Men’s Health Month & Navigating a Cancer Diagnosis

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Funding for Yale Cancer Answers is provided by Smilow Cancer Hospital. Welcome to Yale Cancer Answers with the director of the Yale Cancer Center, Dr. Eric Winer. Yale Cancer Answers features conversations with oncologists and specialists who are on the forefront of the battle to fight cancer. Here's Dr. Winer. 

Dr. Winer
We are still in June, which is Men's Health Month, which is a reminder for men to focus more on prioritizing their health, getting necessary cancer screenings done, and seeking medical attention when needed. That being said, it's also a great time to talk about what patients should know about receiving a cancer diagnosis and steps they can take to be better informed about the process. It was just several weeks ago we also learned of former President Joe Biden's prostate cancer diagnosis — with the cancer having spread to his bones.

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Dr. Winer
Prostate cancer is the most common cancer type in men, with one in eight American men being diagnosed sometime during their lifetime. Often in the later years of their life. This sets the stage for our guest tonight, Dr. William Oh, director of precision medicine for Yale Cancer Center and the service line, medical director of Smilow Cancer Hospital at Greenwich.

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Dr. Winer
Dr. Oh, who I've known for probably close to three decades, is a genitourinary oncologist who specializes in prostate cancer. William, welcome to the show. Thanks for being here.

Dr. Oh
Thank you, Eric. It's my pleasure to be on and happy to talk more about this really important subject.

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Dr. Winer
Yeah, no, it clearly is. So receiving a cancer diagnosis can be pretty overwhelming for patients and for their families. What general advice do you have? And we're going to drill down and talk about prostate cancer in just a few minutes. But for any patient with cancer facing a cancer diagnosis, what would you tell them in terms of dealing with the diagnosis and the first few steps they should take?

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Dr. Oh
Well, everyone processes this information differently, Eric, but I think my approach is that information demystifies many of the myths and confusion around diagnoses like cancer. So I am a big fan of getting good information from the right types of sources. The problem, of course, as you know, is we are bombarded with information everywhere, including the Internet and your next door neighbor and so on.

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And I think the most important thing and why are seeing the right specialist to get that information is so important to help you and your family make the right decisions and guide your therapy. The good news is we've made so many advances. When you said three decades, I should add a little because time goes by so quickly. But it's always it's always been a privilege to work with you.

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Dr. Oh
And I'm really excited to be here at Yale now the last nine months working on these important initiatives. But I think so much has changed, as you know, in the fields we take care of and in cancer in general. So I'm truly optimistic about how information can be delivered and help patients to deal with what is still a terrible and devastating diagnosis of cancer.

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Dr. Winer
Yeah, no, absolutely. And just for the audience, there don't have to think that we, you know, met going on vacation or something. But both William and I worked at Dana-Farber Cancer Institute for many years. So let's talk about prostate cancer. And first, maybe we can talk about prostate cancer screening because this is a topic that has been somewhat controversial for a long time.

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Dr. Winer
And maybe you could tell us in 2025 what the recommendations are for for men in terms of prostate cancer screening, both when they should have it, how often they should have it, and what are the tests that should be done? 

Dr. Oh
Yeah, it's it is confusing and it's really an evolving field. But generally speaking, after the age of 50, men should talk to their doctors about whether they are a candidate for screening this.

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The U.S. Preventive Services Task Force leads the kind of conversation about screening. And right now, their official recommendation is that men between the ages of 55 and 70 should discuss with their doctor whether they should get a a screening test, which is a PSA blood test. And that's a narrow window. So they don't say anything about less than 55 and over 70, well over 70.

00;05;22;00 - 00;05;46;08They explicitly recommend against screening, which was very controversial. And I think will be very relevant to our conversation about Joe Biden. And under the age of 55. They do say that high risk patients should consider earlier screening, but they don't give very clear guidelines. Now, even though the U.S. Preventative Services Task Force is considered a quasi-governmental and maybe the most important organization.

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Unknown
There are many other organizations that have guidelines that are slightly different. For example, the American Cancer Society, the National Cancer Comprehensive Network, and can at the AOA, the American Urological Association. And this is part of the problem. You know, I wrote an editorial saying how can guidelines, how can guidelines give clearer guidance? Because how are patients supposed to know what to do if the doctors can't always agree?

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Unknown
But I do think that there's very something very simple here. In general, you do not need a digital rectal exam, which a lot of men do not want to have, and which may scare them away from seeing their doctors. It diaries are really that's the finger exam and it it's not very sensitive. So it's really not an important first step.

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Unknown
The first step is very simple, very cheap blood test that your primary care doctor can order or your urologist. And if you do have high risk and right now, high risk is defined as black men in the United States or men with a family history. And those men should be screened in their forties, starting in their forties. They should get their first PSA test and certainly entrapped by family history.

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Dr. Winer
You know, let's imagine my 88-year-old father was told he had prostate cancer. Is that a positive family history? 

Dr. Oh
Well, if he and his four brothers had it, that could be considered a positive family history. But you're right. I mean, if you have a very strong family history and your dad had prostate cancer in his forties or fifties, that would signify the possibility of a genetic risk.

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Dr. Oh
The other family history that's relevant here is, as you know, you're a breast cancer doctor. I'm a prostate cancer doctor. And people don't always realize that those cancers can be linked by genetics so that the same genes, the so-called BRCA type genes, BRCA one and two, might lead to a diagnosis of breast cancer in a younger woman and prostate cancer in a younger man.

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Dr. Oh
So family history is depends a little bit on what that history looks like. And it's true. What you're pointing out is many men, as they get older, might have a little bit of cancer in their prostate. But what we've learned over the last few decades since I've been in this field is it's much better to kind of get the test and then figure out what to do with it afterwards rather than just ignore the test.

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Dr. Oh
And again, when we talk about Joe Biden, that'll be a very good illustrative example of where we've gone to kind of understand how not to treat everyone the same. Yeah, And you mentioned the various other organizations that have recommendations. 

Dr. Winer
What is the youngest age that any of them recommend screening for somebody who doesn't have a family history? Or is not black or African-American.

Dr. Oh
Generally for the average risk person without those high risk features, 50 would be the recommendation for the first PSA test.

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Dr. Oh
50 And in terms of the oldest age that people go up to, the idea that you should stop at 70 is a little controversial. Now, I've seen 70 year olds over the years, over the decades. And, you know, one thing you and I both know is cardiologists are getting better and better at their job. And I see 70 year olds running marathons.

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Dr. Oh
So the idea really is more that there's no upper limit. It's really more is this person's somebody who's healthy enough that they may live another ten years or more. That's a better guideline. If somebody is very frail and sickly and they just had a big heart attack and they wheeled into an office, that's not a good person for a PSA test.

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Dr. Oh
But I see many men in their seventies and even in their eighties where they're very vital. And the question again becomes depending on their PSA history, because very few men have not had a PSA, very few men have not had a PSA. But like with colonoscopy, like with prior tests, the question is each individual person should consider their pros and cons.

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Dr. Oh
And because it's such a simple test, my general recommendation is, you know, if you're healthy and you expect to be around for the next decade, there's not a lot of harm in doing the blood test once a year. Okay. That's that is a way of making the guidelines simpler and more understandable. So you get a positive PSA result or I know that sometimes it's not clearly positive or negative.

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Dr. Oh
It's sort of in between and there's some follow up. But ultimately, let's imagine that someone is thought to have prostate cancer based on either the absolute PSA number or what's happened with the test over time. What's the next step? Yeah, one of the big changes of the path over the past few years is that MRI has become a really critical test to look at the prostate.

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Dr. Oh
So prostate MRI can now with a high degree of certainty and in a way replacing the digital rectal exam, can tell you what the prostate actually looks like and whether there's a cancer in it. And there's now a five point scoring system called periods or periods that gives a suspicion level of what's in the prostate. So let's say a man walks in, he's 55 and has a PSA that went up from 3 to 5.

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Dr. Oh
That person would be generally referred to a urologist from their primary care doctor and the urologist. The first test the urologist generally will do if they're convinced that that's a real PSA is to do an MRI. And when I say that other things can make your PSA go up for actual for example, sexual intercourse can do that riding a bicycle, there are things that can actually make your PSA go up that are not cancer.

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Dr. Oh
That's why we don't call it prostate cancer specific antigen, but prostate specific antigen, other things can make your PSA go up. So but if that PSA is elevated above what it should be for that man, there are additional tests that can be done. But generally speaking, an MRI is the really the best way to look inside the prostate.

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Dr. Oh
And if it's abnormal, then the urologist will typically recommend a biopsy.

Dr. Winer
All right. And before we get to talking about President Biden, the biopsy is done and it gets even sometimes a little more complicated because there's a score that is generated. There are actually two different types of scores. And depending on that score, your doctor might tell you that you have something that needs treatment soon, within the next few weeks or months.

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Dr. Winer
Your doctor might also tell you that might be okay. Just hold off and watch. So tell us a little bit about those scores. 

Dr. Oh
Yeah. So there was a doctor named Dr. Gleason who even longer ago than you or I were in practice, created a Gleason scoring system. And that system basically gives a grade to the cancer. And that grade is what it looks like to a pathologist.

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Dr. Oh
And that score can be as low as generally. Six is the lowest score and the highest is ten. And based on that score, we know the aggressiveness of the cancer. Now because it's dependent on the person's visualization, the pathologist visualization. Sometimes it can be changed. So I always recommend that if the biopsy is not 100% clear that it be read by a second pathologist.

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Dr. Oh
And there are additional types of tests that help us to know if that score is right or not. These DNA tests that can help us with that. But as you said, if you have a high score, then that it associated with an aggressive cancer. It's like a guy dressed like a Hell's Angel might cause trouble because of the way he's dressed.

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Dr. Oh
Or he could be growing, you know, collecting Toys for Tots, somebody dressed like an office office worker may look like he's just going to his job, but he might be robbing a bank. So we look at the way it looks under a microscope. And we know historically that that may predict how the cancer will behave. So that's a critical part of assessing the nature of the cancer.

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Dr. Winer
 Well, we're going to take just a brief break and we'll be back with Dr. William O, a prostate cancer expert, to talk more about prostate cancer and a little bit about the recent diagnosis in former President Biden. 

WNPR
Funding for Yale cancer answers comes from Smilow Cancer Hospital, where their survivorship clinic serves as a resource to support cancer survivors, providing patients and families with information on cancer prevention.

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Wellness research on survivorship. Smilow Cancer Hospital Board. The American Cancer Society estimates that nearly 150,000 people in the US will be diagnosed with colorectal cancer this year alone. When detected early colorectal cancer is easily treated and highly curable, and men and women over the age of 45 should have regular colonoscopies to screen for the disease. Patients with colorectal cancer have more hope than ever before, thanks to increased access to advanced therapies and specialized care.

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Clinical trials are currently underway at Federally designated comprehensive cancer centers such as Yale Cancer Center and its Smilow Cancer Hospital to test innovative new treatments for colorectal cancer tumor gene analysis has helped improve management of colorectal cancer by identifying the patients most likely to benefit from chemotherapy and newer targeted agents resulting in more patient specific treatment. More information is available at YaleCancerCenter.org. You're listening to Connecticut Public Radio. 

Dr. Winer
We're back here with Yale cancer answers. My guest is Dr. William Oh, a genitourinary oncologist and director of Precision Medicine at Yale Cancer Center. So, William, I think everybody was a little taken aback when it was announced that former President Biden had prostate cancer. And not only that he had prostate cancer, but that he had prostate cancer that had spread or metastasized to his bones.

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Dr. Winer
And it also led to a great deal of discussion about why was this picked up so late. And so first, let me just ask about screening and former President Biden. It sounds to me like given his age, he wasn't necessarily somebody who should have been getting regular screening. Is that accurate? 

Dr. Oh
I think strictly speaking, Eric, that's right. I think his his doctor followed the guidelines maybe too closely to the letter of the law and did not do a PSA test, which is surprising because, of course, he was, you know, a leader in our government at the time.

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Dr. Oh
But what we're seeing in former President Biden is exactly the trends we're seeing overall. The American Cancer Society recently released some statistics that show that actually we're diagnosing advanced or metastatic prostate cancer more frequently now, 5 to 6% higher per year for the last few years, which is a very alarming trend. And nobody knows for sure exactly why this is.

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Dr. Oh
But I think there's a general presumption that it's because there's less PSA screening, PSA screening, for sure started to lower the rates of advanced prostate cancer when I was training many years ago with you in Boston, working with you in Boston. And and now that trend is reversing, partly because the guidelines seem to be discouraging PSA testing. So in many ways, former President Biden is is kind of following the trends that we are seeing more broadly.

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Dr. Winer
Yes. That's obviously of some concern, though. Isn't it possible that he still would have been diagnosed with advanced prostate cancer even if he had been so many undergoing screening? 

Dr. Oh
I mean, for some cancers, there's never “an early enough”. We just can't pick them up as early as we would like to. You're right. And we don't know all the details of his particular case, but we do know that he had a high Gleason tumor, an aggressive tumor, a Gleason nine.

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Dr. Oh
And those are the kinds that can behave this way and sometimes are not detectable by PSA. So you are 100% right that even with our best testing, we sometimes miss cancers before they spread. 

Dr. Winer
But I think that in the end, you know, I think the question for the average listener here is, is it a good test or a bad test?

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Dr. Oh
And it's I wouldn't put it that way. It's a test that helps along with other types of information like MRI, like your age, like your general health. And there are new tests that are actually helping the PSA. So if a PSA is elevated, there are ways of kind of differentiating just a large prostate. Remember, PSA also comes from a large prostate and prostate enlarge as men get older.

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Dr. Oh
So trying to separate this kind of the types of cancers that you have to pay attention to versus those that you can ignore is one of the things that we're still actively working on in research. And if this cancer had been found before, it had spread to his bones as a as a cancer, where I think they said that the Gleason was nine.

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This was not a cancer that you would have done watchful waiting on. It's a cancer that it found before it had spread. Very clearly he would have surgery or possibly radiation or possibly both, I suppose that's 100% right. So there are cancers that can be watched. We call it active surveillance. And those are cancers that typically have a lower Gleason score, a Gleason score typically of six or below.

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Dr. Oh
Sometimes some Gleason seven can also be watched again, depending on other factors. But a Gleason nine or ten, any high Gleason tumors would generally be treated with treatments like surgery or radiation if the cancer is confined to the prostate. And, you know, I think that I will say that the good news about all of this story really is that two things for for the Biden's case.

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Dr. Oh
The first is that finding cancer earlier is always better. But secondly, we've learned so much about how to treat it. So there's so many new treatments that we can talk a little bit about. But the diagnostics but also the treatments are so much better. So even in the worst case scenario, which is metastatic disease, like former President Biden has been diagnosed with, we know that we can actually keep this cancer at bay for potentially years.

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Unknown
So the news is very good because we have so much new treatments and new understanding of the biology of cancer. 

Dr. Winer
Yeah. Know, so for those who would hear this and say, oh, this is a death sentence, which is of course, a phrase that's often used in conjunction with a diagnosis of cancer, particularly advanced cancer. This is something that former President Biden can live with for many years.

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Dr. Oh
That's right. That's the average. I have patients who have metastatic prostate cancer who've lived for decades, actually. So it is definitely possible. But of course, it's still better to get rid of it. So whenever I have a choice or I recommend to a patient, if it's confined to the prostate, then we have a chance to cure. Once it's out of the prostate, we have a chance to control, but we can't control it.

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Dr. Oh
Typically for years, not weeks or months. And first line treatment is going to be presumably some type of hormonal therapy. That's right. So what makes the prostate cancer grow is male hormone testosterone. And the first treatment is to take away the male hormone. That's not female hormone. It's lowering male hormone. It's kind of like a male menopause.

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Dr. Oh
And I won't say that men want that treatment, but they actually tolerate it very well. I always remind them that women live half their lives without estrogen, naturally. But men don't normally lose their testosterone. But because the cancer stimulates, it can be stimulated to grow with testosterone. The first treatment is hormonal therapy, which is really anti hormonal therapy, right, where lowering testosterone.

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Dr. Oh
And that almost always works for a long time. But we now have extra treatments. These double hormone treatments and sometimes other things that we can add that will make the cancer stay in remission longer and hormonal therapy can work for a extended period of time. That's right. On average, it's years. But the last few years, we actually know that a second hormone pill added to the original hormone shot extends the act to effectiveness of hormone therapy.

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Dr. Oh
And in fact, men live longer with that second pill and sometimes a third treatment. So we know now that blocking hormonal hormones in the body from men with prostate cancer can work for years. And as I said, I have patients who look just like former President Biden, and I met them a ten years ago or more. And they're still their cancers are still in remission.

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Dr. Oh
So we know it is possible. And then there's chemotherapy and there are other sorts of new treatments. Yeah, it's a very exciting time. So for people who are out there and have a loved one or know somebody with that cancer, I will tell you that everyone, it's such a common cancer that if you do start to talk about it, you'll see that there are many, many families that are affected by this.

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Dr. Oh
But the treatments include chemotherapy. But we've actually gone past chemotherapy. Eric, we have so many new treatments, like there's a new treatment called L'ue 177 PSA that kind of hones in and it's like a smart bomb and delivers a payload of, in this case, a radioactive payload and kills cancer cells that's been recently approved. People may even see ads on television.

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Dr, Oh
There are targeted treatments that work. If you carry a certain mutation, it's kind of what we call personalized or precision medicine, something that, you know, you and I both care a lot about and are developing here at the Yale Cancer Center in my role as director of precision medicine for the Yale Cancer Center. I think our goal is to expand those kind of precise treatments, so give the right treatment to the right patient at the right time.

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Dr. Winer
And in prostate cancer, some of those drugs are available as well. And we're going to see a whole bunch of new things come. We just came back from this big cancer meeting in Chicago and there are very promising new immunotherapy treatments, new targeted treatments. Is chemotherapy still an option? 

Dr. Oh
It is still on the table and we use it in certain patients.00;25;46;20 - 00;26;19;01
But we're really expanding the armamentarium quite it's really true across the board in cancer. And even when we use chemotherapy, it's oftentimes to induce a little cancer cell death to make other treatments work better. Right. Exactly. And one of the treatments you use occasionally is also a breast cancer treatment. It's the treatment that we would give people who have BRCA mutations.

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Dr. Winer
It works in women who have BRCA mutations. And my understanding is it works in men who have prostate cancer with a mutation. 

Dr. Oh
That's right. It's about 20% of men with advanced or metastatic prostate cancer will have a so-called HRR mutation, the most famous of which is, in fact BRCA two. In the case of prostate cancer. And these drugs and there's a series of them, as you know, called PARP inhibitors work particularly well if you have that mutation.

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Dr. Winer
So it's one in five men will carry that mutation and that's not trivial. And we've seen when we give that those drugs which are pills, that the cancers can often shrink away. So now it's remarkable. So in our last couple of minutes, could we spend just a little time talking about prostate cancer in black men in the United States? What’s going on? 00;27;12;10 - 00;27;44;16
Because we know across the board that people of color and in particular people who are black, tend to have a worse overall survival with cancer. How much of that is related to poor access to care? 

Dr. Oh
We don't fully know, but certainly a lot of it is. 

Dr Winer
But is there anything fundamentally different about prostate cancer in black men than in white men?

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Dr. Oh
Yeah, they do have in the United States twice the rate of dying of prostate cancer than white men. They have the highest rate of cancer, prostate cancer and really in the world. And we don't fully understand there's probably a combination of factors that may be contributing. But the most important thing for the audience to know is that PSA is a very good test for black men, just like it is for all men and in general, black men present earlier in life.

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Dr. Winer
So we just put out a guideline that suggested that black men should get their first PSA between the ages of 40 and 45. So I'd really encourage those listening to consider that much earlier than the average population. Dr. William Oh is the director of Precision Medicine at Yale Cancer Center and Smilow Cancer Hospital. 

WNPR
If you have questions, email them to canceranswers@yale.edu and past editions of the program are available in audio and written form at Yale CancerCenter.org.

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WNPR
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