Prostate Cancer Awareness Month 2022

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 with
00:08 --> 00:10your host, Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:13latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:22This week, it's a conversation about
00:22 --> 00:24prostate cancer with Doctor Joseph Kim.
00:24 --> 00:26Doctor Kim is an associate professor
00:26 --> 00:28of internal medicine and medical
00:28 --> 00:30oncology at the Yale School of Medicine,
00:30 --> 00:32where Doctor Chagpar is a professor
00:32 --> 00:33of surgical oncology.
00:35 --> 00:37So Doctor Kim, maybe we can start off
00:37 --> 00:39by you telling us a little bit more
00:39 --> 00:40about yourself and what it is you do.
00:41 --> 00:44I'm a medical oncologist.
00:44 --> 00:46I specialize in taking care of
00:46 --> 00:47patients with prostate cancer
00:47 --> 00:49and other urinary tract cancers.
00:49 --> 00:51I've been here at Yale for
00:51 --> 00:52the last nine years or so.
00:52 --> 00:55I received my training at the
00:55 --> 00:57National Cancer Institute of NIH.
00:57 --> 00:59Since I came to Yale,
00:59 --> 01:00I have been taking care of
01:00 --> 01:02patients with prostate cancer
01:02 --> 01:03and other tumor agencies.
01:03 --> 01:06I also specialize in clinical trials.
01:07 --> 01:09It's prostate
01:09 --> 01:12cancer awareness month and many people
01:12 --> 01:14have heard about prostate cancer,
01:14 --> 01:15but there's still a lot of questions.
01:15 --> 01:17So I'm hoping that we can
01:17 --> 01:19unpack a lot of that today.
01:19 --> 01:20So to kick us off,
01:20 --> 01:23why don't you tell us about the
01:23 --> 01:24epidemiology of prostate cancer?
01:24 --> 01:28How common is it, who gets it and
01:28 --> 01:31how lethal or not lethal is it?
01:32 --> 01:33So that's a very good question.
01:33 --> 01:36So prostate cancer is a very common cancer.
01:36 --> 01:38Other than skin cancer,
01:38 --> 01:39prostate cancer is the most
01:39 --> 01:41common cancer in American men.
01:41 --> 01:45And according to the the epidemiology,
01:45 --> 01:47they estimate about
01:49 --> 01:51260,000 new cases of
01:51 --> 01:53prostate cancer this
01:53 --> 01:55year and about 34,000 men will
01:55 --> 01:58unfortunately die of prostate cancer.
01:58 --> 01:59As you see this number,
01:59 --> 02:02not everyone dies of prostate cancer.
02:02 --> 02:04Clearly there's a certain phenotype that
02:04 --> 02:06is very lethal prostate cancer and this
02:06 --> 02:08is very important for us to understand
02:08 --> 02:10who are these group of patients,
02:10 --> 02:12how aggressive it could be in
02:12 --> 02:13identifying these patients and treating
02:13 --> 02:16the patients and improving
02:16 --> 02:18the outcomes of these patients.
02:18 --> 02:20So who gets prostate cancer?
02:23 --> 02:24A common risk factor is age.
02:25 --> 02:27The older the man is, the more likely you
02:27 --> 02:29will develop prostate cancer and also
02:29 --> 02:32it appears that some ethnic backgrounds
02:32 --> 02:34play a role for reasons unclear.
02:34 --> 02:36African American men seem
02:36 --> 02:37to have prostate cancer
02:37 --> 02:39that is somewhat more aggressive.
02:39 --> 02:41And also there are other risk factors
02:41 --> 02:44too such as we'll describe.
02:44 --> 02:47Genetic syndromes such as
02:47 --> 02:48Lynch syndrome.
02:48 --> 02:49Patients with this genetic syndrome
02:49 --> 02:51tend to have prostate cancer
02:51 --> 02:53in early age and also have
02:53 --> 02:55somewhat aggressive biology.
02:57 --> 02:59So tell us a little bit more about
02:59 --> 03:01the screening for prostate cancer,
03:01 --> 03:04because it seems to me that has
03:04 --> 03:08had its ebbs and flows over the years
03:08 --> 03:11from digital rectal exam to PSA to,
03:11 --> 03:14you know, potentially even more
03:14 --> 03:16sophisticated forms of screening.
03:16 --> 03:18And yet not everybody requires
03:18 --> 03:20screening, there are different ages for
03:20 --> 03:22starting screening and stopping
03:22 --> 03:24screening at different intervals
03:24 --> 03:27at which one should get screening.
03:27 --> 03:28What are the latest guidelines in
03:28 --> 03:31terms of screening for prostate cancer?
03:31 --> 03:32So that's a very good question.
03:32 --> 03:34I think prostate cancer screening has
03:34 --> 03:37evolved the last couple of decades or so.
03:37 --> 03:39It's been very confusing because
03:39 --> 03:41the guidelines change, you know,
03:41 --> 03:42over the last few years.
03:42 --> 03:44So the latest guideline is that you
03:44 --> 03:47have to talk to your doctor and your
03:47 --> 03:49doctor should have a very well involved
03:49 --> 03:51discussion about the prescan screening.
03:51 --> 03:53In other words, if you have a
03:53 --> 03:55strong family history,
03:55 --> 03:57if your father,
03:59 --> 04:01your uncles, had prostate cancer in early age,
04:01 --> 04:02you should be concerned about it,
04:02 --> 04:04and you can talk to your doctor about
04:04 --> 04:07this and see what other tests that you
04:07 --> 04:09could do to screen for prostate cancer.
04:09 --> 04:11The most commonly
04:11 --> 04:13used test to screen for prostate
04:13 --> 04:16cancer is a blood test called PSA.
04:16 --> 04:18It's a simple blood draw
04:18 --> 04:20and the normal value is 4.
04:20 --> 04:22If your PSA is higher than four,
04:22 --> 04:24this may raise some concern.
04:26 --> 04:27And you may get referred to a urologist
04:27 --> 04:28for further evaluations
04:28 --> 04:31and the other method you can screen
04:31 --> 04:33for prostate cancer will be doing a
04:33 --> 04:35digital rectal examination,
04:35 --> 04:36which should be done by your
04:36 --> 04:37primary care physician.
04:38 --> 04:41If you have any symptoms in your urination,
04:41 --> 04:44such as weak stream urgency,
04:44 --> 04:47urinary frequency or urinary tract infection,
04:47 --> 04:49that's not going away
04:50 --> 04:51your doctor should evaluate
04:51 --> 04:53this further to evaluate for
04:53 --> 04:54the underlying pathology.
04:56 --> 04:59And so for patients who are at
04:59 --> 05:02average risk, let's suppose that
05:02 --> 05:04they don't have a family history,
05:04 --> 05:06they don't have a genetic mutation.
05:06 --> 05:10When should they start getting PSA testing
05:10 --> 05:13and how frequently should that occur?
05:13 --> 05:15So there's no general consensus about
05:15 --> 05:18what age to start the PSA screening for
05:18 --> 05:20general population and that has been
05:20 --> 05:22the debate over the last few years.
05:22 --> 05:23Generally speaking,
05:23 --> 05:26age 55 is the age that they
05:26 --> 05:28begin to talk about prostate cancer
05:28 --> 05:30screening in patients with risk factors.
05:30 --> 05:33So if you are 55 and older,
05:33 --> 05:34if you have any concern
05:34 --> 05:36about the prostate cancer,
05:36 --> 05:38you can discuss your concern with
05:38 --> 05:39your doctor, especially if you
05:39 --> 05:40have a strong family history.
05:40 --> 05:41If you don't,
05:41 --> 05:44then you don't necessarily have to have
05:44 --> 05:45pre cancer screening.
05:46 --> 05:49What goes into that decision making?
05:49 --> 05:50Because you know,
05:50 --> 05:52when you start off by saying prostate
05:52 --> 05:55cancer is one of the most common cancers,
05:55 --> 05:58presumably not everybody has symptoms
05:58 --> 06:00when they develop prostate cancer.
06:00 --> 06:02So if you're at average risk
06:02 --> 06:04and you don't have symptoms,
06:04 --> 06:07what's the likelihood of you being
06:07 --> 06:09diagnosed with prostate cancer and
06:11 --> 06:13a relatively frequent event,
06:13 --> 06:15why don't we have screening on
06:15 --> 06:17a regular basis like we do for
06:17 --> 06:19other kinds of cancers like
06:19 --> 06:21breast cancer or colon cancer?
06:21 --> 06:22That's a very good question.
06:22 --> 06:24And that's in part because of
06:24 --> 06:26the long Natural History of the
06:26 --> 06:28prostate cancer and very diverse
06:28 --> 06:30biology of the prostate cancer.
06:30 --> 06:33And as I mentioned on epidemiology,
06:33 --> 06:34as you see it,
06:34 --> 06:36not everybody dies of prostate cancer.
06:36 --> 06:37I think it's very important to
06:37 --> 06:38identify this type,
06:38 --> 06:41but the majority of prostate cancer can be
06:41 --> 06:42very indolent in biology,
06:42 --> 06:44meaning that yes you will
06:44 --> 06:46have it, you may develop a
06:46 --> 06:47prostate cancer in your lifetime,
06:47 --> 06:50but you may not die of prostate cancer.
06:50 --> 06:52So having a diagnosis and
06:52 --> 06:54going through a procedures and
06:54 --> 06:56treatments is another and whether
06:56 --> 06:58you die of prostate cancer
06:58 --> 07:00is what we are really afraid of, right.
07:00 --> 07:02So really a lot of things go
07:02 --> 07:04into making a decision.
07:04 --> 07:06Now you know about the prostate
07:06 --> 07:07cancer screening.
07:07 --> 07:09I think the future of prostate
07:09 --> 07:11cancer screening is really identifying
07:11 --> 07:12those who are at
07:12 --> 07:15risk of developing prostate cancer,
07:15 --> 07:16not just prostate cancer,
07:16 --> 07:18but lethal prostate cancer
07:18 --> 07:19and indolent prostate cancer,
07:19 --> 07:22they may not need to be diagnosed because,
07:22 --> 07:25you know, they may live with the disease,
07:25 --> 07:28but they may not die of the disease.
07:28 --> 07:29So that's sort of the things
07:29 --> 07:30that goes on behind the mind.
07:31 --> 07:34And so you mentioned a few of the
07:34 --> 07:36factors that tend to be associated
07:36 --> 07:37with more aggressive disease,
07:37 --> 07:39so being African American,
07:39 --> 07:41having a family history,
07:41 --> 07:45particularly a genetic mutation and so on.
07:45 --> 07:47And so let's suppose
07:47 --> 07:49did fit into that category and
07:49 --> 07:52you went and you had a conversation
07:52 --> 07:56with your Doctor who decided to screen
07:56 --> 07:58you with a PSA and you mentioned
07:58 --> 08:02that the normal value is 4.
08:02 --> 08:03And let's suppose that your
08:03 --> 08:05value was higher than four.
08:05 --> 08:06What does that mean?
08:06 --> 08:08Does that automatically mean
08:08 --> 08:10that you have prostate cancer
08:10 --> 08:11or what happens after that?
08:12 --> 08:13So this will generate a lot of
08:13 --> 08:15questions and
08:15 --> 08:16discussions with your doctor.
08:16 --> 08:18The first step is to be
08:18 --> 08:20referred to a urologist,
08:20 --> 08:24not all elevated PSA means prostate cancer,
08:24 --> 08:26sometimes having inflammation in the
08:26 --> 08:29prostate gland or having some,
08:29 --> 08:30you know, some procedures done
08:30 --> 08:32with the prostate gland,
08:32 --> 08:35these conditions can raise the PSA value too,
08:35 --> 08:38so you don't have to be too worried about it,
08:38 --> 08:40but clearly deserve a conversation
08:40 --> 08:42with the urologist.
08:42 --> 08:43And he or she will guide you
08:43 --> 08:45about the next steps.
08:45 --> 08:46Usually what happens as the
08:46 --> 08:47next step is that
08:47 --> 08:48depending on the timeline,
08:48 --> 08:51he or she may want to repeat the
08:51 --> 08:53PSA value to see whether it's real
08:53 --> 08:54elevation or false elevation.
08:54 --> 08:57If it's confirmed to be elevated, then,
08:57 --> 08:59depending on your medical conditions,
08:59 --> 09:01your doctor will talk to you about
09:01 --> 09:02whether you should get a prostate
09:02 --> 09:07biopsy or not to monitor and
09:07 --> 09:08those are the conversations you
09:08 --> 09:09would have with your urologist.
09:10 --> 09:13And ultimately if you do end up
09:13 --> 09:17having a prostate biopsy and if that
09:17 --> 09:20biopsy indeed confirms prostate cancer,
09:20 --> 09:22there's a whole system of grading
09:22 --> 09:24of prostate cancer that really
09:24 --> 09:26influences whether we need to be
09:26 --> 09:28more aggressive or less aggressive
09:28 --> 09:30in terms of its management.
09:32 --> 09:34So we use what we call Gleason
09:34 --> 09:36score to create groups.
09:36 --> 09:38These are the pathological
09:38 --> 09:40terms to describe the
09:41 --> 09:43logical assessment of the
09:43 --> 09:44prostate cancer and you know,
09:44 --> 09:46the higher the grade is more
09:46 --> 09:49ugly looking the prostate cancer cells.
09:49 --> 09:50In other words,
09:50 --> 09:52this may predict more of aggressive
09:52 --> 09:53biology of the prostate cancer,
09:53 --> 09:55but they also are low grade
09:55 --> 09:56prostate cancer as well.
09:56 --> 09:58So these tumors may have
09:58 --> 09:59more indolent biology.
10:01 --> 10:03And so talk to us a little bit
10:03 --> 10:05more about that because one of the
10:05 --> 10:07things that I think may be confusing
10:07 --> 10:10for people is the fact that some
10:10 --> 10:11people may be diagnosed with a
10:11 --> 10:13more indolent prostate cancer.
10:13 --> 10:17And for them they may have
10:17 --> 10:20watchful waiting or active surveillance,
10:20 --> 10:23whereas others who may have a more
10:23 --> 10:25aggressive prostate cancer may
10:25 --> 10:27have other treatment modalities.
10:27 --> 10:31So at what point is that decision made?
10:31 --> 10:32Is there a particular
10:32 --> 10:35Gleason score cutoff that helps us
10:35 --> 10:36to decide which category people
10:36 --> 10:39fall into or what are the factors
10:39 --> 10:41that go into that decision making?
10:42 --> 10:45When we make a decision on treatment
10:45 --> 10:47there are multiple factors to consider.
10:47 --> 10:48Gleason scores you mentioned
10:48 --> 10:50are one of the critical one,
10:50 --> 10:52but also we look at tumor
10:52 --> 10:54staging, patients
10:54 --> 10:56comorbidities and life expectancy.
10:56 --> 10:59A lot of things factor into making
10:59 --> 11:01a treatment decision to answer your
11:01 --> 11:03questions about the Gleason score,
11:03 --> 11:05generally you will hear
11:05 --> 11:07Gleason score 6,7,8,9 or 10.
11:07 --> 11:10So Gleason six is generally speaking or
11:11 --> 11:14low grade prostate cancer oftentimes.
11:14 --> 11:15A patient is very less likely
11:15 --> 11:17to die of prostate cancer.
11:17 --> 11:18So oftentimes patients
11:18 --> 11:20with increasing 6 disease,
11:20 --> 11:23they can be monitored with what we call
11:23 --> 11:25active surveillance or watchful waiting.
11:25 --> 11:28Score 7 is sort of like
11:28 --> 11:30intermediate risk prostate cancer.
11:30 --> 11:33Again depending on other conditions,
11:33 --> 11:35you could talk to your doctor
11:35 --> 11:36about being treated,
11:36 --> 11:38whether surgery or radiation,
11:38 --> 11:42but for Gleason score 8-9 or 10,
11:42 --> 11:44these are rather higher grade
11:44 --> 11:46prostate cancer and you
11:46 --> 11:48really want to consider receiving
11:48 --> 11:49more definitive treatments
11:49 --> 11:51with the radiation or surgery.
11:51 --> 11:52So again,
11:52 --> 11:54Gleason score is one of the factors
11:54 --> 11:56going in and making a treatment decision,
11:56 --> 11:57but we should also
11:57 --> 11:59think about other factors as well.
12:00 --> 12:03And so when patients are
12:03 --> 12:04treated with active surveillance,
12:04 --> 12:06what does that mean?
12:06 --> 12:09Does that mean that we just kind of
12:09 --> 12:10close your eyes and say, well,
12:10 --> 12:12you have indolent disease
12:12 --> 12:14or are these people followed?
12:14 --> 12:16And if they're followed
12:16 --> 12:17with imaging modalities,
12:17 --> 12:19what modality is that and how
12:19 --> 12:21frequently are people monitored
12:21 --> 12:23or are they monitored with PSA?
12:23 --> 12:25What does active
12:25 --> 12:27surveillance really look like?
12:27 --> 12:29It's an active surveillance,
12:29 --> 12:30not passive active surveillance.
12:30 --> 12:33We go in with an active surveillance
12:33 --> 12:35with the goal of intervening.
12:35 --> 12:37At some point, again, this discussion
12:37 --> 12:39would happen with the urologist.
12:39 --> 12:42Primarily so during the active surveillance
12:42 --> 12:45patient will follow with the PSA one
12:45 --> 12:48summer once a year or prostate MRI
12:48 --> 12:50to really understand the morphology,
12:50 --> 12:52the how the prostate tumor
12:52 --> 12:54looks in the prostate gland.
12:54 --> 12:56They also follow with the
12:56 --> 12:57digital rectal examinations.
12:57 --> 13:00So they follow these patients very
13:00 --> 13:02carefully and throughout the course
13:02 --> 13:04to really make a decision as to when
13:04 --> 13:06to intervene the prostate cancer.
13:06 --> 13:08Oftentimes you may end up receiving
13:08 --> 13:10a surgery or radiation therapy.
13:10 --> 13:12But often other times you may
13:12 --> 13:14not need to be intervened for
13:14 --> 13:16low risk prostate cancer.
13:17 --> 13:20Well, we're going to take a
13:20 --> 13:22short break for our medical minute.
13:22 --> 13:23And when we come back,
13:23 --> 13:25we're going to learn more about the
13:25 --> 13:26treatment of prostate cancer patients
13:26 --> 13:29with my guest, Doctor Joseph Kim.
13:29 --> 13:31Funding for Yale Cancer Answers
13:31 --> 13:33comes from Smilow Cancer Hospital,
13:33 --> 13:35where the gynecologic oncology program
13:35 --> 13:37brings together a team of clinicians
13:37 --> 13:40whose focus is to care for women with
13:40 --> 13:42gynecologic cancers. Learn more at
13:46 --> 13:48yalecancercenter.org.
13:48 --> 13:50There are many obstacles to
13:50 --> 13:51face when quitting smoking,
13:51 --> 13:54as smoking involves the potent drug nicotine.
13:54 --> 13:56Quitting smoking is a very
13:56 --> 13:57important lifestyle change,
13:57 --> 13:59especially for patients
13:59 --> 14:00undergoing cancer treatment,
14:00 --> 14:02as it's been shown to positively
14:02 --> 14:04impact response to treatments,
14:04 --> 14:06decrease the likelihood that patients
14:06 --> 14:08will develop second malignancies,
14:08 --> 14:10and increase rates of survival.
14:10 --> 14:12Tobacco treatment programs are currently
14:12 --> 14:14being offered at federally designated
14:14 --> 14:16Comprehensive cancer centers such
14:16 --> 14:18as Yale Cancer Center and Smilow
14:18 --> 14:20Cancer Hospital all treatment
14:20 --> 14:22components are evidence based and
14:22 --> 14:25patients are treated with FDA approved
14:25 --> 14:27first line medications as well as
14:27 --> 14:29smoking cessation counseling that
14:29 --> 14:31stresses appropriate coping skills.
14:31 --> 14:34More information is available
14:34 --> 14:35at yalecancercenter.org.
14:35 --> 14:37You're listening to Connecticut public radio.
14:39 --> 14:41Welcome back to Yale Cancer Answers.
14:41 --> 14:42This is doctor Anees Chagpar
14:42 --> 14:44and I'm joined tonight by my guest,
14:44 --> 14:46Doctor Joseph Kim.
14:46 --> 14:48We're talking about the care of patients
14:48 --> 14:51with prostate cancer in honor of
14:51 --> 14:53prostate Cancer Awareness Month.
14:53 --> 14:55Right before the break, Doctor Kim,
14:55 --> 14:57you were mentioning that many patients
14:57 --> 14:59have indolent prostate cancer,
14:59 --> 15:01which even if diagnosed,
15:01 --> 15:05may be indolent in its course.
15:05 --> 15:08And it may be followed with
15:08 --> 15:09active surveillance with PSA's.
15:09 --> 15:11And so on and so forth.
15:11 --> 15:13For the patients who have
15:13 --> 15:15more aggressive disease,
15:15 --> 15:16can you talk to us a little bit
15:16 --> 15:18more about their management?
15:18 --> 15:19So first of all,
15:19 --> 15:21how do you know if a patient is
15:21 --> 15:23diagnosed and let's say that they
15:23 --> 15:25have more aggressive disease?
15:25 --> 15:28So we talked a little bit about the
15:28 --> 15:30Gleason score and you mentioned that
15:30 --> 15:33an 8-9 or a 10 is more aggressive if a
15:33 --> 15:36patient is diagnosed with such disease,
15:36 --> 15:38how do we know that this cancer
15:38 --> 15:40is confined only to the prostate?
15:40 --> 15:43And hasn't spread all over their body.
15:43 --> 15:45Is there some sort of staging
15:45 --> 15:47test that we need to do before
15:47 --> 15:49we embark upon therapy?
15:50 --> 15:52A very good question. So yes,
15:52 --> 15:54we do several imaging modalities truly
15:54 --> 15:57understand the extent of the prostate cancer.
15:57 --> 15:59The most commonly used imaging
15:59 --> 16:02modality we use is a prostate MRI.
16:02 --> 16:04This will really give us a better
16:04 --> 16:06description of what's going on with the
16:06 --> 16:08prostate gland and the tumors and how the
16:08 --> 16:10tumors invading around the surroundings,
16:10 --> 16:12around the structures nearby.
16:12 --> 16:16So we use a prostate MRI and if we are
16:16 --> 16:18worried that this is a high risk disease
16:18 --> 16:20then we often get stage and scanned.
16:20 --> 16:22Now with a CT scan and
16:22 --> 16:24the whole body bone scan,
16:24 --> 16:25we get a whole body bone scan
16:25 --> 16:27because bone is a very common site
16:27 --> 16:29that prostate cancer can spread to.
16:29 --> 16:31So we get a CT scan and the
16:31 --> 16:34bone scan in the prostate MRI to
16:34 --> 16:36understand the extent of the disease.
16:36 --> 16:39In some settings when we
16:39 --> 16:42are making decisions as to what
16:42 --> 16:44kind of a local therapy to do and
16:44 --> 16:46in a patient we highly suspect
16:46 --> 16:48to have metastatic disease,
16:49 --> 16:50we now use a new imaging.
16:50 --> 16:52Or PSMA PET CT scan to see
16:52 --> 16:55whether a patient in fact has a
16:55 --> 16:56metastatic disease or not.
16:57 --> 16:59Tell us more about this PSMA.
16:59 --> 17:03Is that the same as a regular FDG pet
17:03 --> 17:06or is it special for the prostate?
17:06 --> 17:08Tell us more about that and in
17:08 --> 17:10what patients you would use that
17:10 --> 17:12as opposed to simply using a CT
17:12 --> 17:14scan and a whole body bone scan.
17:15 --> 17:16So that's a very good question.
17:16 --> 17:21So PSMA stands for prostate specific
17:21 --> 17:23membrane antigen as the name implies.
17:23 --> 17:25It's supposed to be very
17:25 --> 17:26specific to prostate cancer.
17:26 --> 17:27So if you think about this,
17:27 --> 17:30this is actually much
17:30 --> 17:32more sensitive PET imaging than the
17:32 --> 17:35conventional CT scan or the bone scan.
17:35 --> 17:38This is different from FDG PET to
17:38 --> 17:40scan after looking
17:40 --> 17:42for hypermetabolism of the glucose.
17:42 --> 17:45But here we are looking for the
17:45 --> 17:47tumor cells that are expressing PSMA and
17:47 --> 17:50we are trying to detect, you know,
17:50 --> 17:54very low levels of prostate cancers
17:54 --> 17:57by using this trace PSMA tracer,
17:57 --> 17:59so this PSMA.
17:59 --> 18:02has about 3 indications.
18:02 --> 18:04So in a localized setting in patients
18:04 --> 18:06who just received the diagnosis
18:06 --> 18:08of high risk prostate cancer and
18:08 --> 18:10your doctor's discussing NOTE Confidence: 0.849518728333333
18:10 --> 18:12whether we need to do a surgery,
18:12 --> 18:15radiation or whether we should do a
18:15 --> 18:17systemic therapy based on
18:17 --> 18:20parameters such as PSA level, Gleason score,
18:20 --> 18:22which really raised our concern
18:22 --> 18:23that this patient may in fact
18:23 --> 18:25have a metastatic disease.
18:25 --> 18:26Then we may actually get
18:26 --> 18:28a PSMA to scan,
18:28 --> 18:30to document and to prove that
18:30 --> 18:32patient has a metastatic disease.
18:32 --> 18:34So in such a setting we can avoid doing
18:34 --> 18:36surgery or surgery or radiotherapy
18:36 --> 18:38for that group of patients.
18:38 --> 18:41So we use this scan in making a
18:41 --> 18:43treatment decision for whether
18:43 --> 18:45patients receive local
18:45 --> 18:48therapy versus systemic therapy.
18:48 --> 18:50And the caveat for this is that
18:50 --> 18:52this can detect sometimes a false
18:52 --> 18:55signals and false positives as well.
18:55 --> 18:57So one has to look at the imaging
18:57 --> 19:00data in the clinical context.
19:00 --> 19:03Let's suppose a patient is diagnosed
19:03 --> 19:06with a more aggressive prostate cancer
19:06 --> 19:10and their doctor decides that they're
19:10 --> 19:13going to get treatment and staging scans,
19:13 --> 19:16whether a CT and bone scan or a PSMA and no
19:18 --> 19:19metastatic disease is found.
19:19 --> 19:22So this is localized to
19:22 --> 19:25the prostate itself.
19:25 --> 19:27Talk to us a little bit about
19:27 --> 19:28how that's treated.
19:28 --> 19:30You mentioned surgery, you mentioned
19:30 --> 19:31radiotherapy,
19:31 --> 19:34you also mentioned systemic therapy,
19:34 --> 19:36how do you decide which modality a
19:36 --> 19:39patient will be treated with
19:39 --> 19:42or is a combination often used?
19:42 --> 19:44Tell us more about how prostate
19:44 --> 19:45cancer is treated in that setting.
19:46 --> 19:49So a lot of factors go into
19:49 --> 19:50treating patients with a localized
19:50 --> 19:52prostate cancer that is high risk.
19:52 --> 19:55The options are several as mentioned,
19:55 --> 19:58surgery is one, radiation therapy with
19:58 --> 20:01hormone therapy is another, sometimes
20:01 --> 20:03systemic therapy followed by radiotherapy
20:03 --> 20:05is another approach that we can take
20:05 --> 20:07in treating this group of patients.
20:07 --> 20:10And again you know in making a treatment
20:10 --> 20:11decision a lot of factors go into it
20:11 --> 20:13in terms of patients preference as well.
20:13 --> 20:15We counsel him about the potential
20:15 --> 20:18complications of each of these approaches.
20:18 --> 20:20Again our intent here is a cure,
20:20 --> 20:21the long term cure.
20:21 --> 20:23So whenever we make a decision on a
20:23 --> 20:25certain treatment we have to keep in mind
20:25 --> 20:28of their long term complications as well.
20:28 --> 20:32So generally speaking with the surgery,
20:32 --> 20:35we can cure some of these patients,
20:35 --> 20:37but some of these patients may end
20:37 --> 20:40up with the long term urinary issues
20:40 --> 20:43or erectile dysfunctions and other,
20:43 --> 20:45you know, long term complications.
20:45 --> 20:46The rates are relatively low.
20:46 --> 20:48But again, patients would have to
20:48 --> 20:49be concerned about that.
20:49 --> 20:51And with the radiation therapy,
20:51 --> 20:52again,
20:52 --> 20:54patients will receive radiation therapy
20:54 --> 20:56about five to six weeks of radiation
20:56 --> 20:58therapy along with the hormonal
20:58 --> 21:00therapy and these patients would have
21:00 --> 21:02a very nice response in their PSA.
21:02 --> 21:04And their clinical improvement,
21:04 --> 21:06but the long term complication of this
21:06 --> 21:09treatment would be sometimes this can
21:09 --> 21:11cause some issues in
21:11 --> 21:12bladder area,
21:12 --> 21:14some abnormal blood vessels and
21:14 --> 21:16sometimes this can cause second
21:16 --> 21:18malignancy as well in these organs.
21:19 --> 21:20How often does that occur?
21:20 --> 21:22Because I can imagine that patients
21:22 --> 21:24who have just been diagnosed with
21:24 --> 21:26prostate cancer may not want to hear
21:26 --> 21:28that one of the potential risks of their
21:28 --> 21:31treatment is getting yet another cancer.
21:31 --> 21:33So is that pretty uncommon.
21:33 --> 21:35That is a good question.
21:35 --> 21:36Again, remember, we are going
21:36 --> 21:37in with a curative treatment.
21:38 --> 21:39In other words, we want to
21:39 --> 21:41see our patients 10 years out,
21:41 --> 21:4320 years out and 25 years out.
21:43 --> 21:46So the risk of having these
21:46 --> 21:48malignancies with the radiotherapy,
21:48 --> 21:51there's a time factor so
21:51 --> 21:54in patients who live long enough,
21:54 --> 21:57after being treated with NOTE Confidence: 0.885917186
21:57 --> 21:59radiotherapy for prostate cancer,
21:59 --> 22:01I don't know the exact percentage of this,
22:01 --> 22:03but we do see
22:03 --> 22:03some malignancies,
22:03 --> 22:06but relatively this is uncommon,
22:06 --> 22:07I would say less than 5%.
22:08 --> 22:12Now you also mentioned endocrine
22:12 --> 22:14therapy or hormone therapy, for
22:14 --> 22:16which patients is that recommended
22:16 --> 22:18and what are the side effects.
22:19 --> 22:22So hormone therapy is very commonly used as
22:22 --> 22:25systemic therapy to treat prostate cancer.
22:25 --> 22:28So when we say hormone therapy,
22:28 --> 22:29we have to understand the
22:29 --> 22:30biology of the prostate cancer.
22:30 --> 22:32So prostate cancer is really
22:32 --> 22:33a testosterone or androgen
22:33 --> 22:34driven cancer.
22:34 --> 22:37So what we do first to treat prostate
22:37 --> 22:40cancer is to lower the testosterone by
22:40 --> 22:43giving another hormone therapy called
22:43 --> 22:45GNRH agonists or GNRH antagonists.
22:45 --> 22:48This is what we call a shot that
22:48 --> 22:49we give once every three months
22:49 --> 22:51or four months or on a monthly
22:51 --> 22:53basis depending on the dose.
22:53 --> 22:56So when patients receive this
22:56 --> 22:58hormone injection oftentimes patients
22:58 --> 23:01will experience hot flashes,
23:01 --> 23:04male menopause like symptoms.
23:04 --> 23:05Some irritability,
23:05 --> 23:07they may have some fatigue,
23:07 --> 23:09losing muscle mass,
23:09 --> 23:10gaining fat,
23:10 --> 23:12and those are common side effects
23:12 --> 23:14that we see with endocrine
23:14 --> 23:15therapy in prostate cancer.
23:16 --> 23:19It sounds like many patients may
23:19 --> 23:22not particularly love those symptoms,
23:22 --> 23:24especially if they're young.
23:24 --> 23:27Are there other systemic therapy
23:27 --> 23:30options for young patients?
23:33 --> 23:35So there are other systemic therapy
23:35 --> 23:38that we use to treat prostate cancer,
23:38 --> 23:41mostly still hormone therapy,
23:41 --> 23:43hormonal therapy and we
23:43 --> 23:46have other oral hormonal therapies,
23:46 --> 23:49we have immunotherapies and other
23:49 --> 23:52chemotherapies and novel therapies as well.
23:52 --> 23:54But these systemic therapists
23:54 --> 23:56are indicated for patients with
23:56 --> 23:57metastatic prostate cancer.
23:58 --> 24:02Let's talk a little bit
24:02 --> 24:05more about that if a patient is
24:05 --> 24:08diagnosed with metastatic cancer.
24:08 --> 24:10The systemic therapy really the
24:10 --> 24:12mainstay of therapy and what can they
24:12 --> 24:14expect in terms of their management.
24:15 --> 24:18So when patients hear the word
24:18 --> 24:20metastatic disease it can be big
24:20 --> 24:22shocker for many of our patients.
24:22 --> 24:25But I would like to reassure our
24:25 --> 24:26patients that these systemic therapies
24:26 --> 24:29work especially with the hormonal
24:29 --> 24:31therapy the chance of benefiting
24:31 --> 24:33these patients is nearly 100%.
24:33 --> 24:36So other than hormonal therapy
24:36 --> 24:38we use you know other
24:38 --> 24:40oral hormonal therapies and
24:40 --> 24:41chemotherapies to maximize the
24:41 --> 24:43benefit of the treatment to improve
24:43 --> 24:45the outcomes of our patients.
24:46 --> 24:48And when we think
24:48 --> 24:51about all of these therapies,
24:51 --> 24:52the endocrine therapies,
24:52 --> 24:54the systemic chemotherapies
24:54 --> 24:57immunotherapies and all of the side
24:57 --> 24:59effects that go along with them,
24:59 --> 25:03the list that you mentioned was
25:03 --> 25:04not particularly something that
25:04 --> 25:07I think a lot of patients would
25:07 --> 25:09be very enthused about.
25:09 --> 25:11Are there ways that you can help
25:11 --> 25:13them get through those side effects
25:13 --> 25:16or ameliorate those side effects so
25:16 --> 25:18that they still can have
25:18 --> 25:20a reasonably good quality of life,
25:20 --> 25:22especially if they're going to live,
25:22 --> 25:25as you mentioned 10,20,25 years out?
25:27 --> 25:29You know, if the patients
25:29 --> 25:30experience really significant
25:30 --> 25:33hot flash or other side effects,
25:33 --> 25:36we sometimes use other supplements
25:36 --> 25:39to help with some of their side effects.
25:39 --> 25:41But actually in patients with
25:41 --> 25:43metastatic disease, these patients have
25:43 --> 25:45symptoms of the cancer such as pain,
25:45 --> 25:48fatigue and other cancer related symptoms.
25:48 --> 25:50So actually when they start
25:50 --> 25:51this hormonal therapy,
25:51 --> 25:52they do feel better,
25:52 --> 25:54their pain goes
25:54 --> 25:57away and they regain their energy.
25:57 --> 25:58Therefore they should feel
25:58 --> 26:00better while they are on treatment.
26:00 --> 26:02But for patients who have no
26:02 --> 26:04symptoms at baseline, yes,
26:04 --> 26:06these patients will experience some of
26:06 --> 26:08the side effect and there are other
26:08 --> 26:10supplements or medication that
26:10 --> 26:12we can use to treat those endocrine
26:12 --> 26:13therapy related side effects.
26:14 --> 26:16So tell us about some of the new
26:16 --> 26:19and novel things that are exciting
26:19 --> 26:21in coming down the pipeline for
26:21 --> 26:23prostate cancer management.
26:23 --> 26:25You mentioned at the top of the show that
26:25 --> 26:27you're very interested in clinical trials.
26:27 --> 26:29Clinical trials always make us think
26:29 --> 26:31about exciting new developments that
26:31 --> 26:32might be helpful for our patients.
26:32 --> 26:34So what's new in prostate cancer,
26:34 --> 26:36what can we expect in the coming years?
26:37 --> 26:40So the latest development in prostate
26:40 --> 26:43cancer is a treatment called PSA
26:43 --> 26:45targeted radioligand therapy.
26:45 --> 26:47As I mentioned earlier,
26:47 --> 26:49this is in a way a targeted
26:49 --> 26:52radiation therapy in patients who
26:52 --> 26:54have PSA positive prostate cancer,
26:54 --> 26:56which have become refractory
26:56 --> 26:58to multiple lines.
26:58 --> 26:59This treatment can
26:59 --> 27:01be used for this group of patients
27:01 --> 27:03and the studies have shown that you
27:04 --> 27:05know patients receiving this class of
27:05 --> 27:08therapy actually did much better in
27:08 --> 27:10terms of their symptoms in terms of
27:10 --> 27:13disease control and the overall survival.
27:13 --> 27:14So that is one of the newest
27:14 --> 27:16treatment that we have and there
27:16 --> 27:17are other ongoing trials going
27:17 --> 27:20on to really use this therapy in
27:20 --> 27:21earlier setting and in combination
27:21 --> 27:23with other therapies as well.
27:23 --> 27:24So we are very excited about
27:24 --> 27:26this new class of therapy.
27:27 --> 27:29Is this widely available or is this
27:29 --> 27:31available only on clinical trial?
27:32 --> 27:34So actually this therapy was
27:34 --> 27:36recently approved by the FDA in
27:36 --> 27:38April of this year, but then there
27:38 --> 27:39was some issue with the supply.
27:39 --> 27:41So there is a little bit of
27:41 --> 27:44delay in using this therapy
27:44 --> 27:46in operation in our clinics.
27:46 --> 27:48But then there are other trials going
27:48 --> 27:50on to investigate this treatment
27:50 --> 27:52with other therapies to improve the
27:52 --> 27:55outcomes of our patients.
27:55 --> 27:58You also mentioned that immunotherapy
27:58 --> 28:01was something that is is being used.
28:01 --> 28:03Is that pretty standard now?
28:03 --> 28:06Yes, there's two classes of
28:06 --> 28:08immunotherapy for prostate cancer.
28:08 --> 28:10One is a treatment called sipuleucel-T
28:10 --> 28:12and this treatment was
28:12 --> 28:15approved in 2010 and we also have
28:15 --> 28:17another treatment called
28:17 --> 28:18immune checkpoint inhibitors.
28:18 --> 28:20This is really for patients
28:20 --> 28:22with what we call mismatch repair
28:22 --> 28:25deficiency which is seen in about
28:25 --> 28:275 to 10% of prostate cancer patients
28:27 --> 28:29and these patients may be eligible
28:29 --> 28:30to receive this immunotherapy.
28:31 --> 28:34Doctor Joseph Kim is an associate
28:34 --> 28:36professor of internal medicine and medical
28:36 --> 28:38oncology at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:54cancer here on Connecticut Public Radio.
28:54 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Prostate Cancer Awareness Month 2022 September 18, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095