hurt if I coughed or move wrong, and that only lasted a week. I took three hydrocodone tablets, mostly at night, and used acetaminophen the rest of the time.

My abdomen after surgery
My incisions

The pathology report came back by the end of the week:

Surgical pathology report
Prostatectomy Pathology Report.
A. Right neurovascular bundle margin, excision:
-Neurovascular tissue, negative for malignancy.
B. Prostate, radical prostatectomy:
-Prostatic adenocarcinoma, Gleason score 4+5 = 9.
-The margins of excision are negative for tumor.
-Focal extraprostatic extension, left posterolateral, for a total span of 5 mm.
-Uninvolved seminal vesicles.
C. Bilateral pelvic lymph nodes, excision:
-Six lymph nodes, negative for tumor (0/6).
D. Posterior bladder neck, excision:
-Fibromuscular tissue, negative for tumor.
E. Anterior bladder neck, excision:
-Fibromuscular tissue and focal urothelium, negative for tumor.

So, the cancer cells were worse than the biopsy and it had already peeked out beyond the prostate. Having negative margins means the bad stuff was confined to what was taken out. Surgery turned out to be the more prudent approach.

The catheter came out the following Monday. I had to change underwear frequently for a few days but was back to my pre-surgical level of incontinence by the end of the week. It felt strange being able to urinate like I did before my prostate started squeezing my urethra.

I had an appointment for the Vacuum Erection Device Clinic in January, but that is a whole ‘nother story.

Bread and Circuses

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I went to Costco today. They had the normal entrance blocked off and routed people through the cart entrance. (T-W-Th 8-9am are old people hours). They had the walk along the side of the building partitioned with pallets and carts. We had to walk down the sidewalk, around the end and back to the entrance. We got our carts but had to wait in line because they were limiting how many people could be in the store. They had TVs playing a PSA loop featuring Drs. Fauci and Birx, and Dr. Jerome Adams, the US Surgeon General, explaining why we have to keep six feet (or one alligator) distance between us.

We got to go in when some number of people exited. The meat counter was pretty much empty. No ground beef, save for a few packages of “organic” stuff: 4lbs  that was going for about $21. Two packages of stew beef. High end beef going for $30/lb. Five six-packs of boneless chicken breasts. No thighs, no whole chickens. There was plenty of salmon and tilapia as fish doesn’t have the same processing plant issues (and likely because it’s too healthy for some people).

They had plenty of fresh Italian sausage in the pork section. I suspect they ground up what little pork they had left to stretch it out. I also saw a lot of the Kirkland bratwurst (which I think is better and bigger than Johnsonville’s brats). The freezer section had a lot of prepackaged stuff like beer battered cod, pulled pork, sirloin burgers and half a pound of blackened mahi-mahi for $20. Ouch.

Most people kept their distance, pausing at aisle intersections like 4-way stops, but some wandered aimlessly, oblivious to their surroundings and crowding the rest of us. One poor older woman was asking if Costco was handing out masks; the staffer said, “It’s OK for now; you don’t have to wear a mask until May 1.”

One Costco staffer directed people to the checkouts as they became available. The cashiers were behind 2×6 ft acrylic barriers and everything seemed to go smoothly. But everyone looked grim. As Walter would say, “Get your shit and get out!”

We are fortunate there are only two of us. We aren’t waiting for an unemployment check that won’t come anytime soon because the unemployment website is overwhelmed, and no one can apply (or was deliberately sabotaged by a cruel governor). We don’t have a houseful of kids that we have to home school while also working at home and THEN have to worry about feeding after a long day. We’re not in unimaginably long lines at food banks.

We’re the richest country in the world and our government is wasting $8,000 and 1,200 gallons of fuel per hour per jet flying twelve F-16s over cities filled with people who can’t go out of their apartments. If they do, they’re ignoring social distancing, so why bother mandating something people can conveniently ignore? It’s more of a tribute to a feckless leader than to the people risking – or taking – their lives. Bread and circuses.

Soon, we may have no bread, only circuses.

© Can Stock Photo / kvkirillov

(ALMOST) EVERYTHING YOU SHOULD KNOW ABOUT COVID-19

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There is a lot of misinformation and bad advice circulating regarding the COVID-19 pandemic. I’ve tried to provide pertinent and useful information in this blog post. But before I begin, I want you to do two things:

DON’T PANIC
DON’T BE STUPID

Panicking in a crisis does no one any earthly good and often makes things worse. This is not the zombie apocalypse, Outbreak, The Stand, Contagion or The Walking Dead. It’s not even The Hot Zone, a book and miniseries based on the discovery of an non-human primate Ebola virus in Reston, VA in 1989.

We can get through this by helping each other, not by being a selfish asshole hoarding toilet paper, or going out to restaurants because Devin Nunes told you to. Follow current recommendations and guidelines to minimize the risk of getting it or giving it to someone who is at greater risk of dying.

Now, back to our previously scheduled PSA

What is Coronavirus?
Coronavirus is a family of RNA viruses – chunks of genetic material in a protein capsule – that infect human respiratory tracts. Coronavirus, like the more well-known rhinovirus, respiratory syncytial virus (RSV) and parainfluenza, often cause nothing more than a common cold.  It is so named because there are spikes on the surface that make it look like a solar corona. Click here to see an electron micrograph.

Where did it come from?
Coronaviruses are “zoonotic” – transferred from animals to humans. Bats provide a reservoir for coronaviruses and spread them to other animals. SARS was thought to come from civet cats in Guangdong, China, while MERS was transmitted by dromedary camels in the Arabian peninsula before spreading to other countries. (MERS resurfaced in Saudi Arabia in October 2019.) SARS-CoV-2 might have originated from an outdoor wet market in Wuhan, China. Neither the Chinese nor the United States developed it as a bioweapon.

How is it spread?
Coronavirus, like other respiratory viruses, spreads among people through droplets from coughing or sneezing which are then inhaled. It can also spread when hands contaminated with virus touch eyes or nose, or someone else’s hands.

The incubation period (time from contact to developing symptoms) is 5-7 days but can be as long as 14 days, the rationale for a 2-week quarantine. People who carry the virus can spread it even though they feel fine. Health officials estimated a lawyer with COVID-19 in New Rochelle, NY, had contact with 50 people before becoming ill.

No one is sure how long the virus survives on surfaces like countertops, handrails and boxes, although study results published in the New England Journal of Medicine on March 17, 2020 found coronavirus lasts longer on plastic and stainless steel than on copper and cardboard. When in doubt, wear gloves and wipe it off!

VIDEO: Amanpour & Co. Infectious Disease Expert Dr. W. Ian Lipkin Discusses How Coronavirus Spreads

If coronavirus is common, why should I worry?
Viruses, like bacteria, can mutate into more deadly forms. The virus causing the current disease, COVID-19, is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Yes SARS (Severe Acute Respiratory Syndrome 2003) and MERS (Middle Eastern Respiratory Syndrome (2012) were both “novel human coronaviruses,” meaning they hadn’t been seen in humans.  The difference between coronavirus causing a cold and SARS-CoV-2 is like the difference between the E. coli in your intestine and E. coli O157:H7. The former keeps your digestive tract healthy while the latter caused severe illnesses and deaths in people eating contaminated hamburger (1993), “organic” spinach (2006) and Romaine lettuce (2019).

Isn’t it just like getting influenza?
There have been an estimated 34 million influenza infections in the United States over the six-month 2019-2020 season with 375,000 hospitalizations and 22,000 deaths. But we have a vaccine and herd immunity for influenza, so the death rate is about 0.06%. There is no vaccine for COVID-19 and there won’t be one for 18 months or more. COVID-19 is more likely to kill people over 60, those with chronic illnesses (diabetes, asthma/COPD, heart or chronic kidney disease), and anyone with compromised immune systems (cancer, HIV, genetic disorders), regardless of age. The youngest death was a 21-year-old Spanish soccer player with undiagnosed leukemia and coronavirus.

As of March 17, 2020, there have been 197,320 cases of coronavirus and 7,950 deaths around the world. (Source: Worldometer Live Update-Coronavirus) That doesn’t sound like much until you do the math, which gives you a death rate of 4%. The New York Times reported C.D.C.’s worst case scenario:

“…Between 160 million and 214 million people in the United States could be infected over the course of the epidemic, according to a projection that encompasses the range of the four scenarios. That could last months or even over a year, with infections concentrated in shorter periods, staggered across time in different communities, experts said. As many as 200,000 to 1.7 million people could die….”

Take a deep breath and don’t panic. England got through WWII with “Keep Calm and Carry On,” not, “OMG, it’s the apocalypse and I’m going to run out of toilet paper!”

Related: USA Today What does the coronavirus do to your body?

How do I keep from getting COVID-19?

  1. Wash your hands, often! Wash them for 20 seconds, the time it takes to sing “Happy Birthday” twice or recite the Star Trek intro. Hot water isn’t more effective than cold or warm water, so don’t scald yourself.
  2. Use hand sanitizer if you’re out and don’t have soap. Antibacterial wipes are good for public surfaces (shopping carts, handrails).
  3. Don’t touch your face. That is going to be really hard for most people. Cajun hand sanitizer will make you remember not to touch your face!
  4. Although it’s better than using your hand, I don’t think coughing or sneezing into your elbow is a great idea. Get a small pack of tissues or stuff some in a zip-lock bag and keep them handy when out. Use them and toss them in the trash. And use hand sanitizer afterwards.
  5. Stay away from crowded places like subways, commuter trains and airplanes unless absolutely necessary. Many businesses are making their employees work from home.

If you need catchy music to grab your attention, then watch this Vietnamese PSA.

Should I wear a mask?
In general, no. Regular surgical masks stop droplets, which is helpful but won’t filter out viruses. If you are healthy and out in public, you don’t need one. N 95 respirators, masks that can block 95% of particles down to 0.3 microns, are used by people exposed to dust and other small particles. Health care N-95 respirators are a subset, specifically for health care workers. They need to be fitted to be effective and are a bitch to breathe through.

You should wear a mask if:

  • You are a health care worker.
  • You are coughing or sneezing.
  • You are sick and need to leave the house
  • You are sick and can’t isolate yourself from healthy housemates

Why should we practice “social distancing?”
Because health officials want to avoid an exponential increase in coronavirus cases by “flattening the curve.”  (If you don’t understand exponents, you weren’t paying attention in algebra class and I don’t have time to explain them! Just think “increasing really fast.”) We don’t want a lot of people getting sick in a short period of time and overwhelming the health care system. It is better to spread out those illnesses over many weeks or months.

Protecting the vulnerable – those who are elderly or have compromised immune systems – is the single best reason for keeping your distance from other people.

How is COVID-19 treated?
Like any other viral illness there is NO cure. One treats the symptoms whether cough, fever or full-blown respiratory failure requiring mechanical ventilation. Influenza is often treated with oseltamivir, which shortens recovery by 1 to 2 days. Remdesivir, created from a molecule developed ten years ago, may be the best drug to treat COVID-19, but it’s only in the testing stage and it isn’t a cure.

Eating garlic, drinking bleach or colloidal silver, breathing hot air from your hair dryer, taking Vitamin C or zinc, snorting cocaine or masturbating will not protect you from COVID-19.

Related: Buzzfeed News list of coronavirus hoaxes

What should I do if I feel sick?
If you just feel crappy with mild to moderate viral symptoms – cough, fever, aching – call your healthcare provider. DO NOT go to the Emergency Room without being told to!  They don’t want to see your sorry ass for something that is not life-threatening and will just have to run its course.

However, if you are having chest pain or enough difficulty breathing that your lips are turning blue, or you feel as if you are drowning, GO TO THE EMERGENCY ROOM IMMEDIATELY!

Should I be tested?
Not unless a qualified healthcare worker thinks you need to be tested. There aren’t enough tests right now.

Where should I go for information?

  1. The Centers for Disease Control
  2. Your state’s Departments of Public Health
  3. Harvard Medical School’s Coronavirus Resource Center

DON’T PANIC. DON’T BE STUPID. BE CAREFUL.

Coronavirus illustration © Can Stock Photo / feelartphoto

The Prostate Saga, Part 1

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I have something in common with Ian McKellan, Robert DeNiro, Colin Powell, Mandy Patinkin, Warren Buffett, and the Grateful Dead’s Phil Lesh. We’ve all had prostate cancer.

You might ask, “What is the prostate and what does it do?” Well, since you didn’t ask, I’m going to tell you anyway.

The prostate is both a blessing and a curse. Located just below the bladder, the prostate is a collection of muscular glands surrounding part of the urethra, that tube running from the bladder and through the penis to the outside. It has been compared in size to a small apricot. It secretes fluid containing zinc, citric acid and some enzymes which act as a sort of Miracle-Gro® for sperm, aiding in the quest to be the one lucky bastard that fertilizes the egg to create a pregnancy.

The prostate also provides an endless source for amusement for urologists hell-bent on pimping medical students. It works like this. The urologist asks the student to perform a rectal exam on a male patient and describe the impression, then sneer and say, “He’s had a prostatectomy. So, what were you feeling, “doctor?”

However, in our later years, the prostate often enlarges and squeezes the urethra, a condition known as Benign Prostatic Hypertrophy, or BPH. It turns a urine stream rivaling that of a firehose into an annoying dribble that usually ends in our underwear.  

Back in the Dark Ages (more than 30 years ago), we treated BPH with a ghastly procedure known as Transurethral Resection of the Prostate or “TURP.”  A surgeon would put a resectoscope, a lighted tube with a wire-loop cautery at the end, through the penis and drag the prostate out in pieces. I remember seeing men in the recovery room hooked up to 3-liter bags of irrigating fluid to flush out blood and chunks of well-done prostate.

Now we have a group of drugs called alpha-blockers (tamsulosin and others) which make urinating a lot easier. They still don’t make up for the overly large prostate compressing the bladder, which makes us pee a lot during the day and get up two or more times during the night.

The prostate also produces Prostate Specific Antigen (PSA), an enzyme that changes semen’s consistency from Elmer’s glue to runny-nose mucus. Measuring PSA in a blood sample is a screening test for prostate cancer; a “normal” value is ­< 4.0 ng/ml. A value above 10 ng/ml means a 50% chance of prostate cancer. A PSA value of 4.0-10 ng/ml is concerning and often means monitoring more often than yearly.

PSA testing has some of the same limitations as other screening tests. Remember when Gene Wilder promoted CA-125 screening after Gilda Radner died from ovarian cancer? CA-125 only picks up half of Stage I ovarian cancers, and CA-125 can be high with endometriosis, early pregnancy, ovarian cysts and pelvic infection. I had a patient who died of metastatic ovarian cancer with normal CA-125 levels.

A normal PSA doesn’t mean you don’t have cancer, while a high PSA doesn’t mean you do, since levels can increase with BPH, infections and ejaculation within 48 hours of testing. A man I know has been living with elevated PSAs for years despite negative MRIs and biopsies.

I’ve been getting annual PSA checks since 2007, which had been 1.0 ng/ml or less through 2017. It was 1.5 ng/ml in early 2018, but my prostate was larger and neither my urologist, Dr. Li K?, nor I were worried.

However, my level in March 2019 was 2.7 ng/ml. Even though this result was technically “within the normal range,” I couldn’t rationalize an increase this high. Dr. K? agreed and recommended a repeat test in six months (September).

Knowing the health care system often moves slowly, and mindful of the fact that the end of the year (and our deductible limit) was approaching, I got another sample in August, opting for both total (circulating PSA bound to proteins in the blood) and free (PSA wandering merrily by itself like an unaccompanied child) levels. The percentage of free PSA can predict which men with levels between 4 and 10 will likely need biopsies to detect cancer. The higher the percentage, the lower the risk.

May I have the envelope, please? (Drum roll)

PSA, total 4.4 ng/ml
PSA, free 0.4 ng/ml
% total/free 9
Probability of cancer 56%

Well, shit. I sent the results to Dr. K?.

“I want you to get an MRI at our facility. I know our radiologists and trust them.”

I texted my kids with the news, shamelessly figuring it might get their attention as they rarely contact me about anything. It did. No one actually called, but they did text me replies, the communication choice of Millennials everywhere.

“Is there anything you need?”
“How bad is it?”
“Am I in your will?”

No one texted that last one but I’m willing to bet it was in the back of someone’s mind.

The MRI
An MRI is something everyone should experience once, like visiting Graceland, then check it off the bucket list. Have another go at it? No, thanks, I’m good.

I had my MRI the day before my 65th birthday. Imagine stuffing a bratwurst inside a cannoli tube and then loudly banging on a variety of metal objects, at varying tempos, for an hour while telling the bratwurst to lay still. Oh, and we’re going to roast you low and slow.

The earplugs they provided did little to block the noise. A sleep mask would have been more helpful as the top of the machine was about 2 inches from my eyeballs, a bit unsettling even though I’m not normally claustrophobic. I started getting really warm about thirty minutes into the procedure. I complained to the tech who said, “We’re almost done. Just a few more minutes.”

Yeah, right.

Finally, it was over. The tech helped me off the table and said I should get results in 1-2 business days. That was on Tuesday, but I hadn’t heard anything by Friday.

Peg asked, “So, are you going to call them? This is ridiculous. It’s been three days.”
I said nothing.
“So, you think no news is good news?”
“Pretty much.”

On Saturday I got a text message, “You have new test results!” from MyChart, an electronic health record application and one of the few things Epic has done right. My MRI result was posted, and I figured it must be good news since no one had called me. Wrong.

“IMPRESSION: Overall PI-RADS 4: Clinically significant prostate cancer likely within the left posteriolateral peripheral zone.
FINDINGS:
PROSTATE:
Size: 33cc, 4.4 x 3.9 x 3.8cm in the greatest transverse, AP and craniocaudal dimensions. Central zone/transitional zone: There are multiple nodules of varying signal intensity on T2 weighted imaging within the central-transitional zone in an appearance consistent with benign prostatic hypertrophy.
(No shit, Sherlock.)

Peripheral zone: Oblong ill-defined 1.2 x 0.8 cm lesion within the left posteriolateral peripheral zone at the base and mid gland demonstrating markedly hypointense signal…Mild capsular abutment without extraprostatic extension.”
(Translation: You have a tumor about the size of a small blueberry in your apricot and that’s not good.)

Most physicians have had to give patients bad news during their careers, but it’s a bit different when you’re on the receiving end. I wasn’t surprised given the relative rapid rise in my PSA and the probability given on my last test. Still, I stared at the screen for several minutes before printing the report and giving it to Peg.

She was livid.

“No one should get a cancer diagnosis without a phone call from a physician! What if you were someone with no medical background?”

Well, I can’t argue with that.

Sometimes I’ve merely confirmed what patients had already been suspecting. One was a woman I met during one of my locum tenens jobs. I curetted her uterus for heavy bleeding and knew she had cancer just by the tissue’s appearance. A few days later I asked her to come to the office to talk about the results. She had an aggressive endometrial stroma sarcoma that would end her life in less than a year. The irony of working in hospice with terminally ill patients was not lost on her. She was calmer than I would have expected, but I didn’t know what she might have felt in the following weeks.

Peg found my lack of response unsettling.
“Are you not saying anything because you’re worried?”
“Not really. I’m processing. Would you like me to be hysterical?”
“No, I just want you to react! At least say something.”

I didn’t say much to Peg about the probability of having cancer. Maybe it was the physician in me that was used to dealing objectively with bad news. And it was somewhat perplexing as I figured my crappy lungs would eventually do me in.

I texted my kids again with the MRI results and that I’d need biopsies. Number two son said, “Well, if you have to have cancer, it’s good to have the boring kind.”

My eldest texted back, asking if the cancer had spread. Using talk-to-text, I said, “Nodes and pelvis are clear,” which it changed to “Nodes and Elvis is queer.” Gotta love technology.

I was looking for a client’s house somewhere in the northwestern part of Chicago when the office called to set up prostate biopsies. I’d already made an appointment for the following Wednesday to discuss the MRI results, so the scheduler changed the appointment to the procedure. She also said I had to take Thursday and Friday off.

I sent an email to my handler. “I need to take off next Thursday and Friday. I’m having a procedure done and I need to lay low for a couple of days.”

He replied: “How long have you known about this procedure? I need a lot more notice to move things around. I can’t just move things around so easily.”

Ok, wiseass, I was trying to be discrete. Now I’ll be blunt.

“I just found out about it yesterday while driving around Chicago.  I had an MRI last week that indicates probable prostate cancer. They called to set up an appointment for biopsies.”

Silence for several hours. Then: “understood.”

Prostate biopsies are usually done transrectally (through the rectum). The urologist inserts an ultrasound transducer into the rectum, then passes a spring-loaded biopsy needle through a guide and takes several samples, using the ultrasound image for guidance.

The only thing that produces pain in the large intestine is distension (you can clamp, cut, or stitch it with impunity), so, poking a needle through the rectal wall isn’t terribly uncomfortable. Injecting local anesthetic into the prostate produces a familiar pinching sensation, but it doesn’t burn as it does when injected into skin. And it’s much less painful than the old transperineal route, which required an incision between the scrotum and anus, known colloquially as “the taint,” and often done under general anesthesia.

Peg and I arrived early for my 5 p.m. appointment but then sat for 45 minutes in a nearly empty waiting room. The reason for that will become apparent in Part 2.

When we were finally granted access to the inner sanctum, Dr. K?’s nurse led me to the procedure room. The first thing I noticed was an instrument stand covered with a sterile drape on which sat several small containers filled with Formalin, a long needle attached to a syringe, and something that looked like a light sabre handle with a needle sticking out of the business end. She told me to take my pants off and put on the exam gown which barely covered my ass.

After Dr. K? engaged in the usual pre-procedure pleasantries, I lay on my left side on a very uncomfortable examination table, then she inserted the ultrasound transducer through my anal sphincter and halfway to my tonsils. It’s like using a butt-plug with fangs, with none of the erotic sensation.

“First I’m going to inject local into the right side of your prostate.” About thirty seconds later, she said, “Now the left side.”  She waited a few minutes for the lidocaine to do its thing before she started sampling.

The biopsy instrument is a very fine, spring-loaded needle that snaps when one pulls the trigger, capturing a piece of prostate tissue. It’s less noticeable than the anesthetic injection, but still made me wince slightly every time I felt that snap. I lay still and listened as she called out the locations to her assistant, who put the pieces into the small containers.

“Left apex.” *snap* (wince)
“Left mid.” *snap* (wince)
“Left base.” *snap* (wince)
“Right apex.” *snap* (wince)
“Right mid.” *snap* (wince)
“Right base.” *snap* (wince)

She told me to expect blood in my urine and stool for a couple of days and to call if I started passing clots. Clots???

“I’m going to call you with the results before I release them to MyChart.” (You’d better or Peg will have your neck. )

I made a follow up appointment for two weeks later.

My urine was slightly pink that night, but yellow the next morning, like a fine chardonnay. The only rectal bleeding was from an irksome hemorrhoid. Yeah, getting old sucks. I think I could have easily gone back to work, but I welcomed the break.

Dr. K? called me a few days later to tell me she’d received the pathology report; it was what we’d both expected.

Biopsy pathology report
Prostate needle core biopsy, right base:
-Atypical Small Acinar Proliferative (ASAP), in one of two cores
Prostate needle core biopsy, left mid:
-Adenocarcinoma of prostate, Gleason 4 + 3 = 7 (Grade Group 3)
–Tumor in 1 of 2 cores, tumor length 1mm, discontinuously involving 5% of submitted tissue.

Pathologists grade tumor cells based on how abnormal they appear under a microscope. Prostate cancer cell grades number 1 through 5 with five being the worst. The Gleason Score takes first and second most predominant grades and adds them together. The least malignant score is 2 (1+1) while the most malignant is 10 (5+5).  A Gleason score of 4+3 is worse than a score of 3+4, even though the sum of both is 7.

I’d considered radiation treatment as the lesser of the evils but the small amount of tumor in the biopsy relative to the size of the lesion, along with the “atypical” cells on the right side convinced me surgery was the better approach. I like having tumors in a jar; surgical specimen pathology is often more severe than the biopsies.

We saw Dr. K? the following week to discuss options, but I’d already settled on surgery. The problem with doing radiation first is that if the cancer recurs, surgery is nearly impossible because radiation has turned the prostate into mush, and you’re screwed. If you have surgery first, radiation is available if the cancer comes back.

There are considerable risks to radiation: difficult or painful urination; diarrhea, bowel cramping, fatigue, “sunburn” on abdominal skin, and the possibility of developing cancer in bladder or bowel. A Facebook buddy undergoing radiation for colon cancer told me “may I suggest rather than using the very pleasant descriptor, “you may experience occasional diarrhea” with “by week three you will have come to believe you’ve eaten and (sic) entire jar of jalapeños and are pissing pure lemon juice.”

Dr. K?, being a general urologist gave us the names of two colleagues, Dr. Fine. and Dr. Howard, both of whom specialize in robotic radical prostatectomy. Peg caught her off guard asking, “Who would you personally go to and who has the better bedside manner?”  She replied without hesitation. “Dr. Fine.”

I made an appointment with Dr. Fine for the following week.

Next month: To Surgery, and Beyond!

Apricot: © Can Stock Photo / Tigatelu
Prostate © Can Stock Photo / rob3000

Christmas Cheer

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This is the first Christmas since my teens that I haven’t been completely annoyed by the whole thing. Oh, I still rail at the commercial where the Yuppie scum couple celebrate with $100,000 worth of new trucks, or how we’re supposed to think love means buying your spouse a high-end luxury car. But I don’t feel the usual sense of dread mixed with despair.

And I’m not sure why.

Maybe it’s because

  • The weather has been sunny with temperatures in the 50’s, like December in Arizona, instead of cold and gloomy with slushy streets and bad drivers.
  • Peg hasn’t had to do the Death March to Christmas in three years, and we’re going to a 6 p.m. Christmas Eve Mass instead of the 11 p.m. “Midnight” Mass.
  • I’m no longer working for a heartless corporation that doesn’t give a shit about its people, and I’ve been doing something I find far more fulfilling.
  • I’ve been off all month since surgery and I actually have time to enjoy things like wrapping gifts and making cookies, rather than the last-minute blitz to get it all done.
  • I’m too old to be raging at the materialistic “gimme gimme gimme” of the season.

Whatever the reason, something changed. I’ve been pondering my inevitable mortality and prioritizing. As a kid I felt bad for not having much, then I felt guilty as an adult for having more than others. I’m still painfully aware of the divide between the haves and have nots, but I can’t fix it. I can only do my small part to make the world a better place for others, however fleeting that may be.

It’s often said, “The days are long, but the years are short.”  At my age the days are short and, the years are even shorter. Giving and getting stuff isn’t important; friends and family are. Cherish those around you who you love, as you never know which one of them may not be around next Christmas.

© Can Stock Photo / zatletic