Going under the Knife
If all goes as planned, I will, in fact, be going under the knife on Monday morning. They will come for me here at the National Institutes of Health (NIH) in Bethesda, Maryland at about 7:00 a.m. By 8:00, I will be under anesthesia, and they will be positioning me – head down and feet up – on the operating table. Then, they will make seven small incisions in my abdomen, insert cameras and devices for cutting and sowing, and the fun will begin – as my surgeon, Dr. Peter Pinto, sits down at the Wurlitzer in the corner and begins the process of removing my prostate and the lymph nodes associated with it.
I am already on a clear-liquid diet, and the dread “bowel prep” looms on the horizon. I have had an EKG, an Echo Cardiogram, a chest X-ray, and a pulmonary exam, and I have spent the last couple of days cooling my heels in the hospital, working on my book on Sparta, and contemplating mortality. The odds are excellent that I will emerge from this ordeal incapable of further procreation but otherwise intact and cancer free. There can, of course, be “complications,” and none of them are pretty. Some of them you can die from. Others leave you impotent in the fullest sense of the word or permanently incontinent. It all depends on your health in all of its aspects when you go under the knife, on the effectiveness of the antibiotics, and on the skill of the surgeon. I will not tell you that I am glad that I am here. But a prostatectomy is a bit like old age. It is not so bad when you consider the alternative.
The truth is that I am lucky. One of my cousins, on my mother’s side, died of prostate cancer when he was in his early to mid-60s, as I am now. My brother had his prostate out nearly two decades ago when he was my age, and he is still going strong. If this operation goes well and Dr. Pinto removes all of the cancerous tissue, the odds are good that I, too, will still be alive and kicking in my 80s. Apart from chronic asthmatic bronchitis, for which there is now medical help, there is nothing else wrong with me.
But the real reason that I am lucky is that my condition was diagnosed early on. As longtime Ricochet regulars who read my post Prostate Cancer: New Procedures for Diagnosis – and Cure back in April, 2011 may remember, my Prostate Specific Antigen (PSA) level was quite low (ca. 1.07) but took a jump between December, 2009 and December, 2010 and was on track to double within an eighteen-month period – which can be a sign not only that one has cancer but that it is aggressive. Mindful of my family history and concerned about the welfare of my wife and our four young children, I called a distinguished urologist whom I have known since childhood and asked his advice. He consulted Dr. Pinto, who then invited me to join a study he was directing. Here is what took place in March, 2011:
On day one, the staff at the Molecular Imaging Program subjected me to trans-rectal Magnetic Resource Imaging (MRI) with Gadolinium. This involves the insertion of an endorectal coil into the rectum, the inflation of a balloon to hold it steady, and the introduction of an intravenous contrast material into one’s veins. In the course of the MRI, one is slid into a machine that produces a powerful magnetic field – where, from time to time for about an hour, one is assaulted by radio frequency pulses. With the help of sophisticated software, the technicians who operate the machine can produce a detailed picture of the prostate. And here is the kicker – if you have cancer, it shows up as a splotch in the picture, and those working with these procedures can grade any splotches they see with an eye to the likelihood that they are cancerous.
If nothing suspicious is found in the course of the MRI, that is the end of the story. If, however, there are suspicious splotches, one returns to NIH on day two to have a biopsy, which was my fate. Using sophisticated software, the technicians initially map the picture of the prostate produced by the MRI onto the picture produced by ultrasound. Then, guided by these images, a surgeon, performing the biopsy, samples the precise places where the MRI found suspicious splotches. To supplement this procedure, he then performs an ordinary biopsy, taking samples from the twelve sectors into which the ultrasound divides the prostate.
The first set of procedures is not a joy, but they are considerably less unpleasant than a colonoscopy; the second set involves some discomfort, but, at NIH, they use novocaine to deaden the prostate and reduce the pain. In my case, the MRI team identified five suspicious patches – three of them moderately likely to be cancerous, two of them worrisome but much less likely to be malignant. The biopsy revealed two minuscule patches that were cancerous. Each made up something like 2% of the biological material in the particular sample taken. In neither case was there any indication that the cancer is aggressive.
A year later – which is to say, this past March – I underwent another trans-rectal MRI. To all appearances, nothing had changed. Then, I underwent another targeted biopsy. This time, in a number of the samples, 50% of the biological material taken turned out to be cancerous. A couple of weeks after the biopsy, Dr. Pinto called to inform me of the results and to recommend intervention. Given my age (actually, he thought that I was in my early fifties) and my health, he thought that surgery was the best of the options now available, and he urged me to act soon. “Do it within six to nine months,” he said. “I would not wait a year.” I scheduled surgery with him at the first available opportunity.
There is a debate going on within the medical community concerning the PSA test. It is not an especially accurate indicator of cancer, and some think that too many biopsies are done and too many men have their prostates removed. Others, including people here at NIH, are firmly of the opposite opinion. They contend that, in the last quarter-century, there has been a dramatic drop in the number of deaths from prostate cancer. The reason appears to be that PSA testing, digital rectal testing, and biopsies – when these techniques are all in play – often enough enable physicians to detect aggressive prostate cancer early on. And, when early detection is followed by surgery or radiation, they can usually stop the cancer in its tracks.
The new techniques, being pioneered by Dr. Pinto and his team here at NIH, promise to identify the tissue that is suspect and to enable those conducting biopsies to hone in on the suspect tissue. When these techniques are sanctioned for general use, they should make early diagnosis easy, and they should then even more dramatically reduce the number of deaths resulting from prostate cancer.
Tomorrow, if I do not die under the knife, the odds are good that Dr. Pinto will remove everything that is cancerous and that I will get a new lease on life. I owe the fact that the odds are on my side to vigilance on the part of physicians and on my part. If the powers that be succeed in striking the directive that causes physicians to administer the PSA test on men over the age of fifty as a matter of routine and you are such a man, you should exert yourself and insist on having the test done, and – if there is any indication of danger – you should have a biopsy. In my case, the indications were not strongly indicative. At the time of my first biopsy, my PSA had actually dropped from its mildly but suddenly elevated level. And last December, though it had gone up a little, there was no dramatic change. If I am alive in five years, it will be because I was alarmed when I got the news in December, 2010.
One further word of warning. Genes may not be destiny, but, in these matters, they come pretty close to having that status. Know your family history, and take precautions. My father died of pancreatic cancer at the age of seventy-eight. Perhaps by the time I reach that age, there will be a regimen of treatment for that. If I get past this crisis, I will be alert.
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Comments:
Jul '11
Re: Going under the Knife
Paul, then I'm positive you'll do fine unless you have an extremely rare variant, which you won't have. God Bless you and your family. Please remember whatever initial side effects you get will lessen over time.
May '12
Re: Going under the Knife
Go in with a positive attitude.
I learned that from a former MP who underwent a heart transplant in his 50's (when his youngest son was only 2 years old) and lived another 4 years (long enough to take his son on his fishing trip on the Chesapeake Bay - where his son caught a big flounder).
Mar '11
Re: Going under the Knife
God bless you and your family, Dr. Rahe.
May '12
Re: Going under the Knife
You're in the prayer rotation here too. Having been under the knife not too long ago, I can empathize with you, but it's always good to know that you're asleep during the worst of it so it's just not your problem any more. As I told my family: don't worry about me, pray for the surgeon!
Feb '11
Re: Going under the Knife
I wish you a successful procedure and speedy recovery.
Apr '11
Re: Going under the Knife
There has never been a time in history better than today for surviving cancer. We are all pulling for you and wishing for a speedy recovery.
Aug '11
Re: Going under the Knife
Dr. Rahe:
My father in law just visited us from CT. He's a vigorous 83, no signs of slowing down, still keeps up the family home. His prostate was removed when he was in his early sixties, he underwent a series of radiation treatments post-op and he suffered no long-term ill effects. You have the luxury of better surgical methods, better treatments and better meds. No doubt, you will recover completely. As re-insurance, I'll mention you to the BIG GUY this morning.
God Bless,
DK
Edited on June 24, 2012 at 7:58pmMay '10
Re: Going under the Knife
I echo the same good wishes and prayers here from the official Romney Endowed Chair of Managerial Progressivism.
The key point to remember about the naked lies and flaws of the Berwick-inspired studies recommending against PSA screening is hidden in your narrative. The point in time snapshot is not what offers the important information- it is the trend that usually matters. And to detect a trend, you need regular screening even if IPAB thinks it might cost something at some point.
Costs get fixed when medicine is retail, the ambulance-chasers are locked up, and licensing restrictions are reformed.
Nov '11
Re: Going under the Knife
Godspeed, Paul. May a full and rapid healing be yours,
(Rabbi) Ploni
Jan '11
Re: Going under the Knife
Good luck on your surgery and look forward to reading more of your posts.
Re: Going under the Knife
Duane Oyen
I echo the same good wishes and prayers here from the official Romney Endowed Chair of Managerial Progressivism.
The key point to remember about the naked lies and flaws of the Berwick-inspired studies recommending against PSA screening is hidden in your narrative. The point in time snapshot is not what offers the important information- it is the trend that usually matters. And to detect a trend, you need regular screening even if IPAB thinks it might cost something at some point.
Costs get fixed when medicine is retail, the ambulance-chasers are locked up, and licensing restrictions are reformed. · 20 minutes ago
Amen. Knowing the trend is your friend.
Dec '11
Re: Going under the Knife
Thank you, for giving us this chance to show our love and concern. Others have expressed my feelings better than I would be able to so I will end the comment here.
Nov '10
Re: Going under the Knife
"Again I say unto you, That if two of you shall agree on earth as touching any thing that they shall ask, it shall be done for them of my Father which is in heaven."You have a lot more than two people praying for you, Paul.
May '10
Re: Going under the Knife
Adding my prayers for you and looking forward to seeing you in the fight this fall and beyond.
Sep '10
Re: Going under the Knife
God be with you, Professor Rahe. I will add my prayers to the growing number.
Nov '11
Re: Going under the Knife
Good luck, friend.
Dec '10
Re: Going under the Knife
Paul, Thanks for this post. People need to know the importance of the PSA test in detecting prostate cancer. Nineteen years ago, while in my early 50's, it was this test that led to a diognosis of the cancer in my prostate -- subsequently removed. At my annual follow-up with my urologist/surgeon I asked about this PSA controversy. His comments indicated that he would be in complete agreement with the doctors at NIH that this test is an important and vital diagnostic tool.May your recovery be swift and uncomplicated. You've been added to our prayer list.
Jun '10
Re: Going under the Knife
You are a brave man, Professor Rahe. It is humbling to know you care enough about us at Ricochet to share this very personal life event with us. As with everyone else, your success in overcoming this issue of health will be a constant thought in my mind. I pray that it helps. Just to say, I know of others who have had this issue and overcome it with no further complications.
Re: Going under the Knife
Many thanks to you all -- and do not neglect the PSA test. It is not much good, but it is the best thing that we have right now.
Aug '10
Re: Going under the Knife
If you don't mind the odd songified prayer before surgery (I always appreciate a bit of lighthearted humor before grim medical goings-on):
Heavenly Father, we thank you tonight
For all your blessings
You said, “In all things give thanks”
So we wanna thank you tonight
For these medical tools
That you’ve brought before us
Thank you for scalpels that make small incisions
Thanks for anesthesia
And most of all we thank you for
Dr. Pinto's Wurlitzer
Removing the cancer he sees before him tomorrow
Thank you for microsurgery progress and laparoscopic tubing
Thank you for medical robots and laser therapy
That bring performance and power to the OR...
Boogity, Boogity, Boogity, Amen!
Bless the doctors and use them tomorrow
Boogity, Boogity, Boogity, Amen!
Silly song, but serious prayer. Godspeed, Dr Rahe.