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Anus Horribilis

One morning, in Week Five of a six-week treatment regimen, I stepped before a mirror to discover my pubic hair had absconded.

Gone. All of it. Along with 35 pounds of body weight.

A few months before, I’d noticed how fifteen minutes in a desk chair left me squirming. A hemorrhoid no doubt. I’d had them before. Sitz baths would do the trick.

They did nothing. It took all of ten seconds for a gastroenterologist to spot the problem. She directed me to a chair. Speaking deliberately, emphatically, and somewhat in the manner of a supervisor about to inform you you’re being fired for stealing office supplies, informed me that what I had was not a hemorrhoid but a tumor. More specifically, anal cancer.

This was Tuesday. She’d ordered a biopsy for Friday.

“What’s the prognosis?”

“It’s treatable,” she said.

“How?”

“That depends on how early it’s caught. Surgery, radiation, or chemotherapy. Possibly some combination.”

“What does surgery involve?”

“Typically, they remove the rectum and colon.”

* * *

Five weeks later, treatment—a combination of radiation and chemotherapy—commenced. Radiation seems a cinch. Techs situate me on a table. Overhead, something resembling a satellite dish piloted by robots moves left, right, forward, back. From time to time a red beam appears, the sort you might use to excite cats. Music plays. Tuesday, Frank Sinatra. Wednesday, Country and Western.

Requests? Requests?

Chemo’s another matter. Those salmon-colored tablets—three in the morning, three at night—slide down the esophagus, stomach and gut acting like they own the place.

Soon, they will. The intestines burble, wheeze, and sigh. A third element—two separate intravenous infusions of chemo, the first and fifth weeks—is added to the treatment mix. The fluid, via pic line, is blue, opaque and resembles something you’d pour in an auto engine. Hours later, I feel as if I’d been dunked in a vat of Raid and thrown off the roof. I call a friend in NYC who’s been through the same treatment.

“How long will I feel like this?”

“About five days.”

* * *

Cancers are named for where they originate in the body. Cancer Research UK notes there are “more than 200” types.

Among them, anal cancer ranks as rare. How rare? In the year I was diagnosed, 2021, the American Cancer Society estimates 9,090 patients received the same bad news from their doctors. In the same year, the ACS estimated 284,200 new cases of breast cancer, and 235,760 cases of lung cancer. So, that rare.

Cancer, any kind, creeps people out. What really throws them is when the cancer you’re talking about involves that part of the body which doubles as an organ of elimination and one of America’s favorite insults.

“Anal cancer?” someone said, genuinely baffled. “Is that a gay thing?”

You mean, I thought, like wearing kilts or collecting Mid Century highball glasses?

Technically, not. Since anyone can get it. On the other hand, gay men have a greater chance of contracting it. The National LGBT Cancer Network points out that the number of anal cancer cases is roughly two per one hundred thousand U.S. population. Among HIV negative gay men, that jumps to 40 instances per 100,000. Take gay men who are HIV positive, and that doubles to 80 per 100,000. Their conclusion?

“Among men who have sex with men, the incidence of anal cancer is significantly more prevalent and increasing annually.”

While it’s increasing among gay men, gay men are not the major anal cancer demographic. Of those 9,090 cases estimated for 2021 by the National Cancer Center, 3,020 would be men, 6,070 women. “Almost anyone can get anal cancer,” notes the website for Memorial Sloan Kettering Cancer Center, “but it’s more common in women.”

What’s also true, per MSKCC, is that “having anal sex is a risk factor linked to anal cancer. The disease is more common among men who have sex with men.”

* * *

Researchers identify the causal agent as the human papilloma virus (HPV). The same type of virus can lead to cervical, vaginal, and head and neck cancers. The MSKCC site notes that “about 9 out of every 10 cases” of anal cancer are caused by HPV, specifically HPV16.

The first HPV vaccine was introduced in 2006. Three are available today. These block HPV infection, including HPV16. Since vaccines became available and widely recommended, the Center for Disease Control notes that

“infections with HPV types that cause most HPV cancers and genital warts have dropped 88 percent among teen girls and 81 percent among young adult women.”

What about gay men? Research indicates gay men are largely unaware of the HPV/anal cancer connection and therefore feel no reason to be concerned or get vaccinated. A 2021 study “to assess knowledge of human papillomavirus (HPV) as a cause of anal cancer among at-risk gay, bisexual and other men who have sex with men” found that 68 percent of research subjects “were aware of HPV,” but only 20 percent knew HPV causes anal cancer. The study’s authors concluded that men who have sex with men “were no more knowledgeable that HPV causes anal cancer than heterosexual men.”

Not only that, but according to Liz Margolies, LCSW and Bill Goeren, LCSW at the LGBT Cancer Network, a growing number of gay doctors have come to believe “that routine screening, using an anal pap smear, could reduce the incidence of anal cancer as dramatically as it has cervical cancer in women.”

* * *

“In about Week Five, your tumor will die,” a radiation tech one day confided.

I was eager to see it murdered and wondered what that would look like. Sure enough, right on schedule, that blob of bright blood swirled away down the toilet one morning.

Unfortunately, treatment’s side effects didn’t go with it. Fatigue left me feeling indistinguishable from the cushions on the sofa where I planted myself. Meanwhile, as chemo plowed through, abolishing gut bacteria and all else, the digestive tract responded to food with loud, exhausted sighs and gurgling noises reminiscent of Dr. Frankenstein’s lab. Starvation seemed appealing.

“You’ve got to eat,” nutritionist Deb insisted. “You’re on the edge of malnutrition.”

Eating while taking chemo comes with its own set of problems, from constipation and its opposite to explosions of flatulence recalling the fate of the Hindenberg.

It was near treatment’s end that these digestive tract difficulties commenced.

One morning, about 3 AM, the urge to go brought me abruptly awake. I tumbled off the sofa and galloped for the bathroom. Fear of incontinence is its own special dread. For 3 months I left my apartment only for medical appointments. Otherwise, I woke on that sofa and twelve hours later fell asleep there. After about a month I felt marooned.

* * *

Cancer, the hospital literature says somewhere, is “a lonely disease.” It’s strange to ascribe a state of mind to a type of illness but in fact, cancer produces emotional destitution in at least two ways.

First, it thrusts the ultimate unpleasant subject to the fore. I’m going to die, I thought. Why did I never consider this previously? And what will the world do when I’m not around? The answer—that it will blithely go its way—is a thought best expressed in a late Pasolini poem, “On the Day of My Death”:

The beautiful boys

will run in that light

which I’ve just lost,

flying from school

with curls on their brows.

Second, it reduces the patient to full-on dependency. Who, I wondered, will shop, cook, clean, do the laundry, get me to appointments or just visit?

“You’ll be amazed at who shows up and who doesn’t,” said a San Francisco friend, who’d survived a near-fatal bout of blood cancer.

He was right. Two I’d counted on to help proved to be summer soldiers. They vanished. What was more of a shock was the many more who stepped forward to assist.

“I’m going to the supermarket,” an upstairs neighbor emailed. “Why don’t you make up a shopping list and text it to me.”

* * *

My doctor told me he’d never seen a case of anal cancer among his mostly gay male practice until a few years ago when suddenly he had five. Of whom, he noted, four remain with us.

Estimates for the 5-year survival rate for anal cancer range from 60 to 85 percent. That the tumor is often both inside and outside the opening allows for early detection. That compares with lung cancer or Non-Hodgkin’s Lymphoma, where symptoms are more likely to manifest at late stage, making treatment difficult or impossible.

He also pointed out that “maybe a year after treatment, you’ll wake up one day feeling like your old self. As if nothing ever happened.”

Which is, twelve months after treatment ended, what happened. My “annus horribilis”—that phrase ancient Romans used to describe a year of disaster or misfortune”—appeared to have ended.

It was as if some inner weight had lifted. In the bathroom mirror the morning that happened, I noted the mysterious reappearance of crotch hair. Only instead of grayish white the tentative threads appearing here and there were a blondish brown I hadn’t seen in 50 years.

–Jim Cory


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