Advancing Urologic Cancer Treatment with Cutting-Edge Technology

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:04Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:09with the director of the
00:09 --> 00:11Yale Cancer Center, Doctor Eric
00:11 --> 00:11Winer.
00:12 --> 00:14Yale Cancer Answers features conversations
00:14 --> 00:15with oncologists
00:15 --> 00:17and specialists who are on
00:17 --> 00:18the forefront of the battle
00:18 --> 00:19to fight cancer.
00:19 --> 00:21This week, it's a conversation
00:21 --> 00:22about the care of patients
00:22 --> 00:24with urologic cancers with doctor
00:24 --> 00:25Preston Sprenkle.
00:26 --> 00:27Doctor Sprenkle is an associate
00:27 --> 00:29professor of urology at the
00:29 --> 00:30Yale School of Medicine.
00:31 --> 00:32Here's doctor Winer.
00:34 --> 00:36Why don't we start off
00:37 --> 00:39just hearing a little bit
00:39 --> 00:40about you
00:40 --> 00:42and how you got interested
00:42 --> 00:43in urologic cancers.
00:45 --> 00:47So I trained in urology
00:47 --> 00:49residency in New York and
00:50 --> 00:53was really impressed with the
00:53 --> 00:53complexity
00:54 --> 00:55of urologic
00:55 --> 00:57cancers and
00:58 --> 00:59the challenges that we face
00:59 --> 01:01when treating them.
01:02 --> 01:03I think it was
01:04 --> 01:05a lot of basic science,
01:05 --> 01:07the integration of science
01:07 --> 01:08in clinical medicine,
01:09 --> 01:09and,
01:11 --> 01:11really
01:12 --> 01:13how we were able to
01:14 --> 01:15try to integrate all these
01:17 --> 01:19complex technical issues with
01:19 --> 01:21patient care and
01:21 --> 01:22helping patients
01:23 --> 01:25and especially men with prostate
01:25 --> 01:25cancer
01:26 --> 01:27understand their diagnosis and make
01:27 --> 01:29good treatment decisions.
01:30 --> 01:31Since being at Yale,
01:32 --> 01:34this has grown from starting
01:34 --> 01:35an MRI
01:35 --> 01:38ultrasound fusion prostate biopsy program
01:38 --> 01:39to really be more accurate
01:39 --> 01:40in the way that we
01:40 --> 01:42diagnose prostate cancer,
01:42 --> 01:42limit
01:43 --> 01:44the number of men who
01:44 --> 01:45have to have a prostate
01:45 --> 01:47biopsy by using that
01:47 --> 01:48imaging.
01:48 --> 01:49And now
01:50 --> 01:52we've transitioned that
01:52 --> 01:53into
01:53 --> 01:55more precise treatments with prostate
01:55 --> 01:57cancer ablation therapies.
01:57 --> 01:59And we'll drill down
01:59 --> 02:01on some of those.
02:01 --> 02:03As a breast cancer doctor,
02:03 --> 02:05I often think of prostate
02:05 --> 02:05cancer as
02:08 --> 02:09the men's equivalent
02:09 --> 02:10of postmenopausal
02:10 --> 02:11breast cancer.
02:12 --> 02:13And I think it is
02:13 --> 02:15in a number of ways,
02:15 --> 02:16and one of those ways
02:16 --> 02:18is that prostate cancer isn't
02:18 --> 02:19just one disease.
02:20 --> 02:22It's really a range of
02:22 --> 02:23different diseases that
02:24 --> 02:25can vary from those that are
02:27 --> 02:27remarkably
02:28 --> 02:29slow growing
02:29 --> 02:30to those that are more
02:30 --> 02:31aggressive.
02:31 --> 02:32Can you just
02:33 --> 02:34talk a little bit about,
02:35 --> 02:37first, maybe the very slow
02:37 --> 02:39growing prostate cancers and
02:39 --> 02:41what does and doesn't have
02:41 --> 02:42to be done in terms
02:42 --> 02:43of treatment for some men?
02:43 --> 02:44Yeah. Thank you for
02:44 --> 02:46that question.
02:47 --> 02:48There's a tremendous
02:49 --> 02:50almost rainbow
02:51 --> 02:52of ways that we
02:52 --> 02:54interpret and manage prostate cancers,
02:56 --> 02:58a tremendous breadth. So low
02:58 --> 03:00grade prostate cancer, there is
03:00 --> 03:02an ongoing international discussion about
03:02 --> 03:03whether or not we should
03:03 --> 03:05be calling it prostate cancer
03:05 --> 03:06because it seems to have
03:07 --> 03:08such a low
03:09 --> 03:11likelihood of ever causing a
03:11 --> 03:13man's death that we follow
03:13 --> 03:15those routinely with something called
03:15 --> 03:16active surveillance.
03:18 --> 03:19It does not require treatment.
03:20 --> 03:22We monitor it closely so
03:22 --> 03:23that we can pick up
03:23 --> 03:24early if
03:24 --> 03:25it is one of those
03:25 --> 03:27very rare cases that
03:27 --> 03:28has the potential or will
03:28 --> 03:30behave more aggressively in the
03:30 --> 03:30future.
03:31 --> 03:33So that used to
03:33 --> 03:35be about half or more
03:35 --> 03:36than half of the prostate
03:36 --> 03:37cancers that we would diagnose
03:38 --> 03:40with now usage of better
03:40 --> 03:42screening techniques, including this MRI
03:42 --> 03:43imaging for the prostate.
03:44 --> 03:47At most academic centers, it's
03:47 --> 03:48now closer to about a
03:48 --> 03:49third. So we've been able
03:49 --> 03:51to avoid doing prostate biopsies
03:51 --> 03:52and diagnosing
03:52 --> 03:54these low grade cancers in
03:54 --> 03:55about a quarter of the
03:55 --> 03:56men that we used
03:56 --> 03:57to diagnose it in.
03:57 --> 03:59And I'm sure that
03:59 --> 04:01even when someone's told that
04:01 --> 04:02they have
04:02 --> 04:04low grade prostate cancer and
04:04 --> 04:05it's unlikely to cause their
04:05 --> 04:07death, it still causes some
04:07 --> 04:08amount of distress.
04:09 --> 04:11Definitely.
04:11 --> 04:12And that's one of
04:12 --> 04:14the largest challenges that we
04:14 --> 04:15have is how to
04:16 --> 04:18reassure these men
04:18 --> 04:19who have all of a
04:19 --> 04:21sudden gotten this cancer diagnosis
04:21 --> 04:22that this is not something
04:23 --> 04:25that is dangerous to them
04:25 --> 04:27and that in many cases,
04:27 --> 04:30the management or a treatment
04:30 --> 04:31for this prostate cancer
04:32 --> 04:33is probably worse than the
04:33 --> 04:35disease itself. And that is
04:35 --> 04:36one of the major challenges
04:36 --> 04:37that we have in
04:37 --> 04:37managing
04:38 --> 04:39prostate cancer.
04:39 --> 04:41Yeah. Well, here again is
04:41 --> 04:43the parallel with breast
04:43 --> 04:44cancer where
04:45 --> 04:47we recognize that for some
04:47 --> 04:49patients, we need new and
04:49 --> 04:50better therapies, and there are
04:50 --> 04:52still people who die of
04:52 --> 04:53breast cancer in much the
04:53 --> 04:54same way there are people
04:54 --> 04:56who die from prostate cancer.
04:56 --> 04:58But then there's a large
04:58 --> 04:59population where we need to
04:59 --> 05:00figure out
05:01 --> 05:02how we can do less
05:02 --> 05:04and achieve the same outcomes.
05:04 --> 05:06So when you're identifying
05:07 --> 05:08these patients who have
05:09 --> 05:11low grade prostate cancer, you
05:11 --> 05:12still use
05:13 --> 05:15a Gleason score?
05:15 --> 05:16And you wanna talk about
05:16 --> 05:17that a little bit?
05:17 --> 05:20We do. So the Gleason
05:21 --> 05:23scoring system has evolved somewhat.
05:23 --> 05:25We're now using
05:25 --> 05:26a Gleason grade grouping
05:27 --> 05:28system because
05:29 --> 05:31the historical Gleason score sort
05:31 --> 05:32of went from two to
05:32 --> 05:33ten, but
05:34 --> 05:35we only considered things of
05:35 --> 05:36a six or higher to
05:36 --> 05:37be cancer.
05:38 --> 05:39But intuitively, a six out
05:39 --> 05:41of ten seems bad. And
05:41 --> 05:42so even though that's the
05:42 --> 05:43lowest
05:43 --> 05:45grade.
05:46 --> 05:48So a concerted effort by
05:48 --> 05:50the International Society of Urologic
05:50 --> 05:50Pathology,
05:51 --> 05:53they regraded it or rebranded
05:53 --> 05:54it as a grade group
05:54 --> 05:55one through five. So now
05:55 --> 05:56we're on a five point
05:56 --> 05:57scale. A one out of
05:57 --> 05:59five is much more intuitively
05:59 --> 06:00kind of low risk and
06:00 --> 06:00low
06:01 --> 06:02grade. But there still is,
06:03 --> 06:04and there is actually an
06:04 --> 06:04effort
06:06 --> 06:07underway to reevaluate
06:07 --> 06:09Gleason, especially now that we
06:09 --> 06:10have a lot more genomic
06:10 --> 06:12information about prostate cancer.
06:12 --> 06:14There are efforts underway
06:14 --> 06:16to reevaluate that.
06:16 --> 06:18And is a Gleason six
06:18 --> 06:19the equivalent now of a one?
06:19 --> 06:21That is correct. Yep.
06:21 --> 06:22So grade group one is
06:22 --> 06:23a Gleason six. Grade group
06:23 --> 06:25two is a Gleason three
06:25 --> 06:26plus four equals seven. And
06:26 --> 06:27that was the other confusing
06:27 --> 06:28thing is you had a
06:28 --> 06:29three plus four equals seven
06:29 --> 06:30and a four plus three
06:30 --> 06:32equals seven. Those are now
06:32 --> 06:33grades one, two, and three.
06:33 --> 06:35So it's a little bit
06:35 --> 06:36more clear
06:36 --> 06:37for us to be able
06:37 --> 06:39to communicate.
06:43 --> 06:45Gleason six, or the new one, is
06:47 --> 06:49where you're very often
06:49 --> 06:51talking about active surveillance?
06:52 --> 06:53Correct.
06:53 --> 06:55All of the guidelines internationally
06:55 --> 06:56at this point for grade
06:56 --> 06:58group one or Gleason six
06:58 --> 07:00recommend active surveillance. They recommend
07:00 --> 07:02against treatment. And that is
07:02 --> 07:03because
07:03 --> 07:06the data suggests a greater
07:06 --> 07:07than ninety nine percent fifteen
07:07 --> 07:10year survival without any intervention
07:10 --> 07:12for men with the
07:12 --> 07:14grade group one prostate cancer.
07:15 --> 07:16So some of us are
07:17 --> 07:17very
07:18 --> 07:19adamant about not treating anyone
07:19 --> 07:21with Gleason six or grade
07:21 --> 07:22group one disease.
07:22 --> 07:23And as we've gained more
07:23 --> 07:25experience, we've actually expanded that
07:25 --> 07:26to a large percentage of
07:26 --> 07:27men with grade group two
07:27 --> 07:28prostate cancer
07:29 --> 07:30where we monitor them closely
07:30 --> 07:32but do not require initial
07:32 --> 07:32treatment.
07:33 --> 07:34And, of course, the reason
07:34 --> 07:35that you wanna try to
07:35 --> 07:37avoid treatment is there are
07:37 --> 07:38consequences.
07:38 --> 07:39And maybe this is a
07:39 --> 07:41good time for you to
07:41 --> 07:42just touch on
07:43 --> 07:44some of the problems that
07:44 --> 07:46arise after either
07:46 --> 07:47surgery
07:47 --> 07:49or radiation for prostate cancer.
07:51 --> 07:52You're
07:52 --> 07:53absolutely right. There are kind
07:53 --> 07:54of two main reasons not
07:54 --> 07:55to treat men with these
07:55 --> 07:57low and intermediate risk cancers.
07:57 --> 07:58One is we know that
07:58 --> 07:59it's not dangerous as we
07:59 --> 08:00are talking about. There now
08:00 --> 08:02are randomized clinical trials that
08:02 --> 08:04show really minimal or no
08:04 --> 08:06survival benefit to treating men
08:06 --> 08:07with low and intermediate risk
08:07 --> 08:09prostate cancer with fifteen and
08:09 --> 08:10even twenty years of follow-up.
08:11 --> 08:12In addition to the survival
08:12 --> 08:13safety,
08:14 --> 08:16any treatments that we perform
08:16 --> 08:18have significant or can have
08:18 --> 08:20significant quality of life impact.
08:20 --> 08:22So typically because of the
08:22 --> 08:24location of the prostate being
08:24 --> 08:25in the middle of the
08:25 --> 08:26pelvis, it's near the rectum,
08:26 --> 08:28it's near the bladder. The
08:28 --> 08:30urethra passes through the prostate.
08:30 --> 08:32So this is gonna impact
08:32 --> 08:33potentially a man's urinary function,
08:33 --> 08:34so their ability to hold
08:34 --> 08:36their urine, their sexual function,
08:36 --> 08:38their ability to get an
08:38 --> 08:39erection or ejaculate,
08:40 --> 08:42and also bowel function potentially
08:42 --> 08:44in like diarrhea or other
08:44 --> 08:44problems.
08:45 --> 08:47Surgery is most commonly associated
08:47 --> 08:49with urinary incontinence.
08:50 --> 08:51Radiation therapy
08:52 --> 08:54has significant concern for sort
08:54 --> 08:55of bowel dysfunction or
08:56 --> 08:58bowel function disruption.
08:59 --> 09:01And in terms of erectile
09:01 --> 09:04dysfunction, that's with both surgery
09:04 --> 09:05and radiation or
09:05 --> 09:08more surgery?
09:08 --> 09:09We're starting to get into
09:09 --> 09:10the details, which is great,
09:10 --> 09:12but it in large
09:12 --> 09:13part depends on
09:13 --> 09:14where the cancer is located.
09:14 --> 09:15So surgery
09:16 --> 09:17can be done where we
09:17 --> 09:18try to preserve the nerves
09:18 --> 09:19that are related to sexual
09:19 --> 09:20function,
09:20 --> 09:22but that depends largely on
09:22 --> 09:23if the cancer is near
09:23 --> 09:24those nerves. A primary goal
09:25 --> 09:26of treatment is to get
09:26 --> 09:28the cancer out.
09:28 --> 09:29And this is so called nerve sparing
09:29 --> 09:30prostatectomy?
09:30 --> 09:32Exactly. So with a
09:32 --> 09:34nerve sparing prostatectomy,
09:35 --> 09:37that is pretty equivalent in
09:37 --> 09:39terms of impact on sexual
09:39 --> 09:40function to radiation when we
09:40 --> 09:41look out to five years
09:41 --> 09:43and beyond. Before five years,
09:43 --> 09:45there's less impact with radiation,
09:45 --> 09:47but probably more impact with
09:47 --> 09:47surgery.
09:47 --> 09:48The issue is if you
09:48 --> 09:49start to have cancer where
09:49 --> 09:50we have to remove the
09:50 --> 09:52nerve bundles with surgery,
09:52 --> 09:53that has a much greater
09:53 --> 09:55negative impact on erectile function.
09:55 --> 09:57And that in part
09:57 --> 09:59is why there's a
09:59 --> 10:01growing interest in therapies like
10:01 --> 10:03ablation therapies for prostate cancer,
10:04 --> 10:05where now that we
10:05 --> 10:06have this great imaging and
10:06 --> 10:08ability to do targeted biopsy
10:08 --> 10:09of the prostate, we can
10:09 --> 10:11actually localize the cancers within
10:11 --> 10:12the prostate,
10:12 --> 10:13and we can now, with
10:13 --> 10:15some of these ablation technologies,
10:16 --> 10:17localize and treat the area
10:17 --> 10:19with the prostate cancer
10:19 --> 10:20and leave the rest of
10:20 --> 10:21the prostate alone.
10:21 --> 10:22Is that, on average, a much
10:22 --> 10:24lower rate of sexual dysfunction,
10:24 --> 10:26much lower rate of urinary
10:26 --> 10:28incontinence and bowel dysfunction
10:28 --> 10:30compared to surgery and radiation?
10:31 --> 10:33So this now opens up
10:33 --> 10:36the area of better tools
10:36 --> 10:38we have for both diagnosing
10:38 --> 10:39and treating.
10:41 --> 10:42And what's changed in terms of
10:42 --> 10:43diagnosis?
10:43 --> 10:44The biggest
10:45 --> 10:46change was
10:47 --> 10:49the more widespread adoption of
10:49 --> 10:51prostate MRI. So around two
10:51 --> 10:53thousand ten, two thousand twelve,
10:54 --> 10:55we began to really see
10:55 --> 10:56an uptick
10:57 --> 10:58globally in the utilization of
10:58 --> 10:59prostate MRI.
11:00 --> 11:01At that point, it was
11:01 --> 11:03largely done in very specialized
11:03 --> 11:04centers. We are very fortunate
11:04 --> 11:05at Yale to have very
11:05 --> 11:06experienced
11:06 --> 11:08radiologists who are focused on
11:08 --> 11:08prostate MRI.
11:09 --> 11:10It is now more widely
11:10 --> 11:12accepted and is
11:12 --> 11:13done broadly.
11:14 --> 11:16There still is dramatic variation
11:16 --> 11:17in the quality of prostate
11:17 --> 11:19MRI that's completed, but that
11:19 --> 11:20has really shifted the playing
11:20 --> 11:21field for us over the
11:21 --> 11:22last decade because it allows
11:22 --> 11:24us, like you mentioned earlier,
11:24 --> 11:25to be able to see
11:25 --> 11:26inside the prostate,
11:26 --> 11:28see where lesions are, and
11:28 --> 11:30more accurately diagnose
11:30 --> 11:32the cancer. So by putting
11:32 --> 11:34needles into the lesion, we're
11:34 --> 11:35much more accurate with our
11:35 --> 11:36biopsies,
11:36 --> 11:37and we know
11:38 --> 11:39what is there with more
11:39 --> 11:39confidence.
11:40 --> 11:41And does MRI and I
11:41 --> 11:42think you were mentioning this
11:42 --> 11:45before, does MRI help you
11:45 --> 11:47decide not to do biopsies
11:47 --> 11:47at times?
11:48 --> 11:50It does. Correct. So the
11:50 --> 11:52the major screening tool remains
11:52 --> 11:53a PSA blood test. So
11:53 --> 11:55that is our primary screening
11:55 --> 11:56tool
11:56 --> 11:58that is recommended but
11:58 --> 11:59the guidelines vary. It's a
11:59 --> 12:02shared decision making, so deciding
12:02 --> 12:03whether or not a man
12:03 --> 12:04wants to be screened.
12:04 --> 12:06But in general, that conversation
12:06 --> 12:07should happen starting around age
12:07 --> 12:09fifty to fifty five,
12:09 --> 12:11and that usually is a
12:11 --> 12:12PSA blood test. For people
12:12 --> 12:14with a first degree relative,
12:14 --> 12:15we would
12:15 --> 12:18suggest considering earlier prostate cancer
12:18 --> 12:18screening.
12:19 --> 12:20And in terms of
12:21 --> 12:24more accurately diagnosing the cancer,
12:24 --> 12:26these MRIs help that as
12:26 --> 12:28well so that if you're
12:28 --> 12:29planning to do a biopsy,
12:29 --> 12:30you can do it more
12:30 --> 12:32accurately with the use of
12:32 --> 12:33MRI.
12:33 --> 12:35Correct, the MRI allows us to look
12:35 --> 12:36inside the prostate. We can
12:36 --> 12:37see where a lesion is.
12:37 --> 12:38We can then
12:39 --> 12:40typically, have a 3D
12:40 --> 12:42modeling where we combine
12:42 --> 12:43the MRI with our real
12:43 --> 12:45time ultrasound. It allows us
12:45 --> 12:46to guide the needles for
12:46 --> 12:47a more accurate
12:47 --> 12:48biopsy.
12:48 --> 12:50And finally, before we take
12:50 --> 12:51just a a brief break,
12:53 --> 12:54I mentioned earlier that there
12:54 --> 12:55are more than two hundred
12:55 --> 12:56and fifty thousand cases,
12:57 --> 12:57but,
12:59 --> 13:00many of those are, of
13:00 --> 13:00course,
13:01 --> 13:02cases where
13:02 --> 13:03a man's life is not
13:03 --> 13:04threatened.
13:05 --> 13:07How many cases of prostate
13:07 --> 13:09cancer are there where you're
13:09 --> 13:10more worried
13:10 --> 13:11about
13:12 --> 13:14the potential impact on survival?
13:14 --> 13:15For that matter, how many
13:15 --> 13:16deaths a year?
13:17 --> 13:18Yes. So that is
13:18 --> 13:19a very good question. I
13:19 --> 13:21mean, I don't know the
13:21 --> 13:22exact number of deaths off
13:22 --> 13:23the top of my head.
13:23 --> 13:25It is pretty significant, though.
13:25 --> 13:26The last number I recall
13:26 --> 13:27was around probably twenty seven
13:27 --> 13:28thousand.
13:29 --> 13:31It is a percentage of
13:31 --> 13:31of the men who were
13:31 --> 13:32diagnosed.
13:32 --> 13:34It's really those with metastatic
13:34 --> 13:36prostate cancer that
13:36 --> 13:38we really worry about.
13:38 --> 13:40And that's why screening and
13:40 --> 13:41early detection is really, really
13:41 --> 13:43important. Finding this cancer before
13:43 --> 13:44its metastatic
13:44 --> 13:46allows us to intervene.
13:48 --> 13:49And in
13:49 --> 13:50many, many, of those
13:50 --> 13:52men, we can prevent the
13:52 --> 13:54development of metastatic disease. So,
13:54 --> 13:56again, a disease where sometimes
13:56 --> 13:58it's just very slow growing
13:58 --> 13:59and sometimes
13:59 --> 14:01more aggressive and still
14:01 --> 14:03a disease that
14:03 --> 14:04threatens quite a number of
14:04 --> 14:06people's lives. Well, we're gonna
14:06 --> 14:08take just a brief
14:08 --> 14:09break and we'll be back
14:09 --> 14:12and continue our discussion about
14:12 --> 14:14prostate cancer with doctor Preston
14:14 --> 14:14Sprenkle.
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14:22 --> 14:24Day celebration on June fifth.
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14:26 --> 14:27please reach out to canceranswers
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14:32 --> 14:33Breast cancer is one of
14:33 --> 14:34the most common cancers in
14:34 --> 14:36women. In Connecticut alone, approximately
14:37 --> 14:38three thousand five hundred women
14:38 --> 14:39will be diagnosed with breast
14:39 --> 14:41cancer this year, but there
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14:45 --> 14:45should schedule
14:50 --> 14:51a baseline mammogram
14:51 --> 14:52beginning at age forty or
14:52 --> 14:54earlier if they have risk
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14:56 --> 14:58With screening, early detection, and
14:58 --> 14:59a healthy
14:59 --> 15:01lifestyle, breast cancer can be
15:01 --> 15:01defeated.
15:02 --> 15:03Clinical trials are currently underway
15:03 --> 15:06at federally designated comprehensive cancer
15:06 --> 15:08centers, such as Yale Cancer
15:08 --> 15:10Center and Smilow Cancer
15:10 --> 15:10Hospital,
15:10 --> 15:12to make innovative new treatments
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15:14 --> 15:15Digital breast tomosynthesis
15:16 --> 15:17or three d mammography is
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15:23 --> 15:25while picking up more cancers.
15:25 --> 15:27More information is available at
15:27 --> 15:29yale cancer center dot org.
15:29 --> 15:31You're listening to Connecticut Public
15:31 --> 15:31Radio.
15:32 --> 15:33Good evening again. This is
15:33 --> 15:35Eric Winer with Yale Cancer
15:35 --> 15:37Answers. I'm joined tonight by
15:37 --> 15:40doctor Preston Sprenkle, a urologic
15:40 --> 15:40oncologist
15:41 --> 15:43and an associate professor in
15:43 --> 15:45urology here at Yale School
15:45 --> 15:46of Medicine.
15:46 --> 15:48We've been talking about prostate
15:48 --> 15:49cancer. We're gonna move on
15:49 --> 15:50and talk a little bit
15:50 --> 15:52about testicular cancer in just
15:52 --> 15:52a few minutes.
15:53 --> 15:55But, before we leave the
15:55 --> 15:56area of prostate cancer, I
15:56 --> 15:58wanna talk about
15:58 --> 15:58this
15:59 --> 16:00new approach,
16:01 --> 16:03that involves focal therapy
16:03 --> 16:05or doing something less than
16:06 --> 16:07treating the entire prostate,
16:08 --> 16:10when a man has cancer.
16:10 --> 16:11And,
16:11 --> 16:13maybe you can just touch
16:13 --> 16:14on this and how long
16:14 --> 16:15it's been going on and
16:16 --> 16:18how focal therapy is done.
16:19 --> 16:20Sure. Thank you.
16:21 --> 16:21So
16:22 --> 16:23focal therapy is an
16:24 --> 16:27exciting new intervention. It's actually
16:27 --> 16:28not that new. There have
16:28 --> 16:29been ablation
16:29 --> 16:30therapies
16:30 --> 16:32for prostate cancer for decades.
16:32 --> 16:33So one of the early
16:33 --> 16:34ones was cryoablation
16:35 --> 16:37or using cold energy to
16:37 --> 16:39destroy prostate tissue.
16:40 --> 16:40Initially,
16:41 --> 16:42we were doing whole prostate
16:42 --> 16:44treatments with this approach. And
16:44 --> 16:46at that time, it did
16:46 --> 16:48have less of the impact on
16:49 --> 16:52urinary continents than prostatectomy, and
16:52 --> 16:54so it was used not
16:54 --> 16:54infrequently.
16:55 --> 16:57As we gained more information
16:57 --> 16:59using MRI to
16:59 --> 17:00be able to localize prostate
17:00 --> 17:02cancer within the prostate,
17:03 --> 17:04the idea of focal therapy
17:04 --> 17:05or treating just part of
17:05 --> 17:07the prostate where the cancer
17:07 --> 17:08is located
17:10 --> 17:12became of more interest. And
17:12 --> 17:13this is something you mentioned in
17:13 --> 17:15breast cancer. You do lumpectomy.
17:15 --> 17:16In kidney cancer, we remove
17:16 --> 17:17just the tumor. We don't
17:17 --> 17:19remove the whole organ necessarily,
17:20 --> 17:21anymore now that we
17:21 --> 17:23can localize where the cancer
17:24 --> 17:25is in
17:25 --> 17:26the gland or in the organ.
17:27 --> 17:29So focal therapy for prostate
17:29 --> 17:31cancer has evolved. I've personally
17:31 --> 17:32been doing that for almost
17:32 --> 17:33ten years, with a combination
17:34 --> 17:34of cryoablation
17:35 --> 17:36and irreversible
17:36 --> 17:37electroporation.
17:37 --> 17:38These are both needle based
17:38 --> 17:39technologies
17:40 --> 17:40where
17:40 --> 17:42we can see the prostate
17:43 --> 17:44with the MRI. We localize
17:44 --> 17:46it with a targeted biopsy.
17:46 --> 17:47We localize the cancer within
17:47 --> 17:48the prostate,
17:48 --> 17:49and then we can use
17:49 --> 17:51those images and information to
17:51 --> 17:53place needles into the prostate
17:53 --> 17:54in the area where the
17:54 --> 17:55cancer is located and really
17:55 --> 17:57destroy that prostate tissue.
17:58 --> 17:59By leaving the urethra,
18:00 --> 18:01leaving the other side of
18:01 --> 18:02the prostate alone,
18:03 --> 18:05even potentially leaving both nerve
18:05 --> 18:07bundles alone, we see much
18:07 --> 18:09better preservation of quality of
18:09 --> 18:10life in terms of sexual
18:10 --> 18:12function, urinary function.
18:12 --> 18:13Now
18:13 --> 18:14while I've been doing these
18:14 --> 18:15technologies for ten years, they
18:15 --> 18:18are not widely accepted or
18:18 --> 18:19widely done around the country.
18:20 --> 18:22The technologies are still considered
18:22 --> 18:24investigational in many areas, and
18:24 --> 18:25so we do this as
18:25 --> 18:27part of an IRB approved
18:27 --> 18:30research registry. We're still tracking
18:30 --> 18:31the outcomes.
18:32 --> 18:33We're making sure that it
18:33 --> 18:34is safe. We're making sure
18:34 --> 18:35that the cancer control
18:35 --> 18:37is adequate and appropriate.
18:38 --> 18:38So I think it is
18:38 --> 18:40very exciting, but it's
18:40 --> 18:42not something that I think
18:42 --> 18:43at this point, is appropriate
18:43 --> 18:44for just anyone to be doing.
18:44 --> 18:47And reading the tea
18:47 --> 18:48leaves, do you think that
18:48 --> 18:50this is something that will be
18:51 --> 18:53done more widely in another
18:53 --> 18:54five to ten years?
18:54 --> 18:55I believe it will. We
18:55 --> 18:57just had our
18:57 --> 18:59International American Urological
18:59 --> 19:00Association meeting.
19:01 --> 19:02It was presented as one
19:02 --> 19:03of the plenary
19:04 --> 19:06lectures, and there is definitely
19:06 --> 19:07growing interest.
19:07 --> 19:08Those of us who've been
19:08 --> 19:09doing it for a while
19:09 --> 19:11do think it is approaching
19:11 --> 19:12sort of what we call
19:12 --> 19:13primetime.
19:13 --> 19:14It is almost ready for
19:15 --> 19:15wider
19:15 --> 19:17distribution and dissemination
19:17 --> 19:19as the quality controls
19:19 --> 19:21are being better put into
19:21 --> 19:21place.
19:22 --> 19:23But just
19:24 --> 19:26an educated guess, this is
19:26 --> 19:28not something that is for
19:28 --> 19:29a patient who has
19:29 --> 19:32more locally advanced prostate cancer
19:32 --> 19:32or
19:33 --> 19:35maybe somebody who has a
19:35 --> 19:37more aggressive subtype of prostate
19:37 --> 19:37cancer?
19:38 --> 19:39You're absolutely right. I mean,
19:39 --> 19:41at this point,
19:42 --> 19:43this is not for everyone.
19:43 --> 19:44So an ablation therapy is
19:44 --> 19:45not for when there are
19:45 --> 19:46a lot of anatomic considerations
19:46 --> 19:49in addition to cancer aggressiveness
19:49 --> 19:49considerations.
19:50 --> 19:51We currently only recommend this
19:51 --> 19:53really for men with intermediate
19:53 --> 19:55risk prostate cancer. There is
19:55 --> 19:56not a role at this
19:56 --> 19:57time for
19:58 --> 19:59treating high risk disease, although
19:59 --> 20:01there are some clinical trials
20:03 --> 20:04evolving in those areas.
20:04 --> 20:06So even as part of
20:06 --> 20:06the research,
20:07 --> 20:08one has to be quite
20:08 --> 20:08selective.
20:09 --> 20:10That is correct.
20:10 --> 20:11Good.
20:11 --> 20:13And then finally,
20:14 --> 20:16there are still many men
20:16 --> 20:17who need to have their
20:17 --> 20:19prostate removed when diagnosed with
20:19 --> 20:20prostate cancer.
20:21 --> 20:24And sometimes an alternative is
20:24 --> 20:25radiation. How do you make
20:25 --> 20:26those decisions?
20:27 --> 20:29So radiation and surgery very
20:29 --> 20:30often are considered
20:30 --> 20:32to have pretty equivalent cancer
20:32 --> 20:33control.
20:33 --> 20:34So it largely is a
20:34 --> 20:36very personal decision of the
20:36 --> 20:37patient
20:37 --> 20:39and comparing the quality of
20:39 --> 20:41life impact of the different
20:41 --> 20:42treatment approaches.
20:44 --> 20:45It's a long discussion,
20:46 --> 20:47but in brief, we sort
20:47 --> 20:48of compare the impact on
20:48 --> 20:50urinary function, impact on sexual
20:50 --> 20:52function, the duration of treatment,
20:52 --> 20:53the recovery from treatment,
20:54 --> 20:55what are some of the
20:55 --> 20:56long term consequences that you
20:56 --> 20:58can expect from the treatment.
20:58 --> 20:58But it often is
20:58 --> 21:00focused on quality of life
21:00 --> 21:00factors,
21:01 --> 21:02since the cancer control is
21:02 --> 21:04relatively similar.
21:06 --> 21:07Well, we're gonna move
21:07 --> 21:09on and talk a little
21:09 --> 21:11bit about testicular cancer.
21:12 --> 21:13Testicular cancer,
21:13 --> 21:16unlike prostate cancer, which predominantly
21:17 --> 21:18is a disease in
21:19 --> 21:20middle aged or older men,
21:20 --> 21:22though it can occasionally happen
21:22 --> 21:24in people in their forties
21:24 --> 21:26and younger, but quite rarely.
21:27 --> 21:29Testicular cancer is quite different.
21:30 --> 21:30There
21:31 --> 21:33are under ten thousand cases
21:33 --> 21:34a year in the US,
21:34 --> 21:36and the average age is
21:36 --> 21:37thirty three.
21:37 --> 21:38So this is a cancer
21:38 --> 21:40of young men.
21:40 --> 21:41And,
21:42 --> 21:43maybe you can just
21:44 --> 21:45talk a little bit about
21:46 --> 21:48what often brings someone in
21:49 --> 21:50with a new diagnosis of
21:50 --> 21:51testicular cancer.
21:52 --> 21:53In general, there isn't a
21:53 --> 21:55lot of screening that goes on.
21:56 --> 21:57Correct. So there
21:57 --> 21:59is not a
21:59 --> 22:02systematic screening that is done
22:02 --> 22:03by a health care provider
22:03 --> 22:04typically, although
22:04 --> 22:06and that's largely because testicular
22:06 --> 22:07cancers,
22:07 --> 22:08when they do occur,
22:09 --> 22:10tend to be very
22:10 --> 22:12fast growing and present rather
22:12 --> 22:13quickly.
22:14 --> 22:15There is screening that can
22:15 --> 22:17be done. So young men
22:17 --> 22:18starting in their late teens
22:19 --> 22:20should do testicular
22:20 --> 22:22self exams probably on a
22:22 --> 22:23monthly basis.
22:24 --> 22:25And that is honestly how
22:25 --> 22:26men present. So it is
22:26 --> 22:29a new mass that they
22:29 --> 22:31feel in the testicle or
22:31 --> 22:32in their scrotum.
22:32 --> 22:33That is the most common
22:33 --> 22:34presentation.
22:35 --> 22:37And it can be picked
22:37 --> 22:38up early if someone is
22:38 --> 22:40doing a routine testicular self
22:40 --> 22:42exam. But I'm gonna guess
22:42 --> 22:44that most young men don't
22:44 --> 22:45do that routinely and that
22:45 --> 22:47when they find this, it's
22:47 --> 22:47just
22:48 --> 22:49almost an accident.
22:51 --> 22:52That is often the case.
22:52 --> 22:53Yes. And that's why we
22:54 --> 22:55attempt to
22:56 --> 22:59engage young men and pediatricians
22:59 --> 23:00to educate young men. And
23:00 --> 23:01there is
23:01 --> 23:04outreach on college campuses to
23:04 --> 23:05sort of tell guys
23:05 --> 23:07or instruct guys on how
23:07 --> 23:08to do a testicular self
23:08 --> 23:10exam. But you're correct. Most
23:10 --> 23:11often it is
23:11 --> 23:13something that it's hard to
23:13 --> 23:14miss and you note a
23:15 --> 23:16change in the testicle or on it.
23:19 --> 23:20And there are
23:21 --> 23:22a few different types of
23:22 --> 23:23prostate cancer,
23:23 --> 23:24some of which are
23:25 --> 23:27potentially more aggressive than others,
23:28 --> 23:29typically
23:30 --> 23:33divided as seminomas and non
23:33 --> 23:34seminomonas cancers.
23:35 --> 23:37Correct. Yeah. So testicular cancer
23:37 --> 23:39has two large subgroups and
23:39 --> 23:40there are other small subgroups.
23:41 --> 23:42Seminoma
23:45 --> 23:46is the most prevalent or
23:46 --> 23:48most common type of testicular
23:48 --> 23:50cancer, and then we cluster
23:50 --> 23:51a bunch of the others,
23:51 --> 23:52embryonal,
23:54 --> 23:56and others into yolk sac
23:56 --> 23:57into nonseminoma.
23:57 --> 23:59And that's because the prognosis
23:59 --> 24:01with seminoma is quite good.
24:01 --> 24:02The way that we treat
24:02 --> 24:03them are a little bit
24:03 --> 24:04different, but pure seminoma
24:04 --> 24:06is often cured just by
24:06 --> 24:08removal of the tumor alone.
24:09 --> 24:11Whereas non seminoma can
24:11 --> 24:12also often be cured by
24:12 --> 24:13that alone, but has a
24:13 --> 24:15slightly higher rate of
24:15 --> 24:17recurrence and needing additional treatment.
24:19 --> 24:21Testicular cancer, in truth, was
24:21 --> 24:21the
24:22 --> 24:22original
24:23 --> 24:25huge success in medical oncology.
24:25 --> 24:27It's the one tumor type,
24:28 --> 24:29albeit rare,
24:29 --> 24:30that
24:30 --> 24:32early studies with chemotherapy
24:32 --> 24:33demonstrated
24:33 --> 24:35that you could dramatically
24:36 --> 24:37increase the cure rate
24:38 --> 24:39with the use of chemotherapy
24:40 --> 24:40in these
24:41 --> 24:43germ cell tumors, the non
24:43 --> 24:45seminomonas cancers.
24:46 --> 24:47Correct. Yes.
24:47 --> 24:48Chemotherapy
24:48 --> 24:50use, especially in non seminoma,
24:51 --> 24:53because initially we use radiation
24:53 --> 24:55therapy for seminoma. That has
24:55 --> 24:57changed now. We now will
24:57 --> 24:59often use chemotherapy for seminoma
24:59 --> 24:59as well.
25:00 --> 25:02But, yes, it absolutely was
25:02 --> 25:04one of our great success
25:04 --> 25:07stories in in oncology, especially
25:07 --> 25:08because patients are young,
25:08 --> 25:10and we're able to have
25:10 --> 25:12very, very high treatment success
25:12 --> 25:14rates. I think the caveat
25:14 --> 25:15to that, I mean, it's
25:15 --> 25:17excellent that we're able to,
25:18 --> 25:18you know, save
25:19 --> 25:20many people and keep them
25:20 --> 25:20alive.
25:21 --> 25:22But
25:22 --> 25:23I still need to make
25:23 --> 25:25a plug for early detection
25:25 --> 25:26because when we find these ealry
25:28 --> 25:29and we can treat them
25:29 --> 25:30with surgery alone, we don't
25:30 --> 25:31have to give chemotherapy.
25:32 --> 25:33And the longer that we
25:33 --> 25:34wait, the worse the cancer
25:34 --> 25:36is, the more chemotherapy is
25:36 --> 25:37needed and the more chemotherapy,
25:38 --> 25:39again, the more side effects.
25:39 --> 25:41And especially in young men
25:41 --> 25:43who have a long time
25:43 --> 25:44to live after treatment,
25:44 --> 25:46we do unfortunately see that
25:46 --> 25:47secondary cancers and other problems
25:47 --> 25:49can develop when we have
25:49 --> 25:51to give more chemotherapy. So,
25:52 --> 25:53still is very important to
25:53 --> 25:54kind of if you hear
25:54 --> 25:55this, if you're a young
25:55 --> 25:57man, you know, testicular self
25:57 --> 25:58exam is something you could
25:58 --> 25:59do in the shower once
25:59 --> 26:01a month. It's not difficult.
26:01 --> 26:02Doesn't take much time.
26:03 --> 26:04And, it can definitely
26:06 --> 26:07you know, if God
26:07 --> 26:09forbid, something happened,
26:09 --> 26:10by detecting it
26:10 --> 26:11early, it can help prevent
26:12 --> 26:13a lot of
26:13 --> 26:14difficulty down the road. I
26:14 --> 26:16think it's a really important
26:16 --> 26:17message because the chemotherapy,
26:18 --> 26:19while
26:19 --> 26:19relatively
26:20 --> 26:22brief, meaning a few months,
26:23 --> 26:24is not for the faint
26:24 --> 26:25of heart.
26:26 --> 26:27And it's tough chemotherapy
26:28 --> 26:29and no one wants to
26:29 --> 26:30get it if they can
26:30 --> 26:32manage to avoid it.
26:32 --> 26:33And I think, you know,
26:33 --> 26:35the other message is
26:35 --> 26:36because
26:36 --> 26:38young people tend to sometimes
26:38 --> 26:40put things off is if
26:40 --> 26:41someone finds something, they need
26:41 --> 26:44to take action
26:44 --> 26:45and see their doctor
26:46 --> 26:47and not just wait until
26:47 --> 26:49it gets bigger and bigger.
26:49 --> 26:51Correct. And it's very easy
26:51 --> 26:51for us to do an
26:51 --> 26:53evaluation. So it's a quick
26:53 --> 26:54physical exam to see if
26:54 --> 26:55we feel something in the
26:55 --> 26:57testicle and then an ultrasound.
26:57 --> 26:58So it's a really noninvasive
26:58 --> 27:00initial diagnostic evaluation.
27:01 --> 27:02Yes.
27:02 --> 27:04Well, that's important.
27:05 --> 27:06And what are some of
27:06 --> 27:07the things that
27:07 --> 27:10can masquerade as testicular cancer?
27:10 --> 27:11So what other kinds of
27:11 --> 27:13lumps arise in the testis?
27:14 --> 27:14There can be a lot
27:14 --> 27:15of lumps and bumps in
27:15 --> 27:16the testis. So, you know,
27:16 --> 27:18very commonly there can be
27:18 --> 27:19a cyst, in the epididymis,
27:20 --> 27:21which is something that sits
27:21 --> 27:23right behind the testicle. You
27:23 --> 27:24can even have a cyst
27:24 --> 27:24in the testicle,
27:26 --> 27:27varicocele
27:27 --> 27:29sort of this bag of
27:29 --> 27:31worms feeling that people describe
27:31 --> 27:32as just a vein that's
27:32 --> 27:32in the scrotum.
27:33 --> 27:35So there are other things
27:35 --> 27:36that can definitely masquerade as
27:36 --> 27:38a testicular cancer,
27:38 --> 27:40but, again, all of those
27:40 --> 27:41can pretty easily be differentiated
27:41 --> 27:43with a scrotal ultrasound. So
27:43 --> 27:44if you feel something that's
27:44 --> 27:45abnormal,
27:45 --> 27:47just get it checked out.
27:47 --> 27:49And this is a situation
27:49 --> 27:51where you're not doing things
27:51 --> 27:53like focal ablative therapy. You're
27:53 --> 27:54doing surgery.
27:55 --> 27:57If someone has testicular cancer,
27:57 --> 27:59what does the surgery
27:59 --> 27:59involve?
28:01 --> 28:01So
28:01 --> 28:03the surgery for testicular cancer
28:04 --> 28:05is often
28:05 --> 28:06removal
28:06 --> 28:08of the involved testicle. So
28:08 --> 28:09a surgical removal of the
28:09 --> 28:10involved testicle.
28:12 --> 28:13Men have two
28:13 --> 28:14testicles typically,
28:15 --> 28:16and
28:16 --> 28:17so removing one does not
28:17 --> 28:20appear to change the
28:20 --> 28:22fertility risk or change
28:23 --> 28:23testosterone
28:23 --> 28:24levels.
28:24 --> 28:25So
28:25 --> 28:26if there is someone who
28:26 --> 28:28has only one testicle, we
28:28 --> 28:28will consider
28:29 --> 28:30doing a partial
28:30 --> 28:32orchiectomy, removing just the tumor,
28:32 --> 28:33but that's a very rare
28:33 --> 28:34occurrence.
28:34 --> 28:36Doctor Preston Sprenkle is an
28:36 --> 28:38associate professor of urology at
28:38 --> 28:39the Yale School of Medicine.
28:40 --> 28:41If you have questions, the
28:41 --> 28:42address is canceranswers
28:43 --> 28:44at yale dot edu,
28:44 --> 28:46and past editions of the
28:46 --> 28:48program are available in audio
28:48 --> 28:49and written form at yale
28:49 --> 28:50cancer center dot org.
28:51 --> 28:52We hope you'll join us
28:52 --> 28:53next time to learn more
28:53 --> 28:54about the fight against cancer.
28:55 --> 28:56Funding for Yale Cancer Answers
28:56 --> 28:58is provided by Smilow Cancer
28:58 --> 28:59Hospital.

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Advancing Urologic Cancer Treatment with Cutting-Edge Technology with guest Dr. Preston Sprenkle May 18, 2025

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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Dr. Preston Sprenkle

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