The Ride (part 2)

There is this guy, George (my wife refers to all of her clients as George, or Georgette if they identify as female). He is definitely George, as will become obvious. And he’s not my wife’s client. I just borrowed the name.

George was planning a marathon athletic endeavor and thought he would visit his PCP (primary care provider) for a checkup, specifically to be sure he could embark on this months-long endeavor.

The good doctor suggested a PSA (prostate-specific antigen) test, as George was of a certain age. They discussed the pros and cons. (It is not a particularly reliable nor specific [despite its name] test and can result in unwarranted worry.) Please note that nothing in this post should be construed as medical advice. If you have questions or concerns, consult your primary care provider.

The result was worrisome (a greater than 50% chance of cancer) and the doctor thought George should see a urologist. The urologist ordered another test, which yields a ratio of free to total PSA. This shows a percentage chance of cancer if the overall PSA level is in the grey area. This again showed a high probability of cancer. Looking at the two tests, the doctor told George he had a >60% chance of having prostate cancer.

The next step was a prostate biopsy. This involves the rectal insertion of a small tool which snips out 12 pieces of tissue. If you imagine a clock face, one snip is taken at each hour mark. The theory is that, if there are cancer cells present, you’ll find some in at least one of those twelve samples. The test has a couple of side effects. George would likely pee blood for a few days and he might not want to sit on a bicycle seat for a while. If his marathon athletic endeavor were to include any time on a bike, doing this test while in training might not be the best idea.

George and his urologist talked it over and decided there were three possibilities: 1) George didn’t have cancer, and the test would keep him off his bike long enough to disrupt his training, possibly throwing his trip into jeopardy; 2) George did have cancer, but it would be a slow-growing cancer. (Hence the oft-heard “prostate cancer is a cancer you will die with, not of.”) Again, his trip would be in jeopardy for no good reason; 3) George had a fast-growing and aggressive cancer. He would need serious interventions which may include chemo, radiation, and surgery. His trip definitely would be canceled, likely forever.

George decided that what he didn’t know wouldn’t hurt him. If 1) he had no cancer, he didn’t want to lose the chance to embark on this endeavor. If 2) he had a slow-growing cancer requiring no treatment, he didn’t want to waste his training. If 3A) he was going to require extensive treatment, or 3B) he was going to die soon anyway, he didn’t want to miss out on this (now clearly once-in-a-lifetime) opportunity. His doctor agreed that he could go on the trip and come and see him after it was over. George told no one of this, not seeing any reason to worry others.

He went on his marathon athletic endeavor (which might be compared to a coast-to-coast bike trip), and went back to the doctor afterward. They repeated the PSA tests. It now showed a 20% chance that he had cancer. A year went by. The numbers were back up again. He had a prostate biopsy. He peed blood, he stayed off his bike for a while, and the result was negative. He didn’t have cancer.

Why did the test show he had a 60% chance of cancer before the trip and 20% chance after? Did a marathon athletic endeavor cure him of cancer? Not likely. The doctor said that inflammation could cause a false positive. Would sitting on a bike seat for two months make inflammation in that region more or less likely? Well, more, it seems. Evidence is inconclusive – the best evidence we have (a meta-analysis of multiple studies [Prostate Cancer and Prostatic Diseases, 2015]) shows no correlation between bicycling and elevated PSA. So why would he have inflammation before and not after? The doctor couldn’t say.

So what is this prostate cancer thing? And why is it so hard to detect? The symptoms look a lot like the symptoms of BPH (benign prostatic hypertrophy). That just means your prostate got bigger but isn’t harmful. BPH is considered a normal part of aging. The symptoms are things like: needing to pee more often (including waking up multiple times during the night); incomplete bladder emptying (therefore needing to pee more often – maybe even peeing, going back to bed, and getting right back up to go finish the job); urinary urgency – having to pee right now.

The National Cancer Institute says there were nearly 200,000 new cases in 2020, with more than 33,000 deaths. Prostate cancer is the second most common cancer in men (after lung cancer) (World Journal of Oncology, 2019). The incidence is higher for Black men.

Side effects of treatment may include urinary incontinence and erectile dysfunction. There continues to be controversy over whether men should be tested and, if cancer is detected, if they should be treated.

The Carbone Cancer Center performs research and treatment. One of the trials is known as the International Registry to Improve Outcomes in Men with Advanced Prostate Cancer (IRONMAN). Seems fitting for George, eh?

Prostate cancer tends to be ignored because it is “seldom” fatal – tell that to the 33,000 men who will die this year. In September I will be riding to support the Carbone Cancer Center to help people like George. Please join me in donating at: https://runsignup.com/half-fast. Thank you. (Since this is not a scholarly article, citations are incomplete. Ask if you want more detail.) (This post dedicated to KR2 and “George”.)

Cyclocross commute

To get to work this morning, I had to dismount and carry my bike through this downed tree. That was the easy part.

The ride home was into a 20 mph headwind with a temperature of 40 degrees (32 km/h and 4.5 degrees C), with rain driven by that wind. Since last night’s ride for fun was in ideal conditions (70 degrees, low humidity, breezy), I have nothing more to say about that.

And to think that, three years ago, I did this for fun.

This is how we looked at lunchtime of a 103 mile ride in the rain at 40 degrees F. Still smiling. You can’t see the bread bags on Ally’s feet, as she didn’t have neoprene shoe covers. And, yes, Ed was crazy (or ill-prepared) enough to be riding in shorts. (Photo from CycleAmerica Facebook page.)

Speaking of fun, Cycle America will be riding coast-to-coast again in the summer of 2022. The trip leaves from Seattle on Father’s Day and arrives in Gloucester, MA on August 20. The total cost (which includes 3 meals/day on riding days, and a place to pitch your tent or a gym to lay your sleeping bag) is $7415 until June 18 (one year before departure). Meals are on your own on rest days (one per week) and you’re on your own if you stop for espresso or beer. You can stay in motels some nights if you need a bed. That costs extra. More information at CycleAmerica.com.

Noluck

In a normal year, this would have been the first Wednesday Night potluck. I would have brought a rhubarb pie. Dave would have brought his famous braised asparagus, with cayenne and lots of garlic. This is not a normal year. While it was billed as a potluck, I saw half a dozen people at the park shelter. Too rich for my blood and, it appears, most others’.

The ride starts in Blue Mounds and immediately drops downhill to Tyrol Basin. With names like “Mounds” and “Basin” you could have guessed what direction we ride. In those first few downhill miles, it is best not to think about the fact that you will have to go back up at the end. Enjoy it while you can. The good news is that it’s not four miles back up. The bad news is that’s because the other side of the hill is steeper.

From Tyrol Basin the route follows the route of the Wright Stuff Century for a few miles, so they are roads filled with memories. We climb the famed Fesenfeld Road. I always know I’m near the top when I see this giant oak. One advantage to riding alone is that this is the first time I have stopped to take a picture of it.

From this tree there is a bit of up and down before a screaming downhill into a gentle left hand bend. The only problem is the traffic coming from the other way around that bend. Some of them might turn left across your path. Today the pavement is damp in the shady areas, which tend to be the downhills. Feeling the water sprayed onto your legs by the front wheel is a hint to feather the brakes.

In the next valley I met two friends in a field. Right after I took the picture, the sheep started over toward the fence, whether because it likes human company or thought I was coming with food, I don’t know. Not wanting to come between friends, I cross the road to shoot the historical marker.

At the midpoint of the ride we reach the lowest elevation. While it has been up and down to here, it has been mostly down; meaning from here it’s mostly up. There is a six mile lead-in to the infamous Mounds Park Road; six miles slightly uphill and usually with a headwind. Nothing like reaching the base of a climb already tired from six relentless miles – you can never stop pedaling for those six miles. Today the headwind was brisk, but I got lucky. A group of four strong riders overtook me at the beginning of that stretch. I tucked in behind and we rode it together. I took the last pull before the turnoff, so I paid my way. We rode faster and I felt fresher than if I’d done it alone.

The best part of Mounds Park Road is that, when the road flattens out to give you a rest, the slope decreases to 8 or 9%, unlike the double-digit grade most of the way. At the top we turn into a long and shady descent. Normally this is a fast drop, but less so today due to the wet pavement. Since I had a recent patient who was admitted after a 40 mph downhill crash, I was maybe more cautious than usual.

The final climb back to the park is, as regular readers know, my favorite stretch of road and the adopted highway of the half-fast cycling club. After the ride, I sit on a roadside bench, sipping a Scotch Ale and cheering on the other riders as they climb to the finish. It is the only channel on this TV, but it’s a good one.

We don’t need no education…

One day at work, when a doctor had done something particularly stupid, I wrote on our white board “Education ≠ Intelligence”. It struck a chord and no one erased it for weeks; in fact, people would point to it to illustrate something they were saying.

I spent years in retail, maintenance, and plumbing before going to college at the age of 40. Did college suddenly make me smart? (“Who says you’re smart?” I hear someone in the back saying.)

The sooner we learn that intelligence, education, and common sense are not the same, the better. I would argue that common sense is the most important of the three. The 18th century swordmaster Chozen Shissai said “If I draw one corner and the student cannot complete the other three, I do not continue”.

| Another way to put that is to look at the line segment to the left. If I ask you to use that to draw a square, can you draw exactly the square I have in mind? People are often paralyzed by the fear of being wrong and stall by deciding that they need more data. In this case, no more data are necessary. We have all we need. The line segment is at the far left margin so the square has to go to the right. We know a square contains four 90 degree angles. We know it contains four line segments of equal length. There is only one square there. Sorry if that seemed obvious to you, but I posed this to a roomful of college-educated folks and was asked for more information. Yes, the problem requires some education, but we should have learned what a square is well before college.

Another doctor did something stupid (that primarily involved not talking to the nurse who actually knew the patient), ordering a bunch of unnecessary tests overnight. The next morning in a meeting, a different doctor said, “Just because you’re smart doesn’t mean you can’t be a fucking idiot.”

An advice columnist was talking about college today. When I was contemplating college in my late 30s, a neighbor told me to take one class at night while I continued to work full time. It should be a class that was inherently interesting to me and also applicable to whatever degree I was considering. It was the best advice I ever got about education. For possibly the first time in my life, I liked going to school. I found myself doing more than was expected of me. For a speech on the Black Budget (the Pentagon’s secret budget, concealed in hundreds of separate line items scattered throughout the federal budget in an attempt to prevent scrutiny) I went to a pay phone and called the Pentagon for a response. They didn’t answer my questions, but did ask for my full name, address, and telephone number. Relating that story was probably the most well-received part of my speech. All the data may have been hard to process, but recognizing that the Pentagon wouldn’t talk to me but was trying to keep tabs on me resonated with my fellow students.

On some level, education seems to matter only if you know what you want to learn. As an empty vessel waiting to be filled, or as a student because it was expected of me, I gained little. As a committed learner, school was fun. As a parent, I realized my job was to provide exposure to the things that interested my kids and support them when they found the ones they wanted to pursue. Sometimes we don’t know what interests us until we see it, so a little random exposure helps.

While I teach for a living (much of my work with patients is teaching, plus I teach a workshop to other therapists when there isn’t a pandemic going on) I’d say there’s no such thing as teaching. There is learning and there is the facilitation of learning; but for a teacher to think s/he is pouring knowledge into empty vessels seems like the ultimate in self-importance. If you don’t know what you don’t know, you have to start somewhere. Chew on that paradox for a while. I could write a few more paragraphs to clarify or, as Mike Myers as Linda Richman would say, “Talk amongst yourselves.”

https://www.youtubetrimmer.com/view/?v=oiJkANps0Qw&start=146&end=158

As far as learning is concerned, I never learned anything I already knew. Duh. What I mean is that to truly learn, one must come from a place of Not Knowing. If we are busy showing off our knowledge or trying not to look dumb, there is no room to learn. Only after we admit to not knowing are we able to learn.

Forty five years ago, while contemplating a bike trip across the US, I read Robert Pirsig’s Zen and the Art of Motorcycle Maintenance. The book chronicles a trans-continental journey as well as a journey to mental health. It looks at our relationship to machinery and to the world around us. Caring for a motorcycle is, in part, a metaphor for caring for ourselves. I thought of the book while working on a bike this afternoon. The bike is more than 30 years old and I realized that maintaining it is balancing acceptance and acquiescence. No matter what I do today, the bike will not be new. I have to accept its aging while not acquiescing to letting it fall apart. I have to know what I can fix and what I need to replace, and when. Failing to keep it in shape can be an actual life-threatening situation. Since I am the engine, maintaining the engine is more than a metaphor for taking care of myself.

Years ago, a friend wanted me to go bungee-jumping. I chose not to. The reason is tied to the paragraph above. I may ride my bike down a hill at 50 mph. At that speed, crashing would likely result in death. If I survived, I may not want to, or I may not ever recover from the injuries. Why do I do it? I am responsible for many of the circumstances. I maintain the bike. A mechanical problem is my responsibility. I am operating the bike. An operator error is my responsibility. Sure, there are things I cannot foresee. An animal may dart into my path. I can be watching for that and prepared for it. A car may pull out of a driveway or cross the centerline. Again, I have some ability to respond to those situations. My awareness and my skill at bike handling (or lack of either) will influence the outcome. I don’t go that fast over unfamiliar roads. (Nor do I go that fast very often.)

Bungee jumping requires that I give up all control to someone else. Once I jump, everything is out of my hands. They maintain the cord. What is the lifespan of a bungee cord when used in this way? Hs anyone studied it? How do they fail? Do they snap, sending one plummeting to the earth? Do they lose elasticity, elongating so that there just might not be enough recoil to pull me back up before I hit the ground? Is the platform the same height and the cord the same length as the last time they did this? None of this is in my hands. It is all in the hands of a stranger. Am I willing to turn my life over to this stranger? Nope. Maybe you are. Maybe bungee jumping is a lot of fun. You tell me. I’ll ride my bike up and down mountains.

You may notice I haven’t answered my own question – why? The answer is probably somewhere in the last three years of this blog. It’s also not one of my favorite questions. What is the favorite question of 3 year olds? Can you ever give them a satisfactory answer, one that does not lead to the next “why?”

Why do I ride a bike? Why do I ride down hills? Why do I ride fast? Because I can. Reasons? We ain’t got no reasons. We don’t need no reasons. I don’t have to show you any stinking reasons.

Rather than “for what reason?” I prefer to see the question as “for what purpose?”

Why are these photos relevant? Because I took them this week. One is from my Wednesday Night Bike Ride. We rode from Salmo Pond, which was the turnaround point for many a ride in my youth. We would stuff our jersey pockets with food and ride to the pond, where we would swim and eat before riding back home. (Small pond image from Channel3000.com)

For this ride, we met at the pond and rode the ridges south of the valley drained by Black Earth Creek. At the end of the ride, a large maskless group was gathered in the parking lot chatting. I still am not ready for that. Soon after, the CDC came out with new guidelines that say we can do just that. A few days later I came across a gathering of 35 maskless people in my neighborhood park. I’m inching towards acceptance. Why did I get vaccinated if I can’t begin to change my behaviors? I have been walking the dog without a mask this week. Maybe I’ll even ride with vaccinated friends this week.

I kinda like that this path appears in the photo to go nowhere. It seems to start and end just for the purpose of crossing the little bridge over the creek.

The other photo is a motivational postcard from a workplace which shall remain nameless.