Dealing With Prostate Cancer: (Part 2)

William Martin didn't need a doctor to tell him that his prostate was in trouble. But when further tests indicate he may have cancer, Martin faces a difficult decision.

Editor's note: William Martin is a professor at Rice University who has lectured on sociology and wrote books on religion, as well as a memoir about surviving prostate cancer.

Increasingly, strategic planning for urination became a conscious part of my routine. I learned to void just before leaving the house and then again upon arriving at almost any destination -- church, a restaurant, my office, a friend's home -- in the hope, often vain, that I would not have to excuse myself more than once during an average sojourn.

At a concert or theater, I tried to arrange for seats on the aisle, and at intermission I tried to use a closed stall rather than a urinal, to avoid having some young man in line behind me ask if he could "play through." At public gatherings, I ignored requests to move to the center. At movies, I learned that episodes of high excitement or intense emotion are typically followed by slow spots that allow a quick trip to the toilet. (Scenes beginning with a shot of a car or bus on a long, straight highway are ideal.) I began to select supermarkets and video stores less for their stock and prices than for their provision of public rest rooms, though I quickly learned that one can find an unadvertised restroom in most grocery stores simply by walking through the swinging doors next to the meat counter.

Scouting for relief

Eventually, I learned the location of the john in virtually all the places I frequented. At the Brazos Bookstore near the university, you go straight back through the open door at the rear of the display area. In the sprawling Bookstop at Alabama and Shepherd, the restrooms are locked, but the key is attached to a whiskbroom right next to the cash register. You don't have to ask for it; just take it. And in the River Oaks Book Shop, you are welcome to use the small unisex bathroom upstairs in the children's section, but the ladies who run the store appreciate it if male customers heed a sign asking them not to rest their hands on the wall over the toilet. (It's a balancing feat that takes some getting used to, but it can be learned.)

Travel called for similar calculation and logistic expertise. On most weekends, Patricia and I make a three-hour drive between Houston and Wimberley, a little town in the Texas Hill Country where we have a home to which we expect eventually to retire. If the westbound traffic on a Friday afternoon was especially heavy, we would need to stop at the Knox Truck Stop near Sealy. I like that one both because the coffee is good and because, if I don't want coffee, the restroom is far enough from the cash register that the cashier is not likely to notice that I didn't buy anything, or perhaps she might think I just dropped in to pick up an assortment of exotic condoms. On a light-traffic and low-liquid day, I could sometimes last the 70 minutes it takes to make it to Columbus, where McDonald's Golden Arches welcome the squirming traveler.

Just a few miles past Columbus sits a roadside rest area whose purpose is quite explicit and the accommodations acceptable, if one doesn't mind standing in a quarter-inch of water of indeterminate origin. Further down the road, Grumpy's at Flatonia and Love's at Luling offer additional shame-free opportunities for relief and the chance to refill our no-spill insulated coffee mugs. In case you are wondering, I am quite aware of the connection between caffeine and bladder stimulation, but compromise has its role in a life of moderation, and I seldom drink more than two cups a day anyway.

I should make it clear that we never stopped at all these places on the same trip. On the other hand, we almost never stopped less than twice during the first two hours. The last hour of the journey offers fewer opportunities for convenient relief, but by that time I was usually fairly well drained. In case of extreme need, we could sometimes find a country road to turn down or, in a real pinch, there was always the empty Snapple bottle under the seat. In general, my condition made me feel mildly rueful rather than genuinely humiliated, and Patricia laughed with me rather than at me, as best I could determine. If David Bybee thought it best, I could doubtless stand it a while longer, but I could not help pondering whether a dry orgasm might not be less discomforting than a chronically constricted urethra.

The second exam

Despite intensifying symptoms, I did not see Dr. Bybee professionally again until the summer of 1993, when I had my next general physical. As usual, I went in several days before my appointment to let his nurses draw blood, collect a urine sample, and run an EKG.

When he examined me directly, I told him my urinary symptoms had worsened and he told me my PSA (prostate specific antigen) count was up to 8.23. Apparently, prostatitis had not been the sole culprit for the higher reading the previous year. He thought I needed another ultrasound. He also thought it was time to try some medication. He talked about Hytrin, an "alpha-blocker" developed to control mild high blood pressure but known to be useful in relaxing the bladder and urethra sufficiently to relieve some of the symptoms of BPH (benign prostate hyperplasia). It wouldn't affect the size of my prostate, but it might moderate my discomfort. The other choice was Proscar, a highly touted drug developed by Merck and designed actually to shrink the prostate. The main and relatively uncommon side effect documented so far is diminution of libido, or sex drive.

I knew about Proscar. Merck has long been a favorite stock of mine and I had raised my holdings a bit when the new drug was introduced. Unfortunately, I held on a bit too long after President Clinton began attacking the pharmaceutical companies, but I had read a good bit about the drug and had decided that loss of libido was, at this point, too great a price to pay for a smaller prostate, especially since the drug has proved effective in only about half the men who take it. I agreed to give Hytrin a try. The main possible side effects were drowsiness or dizziness, particularly in people with low blood pressure. Since my usual pressure is around 115 over 70 (normal, as most people know, is 120 over 80), he suggested I build up my tolerance slowly and take the drug just before going to bed, to minimize any dizziness or drowsiness. Finally, he asked me to come back for another PSA test in two or three weeks, since considerable fluctuation is possible, and to plan on yet another visit in 60 days, to see if the Hytrin was having any effect.

As I had fully expected, the ultrasound showed nothing irregular. My insurance company and I were out $280, and I was still as healthy as ever, except for my engorged gland. Even better, the Hytrin seemed to be working. It was hard to be certain, but the calls of nature, while still fairly frequent, did seem somewhat less demanding. A couple of times, I slept through the night without having to go to the bathroom even once.

About that same time, a widely advertised national screening program for prostate cancer prompted thousands of men to show up at clinics to have doctors probe their rectums and draw their blood. For once, I felt ahead of the curve on the latest biomedical fad. I had already been there, done that, received a clean bill of health, and had some little pills that were fixing me up. When I got a mail order solicitation to buy a vitamin and mineral supplement called Prostata, which the flier assured me would shrink my prostate, lower my PSA, and add zip to my sex life, I ordered a two-month supply. They couldn't make claims like that if they weren't true, could they? I was on a roll.

A troublesome score

Then I got a letter and a follow-up call from David Bybee. My 60 days weren't up yet, but my score on the second PSA test had been 8.02. That was down a little from the 8.23, but still high enough to be worrisome. He thought I ought to see a specialist and gave me the name of C. Eugene Carlton, who was, he noted, the former chair of the Department of Urology at Baylor and the incoming president of the American Urological Association. Gene Carlton, he said, is not overly aggressive in his approach, but might well suggest I have a biopsy done on my prostate. In his matter-of-fact way, he explained that the biopsy would involve drawing tissue samples by means of a spring-loaded gun inserted through the rectum. It might hurt a bit for a couple of hours and there would probably be some blood in my urine and ejaculate for several days. There was also the possibility of an abscess, but that didn't happen too often.

Nothing about that description sounded appealing to me and I did not rush to contact Dr. Carlton. To slow things down further, school was just starting and I was having to prepare class materials and attend the usual round of meetings. Then, two chance conversations moved me to action. At an informal dinner for a small group of my freshman advisees, I fell into conversation with an alumnus who was hosting the event and who happens to be a urologist. I mentioned that I had been giving urology a great deal of thought in recent weeks, and he asked if I knew my PSA count. When I told him it was an 8, his expression clearly indicated that he regarded that news rather seriously. I told him I had had two ultrasounds and both had been negative, but he said. "Still, that's pretty high. You ought to have your doctor watch that."

A few days later, I was having lunch with Frank, a friend about 15 years older than I. We got to discussing the President's healthcare proposals and I ventured that, while I favored some kind of general program, I feared it would be difficult to keep the costs from becoming ruinous. I volunteered that my doctor, whom I trust and admire, had just prescribed an ultrasonic exam of my prostate and, even though it had shown nothing whatever, now thought I should have it biopsied. I knew his concern was primarily for me and that he was not prescribing tests to fatten his or a colleague's bank account, but I also felt fairly sure I was being overtreated. I could afford it, so I would do it, but I wasn't convinced it was necessary and I could see that sort of thing happening millions of times over in a government-sponsored program, even if all the physicians in the country were as conscientious and ethical as mine.

My friend said, "Well, I know how you feel. Last spring, my doctor got worried about my PSA count and sent me to a urologist. He referred me to M.D. Anderson [The University of Texas M.D. Anderson Cancer Center in Houston]. They did a biopsy and drew samples from six areas. I went downstairs to the cafeteria and had cup of coffee. I felt great and I had no worries at all. When I came back up in about 15 minutes the doctor told me that three of the six samples contained cancer. I was floored."

"If you don't mind me asking," I didn't mind asking, "what was your PSA count?"

"It had bounced around. At first, it was 6, then 7, then 5, then 8."

"Hmm. What did they do?"

"At M.D. Anderson, they do a lot with radiation, which was fine with me. My brother had a prostatectomy two years ago, and he didn't bounce back. That is a mean, cruel operation. But let's face it. Doctors -- surgeons especially -- want you to get well, but they are also in a business, and they are going to do what makes the money. But what they did with me at Anderson was just the easiest thing you could imagine. I went in five days a week for six weeks for a radiation treatment. After the first visit, when they got everything lined up just right and marked me up, it only took about 15 minutes from start to finish. Toward the end, I would get a little tired in the late afternoon, but that was the only thing I ever noticed. That was just the happiest, most upbeat place I have ever been in. It was such a pleasant experience that I almost think a person ought to go through it whether he needed it or not."

Frank, as you might gather, is a man with a positive outlook. I do not hold that against him, but I might have paid less attention had he not told me that a PSA count similar to mine had corresponded to cancer in half his tissue samples. I called Gene Carlton's office that afternoon and set up an appointment for the following week.

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