MRI-invisible man shares his story
He likes being on AS and being MRI-invisible--best of both worlds
By Howard Wolinsky
Ted Wigdor is an invisible man.
He’s one of the 50% of men with low-risk Gleason 3+3=6 (Grade Group 1) whose lesions can’t be seen in an MRI scan. (Note: The number is based on the experience at Johns Hopkins.)
MRI-invisibility sounds like a problem, but I view it as more of a superpower.
MRI-invisibility means these men can avoid a biopsy and also avoid potential diagnosis with low-risk prostate cancer and facing the inconveniences of being on Active Surveillance with regular PSA blood tests, MRIs and biopsies.
Two years ago, Wigdor, 60, a government relations professional in Toronto, was diagnosed with a single core of Gleason 6.
“This was BEFORE I had an MRI,” he noted.
In the U.S. and Canada, unlike say the UK, prebiopsy MRIs aren’t SOP. So the patients get biopsies that under the microscope might result in a cancer diagnosis with a Gleason 6.
In Wigdor’s case, “Nothing was detectable” on a post-biopsy MRI, he said. He had a MRI-invisible lesion.
But before this MRI, he had had a biopsy and hitched a ride on the Active Surveillance conveyor belt.
MRI-invisible lesions are good news, according to doctors like Dr. Mark Emberton, director of interventional oncology at University College London and Dean of its Faculty of Medical Sciences and a pioneer in prostate MRIs.
He believes that if you can’t see a lesion on MRI, it’s not a cancer. Check out my previous edition for more on MRI-invisibility.
Emberton’s view is that you can’t see, won’t harm you.
[Note: Dr. Emberton will be the featured speaker at ASPI’s webinar on Saturday, January 25, 2025, from noon – 1:30 p.m. Eastern (5:00pm-6:30pm UK time). I’ll be the moderator—so come on. If I gotta be there, you should be, too.
[Don’t be webinar-invisible. Register here: https://zoom.us/meeting/register/tJYldu-qqzojGNEzCkgPQuTOWYGhcL80Dhec']
This approach to MRI-invisibility has profound implications for patients whose urologic oncologists follow the MRI-first approach. If cancer is MRI-invisible, it means these men can avoid a transrectal biopsy, which means they won’t be exposed to risks like potentially deadly and disabling sepsis, and they won’t be diagnosed with prostate cancer, which means they won’t have to be treated or even go on AS, which can cause psychological and financial consequences along with exposures to serial biopsies. (Long sentence,)
Wigdor of course is in the Canadian health-care system, where it turns out he can he get a biopsy more quickly than an MRI. His PSA was rising, just above 4. He wanted answers ASAP. Most of us do.
(I was in a similar boat with a 3.95 PSA in the U.S. commercial insurance market 14 years ago at the age of 63. My internist freaked out and hustled me off to a urologist who did a biopsy on the spot.
(In those days, MRIs were just being introduced for the prostate in the U.S. And insurers then wouldn’t cover MRIs unless you were already diagnosed with PCa. So I had a post-biopsy MRI.)
“My family doctor was concerned with rising PSA. He referred me to a urologist, who ordered a second PSA and was concerned with the result. It was the urologist who sent me to Princess Margaret for the biopsy (and suggested I skip the MRI and go straight to the biopsy). It was only once I was diagnosed with cancer in one of the 12 cores that I went under the care of the urologic oncologist.
“Based on the results, he suggested that I go straight to a [transrectal] biopsy as it could be scheduled much more quickly than an MRI,” he said. “[The urologic oncologist] also felt that if an MRI showed something, I would need to get a biopsy anyway, so he figured we should just go straight to a definitive test.”
The biopsy found a small single core with Gleason 6. “All I understood from the result at the time was CANCER, and I wanted to treat it immediately. My urological oncologist strongly encouraged AS,” Wigdor recalled.
(I wonder, in the face of growing evidence of the value of MRI-first, if his urologist now would suggest waiting for an MRI-first? In the Gleason 6 racket, and most of the rest of the PCa world, there generally is no rush to judgment needed--though waits can be nerve-wracking.)
Wigdor is quite happy with his care.
(Ted Wigdor in Sintra, Portugal)
Wigdor came up empty on his MRI. So he had an MRI-blind lesion.
“Of course, hearing that I had cancer was scary and anxiety producing. However, with research and understanding of my situation, I'm over it now. My AS rigamarole is just regular PSA tests and follow up with my urologic oncologist.”
It should be noted that one of the biggest advocates for “MRI-invisibility is good place to be” is another Canadian, none other than the visionary Dr. Laurence Klotz, one of the developers of AS back in the late 1990s.
Klotz told me: “Several active surveillance cohorts have shown that the patients with invisible cancers on surveillance do drastically better than the ones who have visible cancers. The message is that invisible cancers have favorable genomics. They have an indolent natural history. You don't need to find them.”
Klotz said the concept of invisible lesions has been gaining traction recently with the emerging field of radiogenomics, correlating gene alterations in the tumor tissue and MRI invisibility.
He reported in the September issue of the Journal of Urology (https://www.auajournals.org/doi/full/10.1097/JU.0000000000004069) that recent radiogenomic analysis revealed that the genetic aberrations that account for tumor visibility on MRI are the same mutations linked with cancer invasion and metastasis. He said the implication is that invisible cancers are “genomically and clinically indolent and benign in their behavior.”
Wigdor understands and philosophically accepts the implications of what happened in his case: “Had the MRI been done first, I would never have had the biopsy so I wouldn't know that I have cancer. On one hand, I would be in blissful ignorance. Is that good or bad? I wouldn't be on AS since there would be no reason. That said, getting regular PSA tests and being monitored is probably a good thing. If my situation deteriorates, I'll know in plenty of time and it will be treated promptly.”
Different strokes for different folks.
Personally, I would have preferred to have been MRI-invisible and walked away from Active Surveillance. In fact, I experienced something similar—MRI revealed two lesions and a pathology exam showed only one. But within a year (ever since my diagnosis) I am MRi-lesion invisible and biopsy-invisible, too.
Wigdor has a different view, praising the virtues of both MRI-invisibility and AS.
“Truthfully, I don't mind being in this position,” he said. “This way, I'm being monitored by excellent doctors and getting the best care possible under my circumstances.”
Check out the first edition of the Prostate Cores Substack newsletter linked here. Why not subscribe?
ASPI seeking nominations for 2025 awards program
Active Surveillance Patients International (ASPI) is inviting the surveillance community to submit ideas for its fourth 2025 awards program.
The awards program includes the Chodak Award honoring the late Dr. Gerry Chodak, ASPI’s first medical advisor and a University of Chicago researcher who encouraged the development of early conservative approaches to prostate cancer.
Winners have included such pioneers as Dr. Laurence Klotz, of the University of Toronto, Dr.Peter Albertsen, of the University of Connecticut, and Dr. Peter Carroll, of the University of California, San Francisco. All were early advocates and researchers of the protocol now known as Active Surveillance.
(For videos on all awards presentations, go to: https://aspatients.org/awards/)
Two other awards are now presented:
--The ASPI Special Awards to groups or individuals who have made major contributions to AS research. Winners have included Drs. Freddie Hamdy and Jenny Donovan, who were the principal investigators of the landmark ProtecT trial, which proved the safety and effectiveness of AS, and the Michigan Urological Surgery Improvement Collaborative (MUSIC) for its success in demonstrating how AS can be widely accepted in small or large practices in the community or academic urology practices, alike.
--The ASPI Patient Advocacy Award is named for ASPI co-founder Thrainn Thorvaldsson, the first recipient, and E. Michael Scott, founder of Prostate Cancer International, an early advocate for AS even though he doesn’t have prostate cancer.
“If you have names of folks who have fought the headwinds, and showed courage in furthering AS, please send them to us with your justification,” said Mark Lichty, ASPI chairman and co-founder.
Send your nominations to contactus@aspatients.org by Jan. 31, 2025.