June 1, 2026
An “adventure” in health care (American style), part 5
Gary Engstrand
Pieces of a Prologue
An egregious omission from this narrative is my wife Kathy. She has shared my concerns, listened sympathetically to my sometimes endless fretting, and been a source of support without which this entire set of events would have been far more unnerving and depressing.
I know that I have a propensity for
imagining the worst outcomes and fret about the possibility. The treatment and
cure rate for prostate cancer caught sufficiently early is not 100%. I manage
to be concerned that I’m in the small percentage of cases where the cancer is
not cured. That I am wont to worry is odd because I’m usually an optimistic guy
and I follow my father’s oft-issued advice to my mother: “Betty, don’t worry
about it.”[1]
My friend Sam got annoyed that I alluded to Samuel Johnson’s (1777) quip. “Depend upon it, Sir, when a man knows he is to be hanged in a fortnight, it concentrates his mind wonderfully.” I agreed that it was true, I probably didn’t face the (figurative) hangman, but the fleeting brush with death nonetheless made me think more carefully about how I spend my hours. I have done so off and on for several years, as I realized my time was getting shorter, but this medical situation revived my contemplation of what I want to do and with whom I want to spend time.
I want to note that my friend Sam, counselor and cheerleader all during the process, and especially during the nerve-wracking months in Florida earlier this year, has retained those roles as the weeks have passed. I remain grateful for the commentary and advice. I’ve also failed to note the support from a retired faculty friend, a bioethicist, who has been a recurring source of encouragement. Sam has told me that he was more easily able to get through the process by talking with people as he went along. I have found that to be true for me as well.
The Treatment Outcome
I tried
to describe earlier the machine that I have visited 26 times. With the
(laughing) consent of the technicians, Kathy took a picture of me lying on the
carbon fiber slab just before treatment began.
The photo shows three of the four “arms” that come out from the head of the machine; the fourth one is underneath me. The one over my pelvis is the radiation-emitting arm. Once treatment begins, the technicians leave the room and go to the control panel and those four arms go around me slowly four times, twice clockwise and twice counterclockwise.
* * *
Numbers in medicine can be traumatic. Think “stage 4” anything, for example. Numbers in our lives, work or pleasure, can be disappointing or pleasing, but I think that in most cases they are not traumatic nor do they render us ecstatic. Sales might be up or down, your salary might be going up a large percent, the estimate on the home repair came in low, your kid ran a marathon in record time, ad infinitum. But at least for me, those kinds of numbers do not elicit the same reaction as the ones in medicine that demonstrate my status and likelihood of continuing to live. So yes, the numbers in medicine can be traumatic—but they can also be exhilarating.
The magic PSA numbers:
Dec 30 13
Feb 6 17.7
April 13 27.4 (these numbers are going the wrong way!)
May 22 0.697 (this one did not go the wrong way!)
On May 20 Dr. Hirtz told me that he wanted to see the PSA number drop below 10. The May 22 number was significantly below 10.
I cannot recall ever being so relieved in my life. When I told Kathy the number, she asked me if I was happy. I told her that of course I was happy—but the overwhelming sentiment was one of relief. I was extremely happy when I got married (both times) and when the two kids were born; this case is less a matter of happy than finally relaxed, for the first time since the end of December.
Of course I had a number of questions, relief aside. At my last session with Dr. Hirtz, he answered them but said that my urologist would have additional comments. Dr. Hirtz is a really nice guy; I wish I could have him as my physician for any other medical issues that may crop up in the future.
-- Is the drop in the PSA (from 27.4 on April 13 to 0.697 on May 22) typical when a patient has started on radiation and hormone therapy?
It is.
-- Is it possibly a fluke in the test and should be retested?
That is highly unlikely, and further PSA tests will confirm the result.
-- What is the probability that this is a false negative?
Also highly unlikely, but further PSA tests will show whether it is.
-- Assuming it is accurate, what implications does the 0.697 have for continuing treatment?
Primary responsibility for treatment now passes back to the urologist, who will make that decision about continued hormone therapy.
-- If I recall correctly, you said the PSA number will not get to zero. Is 0.697 close enough to zero to call it a win?
It may get to zero, at least during the hormone therapy, but it will likely return to a positive number. They are satisfied with anything below 0.2, so it needs to be lower.
-- I ask this only half seriously: If, as you told me, any drop in the PSA # this early would be due almost entirely to the drugs, not the radiation, then given the numbers, one might ask what the purpose of the radiation is 😊
The hormone therapy doesn’t kill the cancer cells; the radiation does that.
Dr. Hirtz also gave me an article from The Lancet (British, one of the most respected medical journals in the world) about prostate cancer treatment outcomes, and he’d even taken a highlighter to some of the language. Wow.
Dr. Hirtz concluded by saying he still expected a cure, with the remaining hormone therapy, and said I was in an excellent position.
* * *
As the radiation and hormone therapy was progressing, I told my friend Sam that everything at Planet Fitness was harder than it has been.
I think that’s attributable to two factors: (1) I was only at a gym three times in the entire month of April, and (2) the radiation, which my radiation oncologist cautioned me would likely happen: a loss of stamina. I went for 3 minutes on the treadmill at my usual 8% gradient and 4.1 mph and thought I was going to collapse at the 3-minute mark. I did 3.8 mph the second time and I could handle that. The 20-pound weights felt like 30. The 120 pounds on the leg press felt like 150. I imagine it is important that I keep up a regular exercise regimen or this cancer treatment will leave me much worse off physically than I want to be.
As of late May, the situation was about the same. I received an interesting piece of advice from my son Elliott (self-taught expert on fitness whose judgment I have come to trust): since cardio conditions decline more slowly than muscles atrophy, for the time being focus on weights and strength and muscles more than on cardio. I am following that advice.
* * *
After 26 days of treatment, I got to know the technicians who administer the radiation. There were six of them (I was told); they work in two-person shifts. Over that many days, I met all of them several times. On my last day, one of them, an older woman (who told me she was going to her grandson’s first birthday the next day) gave me a hug. That was sweet. So were the donuts I brought them that morning from our local bakery.
* * *
As I
noted, my oncologist Dr. Hirtz passed me back to my urologist Dr. Olin. I spoke
with the latter this morning. He told me that everything is going well and
expects the PSA level to be “undetectable” at six weeks after the radiation
ended on May 22. He cautioned me not to focus too much on the PSA; it’s merely
a reflection of the situation at the time.
Dr. Olin also told me that the
hormone therapy will continue for at least 18 months, it’s better to do it for
two years, and optimally for three years, to be sure the cancer is eradicated. Some
men have such adverse reactions to the hormone drugs that they stop after 18
months or two years. I’ve had very little reaction, so I suppose I’ll go the
full three years. I guess I can put up with six pills per day.
Given what Dr. Olin had to say, I have no reason to think there needs to be a “part 6” to this story. Now comes simply the continued hormone therapy and a predicted positive outcome. If you’ve taken the time to read it all, thank you. It’s been therapeutic for me to write it.
A Last Digression on Word Choice
A friend, also going through cancer treatment, wrote that “I particularly resonated with your questioning of the various word choices. Journey and battle never resonated with me either. It’s more enduring because so much is being done TO you with very little that you can contribute (other than keeping your body and mind in as good as state as possible). Battle is also wrong to me because there is very little fighting. It’s a lot of surrendering, surrendering to this road that we are on.” Instead of the events planned in her life, “I got detoured onto this bumpy gravel, potholed, uphill road.”
Another
friend suggested I am on an adventure, as I titled these narratives. In retrospect,
I realize that was an inapt choice. "Adventure" to me implies an
activity that is new and interesting and fun. This is new (but unwelcome),
interesting (not in a way I like) but it is certainly not fun. I have retitled
these stories: An “adventure” in health care, which presumably implies sarcasm
or skepticism.
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