It was November, and we had been dealing with this issue for most of the year. Did it make sense to wait another month for the NCI appointment so that an MRI could be scheduled? Or should Jim just go ahead and get some form of treatment? I had recently seen a brochure advertising a local hospital support group for prostate cancer survivors and their wives. “Let’s go to this,” I said, and he agreed.
The hospital conference room was crowded with men at various stages of the prostate cancer continuum. Some were quite sick, dealing with metastatic disease that had spread to the bones. Others were Jim’s age who, with a similar diagnosis, had opted for surgery. Hesitant to touch the delicate topic of impotence, the men instead discussed incontinence issues and the rate of improvement. In a difficult situation, most were seeing the glass as half full. Compared with many of the men, Jim was in an enviable position. He had a small tumor, and he had time to educate himself and make an informed decision.
After the session, an older man came up to us. “I think you should have the advanced MRI offered by NCI, and see if you can get into the surveillance protocol,” he told Jim. Now approaching 80 years old, the man said that he had entered that protocol when he was younger. Then, at age 75, his prostate had become enlarged and he had no choice but to have it removed. But for the many years that he was on watchful waiting, he was only monitored and he was able to live without treatments and their side effects. He seemed robust and healthy.
He told us that the MRI device maps the entire prostate and that the information it produces would allow us to decide about treatment based on facts, not speculation. It made sense; Jim would keep his appointment at NCI before making any decisions.
‘A breakthrough in imaging’
For almost a decade, research oncologists and medical engineers have been developing and refining a system using an advanced MRI device to take images of all 12 cores of the tiny prostate gland. This method “is a breakthrough in imaging for prostate cancer, analogous to the introduction of mammography for breast cancer,” said Peter A. Pinto, head of the prostate cancer section of NCI’s urologic oncology branch.
The advanced scanning and the physicians with expertise to interpret them are available at a couple of academic centers in this country. The MRI identifies potential cancerous sites, which can then be biopsied if necessary, but with a huge advantage: “When we do a biopsy, we have a map in front of us,” Pinto said. “The information provided by the MRI guides the biopsy. It is no longer hit-or-miss,” which he said is often the case with regular biopsies.
When the NCI physicians looked at Jim’s MRI results, they were able to see that his prostate was free of large tumors. They saw the same small tumor, or lesion, that had shown up in the community hospital biopsy, but that was all. What’s more, the suspicious areas identified in the earlier biopsy looked totally normal. The precision of the MRI meant the doctors would be able to do a targeted biopsy. And they were thrilled to have Jim in the surveillance program, which meant no treatment, just regular monitoring
About six months after that MRI at NCI, Jim returned for a scheduled MRI-guided biopsy. We assumed that the tumor would be about the same. What we didn’t expect was the news we received: The tumor was smaller than originally thought. We even wondered whether Jim had cancer.
“Yes, the cancer is there, but it’s so microscopic that the needle doesn’t always pick it up,” Pinto told Jim. “And because your tumor is low-volume and low-grade, it doesn’t present an immediate threat, and it’s possible it may never do so.” He added that this is the kind of situation physicians hope for when recommending surveillance.
I can’t tell you the mix of emotions we had: relief and happiness, of course. But also a heightened awareness that it was only through a combination of luck and Jim’s stubbornness in putting his cancer fears on hold — and helping me assuage mine — that we were able to avoid unnecessary treatment.
Fenichel, a principal of Cassell and Fenichel Communications, lives in Silver Spring. For more information about the MRI protocol for prostate cancer, contact Peter A. Pinto of the National Cancer Institute at 301-496-6353 or NCI’s Clinical Trials Referral Office at 888-NCI-1937.