Health Commissioners Blog

Part 5 - My Prostate Cancer Story

The Operation and Recuperation

I had to starve myself for three whole days prior to the operation.  I could consume only clear liquids, like water, weak tea, Gatorade, and popsicles.  No beer or alcohol, either.  I was starving when I reported for surgery at some ungodly hour like 5:30 in the morning on June 16^th.  Everybody was very nice.  I think surgery started around 7:00 or 8:00 a.m.   Once they stuck the needle in the back of my hand, the next thing I knew was I was waking up in the recovery room in mid-afternoon.  They told me the surgery lasted for three hours.  My wife was there once I started coming around from the stupor.  They wheeled me up to the ninth floor into a semi-private room.  The other guy in the room was making all sorts of noises all night long and I couldn’t get much rest.  I was pretty worn out.

I felt pretty good, though.  I was desperately hungry.  I was allowed to eat almost anything, so what did they bring me?  Weak broth and Jell-O cubes.  Ugh!!!!  I hit the call button.  The nurse came in.  “How about a grilled cheese sandwich?” I asked.  “No problem” she said.  About twenty minutes later the angel of culinary excellence brought me the sandwich.  Finally, some food!!!  I was starving and now I was feeling a lot better.

I had IVs in my harm and a catheter running up into my bladder.  During the operation, they cut away a portion of the urethra that is inside the prostate gland.  They run a catheter into your bladder; then they stretch the remaining part of the urethra up to the bladder and sew it to the part just below the bladder sphincter.  This has to heal up over time and is the reason for the catheter and the incontinence that will follow removal of the catheter.  In the early evening, they got me up to walk around the corridors, to get some exercise.  I had to take my urine bag off the bed and hood it onto that IV stand on wheels.  I was now mobile as long as I kept a good grip on the IV stand.  During the night, I would do some laps in the corridors.  I think I did a half mile or so.  I liked joking around with the nurses on duty.  “How many laps in a mile?” I asked.

They released me the next day around noon.  My wife brought me home for the recovery period.  I had prescriptions for pain medications, which I didn’t take.  I was uncomfortable with that damn catheter in me, but there was no pain.  I couldn’t go to work for a week because of the catheter.  There is actually a leg bag you wear.  I took walks down the street and tried to avoid inquisitive neighbors.  I hadn’t told any of them what I was up to either. My abdomen turned all sorts of shades of red, blue, black and purple.  Apparently, those robot arms do the trick inside, but as they move around, they bruise all of your abdominal wall muscles and skin and it looked like someone held my arms while someone else walloped the tar out of me.   Blood and fluids would sink inside of me.  Eventually, it would be absorbed and dissipate.

I went back a week later to have the catheter removed.  It was only a little uncomfortable.  This is a job they assign to residents.  I was glad to be free of this thing.  They tested it for leakage and found none.  I was good to go.  I could almost walk normal now.  I was to do no lifting over 5 lbs. for the next few weeks, as I might tear apart the stitches that held the urethra to the bladder.  They threatened me with a fate worse than death (wearing a catheter for six weeks) if that thing ever came apart.  I was scared straight.  I was off work for two more days.  I was off work for a total of seven days.

My surgeon, Dr. Abaza, has since told me that in the old style surgery, the most vexing problem for patients was the healing of the big long scar.  With robotic surgery, that nearly ceases to be an issue and the focus is now on the nuisance and the discomfort of the catheter, a testament to the advantages of the less invasive robotic  surgery.

I had to wear pads now to catch the leakage.  We stopped once on the 90 minute trip home to change.  There is more leakage in the beginning and it lessens as the bladder sphincter muscle heals.  Leakage is supposed to last from six weeks to three months for most men.  In the first day after removal of the catheter, my bladder was holding more urine.  I went through the first night with no leaks, maybe because I slept on my back and there wasn’t much pressure on the bladder sphincter.  In any case, over the next few days, leakage was down to a few drops a day.  On July 4, I declared independence from pads.  I was leak-proof.  Today, I can sometimes go the whole night without getting up.  I go to bed around 11:00 or 11:30 p.m. and don’t have to get up until about 5:30 a.m.  My usual getting up time is 6:00 a.m.  It helps not to drink anything after 9:00 p.m.  I still can’t consume great quantities of liquids and hold it for a few hours, but I never could.  With practice and time, maybe I can.

The potency restoration strategy.

The potency restoration strategy revolves around two things.  First, take 50 mg. of Viagra (or Cialis or Levitra) every evening before bed.  Don’t expect anything to happen for at least six months.  The medication is supposed to improve the healing process for the damaged nerves.  It is supposed to be long and slow.  The second thing they want you to do is use a vacuum constriction device once or twice a day on the penis.  This is the gizmo that Austin Powers brought with home from the 1960’s in his first movie.  It is supposed to be funny.  Laugh if you like.  The idea here is that there have been reports by researchers that if you don’t use your penis for the real deal, then it will shrink.  Just the thought of that scenario strikes fear into the hearts of most men. These are sort of penis calisthenics, to get the blood into it and make it big, even if only artificially so.  If, after some practice, you actually want to use it for sex, you can use a rubber band-type constriction device.  It rolls onto the base of the penis after you engorge it.  It stays on until you release it.  Don’t leave it on too long or your penis will turn blue and fall off.  Imagine putting a rubber band about your wrist and watching your hand turn blue.  You get the picture.

Five weeks after surgery I regained potency.  I was stunned.  I couldn’t believe it.  The folks at Ohio State Medical Center, where I go for follow-up checks, said that I was the earliest person on their records to regain potency.  I am now an official outlier, at least statistically speaking

My follow-up PSA numbers are in the non-detect range, essentially zero.  The biopsy from my prostate showed that no cancer had reached the margins of the prostate.  The lymph nodes adjacent to the prostate looked good and functional.  (prostate cancer often affects these lymph nodes)  It appears no cancer cells escaped and that, at least for now, I am cancer free.

A word about Viagra (and the others).  When you depart the hospital after having the catheter removed, they will hand you a prescription for Viagra for 100 mgs/day for three months supply, along with a letter of medical necessity.  Once you get this you are supposed to cut the pills in half, because the real dose is 50 mg. and they cost just the same (or similar) as the 100s.  They sort of tell you “good luck with getting your prescription filled”.  Your prescription provider usually only allows you to buy six pills per month.  Apparently, the folks at the insurance company haven’t heard of this treatment modality and they think you are just some sort of party guy, or you’re selling to your best buds.  Plan on a bit of a fight with your insurance company.  Or you can go avoid the hassle and go on-line to Canada, but I’m not supposed to tell you that.

A final word of my Swedish daughter.  She told me that her Swedish father had prostate cancer the year before and had his removed the old fashioned way.  They have robots in Sweden, but he would have had to travel to Stockholm, a distance of some five hours away.  He preferred having the procedure done closer to their home in Nässjo, so he opted for a local community hospital.  She said he was doing just fine.

If anybody wants to contact me with questions about prostate cancer, its treatment or the side effects of treatment, you can contact me at jluken@miamicountyhealth,net.

 

A Final Word

 

I have to give tremendous credit to my wife, Ellen.  She has been the most understanding and helpful person through this entire ordeal.  She had to put up with my mood swings (in fairness, I had to put up with hers during her recent “change of life” status), my anxieties and a guy who lays around watching TV for a week. 

 

Part 4 - My Prostate Cancer Story

Making a Decision:

 

Odds, schmods.  Statistics are aggregates of individual cases.  They don’t tell you anything about the individual.  They may guide you in your decision making process, but they don’t make the decision for you.  My odds of getting cancer were now 100%, since I already had it.  My odds of surviving cancer were pretty good, since I was relatively young.  There was a chance that I could carry this cancer the rest of my natural days and die of something else, with no complications.  At this point in time, I had only one point in time picture of the cancer.  To determine rate of possible growth, you need more than one picture over time.  I could have opted for the watchful waiting approach.  Every six months for some undetermined time into the future, I would have to undergo uncomfortable biopsies.  Those are accompanied by consultations with urologists who are generally eager to get on with treatment.  Ultimately, I may end up having the treatment anyway.  But at least this way, my life of perfect potency and continence would at least continue for some period of time.

 

It is here, at this time, I have to mention that singer Dan Fogelberg died on December 16, 2007 from prostate cancer.  He was 56 years old.  This was still very fresh in my mind.  He obviously had the fast growing variety.

 

What to do?  Not making a decision was making a decision to tempt fate.  I didn’t like that either.

 

I did a lot of research, which is what people with medical afflictions do.  And I did it on the Internet, which is usually the first and sometimes the only place where people go.  Ahhh, the Internet: the bastion of instant information at your finger tips.  It’s a great and convenient place to get information.  Unfortunately, there’s a lot of crap on the Internet, too.  My job now was to separate the good stuff from the crap.  How would I know the good stuff from the bad?  Fortunately, my MPH degree taught me the fundamentals of study design and evaluation, so that I could pick out the flaws (or as we so politely put it, the limitations) of studies and claims.

 

I was really interested in finding the best treatment method to avoid incontinence and impotence.  That’s where I wanted to be.  I wanted to know where to get it and who I would choose to do the work.

 

In the old days (ten years ago) of radical prostatectomies, the surgeon would make an eight inch vertical cut in your abdominal wall, clamp everything open, and with his naked eyes, cut the prostate out.  Unfortunately, others things that are attached to the prostate come out as well.  Things like part of the urethra, which runs right through the middle of the prostate.  Also taking a trip outside your body are the seminal vesicles, that little gland that collects the sperm and sends it to the along with semen into the urethra when called upon to make babies.  The vas deferens, or the sperm carrying tube, is cut.  And the nerves that surround the prostate, which go from the brain to the penis are summarily removed with this whole mess.  In the early days of prostatectomies, virtually all men were rendered permanently impotent.  A good many of them were also rendered permanently incontinent.  It was quick and expedient.  And best of all, the cancerous prostate was gone.  They hoped no cancer cells escaped to live another day during the process and come back to haunt you later.

 

We’ve come a long way since those earlier days.  Medical folks have been honing in on how to save the nerves and increase the odds of continence and potency.  The advances have been in two areas.  First, they try to save the nerves.  When the surgeon is in there carving away, he tries to cut around the nerves and separate them gently from the prostate gland.  Imagine the trauma you case a plant when you transplant it from a small pot to a larger one.  All those roots have to be fanned out and separated and place gently into new soil.  While you try to minimize the damage to the roots, there is still some trauma and a delay in the growth of the plant.  The same goes for the nerves surrounding the prostate.  The nerves will be traumatized and unavoidable cut in the process.  The rate of re-growth is something in the neighborhood of one quarter millimeter per month.  That’s awfully slow.  Therefore, all men who undergo radical prostatectomies will be impotent for some period of time.  It is just unavoidable.  The second thing that has been modernized is the use of robots.  In this procedure, the surgeon cuts six holes through the abdominal wall and in those holes go the reticulating robotic appendages, lights and a magnifying thingy.  It magnifies things by a factor of ten.  That’s much better than the naked eye.

 

You probably know by now where this decision making process is going.  I opted to have the prostate removed sooner than later and to have it done by the best surgeon I could find that used the robot. 

 

If you Google on “davinci robotics”, you’ll come with a variety of hits.  The da Vinci robot is used for various procedures, including prostatectomies, cervical cancer removal, bariatric procedures, and many others.  Find this one: http://www.davinciprostatectomy.com/index.aspx.  There is a surgeon locator button.  Click on that and enter your zip code.  As of this writing there were more than 75 physicians within a three hour drive from me that were licensed to use the machines for prostatectomies.  Many of them were at well respected institutions in our major cities.  But who was the best?

 

My friend Nancy from my high school days in Huber Heights recently lost her husband to cancer.  I was commiserating with her about cancer and how she dealt with it.  I understood that the Cleveland Clinic, with its reputation as a world-class medical center, was a place that I was considering.  Indebir Gill was a surgeon there who had a nice video on the Clinic’s web site.  Nancy said that she new Indebir Gill.  He treated her husband and he was the best, most caring surgeon in the world.  She pleaded with me to choose him. 

 

However, in my search, I also went to the OSU Hospital and Medical School.  There I discovered a young surgeon (at least on the Internet) by the name of Ronney Abaza.  While he was very young, he came with a pretty lengthy list of accomplishments.  Besides, it was half the distance to Columbus as it was to Cleveland.  Not only do you have to report for surgery, but there are preoperative visits and postoperative visits that could go on for years.  I might as well make an appointment and check this guy out for myself.  If he didn’t make the grade or impress me, then I could always go to Cleveland.  After all, it’s only my life.

 

Another reason that I chose Ohio State was that they had a well documented complete program.  They were into fixing the ills that normally follow the surgery, particularly the impotence.  They have and erectile dysfunction clinic available as a matter of course for all patients.  It’s a new treatment modality that is more theoretical and experimental than based on actual proven results.  But it was all that was available.  Better to have some hope than none at all.  More about this in the post-operative phase.

 

The urologist that I had been seeing in Troy for the biopsy also did prostatectomies.  He did the old-fashioned kind that I referenced earlier.  He pooh-poohed the robotic surgery as no big deal, that my fears of impotence were overblown.  “You just take some Viagra and you’ll be fine.”  He had undoubtedly done hundreds of the open-cut surgery and was probably very good at it.  He said that his surgery would result in a two day hospital stay and recovery would be about six weeks.  He recommended that I have the surgery as soon as possible.  I decided then and there that he wasn’t going to do my operation.  It had to be someone else.

 

I decided to make an appointment with Dr. Abaza at the Ohio State Medical Center.  I did this on April 23^rd.  I brought all my charts and cancer slides.  He looked at them and made the same conclusion: I definitely had prostate cancer.  It wasn’t very much and it was very early, but it was still cancer.  With only this one snapshot of a single biopsy, he stated that the first urologist could have been either very lucky to hit it on one needle sample or could have been just as unlucky not to hit more.  We could always take more samples over time, but it was till cancer.  It may grow, it may not; no one really can predict at this point.  He also suggested removal.

 

I also spoke about my odds of having permanent impotence.  After all, I was a 56-year old active and healthy male.  20%, he said.  No better than the posted odds on the Internet.  “It only gets worse as you get older” he said.  For that reason he said that it would be best to do it sooner rather than later. 

 

He also explained the benefits of using the robot.  Six small incisions, one day in the hospital, one week on a catheter, three to four weeks to being back to normal.  This was roughly half the time of the old style cut-em-up-the-middle surgery.  Also, there is much less blood loss, rarely calling for blood transfusions.  If I was going have the procedure done, this is where it was going to be.  I didn’t want to travel all the way to Cleveland.

 

I have to mention here that there was one thing about Dr. Abaza that had me a little on edge.  He was very young.  He couldn’t be much over 30 years old.  He did his residency with the da Vinci machine at the University of Toledo Hospital.  He had only been at OSU for a relatively short period of time, maybe a year or two.  But this is all he did.  He does three surgeries twice a week.  He probably has about a thousand chances under his belt by this time.  I guessed that was enough practice on other people.  I decided to go with him.  I made the appointment for Monday, June 16^th.

 

In the intervening two months I went in for more preoperative tests and they loaded me up with a booklet of information about what to expect along the way.  And let’s not forget those instructions about how you have to clean out your insides and starve yourself for three days prior to surgery.

Part 3 - My Prostate Cancer Story

A word about my father.

 

In June 1974, when he was 50 years old, my father retired.  He had seen four of his five children through college.  The fifth, my younger sister, graduated from high school that same month.  She had a full scholarship to the University of Dayton.  His child rearing responsibilities were over.  He decided that thirty-two and a half of working for the Federal Government in one capacity or another was too stressful. 

 

Dad had a variety of ailments and he had some sort of premonition that he didn’t have all that many years left on the planet.  He suffered from hypertension since he was a teenager and had been medicated ever since.  In 1951, the year I was born, he had one of his legs crushed in an industrial accident.  He was off work for a year and he never walked straight again.  When I was sixteen years old (when I was learning to drive a car), he was off work for six weeks with high blood pressure issues.  He had kidney stones and a heart attack when he was 48 years old.  The same year (1972) my parents were in a serious automobile accident that left both of them hospitalized for a good part of the summer.  He deserved a break.

 

In 1977, my parents moved to Cape Coral Florida.  (We found them a year later!!)  He worked a little bit, but mostly he enjoyed things, like travel, gardening, and just tinkering around the house.  Fast forward to 2000.  Dad was now 75 and was diagnosed with prostate cancer.  I didn’t know it until after he started treatments.  He didn’t tell me about things (or I didn’t listen) until treatments were initiated.  At this point in time, the Swedes hadn’t come out with their study that recommended no treatment for old men.  Treatment, as mentioned before, was guaranteed to bring nasty side effects.  The older you get, the more probable and the worse they are.  This is why “watchful waiting” is a standard treatment modality for older men in Europe.  But, his health insurance being as great as what it was, the docs in Florida were anxious to treat.  He opted for hormonal treatment in conjunction with brachytherapy.  This is where small radioactive “seeds” are injected into the prostate next to the cancerous places in order to kill the cancer.  It is supposed to be less invasive.  You get to keep your prostate and hopefully resume you life relatively uninterrupted.  Brachytherapy is preceded by hormone therapy, whereby they inject you with a drug or drugs that halt the production of testosterone.  This is supposed to stop the growth of the cancer, which is associated with being stimulated by testosterone.  However, it didn’t work out that way for him.  It didn’t stop the cancer’s growth and it left him both impotent and incontinent.  I never knew how much the potency issue bothered him, but the incontinence was a seriously depressing problem for him.  He was in full-fledged adult Depends all the time.  Also, the hormone therapy results in other negative side effects.  Dad experienced emotional problems, hot flashes, decreased sexual desire, erectile dysfunction, fatigue, weight gain, decreased muscle mass, and memory loss. Most men who are on hormone therapy experience at least some of these effects.

 

In April 2002, Dad developed head and neck cancer.  He underwent removal of the tumor and several moths of external beam radiation.  He lost is teeth and his sense of taste.  In July of 2002, we moved Mom and Dad into an assisted living facility in Cincinnati, the city of their birth.  In December 2002, at the age of 78 and pretty worn out, he underwent an operation to install an artificial bladder sphincter to control the incontinence.  During the recovery period in mid-January 2003, he went downhill again.  He was admitted to the hospital with a diagnosis that he had squamous cell carcinoma that had spread to his lungs and the rest of his body.  He spent his 79^th birthday on January 25 in Hospice of Cincinnati.  He had a cupcake and beer.  It was not a celebration.  He died on February 3^rd.

 

His prostate cancer period was hard on him.  His quality of life sunk pretty low during the two years before he came down with the head and neck cancer.  If we knew then what we know now, I would have advised him to take his chances by foregoing treatment and living without the Depends.  What I mean by that is not so much that we could possibly second guess the future course of his cancer or treatment, but that the Swedish study hadn’t come out yet.  In all likelihood, as much as we don’t like to think of dying, his odds of dying of something else was greater than dying of the prostate cancer. 

 

This was the source of my greatest anxiety.  I could see what it did to him and it was horrible.  If what happened to him was going to happen to me, then my life, at least as I knew it, truly was over.  There were several possible treatment interventions and I didn’t like any of them.  Unfortunately, non-treatment wasn’t a very good alternative either.

Part 2 - My Prostate Cancer Story

Prevention

 

My life’s work is preventing diseases.  The first question you might ask is “can prostate cancer be prevented?”  It can be if you avoid risk factors.  Here are some of them:

 

1.     Choose your parent’s well, because there is an association with prostate cancer if you father and/or male relations had it.

2.    Age.  As males get older, their chance of getting prostate cancer increases.  Most men will get prostate cancer, but they won’t die from it.  Mostly it is very slow growing.  However, we cannot distinguish yet from slow growing cells and fast growing cells.

3.    Diet.  A high fat diet is associated with (but does not necessarily cause) prostate cancer.

4.    Smoking is associated with higher levels of prostate cancer.

 

There have been clinical trials using selenium and vitamin E supplements.  These were halted in late October 2008 because not only did they not show a protective effect, but they were causing some other problems with the study subject’s health.

 

In my case, my father had prostate cancer.  That’s one strike against me, but that’s something I didn’t have much choice in.  The same goes for ageing.  At my age (56), there is a one in one hundred chance that I could get prostate cancer.  Lucky me.  My diet is low in fat and always has been.  I don’t smoke and haven’t had a cigarette since my experimental teen years.  In short, there wasn’t much I could do to prevent it.    There are web sites that tout supplements and special milk shakes that you purchase from them.   These are all nothing more than shameless snake oil.  Avoid them.  Avoid any business that says they have a purchasable prevention method for prostate cancer.  It doesn’t exist.

 

Treatments

 

I started reading about the treatments.  Treatments fall into two broad categories:  you can either remove it or leave it in.  There is actually a third alternative: no treatment or more precisely, something called “watchful waiting”.  I’ll tackle these one at a time.

 

Removal:  This is called a radical prostatectomy.  This is where a surgeon removes the entire prostate and possibly some surrounding tissue and lymph nodes.  It can be done by cutting the patient open through a variety of places near the prostate, but the most common one is straight up the middle.  An incision is made in the abdomen, thought the abdominal wall and they just open you up, cut out the offending parts, and then sew you back up.  Pretty simple.  The other, newer way is to use a robot to perform the surgery.  Six holes are poked though the abdominal wall and various instruments are poked though these holes, such as microscopes, lights and reticulating “fingers”.  The stomach is distended with CO2 gas to give the surgeon more space.  The microscope blows the image up by a factor of 10. 

 

In Place:  There is radiation therapy, either by external beam or brachia therapy (or seeding).  There is also hormone therapy, whereby the patient is given drugs that halt the production of testosterone, which in turn is supposed to stop the growth of the tumor.  And finally, there is cryotherapy.  It kills the cancerous prostate tissue in place by freezing it.

 

This story isn’t going to go into great detail about every treatment option, as it would take too long, but I’ll briefly go over the ones that I considered.  More detail can be found at www.cancer.gov/cancertopics/types/prostate

 

The most distressing of all these treatments is that all of them have possible negative outcomes.  With all of them, there will be incontinence and impotence.  All men undergoing any of these procedures, and I mean every one of them, will experience both of these maladies, for at least some period of time and possibly forever.  Other than dying, these outcomes are the most important to a man, and in particular, this man.  If you have to go around wearing diapers for the rest of your life or not be able to engage in the joy of sex, then life isn’t much worth living, is it?  Now, I know there are veterans with arms and legs blown off or who are paralyzed due to war injuries who seem to be getting along fine and are downright inspirational in their abilities to overcome their adversities and lead a joyful life.  But I’m not them right now.  I am a guy who is in near-perfect health, who did everything right to be that way, and right now, life as I knew it was over.

 

My odds of being incontinent post-surgery were 100%.  Normally, most men would overcome this problem in six weeks to three months.  I would have to wear kotex-like pads to catch the leakage.  I could be one of a few percent that it would be worse and would have to wear Depends.  There was a chance that I would have leakage the rest of my life.

 

Impotence was another matter.  I’ll let you in on a little secret, just so that you can get an idea of my frame of mind at the time.  I’m 56 years old.  Never in my life have I had what is termed “a failure to launch.”  A little research was telling me that 50% of men aged 40 to 70 experienced erectile dysfunction.  I am by training and education and epidemiologist and I could tell that there was something very wrong in the way this statistic is presented, especially if you are 56.  It lumps old men in the same group as young men, both healthy and unhealthy.  I couldn’t tell how many 56 year old men are impotent.  The only thing I could really tell from his statistic is that there were a whole lot of men with ED out there, like it or not.  I also couldn’t tell from statistics (and you rarely can) who is actually dissatisfied with their condition.  Statistics are cruelly cold and lack depth, emotion and quality.  That statistic did me absolutely no good in assessing my situation, because I was fine at the moment.  Other statistics said that if I had a radical prostatectomy, that my odds of regaining potency were only 80% and that I would be impotent for between six months and two years.  That also means that the odds that I would be permanently impotent were 20%.  And that was for a man my age that was in excellent health.  I hated those odds.  They weren’t good enough for me to relieve me of any stress.

My Prostate Cancer Story - Part 1

Since discovering that I discovered that I had prostate cancer, I told as few people as possible.  At work, only my secretary and medical director knew.  My medical director is also my personal physician.  My wife and two daughters know, and my Swedish daughter, who is a doctor in Sweden, knows.  I felt that this was a very personal thing and I’m just not in the habit of sharing personal information.  Furthermore, I didn’t want people to have pity on me.  Ultimately, I knew I was going to be fine, at least alive, and I didn’t want people inquiring all the time.  Besides, how do you go about explaining impotency and incontinence to those you work with every day?  Why tell the story now?  Maybe I can help somebody who is facing the same fears and anxieties that faced me.  I cannot recommend what course or path they should take because we are all different.  But at least it may help the understanding of the process and may help them make up their own minds to make the choices they think best. 

 

First, the Bad News

 

It all started out as a routine physical exam in December of 2007.  After having gone decades without seeing a doctor for much of anything, I committed seeing one for a routine physical in my early 50’s.  I was very healthy and active and within a normal weight range.  I always felt pretty good.  During a physical exam about four years ago, I was diagnosed with mild hypertension and started on a one pill a day regimen.  The semi-annual checkups were now the routine and this December visit was the latest.  Of course, my doctor always throws in one or two other test for good measure.  This time it was going to be a PSA test and a digital rectal exam.  At a follow-up visit in January, he said the PSA test was around 3.0, which was still in the normal range, but he said that my prostate gland was a little bigger on one side than the other.  He was sending me to a local urologist for a biopsy, just in case.  “You never know about these things.  It could be nothing. Better to check it out than let it go.” 

 

The biopsy and ultrasound were scheduled for mid-February.  These are office procedures.  The biopsy consists of going up through the rectum and poking through the bowel wall to the prostate gland and collecting twelve needle biopsy samples of the prostate in a grid pattern.  It was a bit uncomfortable, but no big deal.  I thought that I’d get this done early in the day, then head straight back to work.  The discomfort was more than I guessed it would be, so I took the rest of the day off.  By normal quitting time, I was feeling back to normal.  Funny how that works.

 

I was supposed to get results in about two weeks.  When I called, they said it would be another week because the local doctor needed a second opinion from the experts at Johns Hopkins.  I suppose this is when I started to become a little nervous about the possible results.  A week later I went to the Urologist’s office.  The doctor brought in the file and said rather matter-of-factly,”You have cancer.”  Just pretty much straight out, no emotion, no nothing.  He showed me the slides and the lab results.  He informed me of my Gleason Score and something else.  It was either too confusing or I didn’t listen.  He said that I needed treatment.  There were several kinds available.  He loaned me a paperback book titled 100 Questions and Answers about Prostate Cancer (available at Amazon.com) and told me to come back in two weeks and tell me what kind of treatment I wanted to do.  Maybe I’d find answers in the book.  He told me not to put the treatment off for too long. 

 

There you have it.  I had the “C” word.  Now it was my turn to deal with it.  Millions of other people have to deal with it, but now things are different because it’s me and I’m supposed to come up with some sort of life and death decision.  My wife and I had a Spring break vacation coming up in a week or so, and I would settle in, educate myself and work through what was starting to be a lot of anxiety and depression.

 

I had no symptoms of anything.  I knew what symptoms were or might be.  When I was 23 years old I had a bout of chronic prostatitis (spell check was having a problem with this word; it kept coming up as prostitutes).  I had to get up several times during the night.  I had the sensation of having to urinate very frequently.  Yes, I had experience with symptoms but this time I had none of them.  Aside from a few aches and pains that come with being a weekend warrior, I felt great.

 

Adding to my anxiety was the fact that my father had prostate cancer.  He was about 75 years old when he received his diagnosis.  He underwent a variety of treatments.  All of his outcomes were adverse.  More on this later.

 

My wife and I went to Florida and I read the book.  It helped a lot in understanding the disease, the treatment options, therapies for recovery, and the odds of certain things happening that would cripple me forever.  Vacations are supposed to be relaxing and a time for renewal of the spirit.  This one was getting to be a bit depressing.  It didn’t help me make up my mind very much. 

Free Money!!!

This past week a local school system, in an attempt to pass a school levy to fund new construction, told teachers that roughly half of the new construction costs would come from what they termed "free money."  One teacher asked "where does the free money come from?"  The school administrator explained that it came from the tobacco companies in the Master Settlement Agreement, set aside for school building construction.

This begs the question: Where does "free money" come from?  In the case of the MSA, it comes from the tobacco companies.  Where did they get it?  They got it from selling cigarettes to smokers.  Therefore, somebody parted with it after they got their paycheck and it ultimately wasn't free.  But when you take money from smokers (predominantly low-moderate income folks who can least afford it) it seems to be, well, politically safe and the right thing to do.   After all, tobacco companies are sort of evil and using their money seems perfectly justified, even though they get it from smokers.  I didn't hear any wails from anybody when Ohio accepted their billions in the first place.  And smokers aren't getting much sympathy these days either, so that seems to be OK, too.

That leads me inevitably to the Ohio Tobacco Foundation's money that was recently expropriated by the gov and the legislature.  The legislature declared it was "their" money and so they took it.  Nothing wrong with that, they declared. 

Since taking money from tobacco companies feels good to most people, why didn't the legislature solve this problem by just taking more of it from the smokers?  A nickel per pack would generate about $35 million/year.  Problem solved with free money!!!

Smoking Away in Austria

My wife, daughter, son-in-law and I just returned from a Christmas ski trip to Innsbruck, Austria.  I love Austria.  It is a beautiful place and the people are as hospitable as can be.  I highly recommend it.  And the skiing is great, too.  There are at least a half dozen snow covered slopes a free short bus ride away.  I like everything about Austria except for one thing:  They smoke.  I mean they smoke cigarettes inside restaurants.  All of them.  It came as somewhat of a shock to our systems, what with a complete ban in Ohio and many states.  And prior to that, just about everywhere in the U.S. there were no smoking sections in restaurants.   

They smoke in almost every restaurant.  And rarely is there a no smoking section.  In fairness, there are several small bakery-cafes that totally prohibit smoking.   What is so ironic is that my image of Austria is of outdoorsiness, hiking up into the fields of Edelweiss and Julie Andrews twirling and singing in the crisp, pure mountain air.  While it is this and more, it is also a place where legions of beautiful young ladies and handsome young men in their twenty-somethings sit in restaurants for hours on end puffing away on cigarettes.  How unfortunate. 

Our last restaurant of the trip was at a very nice little Italian place.  The maitre'd insisted they had the best, freshest fish of any place in town.  That was appealing.  But I looked around and noticed there was smoke everywhere.  I asked him if there was a nicht rauchen zimmer.  He said, no, but perhaps next year.  Instead of saying "mi dispiace, troppo fumo" and leaving, we decided to stay and take up a seat in a corner of the place.  This restaurant was one of those authentic looking Italian places with the low cavern-style vaulted ceilings that cut off about half of the overhead airspace.  The fish was excellent, by the way.  In Europe, dining out is meant to be a leisurely experience.  They bring you the food and don't bug you much.  you can stay forever.  You have to actually trip a waiter and request him to bring the bill.  So, after about two hours, the place was so filled with smoke that my little family was literally gasping for air.  it was truly that bad.  We grabbed our smoke-tainted coats and took our smoking bodies outside for some fresh air.

Now, what was this "next year" thing the waiter was talking about.  When I got home I looked up some information on Austria and smoking.  Apparently about 30% of adults are regular smokers and another 20% are occasional smokers.  Austria does have something called a partial smoking ban.  Smoking is banned in schools, hospitals, and airports.  And restaurants that have more than 750 square feet of space must have a no smoking section.  But the rules are voluntary and I can vouch that the no smoking section rule is being blatantly ignored.  Austria, it appears, is determined to be the last great bastion of smoke-filled air in Europe.  France and Germany went smoke-free as of Jan 1, 2008.  They join 15 other European countries in banning smoking in restaurants.  Crimony, even Albania has banned indoor smoking!!  Turkey is about to do the same. 

I wish Austria would get on the smoke-free wagon.  It would make a wonderful country perfect.  And perfectly healthy.  The next time I visit Austria, if smoking is still going on in restaurants, I'll seek out those smoke-free bakeries and take all my meals there.  Yeah, I can handle that. 

Socialized Medicine?

On October 3rd, President Bush vetoed bipartisan legislation that would have extended Medicaid benefits to lots of poor children.. One newspaper reported that the main reason he did so was that it "moved our health care system toward socialized medicine."  I went to the White House Press office website to see if that was a correct quote.  It was not.  In a speech delivered to the Lancaster Chamber of Commerce, he used the words "federalize health care."   He prefers that poor children purchase health insurance from privately owned insurance companies.  You know the ones I'm talking about, the expensive policies.

I'm not sure of what the President's definition of "federalize" means, but I'm going to take a stab at it.  It means a health care system that is run by the government, where the doctors work for the government and the government doctors tell you what to do.  Would somebody please tell the guy that the federal government already has such a system, and by all accounts its working pretty well.  Its called The Military.   Yep, when you go into the military, you enter the world of socialized medicine.  All of your doctors are military officers, paid with tax dollars.  They tell you when to show up for your physicals and immunizations, and you have no choice but to go.  They have a 100% compliance rate with preventative medicine.  For some odd reason, the military desires soldiers that are healthy.  Their outcomes are some of the best in the world.  Of course, the start out with a fairly healthy group of folks.  Preventative medicine keeps them that way.  Now, there's a concept. 

In the same speech, Mr. Bush gave himself credit for being consistent in his decision making.  If that were the case, maybe he should abolish the military health care system and tell our troops to go out and buy private insurance.

Flu Shot Blues. Again. And Again. And Again.

I’ve been very attuned to the frustration level of LHDs over the delivery problems with flu vaccine this year.  With an early start, put-or-pay revenue guarantees from the Federal government to produce over 117 million doses, three manufacturers, and four or five different vaccines, why can’t they deliver it on time?  The “they” in this case is the private sector producers, Sanofi-Pasteur, GSK, and Chiron.  No one seems to know, or at least take responsibility for this continuing debacle. 

Do you remember in the aftermath of 9/11 and the anthrax aftermath?  Congress gave several billion of our tax dollars to the drug companies to research better, faster and quicker ways to manufacture vaccines rather than the old fashioned way of using chicken eggs.  Has anything come of it?  Obviously not.  Has there been any improvement in the delivery and distribution system to make sure that public health clinics receive vaccine in time for the season?  Obviously not.  With the exception of the last five years, which have been consistently bad years for vaccine delivery, they used to deliver it on time for the past several decades.  Five years ago, the issue was price.  An artificial shortage was created, and the cost of vaccine doubled for the next year.  You think that would solve the problem.  But it didn’t.  The price keeps going up and service keeps getting worse.  A congressional investigation is warranted.

And why can retailers such as Kroger, CVS, Meijer, and other chains whose sole purpose is to lure customers into their store to sell groceries get the vaccine before we do?  In reality, there is no coordinated system of getting vaccine to the people and places that need it most and who are most accountable to the public.  The episodes of the past few years instill complete confidence in the manufacturing and delivery system when an emergency arises.

After months of planning, most of us have had to cancel, postpone and reschedule our flu shot clinics.  To add insult to injury, our friends at ODH have refused to adapt to the situation.  One very simple solution would be to release the vaccine allocations to LHDs for drive-by pick-ups as it came in.  But no, they refuse to think outside the box and adapt to adversity.  These are the people who want to run the show in an emergency.  This is an emergency and so far they have proven that their plans don’t include getting vaccine to the customer ASAP. 

Perhaps one of the solutions in future years would be that we let the grocery stores and drug stores administer the flu shots.  (Remember that our job is to assure that it is being done, not that we do it).  We can reduce our vaccine orders by 75% and hold open walk-in clinics for the stragglers from November 15^th to December 15^th.  And we would by the smaller amount of vaccine from the closest supplier that actually had it.

Things That Make Us Fat

In my previous blog on vending machine vigilantes, I stated that removing vending machines in schools would prove to fruitless in the battle with childhood obesity, as obesity is multifactorial in nature.  Getting one's weight in the healthy range requires a combination of both good diet and plenty of exercise.  The San Man, in a comment, suggested many environmental changes such as more recreational opportunities, bike paths, etc.  But he seemed to support the removal of vending machines as one small step in the right direction.  Maybe so, but most likely not.

Consider that if you were into banning things that you believed were causal to weight gain, then consider banning the some things that were not around much 50 years ago when obesity wasn't the problem that it is today:

• Air Conditioning (we now live in climate controlled environments and don't even sweat anymore).
• Television (Need I say more?)
• Computers and the Internet
• Starbucks (Another Cup o' Sugar?)
• Fast Food
• Two-thirds of the food in my grocery store.
• Bloomin' Onions
• Fair Food
• SUV's
• Modern Subdivisions
• Cheap Gas (yeah, it's still cheap compared to Europe, where people walk a lot).

Why do I bring this up?  Because 40 and 50 years ago, our parents told us to turn off the TV and go outside and play.  We had to do chores around the house.  We didn't have air conditioning to cool and comfort us.  We actually perspired back in those days.  Perspiration is a sure sign that you are burning calories.  Older houses built before the advent of air conditioning had front porches.  people escaped the heat of the house in the evening and sat on their porches.  Or they took walks after dinner and talked to their neighbors who were hanging out on their porches.  Everybody was outside.  No one watched TV or blogged on the Internet

When I go into my local Kroger store to shop, I have a choice.  I can load up on fresh fruits and vegetables and lots of other healthy foods.  Or I can breeze right by the healthy stuff and go straight to the bakery, soda, chips and cookie aisle.  Surely, it seems that at least half the store is stocked with luscious temptations.  Should we ban them?  Heck, no!!  I want to buy and consume bad stuff every now and then.  And Every now and then I work very hard, eat very little and become calorie deprived.  Personally, I make the choice to buy good, healthy foods.  The operative word here is choice.   We should all be free to make the choices.  We know what they are.

Progress is a double-edged sword.