Watch and Wait

Watch and Wait: The Waiting Game

Carol Krucoff is a former Washington Post writer and editor, yoga teacher at Duke Integrative Medicine in Durham, N.C., and author of "Yoga Sparks: 108 Easy Practices for Stress Relief in a Minute or Less." Visit her website

Watching my little brain tumour grow slowly over the past decade has been an extraordinary exercise in courage, patience, gratitude, and faith. I learned about my tumour by accident in 2003 around my 50th birthday when I'd had an MRI scan after collapsing from drinking too much water during a marathon.

Fortunately, my tumour is a benign and generally slow-growing type called an acoustic neuroma. Located inside my skull on the nerve responsible for hearing and balance, it measured just three millimetres - about the size of a sesame seed - when discovered. Although I had no symptoms, an expert I consulted recommended two possible treatments: surgery to remove it or radiation to stop its growth. While this tumour wouldn't metastasize, its growth could impair my facial nerves, balance and hearing, or even threaten crucial brain function. She advised acting early when the tumour was small. Instead, I decided on a course of action known as "watch and wait."

Also called "expectant management," "active surveillance," and "watchful waiting," this involves closely monitoring an ailment but withholding treatment unless symptoms appear or progress. Often used with slow-growing or precancerous lesions and with conditions where treatment risks may outweigh benefits, this strategy does not mean doing nothing. It involves regular checkups - which could mean blood tests, biopsies or imaging scans, all involving some physical, emotional and financial stress. And it requires a tolerance for uncertainty, the willingness to live with something that could be a ticking time bomb or a harmless growth.

Over a decade of watchful waiting, I've had 10 MRIs. Each of these scans was followed by a hearing test and a meeting with my doctor. I'm grateful to have health insurance, which means - in the most recent case - I paid $160 coinsurance for the $3,579 MRI, and $50 for the $960 hearing test/doctor's appointment.

The emotional cost, however, is harder to calculate.

When first diagnosed, I immediately went on the Internet and learned that most acoustic neuromas are slow-growing - but others increase rapidly. Anytime I felt dizzy or had trouble hearing, I worried. I joined a support group and met a woman whose surgery to remove an asymptomatic two-millimeter tumour had left her with crippling headaches and facial pain. I logged on to the discussion forum on the Acoustic Neuroma Association's website and read horror stories of botched treatments as well as wonderful examples of excellent results. After several months of almost daily trips to the forum, I became overwhelmed by the anxiety these posts aroused and signed off.

I tried to remain calm over the years as I watched my tumour's creeping growth, at a rate of about one millimetre - the size of a grain of sugar - a year.

Navigating an emotional tightrope between responsible vigilance and anxious obsession, I gratefully clung to the fact that I had no symptoms. My hearing and balance seemed unaffected. My yoga practice proved extremely helpful since a central teaching is finding equilibrium - that steady place between effort and surrender - which is the key to watchful waiting. I found comfort in viewing the experience as an opportunity to cultivate gratitude and faith, and I meditated daily on visualising the dissolving of my tumour.

By 2006, about three years after it was discovered, my tumour had grown to six millimetres - about the size of a pea. At my doctor's urging, I met with a radiation oncologist, who recommended that I undergo radiation treatment intended to halt the growth. But since I was still asymptomatic and the tumour was still small, I chose to continue watchful waiting. I'd read that some tumours stop growing on their own, and I hoped this would be the case with mine.

In April 2013, based on an article I had written about the accidental discovery of my tumour, I was asked to testify before the Presidential Commission for the Study of Bioethical Issues at a meeting devoted to the ethical implications of incidental findings. Representing the patient's perspective, I told the panel, "As a health journalist I'd always thought there was a great benefit in early detection. However, my experience has made me question the wisdom of learning about an abnormality if all it offers is anxiety - as well as potential harm from treatments for something that might never affect my health."

Yet when a panel member asked me, "Do you really wish that you simply had never been told?" I had to admit, "Definitely no. If [the doctors] know, I want to know. I wouldn't want to be shielded for my own protection. That's my decision; this is my brain." I urged the panel to keep patients informed "in simple, direct language of what's been found and its implications for health" and to "consider adding a support person to the health-care team, such as a social worker or psychologist, to help the patient and their family process the information and decide on a course of action."

Ironically, four months after my testimony, I had my scheduled MRI and hearing tests and learned that my tumour measured 1.2 centimetres - about the size of a small walnut.

While I still had no symptoms, tests of my vestibular function - the sensory system that contributes to balance - on the affected side were abnormal even though I had not experienced balance problems. Continued growth would now mean a strong likelihood of negative effects on my hearing and facial nerves. A common way people learn of an acoustic neuroma is experiencing sudden, one-sided hearing loss, which may be permanent. So perhaps my incidental finding had been a blessing after all. It was time to take action.

I spent six weeks visiting brain surgeons and radiation oncologists, spoke with patients who had chosen each approach. I made the decision to have what is known as gamma knife radiosurgery.

In my decade of waiting, there had been significant advances in this minimally invasive treatment option, which uses imaging to direct gamma radiation very precisely to a target point. The radiation is designed to inactivate further growth of the tumour. In the large majority of cases it is successful, but sometimes the tumour continues to grow, and further treatment is necessary. And there are scary reports of rare instances where benign tumours turned malignant through radiation. Yet weighed against the potential risks of brain surgery - including a likely hearing loss in one ear - the gamma knife seemed right for me.

In February 2014, I had the morning-long outpatient procedure, which involved being given a mild sedative and having a head frame attached to my skull, then lying very still, similar to what you do while having an MRI. I left the hospital in the afternoon with gauze wrapped around my head, feeling just a little unsteady, and rested the next few days. By the following week, I felt fine, and I was back to teaching yoga.

MRI and hearing tests were done six months and then one year later showed that my hearing and the tumour were stable. Thankfully, I have felt no ill effects from the procedure, although I have been told that effects of radiation may emerge years later.

It could take at least two years after the radiosurgery to learn whether my tumour has stopped growing. After that, further scans are recommended at two, four and eight years. So I will be watching and waiting for some time. And I am not alone.

The boom in life expectancy - from about 47 years in 1900 to about 78 in 2012 - has resulted in an unprecedented "silver tsunami" of older adults, and technological advances mean an increased likelihood of finding some abnormality during those extra decades of life. While humans have always been aware of our mortality, we have never been able to see the approaching train that may take us out so clearly.

For me, this unsettling knowledge presents a spiritual opportunity. Like the ancient yogis who were taught to imagine death sitting on their shoulder, having a heightened awareness of impermanence can serve to make the present moment that much sweeter.

And in my case, watchful waiting involves more than my little brain tumour. As with the old joke "What do you always look for but hope never to find?" (Answer: a run in your stocking), I'm continually monitoring a variety of conditions. I have regular echocardiograms to check my prosthetic bovine aortic heart valve. (I acquired this valve during open-heart surgery in 2008 to replace a congenitally abnormal valve that had become dangerously narrow and created an aneurysm that needed repair.) I have twice-yearly examinations by a retina specialist for a potentially precancerous "eye freckle" called a choroidal nevus. A dermatologist checks multiple moles on my skin once or twice a year, and every five to 10 years I have a colonoscopy to check for polyps since there's a family history of colon cancer.

That said, I'm grateful to feel quite well, thank you. I walk my dog several miles every morning, practice yoga daily and teach yoga classes. My friends marvel at how such a healthy person can have such a long list of medical problems, and they often compliment me on my bravery.

The truth is, I've been terrified facing brain radiation, open-heart surgery, and other challenges, and I have had some dark moments. But I'm grateful to have wonderful family and friends to support me, and I don't want to weigh them or myself down with prolonged upset. Life is too short to waste precious time wallowing in worry.

And I've learned that courage isn't the absence of fear - it's being afraid, but doing what you need to do anyway.