Prostate Imaging with Color Doppler Ultrasound

BY MARK SCHOLZ, MD

Prostate cancer is the most common form of cancer in men. While some types are life-threatening others are not.  Recently the media have been reporting on serious concerns that have surfaced about men with the benign forms of the disease undergoing unnecessary radical treatment.  PSA screening has been receiving most of the blame, but the real problem is over reliance on random needle biopsies performed by an aggressive medical community made up of surgeons.

Significance of an Elevated PSA
An elevated PSA can occur as a result of any physical alteration of the environment in the prostate-- recent sexual activity, infection, cancer, and gland enlargement (BPH). A modest elevation of PSA is medically nonspecific. As one man explained, “Think of the Check Engine light on the dashboard of your car. It’s significant if it is ON, but further specifics need to be determined before taking any action.”

Time for a Random Biopsy?
PSA elevation typically triggers an immediate 12-core random biopsy. Presently, over a million men are undergoing biopsy every year at a cost of billions of dollars. Unfortunately, low grade prostate cancer is so prevalent in the general male population that a random biopsy will find prostate cancer 20% of the time, even when PSA is normal. Obviously a great preponderance of all this “cancer” must be harmless. After all, historical death rates from prostate cancer before 1987, when PSA screening first became available, were only 3%.

Damn the Possible Side Effects, Treat it Anyway
Cancer is a frightening word. To many, it portends death. Therefore it’s hardly surprising that both doctors and patients swing into immediate action when the biopsy shows CANCER. Amending and tempering words such as “low grade” or “microscopic” seem to produce no soothing affect whatsoever on the instinctual fears generated by this venomous diagnosis.   Despite the universal agreement of hundreds of prostate experts at a consensus conference back in 2007 which concluded that low-grade prostate cancer can be safely monitored, 85% of all men diagnosed still throw caution to the wind and get treatment anyway.

Imaging is “Blind” to Small Low-Grade Cancers
Back when doctors regarded all types of prostate cancer as universally dangerous, prostate imaging, which is prone to miss small, low-grade lesions, was deemed inadequate. However, with our modern perspective, knowing that only larger, higher-grade lesions are clinically relevant, imaging makes perfect sense. There are two types of prostate imaging: High-resolution Color Doppler Ultrasound, which is the subject of this blog, and multiparametric 3-Tesla MRI which was the subject of my last blog.

Color Doppler Ultrasound Imaging
It’s no longer appropriate to needle the prostate multiple times with the outdated belief that it’s essential to diagnose every tiny prostate cancer.  Practically speaking, only prostate cancers large enough to be “seen” (with imaging) need to be considered. Color Doppler Ultrasound scanning of the prostate is performed by a physician in the doctor’s office. It is actually two scans in one: Standard “Grey Scale” imaging and Color Doppler imaging to detect areas of increased blood flow.  First, ultrasound enables accurate measurement of the gland size. Second, from a cancer point of view, imaging with Color Doppler has three possible outcomes:   

A)   Completely clear

B)   An overtly suspicious lesion is detected

C)   Ambiguous lesion(s) are detected

Targeted Rather than Random Biopsies
When an overtly suspicious lesion is detected, a targeted biopsy (a limited number of cores aimed directly at the lesion) is typically recommended. Lesions that are biopsy-negative or show low-grade cancer are simply monitored.  When high-grade disease is diagnosed, a process of further staging followed by pertinent counseling about the different treatment options is initiated.

When to Biopsy Ambiguous Lesions
Expert judgment, with appropriate attention to the individual patient characteristics, comes into play during a discussion between patient and doctor about whether or not to do a targeted biopsy. Color Doppler “sees” all sorts of things including scar tissue, areas of active prostatitis, and nodular areas from BPH. A follow-up scan in six months to see if a lesion shows further growth may be preferred to immediate biopsy.  Lesion characteristics that raise greatest concern tend to be located in the peripheral zone of the prostate, and include lesions over a centimeter, lesions that bulge the prostate capsule and lesions that have increased blood flow.  Targeted biopsy is advised more frequently in men who are younger, are more anxious about missing cancer, and in men with PSA levels higher than they “should be” relative to the size of their prostate. 

“Cross Checking” Ambiguous Lesions with Multiparametric MRI
Color Doppler Ultrasound and Multiparametric MRI (MP-MRI) are complementary. In our experience the imaging findings match. However in a minority of cases one imaging modality will illuminate a specific lesion substantially more clearly. Therefore, in ambiguous cases, a combination of both modalities increases confidence that high-grade cancer isn’t being overlooked. Doing a second imaging procedure with MP-MRI is often preferable to doing an immediate biopsy.  If subsequently a targeted biopsy is deemed necessary, the additional imaging information obtained from MP-MRI may further increase the accuracy of the targeted biopsy.

Color Doppler for Monitoring Low-Grade Cancer
These days’ experts advise men with low-grade prostate cancer to forgo surgery or radiation and monitor their condition with Active Surveillance. The most common protocol used presently is regular PSA testing and periodic random biopsy. However, multiple random biopsies are associated with discomfort and progressive risk of serious infections and impotence.  Sequential monitoring of small lesions with Color Doppler to determine if they are growing or stable is a far more logical approach than subjecting men to repeated biopsies.

Final Thoughts
Men with elevated PSA, who initially undergo a Color Doppler, rather than random biopsy, are often spared biopsy altogether if their scan is clear.  Men who do require biopsy will need far fewer cores taken because the biopsy is targeted to a specific lesion within the gland. Men on Active Surveillance and men who have undergone previous treatment with surgery, radiation, cryotherapy, HIFU or hormone blockade are also candidates for Color Doppler Ultrasound to determine how well they are responding to treatment. 

So How Are You Doing Otherwise?

BY RALPH BLUM

At times, over these past decades, I have heard myself say, almost flippantly, about the chronic form of prostate cancer that I, and most men with the disease are dealing with, “Don’t worry—we’re going to die with it, not from it.” But in the meantime?

I almost had a bad fall last night. Barely recovered in time.  I notice I am increasingly wobbly. Unsteady. I lose my balance and barely recover to avoid what might have been a serious fall. Suddenly the world is full of sharp edges and uneven paths. What to do?

I know the rules about exercise. But my body, heading for 82, is noticeably less trustworthy than it was even a year ago. And because my knees and arms are not capable of their former range of exercise (stationary bike, yes, walking and treadmill, no) I can feel the constant ache and low-grade pain as my muscles proceed to atrophy. And while I know there is “armchair yoga,” it isn’t that easy to find a class, and I am less than enthusiastic to try it, so for now I am yoga-less. What to do?

My moaning is muffled. It could be so much worse!  has become one of my mantras, almost a prayer of thanks. I have one old friend, Jack, whose pacemaker, following a stroke, has helped his heart outlive his brain. His loving wife and friend of 43 years, Muriel, is still his aide and comforter, helping him to the toilet, changing his diaper, getting him back comfortably onto the couch, but, but . . .

Anton Chekhov, who died of tuberculosis in 1904, wrote: “Whenever there is someone in a family who has long been ill, and hopelessly ill, there come painful moments when all timidly, secretly, at the bottom of their hearts, long for his death.” The truth is, secretly, and at the bottom of her heart, Muriel would hope for that pacemaker in Jack’s chest to fail.

Which brings me to the troubling issue of American Medical Overdoing. All the advances are functioning to keep Jack functioning. Why? Because they can. Because someone is making money off stents, pacemakers, airport  defibrillators, 911 emergency assistance, insurance that pays for hugely expensive specialists. I can only tell you that Muriel, who has seen too many close friends losing control of their lives and slowly dying, keeps a copy of the Hemlock Society’s Final Exit, underlined in red, on her desk.

The problem is—and it’s the result of medical advances—the number of us who survive health crises that previously would have killed us, is growing rapidly. The eldest of us are the nation’s most rapidly growing age group. And, God help us, nearly one third of all Americans over 85 have some degree of dementia. At least half of them need someone’s help with daily, life-sustaining activities.

What makes my life worth living? Being able to peck out my thoughts on my Mac. Being able to share my thoughts with others who, I hope, will appreciate them. Being able to reach out to friends. To be of some small service to others who find themselves “in the same boat.” And maybe most important, not be too alarmed by death or its not so clandestine approach. As someone put it, “Nobody is really in charge except the marketplace.” And we wait for the bio-ethicists to have some impact on the opposite of over-kill. Maybe “over save-gate?” When does a life cease to be a life, and become a prolonged and agonizing dying? Sick enough to never get better? When indeed?

Prostate cancer and I have been working allies for almost a quarter of a century. Working my way through the thickets of fear and health concerns, having a black belt prostate oncologist, Dr. Mark Scholz as my guide, has left me far more conscious of health maintenance and wise options. I have to confess I am in some ways a healthier and happier man from living all these years with my cancerous prostate.

Multiparametric MRI Prostate Imaging

BY MARK SCHOLZ, MD

Historically, prostate imaging with CT, ultrasound or MRI has been too inaccurate for diagnosing prostate cancer.   Random needle biopsy has been the mainstay of accurate diagnosis. However, after a number of false starts, advances have brought multiparametric MRI (MP-MRI) into the winner’s circle, even surpassing the accuracy of random biopsy.

Prostate Imaging Presents a Special Challenge
Success with prostate imaging has been a long time coming. While mammography for breast imaging and CAT scans for lung cancer have enjoyed mainstream use for decades, the technology to differentiate the high-grade prostate cancers from harmless, low-grade prostate cancers—those that experts believe are better off being left undiagnosed—has only been developed recently.

New Technology Brings Growing Pains
You might think that new technological advances would immediately revolutionize prostate cancer management. Not necessarily. Many doctors simply don’t know what’s now available. Those that are aware are often unacquainted with the full extent of its capabilities. And finally, even the fully informed doctors may be reluctant to venture outside their comfort zone and embrace MP-MRI as a substitute for doing a random biopsy.

Barriers to Change—The Status Quo has Deep Roots
Random biopsy has been the de facto standard for 25 years.  Prior to MP-MRI, biopsy was the ONLY way to confirm the diagnosis of prostate cancer and obtain accurate information about its extent. Additionally, periodic random biopsy has been fundamental to the monitoring process in men with low-grade prostate cancer on Active Surveillance. Biopsy has grown to become a very big business, performed in more than a million men annually.  It is financially lucrative, paying thousands of dollars to providers for each procedure.

Ending the Twenty-five Year Reign of Random Biopsy
Random biopsy has major drawbacks. It misses high-grade cancer 15% of the time and 3% of men end up in the hospital with uncontrolled infections.  Repeat biopsies, such as those done to men on active surveillance are uncomfortable, affect erectile function and incur an even higher risk of infection. Most importantly, random biopsy over-diagnoses 100,000 men annually, leading to rampant and excessive use of surgery or radiation.

Imaging with Multiparametric MRI 
MP-MRI detects high-grade disease accurately and, thankfully, overlooks low grade disease, thus sparing the shock of an unnecessary cancer diagnosis and, in many cases, unwarranted treatment. Any suspicious lesions that are detected can be further investigated with a targeted biopsy, a more accurate way to find high-grade disease that requires far fewer biopsy cores. Men with a clear scan can usually forgo biopsy altogether. The word “Multi-parametric” means the performance of three scans sequentially during a single visit to the imaging center: 

1)    T2-weighted imaging allows for the best assessment of the prostate morphology, size, margins and internal structures with easy differentiation between the central and peripheral zones.

2)     Diffusion-weighted imaging details the tissue microstructure and generates an “apparent diffusion coefficient” (ADC) which helps to determine the aggressiveness of a lesion if one is seen.

3)    Dynamic contrast-enhanced imaging detects areas of increased vascularity to better detail any suspect lesions.

The radiologist who reads the scans unifies the information from all three modalities to compile a report. Findings are then summarized in an overall impression which falls into one of three categories:

First: No evidence for high grade disease, no need for biopsy

Second: A suspicious lesion is detected, a targeted biopsy is probably necessary

Third: An ambiguous area is detected. Either a targeted biopsy can be considered or alternatively, ongoing monitoring with another scan in 6-12 months can be considered

Scanning in the Context of Prostate Size, PSA and Age
Men’s prostates come in many sizes and shapes.  MP-MRI accurately measures prostate size, which is essential to interpreting PSA because an enlarged prostate produces higher PSA levels. An oversized gland, therefore, provides a reassuringly benign explanation for a modestly elevated PSA. Since many forms of prostate cancer take decades to grow large enough to present a problem, a man’s age is also relevant to the interpretation process. For example, elderly men with rather small ambiguous lesions (Third) might be advised to follow up with further scans to determine if it grows rather than going to a biopsy right away.   

Scanning at a Center of Excellence
Very few imaging centers can do prostate imaging at the level of quality we are discussing. There are essentially three components required to achieve reliable results: State-of-the-art, three-Tesla hardware; technicians who are precisely trained in how to perform prostate imaging; and physicians carefully trained specifically in the interpretation of prostate imaging. Imaging technology is developing so rapidly that even some board-certified radiologists remain unaware of what the latest technology can achieve.   

Don’t Be Cheated Out of the Best Technology
Today’s MP-MRI scans, when performed at centers of excellence, generate prostate images of stunning clarity. Every effort must be made to raise general awareness among patients and doctors alike about the advantages of MP-MRI over random biopsy in men with high PSA levels and in men who have been diagnosed with low-grade cancer that are pursuing Active Surveillance.   

Stress in Our Lives

BY RALPH BLUM

Sometimes stress leaves a path as distinct as a hurricane. Its onset can usually be tracked from the moment cancer is diagnosed.

If someone asked you if you were feeling stressed, and if so, what were the symptoms, how would you describe your condition? Signs of stress vary, and may be cognitive, emotional, physical, or behavioral. And often the symptoms overlap.

If we start with “cognitive” symptoms, we encounter difficulty concentrating, a negative approach to simple matters, anxious thoughts, excessive worrying, and unusual memory lapses.  When I was first diagnosed, I felt as if I was in a stupor. A daze. I lived in fear that my impaired memory and brain function would be noticed by the people I was working with. I was sensitive to loud noises. As one guy I know put it: “I couldn’t exercise at my gym because they had 8 TVs playing different stations and music piped through the entire exercise floor. The amount of information overload was more than my brain could handle. Too much sound and light made me feel both angry and anxious.”

Emotional symptoms are fairly obvious: Moodiness, and irritability, short temper, inability to relax, feeling overwhelmed and depressed. Some people have a sense of loneliness and isolation. Others feel a frightening loss of control. My stress made me feel paranoid. I took things personally that had nothing to do with me. I found myself overly sensitive to the criticism of other people.

If someone didn’t respond to a text or call me back immediately, I assumed they didn’t want to interact with me and didn’t want to be my friend. If someone didn’t smile or say “Hi” as I walked by I took it personally and began to analyze what I did wrong. I kept all my friends at arm’s length because of an inordinate fear of being rejected or not included.

Physical symptoms from stress are also very common. They vary from person to person and run the whole range:

• Aches and pains
• Diarrhea or constipation
• Chest pain, rapid heartbeat
• Frequent colds
• Indigestion\
• Loss of sex drive (whatever was left of it)
• Low blood sugar
• Nausea, dizziness

Behavioral symptoms present in a variety of ways, again depending on personality type. They would include irregular eating habits and sleep habits, neglecting responsibilities, isolating oneself. You can probably come up with other aspects of the “hurricane.” Just know that you are not going crazy, that the symptoms you are experiencing are normal for anyone after a diagnosis of prostate cancer, and that with proper counseling stress can be eased. Whether you choose to attend a Support Group, work with a therapist, find solace with prayer and meditation, or try Relaxation Therapy, it is important to do something to master your stress so that you can continue to manage your everyday life as well as make the right decisions to fight the cancer.