Surgical Innovations for Prostate Cancer Treatment

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided 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 --> 00:14latest information on cancer care
00:14 --> 00:16by welcoming oncologists and
00:16 --> 00:18specialists who are on the forefront
00:18 --> 00:20of the battle to fight cancer.
00:20 --> 00:22This week, it's a conversation about
00:22 --> 00:24innovations in the treatment of
00:24 --> 00:26prostate cancer with Doctor Isaac Kim.
00:26 --> 00:28Doctor Kim is professor and chair of
00:28 --> 00:31Urology at Yale School of Medicine,
00:31 --> 00:34where Doctor Chagpar is a professor
00:34 --> 00:36of surgical oncology.
00:36 --> 00:37Maybe we can start off by you
00:37 --> 00:39telling us a little bit more
00:39 --> 00:41about yourself and what you do.
00:42 --> 00:46I am a urologic oncologist
00:46 --> 00:49with my clinical practice and research
00:49 --> 00:53specifically focused around prostate cancer.
00:53 --> 00:55And to that end my surgical
00:55 --> 00:56expertise is robotic surgery
00:56 --> 00:58or minimally invasive surgery.
00:58 --> 01:01This is where surgeries are performed
01:01 --> 01:03through very small or multiple
01:03 --> 01:05or single hole incisions.
01:05 --> 01:06The advantage is the patients
01:06 --> 01:08recover faster and they they go home
01:08 --> 01:10a lot quicker and as a result are
01:10 --> 01:11able to get back to activity
01:11 --> 01:13a lot quicker as a result of the surgery.
01:14 --> 01:16So we're going to dive into a little
01:16 --> 01:18bit more of the surgical innovations,
01:18 --> 01:20but maybe we can take a step
01:20 --> 01:23back and talk a little bit more
01:23 --> 01:25about prostate cancer in general.
01:25 --> 01:27Tell us a little bit more
01:27 --> 01:28about prostate cancer.
01:28 --> 01:30I mean, it seems to be pretty common,
01:30 --> 01:33but these days not everybody
01:33 --> 01:35is getting screened.
01:35 --> 01:38There are different screening
01:38 --> 01:40modalities and not everybody who
01:40 --> 01:43even gets diagnosed with prostate
01:43 --> 01:45cancer needs surgical management.
01:45 --> 01:49So can you kind of lay the groundwork for
01:49 --> 01:52us on what exactly is prostate cancer?
01:52 --> 01:53How common is it?
01:53 --> 01:55Who should get screened, and how?
01:56 --> 01:57Yes, silver again,
01:57 --> 02:01that is actually a a loaded question
02:01 --> 02:04because as you've alluded to.
02:04 --> 02:06There is not an agreement amongst
02:06 --> 02:08all the experts in the field,
02:08 --> 02:09so I'll just be able to go over
02:09 --> 02:11some of the general guidelines,
02:11 --> 02:14but at the end the most important
02:14 --> 02:16thing for any men with any
02:16 --> 02:18sort of a prostate issues,
02:18 --> 02:21it's really important to have an
02:21 --> 02:23established relationship with the
02:23 --> 02:25urologist to discuss these issues,
02:25 --> 02:27and this is also called the the
02:27 --> 02:28concept of shared decision making
02:28 --> 02:31where the patients do have a say in
02:31 --> 02:32whether they're going to undergo
02:32 --> 02:34prostate cancer screening or not.
02:34 --> 02:37Or not, but just to give you an overall,
02:37 --> 02:39you know like a 10,000 feet
02:39 --> 02:41view of prostate cancer,
02:41 --> 02:45it is the most common form of cancer in men.
02:45 --> 02:48Besides skin lesions or skin tumors.
02:48 --> 02:51The estimated number of men who
02:51 --> 02:53are going to be diagnosed with
02:53 --> 02:56prostate cancer in this year or in
02:56 --> 02:592022 is a little less than 300,000
02:59 --> 03:01men and and all of these men,
03:01 --> 03:04or of the men who are diagnosed
03:04 --> 03:05with prostate cancer.
03:05 --> 03:07Approximately 34,000 men are
03:07 --> 03:10expected to die from the disease,
03:10 --> 03:12so just based on the statistics
03:12 --> 03:15of 30,000 men is not a very.
03:15 --> 03:16It's not a small number.
03:16 --> 03:17In fact,
03:17 --> 03:18that's a very large number
03:18 --> 03:20compared to the number of men who
03:20 --> 03:22are diagnosed with the disease.
03:22 --> 03:24The death rate is quite low and
03:24 --> 03:27and herein lies the controversies
03:27 --> 03:29or debate around whether every man
03:29 --> 03:33needs to be needs to be screened for
03:33 --> 03:35prostate cancer. And this is true.
03:35 --> 03:37Most men who are diagnosed with
03:37 --> 03:39prostate cancer at all will not
03:39 --> 03:40die from the disease because our
03:40 --> 03:42human is very good these days,
03:42 --> 03:45as well as a lot of the prostate.
03:45 --> 03:48Cancers are indolent or they will not
03:48 --> 03:51hurt the patient if leave them alone.
03:51 --> 03:54The controversy is in that you know we don't.
03:54 --> 03:57As doctors we don't have that the
03:57 --> 03:59hindsight right when you have the
03:59 --> 04:00benefit behind so you can always
04:00 --> 04:02go back and take a look and say
04:02 --> 04:03whether this is good or not.
04:03 --> 04:05Good for the patient.
04:05 --> 04:06When a patient is.
04:06 --> 04:08Is contemplating whether we're going to
04:08 --> 04:11get a prostate cancer workup done or not,
04:11 --> 04:11right?
04:11 --> 04:13They have to make the best decision
04:13 --> 04:15based upon the current literature
04:15 --> 04:17and what the recommendation is.
04:17 --> 04:19And that guideline is going to be
04:19 --> 04:21different based on the patient's age
04:21 --> 04:23as well as general health status.
04:23 --> 04:24So again,
04:24 --> 04:26This is why it's important for
04:26 --> 04:28the patients to have an engaged
04:28 --> 04:30relationship with a urologist,
04:30 --> 04:32say well trained urologist.
04:33 --> 04:35So, so let's dive in a little
04:35 --> 04:37bit more into the age issue,
04:37 --> 04:40because I mean certainly your point of
04:40 --> 04:42their general health status makes sense
04:42 --> 04:45and is something that we apply across
04:45 --> 04:47various cancer screening modalities.
04:47 --> 04:51So if you know you are in a physical
04:51 --> 04:54health condition such that finding a
04:54 --> 04:57very small cancer at its earliest stages
04:57 --> 05:00would be the least of your worries,
05:00 --> 05:03you may not want to have be screened.
05:03 --> 05:05But age is a different issue.
05:05 --> 05:08So we've found that, you know,
05:08 --> 05:10for some cancers now we are beginning
05:10 --> 05:13to screen people earlier and earlier.
05:13 --> 05:16Colorectal cancer is a a classic example.
05:16 --> 05:18For other cancers,
05:18 --> 05:21we're stopping screening at particular ages.
05:21 --> 05:24What's the story with prostate cancer?
05:24 --> 05:26When should men start having a
05:26 --> 05:28conversation with their doctor about
05:28 --> 05:30whether or not they need to get screened?
05:32 --> 05:34So this is where I'll
05:34 --> 05:36have a 2 answer for you.
05:36 --> 05:38One is what our national guideline
05:38 --> 05:40says and then just based on my
05:40 --> 05:42experience what I prefer or when I
05:43 --> 05:45have this shared decision making
05:45 --> 05:47conversation with my patients.
05:47 --> 05:49What I suggest or or or you know,
05:49 --> 05:51my inclination. My opinion on this.
05:51 --> 05:52So I'll give you 2 answers.
05:52 --> 05:55Again the guideline and in my opinion
05:55 --> 05:58so you know this all goes back to the
05:58 --> 06:00clinical trials that were conducted
06:00 --> 06:03to assess whether prostate cancer.
06:03 --> 06:04Screening makes sense or
06:04 --> 06:05not for our patients,
06:05 --> 06:08our men and this is based on a a really
06:08 --> 06:11a critical blood test or or called
06:11 --> 06:14a prostate specific antigen or PSA.
06:14 --> 06:16It's a simple blood test.
06:16 --> 06:18You get drawn in the doctor's office and
06:18 --> 06:20then you get a number and based upon
06:20 --> 06:23that we can risk stratify the patients.
06:23 --> 06:24Say what's your risk of having
06:24 --> 06:26a prostate cancer is and in the
06:26 --> 06:28past this number has traditionally
06:28 --> 06:29been somewhere around 3:00 to 4:00
06:29 --> 06:31cut off and then patients are
06:31 --> 06:34asked to undergo biopsies.
06:34 --> 06:34But again,
06:34 --> 06:37this is based on many laboratory findings,
06:37 --> 06:39so in order to assess whether this
06:39 --> 06:41screening method is effective or not,
06:41 --> 06:44a a large scale or clinical
06:44 --> 06:46trials have been conducted,
06:46 --> 06:48one in the United States and
06:48 --> 06:49the other one in Europe.
06:49 --> 06:52And what this study at the end suggested was,
06:52 --> 06:54is that prostate cancer screening
06:54 --> 06:57may not be all that effective,
06:57 --> 06:59but in the at the end it turns
06:59 --> 07:01out that the studies on some of
07:01 --> 07:03the studies of the one that was
07:03 --> 07:05conducted in the states were had
07:05 --> 07:06a significant contamination.
07:06 --> 07:09There's some questions about the the
07:09 --> 07:13scientific validity or the OR the
07:13 --> 07:16rigorous in which the study design
07:16 --> 07:19was followed. So at the end, the.
07:19 --> 07:22Consensus was that prostate cancer
07:22 --> 07:25screening still is pretty effective,
07:25 --> 07:26and that's, again,
07:26 --> 07:29that's what the the European data has shown.
07:29 --> 07:29Nevertheless,
07:29 --> 07:32you know the issue with that is that
07:32 --> 07:34the studies were were conducted
07:34 --> 07:36in men over age older than 55.
07:36 --> 07:39So in medicine, as you know,
07:39 --> 07:41we have different levels of evidence
07:41 --> 07:42in a house.
07:42 --> 07:43Strong on the level of evidence
07:43 --> 07:45is and the level that we aspire
07:45 --> 07:47to is a level one evidence.
07:47 --> 07:49So currently the level on evidence
07:49 --> 07:51suggests a prostate cancer.
07:51 --> 07:53During his effective for men
07:53 --> 07:55over the age of 55.
07:55 --> 07:57That said then that doesn't preclude
07:57 --> 07:58the fact that prostate cancer
07:58 --> 08:00screening is still effective or
08:00 --> 08:02not effective medium younger than
08:02 --> 08:04age 55 simply because they are not
08:04 --> 08:06included in the clinical trials.
08:06 --> 08:07All right.
08:07 --> 08:09So I think they're in lies the dilemma now.
08:09 --> 08:11So the national guidelines right
08:11 --> 08:14now still say for most part that
08:14 --> 08:16prostate cancer screening should be
08:16 --> 08:19in men over the age of 55 to 865.
08:19 --> 08:21So again based on.
08:21 --> 08:25On these guidelines, that's what we use,
08:25 --> 08:26but also the question about them.
08:26 --> 08:28What about the younger patients, right?
08:28 --> 08:30What about the men who are at a
08:30 --> 08:31higher risk on such as you know,
08:31 --> 08:32fathers, brothers having prostate
08:32 --> 08:35cancer as well as the the minorities?
08:35 --> 08:37You know the the black community
08:37 --> 08:39does have a significant higher
08:39 --> 08:40incidence of prostate cancer.
08:40 --> 08:44So in general, based on the data,
08:44 --> 08:47what I say what I see is is a
08:47 --> 08:48prostate specific antigen PSA?
08:48 --> 08:52Still a very very effective tool.
08:52 --> 08:54So I use that as the initial entry
08:54 --> 08:56of I would like to establish a
08:56 --> 08:59baseline level semi around age 40
08:59 --> 09:01and based on that level that I
09:01 --> 09:03think we can start guiding in terms
09:03 --> 09:06of how intense that follow up or
09:06 --> 09:07the screening process should be.
09:07 --> 09:09So for instance if you're if
09:09 --> 09:12you're at age 40 and you have a
09:12 --> 09:14PSA level that is less than one,
09:14 --> 09:17chances of you of that men having
09:17 --> 09:20a lethal prostate cancer over
09:20 --> 09:22its lifetime is essentially 0.
09:22 --> 09:25So for that patient then the in
09:25 --> 09:27terms of the of the screen intensity,
09:27 --> 09:30you don't have to be as as intense
09:30 --> 09:32as somebody at the age of 40
09:32 --> 09:34with a PSA of three or four.
09:34 --> 09:37So This is why this shared decision
09:37 --> 09:38making becomes very important.
09:38 --> 09:39And again,
09:39 --> 09:41I suggest that the baseline
09:41 --> 09:43should be assuming around age
09:43 --> 09:4540 for the reasons that I think.
09:45 --> 09:46Again,
09:46 --> 09:47that's a very good guiding policy
09:47 --> 09:49in terms of how intense the future
09:49 --> 09:50follow up should be for that man.
09:52 --> 09:53When you say intensity,
09:53 --> 09:57do you mean that if somebody at the
09:57 --> 09:59age of 40 has a PSA less than one,
09:59 --> 10:01that they should never get
10:01 --> 10:03another PSA and somebody who has
10:03 --> 10:06a PSA of three or four should
10:06 --> 10:08be screened at least annually?
10:08 --> 10:09Or is it more frequent?
10:11 --> 10:13Well, that's why I soap all again.
10:13 --> 10:15These are all retrospective data.
10:15 --> 10:16That said, you know, for someone
10:16 --> 10:19whose PSA is less than what age 40.
10:19 --> 10:20I recommend getting another check up
10:20 --> 10:22at age 50 and a 10 year follow-up.
10:22 --> 10:24So for someone who's PSA
10:24 --> 10:26between 2:00 and 3:00,
10:26 --> 10:30or I recommend a PSA check every five years
10:30 --> 10:33age 404550 over the age of PSA of three.
10:33 --> 10:35I recommend annual checkups,
10:35 --> 10:39so again, these are just based upon
10:39 --> 10:41the retrospective data large body.
10:41 --> 10:43Suspected that and that they're
10:43 --> 10:44not prospectively or they're
10:44 --> 10:46not have been validated in a
10:46 --> 10:47rigorous clinical trial setting,
10:47 --> 10:48but my take is,
10:48 --> 10:51is that really the harm of using
10:51 --> 10:53this approach is not significant.
10:53 --> 10:56That was the original concern with the
10:56 --> 10:58mass screening of of prostate cancer.
10:58 --> 11:00Is is that the aggressive intervention?
11:00 --> 11:02That would be a result of the screening
11:02 --> 11:04may not be helping the patients,
11:04 --> 11:06but I think by using this more
11:06 --> 11:07of a creative approach and
11:07 --> 11:09really working with the patients,
11:09 --> 11:11I think that concern is is mitigated.
11:11 --> 11:16There's a lot less, so I do think again.
11:16 --> 11:18Tailoring the the follow up resin
11:18 --> 11:20based upon the patient's age as
11:20 --> 11:21well as the baseline levels or
11:21 --> 11:23the last previous levels.
11:23 --> 11:24I think it's a good approach to do so.
11:26 --> 11:27One other question.
11:27 --> 11:29So in terms of screening,
11:29 --> 11:31what role does Bridget
11:31 --> 11:33digital rectal exam play?
11:33 --> 11:35I mean, are we good with a PSA
11:35 --> 11:37alone or or do we still need to
11:37 --> 11:39have rectal exams which many
11:39 --> 11:40men might not really prefer?
11:42 --> 11:45There's a. There's another very important
11:45 --> 11:48critical question that you're raising,
11:48 --> 11:50and again, that is a question that
11:50 --> 11:53I faced not only from Mike and our
11:53 --> 11:55medical students that we teach here,
11:55 --> 11:57but also from our colleagues
11:57 --> 11:59across in our in our field.
11:59 --> 12:01I say this at the end though,
12:01 --> 12:03or the in terms of statistics.
12:03 --> 12:06You know how many prostate cancer
12:06 --> 12:09can be picked up by a rectal exam on
12:09 --> 12:11that could not be picked up by PSA.
12:11 --> 12:12That number is.
12:12 --> 12:14Quite low, it's going to have
12:14 --> 12:16to be in the single digits,
12:16 --> 12:19so because of that again the question is,
12:19 --> 12:21is that for those patients whose
12:21 --> 12:23PSA or prostate cancer restricted
12:23 --> 12:26by our digital rectal exam that
12:26 --> 12:27if you left them alone,
12:27 --> 12:28eventually the PSA would
12:28 --> 12:29have declared itself?
12:29 --> 12:32So what is really the utility of the
12:32 --> 12:35rectal exam is the question at hand there,
12:35 --> 12:37and you know, again,
12:37 --> 12:39we don't know the answer 100% for sure,
12:39 --> 12:42but really at the end what it was.
12:42 --> 12:44Your Mendez is it really is not
12:44 --> 12:46a difficult or painful exam,
12:46 --> 12:47it's just that it's it deals with
12:47 --> 12:49the private parts, you know it has.
12:49 --> 12:51You know that.
12:51 --> 12:52The private issues on some
12:52 --> 12:53patients are reluctant,
12:53 --> 12:54especially men are reluctant
12:54 --> 12:56to undergo such an exam,
12:56 --> 12:59but it's not a anything that has a a
12:59 --> 13:01long term complications or any other
13:01 --> 13:04long term consequences of their exam.
13:04 --> 13:06It's is a simple of physical exam.
13:06 --> 13:06I mean,
13:06 --> 13:08you know my wife has to go
13:08 --> 13:10into a gynecologist and has to
13:10 --> 13:12get her annual pelvic exam.
13:12 --> 13:13In that sense,
13:13 --> 13:14it's not all that different
13:14 --> 13:16here in terms of complexity.
13:16 --> 13:17In fact,
13:17 --> 13:18in the pelvic exam would be even
13:18 --> 13:21more complex, so it's not a.
13:21 --> 13:23Difficult exempt conduct,
13:23 --> 13:26so I think once you can overcome
13:26 --> 13:27that psychological component,
13:27 --> 13:28a patient has been very good at it.
13:28 --> 13:31So at the end I do stress that rectal
13:31 --> 13:35exam still is a important part of
13:35 --> 13:37monitoring patients or screening
13:37 --> 13:39patients who are potentially
13:39 --> 13:40at risk for prostate cancer.
13:42 --> 13:44Well, we're going to pick up the
13:44 --> 13:45conversation about prostate cancer
13:45 --> 13:47and what happens after screening,
13:47 --> 13:48and what happens?
13:48 --> 13:50Who needs a biopsy and who
13:50 --> 13:52gets treated and how?
13:52 --> 13:53Right after we take a short
13:53 --> 13:55break for a medical minute,
13:55 --> 13:57please stay tuned to learn more
13:57 --> 13:58about prostate cancer treatment
13:58 --> 14:00with my guest Doctor Isaac Kim.
14:01 --> 14:03Funding for Yale Cancer answers
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14:05 --> 14:07where you can view videos from their
14:07 --> 14:09survivorship team by searching for the
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14:13 --> 14:15Breast cancer is one of the
14:15 --> 14:17most common cancers in women.
14:17 --> 14:18In Connecticut alone,
14:18 --> 14:20approximately 3500 women will be
14:20 --> 14:23diagnosed with breast cancer this year.
14:23 --> 14:24But there is hope.
14:24 --> 14:25Thanks to earlier detection,
14:25 --> 14:26noninvasive treatments,
14:26 --> 14:28and the development of novel
14:28 --> 14:30therapies to fight breast cancer,
14:30 --> 14:32women should schedule a baseline
14:32 --> 14:34mammogram beginning at age 40 or
14:34 --> 14:36earlier if they have risk factors
14:36 --> 14:38associated with the disease.
14:38 --> 14:40With screening, early detection,
14:40 --> 14:41and a healthy lifestyle,
14:41 --> 14:43breast cancer can be defeated.
14:43 --> 14:45Clinical trials are currently
14:45 --> 14:47underway at federally designated
14:47 --> 14:49Comprehensive cancer centers such
14:49 --> 14:51as Yale Cancer Center and its Milo
14:51 --> 14:53Cancer Hospital to make innovative
14:53 --> 14:55new treatments available to patients.
14:56 --> 14:57Digital breast tomosynthesis,
14:57 --> 14:59or 3D mammography,
14:59 --> 15:01is also transforming breast
15:01 --> 15:03cancer screening by significantly
15:03 --> 15:05reducing unnecessary procedures
15:05 --> 15:07while picking up more cancers.
15:07 --> 15:09More information is available
15:09 --> 15:10at yalecancercenter.org.
15:10 --> 15:13You're listening to Connecticut public radio.
15:14 --> 15:16Welcome back to Yale Cancer answers.
15:16 --> 15:18I'm doctor Anish Treg Park and I'm joined
15:18 --> 15:21tonight by my guest Doctor Isaac Kim.
15:21 --> 15:22We're talking about prostate
15:22 --> 15:25cancer treatment and right before
15:25 --> 15:27the break we were learning that
15:27 --> 15:29prostate cancer is very common,
15:29 --> 15:31but oftentimes is pretty indolent.
15:31 --> 15:34We went over who needs a a digital
15:34 --> 15:36rectal exam and who needs a PSA.
15:36 --> 15:38But my next question for you,
15:38 --> 15:40Doctor Kim, is this?
15:40 --> 15:44At what point do you move on to a biopsy?
15:44 --> 15:47I mean, at what point is a PSA number
15:47 --> 15:50or a digital rectal examination
15:50 --> 15:52finding so concerning that it's
15:52 --> 15:55time to start looking for a cancer?
15:56 --> 15:59Yes, so so again that is a question
15:59 --> 16:02or the answer to that is not a
16:02 --> 16:03simple straightforward answer.
16:03 --> 16:07It really depends on the patient's age as
16:07 --> 16:11well as his general health status. That said,
16:11 --> 16:15in general the standard cutoff for PSA,
16:15 --> 16:17which will trigger a prostate biopsy,
16:17 --> 16:20which I'd recommend on prostate biopsy,
16:20 --> 16:24is generally around PS 4.0.
16:24 --> 16:26For patients or younger than age 50 on
16:26 --> 16:29PSAT of 3.0 or I will start monitoring
16:29 --> 16:30those patients very intensely.
16:30 --> 16:32And if there's any sign of their
16:32 --> 16:34PSA's rising for those of you,
16:34 --> 16:37I would actually trigger the biopsy or react.
16:37 --> 16:41Recommend a biopsy at a much earlier point.
16:41 --> 16:42On the other hand,
16:42 --> 16:45if the man is older than age 6570,
16:45 --> 16:47then you can go up on the PSA
16:47 --> 16:50to over 6 on 6 1/2 or so.
16:50 --> 16:52The other sign that would
16:52 --> 16:54trigger a prostate biopsy.
16:54 --> 16:55In my mind,
16:55 --> 16:57is an abnormal digital rectal exam.
16:57 --> 16:58It comes to mind.
16:58 --> 17:01A patient that I saw a couple of months ago.
17:01 --> 17:04I actually was seen by a primary
17:04 --> 17:06doctor just monitoring his PSA,
17:06 --> 17:11but again this patients PSA remained low but
17:11 --> 17:13he started having difficulty with urination.
17:13 --> 17:15That's why he's referring to my clinic
17:15 --> 17:18and on a rectal exam was pretty profound.
17:18 --> 17:19What he had.
17:19 --> 17:20So for this patient,
17:20 --> 17:22clearly not having a rectal
17:22 --> 17:24exam was an issue so.
17:24 --> 17:25I do recommend again annual
17:25 --> 17:27rectal exam for patients at risk.
17:27 --> 17:30And one more thing I think more
17:30 --> 17:31nuanced approaches is that there's
17:31 --> 17:33something called a PSA velocity.
17:33 --> 17:35So over the dynamics,
17:35 --> 17:38or how PSA changes over year over year.
17:38 --> 17:40It's another parameter that the
17:40 --> 17:41doctor should pay attention to.
17:41 --> 17:43But then again there is more
17:43 --> 17:44of a nuanced approach.
17:45 --> 17:47The next question, of course is you know,
17:47 --> 17:51PSA is a blood test, so the PSA rising or
17:51 --> 17:54being beyond a certain level tells you that
17:54 --> 17:56something's going on with your prostate.
17:56 --> 17:59But it doesn't necessarily tell you where
17:59 --> 18:01right, and I think that is probably
18:01 --> 18:04the one of the areas in which the
18:04 --> 18:06prostate cancer field has made a huge
18:06 --> 18:08progress over the last decade or so.
18:08 --> 18:11It's so-called the targeted biopsies.
18:11 --> 18:14And really, what this technique involves,
18:14 --> 18:18is imaging of the prostate using the MRI,
18:18 --> 18:21and based on the MRI findings and we'll
18:21 --> 18:24often find lesions that are not normal and
18:24 --> 18:27the radiologist using his or her expertise.
18:27 --> 18:31Will grade the the appearance of the OR
18:31 --> 18:33how abnormal that particular lesion is
18:33 --> 18:37from a Group One through Group 5 and these
18:37 --> 18:40grouping area categories does tell a lot
18:40 --> 18:42about the potential risk of the patient.
18:42 --> 18:44They actually having a a clinically
18:44 --> 18:46significant prostate cancer.
18:46 --> 18:48And here what I mean by clinical significant
18:48 --> 18:50is is that if you leave this alone,
18:50 --> 18:52this prostate cancer proton life is
18:52 --> 18:54going to be progressing and actually
18:54 --> 18:56ultimately compromising the survival
18:56 --> 18:59or the quality of life of the patient.
18:59 --> 19:00So in general,
19:00 --> 19:01based on the MRI findings,
19:01 --> 19:05if the category is 3 or higher is when
19:05 --> 19:08the prostate biopsy is recommended.
19:08 --> 19:10What the more recent studies have
19:10 --> 19:12shown there's a little more sobering
19:12 --> 19:14in the sense that it turns out that
19:14 --> 19:15the MRI is not 100% accurate in
19:15 --> 19:18predicting as you as you are fully over.
19:18 --> 19:19Also, is this anything that we do?
19:19 --> 19:21All this image and still have some
19:21 --> 19:23sort of a a technical engineering
19:23 --> 19:25type of limitations there,
19:25 --> 19:27so it's it's apparent this is
19:27 --> 19:29true also for prostate cancer.
19:29 --> 19:31The MRI is not able to pick up
19:31 --> 19:32all the lesions,
19:32 --> 19:34So what the current recommendation
19:34 --> 19:36for from most urological oncologist?
19:36 --> 19:39So we do the so-called the
19:39 --> 19:40systematic biopsies.
19:40 --> 19:42We actually divide up the process that
19:42 --> 19:45into different grids and take the
19:45 --> 19:47systematic biopsies in addition to that.
19:47 --> 19:50These targeted biopsies that they're
19:50 --> 19:52based on, what the MRI shows,
19:52 --> 19:53is carried out.
19:53 --> 19:55That brings up the next issue,
19:55 --> 19:58which is what is quote
19:58 --> 19:59clinically significant.
19:59 --> 20:02Enough, UN quote, to actually
20:02 --> 20:05warrant some form of treatment.
20:05 --> 20:08Many men who get diagnosed with
20:08 --> 20:12prostate cancer will embark upon a
20:12 --> 20:14course of watchful waiting or kind
20:14 --> 20:16of close observation rather than
20:16 --> 20:19having any kind of active treatment
20:19 --> 20:21in terms of surgery or other
20:21 --> 20:24modalities to treat their cancer.
20:24 --> 20:26How do you make that determination?
20:26 --> 20:28So that is also again a depends
20:28 --> 20:30on there's two critical.
20:30 --> 20:32Criteria that you have to assess
20:32 --> 20:34one is a disease itself and 2nd
20:34 --> 20:36is a patient's overall conditions.
20:36 --> 20:39So I'll just cover the second part first.
20:39 --> 20:42Basically, even if the patient has
20:42 --> 20:44an aggressive prostate cancer.
20:44 --> 20:46If the patients, let's say 80 years old,
20:46 --> 20:48probably it is unlikely that prostate
20:48 --> 20:50cancer is going to hurt that patient,
20:50 --> 20:51so more often than not,
20:51 --> 20:52even if the prostate cancer
20:52 --> 20:54aggressive in an 80 year old man,
20:54 --> 20:56I would recommend that probably
20:56 --> 20:58an observation or surveillance is
20:58 --> 21:00probably the better route to go.
21:00 --> 21:01So again, it really depends on
21:01 --> 21:02the age of the patient.
21:02 --> 21:04That said, if you're really looking
21:04 --> 21:06at prostate cancer biology itself,
21:06 --> 21:08we divide prostate cancer into
21:08 --> 21:09three different categories.
21:09 --> 21:12The low risk, the intermediate risk,
21:12 --> 21:13and the high risk.
21:13 --> 21:15So for men with high risk,
21:15 --> 21:17there is no debate about whether
21:17 --> 21:18these patients need interventions.
21:18 --> 21:19Also,
21:19 --> 21:21with patients who have a low
21:21 --> 21:23risk disease surveillance,
21:23 --> 21:25there's no debate there.
21:25 --> 21:27So it's really the debate is
21:27 --> 21:28in the intermediate category,
21:28 --> 21:30and you know who would.
21:30 --> 21:32Undergo a surveillance or not,
21:32 --> 21:34and right now there's a lot
21:34 --> 21:36of scientific studies going on
21:36 --> 21:37to address this question.
21:37 --> 21:39Current standard right now is
21:39 --> 21:41to use a lot of genomic testing,
21:41 --> 21:43so we have a couple of platforms
21:43 --> 21:46out there that's been approved by
21:46 --> 21:48the FDA that would like to use to
21:48 --> 21:51assess the risk of patients having
21:51 --> 21:53a potentially the cancers are
21:53 --> 21:55progressing or spreading to other
21:55 --> 21:58parts of the body in the future.
21:58 --> 22:00But again, these are sophisticated.
22:00 --> 22:00Testing again,
22:00 --> 22:02it should all be interpreted with an
22:02 --> 22:05experts experience and experts perspective,
22:05 --> 22:07so this should be all done in in
22:07 --> 22:08consultation with the urologist
22:09 --> 22:14and so for those patients who either are.
22:14 --> 22:17Advised to pursue more aggressive
22:17 --> 22:20treatment or choose to do that.
22:20 --> 22:21What does that look like?
22:21 --> 22:24I mean, is surgery the mainstay of therapy?
22:24 --> 22:27Is there a role for neoadjuvant
22:27 --> 22:28therapy so people getting
22:28 --> 22:31chemotherapy before surgery?
22:31 --> 22:32How does that work?
22:33 --> 22:35I'll take your question in in
22:35 --> 22:36in two different segments.
22:36 --> 22:37Here one is, you know, just giving
22:37 --> 22:40an overall perspective on treatment.
22:40 --> 22:41What the available treatments were
22:41 --> 22:44prostate cancer and then talk about
22:44 --> 22:46this new ads even or having sort of
22:46 --> 22:48chemotherapy as part of the region really
22:48 --> 22:51is in the high risk and advanced disease.
22:51 --> 22:53So in patients you know who are
22:53 --> 22:54diagnosed with prostate cancer
22:54 --> 22:56in terms of the decision making.
22:56 --> 22:58For potential options,
22:58 --> 23:01there are really 3 broad categories.
23:01 --> 23:03One is even this alone.
23:03 --> 23:04Surveillance, by the way,
23:04 --> 23:06surveillance does not mean that you
23:06 --> 23:08actually do not monitor the disease.
23:08 --> 23:10The intent of the surveillance is
23:10 --> 23:12to continue to monitor the disease,
23:12 --> 23:15and when that ratio between the
23:15 --> 23:17risk of intervention versus the
23:17 --> 23:19benefit of intervention flips in
23:19 --> 23:22the patient's favor is when you're
23:22 --> 23:24going to actually intervene.
23:24 --> 23:25So in surveillance context,
23:25 --> 23:28the patient is not just being ignored,
23:28 --> 23:31but he still has to pursue.
23:31 --> 23:33And as you monitor continuously.
23:33 --> 23:34That said, then,
23:34 --> 23:36with the surveillance being one option,
23:36 --> 23:38the second option is radiation,
23:38 --> 23:41and third option is in surgery.
23:41 --> 23:43If you look at the the overall
23:43 --> 23:45landscape of treatments of being
23:45 --> 23:46deployed or being utilized in in
23:46 --> 23:48the United States these days,
23:48 --> 23:51surgeries are done in about 40%
23:51 --> 23:53of men diagnosed prostate cancer.
23:53 --> 23:56Radiation is about 3035% and
23:56 --> 23:58surveillance about 25 to 30%,
23:58 --> 24:00so it's a reasonable even split in
24:01 --> 24:04terms of the treatments are being being used.
24:04 --> 24:05Now then,
24:05 --> 24:07to the point about the potential
24:07 --> 24:11for a new age event or any sort
24:11 --> 24:13of combination therapy.
24:13 --> 24:14In the prostate,
24:14 --> 24:17cancer is unique or is unique or
24:17 --> 24:20different from other cancer that is
24:20 --> 24:21exquisitely sensitive to hormones
24:22 --> 24:23or male testosterone.
24:23 --> 24:25For this reason,
24:25 --> 24:28hormonal therapy or androgen deprivation
24:28 --> 24:31therapy ADT has been contemplated,
24:31 --> 24:33has been assessed in many trials to
24:33 --> 24:36see if that can be used in combination
24:36 --> 24:40with any of these as surgery or radiation.
24:40 --> 24:42What the studies have demonstrated
24:42 --> 24:45as is that in surgical patients it
24:45 --> 24:47doesn't make a huge difference,
24:47 --> 24:50although again where I work right
24:50 --> 24:53now as an investigator really
24:53 --> 24:54interested in this disease space,
24:54 --> 24:56I am still exploring the use of a a
24:56 --> 24:58more recent agents in the disease
24:58 --> 25:01space and how that would help or
25:01 --> 25:02potentially help patients with
25:02 --> 25:04advanced disease include metastatic
25:04 --> 25:05prostate cancer.
25:05 --> 25:08But where did new ads were in or
25:08 --> 25:10using hormonal therapy before?
25:10 --> 25:12Intervention has really shown effectiveness.
25:12 --> 25:14It's with radiation.
25:14 --> 25:18The precise mechanism is not quite clear yet,
25:18 --> 25:21but multiple studies have suggested
25:21 --> 25:25that the hormonal therapy itself can
25:25 --> 25:27cause cells to die and potentially
25:27 --> 25:29immune response can be wrapped up.
25:29 --> 25:32The other thing is that it can
25:32 --> 25:33potentially a fragment DNA also,
25:33 --> 25:36so that then can augment the effect
25:36 --> 25:38of the radiation.
25:38 --> 25:40So in general in patients who are.
25:40 --> 25:42Contemplating radiation that hormonal
25:42 --> 25:44therapy should be a significant
25:44 --> 25:46part of the Truman armamentarium,
25:46 --> 25:48as again the patients concerned radiation.
25:49 --> 25:52So then the the next question of course,
25:52 --> 25:55is what factors will prompt
25:55 --> 25:58somebody to opt for surgery?
25:58 --> 26:00And can you talk a little bit
26:00 --> 26:02about some of the innovations in
26:02 --> 26:03surgery at the top of the show?
26:03 --> 26:06You mentioned that you were very
26:06 --> 26:08interested in robotic surgery.
26:08 --> 26:10Tell us a little bit more about that,
26:10 --> 26:13sure. So so in general, if you look
26:13 --> 26:16at the the data and who would benefit
26:16 --> 26:19the most from a surgical intervention?
26:19 --> 26:22These are patients who are relatively
26:22 --> 26:24younger who are in generally good
26:24 --> 26:27health who have long life expectancy.
26:27 --> 26:30In my practice, I strongly recommend
26:30 --> 26:32surgery to men with more than
26:32 --> 26:3515 years of life expectancy.
26:35 --> 26:37Again, you have to take a look at
26:37 --> 26:39assess the patients or general health
26:39 --> 26:42status and and calculate the the
26:42 --> 26:45potential of survival for that patient.
26:45 --> 26:47So it has to get done in conjunction
26:47 --> 26:49with in consultation with the patient.
26:49 --> 26:51But in general. Or healthier patients?
26:51 --> 26:53I do think that they are gonna benefit
26:53 --> 26:55a lot better from surgery because
26:55 --> 26:57in in this is in operation they can
26:57 --> 26:59go in and take the process it out
26:59 --> 27:01and then patient recovers and you
27:01 --> 27:04can go on through some of his normal
27:04 --> 27:06life with really not much risk going
27:06 --> 27:08or or the the nose of significant
27:08 --> 27:10complications from the operation
27:10 --> 27:12long term provided that the in the
27:12 --> 27:15near term he has recovered all his
27:15 --> 27:16functions and that is going.
27:16 --> 27:18That's a a statement that I am
27:18 --> 27:19putting out the loaded statement
27:19 --> 27:21that I'm putting out there in that.
27:21 --> 27:23The recovery after operation is
27:23 --> 27:27where a lot of men fear on because
27:27 --> 27:30the prostate sits right outside are
27:30 --> 27:33just external distal to the bladder,
27:33 --> 27:35and that is where a lot of the
27:35 --> 27:35important malfunctions,
27:35 --> 27:37including erectile function,
27:37 --> 27:40the nerves responsible erectile
27:40 --> 27:41function runs through.
27:41 --> 27:46So in this patients again the the
27:46 --> 27:51chance to have the the surgery is again.
27:51 --> 27:53Has to depend on the experience of
27:53 --> 27:56the operator operator to surgeon.
27:56 --> 27:58Where I come in is is that I do the
27:58 --> 28:00robotic surgery and really in my mind
28:00 --> 28:02this has really mitigated or address
28:02 --> 28:04a lot of this potential concerns in
28:04 --> 28:06terms of the complication for that patient.
28:06 --> 28:08And again that's another area where
28:08 --> 28:11the last 10 years we have made a
28:11 --> 28:13significant and a huge progress in
28:13 --> 28:15terms of technology and engineering.
28:15 --> 28:18And as you move forward on the paradigm
28:18 --> 28:20is shifting where we used to make it
28:20 --> 28:22big incision and the smaller incisions.
28:22 --> 28:24And the more recent technology
28:24 --> 28:26is so-called the single port
28:26 --> 28:27prostatectomy technology,
28:27 --> 28:29where now we're after this operation.
28:29 --> 28:31Patients are able to go home because
28:31 --> 28:32on the same day essentially.
28:33 --> 28:35Doctor Isaac Kim is professor and chair
28:35 --> 28:38of Urology at 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 --> 28:55cancer here on Connecticut Public
28:55 --> 28:56radio. Funding for Yale Cancer Answers
28:56 --> 29:00is provided by Smilow Cancer Hospital.

Information

Surgical Innovations for Prostate Cancer Treatment with guest Dr. Isaac Kim August 14, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095