Howard Wolinsky, a journalist based in the Chicago area, was diagnosed with early prostate cancer in 2010 and chose an active surveillance management strategy. In an ongoing series of articles for 鶹ý, he describes how he came to that decision and his experiences since. In this report, Wolinsky reacts to a new finding of intraepithelial neoplasia.
This summer, I ended a 3-year vacation from prostate biopsies. I expected the best after years of good news.
In early August, my urologist, , of NorthShore University HealthSystem, called me with what he called "great news."
I wasn't so sure about that.
The overall picture was this: Helfand said the pathologist found "no evidence of malignancy" in slide after slide -- 13 all told.
But one biopsy stood out. So the news wasn't all great.
The pathologist reported: "Prostate gland, left mid, needle core biopsy: High-grade prostatic intraepithelial neoplasia."
Helfand explained that high-grade PIN cells are closer to being cancerous than normal. He said some consider high-grade PIN to be a precursor to cancer.
A high-grade PIN in anywhere from 4% to 8% of men who undergo prostate biopsies.
Almost half of all men have low- or high-grade PIN cells by the time they reach 50, according to the American Cancer Society.
"High-grade PIN is considered a pre-cancer of the prostate because it may turn into prostate cancer over time," the society said. "In most cases, high-grade prostatic intraepithelial neoplasia will not turn into cancer over the next several years. Still, the risk of getting cancer later is higher if high-grade PIN is found in more than one biopsy core."
Note the words: "more than one." I only had one. But as a patient, one core sounds like a legion. Your imagination can get the better of you.
In my case, since I already had a cancer diagnosis, the presence of high-grade PIN cells doesn't mean I have aggressive cancer there, Helfand said.
In the case of men not diagnosed with cancer, the presence of high-grade PIN cells doesn't mean cancer cells are there.
But Helfand said I shouldn't worry. In fact, he didn't recommend another biopsy for 2 or 3 years.
Still, high-grade PIN sounds ugly with the words "high grade" and "neoplasia."
Down this Road Before
High-grade PIN sounded familiar.
In fact, I was diagnosed with this before. In June 2010 when my PSA was rising, I underwent my first biopsy. The lab reported a high-grade PIN. I sensed grave concern on the part of my former urologist.
The lab sent my slides out for a second opinion to , a world authority on urologic pathology based at Johns Hopkins Hospital in Baltimore.
Epstein agreed with the high-grade PIN diagnosis in 2010 and recommended a follow-up biopsy. I was diagnosed with Gleason 6 in a single slide in a follow-up biopsy months later.
So 6 years later I found myself with high-grade PIN again. Despite Helfand's reassurances, I had some concerns.
So I decided to ask some pathologists I knew what they thought.
I met , in 2012 while researching an ebook on the future of pathology for the College of American Pathologists. Uthman is a thoughtful critic of his specialty. He is co-owner of , a popular pathology-oriented online discussion group.
His view of PIN? "I think PIN represents a general trend in pathology that is just now ending: diagnosing cancer earlier and earlier, to the point it is not even cancer. Now we are seeing blowback, especially in the case of breast pathology, where an analogous situation exists. (PIN in the prostate is like ductal carcinoma in situ in the breast.)"
I doubled back to Epstein, whose research has helped define high-grade PIN.
Even in the short time since my cancer was diagnosed, I learned that there had been a change in how high-grade PINs are viewed. As a result of Epstein's research, the pathologist downplays the significance of high-grade PIN.
In the 1990s, when maybe only four or six samples were taken, any abnormality was seen as worrisome. Now, with so many more core biopsies, there is less concern about discovering high-grade PINs.
Findings of high-grade PINs, especially a single one as in my case, are no longer considered such a big deal.
Epstein stressed that "high grade" as it refers to PIN is to separate it from "low-grade PIN," which has totally no significance. Also, he pointed out, "high-grade PIN" is not the same as "high-grade carcinoma," which indicates aggressive cancer.
Epstein said: "We are more relaxed around high-grade PIN. If there is only a single core with high-grade PIN, for the most part, there is no change in follow-up or management. If there are multiple cores with high-grade PIN, it is controversial."
He said some pathologists would do a repeat biopsy because there is a 40% chance of cancer. However, others would just follow without a repeat biopsy as most of the cancers found after high-grade PIN are low grade, which might require no treatment at all.
"In your case, given that you already were found to have cancer, I would not do anything based on finding more high-grade PIN on your repeat biopsy," he said. "You have cancer and it won't disappear, but it is small and hard to get on repeat biopsy, which is a good finding for keeping on active surveillance."
So, I am adjusting to my PIN cells and will stay on course with active surveillance. It was great news after all.
Meanwhile, after months of tracking, I found my 2010 slides in a lab in New Jersey and had them sent to NorthShore University. Helfand said he isn't ready yet to use up that smidgen of Gleason 6 tissue in tests that might determine how aggressive the tumor is.
Frankly, my cancer seems pretty laid back right now. I'll have my next PSA in 2017. I'm back on a biopsy vacation.