How We Do Harm (30 page)

Moore’s office is busy.
You have to hunt for a chair in the waiting room.
Ralph picks up a two-month-old copy of
Field & Stream,
but can’t concentrate on the articles or even the pictures.
He listens instead.
Many guys in the waiting room have abnormal screens that were picked up at the same health fair Ralph attended.

The wait is long, but in the end Ralph gets his twenty minutes with Moore.
The doctor examines Ralph’s prostate again and prescribes antibiotics in case this PSA elevation is due to prostatitis, a benign inflammation of the prostate.
An inflammation can push up your PSA.
They will repeat the PSA after several weeks of antibiotics, and if the score is still high, they’ll be pretty sure it’s prostate cancer.

Ralph was hoping to find out whether he has cancer that very day.
After thinking about it for two weeks nonstop, he isn’t as afraid of it as one might think.
Ralph is ready to duke it out, he’s ready to start fighting.
Instead, he is faced with more waiting.
He stuffs the prescription in his pocket, makes another appointment, and leaves.
If the place had a door that could be slammed, he would have slammed it.

Ralph takes the antibiotic religiously.
His worry about the Big C is obvious.
It affects his relationships with friends and family.
He loses interest in family gatherings.
His poker buddies notice a change.
He thinks about the cancer virtually all the time.
He goes to sleep every night envisioning a smoldering fire deep in his pelvis.
He is standing face-to-face with the Grim Reaper, staring into his vacant eye sockets.

Ralph returns to Moore and gets blood drawn for a repeat PSA.
Twenty-four hours of waiting and praying follow.
He finds his mother’s rosary, and he prays in his den, with the door closed.

The result comes back at 4.3 ng/ml, 0.3 above what is considered normal.
Moore’s office assistant tells Ralph over the phone that he needs to come back and get a biopsy.
The next available opening is a week later.
All added up, it is now six weeks after the original screening at the mall.

The biopsy takes ten minutes and is actually twelve biopsies, six on the left and six on the right.
Ralph later recalls that he learned that there is a left and right side of the prostate.
He learned by feeling—the biopsies hurt like hell.
Ralph is told that it will be three to four days before the results are known.

At the biopsy, for the first time in years, Ralph gets his blood pressure taken.
It’s high: 160/105.
Moore suggests that Ralph see an internist.
The internist starts therapy with enalapril, an ACE inhibitor.
It works well enough.

Now comes verdict time: Ralph returns to Moore’s office, this time with Ann.
Things are looking grim, and she has to be in the know.
Moore seats them in his office and gives them the news.
Two of the twelve biopsies show cancer.
They are Gleason 3 plus 3.

This score is associated with the most commonly diagnosed and most commonly treated form of prostate cancer.
There is no way to know whether a patient with this diagnosis will develop metastatic disease or live a normal life unaffected by disease.
This uncertainty goes back to the way urologists assess and categorize cancer.

The problem is, we still identify cancer optically, classifying tumor cells as they appear in the microscope.
It’s telling that the founder of that approach—the German scientist Rudolf Virchow—made his principal contributions to science in the mid-nineteenth century.
Classifications based on what we see—Virchow actually made drawings—don’t always tell us how the disease will behave.
Will it turn aggressive or will it sit in place?
Does it need to be treated aggressively or should it be left alone?
In the case of a Gleason 3 plus 3 tumor, you just don’t know.

It would be nice to have molecular-level definitions of prostate and other tumors, but medicine based on genomics and proteomics isn’t there yet.
Relying on 140-year-old technology, we say to our patients, “There is something here that may or may not kill you.”

The two bad biopsies are next to each other in the right side of the prostate.
Ten to 15 percent of each of the biopsies has cancer.
Ralph and Ann are overwhelmed, yet somehow relieved.
They feared this moment for weeks, but hearing the words “You have cancer” brings some resolution.
At least they know what they are up against.

Ralph is mostly healthy.
He has no history of medical problems, and his moderate hypertension is now well controlled.
Moore suggests that Ralph get his prostate surgically removed, a radical prostatectomy.
Ralph asks the doctor about side effects.

“Are you still able to have erections?”
Moore asks.

Ralph says yes.

The doctor says the operation has a 30 percent risk of impotence and a 15 percent risk of urinary incontinence.

He explains that Ralph will have a catheter in his penis for twelve days and will not be able to drive for about six weeks.
Considering the gravity of the situation, the conversation with Moore seems awfully quick, way too brief for Ralph’s taste.
The doctor seems stingy with information, leaving too many blanks.

Now Ralph has to figure things out for himself, to make his own decisions.
His daughter helps him get online and he searches the Net for information on prostate cancer.
He truly wants to know more.
He finds the Web site of Us TOO, the prostate-cancer support group, and reads virtually every word about prostate-cancer treatment on the site.

Also, he finds information from the National Prostate Cancer Coalition.
(This organization would later change its name to Zero: The Project to End Prostate Cancer.) It claims to be giving out unbiased information about screening and treatment.
Other sites that Ralph consults include the American Urological Association (a professional group composed of doctors who treat prostate cancer) and the American Cancer Society.

He finds an ad on the Web about cryotherapy, or freezing of the prostate, as a treatment for prostate cancer.
Then, quickly, he finds a blogger who writes about his experiences with cryotherapy.
The blogger says that this therapy, if done right, by definition freezes the nerves running along the side the prostate.
So, again, if done right, the patient will be incontinent and impotent.
The blogger attests to this, being both.
Ralph concludes that cryotherapy is a slick sales job and rules it out.

All the information Ralph finds gives brief mention to radiation therapy and watchful waiting, a strategy also known as observation therapy.
These strategies are interconnected.
If you choose watchful waiting and the disease stays in place, you may never have to treat.
If it begins to move, you may want to do radiation.
To Ralph this sounds like an option for an older man.

After reading everything he can find, Ralph concludes that radical prostatectomy represents the gold standard of care.

The concordance of opinion is remarkable: Ralph wants a radical prostatectomy.
His family wants him to have a radical prostatectomy.
Moore wants him to have a radical prostatectomy.

*

ABOUT
this time, a Catholic hospital in town launches an ad campaign about its new, less noninvasive treatment for prostate cancer.
The ad is built around a picture of a young, handsome urologist, Max Barrish.
Barrish uses the da Vinci robot.
They look like a fine combination—a young man and his multimillion-dollar robot.
It makes Ralph think of the movie
Star Wars.
This duo seems more promising—more up-to-date—than the middle-aged, heavyset, rushed Moore and his knife.
The ad notes that hospital time with robotic surgery is lower than with conventional prostatectomy, and that postoperative side effects are lower, too.

Ralph decides to go see this young man and his R2-D2.
Ralph gets an appointment within two days and goes with his wife and adult daughter to an office in a building next door to the hospital.

Barrish seems personable, likable.
He has gotten Ralph’s records from Moore, whom he describes as “a wonderful doctor.”
Ralph likes that Barrish speaks highly of Moore, a competitor.

“You got me sold on robotic prostatectomy,” Ralph says.
“But I feel kind of bad about leaving Dr.
Moore after everything he has done.”

“I am sure Dr.
Moore would understand,” Barrish assures him.
“You are doing what’s best for you.
The decision is yours.”

Barrish gets his office to book an operating room in the hospital and offers a date five days away.
Barrish explains the procedure in detail, giving the DeAngelos as much time as they need.
He doesn’t just address Ralph.
He makes eye contact with Mrs.
DeAngelo and the couple’s daughter.

With the robot, Ralph will receive four small incisions of one inch or less at various places on the abdomen.
The abdomen is inflated with a gas.
A scope is placed in at the navel to allow a clear view of the internal organs.
The other three holes are for the instruments used to remove the prostrate.
Barrish shows the DeAngelos pictures of the da Vinci.
The surgeon uses video-game-like joysticks to manipulate the arms.

Ralph knows that Barrish went to Henry Ford Hospital in Detroit and studied the procedure under Mani Menon.
Menon was the first to introduce the robot in urology and is one of the best-known and most experienced robotic surgeons in the world.
Ralph hopes this will give him an edge in getting a good surgery.
It gives him some peace.

Ralph gets all the preoperative studies: an EKG and nuclear-medicine scan of his heart two days before the surgery.
He meets with the anaesthesiologist the day before the operation.
Things seem to be progressing well, but like all patients before surgery, Ralph is nervous.
He arrives at the hospital at 5:00 a.m., as instructed, and is brought to the surgical ready room.
He sees Barrish around 7:30 a.m.
The doctor brings in Ann to see Ralph before the operation.
This is a nice, comforting gesture, and it’s appreciated.

The operation goes without a hitch, and Ralph is wheeled into the recovery room.
He stays in the hospital for two nights.
His pain is controlled with Percocet.
The catheter running up his penis is a bit annoying, but he lives with it.

The second night after the operation is the first night he goes to sleep without thoughts of the smoldering fire deep in his pelvis.
He is discharged with an appointment to see Barrish and talk about his pathology, the analysis of his surgical specimen.
This appointment would also allow for a check of the wounds and his Foley catheter.

At the visit, Ralph hears good news.
He had a small tumor 5 mm by 5 mm by 6 mm in a moderate-size (50 cc) prostate.
The tumor was all in the right side of the prostate and was Gleason 3 plus 3.
This means that the tumor didn’t appear highly aggressive under the microscope.
The outlook is good.
Ralph will return in seven days to have the catheter removed.

Over the next week, Ralph feels happy, energized, free.
The catheter is removed without a problem.

Unfortunately, Ralph realizes that he is now incontinent.
This has to be temporary.
Ralph starts trying to do the Kegel exercises in which he has been instructed by one of Barrish’s nurses.
Three months later, incontinence is still there.
No better, no worse.
Ralph is wearing diapers continuously.
Barrish is reassuring, but there is no improvement.

Before the surgery, Ralph was able to get erections, and he and Ann enjoyed sex.
Since getting the news that his PSA was elevated, he has not been able to perform.
Could the stress have caused impotence?
Or was it the prostate cancer, chipping away?

The doctor who treated his blood pressure gives Ralph a trial pack of Viagra.
It does no good.
The internist and urologist tell him to be patient as sometimes men can start getting erections six to nine months after surgery.

Soon, Ralph has to confront another calamity: three months after surgery, his PSA is measured at 0.9.
Why isn’t it zero?
His prostate is in a bottle in some pathology lab.
He has no prostate tissue.
Barrish acknowledges that this is disconcerting, but not unheard-of, and says, “This happens.”
He suggests that Ralph watch the PSA and do nothing unless it climbs further.

*

RALPH
is more scared than ever.
He worries that he has metastatic disease.
Everything he has read indicates that cancer that has spread out of the prostate is not curable.
Barrish tries to be reassuring, but nothing he can say works.

After consulting with members of Us TOO, the patient support group Ralph first encountered at the health fair, he decides to take matters in his own hands.
He goes to see a local radiation oncologist, Joe Salgado.
Salgado reviews the data and suggests a repeat PSA.

Ralph is a mental mess as he waits and then goes to see Salgado two days later to get the result: 0.95 ng/ml.
They are in Salgado’s office when the doctor lets this little factoid fly across the walnut-top desk.
He does it without emotion, almost making Ralph feel guilty about being scared to death.
But the guilt goes away as quickly as it sets in as Ralph realizes that the surgeon who did his prostatectomy was the only one of that bunch to even try to fake compassion.
Or maybe it wasn’t fake.
Maybe it was the real thing.
The other guys aren’t even trying.

Salgado tells Ralph to consider two paths.
One is to watch the PSA and act if it rises over time.
Salgado notes that a residual PSA after surgery is not unusual, especially after a robotic prostatectomy.
The other option is to do a ProstaScint scan, a nuclear-medicine test, to see whether they can find prostate cancer.
If there is a signal from the pelvis, the doctor would recommend radiation to the pelvis to kill the residual cancer.

It’s news to Ralph that a measurable serum PSA after robotic prostatectomy is not unusual.
Because of the limit of vision through the scope during the surgery, a small amount of the apex, or lowest part of the prostate, is left behind in robotic operations.