Thursday, February 26, 2009

Health Care and Uncertainty

Having dwelled on the question for about a week, I have decided that I shall try to apply my own "author's voice" to what is likely to be an unfolding narrative of my own health care. When I alluded to this topic last Saturday, I only suggested the key points leading up to my current position in the flow of this narrative. I shall now try to review these points more concretely and systematically.

During my annual physical in the fall of 2002, my primary care physician detected a rise in the level of the prostate specific antigen (PSA) in my blood. He said that the value was right on the edge of being serious; but, because the level had been so much lower in past blood tests (from 1.5 to 4.5), he recommended that I see a urologist. The urologist basically agreed with my primary care physician's assessment and scheduled a biopsy, whose results revealed prostate cancer. (For those interested in such details, the Gleason grade in left and right prostate was 3-4.) He recommended the surgical procedure of a radical prostatectomy (during which he would also repair hernias on both sides, which he had detected during his examination); and, as I wrote last Saturday, I began to prepare myself with background knowledge from both objective and subjective sources.

During the surgery, the prostate, its seminal vesicles, and the bilateral pelvic lymph nodes were removed and sent to Pathology for evaluation. That evaluation concluded that there was little evidence that the cancer had spread: "safe" margins in the prostate itself and no detected cancer in the other removed items. To confirm that the surgery had been successful, I was instructed to have a PSA blood test every three months. I did this for two years, after which PSA continued to be checked annually. The value was always "negligible," which usually meant less than 0.1, reflecting the specificity of the analytic equipment.

The first change in this routine surfaced during my annual physical this past October, when the PSA came in at 0.1 (without the less-than sign). My primary care physician decided this required a second measurement, and a month later PSA was up to 0.2. This is when I made arrangements to consult a urologist once again. He recommended that I schedule an ultrasound examination preceded by another blood test; so he would have an up-to-date PSA measurement at the time of the ultrasound. The blood test was performed at the very end of January, prior to the ultrasound at the beginning of February. This time the level was 0.17 (but the measurement equipment was from a different laboratory than the one used for previous measurements). The ultrasound revealed a small region in the (former) prostate area that was "different" from the neighboring tissue (with no clear interpretation of what it actually was).

My urologist decided that radiation would be the wisest course of action and made arrangements for me to see a radiologist. That session took place last Friday, and the ultimate recommendation was that I should go ahead with treatment. Everyone in the session (the radiologist was assisted by two residents) kept stressing how small the affected area was, but they all agreed that this made it all the easier to deal with that area with low risk. This will involve (as I recall) about 38 daily sessions (Monday through Friday), each of which lasts about half an hour. This is preceded by a fair amount of preparation and planning in the interest of making the application of radiation as focused as possible. My urologist has to inject some markers that delimit the border of the tissue needing treatment, basically using the same sort of equipment that was employed for my biopsy (but going the other way). These markers are detectable by CAT scanning. Once the markers are in place, they schedule a CAT scan and develop a "map" for directing the radiation beam. The side effects are supposed to be minimal; so I shall probably be able to walk to my treatments (which takes less than half an hour from where I live). Because of all of the prerequisite planning, I am not sure when the actual treatment will begin; but that is where things now stand.

Being more specific about the side effects, they have to do with unanticipated tissue damage from the radiation source. Various sites along the urinary tract are in jeopardy but are rarely affected. The symptoms can go in either direction. Some damage leads to reduced urine flow, resulting from congestion that can be cleared by either medication or a catheterized balloon (like clogged blood vessels). The other extreme is incontinence. I have already filled out two questionnaires about my urination habits, and I expect that I shall receive many more of these in the course of the treatment.

I have to confess that I find the whole process pretty awesome. It gives me a sense of just how much radiation therapy has improved as the technicians have better ways to see what they are doing (so to speak). My biopsy procedure was tolerable but hardly enjoyable; and I cannot expect this "marking" process to be any better. However, that is the only invasive part of the whole experience. Obviously, I shall have to rethink how I plan my days during the treatment period; but that is not much of a problem. On the whole I feel pretty comfortable with the staff who will be involved in this whole episode, and that is what counts the most.

Given what I have been told, I do not anticipate that this procedure will interfere with my writing habits (just as it should not interfere with my preferred habit of getting around by walking). Nevertheless, there will obviously be various elements of the routine (such as the overall structure of my day) that will be impacted. True to my own beliefs, I shall do my best to provide an account that does justice to my objective, subjective, and social worlds in equal measure; but I am not quite sure how successful I shall be in dealing with myself as my primary subject matter!

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