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Public Talk About Private Matters: Men and Prostate Cancer

Isn't This Too Personal? My Prostate Cancer Diagnosis

An elevated PSA was the beginning of my journey and after a conclusive biopsy, it was time for me to consider next steps

By Jackson Rainer

Editor’s note: In our lifetime, one in eight men will be confronted with the challenges presented by prostate cancer.  This is the first story in a series of six articles by Jackson Rainer that will discuss the implications of prostate cancer diagnosis, treatment and the impact on quality of life.

A graphic that reads, "Public talk about private matters. Men and prostate cancer". Next Avenue
Credit: Illustration by John Gilman for Next Avenue

A year into living into what I considered a routine life, as a widower and solo ager in my late 60s, financially stable, working part-time, happily residing between two communities and dividing my time between the urban landscape of Atlanta and the Blue Ridge mountains of western North Carolina, I blithely continued moving through the world with the rhythms of a 'hail fellow, well met.'

I have good friends, a strong social network, and an active life that includes satisfying erotic energy with a loving partner (this information will be more relevant later). I take vitamins, exercise, floss and see my primary care physician twice each year. There is no history of cancer in three generations of my family of origin.

A psychological hammer dropped on my psyche when I was assessed for prostate cancer. 

So, during a routine physical when my PSA was noted as elevated, I took it as a matter of course. I stay current on relevant reading and recognized the controversies over the PSA test focusing solely on routine screening for potential cancer. 

It was not until later that I learned the utility of the PSA test as a gauge for how effectively a particular prostate cancer treatment is working. I knew the PSA was a standard test included in health-related screening but never paid it much mind. 

Because of my elevated score, my physician moved me into the diagnostic class of "watchful waiting." Subsequently, I learned that the prostate-specific antigen, the PSA, is a protein of normal prostate cells that is released in higher amounts by prostate cancer cells.

More Than 'Active Surveillance'

A psychological hammer dropped on my psyche when I was assessed for prostate cancer. I was referred to a urologist, the medical specialist who treats conditions involving the reproductive organs and adrenal glands. He recommended "active surveillance," which is closer monitoring than "watchful waiting" and involves a more aggressive treatment plan if tests show definitive cancer.

Usually, this approach includes doctor visits with a (PSA) blood test about every 6 months and a digital rectal exam (DRE) about once a year. As a practicing psychologist, this approach involved what sounded too much like denial, the defense mechanism that involves ignoring the reality of a situation to avoid anxiety.

Defense mechanisms are psychological strategies used to cope with distressing feelings. In the case of denial, it involves not acknowledging reality or denying the consequences of that reality. For me, not knowing is more anxiety provoking than even the starkest of realities.

"Something's going on. I want to schedule you for a targeted biopsy."

I encouraged the urologist toward more aggressive diagnostics. He was reluctant because I was asymptomatic, even though my PSA continued to tick upward. "There are many conditions other than cancer that can elevate your PSA level," he said. 

I could not be mollified and was moved into diagnostic imaging and biopsy procedures. "I feel like a quack doing this early," the doctor said as he acquiesced to my wishes.

An MRI was prescribed and scheduled on a bright, sunny Saturday morning. A Magnetic Resonance Imaging machine uses a very large magnet, a radio-wave transmitter, and a computer to construct detailed pictures of structures inside the body. Cancerous tissue has a different set of magnetic properties than normal tissue, and MRI can capture these differences.

Early the next week following the test, the physician called and said, "You are good to push this process along. Something's going on. I want to schedule you for a targeted biopsy."

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The procedure is known as a fusion biopsy. It combines the pictures from an MRI scan and an ultrasound to create a detailed 3-D image of the prostate. This procedure makes it easier to see an abnormal area of tissue and guides the biopsy needle into the exact area under investigation.  

While necessary and vital for proper diagnostics, the procedure is not for the faint of heart. In addition to routine preparation protocols for the biopsy, I was given a mild sedative. 

Sitting with this fine physician, I heard the words no one wants to hear: "You have cancer."

"I need you relaxed," said the urologist, "and anxiety is going to tighten you up in all the wrong places for me to do my work." I later learned that I had more equipment placed inside of me than seemed possible. After the procedure, I wondered out loud if the fusion biopsy could be classified as a crime against humanity. I specifically asked the urologist if it had been "… absolutely necessary to put that bowling pin in my lower quarters while you poked and prodded."

The fusion biopsy removes small pieces of tissue from the prostate that can be evaluated for "significance" in laboratory findings. A cancer tumor was found, and I was moved to the process of staging so decisions about treatment might be considered.

The Discovery of Cancer

The staging system is a common way of describing how far a cancer has progressed. An assessment scale predicts the behavior of a prostate tumor, based on microscopic evaluation of biopsied tissue cells. A numerical grade, called the Gleason score, describes the cancer based on its aggressiveness and potential to spread, known as metastasis.

The findings of the tumor's biopsy yielded another call from the urologist. "We need to talk.  Can I see you first thing tomorrow morning?" he said.

When alarmed, I am prone to retreat to platitudes from childhood television. I thought to myself, "Danger, danger, Will Robinson!" as I met with the physician who described the findings, including the Gleason scores and patterns, the staging, and the shape and dispersal of the errant cells. Sitting with this fine physician, I heard the words no one wants to hear: "You have cancer."

According to the American Cancer Society, the risk of dying from prostate cancer has fallen by roughly half since the mid-1900s, mostly because of advances in treatment. Still, prostate cancer remains the second most diagnosed cancer in the United States and the second leading cause of cancer death among men (after lung cancer.) 

According to the ACS, the 10-year survival rate for all stages of prostate cancer combined is 98%, and the 15-year survival rate is 96%. I did not have any of the typical risk factors of the disease, other than age. 

Once I had full a complement of diagnostic data, we gathered at the dining room table and began weighing options for treatment based on longevity and quality of life. 

"Why you have cancer is a mystery, Jack, but not as important now as making some immediate decisions about the different treatment options that will yield the best possible results," said the urologist.

Making Decisions

I am fortunate that several of my intimates and close friends are physicians and brilliant scientists in medical research. As a group, my friends and I love and care for each other in pragmatic, immediate and forthright ways. Once I had full a complement of diagnostic data, we gathered at the dining room table and began weighing options for treatment based on longevity and quality of life. 

We are bold with each other. I asked for and received the benefit of their medical expertise and was given access to their collegial networks, all resonantly undergirded on the foundation of our mutual respect and affection. I answered their questions about my personal habits and heard medical terms about somatic functions rarely discussed over a meal. 

Memorably, I remember my friend Valerie, a GI physician, discussing the impact of different forms of radiation on my 'rectal vault' as she casually said, while dessert was served, "Can we open another bottle of wine?" 

Another of my great friends, Mike, chimed in, saying, "Jack, guess what?  Your privates are public."

Private parts. Public matters.

Jackson Rainer
Jackson Rainer is a board certified clinical psychologist living and working in Atlanta, Georgia and Tryon, North Carolina.  He may be contacted  by [email protected].
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