Prostate cancer testimonial: active surveillance & fusion MRI
Prostate cancer testimonial: active surveillance & fusion MRI3 Jul 2016
Looking back over the 5 ½ years since I was diagnosed with Gleason 6 prostate cancer, I realize the easy approach would've been to undergo a prostatectomy.
“Instead, I opted for active surveillance”
That's what my first urologist recommended. He urged me to take a road followed by so many men diagnosed with early prostate cancer. Just remove the prostate and get it over with. I might have encountered postsurgical issues, including urinary incontinence and sexual dysfunction, but I would've been done. I wouldn't have had to learn to "live" with cancer, with the back-of-the-mind thought, "I have cancer." Men with early prostate cancer typically dispense with it. Out, out damned spot -- or more. And then move on -- unless things get complicated.
Instead, I opted for active surveillance, the choice of a minority of patients, though that number is growing. My second urologist at the University of Chicago, where I joined the active surveillance program, told me in 2010 that research showed that 10 years from then, at age 73, I would be in essentially the same situation. That was good news.
But I had a lingering concern. The prognosis was based on statistics, not on my tumor's genetic makeup. Over the years, I asked my surgeon repeatedly about DNA studies I had run across. He mainly discounted them, noting that they wouldn't add much for me since we knew I had cancer.
Still, I wondered.
“I trusted my doctor. But he sometimes annoyed me“
The years passed. And I kept getting good news. By 2013, I had undergone five biopsies. The first biopsy in summer 2010 was ambiguous. The second a few months later confirmed Gleason in a single one millimeter sample. But three subsequent biopsies showed no signs of cancer. I went on a biopsy vacation in 2013 at the suggestion of my urologist Scott Eggener, MD.
Generally, I was happy with my care at University of Chicago. I trusted my doctor. But he sometimes annoyed me, just as I'm sure I annoyed him. He didn't like to respond to my emails. When I asked a question, say about a new genomic study, he would say -- we can discuss it the next time we're in clinic. Only I wanted more immediate responses.
Also, the doctors and staff at U. of C. tend to be formal -- too many misters from my point of view. I prefer a more laid-back, first-name approach. It's a matter of style and personality. You say to-may-toes and I say to-mah-toes. As luck would have it, I met another urologist at NorthShore University HealthSystem -- actually a classmate of the U. of C. doc -- while interviewing some researchers at NorthShore for a story on medical genomics. NorthShore is more than 50 miles and at least an hour-long drive for me. U. of C. is only a half hour drive.
I was considering a change. It felt like breaking up.
My new doctor suggested a new type of prostate exam, a fusion MRI
The new guy, Brian Helfand, MD, PhD, not only is an urologist, but also has a doctorate in molecular biology. I scheduled a consultation with him, not sure if I actually wanted to change physicians. We hit it off personally. We even like the same Chicago hot dog place, a sure sign of something, right?
Helfand suggested some additional testing and potentially a new -- new to me anyway -- type of prostate exam, known as a fusion MRI. Then, we might explore the genomic market and get upfront and personal -- genomically, which had been my goal. I had two PSA tests. The Prostate Health Index looks at three measures of PSA, including total PSA, free PSA, and PRO2PSA. My total PSA was 6.6 ng/mL, down from a high of nearly 9 just a few years ago.
Helfand said this was good. The test said the odds for a biopsy finding a cancer were one in three; but since I already had been diagnosed that wasn't a factor. More relevant was that my PSA was on the decline. Helfand prefers PHI, but he wanted to check my PSA with a more traditional model to be sure he was comparing apples to apples. He said that there can be variance of 30% between platforms.
I had a PSA using the Roche blood test. The Roche showed my PSA even lower -- 5.19 ng/mL, slightly above its normal of 4.5. I liked the sound of that. I mentioned to Helfand that I began taking the supposedly anti-inflammatory supplement turmeric more than a year ago. I asked if that might account for the decline in my PSA. He said maybe (some tests of animal cancer cells showed a benefit), but no way to know for sure and, in any case, it wasn't hurting me.
“I dreaded the MRI scan but this scan was a breeze”
Meanwhile, the Roche test found I had a reading of free or unattached PSA protein of 1.48 ng/mL. A ratio is created by dividing the free level by the total. My ratio was .29. Helfand said anything above .25 is considered good. On to the MRI. I dreaded the scan. I had one in 2010 at University of Chicago after I had a biopsy. I was uncomfortable in the machine. I even experienced temporary hearing loss resulting from improper positioning of hearing protection and the constant clanging of the magnets. Plus, the results suggested I had two tumors -- something that subsequent biopsies failed to confirm.
Helfand had recommended a fusion MRI. First, I'd have the MRI and then that image would be combined or fused with a 3-D ultrasound image in real time with a guided biopsy. I found the MRI in January a breeze. Instead of head first, I went into the machine feet first. This greatly reduced my claustrophobia. My hearing was intact after the exam.
Even better, the results were negative. No cancer. Hence, I was unable to undergo a focused biopsy. Helfand said there was nothing in the MRI that the 3-D test could focus on -- a good thing clinically. He recommended a routine 2-D biopsy since it is considered the "gold standard" and I hadn't had one in 2 ½ years. He said the 3-D focused biopsy was "cool technology," but not necessary for me. "We have no additional target or region of interest on your MRI. For you, there is no additional advantage. No one can make the case that it helped yet," he said.
"Right now, what you have in your favor is you have a negative MRI, meaning we can't detect any obvious lesions. Your PSA has gone down. Your PHI is reasonable. It's not off toward 100. [Mine was 46.] You have a lot of positives going for you," he told me.
So far, so good. I have learned to live with cancer and avoided prostate surgery. Next, I am tracking down a one millimeter sliver of tumor sitting in a lab somewhere. The hope is that the tissue will be adequate to sequence the DNA for at least one of a new generation of genomic tests that might give me the personalized answers regarding prostate cancer that I have been seeking since I started on this journey.
Source: MedPage Today
Source: MedPage TodaySource: MedPage Today