(light music) - [Narrator] The region's premier medical information program "Call The Doctor".

- [Narrator] Prostate cancer is the most common cancer and the second leading cause of cancer deaths among men in the United States.

That's according to the National Cancer Institute.

Some cases of prostate cancer are aggressive and can spread quickly, but often prostate cancer grows very slowly and it's possible to find it and treat it early, making screenings incredibly important.

We'll talk about screenings, risk factors, symptoms to look for and how it's treated.

Understanding prostate cancer now on "Call The Doctor".

- And hello, and thank you so much for tuning in for this episode of "Call The Doctor".

I'm Julie Sidoni, I'm the News Director here at WVIA and I'll be the moderator of "Call The Doctor" this season.

This episode is called understanding prostate cancer, a common type of cancer according to the American Cancer Society.

About one in eight men will be diagnosed in his lifetime.

And that's kind of what I wanted to start with here.

We have three experts we have invited to be part of the show to help us wade through all of this.

So, first question I suppose, is we will have you just introduce yourself, no question at all.

Tell us who you are and where we can find you.

- My name is Michael Rittenberg and I'm a urologist at Commonwealth Health Physician's Network in Kingston, Pennsylvania.

- [Julie] All right, welcome.

- I'm Heath Mackley, I'm a radiation oncologist at Geisinger and I practice at both Wilkes-Barre and Danville.

- Okay, welcome, and you?

- I'm Chris Peters I'm also a radiation oncologist and I'm at NROC in Dunmore.

- All right, welcome to all of you.

So let's start with that first statistic.

One in eight that is, that seems like it's common.

It seems like it's-- - It's very common.

I generally quote one in 10 because African Americans have a higher incidence and they would be one in eight or one in nine.

It's a disease of aging.

If you live long enough, you will get prostate cancer.

Most prostate cancers in the elderly tend to be slow-growing and don't require diagnosis or treatment.

But certainly in the younger age group, the only way we find prostate cancer is to look for it.

- Now, I understand there are risk factors, of course, risk factors for everything, who would be most at risk for prostate cancer, Dr. Mackley?

- Well, the men that are highest risk of prostate cancer, first of all, there's an age.

So in general, once a man passes 50, his age steadily increases.

And so the higher the age, like if you look at a group of 75-year-old men, for example, a good chunk of them will have prostate cancer.

But we don't have like many specific tests to identify who's truly at the highest risk.

But in general, if you have a family history of prostate cancer, you are at a higher risk in general.

And you are more likely to benefit from screening.

- What is the recommendation right now for someone of average risk, Dr. Peters?

- So it's a good question.

Screening for prostate cancer is a remarkably complex subject and we can spend hours discussing it.

But briefly I think most of us in consensus would agree on if without a family history average risk, late age 50, you should at least have a digital rectal exam performed.

That's in-office procedure where the doctor can examine the prostate and the rectum and also get a baseline PSA or blood test.

Once that's done, then really, and this will be a common theme, there'll be a discussion with the doctor and the patient about what to do with that information and how to go moving forward in terms of screening benefits, risks, because there can be some risk in screening too.

But in general, getting a rectal exam and at least knowing your PSA at a young age is a good idea.

- So a man who's 40 years old goes to the doctor.

This is not something on the radar quite yet, is that what I'm hearing, unless there's a family history?

- So as a urologist, I'm usually the point of entry into the healthcare system for somebody concerned about prostate cancer.

And I never turn anyone away from having a digital rectal exam.

I think that's part of examining the body, just like listening to the chest.

The PSA again is very controversial.

There are guidelines that we follow.

The US Preventative Services Task Force came out with recommendations that suggest that men between the ages of 55 and 69 benefit most from having a screening PSA in order to save their life.

Over 70, the risks of screening may be higher than the risk of dying from cancer.

Likewise, under 55, there are fewer cases of prostate cancer.

Unfortunately, you can't predict that because I see people in their forties and early fifties who have prostate cancer that just gets found accidentally.

- Before we get into the screenings issue, and I understand that is a controversial issue, what symptoms might I look for if I have developed prostate cancer?

Forget about the screening.

Are there things that people can look for in case they feel like they're having an issue, or is this something that cannot be found unless it is screened for?

- Again, as the entry point, there are no symptoms for early prostate cancer.

It's generally a microscopic disease in the prostate, which can be confused with a very common disease called BPH or benign prostatic hyperplasia, which happens in 50 to 75% of men over the age of 50.

But the symptoms of the BPH are independent of the presence or absence of prostate cancer.

But those symptoms often drive men to the urologist's office to get checked out.

- Those symptoms, just to clarify, they're usually urinary symptoms.

So a gentleman might get up more at night.

He may have a weaker stream.

He may have some urgency like he really has to go.

And so those are often symptoms that trigger the visit.

But usually it's the benign growth, benign meaning non-cancerous.

It's the benign growth of the prostate that actually drives those symptoms more than the cancer itself in most cases.

- Are there issues that are precursors to prostate cancer, or if someone comes in with a certain type of issue where they're having trouble, they go to their urologist and say, we're having some issues here, or is there a disease or something that might make you say, you know, I probably should watch you a little closer?

- Certainly a family history of prostate cancer.

We know that there are genetic abnormalities, BRCA genes are the most common one that often present in families which make women more prone to breast cancer and more prone to ovarian cancer in addition to prostate cancer in men.

But in terms of something that you feel that's gonna make you be concerned that you have prostate cancer, generally not.

Unfortunately, however, we commonly, not uncommonly see people who come to our office who've already developed advanced prostate cancer with spread of the cancer to their bones or other organs who do have symptoms.

These are people who are just not diagnosed at an early enough time.

- Let's get into that screening issue, because I know it's something that you're all anxious to talk about.

For most cancers, you hear just kind of right off the bat, just go get screened, what's the worst that happens, it's a false positive.

And not to diminish that.

I know that there are a lot of anxiety issues that go along with false positives.

But it seems as though, I mean, I've not heard that screening is controversial except through prostate cancer or surrounding this topic.

So why, why is it such an issue that people are back and forth about it, Dr. Peters?

- It's a loaded question and answer but essentially, this is good news.

Fortunately, most prostate cancer that we diagnose is curable.

And that's wonderful.

If you look at the statistics that we started out with somewhere between 250,000, 300,000 cases of prostate cancer each year in the United States, yet only about 30,000 deaths.

That's a good ratio.

Take, for example, lung cancer.

That ratio is closer to one to one.

So we know that most prostate cancers that we can diagnose, we have very effective treatments, which we'll get into to cure, which is wonderful.

The issue with screening becomes that we can diagnose someone that may not need treatment.

Now that may not be a bad thing because sometimes the treatment is something called active surveillance, where doctors like all of us, and there are others can, and we pit this word earlier, the shared decision making, we can kind of counsel the patient.

You may have an early prostate cancer, but it's so favorable that we can watch it.

So it's an indirect answer to your question because the complexities of screening PSA, which is what we're talking about have led to probably some over-diagnosis.

That being said, as doctors that treat prostate cancer, we like to know what the PSA is.

And especially in those gentlemen probably less than 70 years old.

I always like to tell my patients, you gotta know what the number is.

And then we look at the trends.

So it's a kind of a 40,000 foot answer to your question, but hopefully sufficient to at least give you some of the answers that you're looking for.

And I welcome comments from my fellow panelists there.

- There have been some large international trials specifically looking at screening.

And the results were mixed as far as whether or not they actually reduced prostate cancer death.

And that's really where combining that with the concept of you're over-treating and you're exposing men to side effects that they wouldn't have had had you not treated them, those two things is what really led to decreasing the screening.

However, we've all seen plenty of men where, because they were never screened, they present with a PSA of 100 or 200 and their cancer was incurable.

Whereas if they would've been screened, that wouldn't have happened.

And so to me, I understand the controversy of screening, but I think that as long as you have a group of physicians that are committed to not over-treating and are appropriately actively watching guys with low risk prostate cancer, it's better to screen them so that way we catch the ones that have the high risk prostate cancer, because as Dr. Peters said, there's still a lot of men dying of prostate cancer.

And a lot of that could have been prevented with screening.

- Well, go ahead, Dr. - Diagnosing prostate cancer.

There's only one way to make a diagnosis and that's to do a needle biopsy where we actually take tissue from the prostate.

And I try to biopsy people that I believe are at risk for having prostate cancer that may hurt them.

And having prostate cancer that if it is there and is aggressive, I can treat with hopes of curing.

But doing a biopsy subjects the patient to risks of bleeding and infection, hospitalization.

So I tend not to do screening PSAs per se in people above 70 with exceptions.

Because if I find prostate cancer in a 75-year-old that patient, unless he has an aggressive cancer is gonna get treated with active surveillance as opposed to surgery or radiation therapy.

- I'm glad you brought that term back up, active surveillance.

'Cause it's something I picked up on that you said.

It seems like that would be a very tough sell in some cases when you tell a patient you have cancer, we're not gonna do anything about it 'cause you're actually okay.

I mean, it just kind of runs afoul to everything that we think we know about cancer.

what kind of conversations do you have with your patients?

- I think you're right, Julie.

So the key thing here is when we get a diagnosis of prostate cancer, it's very complex as to what goes in, involved in the stratification, but we basically stratify patients into a couple different categories, low risk disease, intermediate risk, high risk disease, or advanced disease.

And by breaking it down simply in an office interview with one of us or doctors like us, you can basically report to those patients, here are the options.

For example, low risk disease, active surveillance, where we can watch the patient carefully, rectal exams and PSAs, and sometimes advanced imaging techniques, such as MRI can be very useful at delaying treatment, sometimes in the short run, sometimes permanently.

And they also have the other conventional excellent choices of either surgery or radiation.

As we move higher into the intermediate high and very high risk or advanced disease, active surveillance goes away and then we really get into treatment.

And so the key thing for, I think the viewership is if you get a diagnosis of prostate cancer, what risk category are you in?

And we have certain parameters that are very standard across the country.

And then you and your doctors will kind of discuss the options that you have.

- Yeah, again, the biopsies happen in my office and I have to present the information yes or no to the patient.

And one of the things that some people have difficulty with is what do you mean I have prostate cancer and you're not going to do anything about it?

That's where there's a lot.

I mean, these are hour long conversations with people.

And as Dr. Peters said, the National Comprehensive Cancer Network has guidelines for low risk, very low risk prostate cancer, intermediate risk.

And these are stratified to include all the different categories of prostate cancer based on their PSA, based on the Gleason score which is the, what the pathologist sees on the biopsies and based on any imaging techniques that may be used.

- Explain to people who might not know what a Gleason score is or where that came from.

- Sure, we take a prostate biopsy, we put a needle into the prostate and take a piece of tissue and send it to the pathologist.

The pathologist stains it and looks at it and decides A, is this benign or is this malignant?

And then he grades the cancer in terms of the Gleason score, which is based on the appearance of the different glands in the prostate and in the cancer.

And there are a bunch of very nice drawings that characterize each one of these things.

More recently we've started using, in addition to Gleason score, what's called grade grouping where different Gleason scores are grade one, then grade two, grade three, grade four.

I think it doesn't matter really what system you use, the higher the Gleason score, the more aggressive the cancer is.

The lower the Gleason score, the less aggressive it typically is.

- So let's say you have a patient.

It has been determined now that this patient has prostate cancer and is not in that low score.

We'll kind of segue into treatment options.

So what are, I'll open this to the two of you, what are some of the treatment options that are out there should your doctor recommend that you be treated?

- Sure, the first broadly speaking, surgery and radiation are the two most common curative intent treatments for prostate cancer.

Within both of them, there's a lot of nuances and different technologies.

For example, in radiation, there's internal radiation where they can put radioactive seeds inside of the prostate or there's external radiation where a patient's laying on the table, the machine rotates around them and points an x-ray beam at them.

And that ends up becoming a really important but long discussion with the patients because when we see them, even though we know there's a number of choices, we're able with our experience and expertise to help narrow the choices for them.

'Cause there are some patients that will say only a certain schedule of radiation would be appropriate for you as opposed to other ones, same thing with surgery.

- I want those seeds.

- Yes.

- That's what commonly people say to me.

- Yeah, yeah, people will come in - And order?

- With preconceived notions.

- And order their.

- And we'll say, you know, - I hear what you're saying now let us explain to you, why would we do this, what's the schedule, what are the side effects?

And let's compare those things to your different options.

And then we often don't make a decision in that first visit because it's a lot to take it once.

And really patients should meet a surgeon and a radiation oncologist at a minimum.

There's often a bigger team than that too.

So this is something where in most cases, men have time to listen to their options, seek other expert opinions and then come to the decision that's best for them.

- That might be the most fascinating part about all of this, Dr. Peters.

And I heard you mention earlier in so many cases, it's gonna be, listen, you have cancer and we're gonna act right now.

And this seems to be a situation where in some cases you have the time, the luxury of time to figure out what to do.

- Yeah, it's a good point.

Roughly if we use the statistics we talked about earlier, roughly nine out of the 10 men diagnosed with prostate cancer do not have very advanced disease and they have the luxury of choice and time when making their decision.

It's very important because as the other doctor said, when you're trying to kind of synthesize tons of research and treatment options into a consultation it can be very overwhelming.

So generally speaking, you present this to the patient and their family and what we all call shared decision making, we want that patient to get all the information.

We can direct them, not only with our expertise, but to reputable websites and getting other opinions and include of course their primary care doctor who knows the patient very well before their diagnosis.

And usually almost always what we tell a patient is, look, you have choice.

There are lots of choices.

The good news here is almost all the treatments that we can give for localized prostate cancer are very effective.

And patients do have side effects of those treatments.

But for the most part, they can get through treatments with fairly minimal side effects long term.

There's always exceptions.

And so it's important to us as providers to include the patient and their family in the decision and say, hey, don't rush this, think about it.

Now the only caveat I will say is there are those patients that come with, as we said earlier, very advanced disease and they still have choice, but their decisions may have to, they may have a symptom of advanced cancer that needs more immediate treatment.

So again, every case is different.

And that's why it's hard to say for, for patient one, you need surgery, for patient two, you need radiation.

Generally speaking, almost always the treatments are gonna be patient-driven once they get all the information.

- Well, just to elaborate on that as you said for the garden variety, low grade, prostate cancer, somebody who needs or wants to be treated, we know that radiation therapy and surgery are almost equivalent in terms of long term cure rates.

So that's a very good thing.

One of the things that I stress to my patients is I'm interested in your quality of life.

And, you know, the downside of having surgery is you gotta have surgery.

The upside of surgery is you're probably gonna be cured and you're gonna live in otherwise normal life.

The upside of having radiation therapy is that you don't have to have surgery.

The downside is with regard to following their PSAs, when we do surgery the PSA goes to zero and that's an absolute indicator of the presence or absence of disease.

With radiation therapy where we leave the prostate in, the PSA does not go to zero reliably.

And therefore there's always some uncertainty going forward five to 10 years later about what does that detectable PSA mean?

But in general cure rates are the same.

- I was about to ask, is there a high risk of recurrence with prostate cancer or does that depend on the case, the type, and how it's treated?

- It's the risk, most men with, for low to intermediate risk prostate cancer, the long term cure rates are around 90%.

- [Julie] Wow.

- But when you get to the higher risk and the very high risk it does drop.

But even men with high and very high risk, as long as it's not advanced, it's still potentially curable.

There are men that even with this more locally advanced cancers can still go back to normal and be cured.. - One of the things I also tell patients, again, looking down the road and with regard to recurrence, when you do surgery and if it's successful, it's great and you do radiation and it's successful, it's great.

But if it's not, then what are your options?

So I tell patients if you've had surgery and you get a recurrence with your PSA, you can have salvage radiation therapy, which is really a second chance at cure.

If you have radiation therapy as your initial treatment, you may not have the option of getting further radiation.

I know about CyberKnife may make that possible, but in general, you have to proceed to the next higher level of treatment.

- I think though it depends on why they fail.

I mean, this gets a little technical.

But most times, if we treat the prostate with surgery, for example, the goal is, as Dr. Rittenberg said, the prostate cancer is gone.

With radiation therapy if you treat the prostate, the cancer of an isolated local failure in the prostate using modern techniques is so low that usually patients fail outside of the prostate in the pelvic lymph nodes or the bones.

And you're correct to say that one of the exciting parts of the field now is salvaging those patients.

In the past, we thought lymph node metastasis was incurable.

We're starting to think very differently about that because with newer medications that we have, not only in terms of hormonal therapy, but also more modern radiation techniques, such as you mentioned one vendor, but stereotactic body radiation therapy.

We're able now to chase disease in ways that we weren't before safely and offer patients durable control and sometimes cure where they weren't curable in the past.

And last thing I'll say on that is there's been such advances in the imaging.

We used to use conventional cat scans and bone scans, but now with multiparametric MRIs, PSMA PET Scans, we're really able to find disease very early and get after it and sometimes make a huge difference.

- It's really very exciting time in prostate cancer treatment with new drugs, new genetic tests, with new technologies.

We're really helping men in ways that we couldn't before.

- Well, I'd like to thank all of you for appearing for the show.

Thank you so much for your time and your expertise.

That's gonna do it for this episode of "Call The Doctor".

If you missed a portion of the show, you can catch it on replay.

That schedule is available online at wvia.org.

You can also watch it online or find it at the WVIA mobile app.

I'm Julie Sidoni, thank you for watching.

And from all of us here at WVIA, we'll see you next time.

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