CHAPTER 11

A Funny Thing Happened on the Way Back to Potency

“Comedy is simply tragedy plus time.”

Unknown (often Attributed to Mark Twain or Carol Burnett)

Cancer is a number of powers mightier than a wart.

My friends and colleagues started sending me journal articles with well-designed studies noting that visualization could help rid the body of warts and other minor viral maladies. Visualization techniques could also manipulate the extent of an inflammatory response after a cut or laceration. Through visualization we could, almost miraculously, either increase the inflammatory response or diminish it.

Ah, the powers of the human mind—a beautiful thing to contemplate. Let’s party, let’s celebrate, let’s rejoice at the wonders of the human spirit, let’s praise man’s capacity to recover and regenerate. Prostate cancer was beating a hasty retreat, and my mind was working wonders on my body.

It was October 1989, five exact years since diagnosis and initial surgical treatment. I was feeling damned good. The surgeons kept reminding me that they had gotten it all, and for good measure we had killed any wayward cancer cells with 6600 rads of radiation. No signs of recurrence. Plus, I had managed to defy the laws of nature by re-establishing some modicum of potency and sexual functioning, with the promise of more to come.

I was continuing with regular acupuncture, having learned to administer the needles myself, with the help of Jing Wu. Monkey see, monkey do—needles into the scar tissue of the lower abdomen and pelvis to help break up that scar tissue. Magnificent visualizations of my magenta, my pink and my purple immune cells grabbing and dismantling any black and yellow fly-like cancer cells in my Venus flytrap apparatus. Magnificent visualizations of the hardened brown scar tissue becoming pink and pliable and perfused. Magnificent experiences of sex with Helen, my libido and lust as strong as ever.

W. H. Auden again: “Lust is less a physical need than a way of forgetting time and death.” I had forgotten time and death. I was in the moment, and moment after moment was magnificent.

My swagger was back. Prowess and pluck and pride were words I became reacquainted with. I left the University of Maryland to become associate director of the newly redesigned Georgetown University Counseling and Psychiatric Service, and I reassured my new colleagues and employers that I was healthy, having recovered from my “bout” with prostate cancer. My cancer had not been a secret. I had written about it in the newly established health section of the Washington Post, and Helen and I had been the subject of a profile on the “sandwich generation” in the local glossy Washingtonian magazine a few months prior—with reflections on our aging parents and our young children and my own health problems.

Everything seemed to be in sync.

Except, there were some flies in the ointment. The Venus flytrap had not been able to catch all the flies.

In December 1989, the surgeon in Manhattan called me a few weeks after our regular yearly follow-up appointment.

“Your PSA is rising,” he soberly told me.

“What the hell is a PSA?”

“This is a new test, the prostate-specific antigen, something we can detect in the bloodstream. We’ve been experimenting with its use here. We didn’t tell you at the time, but we’ve been measuring your PSA for the past two years. In December 1987, two years ago, your PSA was undetectable. Last December it had risen to 0.6, a borderline figure that could possibly have represented a recurrence. But since the test is so new, we didn’t know how to interpret it, and I didn’t want to scare you unnecessarily. But now the PSA is 2.1. Since you have no prostate, you shouldn’t have any prostate activity anywhere in your body.”

He could have added, but he did not, “So, now it’s time to scare you.”

“Isn’t it possible that these are normal prostate cancer cells that have come back to life?” I asked, hopeful, thinking all too bizarrely and optimistically that my visualizations and acupuncture created some immaculate conceptions. Denial is a beautiful thing. In this case it did not last for long.

“No. No chance of that.”

When these surgeons said they got it all, doubt never entered the picture—even when they did not get it all.

“I want you to come up to New York. We’ll put you under general anesthesia and look in the area where the prostate used to be and see if we can find any palpable evidence of the cancer. We can always re-treat if we find the cancer cells in the prostate bed.” Little did he or I know at the time that a PSA of 2.1 generally meant microscopic cancer disease, not something that would be visible in a surgical observation. Again, in 1989, no one seemed to have a clue on how to interpret the PSA.

He insisted, based on the scientific literature that early intervention for metastatic prostate cancer was crucial.

Yeah, early intervention—a euphemism for surgical castration—the cutting off of my balls. All that effort to save my potency, to save my pelvis, to save my life as a man—all down the drain.

I knew enough from medical school to recognize that the only treatment available for metastatic prostate cancer that has spread systemically to lymph nodes and bones and into the bloodstream and beyond the prostate, was castration. In 1941 Charles Huggins and Clarence V. Hodges discovered that prostate cancer growth could be slowed or in some cases eliminated by the removal of testosterone. Male hormones, otherwise known as androgens, were a crucial growth factor for prostate cancer. Androgen deprivation could stop prostate cancer in its tracks, at least temporarily. Huggins and Hodges had won a Nobel Prize in medicine and physiology in 1966 for their discovery.

Without the presence of testosterone, most prostate cancer cells shrivel up and die. But eventually they will find another growth factor to help them propagate and proliferate. These cancer cells have a mind of their own, the same desperate desire to survive and reproduce that I had. A formidable opponent.

Eunuchs – young boys in various cultures who have been castrated in order to make them into couriers and servants and guardians of women and high-pitched singers – never develop prostate cancer. They are immune because of their inability to produce testosterone in their castrated state. I on the other hand was facing the worst of all worlds—being a eunuch and having prostate cancer.

A new kind of castration anxiety. A literal castration terror. Sigmund Freud coined the term, castration anxiety, as a metaphor for the struggles every adult male and female, gay or straight, feels in an ongoing relationship—the struggles in being able to combine a sense of grounding with a genuine sharing of passions in a steadfast relationship. Many of us can have one or the other, but we can feel swallowed up in a relationship—we lose ourselves, we lose our solid sense of identity—when we try to establish both facets in a relationship. It is what’s called the classic Madonna-whore complex, except it occurs just as readily for women as for men, just as readily for gays as for straights. Some of us turn to our partners for grounding and support and nurturing. Others of us turn to our partners for the relief of unbearable sexual urges. Often the twain never meet—or at least do not meet in the same partner. We turn to one partner for grounding and support and to another for the sharing of passions—a phenomenon we can observe in presidents of the United States, in governors of New York, a ubiquitous phenomenon.

Freud’s choice of words was unfortunate. Being swallowed up, losing one’s sense of self, being overwhelmed by the demands of a relationship: None of these are akin to castration, especially for women.

Let’s deal with the real deal, not the metaphor. No metaphors using the notion of castration are allowed in the late twentieth and early twenty-first centuries. Huggins and Hodges with their Nobel Prize-winning research in 1944 made sure of that. Now prostate cancer and real castration go hand in hand.

The surgeon in Manhattan made that case stridently. After poking and prodding and prying around in the soft tissue around my anus (I was under general anesthesia), he later told me that castration was absolutely essential.

“Even though we haven’t found any clear-cut cancer cells, it doesn’t mean the cancer isn’t there. All the literature indicates that the sooner you get castrated the better. Waiting will only lead to your dying sooner.”

He handed me some journal articles from the New England Journal of Medicine, which I looked over halfheartedly. I got the gist: In one way or another I would be dying very, very soon—either a metaphorical death by a literal castration or a literal death via metastatic prostate cancer.

“You have two choices—a chemical castration using medication to shut down your hypothalamus and pituitary and by extension your testicles, or a surgical castration. I can arrange to do the surgical castration here at the hospital. Just say the word.”

I was speechless.

Eventually, I simply said, “Let me get back to DC as soon as possible. I’ll talk to Helen, I’ll think it over, and I’ll let you know. Don’t schedule the surgical castration quite yet.”

All I knew was that I was fucked. The classic Hobbesian choice: I will not be able to fuck if alive, or the prostate cancer gods are really fucking with life itself.

“I’m taking some time off from work,” I told my colleagues at Georgetown University. “It could be a few days, a few weeks, I don’t know how long it will be.” They all seemed to be okay with it. I had told them about some “major complications” with my prostate cancer.

I gathered around my closest friends, along with Helen, and explained my dilemma: “It seems like surgical castration or chemical castration is inevitable—sooner rather than later according to everyone I’ve spoken to so far.” We were sitting in my downstairs office at home, trying to troubleshoot. We all knew the trouble, but none of us had any bullets to shoot with.

Finally, in the midst of a despairing silence, one of my friends piped up, “You’ve gotten to this point by talking to the best minds in the medical business. You’ve never failed to get alternative viewpoints and recommendations. This is not a good time to drop that approach.”

This idea broke the impasse. Speaking to someone, an expert, anyone, had to be better than sitting there in a helpless castration-panic mode.

I got on the horn trying to figure out how to reach Gerald Murphy, who along with his colleagues had developed the prostate-specific antigen, the PSA, a few years before in a lab in a hospital in Buffalo, New York. If anyone might know how to interpret the PSA of 2.1 and what to do about it, he would be the man.

It took me about forty minutes to track him down—remember, this was long before the Internet and search engines. Murphy, it turned out, moved from Buffalo to Atlanta and was now working at the Center for Disease Control (CDC). Amazingly, I was able to reach him on my first try.

My voice quivering, my speech pressured—with my cascading terror I barely had had any sleep for several days—I summarized my story and current predicament, with my rising PSA and a normal bone scan.

I heard giggling on the other end. Is this guy some imperious and insensitive jerk who thinks he is a gift from the gods to our lowly planet?

Boy, were my initial impressions wrong. I never had the pleasure of meeting Gerald Murphy in person before he passed away eleven years later from a heart attack while attending a conference in Israel, yet at that very moment, Murphy actually saved my life. He saved the basic fabric of my life—my work life, my family life, my marriage, my life as a man. He gave me a reprieve from castration, from the testicular guillotine.

“Listen, I’m only laughing because of the unnecessary panic in you and your doctors. Relax, go back to work. Go back to your office and help some people who truly need some help, unlike yourself. You’re fine. You’ll have a nice decent life. There is absolutely no need to panic.

“Here’s the thing: The PSA is a relatively new test as you know, and practitioners have not figured out how to use it and interpret it. I’ve had a number of post-prostatectomy patients whom I’ve followed for several years with experimental PSAs, before the PSA became a commercially available screening test. Some patients have had their PSAs rise to 18 or 20 without any evidence of palpable or visible disease. Your PSA will probably rise slowly over the next few years. The PSA of 2.l, without much doubt, reflects some existing disease, but the disease load is small and inconsequential. In a few years when the cancer becomes more consequential, you can consider some interventions.

“And, who knows?” he reminded me. “We might have some more benign treatments than castration in a few years.” I wanted to tell him I could barely imagine any treatment being less benign than castration.

Dr. Murphy assured me that I could safely buy more time. “It’s foolish to treat a blood test, particularly a blood test whose implications are not as yet known. It’s especially absurd to treat a blood test with a brutal assault on your testicles!”

My thoughts precisely. Gerald Murphy and John Maynard Keynes on the same wavelength. No one can predict the impact of new ideas and new inventions. Let me just stay alive to be able to see those new inventions and new interventions.

Murphy’s calming and reassuring words ring loud and undiminished thirty years later, and they will remain so for the rest of my life.

One of the most gratifying parts of being a physician is the impact we can have on others when we least expect it. A simple suggestion, a throwaway comment, a brief insight—we might find out years later this comment made a major difference in a person’s life. It is all in the timing and in the degree of distress and one’s corresponding openness to a new perspective. My conversation with Gerald Murphy had all three elements. I was open to anything that provided a counterpoint to the terror-inducing agenda of castration.

Although I never spoke to Murphy again, even to thank him profusely, his comments have allowed me to ward off the persistent and insistent suggestions over the last twenty-five years to have my testicles removed. One academic oncologist a few years later had the hubris to tell me that emotionally I would be better off castrated. Surprised that I had not already succumbed to a chemical or surgical castration for my long-term survival, he added, “With castration, at least you never have to worry about your potency, you never have to worry about getting it up. If you don’t have any libido, you don’t have to worry about performance. It makes thing less complicated.”

Come again? The ultimate Orwellian doublespeak. How crucial is it to get a second or third or fourth opinion when you recognize how crazy some of my medical colleagues are? Not crazy in the conventional sense, but how distorted their views may be because of their backgrounds and their own traumas and their own personal crises and their own personal way of relating to the world. Helen had pointed out to me repeatedly in medical school that no sane person would voluntarily go to some of my classmates once these classmates became physicians. What do the comments from the oncologist above tell us about his romantic and sexual life, about his desires for intimacy, and about his desire to satisfy a partner as well as himself? Only later did I find out he was going through a messy divorce at the time.

When we encounter the Gerald Murphys of the world—maybe if I had gotten to meet him and know him, he would have turned out to be a crazy old coot himself—all we can do is savor the encounter, and hold onto it for dear life.

Over the years I have grown to love the PSA. Patients with breast cancer and other cancers would love to have a similar marker. The PSA is indeed specific to the prostate; its source is the prostate and only the prostate. When the prostate has been removed or obliterated by surgery or radiation, there should be no PSA circulating in our bloodstreams. It is a perfect marker for determining whether a recurrence has developed and how fast it is growing.

At the same time, the PSA has been a mixed blessing for men who still have their prostates. It has become a ubiquitous screening tool for determining whether a man might have prostate cancer to begin with. A PSA above 4.0 has been arbitrarily set as abnormal. Yet we see plenty of false positives—men who have a PSA well above 4.0 with no sign of malignant disease, and some false negatives—men who have a PSA below 4.0 who may be harboring a cancer.

And, if a cancer is found, using the new fiber-optic cystoscopies not available in 1984, we still do not know which ones will remain localized in situ cancers and which ones will become aggressive and metastatic.

Gerald Murphy was correct twenty-six years ago: We still do not know how to interpret the PSA, although we have a better understanding of its meaning after the prostate has been removed.

In the meantime I had the man, the expert on PSAs in my hip pocket, in my very being, reinforcing the idea that castration would not be imminent. Yet I knew that castration could be put off for only so long. How would I cope with this eventuality, especially after years of putting forth a special effort to regain my sexual energies and my sexual capacities, and love and romance?

It did not take a long time to find out.