Paul A. Rahe: Prostate Cancer: New Procedures for Diagnosis – and Cure

Here is some news that, before too long, some of you may be able to use. There is a new technique for diagnosing prostate cancer. It is being deployed on an experimental basis at the National Institutes of Health (NIH) in Washington, DC. And it works. I know. I am a guinea pig.

I am in my early sixties, and I have four children under the age of twelve. A maternal cousin died of prostate cancer – after having his prostate removed – when he was in his mid-sixties. After discovering that he had an elevated Prostate Specific Antigen (PSA), my brother had  a biopsy; on the basis of what his physician found, he had his prostate surgically removed; and today, almost two decades thereafter, he is in fine fettle. So mindful of the fate that might be mine, I watch, I wait, and I read what the standard websites have to say on the question. I have no particular desire to die right now; I have even less desire to abandon my wife and children; and my wife seems to think that it might be a good thing if I were to hang around for a while.

Not long ago, my PSA, which was low, took a sudden jump. The websites – this one  is a good place in which to start – indicate that this is a warning sign. If one's PSA doubles in eighteen months, I learned, it may be an indicator not only that one has prostate cancer, but that the cancer is aggressive as well. The distinction matters. Something like 60% of men my age have prostate cancer. In most cases, however, it will take something like thirty years for it to become a threat to their health, and most of them will no longer then be around. But if one has aggressive cancer and it is not caught and dealt with forthwith, one is done for.

Unfortunately, diagnosis is not easy. The PSA test is unreliable. Among other things, it does not distinguish between slow-growing and aggressive cancer. The digital rectal exam is more indicative, but there are no nodules on the prostate that a physician can detect with his fingers until fairly late in the process of a cancer's development.

Even more to the point, the process for taking a biopsy – the only procedure that can eventuate in a reliable diagnosis – is hit and miss. An ultrasound is taken to map the prostate of someone suspected of having cancer; it is then divided into twelve sectors; and the biopsy, guided by the ultrasound, takes a single sample from each of the twelve sectors. If the cancer is quite advanced – as was presumably the case with my cousin – the biopsy will catch it. If it is small and in its early stages, it can very easily be missed.

When my PSA took a jump, I called a distinguished urologist whom I have known since we were children. I laid out the family history, and I mentioned my PSA results. He consulted Dr. Peter A. Pinto at NIH, asked him what he recommended, and I was invited to assist him in his research by serving as a subject. In consequence, over Spring vacation, back in March, I spent two days in our nation's capital, undergoing a set of procedures that will soon in all likelihood, I am told, be more generally available.

On day one, the staff at the Molecular Imaging Program subjected me to trans-rectal Magnetic Resource Imaging (MRI) with Gadolinium. This involves the insertion of an endorectal coil into the rectum, the inflation of a balloon to hold it steady, and the introduction of an intravenous contrast material into one's veins. In the course of the MRI, one is slid into a machine that produces a powerful magnetic field – where, from time to time for about an hour, one is assaulted by radio frequency pulses. With the help of sophisticated software, the technicians who operate the machine con produce a detailed picture of the prostate. And here is the kicker – if you have cancer, it shows up as a splotch in the picture, and those working with these procedures can grade any splotches they see with an eye to the likelihood that they are cancerous.

If nothing suspicious is found in the course of the MRI, that is the end of the story. If, however, there are suspicious splotches, one returns to NIH on day two to have a biopsy, which was my fate. Using sophisticated software, the technicians initially map the picture of the prostate produced by the MRI onto the picture produced by ultrasound. Then, guided by these images, a surgeon, performing the biopsy, samples the precise places where the MRI found suspicious splotches. To supplement this procedure, he then performs an ordinary biopsy, taking samples from the twelve sectors into which the ultrasound divides the prostate.

The first set of procedures is not a joy, but they are considerably less unpleasant than a colonoscopy; the second set involves some discomfort, but, at NIH, they use novocaine to deaden the prostate and reduce the pain. In my case, the MRI team identified five suspicious patches – three of them moderately likely to be cancerous, two of them worrisome but much less likely to be malignant. The biopsy revealed two minuscule patches that were cancerous. Each made up something like 2% of the biological material in the particular sample taken. In neither case was there any indication that the cancer is aggressive.

So, in a year or so, I will undergo another trans-rectal MRI. If nothing has changed that will be the end of it. If the MRI indicates the existence of more suspicious patches or if the previously existing patches have gotten larger, I will undergo another biopsy. If and when they find aggressive cancer, I can opt for treatment – which is most likely to be either surgery or radiation.

In the last quarter-century, I was told while at NIH, there has been a dramatic drop in the number of deaths from prostate cancer. The reason appears to be that PSA testing, digital rectal testing, and biopsies – when these techniques are all in play – often enough enable physicians to detect aggressive prostate cancer early on. And, when early detection is followed by surgery or radiation, they can usually stop the cancer in its tracks.

The new techniques, being pioneered by Dr. Pinto and his team, promise to identify the tissue that is suspect and to enable those conducting biopsies to hone in on the suspect tissue. When these techniques are sanctioned for general use, they should make early diagnosis easy, and they should then dramatically reduce the number of deaths resulting from prostate cancer.

Believe it or not, some of our tax dollars are actually being put to good use.