I had planned to move on to what I consider essential subject matter relevant to AS, but I interrupted that plan to bring you some news of my own.
If you read my first blog post, I ended with the decision to go on Active Surveillance after my confirmatory biopsy, which yielded nine benign samples, including those targeted by a Pirads 4/5 interpretation of an MRI I had had that year. My AS protocol consisted of PSA tests every six months, annual MRIS, a Color Doppler (1) (see glossary of terms at the bottom) thrown in. and embracing a whole food plant based diet. I cut out meat, dairy, and eggs, and I buy organic produce when I can. I have researched various nutritional regimes - most notably the Hippocrates and Gerson (2) protocols. I attended the Optimum Health Institute in San Diego where, for three weeks, a schedule consisted of tasty raw food meals, intermittent juice fasts, many classes, wheatgrass, and more. Look for my entry on nutrition soon. At the moment, the ptrostate cancer medical community embraces a “heart healthy” Mediterranean diet for cancer patients although recently there has been activity from doctors encouraging patients to explore plant-based diets. My go-to is Dr. Greger nutritionfacts.org. For now, before tomatoes disappear from farmers markets since we’re close to end of season, make your own tomato sauce and soak up that lycopene!
My Farmer’s Market
My farmer’s market at the Union Square Greenmarket in NYC operates year-round, but when summer comes, I know I get the great stuff: heirloom tomatoes, fresh organic basil for a vegan pesto, excellent prostate friendly cruciferous vegetables such as cauliflower and broccoli. Instead of pasta, I’ll by yellow and green squash and put it through my spiralizer to have it as spaghetti! Amazingly delicious, healthy, and none of the carbs of regular pasta.
Throw in nutrient rich mushrooms and top the dish with your own marinara sauce or pesto!
Farmer’s market prices are usually higher than supermarket prices; the tradeoff is that you know you’re getting produce freshly harvested!
Back to My News
While I am in charge of my own AS, I should emphasize that I currently have a small team of doctors and specialists who help me monitor my AS on PCa. and my attendant BPH issues.
So it came to pass in August 2022, my annual MRI results were the same as the previous two years, with a small lesion, though this latest report added the word "stable" as it was comparing it to my earlier imaging. However, because I had chosen to have a form of Gadolinium contrast, (3) the MRI was graded a Pirads 4. There was some disagreement on my team as to whether I should follow up with a biopsy. Again, I remind you, the reader, that we, the patients, make the choice – considering shared decision-making and research. Often, the decisions come down to risk assessment, and after I weighed the risks (and benefits), my need for peace of mind was the big decider. Weighing the pros and cons of disparate suggestions among prostate cancer specialists, I chose to go with guidelines from the American Urological Association (4), which recommend a biopsy every 2-5 years for men on AS, no matter the results of an MRI - NOT mandated as part of the AS protocol. The revised AUA guidelines (see Guidelines in the navigation bar) recognize the importance of MRIs in "risk stratification." The AUA, however, does not recommend MRIs when determining whether or not to biopsy. Many men on AS opt for the MRI to determine if they should go for an MRI-guided biopsy. After all, who loves getting poked with needles? I certainly don't! And for the last several years, I accepted the advice of one doctor who felt it unnecessary, with my MRI results, to go for a biopsy. However, there was something different this time – and I had also just engaged a new PCa urological specialist who definitely follows the AUA guidelines. This choice can be a dilemma for men – mainly when their medical team disagrees. Ergo, my research studies came in handy.
The type of biopsy I would have was now forefront. I chose the same transperineal approach that I had four years ago. For me, that was a no-brainer. And although the AUA has not changed its guidelines from recommending the transperineal approach over transrectal – the Association is getting a good deal of feedback to consider a change. So look for next year to see what they might consider. I will also be writing a blog about transperineal vs. transrectal biopsies soon.
However, the question now was whether to have an MRI-guided biopsy only, based on the one lesion on the report or to have a combination MRI-guided fusion/systematic biopsy. (5) Several recent studies point to the efficacy of having a combination biopsy over solely one that is MRI-guided.
Another PCa issue. Still pretty inconclusive. However, Johns Hopkins in Baltimore, MD, which has a large cohort of men on Active Surveillance, has a protocol of mandating a combination MRI-guided/systematic biopsy for every patient every TWO years. I learned of this a couple of weeks ago, in a conversation with someone in the cohort for awhile - and before Ballantine Carter, MD left. If this changes or already has changed, I’ll certainly update the numbers.
I again wanted to have my biopsy at Brigham Women's in Boston., although I live in New York. However, I needed to make one more decision: would I choose a TP MRI-guided in-bore (in the MRI tube receiving live images during the biopsy) as I had previously indergone, or the combination of MRI-guided/fusion/systematic/? I found out that the difference would be that, with the latter, the urologist could use the Precision Point (6) transperineal equipment; it was not available for the in-bore. So I chose a combination TP-MRI-guided/fusion/systematic biopsy. I also decided to have general anesthesia, which required my procedure to take place in the OR in the hospital.
I am awaiting the results from the pathology lab. From the preliminary notes and subsequent talk with the urologist who performed the biopsy, there were 16 samples taken. He targeted the area designated as a lesion in my MRI, including where my first random samples of Gleason 6 were found in 2018 and used a template to take samples from the remaining quadrants. At least, that's what I understood from a phone call fading in and out on an Amtrak train ride back to New York. I'll have more details in my next post – plus the preliminary results before I get a second opinion from Dr. Jonathan Epstein at Johns Hopkins, a world class pathologist …. and a mensch, to boot. Stay tuned!
One more item…..
Embracing Active Surveillance (AS) is to expect things to change—changes in your tests or news from the outside. The information could be coming from within the U.S. or anywhere, i.e., findings from studies on almost any aspect of prostate cancer. This blog site has a dropdown "In The News"; however, I might sometimes add a "breaking" headline to a post. Today, it concerns a study containing a Swedish cohort, a study published on September 14. 2022, with the findings that "suggest that men older than 65 years with low-risk P.C. had a high proportion of treatment-free years (53%-70%) and a low risk of P.C. death (6%-8%); hence AS was indicated among men in this subgroup. In contrast, in men younger than 65 years, AS appeared to be indicated only in those with very low-risk P.C… " Tead this study in full HERE. And, note that this is a study out of Europe where guidelines differ from the AUA. There will no doubt be disagreement with the study’s premise. And it’s still relevant to place into your Active Surveillance research library.
Some studies will sound absolute and conclusive; some, in fine print in their conclusions, will often state that more studies are needed to bolster the findings reached here. As Active Surveillance pioneers grow (up to 60% in the U.S.; 90% in the state of Michigan), it is, by its very nature, a protocol that warrants your staying on top of new studies, discovering the development of new biomarkers, and changes in organizational guidelines.
This blogger advises all on Active Surveillance to stay involved and vigilant – through support groups, your medical providers, peers, and this blog site! As I cannot possibly monitor all news coming down the pike, I certainly welcome you to email me with anything you feel relevant and “fit to publish.”
And remember – scroll down and subscribe to this blog so you'll receive notifications of my new posts. And always a good idea to refresh your browser! Until next time,
I wish you good health always!
Glossary of Terms:
(1) Color Doppler Ultrasound This type of ultrasound, with the practitioner gently inserting a probe into your rectum has been utilized for awhile. I had been referred to the specialist Ethan Halpern at Jefferson University in Philadelphia. Read more about it here. A new type of test, the Microultrasound developed by Exact Imaging has made its way to the states. Laurence Klotz in Canada uses it regularly in tandem with the MRI for periodic checks on AS patients. Currently, the equipment is located in various centers around the country. I have not taken advantage of this newer imaging to date. I’ll explain more as part of a blog post on AS protocols.
(2) Hippocrates and Gerson protocols. Click the names for sources of information. Above, I told of my stay at San Diego’s Optimum Health Institute. They follow the Hippocrates protocol. Remember the Hippocrates saying: “Let Food Be Thy Medicine?”More on this in my nutritional and healthy lifestyle blog post.
(3) Gadolinium Contrast
So there’s no shortage of controversy, questions and debate when it comes to receiving contrast for a 3-T MRI. Webinars from PCa support groups have presented the subject - slanted a bit towards risks and long term side effects. Most radiologists will say that there is no definitive science on dangers of Gadolinium - that it is safe and leaves the body quickly. Other drs either shrug their shoulders and defer to their colleagues. Many cite anecdotal stories of brain and other sordid damage. Given that the latter may exist, the exact risk percentage is not known. I know of one major cancer center, MSKCC, whose radiology department specifically has not used contrast at all for several years. And I spoke at length with one prominent radiologist oncologist who dismisses MRIs without contrast, calling them “useless.” Again, a divide. I found one rather easy to read definition of the contrast, its use and safety, from Yale University. You have every opportunity to consult Dr. Google for other sources. There are plenty of them. Have fun exploring. I personally went for the contrast as I understood it to be a necessary agent for highlighting areas important for radiologists to examine. And again, to counter that, I’ve spoken to a Dr. who calls it hogwash, maintaining that, without contrast, the readers of the imaging have to “work harder - the contrast makes them lazy.” You decide!
(4) American Urological Association
Have a look at AUA’s website. I’ve also posted their 2022 Prostate Cancer Guidelines which you can find in the navigation bar. Note that in their revisions in 2022, they have gone farther than before in recommending that the “preferred” option for low risk (usually Gleason 6 tumors) and favorable intermediate risk (may include 3-4 tumors with no more than 10% involvement in the “4” - but, that can vary from dr to dr). As I said above, the AUA has stopped short of recommending MRIs as part of an AS protocol except in cases of Risk Stratification, and the jury is still out on opining on Transperinneal biopsies vs. TRUS. And don’t even THINK about other biomarkers you’ve heard about. But, not to worry. We’ll get to all the news that’s fit to print about everything from the Microultrasound to Select DMX urine tests to the 4K blood test to measuring a blade of grass. (the latter suggestion being tongue in cheek…)
(5) MRI-guided fusion/systematic biopsy
Take a look at this February 2022 study from PubMed.gov, also known as NIH. Examine previous studies cited. And put the general PubMed/NIH URL in your browser “Favorites.” It is an excellent research tool. Also: clinicaltrials.gov - a go-to tool for finding out about completed studies and those that are still recruiting. Simply type in prostate cancer in the search bar, and, presto! You’ll probably find more than you bargained for. Of course. you can insert specific terms - studies are continuous on all facets of PCa.
(6) Precision Point
Everything you need to know: Precision Point was developed by a company called Perineologic Know that, currently, not everyone performing Transperineal biopsies has this system. An excellent source for support of the Transperineal Biopsy can be found here. Follow several of the proponents of the Transperineal Biopsy on TWITTER. Jeremy Grummet Michael A. Gorin Rick Popert Arvin K. George Matthew Allaway.
Just a Note ON ABOVE LINK TO DR. KLOTZ’S VIDEO:
As much as I have complete respect for Dr. Klotz as a pioneer and for his accomplishments in positively affecting the lives of thousands of men with the advent of Active Surveillance, I disagree with his views on nutritional lifestyle (at the end of the video) - more on that in an upcoming post!
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