Personalized Care of Prostate Cancer

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the latest
00:12 --> 00:14information on cancer care by welcoming
00:14 --> 00:16oncologists and specialists who are on the
00:16 --> 00:18forefront of the battle to fight cancer.
00:18 --> 00:21This week it's a conversation about prostate
00:21 --> 00:23cancer with Doctor Preston Sprenkle.
00:23 --> 00:25Dr Sprenkle is an associate professor of
00:25 --> 00:28urology at the Yale School of Medicine,
00:28 --> 00:29where Doctor Chagpar is a
00:29 --> 00:31professor of surgical oncology.
00:32 --> 00:34Preston, maybe we can start off
00:34 --> 00:36by you telling us a little bit more
00:36 --> 00:38about yourself and what it is you do.
00:38 --> 00:40I'm a urologic
00:40 --> 00:41oncologist by training.
00:41 --> 00:44So that means that I have done a
00:44 --> 00:46urologic surgery residency and
00:46 --> 00:49then an oncology fellowship.
00:49 --> 00:52So I primarily take care of men
00:52 --> 00:55and women with urologic cancers.
00:55 --> 00:58My practice now primarily deals
00:58 --> 01:00with men with prostate cancer
01:00 --> 01:02and also testicular cancer.
01:03 --> 01:05So let's talk a little bit
01:05 --> 01:07more about prostate cancer.
01:07 --> 01:10It seems to be a pretty ubiquitous cancer.
01:10 --> 01:12Many, many men seem to get it,
01:12 --> 01:15but it seems that it's
01:15 --> 01:17a little bit heterogeneous
01:17 --> 01:19in terms of how it's managed.
01:19 --> 01:21So can you give us kind of the
01:21 --> 01:24lay of the land in terms of the
01:24 --> 01:26epidemiology of prostate cancer?
01:26 --> 01:27Who gets it?
01:27 --> 01:30When do they get it and how bad is it?
01:30 --> 01:33Those are a great observations.
01:33 --> 01:36Prostate cancer is very common,
01:36 --> 01:39it's probably the most common
01:39 --> 01:41solid organ malignancy in men.
01:41 --> 01:44It will ultimately affect between
01:44 --> 01:47one and seven and one in nine
01:47 --> 01:49men throughout their life.
01:49 --> 01:52It is however typically in older men.
01:52 --> 01:55So over the age of 50 is when we really
01:55 --> 01:58feel strongly about screening
01:58 --> 02:01and evaluating for prostate cancer.
02:01 --> 02:04Fortunately, most of the prostate
02:04 --> 02:07cancers that we find do not require
02:07 --> 02:11treatment though or at least require
02:11 --> 02:13immediate treatment and it tends to
02:13 --> 02:16be for most of the cases a very slow
02:16 --> 02:18growing and slow progressing disease.
02:18 --> 02:20So one that we can manage more as
02:20 --> 02:23a chronic disease than necessarily
02:23 --> 02:25requiring really intensive therapy.
02:25 --> 02:28There are some patients and men that do
02:28 --> 02:30require or we would recommend treatment
02:30 --> 02:33for because their cancer could cause
02:33 --> 02:35them a problem in the next 15 or 20 years.
02:35 --> 02:38But really prostate cancer, exceptionally
02:38 --> 02:41rarely would cause problems for a man
02:41 --> 02:43within 10 years of diagnosis unless it's
02:43 --> 02:45a very high or very late stage cancer.
02:46 --> 02:49So Preston, some of our listeners
02:49 --> 02:52might be listening to that thinking,
02:52 --> 02:54well then what's the purpose
02:54 --> 02:56of screening if most men are
02:56 --> 02:59going to do just fine with this,
02:59 --> 03:02and for most people it's not going
03:02 --> 03:04to really cause them any problems
03:04 --> 03:07for at least another 10 years.
03:07 --> 03:09Why should we be getting
03:09 --> 03:11screened at the age of 50?
03:11 --> 03:12That's a great question.
03:12 --> 03:14So the reason that we screen
03:14 --> 03:16is because our screening test,
03:16 --> 03:19which is typically a PSA blood test,
03:19 --> 03:20is a blood test that allows
03:20 --> 03:22us to screen for prostate cancer.
03:22 --> 03:24Just because the majority of men or
03:24 --> 03:27the vast majority of men will not have
03:27 --> 03:29a problem from their prostate cancer,
03:29 --> 03:32we can identify those who will and we
03:32 --> 03:34can treat them and interventions for
03:34 --> 03:37prostate cancer can and do save lives.
03:37 --> 03:40So we have studies that have shown
03:40 --> 03:42that screening does improve the
03:42 --> 03:44detection of prostate cancer and
03:44 --> 03:46does improve the survival of men
03:46 --> 03:49in a population who were screened.
03:49 --> 03:50So we do firmly believe that
03:50 --> 03:51we should do that.
03:51 --> 03:54It's an easy intervention to be
03:54 --> 03:59screened and it definitely does save lives.
04:01 --> 04:04Are there certain populations,
04:04 --> 04:08either in a genetically or by
04:08 --> 04:11race category or other factors,
04:11 --> 04:14that might predispose a particular
04:14 --> 04:17gentleman for getting worse prostate
04:17 --> 04:19cancer than others?
04:19 --> 04:21This is an area that we are
04:21 --> 04:23continuing to learn more about,
04:23 --> 04:27but in general, men of black or African
04:27 --> 04:30heritage do seem to have a higher
04:30 --> 04:33rate of developing prostate cancer and higher
04:33 --> 04:35risk and higher grade prostate cancer.
04:35 --> 04:38So that is a population that we
04:38 --> 04:41recommend screening for men with certain
04:41 --> 04:43genomic and genetic mutations so that
04:43 --> 04:46the breast cancer or BR CA mutation
04:46 --> 04:49family is definitely one of those.
04:49 --> 04:52So in men who have multiple first
04:52 --> 04:54degree relatives or even a first
04:54 --> 04:56degree relative with prostate cancer
04:56 --> 04:59or they have women with breast cancer,
04:59 --> 05:01even some with pancreatic cancer.
05:01 --> 05:04So there are familial and genetic
05:04 --> 05:07risks that do increase and demands the
05:07 --> 05:10possibility of developing a prostate cancer.
05:11 --> 05:13And do men who have such
05:13 --> 05:14a genetic predisposition,
05:14 --> 05:18let's say you have a
05:18 --> 05:23sister who has a BRCA mutation.
05:26 --> 05:28We'll get into whether in fact you should get tested
05:28 --> 05:31as a man if a woman in your family
05:31 --> 05:34has a genetic mutation for for BRCA.
05:34 --> 05:36So that's the first question,
05:36 --> 05:39should you get genetic testing?
05:39 --> 05:40And 2nd, regardless of whether
05:40 --> 05:42you get tested or not,
05:42 --> 05:44if you're from that family
05:44 --> 05:47with a genetic mutation,
05:47 --> 05:48granted it increases your
05:48 --> 05:49risk of prostate cancer,
05:49 --> 05:51but is the prostate cancer
05:51 --> 05:53that you eventually get if you
05:53 --> 05:55get a prostate cancer,
05:55 --> 05:56is that prognostically worse?
05:56 --> 05:59Is it a more aggressive cancer
05:59 --> 06:01than if you did not have
06:01 --> 06:02that familial predisposition?
06:04 --> 06:06So the first question regarding
06:06 --> 06:08should you get screened if you're
06:08 --> 06:10in that family, I would say yes.
06:10 --> 06:13I think I would at least recommend that
06:13 --> 06:16you discuss it with a genetic counselor.
06:16 --> 06:18And we have excellent genetic counselors
06:18 --> 06:21here at Yale that can talk with you more
06:21 --> 06:23specifically or talk with them
06:23 --> 06:24more specifically about their risk and
06:24 --> 06:26the benefits of determining
06:26 --> 06:29that versus some of the drawbacks and
06:29 --> 06:30so they can make an informed decision.
06:30 --> 06:31But in general, yes,
06:31 --> 06:33I would say at least having
06:33 --> 06:34the discussion about
06:34 --> 06:36screening would be very important and
06:36 --> 06:38probably would be of benefit not only for
06:38 --> 06:40themselves but for any of their children
06:40 --> 06:42because it is something that can be
06:42 --> 06:45passed down through the generations.
06:45 --> 06:49In terms of BRCA 2 deletion
06:49 --> 06:51associated prostate cancers,
06:51 --> 06:53yes, those are more aggressive.
06:53 --> 06:55So they occur at an earlier age.
06:55 --> 06:57They appear to be associated with
06:57 --> 06:59more aggressive phenotype with a
06:59 --> 07:01higher likelihood of higher grade
07:01 --> 07:03disease and developing metastases.
07:03 --> 07:05So it is something that
07:05 --> 07:08in those cohorts of those families,
07:08 --> 07:10screening and testing is definitely
07:10 --> 07:14one of our important evaluations and
07:14 --> 07:16management plans for those patients.
07:17 --> 07:19So in terms of screening then
07:19 --> 07:22can you tell us a little bit more
07:22 --> 07:24about what screening protocols you
07:24 --> 07:26follow for men at average risk,
07:26 --> 07:29the general population and whether that's
07:29 --> 07:33different for men who may have a genetic
07:33 --> 07:35predisposition or men who might be of
07:35 --> 07:37African American ancestry.
07:39 --> 07:41So that's a very good question and
07:41 --> 07:43it's complex and one that we are
07:43 --> 07:45constantly seeking to find the
07:46 --> 07:48right answer to and and it is elusive.
07:48 --> 07:50So I would say that there's
07:50 --> 07:51an evolutionary process with that,
07:51 --> 07:56but the early detection for prostate
07:56 --> 07:59cancer guidelines from the NCCN,
07:59 --> 08:01and we actually are meeting this afternoon
08:01 --> 08:03to try to finalize exactly that.
08:03 --> 08:09Can we agree on a sort of risk stratified
08:09 --> 08:11protocol for who should be
08:11 --> 08:13getting tested at what frequency?
08:13 --> 08:14I would say we do agree that men
08:14 --> 08:17who are at higher risk should be
08:17 --> 08:19tested starting at an earlier age.
08:19 --> 08:22The frequency of testing depends
08:22 --> 08:25on PSA blood testing results
08:28 --> 08:31and it changes somewhat based on age.
08:31 --> 08:33It's an open discussion of whether or
08:33 --> 08:36not those at a higher risk based on
08:36 --> 08:38genetic or racial characteristics we
08:38 --> 08:41think should be screened more often.
08:41 --> 08:43It's unclear if they should,
08:43 --> 08:45but definitely we want to screen
08:45 --> 08:47them earlier because they can
08:47 --> 08:49potentially be diagnosed with a
08:49 --> 08:51high risk cancer in their 40s,
08:51 --> 08:53at which point intervention has
08:53 --> 08:56a much longer benefit than if we
08:56 --> 08:57can identify the cancer early.
08:58 --> 09:00One of the things that you had mentioned
09:00 --> 09:03earlier was that because so many of
09:03 --> 09:05these prostate cancers are indolent,
09:05 --> 09:06you still recommend
09:06 --> 09:09screening because PSA is a
09:09 --> 09:10relatively easy test to do.
09:10 --> 09:12It's a blood test.
09:12 --> 09:16And so the result of that blood test may
09:16 --> 09:19or may not actually cause an intervention.
09:19 --> 09:22At what point do you start
09:22 --> 09:25looking at that PSA and saying,
09:25 --> 09:29geez, now we really need to do
09:29 --> 09:30something to investigate further?
09:30 --> 09:33Is it a particular number of the
09:33 --> 09:36PSA or is it a trend in the PSA?
09:36 --> 09:40How do you make that distinction
09:40 --> 09:42and what's the next step?
09:42 --> 09:45For a man who might meet those
09:45 --> 09:48criteria in terms of actually trying
09:48 --> 09:50to find prostate cancer earlier,
09:50 --> 09:53we no longer use strict
09:53 --> 09:54cut offs for PSA's.
09:54 --> 09:56Traditionally we had used a
09:56 --> 10:00level of around 3 or a PSA of
10:00 --> 10:02four to indicate that a further
10:02 --> 10:03evaluation was needed.
10:03 --> 10:06We now really have what we call
10:06 --> 10:08shared decision making discussions
10:08 --> 10:10with the patients, with the men
10:10 --> 10:13and talk about the fact that
10:13 --> 10:16a higher PSA is associated with a
10:16 --> 10:19higher likelihood of having a prostate
10:19 --> 10:22cancer detected on biopsy, and what we
10:22 --> 10:25usually consider a cutoff where we
10:25 --> 10:28would consider biopsy and start that
10:28 --> 10:32discussion is if the PSA is over three,
10:32 --> 10:33sometimes over 4.
10:33 --> 10:35It also depends somewhat
10:35 --> 10:37on the age of the man,
10:37 --> 10:39but you also mentioned the
10:39 --> 10:41rate of rise of the PSA.
10:41 --> 10:44If a PSA is completely stable
10:44 --> 10:46that is less often associated with
10:46 --> 10:49a prostate cancer versus one that
10:49 --> 10:52seems to be rising consistently,
10:52 --> 10:54that would be more concerning.
10:54 --> 10:55However, the
10:55 --> 10:56most predictive thing still
10:56 --> 10:58is a PSA that is elevated.
10:58 --> 11:00So a PSA is elevated over 4 statistically
11:00 --> 11:03has the greatest predictive rate
11:03 --> 11:04for their development identifying
11:04 --> 11:06a prostate cancer in the future.
11:06 --> 11:08So it's still a little bit complicated.
11:08 --> 11:09We're trying to make it simple,
11:09 --> 11:11but I think that the easiest way
11:11 --> 11:13to think about it, if you have a
11:13 --> 11:14PSA that has elevated over 4,
11:14 --> 11:16it is worth further discussion
11:16 --> 11:18with your primary care physician
11:18 --> 11:20or urologist about what additional
11:20 --> 11:22steps you may be taking and that
11:22 --> 11:24typically for us at Yale includes
11:24 --> 11:26an MRI of the prostate.
11:26 --> 11:28And then very likely a prostate biopsy.
11:28 --> 11:31So you mentioned this concept of shared
11:31 --> 11:34decision making and talking to
11:34 --> 11:36your doctor about your PSA because
11:36 --> 11:39even if your PSA was elevated,
11:39 --> 11:42if for example you were quite elderly or
11:42 --> 11:45you had a million other comorbidities,
11:45 --> 11:48we actually kind of weigh things all out.
11:48 --> 11:51You know the risk of prostate cancer
11:51 --> 11:53and the treatment of prostate cancer
11:53 --> 11:56might actually be lower in terms of
11:56 --> 11:57the disease itself,
11:57 --> 12:00then the risks of the potential
12:00 --> 12:01intervention and the treatment
12:01 --> 12:03and the the competing risks of
12:03 --> 12:05your other comorbidities.
12:05 --> 12:07Why wouldn't that discussion happen
12:07 --> 12:10before the PSA ever occurred?
12:10 --> 12:11In other words,
12:11 --> 12:13if you know that you're never going
12:13 --> 12:15to act on that PSA screening test,
12:16 --> 12:17why get the test?
12:17 --> 12:19You're absolutely right and it should
12:19 --> 12:22and so there's shared decision making is
12:22 --> 12:24supposed to occur before a PSA is drawn.
12:24 --> 12:26The problem is it is not all
12:26 --> 12:28physicians and that burden often
12:28 --> 12:30falls on primary care physicians
12:30 --> 12:32to be able to have that discussion.
12:32 --> 12:34But you're absolutely right.
12:34 --> 12:37So the first real sort of cutoff
12:37 --> 12:39is unless someone has we think at
12:39 --> 12:42least a 10 year life expectancy,
12:42 --> 12:45we recommend strongly against
12:45 --> 12:46initiating PSA testing.
12:47 --> 12:50Where we're trying to trying to make
12:50 --> 12:52that cut off because for those men
12:52 --> 12:54who we do identify prostate cancer,
12:54 --> 12:56we have lots of new novel treatments
12:56 --> 12:58that have a lot
12:58 --> 12:59less of the side effects that many
12:59 --> 13:01men have been concerned about.
13:01 --> 13:03Some of those include ablation therapies,
13:03 --> 13:04focal therapies,
13:04 --> 13:06things that have many fewer side
13:06 --> 13:08effects than the traditional
13:08 --> 13:09surgery and radiation.
13:09 --> 13:11So we're going to dive a little
13:11 --> 13:13bit more into some of those novel
13:13 --> 13:14therapies right after we take a
13:15 --> 13:16short break for a medical minute.
13:16 --> 13:18Please stay tuned to learn more about
13:18 --> 13:20the care of prostate cancer patients
13:20 --> 13:22with my guest Doctor Preston Sprenkle.
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13:34 --> 13:36treatment plan for each patient.
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13:41 --> 13:43The American Cancer Society
13:43 --> 13:45estimates that nearly 150,000 people
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13:48 --> 13:50colorectal cancer this year alone.
13:50 --> 13:51When detected early,
13:51 --> 13:53colorectal cancer is easily
13:53 --> 13:55treated and highly curable,
13:55 --> 13:57and men and women over the age of 45
13:57 --> 13:59should have regular colonoscopies
13:59 --> 14:01to screen for the disease.
14:01 --> 14:02Patients with colorectal cancer
14:02 --> 14:04have more hope than ever before,
14:04 --> 14:07thanks to increased access to advanced
14:07 --> 14:09therapies and specialized care.
14:09 --> 14:11Clinical trials are currently underway
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14:35 --> 14:38More information is available
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14:39 --> 14:41You're listening to Connecticut public radio.
14:42 --> 14:44Welcome back to Yale Cancer Answers.
14:44 --> 14:46This is doctor Anees Chagpar
14:46 --> 14:48and I'm joined tonight by my guest,
14:48 --> 14:49Doctor Preston Sprenkle.
14:49 --> 14:51We're talking about the care of
14:51 --> 14:52patients with prostate cancer.
14:52 --> 14:54And right before the break,
14:54 --> 14:55we were talking about the
14:55 --> 14:57fact that for the most part,
14:57 --> 15:00many men who get prostate cancer,
15:00 --> 15:04and in fact many men do get prostate cancer,
15:04 --> 15:06will have indolent disease.
15:06 --> 15:08Still, screening is recommended
15:08 --> 15:11because it's an easy screening test.
15:11 --> 15:12It's a blood test.
15:12 --> 15:15And it can pick up prostate cancer
15:15 --> 15:17early when it's most treatable.
15:17 --> 15:20And it's been shown in studies to save lives.
15:20 --> 15:21So Preston,
15:21 --> 15:22we ended the conversation
15:22 --> 15:24right before the break,
15:24 --> 15:25talking about the fact
15:25 --> 15:27that for many patients,
15:27 --> 15:32prostate cancer is relatively indolent.
15:33 --> 15:36You oftentimes will not have problems
15:36 --> 15:40from your prostate cancer and so
15:40 --> 15:42weighing the risks and benefits
15:42 --> 15:46of treatment versus doing nothing
15:46 --> 15:49and certainly watchful waiting
15:49 --> 15:51has been a strategy that has been
15:51 --> 15:54used for some patients with prostate cancer.
15:54 --> 15:57So can you walk us through
15:57 --> 15:58a little bit more of
15:58 --> 16:03what happens when that PSA comes back,
16:03 --> 16:05it is elevated and your doctor wants
16:05 --> 16:08to start looking for prostate cancer?
16:08 --> 16:11Start there and tell us a little
16:11 --> 16:13bit about what men might expect
16:13 --> 16:14in that situation.
16:15 --> 16:17So when
16:17 --> 16:19there is an elevated PSA,
16:22 --> 16:25the first step is to really recheck that,
16:25 --> 16:27to check another PSA test and
16:27 --> 16:30confirm that there is an elevation.
16:30 --> 16:32While the PSA is a very good
16:32 --> 16:34screening test for prostate cancer,
16:34 --> 16:39it is definitely not perfect.
16:39 --> 16:41So there are significant
16:41 --> 16:43limitations that the normal
16:43 --> 16:45prostate tissue also makes PSA.
16:45 --> 16:47So there can be a variety of
16:47 --> 16:51reasons for a PSA blood test to be
16:51 --> 16:54elevated other than prostate cancer.
16:54 --> 16:55So the initial thing would be
16:55 --> 16:57to repeat a PSA blood test.
16:57 --> 17:00We have a lot of new
17:00 --> 17:03biomarkers that can be used
17:03 --> 17:07in that case as well once a PSA
17:07 --> 17:10is found to be elevated that
17:10 --> 17:12confirm whether the PSA is elevated but
17:12 --> 17:14also can give more precise indications
17:14 --> 17:17then try to control or correct for
17:17 --> 17:18some of those benign reasons for
17:18 --> 17:22a PSA to be elevated to evaluate
17:22 --> 17:26someone's true PSA or prostate cancer risk.
17:26 --> 17:28There are a variety of them and I
17:28 --> 17:30don't really want to list all of them,
17:30 --> 17:33but your doctor should know and we
17:33 --> 17:36have quite a few available after
17:36 --> 17:39that if there still is felt to
17:39 --> 17:40be some risk.
17:41 --> 17:44Often, a prostate MRI will be completed.
17:44 --> 17:46The prostate MRI is a relatively
17:46 --> 17:48new thing within the last 10 years
17:48 --> 17:50where we've been using it routinely
17:50 --> 17:52or at a higher rate because it
17:52 --> 17:54allows us to look in the prostate.
17:54 --> 17:56So the prostate previously is one of
17:56 --> 17:58the few solid organs where we were
17:58 --> 18:00not able to really look into it to try
18:00 --> 18:02to identify if there were areas that
18:02 --> 18:05were suspicious for tumor or a cancer.
18:05 --> 18:07The prostate MRI has really
18:07 --> 18:08revolutionized that and allows
18:08 --> 18:11us to look inside the prostate,
18:11 --> 18:12see if there are areas that appear
18:12 --> 18:13suspicious,
18:13 --> 18:16grade them on their risk and allow us
18:16 --> 18:19to then perform a targeted biopsy so we
18:19 --> 18:21can really, in a more selective way,
18:21 --> 18:24sample those areas that are more suspicious.
18:24 --> 18:28This has been tremendous because
18:28 --> 18:31it allows us to
18:31 --> 18:33more accurately identify prostate cancer
18:33 --> 18:35sometimes in a hard to reach
18:35 --> 18:36area of the prostate,
18:36 --> 18:38we would not biopsy at unless we
18:38 --> 18:40knew that there was something there.
18:40 --> 18:42This allows us to know that there's
18:42 --> 18:44an area that's higher risk and do
18:44 --> 18:45targeted biopsies at that area.
18:46 --> 18:52And so once a biopsy is done,
18:52 --> 18:54and it's sent to the pathologist,
18:54 --> 18:57the pathologist can say it's prostate cancer,
18:57 --> 19:00but for many men that prostate
19:00 --> 19:02cancer is different from other men.
19:02 --> 19:06In other words, it's not all the same.
19:06 --> 19:08Some men, based on their prostate
19:08 --> 19:10cancer biopsy, will be given a score
19:10 --> 19:13and they're told,
19:13 --> 19:17we can watch this and monitor you.
19:17 --> 19:20Other men are given a biopsy,
19:20 --> 19:23it's still called prostate cancer,
19:23 --> 19:24but they're told that they
19:24 --> 19:26need more aggressive treatment.
19:26 --> 19:27So what gives?
19:27 --> 19:29How are you making this distinction?
19:29 --> 19:31Tell us more about the scoring of prostate
19:31 --> 19:33cancer and how that affects management.
19:35 --> 19:36Yeah, you're absolutely right.
19:36 --> 19:40So we actually have a 5 point scale
19:40 --> 19:43on which we grade prostate cancer.
19:43 --> 19:47That is the role of the pathologist
19:47 --> 19:50and having expert pathology helped
19:50 --> 19:54tremendously to be able to evaluate those.
19:54 --> 19:55Like you mentioned,
19:55 --> 19:57those pieces of tissue from the
19:57 --> 19:59prostate go to a special Doctor
19:59 --> 20:00who processes them and looks at
20:00 --> 20:02them under a microscope and they
20:02 --> 20:04have a standardized grading scale.
20:04 --> 20:06And based on that grade that is
20:06 --> 20:09the primary driver for most of
20:09 --> 20:11our treatment decisions about
20:11 --> 20:14what to do for prostate cancer.
20:14 --> 20:17We also now use genomic testing.
20:17 --> 20:19So this is different than what we
20:19 --> 20:21were talking about before with testing
20:21 --> 20:23someone's genetics and if they have
20:23 --> 20:25a sort of mutation that's being
20:25 --> 20:27passed down from family members,
20:27 --> 20:28the genomic analysis is actually
20:28 --> 20:30taking the prostate cancer cells
20:30 --> 20:32and doing analysis on those cancer
20:32 --> 20:34cells to determine if this cancer,
20:34 --> 20:38if it's more or less aggressive and I've
20:38 --> 20:41been using those tests for over 5
20:41 --> 20:45years now and find them very helpful in
20:45 --> 20:47discussing with patients what their
20:47 --> 20:49risk may be and helping them determine
20:49 --> 20:51if treatment is indicated and if so,
20:51 --> 20:54what are their best treatment options.
20:55 --> 20:59And so is there a particular cutoff
20:59 --> 21:02on that five point grading scale that
21:02 --> 21:05will tip your into one category versus
21:05 --> 21:07another in terms of how aggressive
21:08 --> 21:10you're going to be with management?
21:10 --> 21:12Similarly on on the genomic tests,
21:12 --> 21:15is this something that's a
21:15 --> 21:17little bit more amorphous, talk to your
21:17 --> 21:19doctor and kind of figure it out together.
21:20 --> 21:22Yeah, so I can definitely tell
21:22 --> 21:25you how I approach it but
21:25 --> 21:28I would say that this is a very
21:28 --> 21:30personalized discussion with your
21:30 --> 21:32urologist or your radiation
21:32 --> 21:34oncologist or your doctor.
21:34 --> 21:36But in general,
21:36 --> 21:39grade one is considered low grade and
21:39 --> 21:41almost universally all of the guidelines
21:41 --> 21:44around the world recommend active
21:44 --> 21:47surveillance or a deferred treatment,
21:47 --> 21:49meaning the treatment is not
21:49 --> 21:51needed right away. Grade 2,
21:51 --> 21:53some of those men can be on surveillance,
21:53 --> 21:55some of them should
21:55 --> 21:56probably consider treatment,
21:56 --> 21:58and that's where the genomic
21:58 --> 22:00testing in my practice comes in
22:00 --> 22:02handy because it helps us identify
22:02 --> 22:05which of those grade two is considered
22:05 --> 22:06favorable intermediate risk,
22:06 --> 22:09which of those patients we can continue
22:09 --> 22:11to observe versus which of them we
22:11 --> 22:13think their cancer will progress
22:13 --> 22:15and we should treat them early.
22:15 --> 22:17And then grade 3-4 and five,
22:17 --> 22:20those are our unfavorable intermediate
22:20 --> 22:22and higher risk prostate cancers.
22:22 --> 22:25Those typically require treatment
22:25 --> 22:27with rare exception.
22:27 --> 22:29And so let's talk a little
22:29 --> 22:30bit more about treatment.
22:30 --> 22:33I mean you had mentioned before
22:33 --> 22:35the break that historically some
22:35 --> 22:37of the treatments are associated
22:37 --> 22:40with side effects that need to be
22:40 --> 22:42considered when you're thinking
22:42 --> 22:44about the risks and benefits
22:44 --> 22:46of therapy for prostate cancer.
22:46 --> 22:48And you also mentioned
22:48 --> 22:50that now there are more novel
22:50 --> 22:52therapies that are coming out
22:52 --> 22:54that have fewer side effects.
22:54 --> 22:58So can you kind of walk us through
22:58 --> 23:00the potpourri of treatment
23:00 --> 23:02options that men who have
23:02 --> 23:04prostate cancer might think about?
23:05 --> 23:07Sure. I will give you a very abridged
23:07 --> 23:10version because this can be
23:10 --> 23:12a very in-depth discussion. But yes,
23:12 --> 23:14I think as I mentioned at the beginning,
23:14 --> 23:17your prostate cancer is a disease
23:17 --> 23:19that grows relatively slowly.
23:19 --> 23:22Most of the time we are treating men
23:22 --> 23:24for prostate cancer not because we are
23:24 --> 23:27worried in most cases, and this is primarily
23:27 --> 23:29talking about localized prostate cancer.
23:29 --> 23:31So not high risk aggressive
23:31 --> 23:33metastatic prostate cancer but for
23:33 --> 23:36men with localized prostate cancer
23:36 --> 23:38we are typically doing our treatments
23:38 --> 23:41to see a survival benefit
23:41 --> 23:42beyond ten years,
23:42 --> 23:45so most men will live 10 years.
23:45 --> 23:46So we're again talking about treating
23:46 --> 23:49those younger men or older men that
23:49 --> 23:51are healthy and have at least a 10
23:51 --> 23:53year life expectancy because the
23:53 --> 23:55survival benefit really materializes
23:55 --> 23:5610,15, 20 years in the future.
23:56 --> 23:58It's not something that happens right away,
23:58 --> 24:00but because of that it is very important
24:00 --> 24:02to consider what the side effects of
24:02 --> 24:04these treatments are and what the
24:04 --> 24:06impact of these treatments on someone's
24:06 --> 24:08quality of life is going to be,
24:08 --> 24:10because it is something that
24:10 --> 24:11they will be living with for
24:11 --> 24:13that extended duration of time that
24:13 --> 24:16we are trying to achieve by doing
24:16 --> 24:18treatment for their prostate cancer.
24:18 --> 24:22So our gold standard therapies are surgery
24:22 --> 24:25to remove the prostate, radiation therapy
24:25 --> 24:29to really treat the cancer where it is,
24:29 --> 24:31a non-surgical therapy
24:31 --> 24:33and as you mentioned,
24:33 --> 24:37we have these newer treatments or ablation
24:37 --> 24:41therapies where we use energy of some sort,
24:41 --> 24:42could be heat,
24:42 --> 24:43could be cold,
24:43 --> 24:48could be electricity to try to destroy
24:48 --> 24:50the prostate tissue within the prostate.
24:50 --> 24:53So we leave the prostate in place and we
24:53 --> 24:55can then destroy the prostate tissue that.
24:55 --> 24:58With the revolution in
24:58 --> 25:00MRI imaging and targeted biopsy,
25:00 --> 25:03we now along with this have much
25:03 --> 25:05better information anatomically about
25:05 --> 25:08where prostate cancers
25:08 --> 25:10are located if they're located in
25:10 --> 25:12just one part of the prostate,
25:12 --> 25:14in multiple parts of the prostate.
25:14 --> 25:16And we can then tailor our treatment
25:16 --> 25:18using these ablation therapies to
25:18 --> 25:21potentially be just one part of the
25:21 --> 25:23prostate or even the whole.
25:26 --> 25:30The reason that these ablation therapies are
25:30 --> 25:32preferred in some cases is that they
25:32 --> 25:35are not associated with many of the
25:35 --> 25:37common side effects or definitely at
25:38 --> 25:40much lower levels than are that we
25:40 --> 25:41see with our traditional treatments
25:41 --> 25:43like surgery and radiation.
25:43 --> 25:47So much less urinary incontinence,
25:47 --> 25:50much better preservation of erections
25:50 --> 25:53and sexual function after treatment,
25:53 --> 25:57many fewer episodes of toxicity
25:57 --> 25:59or long term toxicities.
25:59 --> 26:02So I think it's a really great
26:02 --> 26:04new area of exploration.
26:04 --> 26:08I do have to put the caveat in that
26:08 --> 26:11these are relatively new technologies
26:11 --> 26:14and our national organizations do
26:14 --> 26:17recommend that these procedures be
26:17 --> 26:21done as part of a registry or a trial.
26:21 --> 26:21Fortunately,
26:21 --> 26:23we have several trials that are
26:23 --> 26:25open as well as registry.
26:25 --> 26:26So we have many of these treatments
26:26 --> 26:28available for our patients here.
26:29 --> 26:35It sounds like
26:35 --> 26:38these new therapies have
26:38 --> 26:40significantly lower side effects.
26:40 --> 26:44Do we have data to suggest that
26:44 --> 26:46they are equivalent in terms of
26:46 --> 26:49outcomes to our traditional surgery,
26:49 --> 26:50radiation therapy,
26:50 --> 26:54et cetera or is that really why these
26:54 --> 26:57need to be done in a registry study
26:57 --> 27:00because those data are still lacking?
27:00 --> 27:01That's correct.
27:01 --> 27:03And so our short term,
27:03 --> 27:05we have short term follow-up data.
27:05 --> 27:07We are following these patients very closely.
27:07 --> 27:11So typically we are doing repeat biopsies
27:11 --> 27:14after treatment to evaluate for complete
27:14 --> 27:17treatment success and in those studies
27:17 --> 27:21there are small numbers of persistent cancer,
27:21 --> 27:23but we can then retreat them.
27:23 --> 27:25And so it is a trade off with an
27:25 --> 27:28improved quality of life and a very high
27:28 --> 27:30likelihood of complete cancer control.
27:30 --> 27:33But it is a higher risk of
27:33 --> 27:34needing additional therapy within
27:34 --> 27:37a couple years than you would
27:37 --> 27:39have after surgery or radiation.
27:39 --> 27:41But interestingly, if we look
27:41 --> 27:43at longer term studies,
27:43 --> 27:44there are some studies in Europe
27:44 --> 27:46that have been done now with
27:46 --> 27:48about 10 years of follow up.
27:48 --> 27:50And instead of looking at a
27:50 --> 27:52biopsy a couple years later,
27:52 --> 27:54they looked at what is the likelihood
27:54 --> 27:57of requiring a salvage therapy,
27:57 --> 28:02so a more significant therapy to treat
28:02 --> 28:04recurrent or residual prostate cancer.
28:04 --> 28:06And in those studies there was
28:06 --> 28:07not a significant difference
28:07 --> 28:09between men who had surgery,
28:09 --> 28:11men who had radiation or men
28:11 --> 28:12who had these focal therapies.
28:12 --> 28:15So that's definitely preliminary data.
28:15 --> 28:17This is an area that we
28:17 --> 28:18are learning more about.
28:18 --> 28:20But I think it's safe to say that
28:20 --> 28:22ablation therapies are not going
28:22 --> 28:23to be as effective as a single
28:23 --> 28:25treatment as radiation or surgery,
28:25 --> 28:29but they can be repeated and they
28:29 --> 28:32have a much lower risk profile.
28:33 --> 28:35Doctor Preston Sprenkle is an
28:35 --> 28:36associate professor of urology
28:36 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu,
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Personalized Care of Prostate Cancer with guest Dr. Preston Sprenkle October 9, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095