While you don’t need your prostate to urinate, the gland does get involved in the process, not because it’s a meddler but because it doesn’t have a choice. Again, location, location, location. The urethra, which passes through the prostate on its way from the bladder, is the tube that carries both urine and semen out of the body.
Across the male population, the prostate is much more likely to be involved with urinary issues than with sexual issues. Those of you over 50 are now nodding your heads because you’ve already had conversations with friends about the epic number of times you get up to pee during the night. As men age, the prostate continues to grow and soon necessitates the use of a different comparator, perhaps even a move from nuts to large-sized fruits. In The Definitive Guide to Prostate Cancer, Aaron Katz, MD, writes that a prostate as large as 18 ounces—“the size of two grapefruits”—has been removed from a man. I am still waiting for the first horror film in which a steadily growing prostate escapes the body of a crazed grade school janitor and terrorizes an entire community.
What enlarges the prostate is a condition known as benign prostatic hyperplasia (BPH), though there is nothing benign about a half-dozen trips to the head between midnight and 6:00 a.m. It certainly wasn’t convenient if you were one of the Founding Fathers and from time to time had to do your voiding in freezing outhouses—Benjamin Franklin and Thomas Jefferson were said to be BPH sufferers. It turns out that this condition has a name—nocturia, which sounds like the Greek goddess of sleep, and God knows how inappropriate that is.
BPH generally begins in what is known as the prostate’s transition zone, the tissue that directly surrounds the urethra. The tissue grows inward, enlarging the gland and constricting the urethra, which restricts urine flow. So you have trouble going, or you go and never quite get it all out and have to get up again to try to finish the job, or you have dribbling after urination (sometimes even double dribbling, a clear violation), or you have pain with urination, a weak urine stream, or blood in your urine.
This marching-off-to-the-head condition is often treated humorously. But it’s really not that funny. In January 2013, a California urologist, Ronald Gilbert, MD, was shot and killed in his office by a patient who was reportedly upset over his continued issues with postsurgical incontinence. Also, incontinence is generally treated as a male problem, but it is not. “Men and women have the same urinary issues,” says Steven Kaplan, MD, a well-known urologist at NewYork-Presbyterian Hospital and Weill Cornell Medical College. “With men, it pops up in their 50s, and with women, it’s generally postmenopausal. Urinating symptoms are going to get everybody sooner or later, and by and large it comes down to what the individual thinks about it. Somebody goes every four hours and maybe it doesn’t bother him, but somebody else goes once every six hours and that guy wants a consultation.”
As much of an inconvenience as BPH can be, it is not cancer and is far more common. Rodale’s book hardly mentions cancer and instead targets the other prostate miseries of enlargement and inflammation. In his seminal medical textbook Gray’s Anatomy, Henry Gray describes the simple horrors visited by an enlarged prostate. The important thing to remember is that if you have BPH, it doesn’t mean you have or will develop cancer, and vice versa. I had cancer but never had BPH, a happenstance I consider a small yet much appreciated miracle. And since I no longer have a prostate, it can’t get enlarged, which is one less thing to worry about on my personal road to ruin.
CHAPTER 3
... In which the author for the first time pays real attention to his PSA number
MY FAMILY PHYSICIAN, James Manley, DO, and I had a loose script we followed at my yearly physicals. He would suggest that I get a stress test, and I would say, “Doc, when I go down, I’m going down from the Big C. My heart’s fine.”
I believed that, too. Cholesterol, heart rate, blood pressure—all those things were always good; I took reasonably good care of what I could take care of. But cancer lurked. Cancer that metastasized in the liver killed my father (he was 80), and there are other cancers in my family history. Plus, it didn’t seem like there was much you could do about preventing its onset, with the possible exception of lung cancer—see Chapter 1—and I was not a smoker.
Since my father’s troubles started in the colon, I had been enduring the every-five-years-or-so colonoscopy for quite a while. It’s been uneventful outside of the residual effect that I can no longer quaff orange Gatorade, the drink I choose to accompany that horrible liquid involved with the bowel prep.
I remember that my father had urinary difficulties that stemmed from an enlarged prostate, but I had no idea how one combated that, and my father and I were never much for protracted discussions of any kind, far less ones of a sensitive medical nature.
Dr. Manley started me on prostate-specific antigen (PSA) screening when I was in my mid-40s, but I couldn’t have told you what the letters stood for, what the numbers meant, or even exactly what the hell it was screening for. “Let’s see, your blood work’s good, cholesterol’s under control, PSA’s under 2 . . .” Dr. Manley would intone, and I would nod like a dope and feel like I just passed a test in a course I hadn’t known I was taking.
What finally got my attention about the PSA level was the brave but ultimately futile struggle that a friend of mine named George Yasso had with prostate cancer. George was diagnosed with metastatic prostate disease in 2001 and never got better (see Chapter 15 for his story). After George got sick, I still didn’t understand the inner workings of PSA, but its measurement started to feel more real.
Speaking of feeling real, having a digital rectal examination (DRE) was my least favorite occasion of the year. I began thinking about it a full month before Dr. Manley’s invading finger approached my anus. He could give me an armful of shots with Brobdingnagian needles and it wouldn’t bother me, but the thought of a single digit inserted into a very private space put me off my game. I was pondering going to the David Cronenberg movie Cosmopolis until I learned that the character played by Robert “Twilight” Pattinson receives a DRE in the backseat of his limo. That’s not all he receives back there apparently, but it was enough to keep me away.
My wife rolled her eyes when I complained about the DRE, reminding me that the medical indignities routinely heaped upon the female—and beginning at a younger age—are far worse. Message received, but not helpful. My blood pressure would jump 20 points before the exam, and I always made some joking attempt to discourage the doctor from performing it.
“I felt my prostate just this morning, Doc,” I’d say, “and it was fine.”
“Terrific,” he’d answer, diabolically wiggling his fingers into a rubber glove. “Now bend over and put your hands on the side of the table. You’re going to feel a slight pressure and the need to urinate.”
When a physician performs the exam, he or she feels the peripheral zone of the prostate, which constitutes about 65 to 70 percent of the gland’s total area. (The other two zones are the central, with 20 to 25 percent, and the transition, with 5 to 10 percent of the total area.) I asked Dr. Manley how a doctor learns to perform a DRE. “Usually when a man is being prepped for surgery,” he said. “Residents do it under the guidance of a urologist while the man is asleep. Bringing seven residents into an office to do a DRE on one guy doesn’t work too well.”
To perform the exam, a physician runs his finger along the surface of the prostate from front to back. “Before you do it you need to visualize the prostate, what a normal one would feel like,” said Dr. Manley. “And like everything else in medicine, you have to see a lot of normals to appreciate the abnormal.”
And how might it be abnormal?
“The consistency, the shape, the size, all of those things,” said Dr. Manley. “I have felt what turned out to be cancer many times. It might feel like a pebble under the skin. Or it might just feel rough, bumpy.
“Now, if something is ‘abnormal,’ that doesn’t mean a man has cancer. I’ve felt a bump and it turned out to be a calcium
deposit. A family practitioner should never pronounce a man to have prostate cancer based on a physical exam. Our job is to determine, by the DRE and the PSA, if there’s reason to suggest seeing a urologist.”
Dr. Manley had never digitally detected anything unusual about my prostate, other than that it was “smallish,” which is medically comforting but not necessarily a word that a male of any age wants to hear in relation to his reproductive system. But during my July 2011 physical, Dr. Manley expressed concern about my blood work.
“Your PSA is 3.8,” he said. “That’s not overly high, but the concern is how it has steadily risen.”
My PSA was 1.4 in 2007, 1.7 in both 2008 and 2009, 2.23 in 2010, and now it was 3.888. There is some dispute about the meaningfulness of PSA “velocity”—the rate at which it rises—but to the doctors at Johns Hopkins, who have done much research on it, velocity is highly significant. “Your PSA should not go up more than 0.4 per year,” says Dr. Patrick Walsh of Johns Hopkins.
Dr. Manley recognized mine as a fairly significant bounce and dropped a minor bomb.
“I think you should get a prostate biopsy,” he said.
I suspect that everyone has a few clusters of words that can turn them into Jell-O. Perhaps it’s “creamed chip beef on toast.” Or “ringworm epidemic.” Or “they just created a 24-hour Newt Gingrich channel.” For me, “get a prostate biopsy” was right up there. That’s because years earlier, a college buddy, Mike Steinhilber, described his biopsy thusly: “They stick a needle in your butt and then it feels like they open up a beach chair.” A writer acquaintance of mine, Jeff Jarvis, best known for the book Public Parts and himself a member of the Prostate Cancer Club (see Chapter 15), has a different description of the biopsy, which typically involves taking about a dozen samples. “It’s like shooting harpoons up your ass,” says Jarvis.
Another college friend, Keith Van Arsdalen, MD, is a respected urological surgeon at the University of Pennsylvania, so I sent him my records. He agreed that a biopsy was warranted.
“Can you be asleep for this procedure, Keith?” I asked. “Or maybe half dead? See, Steiny told me once”—Mike and Keith are friends, also—and I went on to relate the beach-chair metaphor.
“Well, I don’t think it’s that bad,” Keith said. “But it’s uncomfortable, and, yes, more and more men are being put to sleep for the procedure.” Thankfully, he didn’t add, “Especially if they’re wimps.” He said that I would have to come to the hospital for routine testing before the procedure because it involves the use of anesthesia.
I talked it over with my wife and decided I would go ahead with it. I trusted both Dr. Manley and Keith to dispense sound medical advice. “There’s no rush,” said Keith. “We’ll do it in September.” That way, I could enjoy a few more weeks of relaxation while thinking about a needle being shoved into my rectum and the possibility that I might have cancer. Hell, golf is bad enough.
So there it was on the calendar for September 7, 2011: “prostate biopsy.”
It was about then that I began hearing the news that I might be nuts to be scheduling a biopsy, and, furthermore, that I should not have even gotten a PSA test. I was confused, and I was not alone.
Thus began a journey to parse what seems to be a disturbing reality with a confounding suggestion.
Some 28,000 men per year will die of prostate cancer.
But we should pretty much ignore it.
Huh?
CHAPTER 4
... In which the author, blissfully unconscious, gets his biopsy and feels confident, but soon gets a sobering phone call
A FEW DAYS BEFORE MY BIOPSY, I was playing golf with a friend of mine, Marc Hellman, who wanted to know if I had ejaculated in the hours preceding the PSA test that had read 3.8.
“You won’t believe this, Marc, but I don’t keep a calendar of those things,” I said.
“Because I heard that ejaculation can elevate the PSA,” he said. Marc himself had gotten a negative biopsy after a higher-than-normal PSA reading. The same thing had happened to two other friends, and all of them thought that ejaculating before the blood test might’ve raised their numbers.
There have been studies testing this theory, and the conclusion seems to be that it might raise the PSA number, particularly if the blood is drawn within 24 to 48 hours of ejaculating, but both the rise and the proportion of men affected are small.
I didn’t remember whether I had ejaculated, but at any rate I started to become convinced that, whatever the reason for my PSA rise, I would not be strolling down Prostate Pathway. I did not have cancer. That was my mind-set.
Biopsy day begins the way all depressing days should begin: with an enema, one of those Fleet jobs that is supposedly easy to self-administer. In my case, though, it required summoning my wife, whose “for better or worse” vows were severely tested.
I trust it is clear by now that when I did not enter the field of medicine, it was not a loss for the world at large.
Before the biopsy at Penn began, there was so much attendant rigmarole—insertion of the IV, conversation with the anesthesiologist, a run through the risk checklist, which includes, of course, death—that I began to feel guilty about getting put to sleep. Plus, the whole thing took so much time, and impatience is the clear leader in my long list of undesirable qualities. Had I submitted to the manly way of doing things, they would’ve sat me down, told me to bite on a towel like in an old Western, opened up that beach chair inside of me, harpooned away, and shoved me out the door.
I got wheeled into the OR, the guilt continuing. The small army of attendants suggested I was about to undergo a heart transplant. The room was cold and huge.
“You sure you need to do all this, Keith?” I said when he entered.
“It’s what we do when there’s anesthesia involved,” he said.
Guilt. And then sleep. And then I was back where I started, my wife sitting near me reading the Philadelphia Inquirer.
“Your prostate is small, which is good,” Keith said when he came in. “Everything looked fine, but you can’t tell by a biopsy. Take care and I’ll call you when I get the results. Remember—no driving. Donna drives home. Even if you feel fine, you had anesthesia.”
It had been a long day, but I was relieved. We sat in the hospital cafeteria and I began deconstructing Keith’s words like an amateur Kremlinologist. “Everything looked good.” “Your prostate is small.”
“I don’t think I have prostate cancer,” I said.
“I don’t, either,” Donna said.
About 25 to 35 percent of men who get biopsied for prostate cancer come up positive. Some studies suggest that the number is even lower if the PSA was below 4, and mine was 3.8.
The percentages were with me.
Then we drove to Vermont to see our son, who teaches at Middlebury College. I climbed into the driver’s seat as my wife glared at me.
“You’re not supposed to be driving,” she said.
“Hey,” I said. “I feel fine.”
And that was that. I knew that the needle had gone into my prostate because I peed blood for a few days and it remained in my ejaculate for a while, too. But other than time wasted, the scoreboard read, as I saw it: one biopsy, no pain (not even soreness), no fuss, no muss, no cancer.
ABOUT 10 DAYS LATER my wife and I were driving home from the beach when Keith called me on my cell.
“I have good news and bad news,” he said.
The first time I heard that line was on an episode of Hogan’s Heroes, an inane 1960s sitcom that had had its moments.
“I have good news and bad news,” Colonel Klink, the German commander, told the Americans.
“What’s the bad news?” asked Hogan.
“You are to be shot at sunrise” was the answer.
“What could possibly be the good news?” Hogan asked.
“They have decided not to drag your body through the streets” was the answer.
I pulled over to the shoulder of the Garden State Parkway
.
“The report shows cancer in 2 of the 12 sections we biopsied,” Keith said.
And the good news? They will not be dragging my walnut-sized prostate through the streets?
“It’s a very low level of cancer,” Keith said. “It’s manageable. We’ll take care of this.”
“So what’s the next step?” I asked.
“Well, our procedure is to do an MRI with an anal probe,” he said. “We do that so that—”
“Excuse me, Keith,” I said. “Did you say ‘anal probe’? I went to sleep for a biopsy and you’re going to put an anal probe in me? I thought that’s what happens to people who get kidnapped by aliens.”
Keith explained that they do the probe MRI for several reasons.
• Perhaps the cancer will be visible in the image (though probably not with a low level of cancer).
• The MRI produces a picture of the nearby lymph nodes; if cancer is suspected there, the nodes are biopsied, and chances are the prostate will not be removed if the cancer has spread. (Again, that would be an unlikely outcome given the low level of cancer in my prostate.)
• An MRI also provides an image that, if necessary, can be compared to later images to show any movement of the cancer or changes in other organs.
Keith allowed that it was probably examination overkill, a CYA (cover your ass) move (or, in this case, a cover-my-ass move) that drives up the cost of medical care but helps protect doctors against liability and might be revelatory.
“Look, with cancer, you never know,” he said.
The Prostate Monologues Page 3