1  - Michael Riordan, Medical Oncologist Peter Schlagel, MD, Urologist Charlie Rinehart MD, and Surgical Oncologist Paul Roach MD embark on a full discussion of Prostate Cancer: what it is, how it happens, how it behaves, and how it's treated.

2  - Guest:  Charlie Rinehart, MD, a practicing Urologist and medical officer in the U.S. Navy, (formerly an officer in the USMC), undergraduate at Georgetown, Medical School at Columbia, and Urologic Residency at US Naval Medical Center, San Diego.  Currently practices at the Captain James A. Lovell Federal Health Care Center, in North Chicago, Illinois. This is his second time on the program; for full introduction to Dr. Rinehart please check out the episode on Bladder Cancer.

3  - Timestamps:

[00:4] - Intro & disclaimer

[01:00] Overview of Prostate Cancer: 

A. Incidence and broad description of the problem

B. What is a prostate? What is a PSA screening test? What does it mean to have an elevated PSA test? How is the PSA test done?

C. Clinical Presentation & who gets prostate cancer?

[10:50] Prostate Biopsy

[12:25] Shared decision making regarding prostate cancer screening

A. The good, the bad, the ugly

B. Risk reduction versus over treatment; the importance of age in the process

C. “Heterogeneity” and variability in prostate cancers

[20:00] Very Low risk, Low, Intermediate, High, Very High risk categories.

[26:15] The “Trifecta”

A. The goal:  Treat the cancer, preserve urinary continence, preserve sexual function.

B. Risks and benefits of treatment options, based off of estimates of baseline risk.

C. What is “active surveillance?” Impact of age, baseline health status on deciding which course of action to take.

[31:20] Active Surveillance & Radiation Therapy

A. Age, health issues, prior experiences and their influence in choosing Surveillance or Xrt.

B. External Beam, IMRT (Intensity Modulated Radiation Therapy), Brachytherapy

[34:03] Side Effects of Surgery, Radiation Treatment

A. Incidence and range of incontinence, erectile difficulties

B. Impact of baseline function, age at time of treatment, time from surgery

C. Sequencing Surgery and Radiation treatments

D. Antitestosterone therapy

[42:00] Staging tests for localized versus widespread cancer.

A. CT scan and bone scans - traditional

B.  MRI’s and PSMA tests - newer

[46:25] Michael’s questions on origin of the cancer: Genetic? Smoking? Diet? Exercise

A.  African American/Black individuals a clearly higher risk of developing prostate cancer and should consider PSA screening 10 years earlier (age

B.  Agent Orange exposure - Viet Nam Veterans.

C. Association with BRCA

i. What is it?

ii. Importance of Family Medical History (males & females)

[51:05]  Summary of points thus far, and Radioactive seeds treatment option

A. When to use which option?

B. Lower risk options and higher risk options

[54:45] Prostatectomy

[56:21] Advanced disease

A. Locally advanced (i.e. spread outside the capsule of the prostate, and/or spread into the local pelvic lymph nodes or organs) disease

B. Distant (i.e. metastatic) disease

i. Androgen deprivation

C. Microscopic disease

D. Survival and quality of life

E. Testosterone supplementation and (+/-) association with prostate cancer.

[1:03:50] How does prostate cancer cause a man to die?

A. “Go-go” phase, “slow-go” phase, “no-go” phase

B. Androgen deprivation

[1:09:22] Closing and thanks

4  - Key takeaways in bulleted format:

-- Prostate Cancer happens to Men alone, as only men have a prostate, and has about the same frequency and risks as breast cancer has for women.

—It typically happens in the more advanced ages, but can happen in younger men (40’s for Black men, 50’s for other demographics)

-- Frequently, Prostate Cancer does not present with symptoms; one needs to have a screening test performed (called PSA) but should discuss risks/benefits with physician prior to embarking on that.  

-- There are a variety of different risk categories for diagnosed prostate cancer (very low, low, intermediate, high, very high) with different risk of progression into advanced disease and death.  The risk categories can change (from less risky —> more risky) over time, so a physician-patient relationship must be maintained over time.

—Multiple treatment options; these are based on stage of disease, risk category of the disease, patient age and health, and patient preferences.  Patient and physician must work with one another to decide which therapy to employ, and when, and why.

5  - Relevant links for the episode:

https://www.cancer.gov/about-cancer/treatment/clinical-trials/disease/prostate-cancer/treatment

https://www.cancerresearchuk.org/about-cancer/prostate-cancer

https://www.cdc.gov/cancer/prostate/

https://www.cancer.gov/types/prostate

https://www.radiologyinfo.org/en/info/imrt

6  - Follow us on your favorite Podcast program, and learn more through the homepage at  https://paulbryanroach.com/so-its-cancer/

7  - Coming up next month:  “Lung Cancer"

8 - Follow us on your favorite podcast platform, please contact me/us via webpage https://paulbryanroach.com, and direct link to show website is here: https://paulbryanroach.com/so-its-cancer/

paul_roach:

Welcome back everybody to So It's Cancer, the podcast where we are dedicated to being a how-to manual for cancer patients and their friends and families. Each month we work through different elements of the overall problem from soup to nuts. Beginning at the beginning, such as the basics of what cancer is, who may be at risk, who is involved in the treatments, why treatments differ so much from one cancer to another, or even within the same type of cancer. This podcast is for informational purposes only and should not be employed for a specific clinical decision making. For any such efforts, please communicate directly with your personal physician. Today, everybody, we're welcoming back our usuals, Peter Schlagle and Michael Reardon.

michael:

Hi

peter_schlegel:

Good evening.

paul_roach:

and Charlie Reinhardt, our urologist.

Charlie:

believing

paul_roach:

Today we're going to take on prostate cancer. And Peter, I'm going to lead off with you.

peter_schlegel:

Yeah, so prostate cancer is one of the leading causes of death for men. It's also one of the leading diagnoses. And there's much to be learned about prostate cancer, both in terms of the lay public and the specialists who are involved in treatment. I'd like to start off by saying that the population that's affected parallels women with breast cancer that we're roughly seeing about the same number of patients is prostate cancer. Patients obviously, according to their gender, although men will get breast cancer, but not the vice versa. It's also interesting to know that the death rate from prostate cancer closely matches that with breast cancer. And in fact, for every 10 people, men diagnosed with prostate cancer, only about one, maybe two will die from their disease. So there's lots and lots of men being treated, being cured, or living with cancer, amount of those who actually succumb to the disease ultimately. On the other hand, it is a big source of pain and suffering. It's a big source of anxiety. It can change your life overnight. And with that, we'll jump right into talking specifically about prostate cancer and who it affects. Charlie, you're kind of the specialist in terms of being in the office and we'd like to hear kind of you see walking into the office with prostate cancer, how they're offered to see a urologist regarding possible prostate cancer, and what typically happens with their first visit when they have say elevated PSA or have urinary problems and so forth.

paul_roach:

Well, I'd like to jump in with a quick question

Charlie:

Yeah.

paul_roach:

on behalf of the audience. What is a prostate?

michael:

Yeah, what's a PSA?

Charlie:

Well, that's a good place to start, Paul. So the prostate is an organ of sexual function. It is part of the male sexual, general sexual, process. So what the prostate does is it essentially creates enzymes, those are chemicals that allow for kind of the semen to live within a sperm and to be viable for fertilization within the woman. So that's what its function is for men of fertile age, but you know kind of after that age of those fertile years, it doesn't really serve much of a purpose cause issues amongst men. So yeah Michael, come here question, what is PSA? That's a good question. So PSA stands for prostate specific antigen. So that's a that's one of these specific antigens or one of these specific enzymes that are made in the prostate that are getting used to kind of prepare the sperm and make the environment viable for sperm. made by every prostate. Every man has some level of PSA in their bloodstream, so it's a blood test. And what we use it for, what the medical field uses it for, is a screener for prostate cancer. So what we have found that, yes, every prostate makes PSA and every man has PSA in the bloodstream, but those men that do have prostate cancer, we find that their PSA levels will rise. And so that's what we use to screen men as we screen for prostate cancer. So I guess that gets us back to the question is how does someone end up in my office being evaluated for prostate cancer? And typically that's done, that starts out at the primary care level. So primary care physicians will draw a PSA. There's kind of certain criteria for when, you know, who and when your PSA is drawn.

michael:

Just a blood test

Charlie:

It

michael:

early.

Charlie:

is. It is a blood test. And so if that comes back elevated, usually that will end up with a referral to a urologist and we'll kind of go from there. That's essentially PSA and that's how someone gets referred to Urology Office.

peter_schlegel:

Yeah.

paul_roach:

And

peter_schlegel:

From um

paul_roach:

most prostate cancers aren't something that people sense. It's just they go to their doctor, they get a blood test, and the test flags it. Most of the time,

peter_schlegel:

Yeah.

paul_roach:

am I correct? That they're not like, hey, I've got this symptom, and then you investigate that symptom and discover they have prostate cancer.

peter_schlegel:

Yeah.

paul_roach:

Most of the time

peter_schlegel:

Yeah.

paul_roach:

it's discovered these days with the blood test. Is that correct?

peter_schlegel:

Yeah, I will add that we used to recommend digital rektal exams in the primary care office and that's kind of gone by the wayside So in a perfect world you get a PSA your screen from age 50 to 70 If it's high then you go see urologist and say yep, unfortunately a prostate cancer. Let's cure you Unfortunately, there's a ton of gray zone between being normal and having prostate cancer And that's probably what causes Charlie nine out of ten of his headaches is in terms of who really needs to be treated and who doesn't, who needs to go through all these tests and who doesn't. The PSA design is such that if it's elevated, it signifies that you have prostate cancer. But in many cases, the elevated PSA just may indicate that you have some sort of infection, you may have some stone disease in your prostate, or another benign condition. Yet it raises red flags, anxiety, diagnostic tests, uncertainty, and expense.

michael:

Peter or Charlie, what is elevated? When you're looking at it, I know my dad had it and his numbers were considered low, but still within a range to be concerned about. And when he went for treatment, he was sitting in the waiting room with another gentleman and they were, as men will do, they were comparing test result sizes. And

peter_schlegel:

Ha ha ha

michael:

the other guy was like three or four times greater score than my dad. What does that mean to have an elevated PSA? And what are the numbers?

Charlie:

Yeah, so there's really not any, I mean, part of the problem with PSA, there's not any real cutoff for what is an elevated PSA. Sometimes it kind of, it can be if your age can play a big factor in what can be considered an elevated PSA. If I see a PSA, let's say four, that's kind of a standard lab definition of above four is considered elevated. If I see a PSA of three in a 45 year old male, that's gonna raise a lot more flags than if I say, see a three and a 75 year old male. So as men age, we know their PSA, as long as well as their prostate inside will get bigger. And so a lot of it has to do with kind of the age of the individual, if they have any family history, prostate cancer, things like that.

michael:

And I asked another delicate question. This is the first time that I had a blood test in many years, having not been to the doctor in a while. And they said, oh, we'll do full work up and we'll take blood. And they said, well, we're a little concerned. Your PSA level is a little bit high. I think it was three, something or whatever. I don't really remember the number. But then they said, wait, have you ejaculated recently? And I said, well, that's kind of a personal question, Doug.

paul_roach:

Yeah.

michael:

But I guess, and you can tell me if this is true or not, basically then said, well, you shouldn't ejaculate within five days of your, you know, this is just my,

paul_roach:

Well, how are you going to get tested, Mike?

michael:

I know,

peter_schlegel:

Hehehe.

michael:

I think they read my baseline at

peter_schlegel:

Ha

michael:

that

peter_schlegel:

ha

michael:

point

peter_schlegel:

ha ha ha!

michael:

in time, but is that something that we should share with people is that when they're going just to their general practitioner, that they should try to refrain from any sexual activity for, I think they said five days or so. So it doesn't skew the test. Is that a real thing or was I just being April fooled? Nobody's going to let us.

Charlie:

No, that is

peter_schlegel:

Ah

Charlie:

a real thing, a two degree. I mean, we say the PSA can be artificially or it can be elevated for a number of reasons. Again, prostate cancer is one of those, but infection can cause an elevation of the PSA, any kind of manipulation of that area. So someone goes, you know, instead of maybe ejaculating or some type of intercourse, say you were on your Peloton, you know, and did a big Peloton ride and a lot of pressure on that area, to artificially go up. Even we had mentioned the digital rectal exam, the thought is that you shouldn't get a PSA immediately after getting your prostate examined, which is through the rectum, because that can cause it to kind of transiently go up in the bloodstream. So yeah, I mean, there is some factor. And typically I will not make any decisions based on a single PSA number. I would repeat that PSA to see or maybe it was something that caused it to just go up for a transient period of time.

michael:

Would you recommend, you know, if I know that I've got a doctor's appointment coming up and I'm gonna have this blood test done, that I should not ride a bike, I should not engage in sexual activity, I should not, you know, one or the other should not.

Charlie:

Yeah, I would say 72 hours. I would stay off of some kind of cycling, any kind of pressure on that area we call the perineum. That's the area on the underside. Intercourse. say 72 hours. So yeah, I think if if you're elevated and you're going and you're having you're having your PSA checked, I would say you avoid those things for three days.

paul_roach:

because you'd like to avoid that biopsy.

Charlie:

Yes.

paul_roach:

So what happens is if your PSA is elevated, let's say two times in a row, and you go see Charlie, he might biopsy it, right?

Charlie:

Correct, yeah, so that's the PSA is a screener, right? So it's a screener, and so like any screening test, it's meant to identify people that are at risk for having the disease. So PSA is not diagnosed to get prostate cancer. Like we said, there's a lot of things that can raise the PSA. And so what we need to do is the next step likely is to get a biopsy. And so a biopsy, We do typically we do in the office just In the urology office and unless there's a reason to do it under some type of sedation, but it is a it's a procedure where we have to take samples of the prostate the axis the prostate it's it sits right at the Right at the rectum right the anus and the rectum so it's a probe into the rectum, and we sampled the bot the prostate in that manner so not necessarily a comfortable procedure There are not only is it uncomfortable for guys, but there are some risks, certainly some risk of infection after a prostate biopsy. So you would want to avoid doing unnecessary biopsies and that's part of the issue that we've seen with kind of wide scale screening of prostate cancer.

peter_schlegel:

I will mention the concept of shared decision making. That's a big deal in medicine these days. It means that there needs to be a conversation in terms of undergoing any kind of testing, a consent if you will, that there's good, bad, and ugly with PSA screening. In fact, some of the major medical boards will give it a C grade, just like a report card saying, you know, this PSA screening much. The good news on the PSA screening is since we've been doing it 20 years ago there's been almost a decrease of 50% in the chance of a male in the United States dying from prostate cancer which is huge.

paul_roach:

That sort of parallels mammograms and breast cancer, doesn't it?

peter_schlegel:

Probably not as good. It matters how you look at the literature and read the studies. So I look at it that as a positive say since we've been doing PSA screening, the number of people dying has decreased a bit. And since COVID came around and the PSA testing has kind of come offline as people are tree. I don't see there's other things to do. We're seeing the number of people with really advanced prostate cancer from someone who sees advanced disease involving the bones and the lymph nodes and all the bad stuff you hear about. So the good of overall that we're probably saving lives with doing screening, the bad is that it's expensive that people who are diagnosed with prostate cancer go down these roads that they don't want to go in terms of having sexual organs operated on, complications, anxiety, and and so forth. We call that over-treatment and saying, you know, some of these people may have lived just fine without having someone do all these interventions on them that may not have cured them in town or may be unnecessary, that we may have caught a disease that was going very, very slowly. We don't understand all these things. When Charlie does his biopsy, he tries to figure out how fast the cancer is going. We have something called Gleason PSA velocity, there's molecular study, blah, blah, blah. Some fancy stuff so he can give you a statistic, but in the end, all he can give you is a number. Say, you know, I think it's this likely it's gonna be cancer and this is what we're gonna have to do to get rid of it. The ugly is that we just miss a whole bunch of prostate cancers by relying exclusively on the PSA test. Obviously, men who have urinary problems, it's pretty ubiquitous. Once you hit your 50th birthday, you're waking up once, to go to the bathroom at night and as you get older it just increases. Is that normal? Is that from cancer? What's going on? But the overall idea is that you need to share

Charlie:

Thank you.

peter_schlegel:

with your primary care who's ordering these PSA tests why you want to do this and you have to understand that there may be consequences doing them that result in you being over diagnosed or over treated or missing something that we were originally trying to find out.

paul_roach:

So I think what you're saying is, let's say Mike is going to go to the doctor. He's turning 50. Again, how many times have you turned 50, Mike? Yeah.

michael:

I can't. Five times now.

paul_roach:

All right.

peter_schlegel:

Hehehe

paul_roach:

So he's turning 50. He's going to the doctor and the doctor says, hey, do you want a PSA test? And Mike's going to say,

michael:

How much does that cost?

paul_roach:

yeah, let's say it's a special deal for you today,

michael:

Yeah.

paul_roach:

Mike. It's free. But it's not free, nothing's free, because the PSA test could, if it flags positive, when it flags positive, it might be accurate, it might be inaccurate, meaning, like let's say he was just on the Peloton, it's gonna be falsely elevated. Let's say, you know, he didn't do anything for 72 hours, it's gonna be accurate. But even if it's accurate, it's from an infection,

Charlie:

Thank

paul_roach:

which

Charlie:

you.

paul_roach:

is something that people get or whatnot. And we start going down the, it might be cancer pathway with biopsies, which are painful and expensive and you can get an infection or MRI scanners, which are super expensive and it's not cancer. So that one little test sort of brought on a lot of other treatments and expenses that had we never even looked,

Charlie:

Hey.

paul_roach:

we'd have been okay.

michael:

Is there a happy middle somewhere in there?

peter_schlegel:

Let me interrupt for one second. So Michael being age 50, that if we do see a prostate cancer, the

Charlie:

Thank

peter_schlegel:

problem

Charlie:

you.

peter_schlegel:

would be over treatment that we're really looking for something that may potentially be life-threatening because of how common it is, how many people die, the screening makes sense. The question is when you start getting older, is it really gonna be effective? Are you gonna be diagnosing a very slow prostate cancer? There's a lot of heterogeneity, a lot of variability. in how these prostate cancers grow and cause problems.

paul_roach:

And

peter_schlegel:

Are you gonna

paul_roach:

just

peter_schlegel:

be capturing

paul_roach:

to interrupt

peter_schlegel:

that at

paul_roach:

here,

peter_schlegel:

age 70?

paul_roach:

heterogeneity for the listening audience would mean that, let's say you have 100 people with prostate cancer. They don't all share the same course. Out of that 100 people, some of them, half of them are going to just have a very slow growing prostate cancer that moves so slowly, it's hardly a problem. that'll break into, let's say, three more groups. Intermediate, high, and very high risk. And the very high risk is a group of people who it's moving super fast. The intermediate and the high are less than that. And that's where the whole treatment plan starts to become effective. For the low risk, let's say that half of those people, observation or radiation or surgery and it all ends up being pretty much the same except the surgery and radiation has more side effects. Is that correct?

peter_schlegel:

I'd like to answer that question. I believe number one is when you see a urologist and they do the prostate biopsies, if they have to do that, that's a fairly black and white. Do you have cancer or don't or do you not? There are some gray cases, but for the vast majority of people, the biopsy is black and white.

Charlie:

Thank

peter_schlegel:

Once

Charlie:

you.

peter_schlegel:

you get to that point, then we can do the risk stratification in terms of how fast, how aggressive we think this cancer is. What are the chances cured or we can't and figuring out the stage and so forth. So the first really question pivoting from an elevated PSA and having to go to the urologist offices, do you have prostate cancer or don't you?

michael:

Well, then

Charlie:

Yep.

michael:

I have a question and it's going to be a tough one to you doctors. Seriously, because if I am told that I have cancer, I wanted, OK, let's go. Let's let's take care of this. Let's get this out early because everything I've heard says take care of it early. And is there a risk of you saying, you know, no, let's let's just observe. Let's wait. Is there potentially a tendency for some doctors to say, okay, let's just go ahead and move ahead because I'm not going to get in any trouble for treating. Whereas I might get in some trouble and be sued if I don't treat and it advances rapidly. Is that a fair thing to say that there might be some doctors that would take me by the hand when I'm anxious and saying let's treat it?

paul_roach:

Well, I think that, oh, go ahead, Charlie.

Charlie:

Now, I was going to answer some, Mike, that's a great question. And, you know, I get that a lot. In clinic, there's pretty good research, pretty good guidelines about how we treat prostate cancer. Maybe that's kind of a good thing to talk about now is how do we treat prostate cancer? What are the treatment options? And Paul, you mentioned the heterogeneity of prostate cancer. actually that's very important to how we how we risk stratify and how we treat patients so if someone is in kind of that low risk the treatment options are probably different than someone's in the high risk so if we start in a low risk guys the treatment options are really kind of one of four I would say you can be you can give kind of local therapy so that's surgery Those are kind of two options. And then we can do something called watchful waiting, which we essentially, we're not gonna treat the cancer. We're just gonna, it's considered low risk, it's slow growing. Maybe they have other medical issues at the time. You know, maybe they have severe heart disease or emphysema or something like that. And we're not gonna treat this low risk prostate cancer. And then the other treatment option is what we call active surveillance. And I think this is kind of getting your question, Mike. is that active surveillance is a pretty well-defined process in terms of how we follow that individual to decide

peter_schlegel:

Bye.

Charlie:

if and when that prostate cancer has advanced or reached a stage where we need to treat it with surgery or radiation or something like that. And so those are pretty well defined and it's pretty well,

peter_schlegel:

Thank you. Thank you.

Charlie:

the data's pretty clear men that have low risk prostate cancer, even some intermediate level risk of prostate cancer that go on to active surveillance do just as well as guys that are treated with radiation or surgery. So we have we have good data to back that up. And so I think I think positions are are protected in order, you know, to offer that treatment based on kind of the guidelines that we have on in the data that supports that.

paul_roach:

Shoot, Chelly, you're fading in and out.

michael:

You know, it may be okay though. Remember last time, the first time that when this happened, he may still be recording properly, even though we can't

paul_roach:

Ah,

michael:

hear him.

paul_roach:

okay.

michael:

I remember that happened our

peter_schlegel:

MBC 뉴스 김지경입니다.

michael:

first episode.

paul_roach:

Yeah, Pete, it sounds like you're a one-man band in the

michael:

Oh yeah,

paul_roach:

background.

michael:

you gotta mute yourself when you go get a glass of wine. Hahaha. That's

peter_schlegel:

Oh, I'm sorry.

michael:

it.

Charlie:

But you can edit that out.

paul_roach:

Yeah.

Charlie:

You've got a

paul_roach:

It's

Charlie:

guy

paul_roach:

not, I mean,

Charlie:

that

paul_roach:

like

Charlie:

edits

paul_roach:

we

Charlie:

this

peter_schlegel:

You

paul_roach:

heard,

peter_schlegel:

can

Charlie:

out.

peter_schlegel:

cut that out, yeah.

paul_roach:

we heard the fucking blender going, yeah, like, oh, he's making a

michael:

Where's

paul_roach:

margarita.

michael:

the tequila salt?

peter_schlegel:

The toilet was flushin' and... He's

paul_roach:

All right, all right,

peter_schlegel:

giving some crones.

paul_roach:

all right, so back to, all right, so Charlie, if I, if I can summarize it based on a couple of factors that you measure, and I think it comes in, in something called like the CAPRA score or whatever, and it's a combination of the PSA score and the biopsy and the person's age and maybe one or two other factors, patient into a risk level. And so for these 50 people, you'll say based on your age, the PSA score you have, the biopsy result you have, you know, whatever, you're low risk. And if you're low risk, that means we can just watch you. We're going to have to watch you. We can't forget about you, but you don't have to go get some sort of procedure. Then to the other 50 You guys aren't quite as low risk. You're intermediate high or very high risk based on these details. And based on that, we're going to recommend either surgery or radiation or the two of them together or hormonal therapy or something like that. Is that a fair

peter_schlegel:

Yeah.

paul_roach:

way to summarize?

Charlie:

Yeah, I think that's a good summary of it, Paul.

paul_roach:

And so

michael:

Let me

paul_roach:

Mike,

michael:

ask

paul_roach:

does

michael:

it.

peter_schlegel:

Can

paul_roach:

that,

peter_schlegel:

I interject? May I interject?

paul_roach:

oh yeah.

peter_schlegel:

The prostate cancer, we talked about heterogeneity. There are cancers that grow very slowly. And what I mean by that is the fingers extend, grow slowly, the chance of it breaking off, spreading, metastasizing is very low. On the other hand, you have very aggressive cancers. I kind of liken it to different dog species. You have some that are Chihuahuas that they don't do a whole lot, but then there's Rottweilers and they can take a big bite. So the aggressive cancers have much more of a tendency to be cancer like i.e. fingers extending beyond where they're supposed to be, breaking off, getting into the bloodstream, going to lymph nodes, going to bones, and so forth. So essentially when we're doing risk-crit stratification, we're in our brain saying, what is the chance of this prostate cancer getting out of the prostate and causing problems? No one dies from prostate cancer in the prostate. It's when gets out of the prostate, winds up the bones, winds up in the organs, winds up in lymph nodes that you wind up having major problems. Not to say that as the cancer grows in the prostate it can't block off your urination, it can't harm some of the nerves that innervate the reproductive organ, the penis, and can get erectile dysfunction. But the fact is that it's the metastatic disease that is really the vital thing that the urologist is trying the cancer from spreading beyond where it started from.

michael:

I'm gonna flip it back to the other side of my question then, which was harsh on you doctors, and now it's gonna be harsh on me patients. What do you do when you have somebody who is in kind of a panic mode that says, uh-uh, I want this out of me, I don't wanna lose my sexual function, I don't wanna die, let's just go, go, go, and your advice would normally be, well let's take a slow surveillance approach to this. Have you had to kind of walk people down, or have you had to, with what they want or refer them to somebody else because you didn't want to treat that.

paul_roach:

Well, it sounds like you got a case of the gimmies. I

michael:

Thank

paul_roach:

want

michael:

you. Bye.

paul_roach:

all these things. So there's something called the trifecta, which is you treat the cancer, you preserve the ability to maintain urinary countenance and you preserve sexual function.

michael:

Mm-hmm.

paul_roach:

That's the trifecta.

michael:

But

paul_roach:

And

michael:

what if

paul_roach:

Charlie

michael:

I'm panicking

paul_roach:

can, what's that?

michael:

and I don't really need a lot of treatment right now, but I'm in panic mode, right? And I'm insisting on more aggressive treatment, right? Does that happen or am I just making up stories?

paul_roach:

Well, it happens

Charlie:

That's

paul_roach:

to me and

Charlie:

it.

paul_roach:

other diseases. I'll ask Charlie. Let's see what he says.

Charlie:

No, it certainly happens. I mean, I see men that have, again, that have, we are, there's pretty clear definitions for our guidelines of what's considered very low risk, low risk, intermediate risk, high risk, very high risk. I see a lot of guys with very low risk and the guidelines are clear that the preferred treatment is active surveillance, meaning not to do some type of focal surgery or radiation. And a lot of those guys will try You know, we'll ask for treatment and they, if after discussion and we talk about the risks and benefit of each of these treatment options, if they still, you know, are seeking treatment, you know, that's something that we can pursue. But, you know, I do kind of try to talk them back and go over the data and go over, again, the nature of what their kind of diseases and surveillance, Mike, is not something that ends. It's about 50% of guys. that go on active surveillance will, at some point in that process, will have some type of treatment be it surgery or radiation. That's not always because the cancer has progressed. Sometimes that's just because of the anxiety that active surveillance does cause. I mean, you have to have repeat PSAs, repeat biopsies, MRIs. It's a process. And not every guy can go through that process, and they elect to move on to treatment.

paul_roach:

You see that in other cancers as well. You know, it's sort of like a fatigue where people are constantly going back at new mammograms or new colonoscopies or whatever. And it's exhausting.

michael:

what would you tell a patient, or I guess, let me flip that around. What would I as a patient need to hear from you to keep me in surveillance mode so that I don't really elect to have surgery or treatments that I don't yet need? What, like what, what are the statistics or things that, that might calm me down, especially if I'm hearing them now when I'm listening to a podcast?

Charlie:

Well, I would,

michael:

What would you tell me?

Charlie:

the two things I would say, you know, it was back to kind of the risks and benefits. The, you know, from the benefits side, I would tell you that there is good, there is good research, good studies that have been done that have shown that men, you know, with certain risk of prostate cancer, whether they have active surveillance or whether they have some type of treatment up front, but those, those, those guys 10, 15, years down the road. essentially are having similar outcomes in terms of prostate cancer death. So you're not at a higher risk of dying from prostate cancer if you do active surveillance up front. So that's the benefit side of it. The risk side, I would tell you, is that these treatments have their side effects, these treatments. The side effects of surgery and the side effects of radiation are pretty clear. And that's, you know, the main, you know, kind of the main categories we talk about, which, you That's the ability to control urine and surgery and radiation have a detrimental effect on both of those. And that can have a detrimental effect on quality of life after those treatments. So that's what I would explain to the patient and let them kind of take that information and make a decision.

paul_roach:

I imagine it's a lot harder to propose active surveillance when people are younger, but maybe it's easier, I don't know, because they have so much longer to live with the disease if you don't either fry it out with radiation or remove it with surgery. Let's say a person's 55 and they're in your office. Do you find it easier to propose surveillance or harder for that?

Charlie:

No, it's harder. And it's, you know, I think some some men, younger, the younger men, we tend to be a little bit more aggressive in terms of treatment because of that reason, Paul, because it they have a longer life expectancy. You're going to be surveilling that, you know, that cancer for a longer period of time. So so younger men that have a diagnosis of prostate cancer tend to have tend to be treated at a higher rate for sure.

paul_roach:

And Pete, as a medical oncologist, what commonalities do you come across in the patients that you see? You see a lot of prostate cancer patients in the VA, I'm sure. Repeat, you're muted.

michael:

Still muted. There you go.

peter_schlegel:

In terms of the medical oncology perspective, I believe that the surveillance is a great idea if you don't need it. Now, everybody has different criteria and as I discussed before, the shared decision making in terms of determining what your risk is and how wise it is to wait. You know, certainly the side effects of incontinence and erectile dysfunction is, a very onerous one if you do go through these treatments and it does occur. Once someone is diagnosed with prostate cancer, you do need a very specific plan. I tend to see more of the older population that may be scared of surgery for one reason or another, not be an ideal candidate because of age or because of other health issues, bad heart, bad lungs. other cancer experiences and so forth and with a lot of the less well Men who also can expect to live 10 years or so longer We we talk about radiation therapy and that is in many cases Fairly close in terms of efficacy to surgery is probably a little bit less The bad news is you never know that you get it out completely You never know What exactly was in there the good news? to undergo the knife. The good news is that most of the men who undergo the therapy do fairly well through the treatment, albeit having radiation beams placed through your prostate for a number of weeks is never a pleasant thing. But I just want to kind of pitch the idea that radiation treatments play a strong role in the definitive treatment of curable prostate cancer. We don't have a radiation oncologist here, all sorts of fancy technologies in terms of stereotactic body radiostrugery. They have seed implants called brachytherapy. They have the standard external beam radiation they can use. So I could expound on them, but the technology is fairly amazing. On the other hand, Charlie and his urology colleagues have quite an arsenal of amazing treatments prostatectomy, there's nurse bearing techniques and so forth. So it's kind of an arms race in terms of benefiting the patient with prostate cancer.

michael:

Charlie,

paul_roach:

I'll jump

michael:

can

Charlie:

Yep.

michael:

you,

paul_roach:

in.

michael:

well, I was hoping Charlie could walk me through, if I'm given a diagnosis and I'm again, I'm kind of worried about it, and you're telling me, you know, where I'm at, what are the statistical likelihoods of some of those side effects happening? Like, how likely am I to become incontinent or to encounter erectile dysfunction from this? are other side effects that we haven't mentioned? What statistically is it high risk, no matter what, or is it again dependent on age? Help me

Charlie:

Yeah,

michael:

understand what I might be running into.

Charlie:

it is. No, so there's a lot of factors that go into play. So after surgery, you know, pretty much I would counsel, you know, most guys immediately after surgery are gonna have some level incontinence and likely some level of rectal dysfunction, you know, from their baseline. Now how it recovers and whether it fully recovers and to what degree often depends on a lot of factors. what their function was before surgery. It can depend on the severity of the disease, whether a surgeon could do a nerve sparing. That's what has been kind of alluded to. If the cancer is, appears that it's spreading, you know, locally spreading out, you know, outside or close to the edge of the prostate, then that surgeon is going to have to do kind of a wide resection. And it's going to have a more significant, profound impact on, on those functions. But yeah, as far as, you know, we kind of quote incontinence, you know, somewhere, you know, 10 to 15, 10 to 20% of guys will have incontinence, you know, a year after, you know, having their prostate removed. You know, there are some therapies to treat the That's even, it also kind of depends on how you, it's not necessarily a black or white thing function and erections are necessarily black or white. So, but a good amount, somewhere between around 50% or more guys will have issues or worse erections after surgery than their baseline level. Again,

michael:

I'm sorry, was that 15 or 50?

Charlie:

50 or more. Again, then that's, Those statistics, depending on the study, range broadly. And a lot of it depends on the age of the patient. A guy that's 55 is going to have better erections after surgery, and then a guy that's 70. That's just a lot of it has to do with age. But I would say, back to Peter's point, we've seen with radiation, radiation is certainly a great option for treatment. And it is a great option for treatment for any patient. patients get older, you know, and they start, the risks of surgery start getting higher. And we sent a lot of guys to talk to a radiation oncologist to have that option explored. But they also, with radiation, you will see some of the similar, probably less in terms of incontinence for sure, and some of less of erectile dysfunction after radiation, therapy than in surgery. But

michael:

Bye.

Charlie:

there are other downsides of radiation. that we haven't spoken about.

michael:

Is there a reason why you would recommend surgery over radiation or is there a tendency to try radiation first before surgery?

Charlie:

There are, it kind of sometimes depends on the age. For younger guys, typically I feel like urologists are a little bit more prone to recommend surgery versus an older gentleman. So if a guy in his 50s has prostate cancer, I think often we will err on the side of surgery. We're surgeons, so maybe we're biased to offering surgery. But there's this idea that if you do surgery after surgery, you're removed the prostate and prostate cancer, there's a long, you go through surveillance, essentially years, maybe your entire life, you go through some level of surveillance, checking PSAs. And after surgery, if you have some recurrence, you can get radiation. We typically don't do it the other way around. If you have radiation, rarely do we go back and remove the prostate.

michael:

Okay, so wouldn't I want, so Peter, more in your court I think, then wouldn't I want radiation as my first option?

peter_schlegel:

I think from the lens of medical oncologists looking at survivorship and preventing complications, it's somewhat of a toss up. And I would say that if you're young and have prostate cancer and you wanna be cured, I really think that the surgery gives you the best opportunity for that. If you wanna prevent complications, you don't wanna have a perioperative wound infection, you wanna be in the hospital for a couple days that the radiation is an excellent option. You know, I think the really take home message is you should talk to both. If you're in a curative position with your prostate cancer, say, hey, we got to deal with this. It's never a wrong idea to talk to radiation oncologist, say, hey, how would you treat this? Well, why would you do this? What are the complications? How long will it take? What do I have to go through? point that is very bothersome with prostate radiation is that you require generally four to five to six months of antitastastroam therapy. That the part of the radiation involves bringing your testosterone down to zero to have male menopause and we found that the rate of being cured is much higher in men who've had that. But that is a really tough therapy to go through male menopause. that's just part of life, deal with it. For men, it's a total game changer. And we could kind of go on a whole episode about testosterone and how important that is with your mojo, your state of health, your happiness level, your activity level, and so forth. So I would just probably pitch that if you are gonna go through radiation that you should understand that part of the treatment anti-testosterone therapy.

paul_roach:

Do you have many chemotherapies or other biological therapies to bring to bear against prostate cancer? You know, for example, when we were talking about lymphoma, the treatment was essentially all chemotherapy, you know? And you had a few other options such as what was mostly chemotherapy, wasn't it? meaning just watch and wait and see if they if they

peter_schlegel:

Yeah.

paul_roach:

stay behaving, or surgery or radiation. But it doesn't seem like you use too many chemotherapies or other types of biological

Charlie:

HEEE

paul_roach:

therapies for prostate cancer.

peter_schlegel:

Yeah, I think one point to make is that staging of prostate cancer is important. And so when the urologist does the prostate biopsy, you look at the PSA, that we have an algorithm in terms of how likely is it the cancer is all contained within the capsule of the prostate? Is it curable? Is it all contained? Can we just take that out and cure the patient? The opposite side of that is what are the chances that it's outside of that? And if so, the options. And so that if we find that there's locally advanced disease, some of the fingers are extending beyond the capsule, urologist cannot honestly tell you that he or she could take the prostate cancer out and cure you. So we'll say, well, maybe to do a wide field of radiation, but probably more likely it's the cat's out of the bag and we're dealing with metastatic disease. So in many cases, when the algorithm kind of hits a yellow or that we do staging tests to determine the degree of spread. It used to be a CT scan and a bone scan and you know $2,000 later you probably have a pretty good idea, but having said that is 80% accurate enough for you. I'm probably not for me. Then there's a whole another set. Sometimes people do MRIs and that does a more accurate job of determining where the spread is. There's a new PET scan called A and basically it's a fancy schmancy nuclear medicine test that is more like in the neighborhood of 90 to 95 percent accurate in terms of the spread so that when people have a that high risk or very high risk that they would go through a stratification to figure out how extensive the cancer is and urologist doesn't take prostate cancer out if the cat's out of the bag and so once the arena of localized prostate cancer, then you become widespread metastatic, and then it's really a game changer in terms of how you approach them.

michael:

I'm going to ask the usual round of questions that come up in these things, which is this is largely genetic, but I can probably, and you'll tell me, I think, the usual suspects smoking, poor diet, lack of exercise, those things have an impact on this cancer, like they have on most of the other cancers that we've talked about. Okay.

peter_schlegel:

Yeah. From my

Charlie:

Thank

peter_schlegel:

experience,

Charlie:

you.

peter_schlegel:

I've seen being an African American, they have a much higher risk of prostate cancer, both of diagnosis and dying. So they need to bring their guidelines down about 10 years younger, so they're an age 40 or so they should start screening. The other risk factor we see is age

Charlie:

be.

peter_schlegel:

and orange, at just being at the VA hospital, we see lots of age and orange exposure, and there's a causality between age and orange exposure and cancer. There may be also some association the BRCA. mutation that leads to a higher risk of familial breast cancer as well as prostate cancer in the males with that mutation.

michael:

Wait, let me see if I understand that correctly. If I'm in a family and some of the females in my family line have had a significant amount of breast cancer, or even just any breast cancer, I imagine, that I may be at a greater risk for prostate cancer, basically, on the same genetic mutations?

peter_schlegel:

Yeah, the same genetic reason, it's called the BRCA mutation, and we see it very infrequently one-two percent, but it's still out there.

michael:

Is that something that doctors would ask me in a medical history? Or not, because I've never heard anybody, I've never heard this before. This is brand new to me. So is that something that you would say to doctors or, you know, general practitioners, Hey, add this in and ask them if anybody in their family has had breast cancer

paul_roach:

Yes,

michael:

or

paul_roach:

absolutely.

michael:

no.

peter_schlegel:

Well.

paul_roach:

So for

Charlie:

Thank you.

paul_roach:

any physician who's doing your annual physical or initial consultation, they should be asking you a couple of things. So, you know, the chief complaint is why are you there? History of present illness is one to two paragraphs on what brings you into it. You know, past medical history, surgical history, psychiatric history. If you're a female OB-GYN history, medications, allergies to any medications. And then, family history. Family history should be always part of this because it's getting more and more understood these days what things run together. It's not all having to do with cancer, but this podcast is, so we'll just stick with the cancer part. Let's say there's a person in your family tree with a BRCA gene mutation.

michael:

We know that.

paul_roach:

If you're in a system like you have in USA and Europe and Australia and New Zealand and Japan those things are being tested for routinely.

michael:

Right, but in my family history, my, let's say my grandmother died of breast cancer.

paul_roach:

Uh-huh.

michael:

I have no idea if she had BRCE, you know.

paul_roach:

Got it, got it. Well, there are criteria that we'll use to decide if, and for all the different conditions, there's genetic potential, genetic transmission generation to generation. And so there's different criteria. So for breast, if you're talking that, it would be typically, if there's a first generation relative, if it was an early onset breast cancer, if it was you know, if there's multi generations, if there was anybody in the family with, let's say, a uterine cancer, et cetera, then you say, hey, you need to get tested for this gene. And the gene would be BRCA1 or BRCA2, and then there's a few other similar symptoms, like leaframini or cowdins or whatever. But let's say it's BRCA1, and let's say your mother had it, and then she had 10 children, five

michael:

which she

paul_roach:

of

michael:

did.

paul_roach:

those, right. Five of those children potentially could have that gene, roughly. It's usually a coin toss and five not, whether they're male or female. The female ones who got that gene would have sort of a jumpstart on a set of cancers and the males slightly less of a jumpstart on a

michael:

still

paul_roach:

different

michael:

significant

paul_roach:

set of

michael:

enough

paul_roach:

cancers.

michael:

to talk to our doctor about.

paul_roach:

Right. And then also that male could transmit it down to their children,

michael:

So I guess

paul_roach:

half of their

michael:

what

paul_roach:

children.

michael:

I'm saying is like I've had the doctor ask me about medical history, but I guess for me it had always been like, you know, was there cancer in your family? But it never would have occurred to me to kind of talk about specific specifically breast cancer because and I think maybe a lot of listeners would feel the same way. Like, well, I'm a male. I'll tell you about, you know, my my uncle who had stomach cancer and my dad who had prostate cancer in his 70s. And, you know, yeah, there were some people who had cancer, my mom or my aunt, but I don't

paul_roach:

We

michael:

know

paul_roach:

ain't

michael:

that.

paul_roach:

talking about the women here, doc.

michael:

Well, in

paul_roach:

Yeah.

michael:

a way, you know, like

paul_roach:

The

michael:

there's

paul_roach:

women

michael:

a bias.

paul_roach:

folk. Yeah.

michael:

As a male, I just automatically bias to the things that I think matter to me. So what you're basically telling me is our listeners who are going in and talking to the doctor and they're giving that medical history or should update their medical history

paul_roach:

Yeah.

michael:

that there's something on the maternal side that could influence their chances for pancreatic. And what do we call it? That's the one.

paul_roach:

Proceed.

peter_schlegel:

Yeah, I will add that in terms of family history, if somebody has died from cancer at an early age, that would much more likely be related to some hereditary or familial condition than if they're diagnosed in their 70s, 80s and whatnot.

paul_roach:

Yeah,

peter_schlegel:

So

paul_roach:

yeah.

peter_schlegel:

if you heard yet, so on, Aunt Betty died at age 40 from breast cancer, that sets off some red flags in my mind versus Aunt Betty died of breast cancer. at age 85. There's a huge difference.

michael:

Okay.

peter_schlegel:

And the same goes with really any other cancer, whether it's prostate cancer or lymphoma, that if it's a hereditary condition, they generally present much earlier in their life and would, you know, alarm the system that it's more worrisome than just, hey, had too many birthdays and unfortunately it happened.

michael:

Okay, that's reassuring actually, Peter, thank you. So, and I think a lot of listeners would agree that there's, it's good to know where I should have alarm because cancer in and of itself is alarming. And so I remember reporting to my doctor when they asked that, well, let me tell you, my grandfather, you know, and they all were elderly at that point in time. So, the last risk, I suppose I should tell them anyway, but I don't have to worry about it as much.

paul_roach:

But right, and most pertinent to the subject would be first generation relatives. So, you know, your parents, you could also talk about grandparents, you know, aunts and uncles, cousins and siblings. You know, those are the, and children I suppose, but those are all the most relevant. You don't have to get into great, great grandpappy, Michael O'Reardon, because that's getting a little far into the distant past. to be too relevant.

michael:

to know.

paul_roach:

All right, so we've got our patient. Patient has prostate cancer. We've categorized whether it's low and medium, high or very high risk. Even if it's low risk and we've been watching them over 10, five, 10, 15 years, a lot of those will fall into the, at sooner or later, will fall into the slightly higher risk such that in the end, probably half of all the people get treatment of one kind or another. And then we're trying to decide between who gets surgery and who gets radiation. And we've kind of arrived at a lot of the healthier, younger people with a long way to go will typically opt for surgery and people with serious medical problems or they're already pretty old or whatever might choose to go with radiation. If they go with radiation, three kind of options, external beam, which is just Zing, the radiation beams flying right through, IMRT, which is sort of the conformal radiation, which is higher attack and it's more focused right on the prostate alone, or seeds. And then for surgery,

michael:

Wait, what seeds, bud?

paul_roach:

oh, okay. It's too bad we don't have a radiation oncologist

Charlie:

Thank

paul_roach:

on the

Charlie:

you.

paul_roach:

show These are, you place these little radioactive seeds, and I don't know how they do it, into the prostate. They'll put in a dozen or more of these little seeds scattered throughout the prostate, and they will emit radiation just inside the prostate, or mostly confined to that prostate. And, you know, they're not going to do that.

michael:

No

paul_roach:

They're

michael:

wait,

paul_roach:

going

michael:

don't

paul_roach:

to

michael:

we

paul_roach:

do

michael:

need

paul_roach:

that.

michael:

Charlie for that as a surgeon? He would go in and put those in or you have to have a specialized doctor for that.

Charlie:

Now, Mike, the radiation oncologists, the same guys that do the external beam radiotherapy. So that's just standard radiation therapy. Those are the same guys that put in the brachytherapy seeds. And so they do that in the operating room under anesthesia. And it's a very precise, pretty high tech between ultrasound imaging, MRI imaging, where they kind of map out the prostate and they put those seeds in. apply radiation to the entirety of the prostate, with the intent of not giving much radiation outside the prostate, that's the goal there. But.

michael:

Thank you.

paul_roach:

And Mike or, I mean, Peter, Charlie, do you have any opinion on using seeds versus the other sort of more standard treatments?

peter_schlegel:

I think some of the recommendations state that the standard risk, you do well doing anything. You want to do external beam radiation, you want to do siege, you want to do surgery. For some of the higher risk situations, then you're kind of either going surgery or you're going to do external beam radiation. Some of the fancy seeds, brachytherapy, are probably a little less effective because they don't address the perimeter as well as external beam radiation. get a precise measurement of what comes out. The once a surgeon does the prostatectomy, they can sample the area around it, the lymph nodes, the areas of evasion beyond the capsule and so forth. So I would say that if you have the lower risk disease, then you have all the options. When you start to get higher risk, it's either external beam radiation or to do surgery.

michael:

You had talked about a prostatectomy earlier too and I was thinking about it then. Peter just said it again. Is that the removal of the entire prostate or is there like a partial and you're leaving some function but removing some functions is the whole thing gone? And then what happens to the body without this particular organ?

Charlie:

Yeah, so a prostatectomy, we remove the entire prostate. That's the goal of the surgery, is to remove the entire prostate. There's no partial removal. And part of that is that we don't have a really diagnosed and localized prostate cancer, within the prostate, it's not all that great. Even from a biopsy standpoint, it's a pretty generalized. You have some prostate cancer. When we do biopsies, maybe on the left side or the right side, but we can't tell you and think the prostates about the size of the walnut. That's how small it is. So it's not a giant organ. where it sits, it sits right between, it sits right where the bladder empties into the urethra. And so when we do surgery, remove the prostate, we are, we're essentially removing, you know, the very kind of end part of the bladder and the first part of the urethra, and then we connect those two back together. But what comes out is that, yeah, it's the prostate. There's really no, it's an organ for sexual function after a guy has a no longer have kids, they will not ejaculate. They will not have, take that back date. You can have an orgasm, but you will not have any semen come out and ejaculate.

paul_roach:

All right, all right. And so, I think at this point, we've covered most of the treatment options for localized disease. But what happens now, let's say the disease is far advanced, either locally, where it involves all the lymph nodes in the pelvis or it's extending into other structures, or distantly, where there's a dozen metastases spots in the spine or the ribs or the pelvis or into the lungs. What are those treatment options looking like and what kind of survival does a person have or quality

peter_schlegel:

Yeah.

paul_roach:

of life?

peter_schlegel:

Well, I think it's important to identify when you cross the line and have metastatic disease, when it's incurable, when you have cancer that's spread outside of the capsule. So it's really critical that we identify when someone's curable, they can go through local therapies to get rid of this and not worry about this. But if it is metastatic, if it is advanced, if it's incurable, we want to know that. And there's a fairly strong line between the two. where the PSA will increase and you say, hmm, that shouldn't go on unless there's cancer or cells somewhere in there. And then we discussed this term called microscopic metastatic disease where we know that there's cancer somewhere in the body we just don't know where it's at. As I discussed before that we have better scans, previously a CT scan and a bone scan, were considered standard of care, but they're becoming somewhat dated and there's a PSMA scan MRI that may give better visualization, much better what we call sensitivity in terms of determining, you know, really what's going on. But once people transition into the more advanced, then you have the discussion of saying, do we want to treat this yes or no? For many other cancers that involves chemotherapy, but for prostate cancer, it generally involves endocrine or hormonal therapy, A very concise way means blocking testosterone. If we can block testosterone, it will block the growth. And in the old days, men would have their testicles removed. We call that an orcheectomy. Their testosterone level will go down to zero. The cancer would starve and go into a state of hibernation. Hibernation could last many months to a few years. We've transitioned to a shot called LHRH agonist that basically tells the pituitary gland to tell the testicles to stop making testosterone and that's basically replaced it. And that's really been the foundation in terms of what the next step is when men present with advanced prostate cancer. The downside is not having testosterone. If you're at a primary care office or probably at a urologist office, everybody wants testosterone. You wanna feel like you're 10 years You want bigger muscle mass? Hey, go on to testosterone. We feel stronger better younger. Why not? The opposite is when we block testosterone we make people we remove their mojo make them feel quite a bit lower They're just their intensity their motivation level goes down in addition to having male menopause with hot flashes and And Vesal motor instability and so forth

michael:

Well, as the corollary of that potentially true, that if you're asking for testosterone supplements or if you're taking testosterone supplements for some reason, does that put you at a greater risk potentially for prostate cancer? Because you're overjuiced?

peter_schlegel:

Charlie,

Charlie:

Yeah,

peter_schlegel:

I'll throw

Charlie:

we haven't,

peter_schlegel:

it back to you.

Charlie:

you know, that's a hot topic. The evidence hasn't panned out to show that giving testosterone to guys that have low testosterone for one reason or another has led to an increase in prostate cancer, though we do keep a little closer eye on guys that are on testosterone therapy through PSA screening. So, yeah.

michael:

still being studied it sounds like and just

Charlie:

Well,

michael:

mixed results.

Charlie:

the studies so far have not shown that it's increases the risk. And there's different theories out there of why that might be the case. But yeah, right now, I know. No.

paul_roach:

I think it's tricky because the original discovery by Charles Huggins at University of Chicago, which got him a Nobel Prize, was that testosterone, that prostate cancer was in part driven by testosterone. So, let's say somebody's testosterone is low, and you're giving them back a normal amount of testosterone, maybe that's safe. But let's say their testosterone is normal for age or normal

Charlie:

Bye.

paul_roach:

for them for their age. And then they're just taking extra because it makes them feel better. I don't know. Is that going to increase the risk of cancer? That would be a hard study to perform. If you think about the logistics

Charlie:

It's a concern,

paul_roach:

of doing that

Charlie:

yeah.

paul_roach:

study,

Charlie:

I don't think it's been a difference.

paul_roach:

yeah.

Charlie:

It's a concern for sure.

peter_schlegel:

Pivoting back to the prostate cancer management for advanced disease once the cat's out of the bag, we had said, you know, what exactly happens when the cancer metastasizes? We can say, well, the fingers extend beyond the capsule and maybe in the pelvis, may drift in the bloodstream to the bones, to the organs. But what does that look like for somebody, for a male who has prostate cancer? Well, the imaging may show that there's spots in the bones and over time as the cancer grows in the bones it may cause pain. Interestingly enough it doesn't cause fractures many other cancers that getting the bones cause fractures but in men with prostate cancer doesn't tend to make the bones brittle or break but it can lead to considerable amount of pain if it grows. The other most common area that prostate cancer can go is the lymph nodes particularly in the lower abdomen and pelvis and we really don't complications of that other than causing more caeccia and growing and just being a parasite on the system drawing energy from the body.

michael:

Peace.

peter_schlegel:

Those tend to be the two most common things. So when someone has advanced prostate cancer, being more ortho-thargic and tired is one of the most common things, losing your energy, decreased activity level, being in bed longer, decreased stamina, Those tend to be common as well as having pain, particularly in the low back and hips. That's kind of where the cancer tends to drift to. Those are more of the common things and that would be a reason why we want to treat that with, particularly with the endocrine or hormonal therapy by blocking the testosterone.

michael:

You used the term Kexia. What is that?

peter_schlegel:

That means just losing your appetite, losing weight, being frail,

paul_roach:

Wasting.

peter_schlegel:

just being unhealthy. Yeah.

michael:

Okay.

peter_schlegel:

Better term. Sorry.

michael:

Well, you're

paul_roach:

So

michael:

sounded cooler.

paul_roach:

yeah,

peter_schlegel:

Ha ha.

paul_roach:

so when a person has very advanced prostate cancer and they are, they're going to die from this, how does that go? What is it that happens? Is it metastases to the lungs that do it? Is it the overall burden of disease that wears them down? Is it... I don't think of prostate going metastasizing to the brain. Maybe it does hit the brain. I don't know.

peter_schlegel:

Yeah, it doesn't go to the brain, but it just causes overall uh, catechia and just failure to thrive. People just don't have energy. I went to a retirement lecture not too long ago and they talked about the phases that there's the go-go phase of retirement, there's the slow go phase of retirement, and there's the no-go phase of retirement. And having older parents were kind of, you can see that in elderly people and with what happens with advanced prostate cancers, you go through those phases a lot quicker. You go from the go-go to the slow-go and then to the no-go. It just, it sucks energy from you. You can have pain and there's good ways to treat that with radiation, with pain medications and so forth, but it's just the wasting and the failure to thrive, the decreased energy. And that at some point, it gets to the point where people lose weight and they don't want to eat and they just basically give up and it's not necessary that their brain gives up but their body gives up.

paul_roach:

just the burden of disease wears them out and sort of saps all the energy out of them.

peter_schlegel:

Precisely. And along the journey, we talked about hormonal therapies and we can get much fancier. We've been using Lupron or Luprolide forever. And now there's a whole class of newer anti-testosterone therapy that docks the testosterone down even lower and results in longer remission or periods where the cancer stays in hibernation. There's chemotherapy that's an option and obviously no one wants to use chemo, into a wall and you gotta do something. And chemo does work in many people. And so that's another resource that we can use. There's some fancy molecular tests where you can take a biopsy and send it for what we call next generation sequencing. And we can see if there's any mutations that would suggest that perhaps a breast cancer drug may work. Every now and then we see that there's a mutation that may indicate that immune therapy for melanoma and lung cancer might work and I've seen some really dramatic results from that. But having said that, you know, it's only about one out of 25% or 5% of the population that may have that mutation. So there are some options for more advanced disease clinical trials and so forth. But the bottom line is that we use hormonal therapy blocking testosterone as the mainstay. And the more you can block testosterone, generally the better that the goes into remission, hibernation, the longer that the people have remissions. It is not a pleasant situation to be without testosterone with male menopause, but it's something like, hey, you got the choice of dealing with active cancer or not having testosterone is a fairly straightforward decision for those men.

paul_roach:

I see, I see.

michael:

That's an interesting segue to a question that I had earlier, which was when you have a young man and they're presented with the option of, you know, you're going to go through surgery and you may become, you have these side effects of incontinence and erectile dysfunction and you'll never have kids again. And so they may say, well, you know what, I'm, I want my sex life and I want my, maybe I want to have kids in the next few years, if I have a few years left. Is there In that choice, is there a false choice in that? Like if I go untreated because I don't want to give up these aspects of my masculinity, so to speak, is the cancer just going to destroy my prostate and destroy my sex life anyway?

peter_schlegel:

Yeah, it's a bad situation because as the cancer grows unchecked in the prostate, it's going to take out the nerves that innervate the penis and you're not going to have erections anyhow.

paul_roach:

I was

michael:

So, yeah.

paul_roach:

looking at some data right before this and it was on this exact issue. And yes, at about, if you have surgery, everyone's the same at like 10 years and radiation, it was 12 or some kind of number like that. But both of these converge after a time and you're in the same boat.

peter_schlegel:

So I guess the man up part of that is you got to deal with your cancer because your family wants you around with a functioning sex life or not.

paul_roach:

Yeah.

peter_schlegel:

It's nice to have that other part, but they need you for who you are, not what that part of your body is.

paul_roach:

What?

peter_schlegel:

And we're talking that for advanced prostate cancer and people have been down the road, they've been going through a lot of things before they get to the point of having to see a medical oncologist and say, This is bad, this is a terminal illness. We can slow it down, hopefully let you live longer, but we're not gonna be able to stop it completely.

paul_roach:

And that sort of gives me my last question that I can think of is let's say you have 155 year olds or 165 year olds or 175 year olds and they've got stage two prostate cancer. Do they have a typical trajectory or is it really based on their initial assessment of risk? You know, low, medium, intermediate high or very high. Do they have separate trajectories for all of those?

michael:

different ages, you mean?

peter_schlegel:

As I talked about in the beginning, the big odds are that nine out of 10 men will beat prostate cancer. They won't die from it. However, a lot of the men that have undergone the treatments for the prostate cancer in terms of the surgery, the radiation, the hormone therapy, you know, will go under, will have therapies that detrimentally affect their health in terms of the trifecta that you talked about, in terms of the the chronic soiling of themselves as well as the rectile dysfunction.

paul_roach:

All right, all right. Well,

peter_schlegel:

I think we lost to

paul_roach:

I think we lost him.

peter_schlegel:

Charlie.

paul_roach:

All right, well, I think we should wrap this thing up. I wanna thank everybody for participating and thank the audience for listening. And again, this is so it's cancer. If you have questions, please write them to letters at paulbrienroach.com, P-A-U-L-B-R-Y-A-N-R-O-A-C-H.com and send us your thoughts for future episodes. Mike and Pete and Charlie, thank you all very much for joining today.

peter_schlegel:

Thank you, Paul.

paul_roach:

Sign it off.