“Mr. Kinnaman, your results came back positive…” That really is the only thing I heard in our brief conversation. As Dr. de la Paz continued to speak I looked at the pictures on my desk, pictures of my wife and I on a cruise, pictures of our four grandchildren. I ask a few questions, write a couple of notes that mostly make sense later, but while hearing, I really am not listening. I have cancer.

The Roller coaster of Rage and Fear

Rage is what fuels all the reading, it is the cranking up of the roller coaster, “clack, clack, clack,” as I am taken higher, the rage that this should happen to me “clack, clack, clack,” higher and higher; rage, being pushed on by the idea that if I read enough I can find a solution, rage that compels me to exhaustion to find the next website, the next procedure, the next presentation on YouTube. And then just as I reach the pinnacle and seemingly have nowhere else to go, I overtop and begin the free fall into fear: fear of loosing my health, fear of the surgery, fear of radiation therapy, fear of incontinence, fear of impotence, fear that I’ve let you down, fear that dying will hurt, fear of leaving my wife alone. While on the way up it felt like rage would leave me with no place to go, fear seems like it could go on forever. And along the way fear throws me into switchbacks of loathing and pity and ultimately into the 360° of doubt: did I do enough, should I’ve been more vigilant, can I make a treatment decision that will make a difference?

Peace

A hymn derailed this mad train of my own making.

Picked weeks before by Pastor Mayes, the opening hymn stopped me cold. I’ve loved this hymn for many years; I love to sing it with gusto. But the words have never meant as much to me as the now did in the opening minutes of the Divine Service.

Christ is the world’s Redeemer,
The lover of the pure,
The font of heav’nly wisdom,
Our trust and hope secure,
The armor of His soldiers,
The Lord of earth and sky,
Our health while we are living,
Our life when we shall die.

Christ has our host surrounded
With clouds of martyrs bright,
Who wave their palms in triumph
And fire us for the fight.
Then Christ the cross ascended
To save a world undone
And, suff’ring for the sinful,
Our full redemption won.

Down through the realm of darkness
He strode in victory,
And at the hour appointed
He rose triumphantly.
And now, to heav’n ascended,
He sits upon the throne
Whence He had ne’er departed,
His Father’s and His own.

That line in the first stanza: “Our health while we are living / Our life when we shall die.” I’ll never sing it again quite the same way. These words stopped my voice in my throat. But in an instant they also stopped my fear, my panic, my rage. Just a few words hiding in a well loved hymn, and I was pulled back into the loving arms of Mother Church. I could only listen to the next couple of stanzas, or I would have lost it. “Our health while we are living / Our life when we shall die.” For me a new cradlesong. These words rested me firmly in the arms of Christ’s Bride, who then took me back to the font, and to the cross, and then to the Supper. I was soothed with the words and the texts of the Divine Service. Yes, the same words that I have proclaimed to others during the years of ministry, but I was hearing them with new ears, ears tuned by my own angst, my own fear, ears tuned by God to now hear how I was going to really be able to make it through it all. And it all turned around on a hymn.  I’ll have it memorized soon.

Glory to God the Father,
The unbegotten One,
All honor be to Jesus,
His sole-begotten Son,
And to the Holy Spirit-
The perfect Trinity.
Let all the worlds give answer:
Amen! So let it be.

Other  posts in the Prostate Cancer Journal can be found under Categories in the sidebar of this blog.

A Bit More Waiting

You can read a lot about the procedure that is technically known as transrectal ultrasound-guided prostate biopsy on WebMD and the many good sites that have written about men’s health and prostate cancer. Most of them will say that it “doesn’t hurt much,” that it’s “not so bad.” But, “doesn’t hurt much” and “not so bad” only seemed to mock me. Despite the vast amount of information I had accumulated over the previous ten days, I am wading deep into the unknown, nearly drowning in a mix of fear and anxiety. As I drove the thirty minutes to the office I’m thinking about the needles. Upon checking in I am shown into a standard exam room by an efficient but very kind nurse who checks my vital signs and goes over a list of questions about my medical history. Then she explains everything that is going to happen from that point forward. Her calm, deliberate, two-minute speech drains away some of the fear that has been washing over me in waves. The nurse leaves, and following her directions I get naked. I put on a hospital gown so it opens in the back and have a seat on the exam table as I wait for the doctor. I’ve been told it will be about ten minutes. This exam room has two carts set up with monitors and keyboards. The nurse has one powered up and sitting next to the exam table. I recognize the image on the screen as the pie-wedge that will display an ultrasound image. But it is the wand clipped in readiness on the side of of the cart that gets my attention. The business end is about eight inches long and about the diameter of a roll of nickles. The doctor is obviously an advocate of safe sex as the wand is sheathed in a form-fitting condom. From my reading, and the nurses’ explanation, the wand will be used to get an ultrasound image of my prostate gland and map where the doctor will take his biopsy. That’s okay. What sets off alarms is the very slim metal tube that runs down the length of the wand. I start to go into meltdown as my forced-calm exterior gives way to the anxiety within. The metal tube indicates the ultrasound wand’s second use: to guide the placement of the biopsy needles. One at a time, a dozen needles will be shot down that metal tube by a spring-loaded biopsy gun, through the wall of my rectum to snatch and bits of tissue I wasn’t all so sure I wanted to surrender. “Good afternoon, Mr. Kinnaman,” says Dr. de la Paz as he offers me his ungloved hand. “How are you feeling?” Summoning a weak smile: “A little nervous, but not too bad, I guess.” He sees right through my bluff and gives me a pat on the shoulder as he makes his way around the table. The nurse takes over. She gets me into position on my left side and has me draw my knees up toward my chest in a loose fetal position. She positions pillows for me, the last one between my knees. All the action is set to go on behind me, and the strategically placed opening in the hospital gown now exposes to the doctor what I would really rather lock-down and hide.

“Okay, now relax.”

The doctor begins by performing a digital exam of the prostate. This is a good bit more aggressive than the standard annual exam. If feels like he’s trying to get to the front side of the gland as well as the back. “Okay, Mr. Kinnaman, now I need you to relax.” As I try my best to follow his direction, he inserts the ultrasound probe. So far so good. The tip of the ultrasound wand assaults my prostrate and, it feels like, a whole lot more. If I didn’t have a clue where my prostate was, I certainly do now. While not painful, it was decidedly uncomfortable “Mr, Kinnaman, you doing okay?” I evidently mumbled, because he asked again a little more urgently. I realized that not only was my butt going to act as host for the doctor’s ministrations, I was going to need to further participate by responding to de la Paz during the procedure. “Mr. Kinnaman, your going to feel a little pinch.” And with that comes several shots of Novocaine, or some such numbing agent, right into the prostate. De la Paz’ assessment of a “little pinch” from each injection is pretty accurate and I felt four little pinches before things became comfortably numb. I find my anxiety growing instead of fading. De la Paz uses the ultrasound wand to take several measurements and pictures. The wand is moved left and right, up and down. I didn’t know my anus can move in so many different directions. The doctor informs me that my prostate weighs 25 grams, about 5 grams more than he would like to see “for a man your age.” Then there is a break in the action. The doctor and nurse are consulting. The moment draws near when the biopsy needles will do their work, all pretense of relaxing “back there” is shot; I take a few deep breathes and try to ignore the technical exchanges between the doctor and nurse. “Ok, Mr. Kinnaman,” he says, “you’re going to feel another little pinch.” Every move he makes is accompanied by grip and release, grip and release. I am nearly out of control with fear. “Shathunk.” I manage to avoid screaming-out in surprise and anxiety. The spring-loaded needle gun sounds like a staple gun being fired behind me. There is definitely pressure from the needle as it pierces the rectum wall, the prostate and then makes it’s hasty exit, but there is no pain. Oh, thank you, God, for creating Novocaine! As the second, third, and fourth, and the rest are announced I begin to breathe easier. “Shathunk,” now means we are getting closer to being done. “Shathunks” eight through twelve, feel decidedly different. When announcing these Doctor de la Paz said they were at the apex of the prostate. By the time he is done, 12 specimens have been collected. When it’s over, the doctor comes around to the front of the table and shows me  couple of pictures of my prostate and says that I should hear from him within a week. If it is positive, he’ll see me in two weeks, if it is negative, I have an appointment in three months. From the time he came in to the time he departed it has been 18 minutes. The nurse has me get up slowly and watches me to make sure I don’t roll off the back of the table. Left to myself, I wash antiseptic and lubricant gel from the work zone and change back into my own clothes. From what I read on the post-op paperwork I was handed, this won’t be the only blood I see back there over the next couple of days. By the time I step off the elevator in the lobby, I am breathing normally. Other  posts in the Prostate Cancer Journal can be found under Categories in the sidebar of this blog.

UPDATE:

I have come across some other interesting post on the subject of the transrectal ultrasound-guided prostate biopsy. While my procedure was decidedly uncomfortable, it was not painful. My anxiety and fear of the unknown was greatly worse than what I experienced in the hands of my doctor. And this is a point that I have learned along the way (now five weeks after the biopsy), there is NO substitute for doctors with skill and experience. Seek them out, and then as your own journey progresses, ask these trusted men and women who they would want to see for the “whatever” that is the next procedure . If all else fails, or your anxiety will keep you from doing what is necessary, Henry Morgenstein’s post, Prostate Biopsy, might give you some options. This post gives a fairly unvarnished blow-by-blow. I like his line, “Fear Factor is a 10, actual procedure is a 2.” That is pretty much it. Herb Greenberg’s blog post brings up another good point. There is no better advocate for your medical treatment than an informed patient. While this post from Ron Kaufman is about his whole prostate cancer journey, his experience of the biopsy is very much what I have heard others say. What I think is very useful are these two paragraphs about early detection:

Friday, April 19 was another milestone day. The results of the pathology came back. Was I to be listed as cured, or did the cancer get away from the prostate, and was I looking at radiation, chemo, or more surgery. It was close. Everything came back perfect. The cancer had come within 1 millimeter of breaking out of the prostate, but in fact had been caught in time. Time. If there is any message that can spell the difference between success and anything else in the detection of this cancer, it is being tested early and annually, and acting quickly once cancer has been found. One millimeter, a few human hairs of tissue thick, was all that remained between me being cured, and a survivor, and my ongoing war with cancer.

This will be an intensely personal post. If you came to this blog expecting something else, you might want to take a break from reading this now, head over to the archives, and wait until the more characteristic posts make a comeback.

This afternoon I will be heading over to my doctor’s office, a urological specialist, and have a transrectal ultrasound-guided prostate biopsy. This test will be used to determine whether my elevated PSA blood test results are indicative of prostate cancer or infection or something else altogether.

Since getting the report of my PSA (prostate specific antigen) levels ten days ago, I have only talked about this with my wife, pastor, and three trusted friends. Those who know me may be surprised that I told that many others about the impending biopsy. When it comes to such personal details, I tend to be intensely uncommunicative, a New Englandish “It’s my business, and only my business” attitude–although I have never lived in New England. I have decided to leave my comfort zone and journal about this experience for two main reasons. First, as a coping mechanism to help give the swirl of emotions some expression and a place to “live” besides in my gut. And second, the majority of my male friends are in their forties and fifties (the women are never older than twenty nine), and if the sharing of my journey–wherever it may lead–gets even one of them into the doctor to begin getting an annual PSA, than this breech in my personal space will be very much worth it. Well, maybe a third reason: wives and mothers get your forty-year-old husband or son to the doctor annually–the years of health and life you will give them is worth the nagging!

My father died on February 3, 1993 at the age of 66. He died from the complications begun by prostate cancer. When Dad was diagnosed in 1989 or 1990 his cancer was already well advanced and had already advanced into his lymph nodes. If prostate cancer is detected and stopped before the lymph nodes are involved, there is every chance that it can be “cured”. However, from everything I have read, once it moves from prostate to the lymph nodes a nearly unstoppable progression has begun that will lead then to bone cancer and death. Prostate cancer is slow-growing. That is one of the characteristics that gives those who are diagnosed early great hope. It also means that Dad could have had his prostate cancer for eight or ten years before the back aches and the blood in his urine finally sent the stubborn man to the doctor.

Much like the plumbing in the walls of our homes, us men don’t think about our plumbing until there is a problem. The prospect of the doctor inserting a finger where the sun don’t shine to palpitate the prostate through the wall of the rectum is generally less uncomfortable than it sounds,  nevertheless it makes most men anxious and, I suspect, most men would certainly choose to avoid the whole issue if offered, say, a beer instead. Really. Every man age forty and up should have a digital rectal examination as part of his annual physical examination. At age fifty the blood test for PSA should be done annually as well. Yes, guys, preventative maintenance. We understand preventative maintenance is necessary for our cars, why is it so hard for us to translate that truth to our own bodies?

If there is a history of prostate cancer in the family, as there is in mine, the PSA testing should begin at age forty. For most men, a PSA below 4.0 is seen as being acceptable. Because of my family history, my doctor wanted to see a PSA level below 2.5. Truth be told I have been less than regular about my annual exams and my last PSA was when I was forty-seven. So now, the 4.8 result from my PSA has prompted the next step: a biopsy of my prostate.

After Dad was diagnosed, and again after he died, I did some reading about prostate cancer. Knowing the details of the disease didn’t help me cope with the loss of my father, it just gave me more information. Well, it is sixteen years later and thanks to the web information is much easier to come by. And for the ten days since I heard the news and that I was scheduled for a transrectal untrasound-guided prostate biopsy, I have been overloading on information. Intellectually I am as prepared as one can be for the procedure. Oh that the knowledge would ease my unease and anxiety. Quite simply, I want to back myself into a corner and tell everyone to just leave my butt alone. Okay, that had to be said, but I guess I have to push on.

Today is an exploration to get answers. What we know is my prostate is slightly enlarged and my PSA level has put my doctor on alert. I have no other symptoms. The ultrasound wand will go in, and working through the wall of the rectum (!) the biopsy needle gun will take ten to twelve core samples from the prostate. These will be sent to a lab for examination and interpretation. The likelihood of cancer will be determined using a Gleason scale. If cancerous cells are found, the technicians and doctors will assess this according to a scale to better determine how the treatment will be handled.

Time to get ready. I have picked up from the pharmacy an interestingly-shaped bottle from Fleet that is supposed to make the work site a bit cleaner. I have my antibiotics that I will start taking two hours before the procedure, and I  know as much as I can know about what to expect. If my resolve to journal holds, I will post later about the procedure.

Other  posts in the Prostate Cancer Journal can be found under Categories in the sidebar of this blog.