Flossing for the future

Up until four months ago, my standard answer to the salutatory question, “How are you?” was “Okay–so far.” I was regularly accused of cynicism, but I defended my answer with a simple realism. We are all mortal, we are all going to die. I figured that a good life, one of health and happiness, was one where I could honestly say, “Okay—so far” right up until a nanosecond or so before my death.

Four months ago, I got my first prostate specific antigen (PSA) test. This is a blood testfor a protein produced by the prostate gland. High levels of PSA in males indicate prostate disease. Urologists recommend that all men get a PSA test once a year, starting around the age of 50, or even earlier if there is a family history of the prostate cancer.

To the best of my knowledge, I come from a cancer-free male lineage. But since I broke the five-oh mark a while ago, it was time for my inaugural PSA test. Although I figured that being 50 and otherwise in good health meant that my final, fateful nanosecond was decades away, a PSA score of 19 quickly forced me to revise that perspective. A PSA of 19 is four to five times above normal for otherwise healthy males of my age.

My PSA result led to further tests and a positive diagnosis for prostate cancer, followed quickly by surgery to remove my tumorous organ. I now wait anxiously to see what happens to my PSA level. A variety of factors, however, such as my high pre-operative PSA score, suggest that the cancer may have spread. I have had two post-operative PSA tests and, although low, my PSA titre is neither negligible nor declining. Thus, I do what most men do who have had a positive diagnosis for prostate cancer–anxiously wait. I wait until my next PSA test.

I am trying to be optimistic. But, as a scientist working in a medical school, I know too much. I know that the only way I can have a measurable amount of PSA in my blood is if I still have some prostate cells in my body. There is a slim chance that those cells might be mature, responsible (benign) prostate cells in the former neighbourhood of my prostate gland. Perhaps they managed to keep their heads down when the surgeon swung his blade. But more likely any prostate cells left in my body are immature, irresponsible and adventurous ones that have taken to the road. It only takes a single rambunctious, adolescent prostate cell camped out in the hinterlands of one’s body to have the beginnings of incurable metastatic disease. I now find the simple question, “How are you?” a philosophical challenge.

How should I reply? Does honesty matter in answering such a question? The scientist inme wants to answer accurately, but honesty here cheers up no one. “Are you feeling better since your surgery?” is another common question that challenges my scientific literalist leanings. Since I had zero symptoms of illness before my first PSA test, how could I seriously claim that I feel better from the surgery? As I stand in front of my mirror each morning I am torn between wallowing in despair (I’m too young to die) and trying not to think about how I might react to a high PSA score on my next blood test. Should I even bother to brush my teeth or floss?

I never was an obsessive flosser, but now I force myself to do it every day. My gums are fine, so I floss not for the here and now, but for the hope of a future. I do not floss just so that my mouth will look good when I’m forced by social circumstances to smile and lie, “Fine, thank you, and how are you?” I floss instead to affirm that my final moment shall not be today, nor tomorrow, or even next week.

One of the odd things about the recent advances in the diagnosis and treatment of cancer is that rather than dying quickly, or in great pain, many of us with incurable cancer, will nevertheless be symptom- and pain-free for several years before the disease overtakes us. Fifty years ago, people had to feel sick before the doctors told them that they had an incurable disease and were going to die. Now, through the wizardry of tests like the PSA, we can get a fateful diagnosis when we otherwise feel perfectly fine. We look good, we feel fine, yet the tests proclaim our impending death. Modern medicine has provided us with prolonged life, but not one full of health and happiness by my definition. Whereas cancer patients used to suffer, we now more often endure the doctor-declared inevitable.

For so many of us, with slow-growing but nevertheless incurable cancers, what we have to endure most is the waiting, waiting for our next diagnostic test. We do not suffer pain, but we do become weary from the waiting. Every time someone asks us “How are you?” we are reminded of the upcoming test that will tell us how quickly the killer inside us is advancing. To us the real question is not “How are we?” but “How are we enduring the slow, silent siege?”

My revised goal in life is to do something each day that pertains to the long-term future — as much of a fantasy as that may be–and not just to the days and weeks immediately before me. Now, when I am asked “How are you?” I smile and, in so doing, show my modest success in overcoming the wait. I smile a big toothy grin and like to say “I’m still flossing.” To those who have never been diagnosed with cancer, I may no longer seem cynical, but instead a bit insane. But those who share my diagnosis smile back. They know exactly what I’m talking about.