Focal Therapy/Prostate Cancer Awareness

Transcript

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00:14 --> 00:15Welcome to Yale Cancer Answers.
00:15 --> 00:16with your host Dr. Anees Chagpar.
00:18 --> 00:20Yale Cancer Answers features the
00:20 --> 00:23latest information on cancer care by
00:23 --> 00:24welcoming oncologists and specialists
00:24 --> 00:27who are on the forefront of the
00:27 --> 00:28battle to fight cancer. This week,
00:28 --> 00:30it's a conversation about focal
00:30 --> 00:31therapy for prostate cancer
00:31 --> 00:33with Doctor Preston Sprenkle.
00:33 --> 00:35Doctor Sprenkle is an associate
00:35 --> 00:38professor of urology at the Yale School
00:38 --> 00:40of Medicine where Doctor Chagpar
00:40 --> 00:43is a professor of surgical oncology.
00:44 --> 00:46September is
00:46 --> 00:48Prostate Cancer Awareness Month.
00:48 --> 00:50Tell us what's new and
00:50 --> 00:52interesting in the world
00:52 --> 00:53of prostate cancer.
00:53 --> 00:56Well, we're making a lot of
00:56 --> 00:58advances in the treatment of
00:58 --> 01:01high risk advanced disease with
01:01 --> 01:03many new medications that have
01:03 --> 01:06been released in treatments
01:06 --> 01:08on the diagnostic side,
01:08 --> 01:09we've continued to pioneer
01:09 --> 01:11improvements in noninvasive
01:11 --> 01:13diagnostics such as prostate MRI.
01:13 --> 01:15And we're very excited to continue
01:15 --> 01:17to identify patients who may
01:17 --> 01:18not need evaluation.
01:18 --> 01:21Or maybe we can avoid a prostate biopsy.
01:21 --> 01:23Wow, that all sounds
01:23 --> 01:23really interesting.
01:23 --> 01:26Those are two very
01:26 --> 01:28different ends of the spectrum,
01:28 --> 01:31so maybe we will take each of them in turn
01:31 --> 01:34and work our way from prevention
01:34 --> 01:37all the way up to metastatic disease.
01:37 --> 01:39In terms of prevention and detection,
01:39 --> 01:42you mentioned that you have been doing
01:42 --> 01:44some great work in terms of detection.
01:44 --> 01:47Tell us more about that and
01:47 --> 01:49what are the current guidelines in terms
01:49 --> 01:53of what people should be doing in order
01:53 --> 01:55to either prevent prostate cancer or
01:55 --> 01:58find it early.
01:58 --> 02:00Prostate cancer screening, which is evaluation of risk
02:00 --> 02:02factors for prostate cancer,
02:02 --> 02:03has been somewhat controversial
02:03 --> 02:05over the last decade. Fortunately,
02:05 --> 02:08within the past five or six years,
02:08 --> 02:11it has become pretty clear that screening
02:11 --> 02:14for prostate cancer remains a very important
02:14 --> 02:17part of menn's general health.
02:17 --> 02:19So we screen for prostate cancer
02:19 --> 02:23starting in men at around the age of 50.
02:23 --> 02:26If a man has a higher risk feature for
02:26 --> 02:28potentially having prostate cancer,
02:28 --> 02:30which currently is a first degree
02:30 --> 02:32relative with prostate cancer or
02:32 --> 02:34being of Afro Caribbean descent,
02:34 --> 02:37those men can be screened even
02:37 --> 02:39earlier at around age 40 to 45.
02:39 --> 02:40And by screening.
02:40 --> 02:43this entails a PSA blood test.
02:43 --> 02:45So it's a simple blood test
02:45 --> 02:47as well as a
02:47 --> 02:49physical examination of the prostate
02:49 --> 02:51with a digital rectal exam.
02:51 --> 02:54Are those recommendations in terms of if you
02:54 --> 02:56don't have one of those high risk features,
02:56 --> 02:59every man at the age of 50 should have
02:59 --> 03:01a PSA and a digital rectal exam?
03:01 --> 03:04As you say,
03:04 --> 03:06it's been so controversial and it seems
03:06 --> 03:08like it gets really confusing.
03:08 --> 03:10They say everybody should do this,
03:10 --> 03:12sometimes they say, well,
03:12 --> 03:14you should really talk to your
03:14 --> 03:15doctor about pros and cons.
03:15 --> 03:17So where are we at right now?
03:17 --> 03:20I think the large part
03:20 --> 03:23depends on who you talk to.
03:23 --> 03:26Unfortunately, the US Preventive Services
03:26 --> 03:29Task Force which is given the power
03:29 --> 03:32to review and make recommendations on
03:32 --> 03:35what kind of screening is necessary,
03:35 --> 03:38in 2016, finally gave prostate cancer a
03:38 --> 03:41more likely to be beneficial than not
03:41 --> 03:44in terms of prostate cancer screening,
03:44 --> 03:46so it is still, however,
03:46 --> 03:49something that not everyone does routinely.
03:49 --> 03:52I think for a man who is concerned
03:52 --> 03:54about possibly having prostate cancer,
03:54 --> 03:57they definitely should be screened.
03:57 --> 04:00There are men who preferred not to,
04:00 --> 04:01and the language,
04:01 --> 04:04as used in many of the guidelines,
04:04 --> 04:05is informed decision-making.
04:05 --> 04:07And informed decision making is
04:07 --> 04:09a challenging term because who
04:09 --> 04:11is informing the patient?
04:11 --> 04:13Very often primary care physicians
04:13 --> 04:16do not have time to have a full
04:16 --> 04:17informed discussion with their
04:17 --> 04:20patients about what are the risks and
04:20 --> 04:22benefits of prostate cancer screening.
04:22 --> 04:25And so it is kind of challenging for
04:25 --> 04:30them to be able to figure out when they
04:30 --> 04:33should screen and when they should not.
04:33 --> 04:35As urologists we are very comfortable
04:35 --> 04:36having those discussions,
04:36 --> 04:39but it's hard to say that across the
04:39 --> 04:42board everyone should be screened.
04:48 --> 04:51I think I'm still a little confused because,
04:51 --> 04:52you know, at least coming
04:52 --> 04:54from the breast cancer world,
04:54 --> 04:57which is kind of my neck of the woods,
04:57 --> 05:00it seems to me that screening
05:00 --> 05:02allows people to detect cancer earlier,
05:02 --> 05:05so if you told a woman
05:05 --> 05:07you can get a mammogram,
05:07 --> 05:10but it's really up to you,
05:10 --> 05:11most women would say, well,
05:11 --> 05:14I want to detect cancer early so that it
05:14 --> 05:17can be treated more effectively and it
05:17 --> 05:20reduces my chances of dying of the disease.
05:20 --> 05:22So what does that conversation really
05:22 --> 05:24look like in terms of prostate cancer?
05:24 --> 05:27When you're talking to a man about,
05:27 --> 05:29should you get prostate cancer
05:29 --> 05:30screening or not?
05:30 --> 05:32Let's suppose that they don't have
05:32 --> 05:34one of those high risk features.
05:34 --> 05:37They haven't had a family history and
05:37 --> 05:39they are not of Afro Caribbean descent,
05:39 --> 05:42but they are your regular 60
05:42 --> 05:44year old Caucasian gentleman who
05:44 --> 05:46really doesn't have family history
05:46 --> 05:48of cancer but doesn't want to be
05:48 --> 05:50the first one to get it either.
05:50 --> 05:54And doesn't want to find it late.
05:54 --> 05:56What does that conversation look like?
05:57 --> 05:59How do men make that decision?
05:59 --> 06:01because it seems to me that a
06:01 --> 06:03lot of gentlemen are going
06:03 --> 06:05to do whatever you recommend.
06:07 --> 06:09I think you hit it on the head
06:09 --> 06:12when you said men don't want to be the
06:12 --> 06:16first one to be diagnosed with it either.
06:16 --> 06:18I think there is a large
06:18 --> 06:22component of fear.
06:22 --> 06:24And as we discussed mens health,
06:24 --> 06:28many men do not necessarily take care of
06:28 --> 06:31themselves to the extent that women do,
06:31 --> 06:34and so in a sense, we,
06:34 --> 06:37as urologists and as physicians that
06:37 --> 06:39are concerned with men's health,
06:39 --> 06:43a large part of it is
06:43 --> 06:44an information campaign to
06:44 --> 06:47reassure men that we do have ways
06:47 --> 06:50of managing these scary diseases,
06:50 --> 06:53so the conversations are a large part
06:53 --> 06:56about information,
06:56 --> 06:58and helping men assess what is their
06:58 --> 07:01actual risk of having prostate cancer.
07:01 --> 07:04What is the drawback to screening?
07:04 --> 07:07What is a drawback to having
07:07 --> 07:08a simple blood test,
07:08 --> 07:11which can be exceptionally
07:11 --> 07:13reassuring if it's normal
07:13 --> 07:15and a little bit anxiety provoking
07:15 --> 07:16if it's not.
07:16 --> 07:19But then what are the benefits of doing that?
07:19 --> 07:21So there are more extended risk benefit
07:21 --> 07:24discussions on a pretty routine basis.
07:25 --> 07:26Overall the important thing to
07:26 --> 07:28understand is that
07:28 --> 07:30prostate cancer is common,
07:30 --> 07:33but it's not so common that everyone gets it.
07:33 --> 07:35It's common enough though,
07:35 --> 07:37that most men as they get older
07:37 --> 07:40are at risk and it's worth having
07:40 --> 07:42some simple tests to evaluate if
07:42 --> 07:44you are at higher risk than others.
07:44 --> 07:47Because cancer can definitely be
07:47 --> 07:50treated and stopped in his tracks, right?
07:50 --> 07:53So it sounds like the general recommendation,
07:53 --> 07:55and I know that
07:55 --> 07:57we don't always want to give
07:57 --> 07:58general recommendations,
07:58 --> 08:00but it seems to me that in general this
08:00 --> 08:03is something that people really should
08:03 --> 08:06consider andvtalk to their doctor
08:06 --> 08:08about in terms of getting screened.
08:08 --> 08:11So let's move on to the next kind
08:11 --> 08:14of phase after screening comes detection,
08:14 --> 08:16and you alluded to some of the really
08:16 --> 08:19interesting work that's been happening
08:19 --> 08:21and pioneered really here at Yale.
08:21 --> 08:23Tell us more about that work and
08:23 --> 08:26where we are in terms of state of the
08:26 --> 08:29art detection for prostate cancer.
08:30 --> 08:32The first step as you
08:32 --> 08:34mentioned is screening so that the
08:34 --> 08:37first test with a PSA blood test and a
08:37 --> 08:39prostate exam are the initial ways
08:39 --> 08:42that we evaluate if a man may be at
08:42 --> 08:44risk for harboring a prostate cancer.
08:46 --> 08:49As you mentioned, Yale was one of the
08:49 --> 08:52first sites around the country to
08:52 --> 08:55be interested in use an MRI or a non
08:55 --> 08:58invasive imaging test to evaluate a prostate
08:58 --> 09:01and look at a prostate for
09:01 --> 09:02possible cancers within it.
09:02 --> 09:04It's really interesting as the
09:04 --> 09:07prostate is the only solid organ
09:07 --> 09:09until we started doing these mris,
09:09 --> 09:12for which we did not have cross sectional
09:12 --> 09:15imaging that could look inside the
09:15 --> 09:18inside that organ to evaluate for tumors.
09:18 --> 09:20So this has been a real boon
09:20 --> 09:23in terms of our ability to
09:23 --> 09:24diagnose prostate cancer in
09:24 --> 09:28a non invasive manner.
09:30 --> 09:32And so if somebody's
09:32 --> 09:34PSA comes back high or
09:34 --> 09:36somebody finds a lump in their
09:36 --> 09:39prostate on digital rectal exam,
09:39 --> 09:41is that the next step?
09:41 --> 09:43It is at our institution.
09:43 --> 09:46It is not the next step everywhere,
09:46 --> 09:47because the reading and performance
09:47 --> 09:50of the mris is an acquired skill
09:50 --> 09:52and it does take experience.
09:52 --> 09:54It is becoming more widespread to use
09:54 --> 09:58an MRI of the prostate as the next step,
09:58 --> 10:00and there recently have been
10:00 --> 10:02some publications in major medical journals,
10:02 --> 10:04including the New England
10:04 --> 10:05Journal of Medicine,
10:05 --> 10:08looking at MRI of the prostate,
10:08 --> 10:10and really the important thing
10:10 --> 10:12about MRI is combining it with
10:12 --> 10:14a targeted prostate biopsy.
10:14 --> 10:16So then using that information from
10:16 --> 10:19the MRI and if suspicious areas are
10:19 --> 10:21identified using that information
10:21 --> 10:23to target or direct prostate
10:23 --> 10:26biopsies to detect prostate cancer,
10:26 --> 10:28the MRI alone is very useful,
10:28 --> 10:30but it's really in combination
10:30 --> 10:32with the biopsy.
10:32 --> 10:35And is MRI
10:35 --> 10:37covered by insurance
10:37 --> 10:39for people who are at risk
10:39 --> 10:41of prostate cancer or
10:41 --> 10:43people who have an elevated
10:43 --> 10:45PSA and so on, are most
10:45 --> 10:47insurance companies covering this?
10:47 --> 10:49I would say most
10:49 --> 10:51are and especially now after
10:51 --> 10:53some of those recent articles,
10:53 --> 10:56including the one in the New England Journal,
10:56 --> 10:58there is more support of that,
10:58 --> 11:01but there still are some insurance
11:01 --> 11:04companies that will not pay for an MRI
11:04 --> 11:07as an initial diagnostic biopsy,
11:07 --> 11:09they still require an initial transrectal
11:09 --> 11:11ultrasound guided prostate biopsy,
11:11 --> 11:14which is the goal which has been
11:14 --> 11:17the gold standard for 30-40 years.
11:19 --> 11:20They will require that first,
11:20 --> 11:23and only if that does not detect cancer
11:23 --> 11:25would they pay for an MRI targeted biopsy.
11:25 --> 11:27I believe we're continuing
11:27 --> 11:28to see a shift, though toward
11:28 --> 11:31use of MRI as an initial diagnostic tool.
11:31 --> 11:34In the United Kingdom
11:34 --> 11:35it actually is mandatory.
11:35 --> 11:37Anyone with an abnormal PSA
11:37 --> 11:38that next step is an MRI,
11:38 --> 11:41and they use it as a screening tool.
11:41 --> 11:43We're not quite to that point
11:43 --> 11:44yet in the United
11:44 --> 11:46States.
11:46 --> 11:48That's so interesting because we always think
11:48 --> 11:49about the UK as being
11:49 --> 11:51a country that really does put
11:51 --> 11:54a premium on value in terms of
11:54 --> 11:56healthcare costs and so on
11:56 --> 11:59and their National Health System.
11:59 --> 12:01It seems if they're adopting it,
12:01 --> 12:04they have such a rigorous process to
12:04 --> 12:07make sure that things are cost effective,
12:07 --> 12:10that that would be reasonable to adopt.
12:11 --> 12:13I think we're starting to get into
12:13 --> 12:16some of the nuances of
12:16 --> 12:19the health care systems and some
12:19 --> 12:21of the cost and price disparities
12:21 --> 12:24across providers that we see in
12:24 --> 12:26the United States,
12:26 --> 12:29which is a much bigger and
12:29 --> 12:30more complicated discussion.
12:30 --> 12:32But in general MRI is significantly
12:32 --> 12:35cheaper across the pond than it is here.
12:36 --> 12:39Interesting, so the next step,
12:39 --> 12:42as you mentioned that goes hand in hand
12:42 --> 12:46with the MRI of course is the biopsy.
12:46 --> 12:48So tell me a little bit more
12:48 --> 12:52about some of the work that's been
12:52 --> 12:54going on with prostate biopsies.
12:54 --> 12:57I understand that people are now
12:57 --> 12:59looking at artificial intelligence
12:59 --> 13:01and machine learning to improve
13:01 --> 13:02biopsies of the prostate.
13:02 --> 13:05That just sounds so Avantgarde.
13:07 --> 13:10Well it is. It is one of the
13:10 --> 13:12directions that
13:12 --> 13:14we are embracing technology
13:14 --> 13:17to improve what we do
13:17 --> 13:19using that same MRI image
13:19 --> 13:22in an MRI of the prostate,
13:22 --> 13:24we are able to make a 3D model
13:24 --> 13:27of the prostate gland and we
13:27 --> 13:29combine that with a real time
13:29 --> 13:32ultrasound 3D model of the prostate
13:32 --> 13:34to guide our needle biopsy in
13:34 --> 13:37the office so it's different than
13:37 --> 13:39doing it in the MRI scanner where
13:39 --> 13:42you do have an image and you
13:42 --> 13:44have a 2D image and you can place
13:44 --> 13:47the needle by using 3D imaging
13:47 --> 13:49which allows us to perform the procedure
13:49 --> 13:51in the office in the outpatient
13:51 --> 13:54setting in a more convenient and for
13:54 --> 13:56many patients more comfortable way.
13:56 --> 13:58The machine learning is
13:58 --> 14:00enhancing our modeling so it is
14:00 --> 14:02making the way that we target
14:02 --> 14:04the biopsy is much more accurate.
14:05 --> 14:08We need to do delve more into that,
14:08 --> 14:11but first we need to take short break
14:11 --> 14:14for a medical minute. Please stay
14:14 --> 14:17tuned to learn more about prostate
14:17 --> 14:19cancer with my guest doctor
14:19 --> 14:21Preston Spenkle.
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14:32 --> 14:34This is a medical minute about Melanoma.
14:34 --> 14:36While Melanoma accounts for only
14:36 --> 14:39about 4% of skin cancer cases,
14:39 --> 14:41it causes the most skin cancer
14:41 --> 14:43deaths. When detected early,
14:43 --> 14:45however, Melanoma is easily treated
14:45 --> 14:46and highly curable. Clinical
14:46 --> 14:49trials are currently underway to test
14:49 --> 14:51innovative new treatments for Melanoma.
14:51 --> 14:53The goal of the specialized programs
14:53 --> 14:56of research excellence in skin cancer
14:56 --> 14:58or spore grant is to better understand
14:58 --> 15:02the biology of skin cancer with a focus
15:02 --> 15:04on discovering targets that will lead
15:04 --> 15:06to improved diagnosis and treatment.
15:06 --> 15:08More information is available
15:08 --> 15:09at yalecancercenter.org.
15:09 --> 15:15You're listening to Connecticut public radio.
15:15 --> 15:15Welcome
15:15 --> 15:17back to Yale Cancer Answers.
15:17 --> 15:19This is doctor Anees Chagpar
15:19 --> 15:23and I am joined tonight by my
15:23 --> 15:25guest doctor Preston Sprenkle.
15:25 --> 15:27We're talking about diagnosis and
15:27 --> 15:29treatment of prostate cancer and
15:29 --> 15:31right before the break Preston you
15:31 --> 15:34were talking about this really cool
15:34 --> 15:36technique of using MRI to diagnose
15:36 --> 15:39prostate cancer and what was interesting
15:39 --> 15:42was that you were talking about how
15:42 --> 15:44that really gets paired with biopsy,
15:44 --> 15:47but you're not doing biopsies
15:47 --> 15:48in the MRI suite,
15:48 --> 15:50which I can imagine is just
15:50 --> 15:52claustrophobic and not the most
15:52 --> 15:54comfortable setting in the world for men.
15:54 --> 15:58But tell me a little bit more about how
15:58 --> 16:01you take that MRI guided image
16:01 --> 16:04to actually guide a biopsy that you're
16:04 --> 16:07doing with ultrasound in your office.
16:08 --> 16:10Yeah, so there are a few different
16:10 --> 16:12technologies that are available.
16:12 --> 16:15We talk about this as sort of a fusion.
16:15 --> 16:18How do we fuse these two images
16:18 --> 16:21and we can use cognitive fusion which
16:21 --> 16:24is using the human brain to look at
16:24 --> 16:272 pictures side by side and say OK
16:27 --> 16:29this looks like where they line up.
16:29 --> 16:32We then use computer fusion which is what
16:32 --> 16:35we use at Yale with our Artemis Device.
16:35 --> 16:38And then there are quite a few
16:38 --> 16:40of these computer fusion devices
16:40 --> 16:42that exist around the world.
16:45 --> 16:48And we like using this Artemis device because it has,
16:48 --> 16:49like I mentioned earlier,
16:49 --> 16:53the ability to take a 3D model
16:53 --> 16:55of the prostate from the MRI.
16:55 --> 16:59We use Artemis Device to create a 3D model of
16:59 --> 17:01the prostate with the ultrasound
17:01 --> 17:04and then we overlap those and
17:04 --> 17:06we're moving towards the computer
17:06 --> 17:09having the ability to overlap them.
17:09 --> 17:12Right now the urologist and surgeon are
17:12 --> 17:14very involved in making sure
17:14 --> 17:15the pictures lineup,
17:15 --> 17:17but then the artificial intelligence
17:17 --> 17:20side is learning what are the shapes
17:20 --> 17:22of these prostates and can we predict
17:22 --> 17:25how these prostates are going to
17:25 --> 17:27deform and change and really matching
17:27 --> 17:30up that fusion product or that model
17:30 --> 17:33of the prostate so that it's much
17:33 --> 17:35more precise and this translates
17:35 --> 17:38to more accurate biopsies.
17:38 --> 17:40The Artemis Device, just so that
17:40 --> 17:43I've got this straight,
17:43 --> 17:46I kind of get the idea that the
17:46 --> 17:50man goes in and gets an MRI of the prostate,
17:50 --> 17:53just like you get an MRI of your
17:53 --> 17:56knee or your brain or whatever else.
17:56 --> 17:59They get an MRI of the prostate.
17:59 --> 18:02This Artemis device kind of takes that
18:02 --> 18:04image and transforms it into an image
18:04 --> 18:07that you could get with an ultrasound
18:07 --> 18:09so that it can overlay it well.
18:09 --> 18:10Interestingly,
18:10 --> 18:12we still rely very much on
18:12 --> 18:14non human interpretation so
18:14 --> 18:16the radiologist takes the MRI,
18:16 --> 18:19so a man will have an MRI of his prostate,
18:19 --> 18:21the radiologist will read that and will
18:21 --> 18:24evaluate and look at the MRI for
18:24 --> 18:25any areas that look suspicious,
18:25 --> 18:27they grade it on a standardized grading
18:27 --> 18:29scale that was helped developed by
18:29 --> 18:32one of our radiologist here at Yale,
18:32 --> 18:32Jeff Weinreb.
18:32 --> 18:34So it's an international scale and is
18:34 --> 18:36now the gold standard,
18:36 --> 18:38and that was partly designed at Yale,
18:38 --> 18:40so they'll get a score of any
18:40 --> 18:42lesions that are in the prostate.
18:42 --> 18:44The radiologist then
18:44 --> 18:47outlines the prostate and those images
18:47 --> 18:50are imported into our Artemis device.
18:52 --> 18:55I, or one of our other urologists,
18:55 --> 18:56are doing the biopsies.
18:56 --> 18:58We similarly use an ultrasound to
18:58 --> 19:01make a model of the prostate and,
19:01 --> 19:03then the job of the computer and what
19:03 --> 19:06we're trying to improve with some of
19:06 --> 19:08our mathematical models and
19:08 --> 19:10artificial intelligence has now improved how
19:10 --> 19:12those two pictures of the prostate,
19:12 --> 19:15look or
19:15 --> 19:16if they look different,
19:16 --> 19:18why are they different and how do
19:18 --> 19:19we correct for that difference?
19:21 --> 19:23So this is interesting
19:23 --> 19:25because you're taking two different
19:25 --> 19:27pictures of the same organ done by
19:27 --> 19:30different modalities, and
19:30 --> 19:32if I understand this correctly,
19:32 --> 19:34you're putting both of them
19:34 --> 19:35into this Artemis system,
19:35 --> 19:38which kind of lines them up and says
19:38 --> 19:41what you saw here on the MRI is what
19:41 --> 19:44you see here on the ultrasound and
19:44 --> 19:47kind of making this image that
19:47 --> 19:50when you see that on the ultrasound,
19:50 --> 19:52that really is that area that was
19:52 --> 19:54on the MRI and that's what you
19:54 --> 19:56need to go after with your biopsy.
19:56 --> 19:57Do I have that right?
19:57 --> 19:59Yep, you're absolutely correct,
19:59 --> 20:00so it's taking
20:00 --> 20:02two things side by side.
20:02 --> 20:04You can imagine these
20:04 --> 20:06two pictures just merging into
20:06 --> 20:07one and overlapping and we make
20:07 --> 20:09sure that where those overlap
20:09 --> 20:11appears correct and so then
20:11 --> 20:13that that is a real boon because then
20:13 --> 20:16you can use something that is
20:16 --> 20:18patient friendly like an ultrasound
20:18 --> 20:21and do the biopsy in the office.
20:21 --> 20:23I mean that is just such cool technology.
20:23 --> 20:25I wonder if the same thing can
20:25 --> 20:28be done in other organ systems.
20:28 --> 20:30Do you know if this Artemis
20:30 --> 20:32devices is being used in other
20:32 --> 20:34diseases?
20:34 --> 20:36It isn't really
20:36 --> 20:39because
20:39 --> 20:41if you think about many other
20:41 --> 20:43lesions, in liver lesions,
20:43 --> 20:45many of those are very well
20:45 --> 20:46visualized with ultrasound,
20:46 --> 20:50and so the real time ultrasound is actually
20:50 --> 20:52as good or better at characterizing
20:52 --> 20:56where the lesion is than MRI or CT.
20:56 --> 20:58That kind of fusion that we need
20:58 --> 21:02to do for the prostate is kind of
21:02 --> 21:04unique compared to, for example,
21:04 --> 21:06the brain where you have a solid
21:06 --> 21:08calvarium around the brain and
21:08 --> 21:11so the ability to predict and do
21:11 --> 21:12stereotactic localization within
21:12 --> 21:14this solid structure is much
21:14 --> 21:16easier than with a soft,
21:16 --> 21:19malleable organ that is very able
21:19 --> 21:21to move around within the pelvis.
21:21 --> 21:24So the process is really kind of a
21:24 --> 21:26unique location and a unique target
21:26 --> 21:29given all these sort of anatomic limitations.
21:34 --> 21:38Moving on from once you get the biopsy,
21:38 --> 21:40let's talk a little
21:40 --> 21:43bit about getting screening or a
21:43 --> 21:45gentleman went and got screening,
21:45 --> 21:46he got his MRI,
21:46 --> 21:49he had this really cool artificial
21:49 --> 21:50intelligence thing happening so
21:50 --> 21:53he could have his biopsy in the
21:53 --> 21:55office and he gets diagnosed
21:55 --> 21:58with early stage prostate cancer
21:58 --> 22:01because he found it really early.
22:01 --> 22:03Tell us a little bit more about what's
22:03 --> 22:06new and interesting in terms of the
22:06 --> 22:08management of early prostate cancer.
22:10 --> 22:12In the field of
22:12 --> 22:15urology we are becoming much
22:15 --> 22:17more comfortable with active
22:17 --> 22:19surveillance or really a deferred
22:19 --> 22:22treatment for men with prostate cancer.
22:22 --> 22:25And that's based on many large studies.
22:25 --> 22:27Now with long term follow up as well
22:27 --> 22:30as a better understanding of the
22:30 --> 22:32genomic nature of prostate cancer.
22:32 --> 22:35So not only are we typically talking
22:35 --> 22:38about things like the Gleason score
22:38 --> 22:41when we are diagnosed with prostate cancer
22:41 --> 22:43and the higher the Gleason score,
22:43 --> 22:45the sort of worse the prognosis,
22:45 --> 22:47or the more aggressive prostate cancer
22:47 --> 22:49we are now able to sub stratify
22:49 --> 22:51many of these patients using
22:51 --> 22:53genomic testing which is specialized
22:53 --> 22:56testing of the cancer cells themselves
22:56 --> 22:59that tells us if it is at a lower risk
22:59 --> 23:01and intermediate risk or higher risk of
23:01 --> 23:02progression and developing metastasis.
23:02 --> 23:05So I think one of the many
23:05 --> 23:07exciting things is we feel more
23:07 --> 23:09comfortable knowing who does not
23:09 --> 23:11need treatment and really can avoid
23:11 --> 23:14many of the side effects that
23:14 --> 23:15we associate with treatment.
23:16 --> 23:19And part and parcel of that is,
23:19 --> 23:21I know that many gentlemen who
23:21 --> 23:23get their prostate biopsy,
23:23 --> 23:26they've got a low Gleason score and
23:26 --> 23:28they're put on this watchful
23:28 --> 23:29waiting regimen.
23:29 --> 23:30But for some of them,
23:30 --> 23:32that's really anxiety provoking, right?
23:32 --> 23:34Because they're sitting there
23:34 --> 23:36and we already talked before the break
23:36 --> 23:38about how fearful some people are
23:38 --> 23:40with a diagnosis of prostate cancer.
23:40 --> 23:41Here you are telling people
23:41 --> 23:43you've got a prostate cancer,
23:43 --> 23:45but it's really
23:45 --> 23:47pretty indolent, we think,
23:47 --> 23:50so you don't need to be treated,
23:50 --> 23:51but it sounds like with genomics
23:51 --> 23:54you can get a little bit more
23:54 --> 23:55personalized and say no,
23:55 --> 23:57we've looked at your tumor,
23:57 --> 23:59this is a very low score,
23:59 --> 24:01but are there some people who would normally
24:01 --> 24:04be in the watchful waiting category who,
24:04 --> 24:05based on genomic analysis,
24:05 --> 24:06you think, geez,
24:06 --> 24:08I need to be a little bit more aggressive?
24:10 --> 24:12I just want to
24:12 --> 24:13caution and correct
24:13 --> 24:15the terminology just for a second.
24:15 --> 24:16So active surveillance is what
24:16 --> 24:18we do for men with low grade,
24:18 --> 24:20and low risk prostate cancer.
24:20 --> 24:22Watchful waiting is what we
24:22 --> 24:23characterize men with prostate
24:23 --> 24:25cancer who do not want to treat it,
24:25 --> 24:28nor do they want to do any follow up of it.
24:28 --> 24:29Because prostate cancer
24:29 --> 24:30is so slow growing,
24:30 --> 24:32there are some men who are diagnosed
24:32 --> 24:34who are elderly or have other health
24:34 --> 24:36problems that decide they do not
24:36 --> 24:38want to treat it because prostate
24:38 --> 24:39cancer is so slow growing it will
24:39 --> 24:41not cause them a problem ever.
24:41 --> 24:43Those are sort of who we say are on
24:43 --> 24:45watchful waiting because we're waiting
24:45 --> 24:47for them to have any symptoms of
24:47 --> 24:49their prostate cancer before we treat.
24:49 --> 24:50Active surveillance is kind of the
24:50 --> 24:52other end of the spectrum where
24:52 --> 24:54men have a very low grade,
24:54 --> 24:57low risk prostate cancer and we
24:57 --> 24:58are actively surveilling their
24:58 --> 25:00cancer for any signs that it has
25:00 --> 25:02progressed or gotten to the point
25:02 --> 25:04where it may require treatment
25:04 --> 25:06or we may advise treatment,
25:06 --> 25:08but you're absolutely right with
25:08 --> 25:10a genomic testing we can now have
25:10 --> 25:12much more confidence and much
25:12 --> 25:13more security and telling some
25:13 --> 25:15men that it's appropriate to watch
25:15 --> 25:18their cancer and not treat it.
25:18 --> 25:19And you're right,
25:19 --> 25:20anxiety is a major component.
25:20 --> 25:22Very understandably, I think we
25:22 --> 25:24gain confidence with
25:24 --> 25:26data in the genomic testing,
25:26 --> 25:28we can more strongly tell our patients with
25:28 --> 25:30security that they don't need treatment.
25:30 --> 25:34They are not in danger from this cancer.
25:38 --> 25:41Let's say there are some men though that
25:41 --> 25:44do really want to have treatment.
25:44 --> 25:45As a general rule,
25:45 --> 25:48if they have very low risk
25:48 --> 25:50and low risk prostate cancer,
25:50 --> 25:52we do not treat them. Getting
25:52 --> 25:53into an intermediate risk,
25:53 --> 25:55some of those men actually
25:55 --> 25:57don't need treatment either.
25:57 --> 25:58Some intermediate risk men
25:58 --> 26:00may benefit from treatment,
26:00 --> 26:02and again we're using genomic
26:02 --> 26:03testing to stratify that.
26:03 --> 26:06An one of the main reasons that
26:06 --> 26:09we are concerned and we try not to
26:09 --> 26:11treat everyone with prostate cancer
26:11 --> 26:14is that there are side effects so
26:14 --> 26:17there can be an impact on urinary function.
26:17 --> 26:19There can be an impact on sexual function
26:19 --> 26:22with any treatment for prostate cancer,
26:22 --> 26:23whether surgery or radiation
26:23 --> 26:24or even ablation.
26:24 --> 26:27So we're going to talk a little
26:27 --> 26:29bit about that unless you had
26:29 --> 26:30another question.
26:30 --> 26:33I'd love to learn more about ablation,
26:33 --> 26:35because it sounds like
26:35 --> 26:37that might be a minimally invasive
26:37 --> 26:39way to treat prostate cancer without
26:39 --> 26:42having major surgery that can cause more
26:42 --> 26:44side effects, so
26:48 --> 26:50much of the discussion that we
26:50 --> 26:52have in the urology community is,
26:52 --> 26:54will ablation replace surgery,
26:54 --> 26:56or radiation?
26:56 --> 26:58I would say no, it is not a replacement for
26:58 --> 27:00these gold standard treatments,
27:00 --> 27:03but it is an alternative for the appropriate
27:03 --> 27:06person and it is a good alternative.
27:06 --> 27:08So ablation is typically using
27:08 --> 27:11some form of energy beacon.
27:11 --> 27:14Heat, or we can use cold, we can use other
27:14 --> 27:16things like light or ultrasound
27:16 --> 27:19or electricity to generate heat,
27:19 --> 27:22but we're trying to destroy just the part
27:22 --> 27:25of the prostate that has prostate cancer.
27:25 --> 27:27By doing this,
27:27 --> 27:29we can often avoid the structures
27:29 --> 27:32and areas near the prostate that
27:32 --> 27:33are associated with urinary
27:33 --> 27:35control and sexual function,
27:35 --> 27:38so we can have much less impact on
27:38 --> 27:41someone's quality of life while having
27:41 --> 27:44a successful treatment of their cancer.
27:45 --> 27:46So do we know what
27:46 --> 27:48the long term results of that are?
27:48 --> 27:50I mean, do you get recurrence rates
27:50 --> 27:52that are as low as you would get with
27:52 --> 27:54surgery and radiation with ablation?
27:56 --> 27:58It's interesting, there have
27:58 --> 27:59been no randomized trials
27:59 --> 28:01comparing surgery or radiation
28:01 --> 28:03to an ablation, so
28:03 --> 28:07all we can do is compare the sort
28:07 --> 28:11of data from the different studies.
28:11 --> 28:12The combination of treatment with
28:12 --> 28:14ablation tends to be quite successful,
28:14 --> 28:16though because
28:16 --> 28:18we're held to a high standard,
28:18 --> 28:21we are doing repeat biopsy's and many of
28:21 --> 28:23these patients who are having an
28:23 --> 28:24ablation or treatment of
28:24 --> 28:26this part of their prostate,
28:26 --> 28:28and we find very greater than
28:28 --> 28:3180 or 90% success rate when we
28:31 --> 28:32biopsy areas that were treated.
28:32 --> 28:35The trick is that if we're treating
28:35 --> 28:37only part of the prostate and
28:37 --> 28:39this is why it's hard to compare
28:39 --> 28:41to surgery or radiation.
28:41 --> 28:42When we are treating just
28:42 --> 28:44part of the prostate,
28:44 --> 28:46there still is the other side of
28:46 --> 28:48prostate or the rest of prostate that
28:48 --> 28:50could develop cancer in the future.
28:50 --> 28:51So you know,
28:51 --> 28:54if we look at the areas that are ablated
28:54 --> 28:56then yes, things like Cryo Ablation,
28:56 --> 28:56irreversible electroporation,
28:56 --> 28:58HIFU or high intensity focused ultrasound,
28:58 --> 29:00those are very good techniques
29:00 --> 29:02to destroy the cancer tissue
29:02 --> 29:04in the area that is ablated
29:04 --> 29:05but inherently it's not treating
29:05 --> 29:08the other side of prostate so it
29:08 --> 29:10is a little bit of a trade off.
29:10 --> 29:12It's a little bit less treatment.
29:12 --> 29:14Meaning we're not treating the
29:14 --> 29:15whole prostate,
29:15 --> 29:16but definitely associated
29:16 --> 29:18with fewer side effects.
29:18 --> 29:22So in terms of picking patients
29:22 --> 29:25in whom this technique might be optimal,
29:25 --> 29:28it seems to me that if you've
29:28 --> 29:31got somebody who's really worried about
29:31 --> 29:34the side effects of radical surgery,
29:34 --> 29:37has a relatively small prostate cancer,
29:37 --> 29:40and wants a less invasive
29:40 --> 29:42technique and may not have
29:42 --> 29:44long to really wait and get
29:44 --> 29:47a new prostate cancer in another
29:47 --> 29:49part of the prostate,
29:49 --> 29:50that might be a
29:50 --> 29:52good candidate.
29:52 --> 29:53Yes, definitely.
29:53 --> 29:56And this moves towards focal
29:56 --> 29:58ablation so it is becoming more popular,
29:58 --> 29:59especially in academic centers,
29:59 --> 30:02and this has really grown out of
30:02 --> 30:04the interest in it and the increased
30:04 --> 30:06usage of these techniques has really grown
30:06 --> 30:09out of the MRI in a targeted biopsy,
30:09 --> 30:11because we now can localize prostate
30:11 --> 30:13cancer within the prostate, which is new.
30:13 --> 30:14It's new since MRI.
30:16 --> 30:18We can know where to treat.
30:18 --> 30:20So one of the reasons we don't
30:20 --> 30:22have long term data is this is all
30:22 --> 30:24relatively new technology that
30:24 --> 30:26has really been born out of our
30:26 --> 30:28ability to identify and localized
30:28 --> 30:29prostate cancer with much more
30:29 --> 30:31accuracy.
30:31 --> 30:33Doctor Preston Sprenkle is an associate professor of urology
30:34 --> 30:35at the Yale School of Medicine.
30:35 --> 30:37If you have questions,
30:37 --> 30:38the address is canceranswers@yale.edu
30:38 --> 30:40and past editions of the program
30:40 --> 30:42are available in audio and written
30:42 --> 30:44form at Yalecancercenter.org.
30:44 --> 30:47We hope you'll join us next week to
30:47 --> 30:49learn more about the fight against
30:49 --> 30:52cancer here on Connecticut public radio.

Information

Focal Therapy/Prostate Cancer Awareness with guest Dr. Preston Sprenkle September 6, 2020 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095