Two Storms
Prostate Cancer and Katrina in New Orleans
By Iain S. Baird
Published by CyPress Publications
Tallahassee, Florida
Smashwords Edition
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Copyright © 2010 Iain S. Baird
Cover photograph copyright © 2010 Iain S. Baird
All rights reserved. No part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher, except for brief quotations contained in critical articles and reviews.
The information contained in this work is not intended as medical advice; it reflects only the author’s research related to his own personal health-care experience at the time of writing. Readers should consult appropriate health- care professionals for answers to specific questions related to their own health issues.
Inquiries should be addressed to:
CyPress Publications
P.O. Box 2636
Tallahassee, Florida 32316-2636
http://cypresspublications.com
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Library of Congress Control Number: 2010928248
ISBN: 978-1-935083-17-7
First Edition
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Dedication
For Ann, The People of New Orleans, and The Over Two Million Men in the United
States who are Living with Prostate Cancer
* * * * *
In ferreting out information about prostate cancer, I turned to the resources of the Johns Hopkins Hospital, especially the Brady Urological Center, the National Cancer Institute, the American Cancer Society, and the Prostate Cancer Foundation. Any errors in fact are solely mine.
I have great respect for and appreciation of the excellent medical facilities of Touro Infirmary in New Orleans and the Johns Hopkins Hospital in Baltimore, and for the terrific physicians, nurses, and support staff who took such good care of me during this period. A special thanks to Dr. Bob Bencze, M.D., who gave me wise counsel, sound medical advice, and friendship at critical points in my diagnosis and treatment.
To the three fellow travelers who are highlighted in the book: my firefighter neighbor, my Asheville buddy, and my writing friend, my sincerest thanks for your unfailing support.
Thanks to James Nolan and the members of the Loyola Writers’ Group for reading selected passages of this book and for their encouragement over the years. I owe a particular debt to Charlie Wilkinson, who painstakingly read every word of the manuscript and offered insightful suggestions. The book is much improved by all their efforts. Its faults remain my responsibility.
And finally, my appreciation to family and friends who have shown me such love and support, especially my children, Sara and Michael, and my wife, Ann, my first and last reader, my best friend, and the love of my life.
* * * * *
"I feel a very small nodule on the left side of your prostate."
This is how it starts.
I receive the news of this "small nodule" while bent over my doctor’s steel-and-leather examination table. My arms rest across its surface, a fresh piece of white butcher paper rolled across the table’s top. I stare ahead at a child’s drawing of a grassy park with lots of green, blue, and yellow lollipop trees laden with swollen, bright red apples. My Levis are down around my ankles, and the doctor has his gloved and lubricated finger up my butt. It’s not exactly how I imagined getting bad news. It’s supposed to be done in a sedate, formal office with thick, leather-bound medical books on dark walnut shelves. The walls should be covered with impressive, expensively framed certificates rather than a child’s crude drawing. There should be a fresh box of tissues nearby. Well, at least we’ve got the tissues.
"Here, use these man-sized ones," the doctor says, handing me a couple of sheets of paper towel. They’re not for wiping my eyes.
I stand up, clean myself, and pull up my jeans. I’ve just had a procedure called a Digital Rectal Examination or DRE. It’s recommended annually for men over the age of 50. I can’t say I look forward to this yearly rite, but it sounds a lot worse than it is. There’s only mild discomfort when the doctor presses his finger against the prostate through the wall of the rectum, and the procedure lasts only about ten seconds.
It’s a Friday. I’ve pedaled my black, one-speed, street bike the mile or so through the Uptown streets of New Orleans to the Touro Infirmary Medical Complex, where my internist has his office. It’s March 2007, a year-and-a-half since Hurricane Katrina, andTouro is one of the few functional hospitals. I’m here for my routine annual physical. I’m 61 years old.
As I drop the tissue in the wastebasket and wash my hands, my doctor says, "I think you should see a urologist. Do you know one?"
"No, I’ll need your recommendation. Is this something I should be concerned about?" I ask, though, in truth, I’m way past concern, having moved right through worry to fear in the time it took to wash my hands.
"I’d be concerned at about a two percent level," he says. "Your prostate doesn’t feel enlarged. I don’t think it’s anything to worry about, but I’d feel better if you were checked-out by someone who examines prostates all day long. Don’t lose any sleep over it."
Though I should be focused on other matters, I can’t help but wonder about someone who chooses to "examine prostates all day long." Maybe he couldn’t get into proctology school.
Before I leave the doctor’s office, he sends me over to his nurse, who draws a couple of vials of blood. One of these will be to determine my level of Prostate Specific Antigen, or PSA. Like the Digital Rectal Exam, this is a routine screening for men over 50.
So far, I’ve managed to have my annual physical, find the nodule, or small lump, receive a referral to a urologist, and get blood drawn to check my PSA, and no one, neither the doctor nor I, has said the word. It’s as if by not naming it, we can deny it or limit its power. It’s like the evil Voldemort in the Harry Potter stories—He Who Must Not Be Named—for to do so gives him strength. But both the doctor and I know that the PSA test and the DRE are markers for the disease, which must not be named. The nodule, the lump, the bump, the growth, the tumor. Oh, what the hell, prostate cancer. I wait for the bolt of lightning. But that would be like a heart attack. Cancer’s much more subtle and quiet, like rising floodwaters in the night.
When the levees failed in the wake of Katrina, water rose through eighty percent of the city’s streets, drowning its neighborhoods. The storm took Charity Hospital. The flood steeped Memorial Hospital for weeks in fifteen feet of water, fouled by industrial waste and backed-up sewers. University Hospital and Tulane’s Medical Center were so damaged it was a year before they offered even the most restricted of services. A trauma unit for the city was first established in the shell of a department store, then in a ballroom of the ruined Convention Center, and finally at a remote shopping mall. Mold and rot and mud and debris infect the surviving medical institutions of the city like an unchecked disease.
Yet the city fights back. The Sliver by the River, as we call the ridge running from the French Quarter, through the Warehouse and Garden Districts, to the Uptown neighborhood where I live, is largely back on its feet. This is the historic high ground of the city, where the first settlers wisely built their houses and businesses. Felix’s is frying oysters, and Kermit Ruffins is singing at Le Bon Temps Roulé. Neighbors plant trees, and the city collects trash. As survivors stare down the decay rampant in other areas and push back against the corruption that infects too many of the city’s services and try to ignore the rising crime rates plaguing the surrounding neighborhoods, here on the higher ridge medical services carry on. Touro Infirmary and its doctors’ offices, though overcrowded and stressed, are up-and-running while the rest of the city’s medical services remain in shambles.
I ride my bike home along Coliseum Street. Many of the houses have been repaired since the storm. There are fresh coats of paint and replanted gardens. While this part of the city was spared the floodwaters that reached only blocks away, the damage was still severe from Katrina’s winds and then Rita’s rains a month later. A year ago, most of the houses along this street were draped in blue vinyl, courtesy of the Corps of Engineers and FEMA. And while Hispanic workers, new to the city, have stripped off the blue tarps, replacing them with new tar paper and shingles, there is still much evidence of the storms and more work to be done.
I pedal past Dumpsters sitting on curbs, collecting debris as homeowners gut the rotting and moldy wallboard from their rain-soaked houses. At others, workers scurry in and out to the sound of nail guns and electric saws. Some homes remain shuttered and desolate. Not everyone has returned, even to this secure part of town. Most schools are closed, and those that have reopened suffer from the same educational challenges that faced the ailing city before the storms—poorly qualified teachers, disciplinary problems in the classroom, corrupt administrators, a lack of supplies, and antiquated facilities. Crime is back and rages unchecked. Someone is murdered every other day, though rarely on this street. A study from Tulane names New Orleans the murder capital of the nation. Fifteen hundred people died in the floods and many more in the aftermath of fleeing from the city. Yet the city still seems hungry for death and bent on killing more. Many who fled the storms have found other cities where they can walk the streets safely at night and send their children to good schools just down the road. They won’t be returning.
* * * * *
I blame myself for Katrina. Both my children wanted outdoor weddings, and I made a bargain with the weather gods. "Give us a beautiful day, and we’ll never complain about the weather again." The gods listened. On October 11, 1997, and again on September 28, 2002, the sun shone brightly and the temperature was mild, and the outdoor weddings went off without a hitch. At around 6:00 a.m. on August 29, 2005, the gods had their payback when Katrina made landfall ninety miles southeast of New Orleans at Buras, Louisiana, on the Plaquemines Parish peninsula. The now Category 3 storm made its way northeast, passing forty miles to the east of New Orleans, before making landfall again four hours later in Mississippi just over the Louisiana border. In those early hours, many New Orleanians, including me, gave thanks that the storm had veered at the last minute, saving the city from a direct hit. But by then, unknown to us, the storm surge had breached the 17th Street Canal and the Industrial Canal Levees. Before the day was over, there would be fifty-one more levee failures, and eighty percent of New Orleans would be under water.
My wife Ann and I had moved to New Orleans in 2003 to start a new life. We had both retired from our day jobs: Ann as a high school art teacher; I as a senior official in the Commerce Department, working on international trade and security issues. Now, we would have the time to pursue our avocations rather than our occupations. Ann, an accomplished painter with many one-woman and group shows to her credit, could have her own studio and paint full time. I had dabbled in writing fiction and life stories. Now, I’d have my own study and the time to write a long-postponed novel and the series of short stories I’d been outlining over the years. Where better to undertake this new adventure than New Orleans?
We found a perfect house in Uptown, just a couple of miles up river from the French Quarter. I enrolled in a creative writing class at Loyola University and, at its completion, was accepted into the Writing Institute’s advanced workshop. Before long I managed to get a few stories published and even picked up a couple of writing prizes. It appeared my new, modest writing life was underway.
Ann soon acquired a painting studio and was accepted by her fellow painters and the art community as one of their own. Her new work was bold and colorful, as she explored new techniques and materials.
Our new life in New Orleans entered a period of predictable and rewarding rhythms: writing and painting, regular exercise at the gym and long walks in Audubon Park, dining with friends, attending art shows and music festivals, entertaining a stream of out-of-town visitors, both family and friends.
There’s a bumper sticker that I’ve always enjoyed: Life is what happens when you are making other plans. It has a way of surprising you. There’s always something out there in the night waiting to knock on the door. While we were settling into our new life, somewhere out over the Sahara Desert a butterfly turned right instead of left, sending a swirl of air up into the night air that would blossom into a gentle breeze, and then grow and grow as it moved offshore and into the warm Atlantic. Eventually, this gust of wind would gather itself into a storm called Katrina. As chaos was given form over the Atlantic and later the Gulf of Mexico, a mutated cell buried deep within my prostate decided to divide, setting into motion its own cancerous storm.
In looking back at storms, they seem so predictable. A storm hit, then this happened then that happened, and here’s what we did about it. But storms aren’t like that at all. It’s all about "whether" rather than "weather." Whether it will intensify, whether it will swing north or south or east or west. Whether it will make landfall in your city or in a town in the next state. Whether it will push a storm surge. Whether it will arrive at night or during the day. Whether it will be high tide or low tide. Whether the levees will hold. Or not. And even with all the advances in computer modeling, making storm predictions is still more art than science. Three days out, estimates of landfall are only accurate to an average of two hundred thirty miles. At twenty-four hours out, the degree of error still remains at one hundred miles.
Even after landfall, the "whethers" continue. Whether your neighborhood floods. Whether your roof blows off. Whether your house is looted. Whether your friends are safe. Whether they’ll lift the mandatory evacuation and let you return home.
And cancer is all about "whether," too. Whether it will be detected. Whether the biopsy will be positive. Whether the cancer is aggressive. Whether it’s caught in time. Whether the selected treatment is the best one. Whether it works. Whether you beat the average survival rates. Whether the experience changes you. Whether the change is for the better or the worse. Whether you’re cured. Whether you die.
So, while we sat at our iron-wrought table in our secluded courtyard surrounded by blazing Crêpe Myrtle and climbing Philodendron, with the scent of jasmine and ginger in the air; while we enjoyed a breakfast of croissants and café au lait and planned our day of writing and painting, walking and shopping, and stopping by Cole Pratt Gallery for an art opening that evening, little did we expect that hell would soon be joining us for lunch.
Two storms were out there. Katrina would hit on August 29, 2005; my own storm of prostate cancer eighteen months later. New Orleans and I would travel the windswept roads of devastation and recovery. And we would do it together.
* * * * *
Back at home, after returning from my doctor’s appointment and the discovery of the small lump, I call the recommended urologist and make an appointment to see him in a week. By then, I should have the results of the PSA blood test. Ann arrives home, and I brew a pot of Twining’s breakfast tea and share the news with her.
"The doctor found a tiny lump on my prostate. He doesn’t think it’s anything—he assessed it at a two percent concern level. Told me not to lose any sleep over it. But just to be on the safe side, he wants me to get it checked out with a urologist."
She sits down on the couch facing me. "So, are you going to?"
"Sure. I’ve already made an appointment." I take a sip of my tea.
"For when?"
"Next week. Again, he didn’t think it was anything to worry about. It’s very small. Probably nothing."
"Well, I’m glad you made the appointment." Ann was raised in a military family, moving from post to post, under the care of a forceful father—the Colonel—and a self-reliant mother who often had to manage the household when her husband was away fighting wars. Ann was raised to be independent, adaptable, and not to complain. I was raised by Scots who came to this country from Glasgow by way of London, where they hunkered in the Underground during the Battle of Britain. Not a lot of needless fretting there, either. So, neither of us is a public agonizer. We don’t sit around wringing our hands over things we can’t control. We won’t be spending every minute of the coming week discussing possible outcomes. What if this or what if that? We’ll wait to see what the urologist says next week and deal with it as necessary.
Despite this stoical posture, I spend the rest of the day and a good portion of the night hunched over my computer, banging away at the Web sites of the American Cancer Society, the National Cancer Institute, and the Johns Hopkins Hospital’s Brady Urological Center. Again and again, I search Google for hits on prostate cancer and explore the information found there. No needless fretting here.
Here’s what I find. Last year, as a result of DREs or elevated PSAs or inflammation or enlargement, about eight hundred thousand men underwent biopsies of their prostate. Of those, three-fourths were found to be cancer-free. Most were determined to have Benign Prostatic Hyperplasia—a common enlargement of the prostate that occurs to some degree in about fifty percent of men age 51–60 and in about ninety percent of men over the age of 80. However, some two hundred thirty thousand, a little more than one-fourth who underwent biopsies, were diagnosed with prostate cancer. That means that somewhere in the United States a man gets a diagnosis of prostate cancer every two minutes. Two million men walk around with the disease in the United States. Last year, about thirty thousand men died from the disease, more than three dying every hour.
"I feel a very small nodule on the left side of your prostate. Don’t lose any sleep over it," the doctor had counseled. I stare at the ceiling of my bedroom at two o’clock in the morning, replaying those words over and over again, checking the clock every few minutes.
A part of me has been waiting for those words, or something like them— a shadow on your lung, a growth on your back, a sore in your mouth—for years. My father died of lung cancer at the age of 54, my mother from breast cancer at 69. My sister died at 64 from a heart attack, but she had many underlying ailments, likely including cancer, as evidenced by her chronic smoker’s cough and the lump on her breast discovered just before her death. Since we could never get her to a doctor, her medical profile is uncertain. Cancer runs in the family, and I’ve even had earlier brushes with the disease myself—skin cancers. A couple of basal cells removed from my face and two squamous growths, one on my leg and one on my arm. I’ve also had a very small melanoma—the bad kind—removed from my chest fifteen years ago. Those were the paybacks for a fair-skinned, twelve-year-old lad of Scottish descent trying to get a savage tan at the beach alongside his dark Italian girlfriend. I wonder whatever happened to her? She ditched me as soon as she started growing boobs and traded me in for a fifteen-year-old delinquent with muscles and sideburns.
Outside our bedroom, the wind picks up and rustles the branches near the open window. A three-quarter moon lights the night sky, and the sounds of the Mississippi—barges and cranes and railway cars—make plain a city working to get back on its feet. The distant sound of a gunshot makes it clear how difficult any recovery will be. Or maybe it’s just a car backfiring, though the sound of sirens ten minutes later makes me doubt this. I roll onto my left side so I can look out the window at the glowing night sky more easily.
The lump on my prostate is very troubling, but the other key to my meeting with the urologist next week will be the level of my PSA, to be determined through my blood work. Anything exceeding 4.0 ng/mL is considered iffy and may warrant follow-up tests, including a biopsy of the prostate. It’ll take four to five days to get the PSA results.
Two years ago my PSA was 2.6. Last year when I went to see my physician, it had risen to 3.7, a significant jump but still below the 4.0 cut-off considered worrisome. The DRE at that time had revealed no lumps, no physical abnormalities with my prostate. But because my PSA had jumped, we decided to retest it six months ago, and it had dropped to 3.5. PSA numbers can become inflated if the subject has recently ejaculated or had his prostate examined digitally—the DRE. So, six months ago I avoided sex for three days prior to the blood test and skipped the DRE. The result was the slightly deflated reading of 3.5. I’ve been concerned with the past two tests, but not unduly worried. Careful monitoring seemed the right course of action. Yet there is a nagging suspicion that those earlier inflated numbers might have been significant. I also wonder if avoiding the DRE six months ago to get a more accurate PSA reading had been wise. Would a lump have been detected at that time?
As with all cancers, early detection coupled with prompt, aggressive treatment can result in a cure. Delay usually leads to more unfortunate outcomes—either additional, more complex treatments or failure to contain the tumor.
There’s a long wail from the river as a large ship passing in the night sounds its foghorn. A cloud passes in front of the moon, darkening the sky and the room. A dog barks nearby, and far in the distance I can hear a car alarm scream. I roll away from the window and settle on my right side facing Ann, who’s breathing softly beside me.
I try to shake off these dark thoughts. My general health is so good. My blood pressure always registers less than 120 over 80. My resting heart rate is 60. I walk, I cycle, and I go to the gym. Recently, I’ve been working out with a personal trainer. I’ve even dropped twenty pounds in the past year, finally getting rid of the tire of fat I’ve carried around my mid-section for too long. And the plumbing? I piss like a horse and wake up with an erection every morning—well most mornings—okay, some mornings. Who keeps track? And I’m only 61, well, 62 in another month. While prostate cancer can strike men much younger than me, it’s an old guy’s disease. In fact, many of the men who contract it are so old that doctors will forego treating it, figuring that their patients will die of something else before the cancer spreads.
And they don’t even know what causes prostate cancer. It seems to run in families, but I’ve never heard of anyone in my family with it. Of course, my father died at a young age, and I know little about the medical histories of my Scottish ancestors. Like all cancer, there seems to be some relationship to heavy alcohol consumption, and I’ve been a regular drinker for many years. A new study suggests exposure to artificial light at night might increase the risk of prostate cancer. From Bourbon Street’s neon to the round-the-clock operation of the port, New Orleans certainly has a bright nighttime sky. Should I have drawn the drapes more tightly against the glowing ambient light? But I don’t smoke, another possible factor. I did carry around that excess weight for too many years, and it was belly fat, a negative factor for many diseases. I ate a lot of tomatoes, which, with their lycopene, has been associated with a reduced incidence of prostate cancer. And I’ve been exercising regularly for twenty-five years, which is good for you. The bottom line is that they really don’t know why one person gets prostate cancer rather than another.
I roll on my back and lift my head so that I can see the illuminated clock across the room. It’s four-fifteen. Somewhere along the river in this early morning, two railway cars slam into each other with a sound like a tolling church bell.
* * * * *
Two days later, the morning Times-Picayune carries the obituary of Glynn Joseph Francois, Jr., also known as Wimpy. He was one of five people shot over the past bloody weekend. Three of them are dead. He was gunned down with an AK-47 assault rifle while sitting in his car with his sister at a car wash near the busy corner of Esplanade and North Broad at 2:00 p.m. in the middle of a languid Saturday afternoon. According to the paper, his sister tried to hide his handgun before the police arrived.
When I finish reading the paper, I get the call from my internist’s office with the results from my blood tests. My PSA is 4.9 ng/mL. Not good. Not only is it above the worrisome cutoff point of 4.0, it has accelerated significantly since my last test. Once again I had abstained from sex as directed, but I did have the Digital Rectal Exam prior to my blood being drawn. However, the DRE in and of itself wouldn’t account for such a large jump.
From my reading of the literature over the weekend, I know that experts are looking more and more at the rate of acceleration of the PSA scores, so-called PSA velocity, as a more reliable predictor of prostate cancer than the simple, absolute number itself. Over the past six months, my PSA reading has not only ventured into the worrisome range above 4.0, it has jumped some forty percent. This is not good news but is still short of a diagnosis of prostate cancer.
There is considerable debate over the routine ordering of PSA tests. With over eight hundred thousand biopsies being conducted each year on men as a result of elevated PSA in the blood, many are questioning the advisability of such wide use of the test. Biopsies are painful, expensive, and not without their own set of risks. This concern with the possible overuse of PSA tests is especially true for men over the age of 75. Due to its slow-growing nature, most men of this age will die from something else, even if they are diagnosed with prostate cancer. But I’m 61. If I have prostate cancer, I need to know it. And to do something about it. For those at my age and with my history, annual PSA screening seems advisable, at least until a better test emerges.
So, I have yet to receive a diagnosis of prostate cancer, but I don’t like the direction the wind is blowing. First the small lump, now the elevated PSA score, coupled with a forty percent PSA velocity. I try to heed my internist’s advice not to worry, but I’m not having much success. I can feel it in the air; a storm is coming.
* * * * *
The next day I meet with the urologist. He turns out to be a slim fellow, in his late fifties, with an easy smile in contrast to a formal manner. He’s an LSU graduate who also spent some time at Tulane and did his residency in urology at NYU and Mt. Sinai in New York. Sound credentials. He reviews my PSA results and conducts his own DRE. Seems like I can’t enter a doctor’s office these days without an invitation to drop my drawers and bend over.
"I do feel a small ridge on the left side of your prostate, but it’s very small."
After we both have a chance to clean up and get settled, he says, "With the combination of the elevated PSA and the discernable ridge on your prostate, one hundred out of one hundred urologists are going to tell you to get a biopsy."
"So, I guess my worry factor has jumped from two percent to around fifty?"
"Sure, it’s more worrisome, but let’s not get ahead of ourselves. There is still a better-than-even chance that the biopsy will come back negative. We can do the biopsy right here in the office. I do them every other Monday along with a technician who takes an ultrasound image of your prostate. It’s a simple outpatient procedure lasting a couple of minutes."
He’s booked up for next Monday but can take me two weeks later.
"That’ll be in about three weeks. Is that okay? Can we wait that long?" I ask.
"One of the nice things about prostate cancer, if you can use the term nice, is that, except in rare cases, it’s a slow-progressing disease, giving plenty of time for evaluation and the selection of treatments. Three weeks will be fine."
On the way home, I take a slight detour on my bike and stop at the Discount Market just around the corner from our house. A family from Pakistan runs it. They are new arrivals, the grandparents speaking Urdu, the grandmother never without her hijab headscarf. The young parents dress in denim, chatting incessantly on their cell phones. Their chubby, four-year-old boy careens around the shop, wearing a Saints jersey and munching on a Snickers bar. Their Discount Store was one of the first places to reopen after Katrina.
I need a quart of milk, and while I’m there, I also pick up a Powerball lottery ticket. In fact, I get ten of them at a buck a piece. I don’t consider myself superstitious, though I do knock on wood when appropriate to keep the demons at bay. And I do throw spilt-salt over my shoulder. And I do say the Lord’s Prayer during take-offs and landings, though I haven’t been inside a church in years. However, I’ll walk under a ladder, play with a black cat passing by, and drive by a graveyard without whistling or holding my breath, unless it’s very late at night. I do believe in some sort of loosey-goosey combination of the Law of Conservation of Matter and the Second Law of Thermodynamics—the Law of Entropy. As I’ve undoubtedly bastardized them over the years since high school Physics, basically, the total amount of energy and matter in the universe is constant. Though matter is destroyed and becomes energy, at the same time, energy is transformed into matter, so that everything evens out. As disorder increases in one place, order arises from chaos in another. Or as Jerry Seinfeld once said, "It’s all about Even-Steven." You lose something here; you find something there. Bad luck here, good luck there. It all evens out.
So in accordance with the Law of Even-Steven, I buy the Powerball tickets, figuring if bad news is headed my way, I’ll offset it by being the richest person ever diagnosed with prostate cancer. When I check the next day’s results, I’m delighted to learn that none of my tickets are winners. In fact, it’s not even close. I matched only two numbers out of a total of sixty possible hits. Disastrous results, terrible luck, all of which bodes well for the upcoming biopsy exam. The Law of Even-Steven.
But even as I look over my useless lottery tickets, I can feel that things are not balancing out in my favor. Nodule on the prostate, elevated PSA, rapid PSA velocity, a history of cancer in the family. The cards are stacked against me.
New Orleans has had its share of luck, both good and bad. As the Category 5 storm barreled toward the city, most of its citizens heeded the mayor’s warning that "This is the one we have always feared," and evacuated for safer territory. Most fled, but not all. Then, at the last minute, Katrina’s intensity dropped to a Category 3 storm and veered east toward Mississippi, with Biloxi taking the direct blow. The sigh of relief was palpable. Unfortunately, it was also short-lived as news of one break in the levees followed another, and water coursed through the streets, flooding an area five times the size of Manhattan Island. The ravages from the hurricane’s winds and rains would eventually cover a region the magnitude of the United Kingdom.
As I hope for good news from my biopsy, New Orleans waits for some good news, too. Instead the news is of bureaucratic bungling, misappropriated funds, toxic trailers, and crime and death. It seems as if the Law of Even-Steven has failed to return to the city along with so many of its people. I’m hoping for a better outcome but fear that the city and I are on parallel paths, ones that will be long and difficult before the end is reached.
* * * * *
As the days pass, I return again and again to the Internet to learn about my possible disease. I discover that last year in 2006 there were about 2.5 million new cases of cancer in the United States. Cancer is the greatest killer of men, women, and children, except for heart disease. Overall cancer accounts for about twenty-three percent of deaths in the United States. Five hundred sixty-five thousand Americans died last year from one form of the disease or another.
Skin cancer is by far its most prevalent form, counting for over one million new cases. But most of these are the easily treatable basal or squamous cell cancers. The more serious melanoma skin cancer only accounts for some seventy thousand new cases. Lung cancer is the most deadly, with some one hundred eighty-seven thousand new cases in 2006 and about one hundred sixty-three thousand dying from this disease. There are more new cases of prostate cancer at two hundred thirty-four thousand, but with far fewer deaths, some thirty thousand, due to early detection and its less aggressive nature. This is followed by breast cancer with two hundred fifteen thousand new cases but more than forty-one thousand deaths, and colon cancer at one hundred seven thousand new cases with some fifty-one thousand deaths.
Of course this isn’t a competition; no one’s vying for first place in this race. Well, maybe it is a bit of a competition, as I’m surprised to learn of the prevalence of prostate cancer and the fact that it will affect up to thirty percent of men over the age of 50 and up to seventy percent of men who reach age 80; yet, it doesn’t get nearly the attention as other forms of cancer. Thanks to the decades-old Surgeon General’s Report and the Tobacco Settlement, everyone knows about lung cancer. And with the Race for the Cure and the pink ribbons, people are very aware of the tragedy of breast cancer, my own mother succumbing to it many years ago. And thanks to Katie Couric taking us on a nationally televised tour of her colon, we all know about that type of cancer, too. But prostate cancer? Most of us, even guys, aren’t really sure what the prostate is or what it does. It’s that walnut-sized thingy down there somewhere that no one pays much attention to until things start to go south. But like I said, it’s not really a competition, and it’s not like I’m dealing with one of those esoteric and exotic cancers that no one has ever heard of.
I turn again to the computer. So what exactly is the prostate? Here’s what it says in a Johns Hopkins White Paper entitled "Prostate Disorders":
"The prostate is a gland located at the base of a man’s bladder, behind the pubic bone and in front of the rectum. This gland, which is the size and shape of a crab apple, weighs only about an ounce in young men. It surrounds the urethra, the tube that carries urine away from the bladder and transports semen during ejaculation. A good way to envision the prostate is an apple with the core removed, with the urethra passing through the middle.
"The prostate’s primary function is to produce prostatic fluid, a component of semen. In addition, during ejaculation, smooth muscles in the prostate contract to help propel semen through the urethra.
"Technically the prostate is not part of the urinary system. But because of its location and relationship to the urethra, the prostate can (and often does) affect urinary function."
Okay, so it’s more like a cored crab apple than a walnut. I stand corrected. But how or why do you get prostate cancer? No one knows, even though it will affect up to seventy percent of men who reach the age of 80. It does seem to run in families, so if you have a father or brother with the disease, you’re more likely to get it yourself. My father died at the age of 54 from smoking too many cigarettes, and I have no brothers. However, this hereditary aspect gives me pause. I do have a son, Michael, who is now 31. I’ll need to push him to get checked early and often. Being overweight may be a factor, and it strikes black men more frequently than white. My neighbor, an African-American firefighter in the city, told me about nine months ago that he had been diagnosed with prostate cancer. Asian-Americans are at the lowest risk.
There seems to be some evidence that the lycopene in tomatoes and pomegranates may help to protect men from prostate cancer. I guess I should have drunk more Bloody Marys. I’ll encourage my son Michael to start drinking tomato juice. Others have pointed to saw palmetto as possibly being helpful and to various other supplements, such as Omega-3 fatty acids, selenium, and vitamin E, though wouldn’t you know it, recent reports seem to contradict the protection afforded by selenium and Vitamin E. At the same time, new findings suggest a protective benefit from Vitamin D.
Trying to sort out the causes of and protections against prostate cancer is like staggering through a maze blindfolded. The bottom line: At this point in time, the underlying cause of prostate cancer remains a mystery.
* * * * *
Before I know it, the three weeks have passed, and it’s the Monday of my biopsy. During the three weeks, I’ve stayed busy writing, surfing the Internet for information on prostate cancer, getting plenty of sleep and exercise, and eating soundly in preparation for the road ahead. I’ve also had a birthday and turned 62.
It’s hotter today as New Orleans moves closer to its extended summer, which lasts from early May through the end of September. There is a prediction for a shower in the afternoon, and the cloying humidity supports this. The newspaper reports an increase in homicide and violent crime over the same period last year, a rate clearly outpacing the growth of the city’s returning population. The police chief, still operating out of a FEMA trailer, pleads for more federal assistance. Little wonder people are hesitant to come back.
As instructed, I pop 500 mg of Levaquin, an antibiotic, to ward off the possibility of an infection from the biopsy procedure. I won’t be riding my bicycle to the doctor’s today. It’s not the ride there that concerns me; it’s the ride home. I’m not sure I’m going to want to be sitting on a bike seat after having a series of needles shot into my prostate. Ann drives me to my appointment and will pick me up when I’m done.
When we get to the office complex on Prytania Street, she pulls to the curb, a line of cars behind her. Someone honks—a very un-New Orleanian thing to do in a town where most people only toot their horns to say hello. I wave my hand to the line of cars behind us as I jump from the car, trying to get the horn-blower to cool it. I don’t raise my middle finger, though I’m sorely tempted, my nerves just a tad on edge.
"I’ll call you on my cell phone when I’m done," I say.
"Okay," Ann says, looking over her shoulder at the cars stacked up behind her. She eases back into traffic and is gone.
I arrive ten minutes early for my two o’clock appointment; I’m nothing if not punctual, and I’m surprised (I’m not sure delighted would be the correct word) that the nurse takes me immediately to an examination room, where she asks me to drop my drawers so that she can give me a shot of more antibiotic. I mention the Levaquin pill I took an hour ago, but she says that the shot is just added protection. She doesn’t say anything about changing into a hospital gown. All she says is, "Charlie will be with you in a moment."
As I pull up my pants and fasten the buckle of my belt, I think Charlie must be the imaging technician who will work alongside my urologist in figuring out from where to nip the tissue samples. As I wait, I wonder why all examination rooms have to look the same. Linoleum floors, Venetian blinds, fluorescent lights, raised table with white butcher paper pulled across the top, red hazardous material buckets, white cabinets with glass fronts, stainless steel counter-tops strewn with assorted bandages, ointments, wipes, and gloves. On the windowsill sits a small stack of magazines: Time, People, and the Journal of Urology. The room cries for just one piece of art, aside from the predictable Mardi Gras poster hanging askew on the far wall.
Charlie turns out to be an amiable, forty-year-old, fit-looking fellow in green scrubs. He escorts me to another standard-issue examining room, though this one is bigger than most, and introduces me to The Probe. There is a square diagnostic machine, complete with an illuminated screen, from which a flexible cord extends with the plastic, white probe at its end. It’s about the size of my pinky, though I have large hands. At the mention of the probe, for some reason I think of Homer Simpson and Ned Flanders being abducted by aliens. Homer keeps repeating to Ned, "And then they probed you." I’m about to become a character in a cartoon.
Charlie tells me that he will place a condom over the probe before its insertion. "We practice safe-probing," he says, in what will be the first line of a string of comic patter. Maybe I am in a cartoon after all. I look over my shoulder for a camera crew or a team of illustrators.
Charlie’s a comforting, friendly fellow, who soon puts me at ease. Well, sort of at ease, at least as at ease as someone can be who is about to have a foreign object inserted into his rectum by a complete stranger. Maybe ease is the wrong word, but at least I’m not bolting for the door. Yet.
Charlie explains step-by-step what’s going to happen in the next ten minutes and then takes me through it. First, he asks me to drop my pants to mid-thigh and to sit on the examining table. Then I lie back and turn on my side with my face to the wall and my butt facing the room. He asks me to draw my knees to my chest, and he goes to work. I’m lubricated and the probe is inserted. It’s uncomfortable but not painful. For the next three or four minutes he moves it around gently, imaging different parts of my prostate. He tells me that he lets people know he’s a medical technician but rarely gets into the details of his work. Big surprise there. He says that he doesn’t want to be the butt of jokes. Yep, he’s a card.
Now my urologist arrives. After greeting me, he makes sure that I’m comfortable. Oh, sure, for someone with a probe up his ass about to be stuck with a series of hollow needles in an extremely tender region, I’m fine. The doctor tells me to expect six pops and that it will feel like someone has snapped me with a rubber band. And that’s exactly what it does feel like. Though it’s a very, very large rubber band, and I’m being snapped in a very, very tender region. But three minutes later, it’s all over. The doctor tells me he’ll see me in a couple of minutes, and Charlie helps me get cleaned up, dressed, and on my feet. He’s taking it slowly to make sure I’m not going to faint, but I’ll be fine as soon as I wipe the sweat from my forehead. He tells me that I can expect some discomfort and to see some blood in my stool, urine, and semen. I’ll certainly be looking forward to that. He says no heavy lifting for a couple of days and no ejaculating until the end of the week. Somehow I don’t think that’s going to be a problem. He escorts me back to the first examination room, where my urologist joins me a couple of minutes later.
"How are you doing?"
"Not too bad."
"Okay?"
"Okay."
"We’ll get the results on Thursday." He hands me another Levaquin and tells me to take it tomorrow. Any major discomfort, bleeding, or fever, I’m to call him right away. I make an appointment for Thursday with his receptionist and call Ann to pick me up.
This is fast becoming less fun. As I wait for Ann on the street in front of the doctor’s office, I feel a dull ache in my lower abdomen, almost a cramping. I look up the street, anxious for her arrival. It’s hot, and I’m sweating. When she pulls up and I sit down in the car seat, the ache becomes more pronounced. I shift around, trying to relieve the pressure and to get more comfortable. I’m glad I’m not riding my bike.
"I feel terrible," Ann says. "When I dropped you off, I was so distracted by the traffic that I didn’t even wish you good luck."
"Don’t worry about it. I didn’t notice," I say, though of course I did. "I was kind of preoccupied myself. Believe me, I know you are as concerned as I am," and of course she is.
"So, how did it go?"
By the time we pull into the driveway in front of our house, I’ve run through the procedure. Short and sweet, just as promised—ten minutes in and out. Now comes the waiting. More waiting.
* * * * *
The next morning, National Public Radio broadcasts a story about the lack of affordable housing in New Orleans. The Advancement Project, with the support of Congresswoman Maxine Waters, is suing the U.S. Department of Housing and Urban Development, asking that public housing ruined by Katrina and slated for demolition be re-opened instead. There is a sad interview with Gilda Burbank, who is living in Houston and wants to return to New Orleans but who can’t afford the rents in the housing-strapped city. She wants desperately to return to her one-bedroom apartment in the Desire projects. In Houston, she feels lost and abandoned. All she wants is to come home.
While I’m listening to this, I’m reading about the plans for a Museum of the American Cocktail and its goal to open a permanent home in New Orleans. This ambitious announcement is made in conjunction with the notice that the "Tales of the Cocktail" annual event will be launched with a "Wag the Tale" registration party at the Swizzle Stick Lounge. This year the Starfish Cooler, created by Stacy Smith, a bartender at G.W. Fins, will be the official cocktail. The Starfish Cooler is a mix of Moët and Chandon champagne, Lemoncello, pomegranate liqueur, unsweetened iced tea, simple syrup, and muddled orange slices and mint leaves. To me, it seems a waste of good champagne. Somehow I can’t see Gilda Burbank stranded in Houston sipping a Starfish Cooler at the museum’s opening.
I decide to spend the next two days before my meeting with my urologist reviewing biopsy pathology and treatment options, in case the news is bad. Even though only a quarter of the eight hundred thousand prostate biopsies done last year turned out positive, meaning they detected cancer, and even though my particular odds with my PSA level of 4.9 indicate that I still have a fifty-fifty chance for a good outcome, I don’t have a good feeling about this. The forty percent velocity and the lump are just too ominous. Of course, part of me thinks that if I prepare for the worst, it won’t happen, not that I’m superstitious.
I learn that, after taking the tissue samples during the biopsy, they are sent off to a pathologist for microscopic analysis. The first things the pathologist will look for are cancerous cells. If cancer cells are found, then the pathologist assigns a Gleason score from 1 to 10, which measures the aggressiveness of the cancer. Basically, the higher the score, the more aggressive and widespread the cancer. A score of 5–6 is considered a low-grade tumor and very treatable, a 7 is intermediate, and 8–10 is high-grade and good outcomes become iffier.
Then, there is the issue of staging—how much of the prostate has been affected by the cancerous cells. Low staging means that the tumor cannot be detected during a DRE, even though the PSA is elevated. With my "small nodule" I’m past that stage. The next stage is where a growth is discernable during the DRE but confined to one side of the prostate. This seems to be my case. Then there is the stage where the DRE identifies nodules on both lobes of the prostate. As with the Gleason score, the lower the stage the better.
Dr. Alan Partin of Johns Hopkins developed the Partin Tables, which combine PSA ranges, Gleason scores, and stagings to arrive at a means for predicting from the biopsy the likelihood that cancer has spread outside of the prostate and to the seminal vesicles and the lymph nodes. This is helpful in deciding on treatment options. You hope for low PSA ranges, Gleason scores, and stagings, as this combination offers more treatment options and a greater possibility of a cure.
The next two days crawl by. I’m having some mild discomfort, a slight tenderness. The yucky part of the day is in the morning when I have a bowel movement. I see blood in my stool and several drops of blood drip from my penis. That’s something you don’t see every day and don’t want to.
* * * * *
On the day I’m due to hear the results of my biopsy, the newspaper carries a story of a sixteen-year-old boy, a high school sophomore, fatally shot and found face down in the street. He becomes the city’s sixtieth murder victim of the year. Violence infects the city, and the police seem powerless to cure it or even to slow its progress. Death is in the air.
Music is in the air, too. Jazz Fest will start next week. We have friends coming to town from Virginia. One of these is Dr. Bob, a great musician and a talented physician. He was my family doctor when we lived in Virginia before moving to New Orleans. I’ll have a chance to pick Bob’s brain with the biopsy results in hand, if they should turn out unfavorable.
But before hearing the music at Jazz Fest, we need to face the music in the doctor’s office, and Ann and I drive over to Touro to get the biopsy results. The music starts off on a discordant and humorous note, that is, if you like black comedy. When my urologist joins us, his first words are, "Well, this isn’t too bad." Then he shuffles his papers and says, "Oops, I’m looking at the wrong file."
Oops? Oops is a word you never want to hear from your doctor.
This is his first stumble. He’s recovered quickly, but you don’t like your doctor mixing up the files, even if it is just for a moment. There is enough to worry about without being concerned that a diagnosis will be made on someone else’s file or biopsy sample or pathology report.
Then comes the news.
"The biopsy is positive, with four of the six samples showing signs of cancer."
Positive. Cancer. Well, there it is. It isn’t a surprise. The lump, high PSA velocity, my family history. But I can’t help but wonder, not for the first time, why something so negative for me is couched as a positive result.
"The Gleason Score is 6, which is good. You don’t want an 8, 9, or 10." I’m sure this is true, but I wouldn’t have minded a 5 either. Or even a 4.
"What about the staging?" I ask. While the Gleason score indicates the aggressiveness of the cancer, the staging indicates how far it has spread.
"We don’t know for sure. It’s hard to tell, but my guess is that it’s a T1c or maybe a T2a."
This is good, too, and suggests that the cancer is still confined to my prostate and has not metastasized elsewhere. If it spreads beyond the prostate, you’re into a whole other ball game with outcomes not nearly as hopeful. The biopsy also reveals that malignant tissue has been found on both sides of the prostate. It is more widespread than I had hoped and more extensive than the DRE had indicated with its "I feel a very small nodule on the left side of your prostate."
I ask about the weight of the prostate.
"The imaging indicates it at about 36 grams. That’s good. If it’s swollen, sometimes it needs to be shrunk through hormone therapy before you can undertake certain options, such as radiation. Yours is fine."
So the bad news is that I have prostate cancer. The good news is that we appear to have caught it early, or if not exactly early, maybe early enough.
* * * * *
"Well, the good news is that, with your diagnosis, all treatment options are on the table," says my urologist, looking again at my chart, "and all have the same approximate cure and survivability rates."
I guess this is good news, though I’m not sure what to do with it. I had thought that at my age, on the young side for prostate cancer, surgery— getting it out of me once and for all—made the most sense. Now, there seem to be other options that I need to consider.
I don’t do well with too many choices. Growing up, I hated Monty Hall and "Let’s Make a Deal." I always guessed the wrong door—the one hiding the goat. At carnivals, hucksters spotted me heading down the midway and called out to me while they shuffled their decks with glee, knowing instinctively that I’d never be able to pick the right card. Nevertheless, I’d throw down another quarter, hoping I’d do better on my second or third try. But in this case, I won’t be able to pick another card. I’ll need to choose wisely.
My research has identified five major options for a man faced with a diagnosis of prostate cancer. All have different side effects and risks, making the selection difficult. Ultimately, though, the decision really comes down to the clinical stage of the cancer—early/late, confined/metastasized—and the age and health of the individual.
The first option is called expectant management, or sometimes, watchful waiting. Because many prostate cancers grow slowly, for a number of men it is likely that they will die from another cause before the prostate cancer poses any problem. Under expectant management, the progression of the disease is monitored closely with PSA tests, DREs, and an annual biopsy.
This approach can make sense for low-grade cancers, especially in older men. Because of the mid-range grade of my cancer and my relatively young age, expectant management is not for me.
The second option is radiation, and there are basically two types. The first is Brachytherapy, in which dozens of tiny radioactive isotopes or seeds are implanted directly into the prostate. The second is External Beam Therapy, in which the prostate is bombarded with radiation from a machine outside the body. The advantage to brachytherapy is that it is a one-time outpatient procedure with no hospitalization or surgical risks. While it has a low incidence of urinary incontinence, it has a higher probability for other urinary problems, such as retention (the inability to void), urgency, and frequency. Because the prostate isn’t removed, no follow-up diagnostic pathology on the organ can be conducted, so it’s impossible to determine the extent of the tumor and whether the cancer has spread beyond the prostate and whether all malignant cells have been destroyed. In addition, as with all forms of radiation, the prostate itself is so damaged by the treatment that subsequent surgical options are not feasible if additional cancer is detected later through follow-up PSA tests. Yet, for small, contained tumors, this option offers the benefit of a one-time outpatient procedure with a high degree of effectiveness.