'Signs and wonders': The mystery of the disappearing prostate cancer lesions

By Howard Wolinsky

It’s happened to me. It happened to my friends Mark, Phil, and Dan. It seems it happens to many of us. We get diagnosed with Gleason 6 prostate cancer, and like a modern miracle, the cancer disappears.

Urologists claim that prostate cancer is hiding in plain sight—except they can’t find it. Typically, these men and women of science don’t believe that these wimpy, low-risk cancers can mount an immune response big enough to Hoover out that damned cancer.

Doctors prefer to believe that aggressive treatments cause partial or complete remissions.

Yet, some like Laurence Klotz, MD, one of the fathers of active surveillance, which is close monitoring of prostate cancer, believe the immune system can eliminate our lame-oid cancers. He uses the “R-word”—remission.

You can read about my case and that of retired Tampa banker Jim Simms, the “AS pioneer” from Tampa, here: https://www.medpagetoday.com/special-reports/apatientsjourney/81775

Meanwhile, the generation of patients flagged by MRIs are seeing some amazing things with PI-RADS 4 and 5, which trigger suspicions of more aggressive cancers but biopsies show nada. I know several men who had high PI-RADS readings and underwent fusion biopsies. They were expecting the worst—potentially recommendations for prostatectomies or radiation—only to be told there was no sign of cancer.

Poof. Gone.

Peter Lautz, a retired psychotherapist from the San Diego suburbs, wrote me: “I had an MRI of my prostate a few days ago. Just got results—interestingly the one lesion that’s been seen on 4 prior MRI’s since diagnosis in 2017 was not visible, even though it’s a PI-RAD 4. 

“And, 2 ‘new’ lesions never visible before, were seen in other parts of the gland. They each were rated as PI-RAD 4.  

“Have you heard of a lesion ‘disappearing’? 

“Do MRI’s miss things sometimes?

“And, more importantly, does a PI-RAD 4 score always or almost always designate a cancer?   I’m thinking this likely means I need treatment and if the MRI is accurate and now there are 2 or 3 lesions (likely cancerous) in different areas of the prostate focal treatment probably isn’t sufficient.” {I’ll share more stories like this soon.]

I asked columnist Antonio Westphalin, MD, of the University of Wahington, for his take. Here’s his report:

The Enigma of Disappearing Prostate Lesions

The Enigma of Disappearing Prostate Lesions

Dear readers,

In the complex realm of prostate health, a curious phenomenon has been brought to my attention – the disappearance of prostate lesions, particularly those labeled as PI-RADS 4 or 5.

Imagine undergoing multiple MRIs, each revealing a PI-RADS 4 lesion that seems to vanish on subsequent imaging. Is this a medical mystery, or is there a logical explanation? Let's delve into the possibilities.

One plausible reason for the disappearance of lesions lies in the dynamic nature of the prostate. Conditions like prostatitis, or inflammation of the prostate, can mimic the appearance of cancerous lesions on imaging. If the inflammation resolves or is treated, the once visible abnormality may indeed disappear, offering a sigh of relief for patients. An additional mimicker that resolves spontaneously is post-biopsy hemorrhage, which can persist for several weeks after the procedure.

Another factor contributing to this puzzle is the potential for disagreements in interpretation among radiologists. PI-RADS 4 and 5 designations suggest a moderate to high likelihood of cancer, but the subjective nature of imaging analysis can lead to discrepancies. A lesion deemed suspicious by one radiologist may be later characterized as benign by another, resulting in the apparent vanishing act.

Lastly, the possibility of oversight cannot be dismissed. Radiological readings are intricate, and even with advanced technology, the human element introduces the potential for missed details. A lesion may genuinely be present but escapes detection during a follow-up examination.

Now, the pressing question arises: Does a PI-RADS 4 or 5 score always indicate cancer? While a high PI-RADS score is indicative of a heightened suspicion for malignancy, it's crucial to recognize the spectrum of prostate conditions. False positives and misinterpretations can occur, emphasizing the importance of thorough evaluation and, if necessary, seeking a second opinion.

To those facing the uncertainty of disappearing lesions, it's advisable to consult with your healthcare team. Discuss the context of your specific case, explore potential contributing factors, and consider the implications for your treatment plan. Prostate health is a nuanced journey, and informed decision-making is a key ally in navigating its complexities.

In conclusion, the enigma of disappearing prostate lesions highlights the evolving nature of medical diagnoses. As we strive for clarity, understanding, and effective treatments, let us embrace the collaborative efforts of medical professionals and the resilience of those facing prostate health challenges.

Stay informed, stay proactive, and stay well.

Antontio Westphalen. MD

Dr. Antonio Westphalen is the Section Chief of abdominal imaging at the University of Washington and UW professor of radiology. Dr. Westphalen’s research interests are centered on the use of advanced imaging technologies to diagnose and treat patients with prostate cancer,

(Send your questions about AS and urology, radiology, pathology, sexual health, genomics, and lifestyle via email to mailto:pros8canswers@gmail.com, or just cut and paste pro8canswers@gmail.com

How a support session saved John’s prostate in the wake of a uro’s shocking conflict of interest

By Howard Wolinsky

We were discussing conflicts of interest on the part of physicians at a recent meeting of the Wednesday night virtual support group for Active Surveillance from AnCan Foundation.

You know: Does a doctor push for a prostatectomy or radiation therapy when he should be recommending active surveillance? Unfortunately, incentives like cash can rule.

I brought up the case of John, a man from the Chicago area, I had written about who was seeing a urologist who was pushing for radiation therapy by a radiation oncologist who worked for the urologist. Talk about a situation fraught with COI.

But the rad onc told John he didn’t need aggressive care. I referred John to a nearby urologic oncologist—who advocates active surveillance which reduces his revenue—at least in the short term and spares the patients from risks such as impotence and incontinence.

Well, lo and behold, a few days later John wrote me and Rick Davis, the founder of AnCan, an email of appreciation and an update.

With John; ‘s permission, I am reprinting his email here:

Dear Howard,

I am writing you a letter to let you know the absolute positive impact you and the AnCan group has had on my prostate cancer journey and consequently, my life.

After a blood test indicated a rise in PSA around 2 years ago this February, my primary care physician referred me to a urologist in the same “group” for further investigation. The urologist did a haphazard biopsy (no MRI, just poking around and pulling random samples of my prostate) and discovered I did indeed have cancer. Out of the 6 samples he took, only one showed malignancy, and my Gleason scores were low (3/3).

This urologist urged me to receive radiation seeding. I was anxious to get rid of anything cancerous in my body, so I decided on that course of action. Fortunately for me, my prostate was too large for this treatment, so I was urged to do spot radiation.

Around this time, we were advised to contact AnCan by a good friend who is an ovarian cancer survivor and an advocate for this group. I did contact them by phone, and spoke to Rick Davis who gave me the number of Howard Wolinsky.

Howard spoke to me at length about the perils of radiation seeding, spot radiation and even prostate removal, (especially with such low Gleason scores) and referred me to two of the best urologists in the country, one of whom happens to practice only a few miles from my home!

Dr. Brian Helfand was accessible, and assured me I did not need these therapies that would cause very possibly negative life changes for me due to my low Gleason scores. I enrolled in his Active Surveillance study to keep a watchful eye on my condition. He did a biopsy, first ordering an MRI to competently locate where the cancer actually was. I see Dr. Helfand every six months and my last blood test and exam showed everything is “stable.”

If not for Howard and AnCan, I likely would have undergone radical treatment that would have negatively impacted the rest of my life and suffered through “treatment remorse”. I offer a hearty thank you for Rick and Howard’s wonderful counsel and the many informative webinars AnCan provides. The Bible says, in Proverbs 15:22, that “Plans fail for lack of counsel, but with many advisors they succeed.”

True Words.

Thank You, AnCan!

Sincerely,

John McGeown

Shucks, John. Thanks. Join AnCan or other support groups to reduce stress and get advice from others who have walked this path.

Here’s my original story on John:

Only a month away. No excuses. What’re you waiting for? Sign up for ZERO support group on AS in March

By Howard Wolinsky

For the past three years, I have run a special Active Surveillance support group for ZERO. Last year, our virtual support meeting drew 60 patients to talk about AS. By far, it was the biggest session of any at the annual ZERO Summit.

Be there or be square: 11 a.m. Eastern on March 12, 2024.

Register in advance for this meeting:
https://us02web.zoom.us/meeting/register/tZUsfuqgrjIoG9AWf7voMhzT_UjdqbQQbQPA

ASPI webinar on how AI will decrease overdiagnosis and overtreatment of prostate cancer

AI, short for artificial intelligence, is in the headlines increasingly. Medical care is expected to receive the biggest benefits in the field, including prostate cancer.

Join Active Surveillance Patients International  (ASPI) on Feb. 24 at noon-1:30 p.m. Eastern to hear a panel talk about AI and how it will be affecting our lives as prostate cancer patients in a program entitled “How AI will decrease overdiagnosis and overtreatment of prostate cancer.”

CLICK HERE TO REGISTER

The panel includes:

—Niels Olson, MD, is a board-certified pathologist and the Chief Medical Officer at the Defense Innovation Unit in Mountain View, California. In this role, he oversees research programs in machine learning/AI for a broad spectrum of anatomic pathology applications, augmented reality microscopy, and artificial intelligence applications in radiology.

—Daniel Spratt, MD, Chair of radiation oncology at University Hospitals in Cleveland, who ordered Artera for Bruno. He says two-thirds of men making the transition to radiation can now avoid ADT and its serious side effects.

 —Tim Showalter, MD, MPH, is Chief Medical Officer at ArteraAI. He is a radiation oncologist and cancer researcher and a clinical professor at the University of Virginia. The Centers for Medicare and Medicaid Services recently set reimbursement rates for Artera AI.

—Bruno Barrey, a robotics engineer from suburban Detroit, who was able to avoid Androgen Deprivation Therapy because of an analysis by Artera AI as he transitioned from Active Surveillance to radiation treatment.

—A representative (TBA) for Immunis, a Detroit area AI developer, that is working on a test to guide men on deciding whether to go on Active Surveillance.

Send questions in advance to: mailto:pros8canswers@gmail.com, or just cut and paste pro8canswers@gmail.com