By Dr. Michael Misialek
We don’t like to admit it but cancer is rarely black and white. Increasingly a cancer diagnosis means living in a murky morass of constantly reassessing risk.
Here’s one man’s story of living on that precarious line. His saga, seen through a pathologist’s filter, illustrates the uncertainties surrounding prostate cancer. And, as the number one cancer in men, it is increasingly becoming a familiar story for many. Questions like, ‘What do my numbers mean?’ ‘Should we treat or not?’ and if so, ‘Which treatment is best for me?’ inevitably arise.
Mr. B. is a 64-year-old man who was found to have an elevated PSA four years ago on his routine physical exam. Obviously, prostate cancer was the first thought that came to mind, particularly since his father had the disease. What he soon learned is that prostate cancer is a complex diagnosis — one that requires the careful integration of the physical exam, biopsy results, radiographic studies and lab results.
And, of course, it’s a diagnosis that comes with many decisions and choices; choices that depend upon understanding the grey zone of medicine. Prostate cancer is rarely clear cut. As much as numbers like the PSA and Gleason score (the sum of the two most predominant grades in a patient’s tumor) guide diagnosis and treatment, they also contribute to the uncertainties on the best course of action.
When Mr. B’s elevated PSA was first detected, his primary care physician referred him to a urologist at Newton-Wellesley Hospital. His prostate was normal on physical exam and they elected no biopsy at the time. Over the next couple of years the PSA slowly continued to rise, still with no change in his physical exam. Last year a biopsy was done and was negative. No cancer, a relief. What was found was some inflammation. Could this have contributed to the rise in PSA? It certainly could have, but a negative biopsy did not rule out cancer. The journey of watching numbers continued.
This year Mr. B.’s PSA rose yet again, and his urologist ordered an MRI which was negative. Mr. B. underwent another biopsy. (Not an easy process since he takes the blood thinner Coumadin and any invasive procedure needs to be carefully coordinated with stopping and restarting this medication.) The biopsy is also uncomfortable: his first biopsy involved six needles, but this time it was twelve.
The slides came to me. I put them on my microscope and carefully studied each of them. As I scanned at low magnification I found two tiny foci of abnormal glands which qualified for a diagnosis of cancer. Continue reading