Salamander’s Tale

“It is not so much a matter of playing a good hand well; it is much more a matter of how well we play a bad hand.”

—Robert Louis Stevenson

I could now talk prostate cancer lingo with the best of them. My own hubris startled me. One cannot underestimate the impact of a death sentence or a castration sentence. Out of desperation can come a full personality change. Normally shy and retiring, I somehow found a way to take on an air of confidence in presenting crucial questions to busy experts.

My hubris had been helped along by positive reinforcement—read, Gerald Murphy. When faced with experts, I was able to seal over any discouragement and come across as a fellow expert who was simply picking their brain for a new insight or a new discovery. These contacts were often swift and to the point, unmemorable and mercifully brief perhaps for the physician, but extraordinarily memorable for me.

I may have been appealing to these experts’ healthy narcissism and their healthy desire to share with the world their ideas and inventions and breakthroughs. I was also appealing to their altruistic bent, their desire to help a young colleague. They could relate and identify with me, and if they had any sadistic bent, it was not visible in this context.

In some cockeyed way these prostate cancer experts had wandered into a career that catered almost exclusively to septuagenarians and octogenarians. They were catering to the anuses and penises of alter-kockers—a term from Yiddish that is sometimes defined kindly as “old defecator.” These physicians were probably overjoyed to encounter a youngish guy like me who did not reek of urine and feces, and who could take their insights and advice and run with these ideas, with the possibility, though improbable, for a long life ahead. Luck and skill and hubris—the very things I would need in short order.

The PSA continued to rise. By early 1992, three years after the initial early signs of a rising PSA, it was now up to 6.3, and I was getting a little more than nervous. Out of the blue, though—luck and serendipity are all-important in life—I got a call from my surgeon in New York City.

“Listen, two of my colleagues, researchers here, are beginning a study of monoclonal antibodies, to help in determining the whereabouts of prostate cancer in people like yourself with rising PSAs post-prostatectomy. You’re a perfect candidate for this research—you have recurrent disease but we have no idea where to find it. Your bone scans have fortunately all been negative, showing no evidence of disease. So, this study can be a very useful diagnostic test. And who knows? Eventually we may be able to use monoclonal antibodies as a treatment to attack the remaining disease.”

Sounded good to me. I was aware of the promise of monoclonal antibodies, a promise not truly realized at least partially until twenty years later. The premise was a reasonable one: Let’s find a specific antigen or protein from prostate cancer that can stimulate antibodies. Then let’s attach chemicals or radiation or viruses or bacteria to these antibodies that will go specifically to the cancer cells and kill them—without any collateral damage of killing healthy cells. Highly targeted chemotherapy or radiotherapy or pathogen therapy. In my case, though, they were only looking to see where the antibodies might be heading, without the antibodies having any killer capabilities.

I hopped up to New York and the researchers injected me with radio-florescent prostate antibodies with the hope that they would gravitate to the elusive cancer cells. Afterwards, the younger of the two researchers sat down with me after lunch. “Our study shows significant cancer cells in multiple lymph nodes along your abdominal aorta and along the carotid artery in your neck. You appear to have a great deal of disease.”

Subsequent CT scans and MRIs of these areas did not confirm any unusual lymph nodes. All the nodes along my aorta and carotid artery were small and unobtrusive, under one centimeter in width and length.

“We’ve arranged for a vascular surgeon here at the hospital to dissect your carotid artery this afternoon. A surgical suite is ready and waiting. We want to do this procedure as soon as possible. Despite the CTs and MRIs, we think you have real and genuine, though microscopic, disease, and we want to confirm the findings of the radio-florescent antibodies.”

Okay, you are scaring the shit out of me. These two researchers were convincing me it was essential to see where my rising PSA was coming from, yet I knew that dissecting a carotid artery was not without risk.

I quickly called my internist in Washington, DC. To my surprise, I was able to reach him directly, and I succinctly told him the story. He listened quietly, and after a brief moment of silence, he said, through seemingly clenched teeth—this is a guy I had never heard curse—“Get the fuck out of there before they kill you.”

I needed this swift and sober assessment. Anxious to please, I got caught up in the agenda of the researchers. Yes, boxers box, surgeons cut, and researchers do research. Like hedgehogs they know one thing very, very well. But they may not have the multiple interests and skills and sensitivities of the fox. My own survival was now diverging from the researchers’ desire to flourish in their careers.

In the twenty-three years since then, there have been no sightings of cancer cells anywhere near my aorta and carotid arteries.

Before rushing out of Manhattan, though, I followed through on a vow I made before the trip to use the time there as effectively as possible. I made an appointment with the purported king of prostate oncology at Sloan-Kettering Cancer Center, with the hope of just picking his brain and seeing what alternatives there were to castration.

Two hours after the designated appointment time, he raced into the examining room. “I already know a lot about your case,” he noted, much to my surprise. He had just had dinner with the two researchers the night before. “The best and most prudent course for you is immediate castration. There really are no other alternatives. There are some new interesting medications in the pipeline to induce a chemical castration. A new drug Casadex is coming out of England for that purpose.”

I was only half listening. Gerald Murphy’s words were swirling in the other half of my ears and brain.

In almost a throwaway line, he remarked, “There is an oncologist in Vancouver, British Columbia, who is doing some interesting work with an intermittent androgen blockade, an intermittent chemical castration. But you’re not a suitable candidate for that approach. Your cancer is too advanced and too aggressive, your PSA has risen too high and too rapidly, and now there is evidence of spread of the disease to the lymph nodes along your aorta and carotids. I really think you should have a surgical castration, to rid yourself completely and permanently of all testosterone.”

Fortunately Gerald Murphy was still swirling in my head. And who was this guy in Vancouver?

Permanent surgical castration eventually will go the way of leeches and other bizarre and foolhardy medical interventions. But bucking the medical establishment when it has a particular approach, a virtual ideology for understanding or treating a medical condition, is nearly impossible. The medical establishment may be wrong but it is never in doubt. Those same sadistic medical students who loved doing invasive procedures in the third year of medical school also seem to have the cockiness years later to establish the medical ideologies that control treatment protocols. One needs an iconoclast, someone who is thinking differently yet coherently, to buck the tides.

Nicholas Bruchovsky was just that iconoclast. As soon as I arrived home from New York City, I called him in Vancouver. An American-trained oncologist, Nick had been doing his research in cancer endocrinology in relative obscurity in the Canadian health care system, the equivalent of Siberia. He was delighted to explain his research to me over the phone, happy that someone was listening.

“More is not always more, more is not always better,” he pointed out. Less is sometimes more, according to what I now call the “wisdom of Nick.” “If castration works to eliminate testosterone as a growth factor for prostate cancers, then Western doctors tend to keep that intervention going indefinitely. But castration only works effectively for a matter of months or at most a few years. Eventually with testosterone gone, the cancer cells find a way to establish some other protein or hormone as a growth factor or growth stimulus. Huggins and Hodges realized that less might be better even in the 1940s. But everyone seemed to ignore that message.”

Yeah, bombs away. If something works, simply bombard the organism with more and more of that potent intervention. Heap it on, pile it up. Chemotherapy? Let’s do mega-chemotherapy, even if it means destroying the bone marrow and killing the patient. At least we’ve killed the cancer.

Nick seemed to get it: Permanent castration was not the equivalent of, say, the lancing of a skin lesion. Most of the rest of the medical establishment: No lumpectomies allowed, instead let’s remove everything—the breasts and the vaginas and the penises and, above all, the testicles.

“You’re an ideal candidate for this approach. You have PSA-only recurrent prostate cancer. There are no signs of any visible recurrence. And the evidence is that this intermittent chemical castration, this intermittent androgen blockade does no worse than a permanent blockade. And there is a very good chance it might do better in the long run than a permanent blockade. And the quality of your life . . .”

Say no more, Nick. Rarely is one approach infinitely better in its side effects than another approach. Let’s see: Zero sexual life for the rest of my life versus a sexual capacity for as much as two-thirds of the rest of my life. My penis put away for life or my penis imprisoned for eight-month sentences every two years or so.

Plus, we would be having fun fooling the cancer cells. They were fucking with me, and we would be fucking with them. Nick and I as co-conspirators: We’ll give those fucking cells all the testosterone they want and need in order to survive and thrive; then we’ll take away the testosterone and they’ll quiver and shrivel. Then, just when they are about to hunt around for some other substance to fuel their growth, we’ll hit them with a heavy dose of testosterone again. They’ll then stop looking for some other stimulus for their growth.

My interests and the interests of the cancer cells were actually in line: When they were shriveling, my testicles were likewise fizzling and my penis drooping. When they were blooming, my testicles were expanding and my penis was poised and proud.

A new kind of zero-sum game. A new kind of equilibrium, a matching of wits. You guys will eventually kill me but not without a fight. And both of us will survive, not necessarily happily all of the time, but we’ll both have what we want and need a good part of the time. Sometimes it will be win-win; then it will be lose-lose.

In some ways I might have had a competitive advantage. Even in the midst of castration, I had something remarkable to look forward to—a return to arousal and excitement and bliss. I had a will to live that would match the cancer cells’ will to live. Perhaps this was the message of Wilhelm Reich: A man without a sex drive, a man without orgasms, a man without romance, a man without dreams of sexual conquests, a man without a capacity to fully respond to his partner—that man may lose his will to live. As his testicles shriveled, so would he. Other forms of cancer as well as diabetes, heart disease, drug and alcohol problems, depression and suicidality—all of these maladies could kill him.

So, bring on that orgone box, bring back those orgasms, bring back that male rapaciousness. I was still alive and kicking. I would be buying some time in this equilibrium with my cancer, hoping for some new breakthroughs and inventions in treating the cancer, and looking for some greater competitive advantage while in my current steady state.

Helen was more than comfortable with this plan and with the wisdom of Nick. We would work together to find a way to make this temporary castration manageable. We had time to figure it out, to build more romance into our lives—the PSA had not reached a level yet for me to start the chemical castration, but that was coming soon, coming soon to a theater near me.

Yes, cool moss. When facing fierce fiery coals, think “cool moss,” and walk in a directed and purposeful way, and keep your eyes on the desired outcome without a sense of desperation and panic. Above all do not run; do not trip and fall. Keep your eyes on the prize of life itself and the prize of a soon-to-be staggered sexual vitality.