This story is not just about one visit to a doctor or nurse. It involves multiple visits to several doctors. But it is all just one story. It does not have a happy ending. Nor does it paint a particularly flattering picture of the state of the health care industry in the U.S. today. The names of the medical professionals have been abbreviated to obscure their true identities. The source material was not my personal recollection primarily, though I was present for each of the events, but was taken from my late husband's personal journal, written at the time of the events in question.
In the summer and fall of 2003, Laurin's PSA level began to rise. He was 77 years old. At one point, his PSA level was measured at 19--almost double what was considered to be on the high side of normal. His doctor, Dr. S, recommended a biopsy of his prostate. On this particular visit, Dr. S. was accompanied by a young female intern, who was "shadowing" him. Dr. S. asked if it was OK if she was present for the visit. Laurin consented.
In the corner of the doctor's office was an unusual type of lamp. It rested on the floor with a long neck that curved from vertical to horizontal and had a small, elongated but high-powered lamp on the end. I asked Dr. S. what the lamp was for. He said, "I'll show you". He asked Laurin to lie back on the examination table and pull down his underwear. He placed the light at the end of the lamp under Laurin's scrotum and turned it on. With the light behind it, the scrotum became translucent. Dr. S. said, "See that? That's water." I could not begin to imagine what his point was.
Our next appointment was even more bizarre. It was a Monday. Apparently, Dr. S. was intending to perform the biopsy on Laurin's prostate. However, Laurin and I were both confused on that point. Consequently, we had not done the necessary prep. In addition, Laurin (and I) had a number of concerns about possible adverse effects of the biopsy. (Biopsy of the prostate involves inserting an instrument through the anus. Triggering the device causes a hollow needle-like device to penetrate the wall of the rectum and snatch a bit of tissue from the prostate gland. If any procedure is likely to invoke queasiness in a male patient, including me, it is this one.)
Dr. S.'s response was to basically go ballistic. After assuring us that complications have arisen from less than 0.1% of such tests he added, "If you (meaning Laurin) were a 5-year-old, I would simply tell you to lie down and take it."
Well, that was the end of our doctor-patient relationship with Dr. S. We started seeing another urologist, Dr. H. He informed us that Laurin's PSA was at 9. No explanation was given for the apparent sudden drop. In addition, Laurin's Gleason Score--a measure of the aggressiveness of the cancer--was 7. These numbers are borderline-positive for Stage IIa prostate cancer.
The recommended therapy for Laurin was radioactive seed implants, also known as internal radiation therapy. This involves inserting a large number of tiny pellets of a radioactive isotope, such as plutonium, into the prostate gland. In Laurin's case, approximately 70 of these tiny pellets were placed, one-at-a-time, into his prostate by a radiological oncologist, Dr. T. The patient is given a local anesthetic and the process takes less than an hour. The after-effects are mild and short-lived. I was in the waiting room of the doctors' clinic the entire time. Eventually, the prostate dries up--I won't say is fried--so that it looks like a date...or raisin, I'm not sure which.
On one of the follow up visits with Dr. H., Laurin was in the examining room waiting for more than a few minutes. When Dr. H. came in, he couldn't find some instrument that he needed and in a pique of righteous rage at the negligent nurse, with his arm swept everything on the counter onto the floor. I could hear the commotion in the waiting room. Time to look for urologist number three. (Some time later, I asked Dr. T, the radiological oncologist, who was really quite civil and was himself suffering from a rare form of bone cancer, "What is the deal with urologists, anyway?" He answered to the effect that urologists are notoriously emotional creatures, which I interpreted as, "When it comes to your dick, don't get sick."
Recently, medical researchers have been telling men that they should stop getting routine PSA tests if over a certain age. They tell us that a very high percentage of us will develop prostate cancer--somewhat like Alzheimer's Disease--but that it is very slow growing and we could very well die of some other cause first. Laurin was given similar counseling by Dr. H. early on. Yet, doctors don't put croissants on the table by not treating disease. I don't know what Laurin's life would have been like had he not had the internal radiation therapy. I do know what his life was like for years after the treatment, however.
Fecal incontinence, according to Dr. T., affects only about 5% of men who have had the seed implants. Just another seemingly inconsequential factor in balancing prostate cancer treatment against letting it run its course. Other friends of mine who have had surgery to remove the prostate ended up with a perforated rectum or lifelong impotence. In terms of the impact upon a man's quality of life after age 75, I would have to say that fecal incontinence must be the worst of the three side effects. The horrors Laurin and I went through are too embarrassing and humiliating to attempt to describe here. Let me just say that they led to him having to put severe restrictions on his social life, undergoing a colostomy, and suffering the complete loss of his self esteem.
Let me end this diatribe with this caveat: the medical profession will never say "No" to a decision to fight cancer with everything you've got. Medical costs during the last year of life account for an enormous chunk of Medicare dollars expended. In America, we tend to believe in "fight to the last ounce of your strength" or, as Dylan Thomas wrote:
"Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light".
However, if the light has faded to a dung brown, perhaps it's dying be a blessing.
© 22 June 2013
About the Author
Soon after, I retired and we moved to Denver, my husband's home town. He passed away after 13 blissful years together in October of 2012. I am left to find a new path to fulfillment. One possibility is through writing. Thank goodness, the SAGE Creative Writing Group was there to light the way.
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