Surgical Options for the Care of Prostate Cancer

Transcript

00:02 --> 00:03Funding for Yale Cancer Answers
00:03 --> 00:05is provided by Smilow Cancer
00:05 --> 00:06Hospital.
00:08 --> 00:10Welcome to Yale Cancer Answers
00:10 --> 00:11with doctor Eric Winer.
00:12 --> 00:14Yale Cancer Answers features conversations
00:14 --> 00:16with oncologists and specialists who
00:16 --> 00:17are on the forefront of
00:17 --> 00:18the battle to fight cancer.
00:19 --> 00:20This week, it's a conversation
00:20 --> 00:22about prostate cancer with doctor
00:22 --> 00:23Michael Leapman.
00:23 --> 00:25Doctor Leapman is an associate
00:25 --> 00:26professor of urology at the
00:26 --> 00:27Yale School of Medicine.
00:28 --> 00:29Here's doctor Winer.
00:30 --> 00:31I just want to start off
00:31 --> 00:33by asking you how
00:33 --> 00:35you came to be interested
00:35 --> 00:37in prostate cancer and
00:40 --> 00:41what led you down this path?
00:41 --> 00:43I've been
00:43 --> 00:44fascinated with prostate cancer and
00:44 --> 00:45was drawn to the field
00:45 --> 00:46of urology,
00:47 --> 00:48in medical school,
00:49 --> 00:50rotating through surgery. And when
00:50 --> 00:52I came upon urology, I
00:52 --> 00:53was really fascinated
00:53 --> 00:54by a field that was
00:54 --> 00:56focused on treating patients with
00:56 --> 00:57cancer,
00:57 --> 00:59but also tasked with the role of
01:00 --> 01:02preserving or, whenever we can,
01:02 --> 01:03enhancing quality of life.
01:03 --> 01:05And so that challenge of
01:06 --> 01:07dealing with cancer
01:08 --> 01:10and controlling it while also
01:10 --> 01:12helping to walk that razor's
01:12 --> 01:13edge of quality of life
01:13 --> 01:14is what got me interested
01:14 --> 01:16in prostate cancer. It's also
01:16 --> 01:18an area where there's really
01:18 --> 01:19intense
01:19 --> 01:21decision making.
01:21 --> 01:22These are tough decisions to
01:22 --> 01:23make, and so I
01:23 --> 01:25revel in that opportunity
01:25 --> 01:27to help connect with patients
01:27 --> 01:28and help them navigate that
01:28 --> 01:28experience.
01:31 --> 01:33Before we drill down into
01:33 --> 01:34prostate cancer, maybe you could
01:34 --> 01:35just tell us a little
01:35 --> 01:36bit about the
01:37 --> 01:38various cancers that comprise
01:39 --> 01:40urologic cancers.
01:41 --> 01:41A urologist,
01:43 --> 01:44who is the surgeon for
01:44 --> 01:46the people who
01:46 --> 01:47have these cancers,
01:48 --> 01:49takes care of a number
01:49 --> 01:51of different kinds of cancer.
01:52 --> 01:53Urologists
01:54 --> 01:56are doctors who take care
01:56 --> 01:57of the genitourinary
01:57 --> 01:59tract. So in general, if
01:59 --> 02:00something makes urine or is close
02:00 --> 02:02to it, it really falls
02:02 --> 02:04into our umbrella. So
02:04 --> 02:05we're the plumbers. That's
02:05 --> 02:06kinda the way I think
02:06 --> 02:07about it. And so that
02:07 --> 02:08encompasses
02:09 --> 02:11the kidneys, the ureter, which
02:11 --> 02:12is the tube that drains
02:12 --> 02:14the kidney, the bladder,
02:14 --> 02:16the prostate in men, the
02:16 --> 02:18penis and testicles in men.
02:19 --> 02:20Urology is a small field,
02:20 --> 02:21but it's a really
02:21 --> 02:23diverse field. And so
02:23 --> 02:24urologists also
02:25 --> 02:27deal with issues of urinary
02:27 --> 02:27incontinence,
02:29 --> 02:31female pelvic medicine, and urogynecology
02:32 --> 02:33as well. There are also
02:33 --> 02:35pediatric urologists. So in the
02:35 --> 02:36cancer world, we focus on
02:36 --> 02:37kidney cancer,
02:38 --> 02:39bladder and urothelial
02:39 --> 02:42cancer, prostate cancer, testis cancer,
02:42 --> 02:43penile cancer.
02:44 --> 02:45And, of course, the most
02:45 --> 02:47common of those, not that
02:47 --> 02:48the others are
02:49 --> 02:50so very rare or some
02:50 --> 02:51of the others are so
02:51 --> 02:52very rare, but the most
02:52 --> 02:54common is indeed prostate cancer.
02:56 --> 02:58And how big a
02:58 --> 02:59problem is prostate cancer?
03:00 --> 03:01We'll just talk about the
03:01 --> 03:03United States to begin with.
03:03 --> 03:05So prostate cancer is consistently
03:06 --> 03:07the most commonly diagnosed
03:08 --> 03:10solid cancer in men, with
03:10 --> 03:11an estimated three hundred thousand
03:11 --> 03:12cases diagnosed
03:13 --> 03:14this year.
03:14 --> 03:16And so it really is
03:16 --> 03:17very, very common and is
03:17 --> 03:18probably more common than we
03:18 --> 03:20even diagnose it.
03:20 --> 03:21And so it is
03:21 --> 03:23the number one, but the
03:23 --> 03:24real question is what type
03:24 --> 03:26of cancer is it and
03:26 --> 03:27is it something
03:27 --> 03:28we need to treat in
03:28 --> 03:29all people? But it is
03:29 --> 03:31a major public
03:31 --> 03:32health challenge in the United
03:32 --> 03:33States,
03:33 --> 03:34and doesn't appear to be
03:34 --> 03:36going anywhere with some modeling
03:36 --> 03:38studies suggesting that we were
03:38 --> 03:40gonna probably see more cases
03:40 --> 03:41with time.
03:41 --> 03:42And it is
03:42 --> 03:44a disease that becomes more
03:44 --> 03:45and more common as a
03:45 --> 03:45man gets
03:46 --> 03:47older?
03:48 --> 03:49Yes, and my understanding is that
03:49 --> 03:51in autopsy studies
03:51 --> 03:53of older men that a
03:53 --> 03:55very, very high proportion
03:55 --> 03:57of individuals have at least
03:57 --> 03:59some prostate cancer.
04:02 --> 04:03I mentioned this to a
04:03 --> 04:04lot of my patients when
04:04 --> 04:05we have these discussions
04:06 --> 04:07just how common it is
04:07 --> 04:08in people if you go
04:08 --> 04:09looking for it.
04:09 --> 04:11When they've done studies
04:11 --> 04:12of people who pass away
04:12 --> 04:13for another reason and they
04:13 --> 04:14look in their prostates,
04:15 --> 04:16up to fifty percent of men
04:16 --> 04:17in their eighties will have
04:17 --> 04:19some evidence of cells that
04:19 --> 04:20look like prostate cancer. And
04:20 --> 04:21these are folks who passed
04:21 --> 04:23away from another reason. So
04:23 --> 04:24it tells us it's extremely
04:24 --> 04:25common if we go looking
04:25 --> 04:26for it.
04:28 --> 04:29I guess the other relevant
04:29 --> 04:31statistic would be how many
04:31 --> 04:33people die from prostate cancer
04:33 --> 04:33every year?
04:34 --> 04:35Right, it's
04:35 --> 04:37about thirty to thirty five
04:37 --> 04:38thousand people who die from
04:38 --> 04:40prostate cancer. So even though
04:40 --> 04:41it's very common,
04:41 --> 04:42that's still a very large
04:42 --> 04:44number. It's the second leading
04:44 --> 04:45cause of cancer death in
04:45 --> 04:47men after lung cancer.
04:47 --> 04:48But, nonetheless,
04:50 --> 04:52relatively small proportion of men
04:52 --> 04:54who are diagnosed with prostate
04:54 --> 04:56cancer ultimately lose their lives
04:56 --> 04:58to it. So certainly well
04:58 --> 04:59under half.
05:01 --> 05:02Most men have an excellent
05:03 --> 05:04outcome if they're diagnosed with
05:04 --> 05:06prostate cancer and do very
05:06 --> 05:07well with treatment.
05:08 --> 05:10Alright, maybe you could
05:10 --> 05:10tell us a little bit
05:10 --> 05:12about some of the advances
05:12 --> 05:13in prostate cancer over the
05:13 --> 05:14years
05:15 --> 05:17we'll get to screening. We'll
05:17 --> 05:18get to some
05:18 --> 05:20of the decisions around
05:20 --> 05:21early diagnosis,
05:21 --> 05:23but maybe first just some
05:23 --> 05:24of the
05:25 --> 05:27headlines in terms of advances.
05:28 --> 05:29A lot has changed.
05:29 --> 05:30I was on this show
05:30 --> 05:31maybe five or six years
05:31 --> 05:33ago, and I remember being
05:33 --> 05:34asked that question. And when
05:34 --> 05:35I come back today, a
05:35 --> 05:36lot has changed in five
05:36 --> 05:37or six years. And so
05:37 --> 05:37I think
05:37 --> 05:38both in terms of how
05:38 --> 05:40we treat localized disease. So
05:40 --> 05:41when patients come and they
05:41 --> 05:42have cancer that we think
05:42 --> 05:43is only located in their
05:43 --> 05:44prostate,
05:45 --> 05:46we are changing our approach.
05:46 --> 05:48The backbones are still
05:48 --> 05:50radiation and surgery,
05:50 --> 05:52but we have a
05:52 --> 05:54whole flourishing field called focal
05:54 --> 05:55therapy or ablation,
05:55 --> 05:57where we use energy, different
05:57 --> 05:59forms of energy, to destroy
05:59 --> 06:00parts of the tissue or
06:00 --> 06:01the entire prostate,
06:02 --> 06:04without removing it or radiating it.
06:05 --> 06:06We have a large program
06:06 --> 06:08of ablation at Yale where
06:08 --> 06:10we offer these treatments, various
06:10 --> 06:11forms of treatment,
06:12 --> 06:14that aim to improve quality
06:14 --> 06:15of life or preserve quality
06:15 --> 06:17of life while also controlling
06:17 --> 06:18the cancer.
06:19 --> 06:21We've also made improvements in
06:21 --> 06:21how
06:22 --> 06:23surgical prostatectomy is done with
06:23 --> 06:25robotics. The robotics platforms are
06:25 --> 06:28continuously getting better,
06:28 --> 06:30with single port prostatectomy and
06:32 --> 06:33ways of approaching and removing
06:33 --> 06:35the prostate that are less
06:35 --> 06:35invasive.
06:36 --> 06:38So single port prostatectomy
06:38 --> 06:41means you're essentially inserting
06:42 --> 06:43some sort of device into
06:43 --> 06:44one area?
06:45 --> 06:46Yeah. Well, it's a robotic
06:46 --> 06:47device. So robotic prostatectomy
06:48 --> 06:48has been,
06:49 --> 06:51you know, a big
06:51 --> 06:51change in the field
06:51 --> 06:52over the past ten or
06:52 --> 06:54fifteen years. But the typical
06:54 --> 06:56robotic platform involved putting five
06:56 --> 06:58cameras in a laparoscopic
06:58 --> 07:00configurations. Five little keyholes in
07:00 --> 07:01the belly.
07:02 --> 07:03There is a surgical device
07:03 --> 07:05that actually uses one
07:05 --> 07:06incision and then all the
07:06 --> 07:08instruments fan out from one
07:08 --> 07:10incision.
07:10 --> 07:10And how big is that
07:10 --> 07:11incision?
07:11 --> 07:12The incision is about five
07:12 --> 07:14centimeters. So it's a little
07:14 --> 07:15bigger than
07:15 --> 07:16one of
07:16 --> 07:17the small incisions but it
07:17 --> 07:19isn't in one area.
07:20 --> 07:21So it allows us
07:21 --> 07:22in general to get into
07:22 --> 07:23smaller spaces,
07:24 --> 07:25and so it's used in
07:25 --> 07:26the prostate but it's used
07:26 --> 07:28also in other applications as well
07:28 --> 07:30And then you somehow
07:30 --> 07:30control
07:31 --> 07:33what's going on through
07:34 --> 07:36the robot?
07:36 --> 07:37Exactly, the robot,
07:37 --> 07:38that's in general in robotic surgery.
07:38 --> 07:40Now
07:40 --> 07:41we are hearing a lot
07:41 --> 07:42about robots and AI and,
07:42 --> 07:45you know, autonomous devices, autonomous
07:45 --> 07:45cars.
07:46 --> 07:47That is not happening yet
07:47 --> 07:47in surgery. I mean, it
07:47 --> 07:48may be coming down the
07:48 --> 07:49pipe, and I think it's
07:49 --> 07:50very likely that there will
07:50 --> 07:53be truly autonomous surgery
07:53 --> 07:54or robot
07:54 --> 07:56assisted surgery. But right now,
07:56 --> 07:57there's nothing like that. So
07:57 --> 07:59when someone has a robotic
07:59 --> 08:01surgery, we are still driving
08:01 --> 08:02the instruments but it allows
08:02 --> 08:03us to get into a
08:03 --> 08:04small space,
08:04 --> 08:06without making a big opening.
08:06 --> 08:06Fundamentally,
08:06 --> 08:07that's what it's doing. It's
08:07 --> 08:08allowing us to get into
08:08 --> 08:10a small space and also
08:10 --> 08:11moving in ways that the
08:11 --> 08:12human hands can't really rotate
08:12 --> 08:14three hundred sixty degrees,
08:15 --> 08:16and get in tight spaces.
08:16 --> 08:18So it gives you
08:18 --> 08:19more dexterity?
08:19 --> 08:21That's right. But
08:22 --> 08:23if I were coming to
08:23 --> 08:25you with prostate cancer, I
08:25 --> 08:27don't have to worry that
08:27 --> 08:29the OR is gonna be
08:29 --> 08:30empty and there's just gonna
08:30 --> 08:32be a robotic device and
08:32 --> 08:34some computer telling it what
08:34 --> 08:36to do? NOTE Confidence: 0.95293367
08:36 --> 08:37No, we're still doing this, but
08:39 --> 08:40that may change.
08:40 --> 08:41I mean, at some point,
08:41 --> 08:42you know, if you look there are
08:44 --> 08:46AI platforms that
08:46 --> 08:47can drive a car
08:47 --> 08:48from your house to the
08:48 --> 08:48hospital.
08:49 --> 08:50There's a lot of complex
08:50 --> 08:51information that those systems are
08:51 --> 08:53navigating, but there's nothing like
08:53 --> 08:54that going on right now.
08:54 --> 08:56It's all done by a
08:56 --> 08:57very large human
08:57 --> 08:59team still. Y\
08:59 --> 09:00And,
09:00 --> 09:02oftentimes, men are making a
09:02 --> 09:04choice between surgery and radiation.
09:04 --> 09:05What does that choice
09:05 --> 09:06look like?
09:06 --> 09:08We're fortunate to have
09:08 --> 09:10multiple very effective treatments for
09:10 --> 09:12prostate cancer. And so surgical
09:12 --> 09:14removal of the prostate
09:14 --> 09:15is one, but one that
09:15 --> 09:17is also very effective is
09:17 --> 09:18radiation to the prostate.
09:20 --> 09:22And radiation can be given by
09:22 --> 09:23itself or sometimes with a
09:23 --> 09:25course of hormone medication
09:25 --> 09:27to decrease testosterone levels.
09:29 --> 09:30And so the decision about
09:30 --> 09:31where to go is often
09:31 --> 09:33a complicated one.
09:33 --> 09:35The surgery is more invasive
09:35 --> 09:36because it is a surgical
09:36 --> 09:38intervention. The radiation offers
09:38 --> 09:40the advantage that no one
09:40 --> 09:41touches you. There's no hospitalization.
09:43 --> 09:45And so the pros
09:45 --> 09:46and cons really relate to
09:46 --> 09:48undergoing a surgery if people
09:48 --> 09:48want to.
09:50 --> 09:52But both deliver a
09:52 --> 09:53very good outcome and both
09:53 --> 09:54have a good chance
09:54 --> 09:56of controlling localized prostate cancer.
09:56 --> 09:58And is one at all
09:58 --> 09:59better than the other?
09:59 --> 10:01We don't think so. There's never
10:01 --> 10:02been a head to head
10:02 --> 10:04study that has compared radiation
10:04 --> 10:04to surgery
10:05 --> 10:06for the type of cancers
10:06 --> 10:07that we treat nowadays.
10:08 --> 10:10But from the
10:10 --> 10:11retrospective studies, people who've been
10:11 --> 10:13treated in the past, they
10:13 --> 10:14seem to come out more
10:14 --> 10:15or less the same. There
10:15 --> 10:16are some relative advantages to
10:16 --> 10:18one and disadvantages to others.
10:18 --> 10:19When we do surgery, we
10:19 --> 10:21remove the entire prostate and
10:21 --> 10:22we can get a sense
10:22 --> 10:23of what is truly in
10:23 --> 10:24there rather than just getting
10:24 --> 10:26a biopsy of it. And
10:26 --> 10:27we can selectively add more
10:27 --> 10:28treatment in the future if
10:28 --> 10:29necessary.
10:30 --> 10:31Radiation has the advantage of
10:31 --> 10:33having less of an impact
10:33 --> 10:35on urinary continents, which may
10:35 --> 10:36be a higher risk with
10:36 --> 10:37surgery.
10:38 --> 10:39But there are also potential
10:39 --> 10:40drawbacks with each of
10:40 --> 10:42them. So that's why I
10:42 --> 10:43think the main
10:43 --> 10:45thing is having that relationship
10:45 --> 10:46with your doctor, being in
10:46 --> 10:47a setting where you can
10:47 --> 10:48help make a decision that
10:48 --> 10:50is tailored to your individual
10:50 --> 10:51interest.
10:51 --> 10:52A lot of folks have
10:52 --> 10:53a strong sense of where
10:53 --> 10:54they would like to go.
10:54 --> 10:55And so I think that's
10:55 --> 10:57where we see ourselves as
10:57 --> 10:59as really facilitating that decision.
10:59 --> 11:01And before we take a
11:01 --> 11:03break, maybe we just spend
11:03 --> 11:04a couple of minutes talking
11:04 --> 11:05about some of the other
11:06 --> 11:07unintended consequences
11:08 --> 11:09of either prostate surgery or
11:09 --> 11:10prostate radiation,
11:11 --> 11:12the kinds of side effects
11:12 --> 11:13that I think many men
11:13 --> 11:15are very concerned about.
11:15 --> 11:17So there's incontinence. There's also
11:17 --> 11:18sexual dysfunction.
11:18 --> 11:19Those are the
11:19 --> 11:20big two. Those are the
11:20 --> 11:22big two because the prostate
11:22 --> 11:24sits attached to the bladder.
11:24 --> 11:25When a person
11:25 --> 11:27urinates, their urine passes from
11:27 --> 11:29their bladder through their prostate.
11:29 --> 11:30So anything we do to
11:30 --> 11:32that sensitive area runs
11:32 --> 11:34the risk of affecting urinary
11:34 --> 11:36control and sexual function. The
11:36 --> 11:37nerves for erection of
11:37 --> 11:39course are right underneath the prostate.
11:39 --> 11:40So it's
11:40 --> 11:41in a sensitive spot.
11:42 --> 11:43Those are risks even with
11:43 --> 11:45expert surgery or expert radiation.
11:45 --> 11:46There is a risk that
11:46 --> 11:48urinary health could be worse.
11:49 --> 11:51And after surgery, it can
11:51 --> 11:53lead to urinary leakage. So
11:53 --> 11:54laughing, when you laugh, cough,
11:54 --> 11:56or sneeze, people could leak,
11:56 --> 11:57dribble urine for a period
11:57 --> 11:58of time, or in some
11:58 --> 11:59cases permanently.
12:00 --> 12:02And erections can be more
12:02 --> 12:02difficult.
12:03 --> 12:04And is that something that
12:04 --> 12:06gets better over time too?
12:06 --> 12:08After surgery,
12:08 --> 12:10most people improve, but in
12:10 --> 12:11some cases, it can be
12:11 --> 12:14permanent or can require assistance
12:14 --> 12:15where someone didn't need it
12:15 --> 12:17before. So medications like Viagra
12:17 --> 12:19or Cialis are often needed
12:19 --> 12:20for some people at least
12:20 --> 12:21for a period of time.
12:21 --> 12:23And presumably, these are all
12:23 --> 12:24the conversations you have with
12:24 --> 12:26patients when you're counseling
12:27 --> 12:28about these various options.
12:29 --> 12:30Right. Well, it's really that
12:30 --> 12:32balance between cancer control
12:33 --> 12:34and functional status. And
12:34 --> 12:36in many cases, we do
12:36 --> 12:38bring patients safely back to
12:38 --> 12:39where they were before. That's
12:39 --> 12:41really our objective in any
12:41 --> 12:43of these is to
12:43 --> 12:46think about balancing cancer control
12:46 --> 12:47with preserving
12:47 --> 12:48quality of
12:48 --> 12:50life.
12:50 --> 12:51We're gonna take a break for
12:51 --> 12:52just a minute. When we
12:52 --> 12:53come back,
12:53 --> 12:55we're gonna focus on really
12:56 --> 12:57three topics. Talk a little
12:57 --> 12:59bit about screening. We'll talk
12:59 --> 12:59about
13:01 --> 13:03the approach that increasingly is
13:03 --> 13:05being taken where someone is
13:05 --> 13:07diagnosed with prostate cancer, and
13:07 --> 13:08they may not initially undergo
13:08 --> 13:10treatment, they may be observed.
13:10 --> 13:12Finally, I wanna touch on
13:12 --> 13:13the whole subject of prostate
13:13 --> 13:15cancer in younger men, which
13:15 --> 13:17is by no means the
13:17 --> 13:17most common
13:19 --> 13:20age when you see prostate
13:20 --> 13:22cancer, but, it still happens.
13:23 --> 13:24So when we come back,
13:24 --> 13:27I'll continue this conversation with
13:27 --> 13:29our guest, doctor Michael Leapman.
13:29 --> 13:31Funding for Yale Cancer Answers
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13:42 --> 13:43More at smilowcancerhospital
13:44 --> 13:45dot org.
13:47 --> 13:49Breast cancer is one of
13:49 --> 13:50the most common cancers in
13:50 --> 13:52women. In Connecticut alone, approximately
13:53 --> 13:54three thousand five hundred women
13:54 --> 13:55will be diagnosed with breast
13:55 --> 13:57cancer this year, but there
13:57 --> 13:59is hope thanks to earlier
13:59 --> 14:01detection, non invasive treatments, and
14:01 --> 14:03the development of novel therapies
14:03 --> 14:04to fight breast cancer.
14:04 --> 14:06Women should schedule a baseline
14:06 --> 14:08mammogram beginning at age forty
14:08 --> 14:09or earlier if they have
14:09 --> 14:11risk factors associated with the
14:11 --> 14:11disease.
14:12 --> 14:14With screening, early detection, and
14:14 --> 14:16a healthy lifestyle, breast cancer
14:16 --> 14:17can be defeated.
14:18 --> 14:19Clinical trials are currently underway
14:19 --> 14:22at federally designated comprehensive cancer
14:22 --> 14:24centers, such as Yale Cancer
14:24 --> 14:25Center and Smilow Cancer
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14:26 --> 14:28to make innovative new treatments
14:28 --> 14:29available to patients.
14:30 --> 14:31Digital breast tomosynthesis
14:31 --> 14:33or three d mammography is
14:33 --> 14:36also transforming breast cancer screening
14:36 --> 14:39by significantly reducing unnecessary procedures
14:39 --> 14:40while picking up more cancers.
14:41 --> 14:43More information is available at
14:43 --> 14:45yale cancer center dot org.
14:45 --> 14:46You're listening to Connecticut Public
14:46 --> 14:47Radio.
14:48 --> 14:49Good evening again. This is
14:49 --> 14:51Eric Winer with Yale Cancer
14:51 --> 14:53Answers, and I'm speaking to
14:53 --> 14:55our guest, doctor Michael Leapman,
14:57 --> 14:59associate professor of urology
15:00 --> 15:00at
15:00 --> 15:01Yale University.
15:03 --> 15:05So I wanna move on
15:05 --> 15:06and talk
15:07 --> 15:08a little bit about prostate
15:08 --> 15:08screening.
15:09 --> 15:10Of course,
15:11 --> 15:12cancer screening,
15:12 --> 15:15generally speaking, is very important.
15:15 --> 15:17We ideally want to diagnose
15:17 --> 15:17patients
15:19 --> 15:20most of the time with
15:20 --> 15:21the earliest possible cancer.
15:23 --> 15:24Screening is available in a
15:24 --> 15:25number of areas. And I
15:25 --> 15:26think that
15:27 --> 15:27perhaps,
15:28 --> 15:29in the area of prostate
15:29 --> 15:31cancer, there's both more data
15:31 --> 15:32than in some other areas.
15:33 --> 15:35There's also perhaps every bit
15:35 --> 15:37as much controversy as there
15:37 --> 15:37is in other areas.
15:41 --> 15:41Michael,
15:42 --> 15:43thoughts about
15:43 --> 15:44prostate cancer screening.
15:45 --> 15:46When did it all start?
15:48 --> 15:49It's an enduring
15:50 --> 15:51topic that really hasn't
15:51 --> 15:52been settled, but I think
15:52 --> 15:54this really goes back about
15:54 --> 15:55thirty years
15:55 --> 15:57to the early nineteen nineties
15:57 --> 15:58with
15:59 --> 16:01the isolation and advent of
16:01 --> 16:02PSA. And PSA is a
16:04 --> 16:05blood test. It's a protein
16:05 --> 16:06that is made by prostate
16:06 --> 16:08cells. So cancerous cells and
16:08 --> 16:10non cancerous cells of the
16:10 --> 16:10prostate
16:10 --> 16:12make this protein.
16:13 --> 16:14And it is stands
16:14 --> 16:16for prostate specific antigen.
16:17 --> 16:18And so scientists in the
16:19 --> 16:20early seventies
16:20 --> 16:22were able to identify this
16:22 --> 16:22in the blood
16:23 --> 16:25and really began to become
16:25 --> 16:26a biomarker or a test
16:26 --> 16:28that we would order beginning
16:28 --> 16:29in the early
16:29 --> 16:30nineteen nineties.
16:30 --> 16:31And it was found that
16:31 --> 16:32that was a pretty good
16:32 --> 16:34marker for prostate cancer.
16:34 --> 16:35If I can just interrupt
16:35 --> 16:36you for a second, that's
16:36 --> 16:38also the same test that's
16:38 --> 16:39used at times
16:39 --> 16:40when we're taking care of
16:40 --> 16:42patients who have advanced prostate
16:42 --> 16:44cancer or for that matter,
16:45 --> 16:46screening them for recurrence.
16:47 --> 16:48And it it is used
16:48 --> 16:49in those situations as well
16:49 --> 16:50in people who have
16:50 --> 16:52already been treated
16:52 --> 16:54for prostate cancer.
16:54 --> 16:55That's right, it's the same test.
16:55 --> 16:56PSA has been on the
16:56 --> 16:57scene for over thirty
16:57 --> 16:59years. It is an
16:59 --> 17:00amazing test if you really
17:00 --> 17:01think about it, and it
17:01 --> 17:01has transformed
17:02 --> 17:05how we diagnose prostate cancer,
17:05 --> 17:06how we treat prostate cancer,
17:06 --> 17:07and it has really shifted
17:07 --> 17:09the lives and trajectory of
17:09 --> 17:10the disease for probably
17:10 --> 17:12millions and millions of people.
17:12 --> 17:14The issue is that PSA
17:14 --> 17:16levels can be elevated in
17:16 --> 17:17people who don't have prostate
17:17 --> 17:19cancer and in some cases,
17:19 --> 17:20they're not elevated in people who do.
17:21 --> 17:22But overall, it's a pretty
17:22 --> 17:23good test.
17:27 --> 17:28And in the nineteen nineties when
17:28 --> 17:30it was really performed
17:30 --> 17:32in mass, essentially people
17:32 --> 17:33were going to their doctors,
17:33 --> 17:34getting PSA screened,
17:35 --> 17:36and if the numbers were
17:36 --> 17:38elevated, being monitored or being
17:38 --> 17:40evaluated further. So screening really
17:40 --> 17:41has been that PSA blood
17:41 --> 17:43test. And the question has
17:43 --> 17:44been, well, we know PSA
17:44 --> 17:45is very good at finding
17:46 --> 17:48these early stage prostate cancers.
17:48 --> 17:49But will it lead to
17:49 --> 17:50people
17:50 --> 17:52living longer? Will it reduce
17:52 --> 17:52the risk of dying from
17:52 --> 17:54prostate cancer? That has been
17:54 --> 17:55the fundamental question that people
17:55 --> 17:57have been wrestling with and
17:57 --> 17:58has been evaluated in a
17:58 --> 18:00number of clinical trials over
18:00 --> 18:00the years.
18:00 --> 18:01And if I can ask
18:01 --> 18:03you, the people who have
18:03 --> 18:04prostate cancer
18:05 --> 18:06and don't have an elevated
18:06 --> 18:07PSA,
18:08 --> 18:09how common is that, and
18:09 --> 18:11are those cancers any different?
18:12 --> 18:13You know, it seems to
18:13 --> 18:14be the minority. So it's
18:14 --> 18:15not very common that we
18:15 --> 18:17see it. Most people, it is elevated.
18:18 --> 18:20In some cases, after treatment, after
18:20 --> 18:21many rounds of treatment,
18:22 --> 18:24PSA stops being produced by
18:24 --> 18:25prostate cancer cells. And so
18:25 --> 18:26at some point when the
18:26 --> 18:28cells are not responsive to
18:28 --> 18:29androgens or testosterone,
18:30 --> 18:31you may see
18:31 --> 18:33growth of prostate cancer without
18:33 --> 18:34a rise in PSA. But
18:34 --> 18:36overall, it remains preserved
18:37 --> 18:38even after people have been
18:38 --> 18:39treated for prostate cancer. So
18:39 --> 18:40it's a useful marker for
18:40 --> 18:42people who have been treated
18:42 --> 18:43to know
18:43 --> 18:44where they stand.
18:44 --> 18:46What are the reasons that
18:46 --> 18:47a PSA
18:47 --> 18:49goes up if you don't
18:49 --> 18:50have prostate cancer?
18:51 --> 18:52So inflammation,
18:52 --> 18:54infection, growth of the prostate
18:55 --> 18:56can all cause PSA to
18:56 --> 18:58go up. And some people
18:58 --> 18:58just genetically
18:59 --> 19:01are predisposed to have higher
19:01 --> 19:02PSAs than others. So there's
19:02 --> 19:04some interesting research showing that
19:04 --> 19:05you can begin adjusting
19:05 --> 19:07for that genetic variation.
19:08 --> 19:09But let's say someone's having
19:09 --> 19:11screening and the level is
19:11 --> 19:12particularly high,
19:13 --> 19:14it's more likely to be
19:14 --> 19:16a cancer than one of
19:16 --> 19:18these other benign causes?
19:18 --> 19:20That's true. And
19:20 --> 19:21so I think that's
19:21 --> 19:22really where there's been a
19:22 --> 19:23a big revolution in how
19:23 --> 19:24we approach this.
19:24 --> 19:26Ten, fifteen years ago,
19:26 --> 19:27if someone had a high
19:27 --> 19:28PSA level, they would come
19:28 --> 19:30in and get a biopsy,
19:30 --> 19:32essentially a procedure where we
19:32 --> 19:33would take little pieces of
19:33 --> 19:34the prostate and see if
19:34 --> 19:35there was cancer there. Our
19:35 --> 19:36approach has shifted. So if
19:37 --> 19:38a gentleman comes to see
19:38 --> 19:39me and his PSA is
19:39 --> 19:39elevated,
19:40 --> 19:41we will do imaging to
19:41 --> 19:42confirm
19:42 --> 19:43whether or not there's something
19:43 --> 19:44there. And that has allowed
19:44 --> 19:46us to avoid doing a
19:46 --> 19:47biopsy to rule out significant
19:47 --> 19:48cancer in a number of
19:48 --> 19:50people, which is great. If
19:50 --> 19:51we can do something noninvasively,
19:52 --> 19:53that's a big win.
19:53 --> 19:55In most
19:55 --> 19:56cases, it will help identify
19:57 --> 19:57where
19:57 --> 19:59a tumor is located so
19:59 --> 20:00we can take a more
20:00 --> 20:01accurate biopsy of it.
20:02 --> 20:04So when I'm asked the
20:04 --> 20:04question
20:05 --> 20:07by a friend or
20:07 --> 20:08an acquaintance,
20:09 --> 20:11they'll say, well, you know,
20:11 --> 20:12you work at Yale
20:12 --> 20:14Cancer Center. Tell me, should
20:14 --> 20:15I have prostate screening,
20:16 --> 20:18and when should I start
20:18 --> 20:19it, and
20:19 --> 20:21how often should it be
20:21 --> 20:22done? What do I
20:22 --> 20:23tell those people?
20:23 --> 20:25That's a good question.
20:25 --> 20:26And you know
20:26 --> 20:27this is
20:27 --> 20:28always the cocktail
20:28 --> 20:29party conversation.
20:31 --> 20:33It really depends. You know, the
20:33 --> 20:34best evidence we have for
20:34 --> 20:35prostate cancer screening are in
20:35 --> 20:36young
20:37 --> 20:38fifty five to sixty nine
20:38 --> 20:39year old people who are
20:39 --> 20:40well informed
20:40 --> 20:41about
20:41 --> 20:42the risks and benefits.
20:43 --> 20:44And it seems to be
20:45 --> 20:47that getting a PSA test,
20:47 --> 20:47getting screened
20:48 --> 20:49reduces the risk of dying
20:49 --> 20:50from prostate cancer. So that's
20:50 --> 20:51what I would tell people.
20:51 --> 20:53But we've
20:53 --> 20:54had a hard time interpreting
20:54 --> 20:55that. So does that mean
20:55 --> 20:56every single person at any
20:56 --> 20:57age should get it? Probably
20:57 --> 20:59not. Screening people who
21:00 --> 21:01are much older or who
21:01 --> 21:03have serious other medical things
21:03 --> 21:04going on in their life
21:04 --> 21:05might have more risk than
21:05 --> 21:07benefit because you might find a
21:08 --> 21:09prostate cancer and treat it
21:10 --> 21:11when it was never destined
21:11 --> 21:13to harm that individual. And
21:13 --> 21:14then they
21:14 --> 21:15have to deal with all
21:15 --> 21:16of the quality of life
21:16 --> 21:18stuff that really they didn't
21:18 --> 21:19need to go through.
21:21 --> 21:23So, in general, it's a
21:23 --> 21:25highly personal decision.
21:25 --> 21:26It's something that
21:26 --> 21:27we wish we had a
21:27 --> 21:28snap answer for all
21:28 --> 21:28people,
21:29 --> 21:30but it really is something
21:30 --> 21:31that I think is best
21:31 --> 21:32discussed with
21:33 --> 21:34a person and their primary
21:34 --> 21:35care doctor.
21:36 --> 21:37Of course, there's a benefit.
21:37 --> 21:38Right? Because we often find
21:38 --> 21:40aggressive cancers early, and those
21:40 --> 21:41are the ones we can
21:41 --> 21:43treat and cure. And so
21:43 --> 21:44there is tremendous power here.
21:44 --> 21:45So I don't mean to
21:45 --> 21:47be cynical about it because
21:47 --> 21:49screening and early detection is
21:49 --> 21:49what is
21:50 --> 21:50changing
21:51 --> 21:53prostate cancer. Despite our
21:53 --> 21:54treatments getting better and better,
21:54 --> 21:56we are not curing people
21:56 --> 21:58with advanced or metastatic prostate
21:58 --> 21:59cancer. Things are getting better,
21:59 --> 22:00but incrementally.
22:01 --> 22:02We really bend the needle
22:02 --> 22:04and bend the trajectory when
22:04 --> 22:05we find an aggressive cancer
22:05 --> 22:06early before it spread and
22:06 --> 22:08treat it and can cure
22:08 --> 22:09an individual for the rest
22:09 --> 22:11of their life. So imagine
22:12 --> 22:13you have a close friend
22:13 --> 22:14or brother
22:14 --> 22:16who is fifty seven years
22:16 --> 22:17old,
22:18 --> 22:20and says, should I have
22:20 --> 22:21that PSA?
22:21 --> 22:22It sounds to me
22:23 --> 22:24like you'd say,
22:25 --> 22:26I might do it myself,
22:26 --> 22:27but you should talk to
22:27 --> 22:28your doctor because there are
22:28 --> 22:30pros and cons. Is that
22:30 --> 22:31right?
22:31 --> 22:32That's what I would
22:32 --> 22:33say.
22:33 --> 22:34I would
22:34 --> 22:35go back to the evidence
22:35 --> 22:36that having this test
22:37 --> 22:39can, overall has
22:39 --> 22:40the effect of reducing the
22:40 --> 22:41risk of dying from prostate
22:41 --> 22:42cancer.
22:42 --> 22:43And I think that's
22:43 --> 22:44pretty clear.
22:44 --> 22:45And so I would encourage
22:45 --> 22:46those people. But I've got
22:46 --> 22:48family members who I've pushed
22:48 --> 22:48and pushed and they
22:48 --> 22:49say no, and
22:49 --> 22:50I have to respect that
22:50 --> 22:52because, you know, as long
22:52 --> 22:53as that's
22:53 --> 22:54been understood, then
22:55 --> 22:56people should make their decision.
22:56 --> 22:58And is it also fair
22:58 --> 22:59to say that if you
22:59 --> 23:00were talking to your eighty
23:00 --> 23:02two year old great uncle,
23:03 --> 23:05that you would probably suggest
23:05 --> 23:07that he not continue to
23:07 --> 23:08have screening?
23:08 --> 23:09I would, absolutely.
23:09 --> 23:10And that, I think,
23:10 --> 23:11is something that is
23:12 --> 23:13really difficult to navigate, and
23:13 --> 23:14I often see people who
23:14 --> 23:15are older. And the
23:15 --> 23:17question is, well, if I've
23:17 --> 23:19been screened for years and
23:19 --> 23:20years, and as we get
23:20 --> 23:21older, when do you stop?
23:21 --> 23:22And that's a hard
23:22 --> 23:24conversation because when we when
23:24 --> 23:25we suggest to stop, that
23:25 --> 23:26doesn't mean that we're saying
23:26 --> 23:27we don't think you have
23:27 --> 23:29a long life expectancy
23:29 --> 23:30or that your cancer is
23:30 --> 23:31worth finding. So there's that
23:31 --> 23:33stigma that
23:33 --> 23:34you don't think it's
23:34 --> 23:36worth finding this. And it's a
23:36 --> 23:38difficult conversation and to try to
23:38 --> 23:39convey that it's really
23:39 --> 23:41not that. Of course, we
23:41 --> 23:42want you to
23:43 --> 23:44live a long and full
23:44 --> 23:46life, but there's the potential
23:46 --> 23:47for making that life worse.
23:47 --> 23:48And I think that is
23:48 --> 23:48a centering
23:49 --> 23:51point that people get. But,
23:51 --> 23:53that's still tough. There's
23:53 --> 23:54no road map for that.
23:55 --> 23:56Unfortunately, that falls in the
23:56 --> 23:56lap of a lot of
23:56 --> 23:58our primary care doctors who
23:58 --> 23:59are our partners in prostate
23:59 --> 24:00cancer care.
24:02 --> 24:03I had that same
24:03 --> 24:04difficult conversation
24:04 --> 24:06with my mother about mammography,
24:07 --> 24:09you know, and advising her
24:09 --> 24:10as the son who's a
24:10 --> 24:11breast cancer doctor.
24:12 --> 24:13And I can tell you
24:13 --> 24:14that conversation was also a
24:14 --> 24:15little difficult.
24:17 --> 24:17So
24:18 --> 24:19let's
24:20 --> 24:21shift a bit and talk
24:21 --> 24:22about,
24:23 --> 24:24not intervening.
24:24 --> 24:26So someone is diagnosed with
24:26 --> 24:27prostate cancer.
24:27 --> 24:28They've been screened.
24:30 --> 24:30They
24:31 --> 24:33have a biopsy done.
24:34 --> 24:35And sometimes
24:35 --> 24:37I know, and increasingly,
24:39 --> 24:41they're advised, maybe you don't
24:41 --> 24:42need to do anything right
24:42 --> 24:44now. So what's that about?
24:45 --> 24:46That's right. And so it
24:46 --> 24:47all goes back to that
24:47 --> 24:49understanding that
24:49 --> 24:50many of the cancers we
24:50 --> 24:51identify with screening
24:51 --> 24:52are not aggressive.
24:53 --> 24:54And in particular,
24:55 --> 24:57you know, we find these
24:57 --> 24:58lower grade cancers,
24:58 --> 24:59when we go looking for
24:59 --> 25:00them, when we do screening.
25:01 --> 25:02And we have very reliable
25:02 --> 25:03systems for identifying
25:04 --> 25:05which ones are aggressive and
25:05 --> 25:06which ones are not aggressive.
25:06 --> 25:07And so the idea is
25:07 --> 25:09that we can carefully monitor
25:10 --> 25:11those that are nonaggressive
25:12 --> 25:13and offer treatment in the
25:13 --> 25:14future should something change
25:15 --> 25:17while that window of opportunity
25:17 --> 25:18for cure is still there.
25:18 --> 25:19And that is a protocol
25:19 --> 25:21that we call active surveillance.
25:22 --> 25:23And that has also really
25:23 --> 25:25revolutionized our approach to prostate
25:25 --> 25:26cancer because I think it's
25:26 --> 25:27allowed screening to happen
25:28 --> 25:29with a better balance of
25:29 --> 25:30risk and benefit.
25:30 --> 25:31So
25:32 --> 25:33by only treating the truly
25:33 --> 25:35aggressive ones, we are reducing
25:35 --> 25:36the risk of overtreating
25:37 --> 25:39the nonaggressive ones.
25:40 --> 25:41Many people who start on
25:41 --> 25:42active surveillance need to be
25:42 --> 25:44treated eventually, so up to
25:44 --> 25:45fifty percent will eventually need
25:45 --> 25:46some form of treatment.
25:47 --> 25:48But, yeah, I think it
25:48 --> 25:50has really moved the needle
25:50 --> 25:51in terms of reducing
25:51 --> 25:54unnecessary surgery, unnecessary radiation,
25:54 --> 25:56and the associated effect.
25:57 --> 25:59Sure. And I can imagine
25:59 --> 26:00that that conversation is a
26:00 --> 26:01difficult conversation
26:01 --> 26:02as well.
26:02 --> 26:04And I guess the question
26:04 --> 26:05I have is, are more
26:06 --> 26:08people opting for that approach
26:08 --> 26:09than was the case years
26:09 --> 26:09ago?
26:10 --> 26:11They are. Yes. There's really
26:11 --> 26:13been a real change
26:13 --> 26:14over the past few years,
26:14 --> 26:15and it used to be
26:15 --> 26:16where that was a difficult
26:16 --> 26:18conversation and it seemed heretical
26:18 --> 26:20to say, you found prostate
26:20 --> 26:21cancer and you're not gonna
26:21 --> 26:22treat me for this.
26:22 --> 26:23But people have really come
26:23 --> 26:24around to it. So the
26:24 --> 26:26majority of people who have
26:26 --> 26:27a low risk prostate cancer
26:28 --> 26:29are being monitored in the
26:29 --> 26:32United States. At Yale, it's
26:32 --> 26:33much higher than that, near
26:33 --> 26:33the majority.
26:34 --> 26:35And I think people have
26:35 --> 26:36really come around to that
26:36 --> 26:37idea. Believe it or not,
26:37 --> 26:38I don't think it's
26:38 --> 26:39as hard of a conversation
26:39 --> 26:40as it used to be.
26:41 --> 26:42And I think, hopefully, our
26:42 --> 26:44patients are understanding that,
26:44 --> 26:46this is really grounded in
26:46 --> 26:47evidence. There have been large
26:47 --> 26:49trials that have randomized people
26:49 --> 26:51to have surgery, radiation, or
26:51 --> 26:54carefully monitor their prostate cancer.
26:54 --> 26:55And for up to fifteen
26:55 --> 26:57years of follow-up, there was
26:57 --> 26:58no difference in survival between
26:58 --> 27:00surgery, radiation,
27:00 --> 27:01or careful monitoring
27:01 --> 27:03with about a ninety nine
27:03 --> 27:04percent survival in all of
27:04 --> 27:05those groups. And I guess
27:05 --> 27:06the one thing we have
27:06 --> 27:07to remember is that when
27:07 --> 27:09we're doing active surveillance or
27:09 --> 27:11careful monitoring, that does involve
27:11 --> 27:12monitoring.
27:12 --> 27:14And we have to
27:14 --> 27:15have systems to
27:15 --> 27:16make sure that people come
27:16 --> 27:18back and have that
27:18 --> 27:18monitoring
27:19 --> 27:20to keep them from getting
27:20 --> 27:22into any kind of difficulty.
27:22 --> 27:23That's exactly right. And that's
27:23 --> 27:24a challenge. You know, we
27:24 --> 27:26published a paper on that
27:26 --> 27:27last year looking at the
27:27 --> 27:29state of monitoring in the
27:29 --> 27:31Medicare population, and there are
27:31 --> 27:31a lot of folks who
27:31 --> 27:33start active surveillance who do
27:33 --> 27:34not go back for an
27:34 --> 27:37additional test or additional testing.
27:37 --> 27:39And so we are leading
27:39 --> 27:41efforts and really interested in
27:41 --> 27:42ways that we can make
27:42 --> 27:43things better,
27:44 --> 27:45to put systems in place
27:45 --> 27:46that promote
27:47 --> 27:47recall,
27:48 --> 27:49and do this more
27:49 --> 27:50safely.
27:50 --> 27:52So in our last minute,
27:52 --> 27:53if you could just
27:54 --> 27:54comment
27:55 --> 27:55briefly
27:56 --> 27:58about prostate cancer in younger
27:58 --> 28:00individuals.
28:00 --> 28:02In general it's a disease of people who
28:02 --> 28:02get older.
28:03 --> 28:05You talked about screening in
28:05 --> 28:06people fifty five to sixty
28:06 --> 28:07nine,
28:07 --> 28:09but there are occasionally younger
28:09 --> 28:11people with prostate cancer. And
28:12 --> 28:13how common is that, or
28:13 --> 28:15is it just so uncommon
28:15 --> 28:17we shouldn't even talk about it?
28:17 --> 28:18Absolutely. No. it is
28:19 --> 28:20more and more common. We
28:20 --> 28:21are doing more screening in
28:21 --> 28:22younger people, which I think
28:22 --> 28:23is a good thing because
28:23 --> 28:24we are finding aggressive cancers
28:25 --> 28:25earlier.
28:25 --> 28:27It's a very different approach.
28:27 --> 28:28I think the considerations are
28:28 --> 28:29very different for a younger
28:29 --> 28:30person who may be considering
28:31 --> 28:31fertility,
28:32 --> 28:32who
28:34 --> 28:36urinary and sexual function, the
28:36 --> 28:37stakes are a little bit
28:37 --> 28:37different.
28:37 --> 28:39Doctor Michael Leapman is an
28:39 --> 28:41associate professor of urology at
28:41 --> 28:42the Yale School of Medicine.
28:42 --> 28:44If you have questions, the
28:44 --> 28:45address is cancer answers at
28:45 --> 28:47yale dot e d u,
28:47 --> 28:48and past editions of the
28:48 --> 28:50program are available in audio
28:50 --> 28:51and written form at yale
28:51 --> 28:53cancer center dot org. We
28:53 --> 28:54hope you'll join us next
28:54 --> 28:55time to learn more about
28:55 --> 28:56the fight against cancer.
28:57 --> 28:58Funding for Yale Cancer Answers
28:58 --> 29:00is provided by Smilow Cancer
29:00 --> 29:00Hospital.

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A Discussion about Surgical Options for the Care of Prostate Cancer with guest Dr. Michael Leapman

October 13, 2024

email: canceranswers@yale.edu

call: 203-785-4095

12198

Guests

Dr. Michael Leapman

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