Men's Health Awareness and the Movember Campaign

Welcome to Yale Cancer Center Answers with your hosts doctors Anees Chagpar, Susan Higgins and Steven Gore.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital.  Dr. Higgins is Professor of Therapeutic Radiology and of Obstetrics, Gynecology and Reproductive Sciences and Dr. Gore is Director of Hematological Malignancies at Smilow and an expert on Myelodysplastic Syndromes.  Yale Cancer Center Answers features weekly conversations about the research diagnosis and treatment of cancer and if you would like to join the conversation, you could submit questions and comments to canceranswers@yale.edu or you can leave a voicemail message at 888-234-4YCC.  This week it is a conversation about men’s health issues with Dr. Thomas Martin.  Dr. Martin is a clinician in urology at Yale School of Medicine.  Here is Dr. Susan Higgins.

Higgins Dr. Martin, thanks for joining us tonight. I am really looking forward to speaking about mens health issues with you.  We have a campaign that I think some people know about but I would really like to have you fill us in on, what is Movember?

Martin Movember is a campaign which was started in Australia about 10 years or so ago and Mo is the Australian colloquial term for moustache and it started with a couple of guys who were interested in advancing and raising awareness of men’s health issues and so it is kind of something that has snowballed internationally at this point.  It certainly has a big presence here in the United States and again, towards those ideas of raising awareness both in a small way with individual men and in a systemic way with large groups on the importance of men’s health.

Higgins There is a moustache movement that goes with this so that people are aware of what is going on.  Can you tell us a little bit about that?

Martin That is exactly the point, that the participants grow moustaches and it kind of has the effect almost of the pink ribbon that you see for breast cancer awareness and the idea is to provoke people to ask the question, what is that all about? And then to be able to give an explanation and raise awareness just in a small way in individual people that you meet, and what the campaign is actually about.

Higgins A lot of people know about prostate cancer, and that is one of the main things you clinically focus on, but it has a broad scope right, it is all about men’s health and awareness of multiple issues.

Martin It is, it is not just prostate cancer and it sometimes can be pigeonholed that way and yet men’s health is a much broader area in the sense that it involves general prostate health. In a lot of men, as they age, they will have enlargement of the prostate which can provoke a variety of urinary symptoms, also testicular cancer, it certainly covers testosterone issues which affect men as they 

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age and also has taken on an interest in mental health issues, depression, suicide, which affect men to a great degree as well. Higgins This is great because I think that these are topics that are lurking in the back of the mind of a lot of men when they go to their physician and it sounds like part of what this is doing is opening that dialogue.

Martin That is exactly right.  When you look at how men access healthcare, most men through their teens while they are still being cared for by their pediatrician, they tend to access healthcare through their parents and as they reach adulthood, there is a big drop-off in the willingness of men to reach out to their healthcare professional and yet there are a lot of issues that arise in those years and so there is this plummet of men accessing healthcare through their 50s at which point oftentimes, their wives drive them to seek care and the idea is to bring these issues to the forefront because men in general, and this is a little stereotypical, but when faced with the choice, will avoid healthcare and we want to make sure that they know that it is an issue that if they are experiencing problems that they need to be plugged in about.

Higgins It is interesting that you mentioned this issue of healthcare and the age determinant.  Women have a gynecologist that they see on a regular basis and they are plugged into that throughout their 40s and 50s and into their 60s whereas men do not have that structure in their healthcare, so this is a great way to get the word out and to get them to their physician and then when they come to the office, how do you approach these issues with the patient?

Martin There are a variety of different ways and in some instances, when patients come in you have to let them just talk because oftentimes the issues will bubble to the surface and if you give them an opportunity to tell you, they will tell you if you give them a chance to talk and are willing to hear what they have to say and often you will have a patient who will come in and have a kidney stone and he gets to the end of the appointment and say, Oh! doc, what about this sexual dysfunction problem or this urinary issue that I have and it was kind of lying there but you just have to be receptive to the idea of hearing it, so there is that element of it and then I think it is also the public awareness on the part of the guys to know that those are issues that are worth talking about and not feel like they have to bottle it up.

Higgins And there is some screening, obviously PSA screening, and I wonder what the compliance is with that and how do you get people engaged in PSA screening?

Martin PSA is such a hard topic in the first place because there is such a wide disparity in what you read about it in the popular media and so on and even what the various Government panels put forth.  On the one hand, what I usually explain to my patients is that it is very clear that PSA is a good 

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test if you are interested as a patient in decreasing the likelihood of dying of prostate cancer.  The trickier part for patients is understanding the downside of screening which includes the false positive risks of screening where the test will suggest there is a problem and it turns out there is not, or also in the case of prostate cancer, sometimes diagnosing cancer that maybe would not threaten the patient and so those balances are things you have to have an informed discussion with patients about and find out what they want to accomplish.

Higgins I think we as clinicians think of urologists in terms of lots of the procedures that they do but I know, having treated prostate cancer patients, that when it comes to PSA or any issue of prostate cancer, there is so much grey that it actually takes a lot of time in the office to get people to understand those issues and work through them in their own mind so they can make a decision.

Martin It is, again, if you use the controversy in the press as an example of it, there is an awful lot to argue about, and obviously the ultimate goal would be to have a better test but the other question is, are there ways to make the test that we have now, the PSA itself, better? How can we interpret it more wisely, the variety of different parameters there, how do we evaluate the abnormalities better so that we avoid the false positives and that we also at the same time find the cancers that are really important to find? And so that is one of the things I think where you will see urology growing, certainly where you see it growing in Yale, interpreting PSA in a wiser way.

Higgins Because it is not just the number but it is the velocity, how fast it is rising and then putting that together with a clinic picture and then of course sitting down and trying to explain the complexity of that to a patient, it actually takes quite a bit of time.

Martin It does, because there is such a variability in terms of all of those issues from patient to patient and they all have a story where they will come in and say, well I have a friend who had prostate cancer with a PSA of such and such and mine is the same and why is my situation different, and it may be based on the nature of the tumor that they have or the age of the patient or a variety of other different factors and so there it is and it is something that we have to kind of be very patient in terms of walking each patient through that and it is a time consuming process for sure but it is a necessary one.

Higgins I think we have a similar trend that we probably are a little ahead of the curve with prostate cancer but in breast cancer we are always explaining how breast cancer is really many diseases, some more aggressive, some less aggressive, some more of a threat to health and some less, and so I think this is where prostate cancer is going now, how to sort it out with imaging, PSA, etc.  I do not know if you are involved with some of the imaging studies that are being done?

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Martin As far as the variety of treatments, there is a large movement towards active surveillance which means monitoring but not necessarily initially treating a cancer and again that is something for patients that is sometimes very anxiety provoking and they will say, I have got this cancer and we are just not treating it? It seems counter intuitive to them and it takes a major educational effort to help them be comfortable with that if that is something that fits their needs as we educate them about it.  The other question about the imaging is both in terms of detection and in terms of treatment. Preston Sprenkle is doing some really nice work in our department with MRI both in terms of using MRI to help make the PSA a better test, guiding biopsies better, but MRI also is useful in terms of planning treatment once the cancer is diagnosed and also is useful in following patients who choose active surveillance, and so you are right, the ability to image and actually see the cancer, which is not something that we had 10 years ago and this is a place where prostate cancer care changes so much.

Higgins And you will be of course struggling with the thing that we struggle with in breast cancer, which is the false positives and false negatives and that is a whole other conversation that you have with the patients.  There is some anxiety that goes with this testing and then interpretation of the results and if you are going to undergo this test you have to know that no test is perfect.

Martin There is no doubt that anxiety is one of the things that critics of the PSA bring up and it is something that we have to work through with patients once they have embarked on the decision to be screened and tell them they are going to have to tolerate some degree of anxiety.  The interesting thing is that with guys especially, they oftentimes are willing to bottle that up and not be tested just to not worry about it and then the question always is, is the anxiety of being screened in fact a lot less of a bother than the anxiety of dealing with a big problem that blows up for lack of being screening at a later date, and you have to walk patients through both sides of that story.

Higgins We see this in the breast cancer world, and I just had this conversation with a patient the other day, that when they are thinking about mastectomy, they are not actually making these choices based in part on the anxiety that will come in days and years to come with biopsies and surveillance so we have a little bit of a double edge sword with the surveillance and we are all dealing with that.

Martin It is one of the things that when you have a patient who has a biopsy that comes back positive, you have to counsel him about if you are inclined to be monitored, there is this worry that is going to go along with it and you have to be prepared for that and it is difficult in advance to tell them about the worries of treatment as well because they have not gone through the side effects 

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or things of that sort, but in some instances you have to try to predict the future for them to a certain degree so that they can kind of compare and contrast when they make their decision as to how they are going to proceed, so it is a difficult project at times.

Higgins And I think this is the art in science, as a clinician knowing how to present the issues so that it is helpful, but not so fear inducing that people do not come back and get screened, because this is something we are really seeing, that the anxiety is another symptom to manage and it really does affect someone’s health care.

Martin And that I think is one of the benefits of this campaign, men operate sometimes in the realm of the problems that they are experiencing as they are the only ones who have the problem and this campaign is something that lets them know that there is a whole world of guys out there that have the same problems and you are not the only guy and we can walk you through it and you will be walking with guys who have got the same issue.

Higgins That is great, and I cannot wait to speak to you a little bit more about this Movember campaign, but right now we are going to take a short break for a medical minute.  Please stay tuned to learn more information about Movember and the new advances in prostate cancer diagnosis and care with Dr. Thomas Martin.

Medical Minute Breast cancer is the most common cancer in women.  In Connecticut alone, approximately 3000 women will be diagnosed with breast cancer this year and nearly 200,000 nationwide, but thanks to earlier detection, noninvasive treatments and novel therapies there are more options for patients to fight breast cancer than ever before.  Women should schedule a baseline mammogram beginning at age 40 or earlier if they have risk factors associated with breast cancer.  Clinical trials are currently underway at federally designated comprehensive cancer centers such as Yale Cancer Center and at Smilow Cancer Hospital at Yale-New Haven to make new innovative treatments available to patients.  Digital breast tomosynthesis or 3D mammography is transforming breast screening by significantly reducing unnecessary procedures while picking up more cancers and eliminating some of the fear and anxiety many women are experiencing.  This has been a medical minute brought to you as a public service by Yale Cancer Center and Smilow Cancer Hospital at Yale-New Haven.  More information is available at yalecancercenter.org.  You are listening to WNPR, Connecticut’s Public Media Source for news and ideas.

Higgins Welcome back to Yale Cancer Center Answers.  This is Dr. Susan Higgins along with Dr. Thomas Martin.  He is our guest tonight and we are talking about recent advances in prostate 

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cancer, diagnosis and care and in particular we are focusing on the Movember campaign.  We just discussed how this Movember campaign can really help open a dialogue between the patient and their doctor on an individual basis but it also opens the dialogue on a bigger stage and allows men to get together and advocate for themselves, for funding, and sort of on a more global level, maybe you can talk about what the history of men’s advocacy for their health issues has been and how that is changing?

Martin The history has not been great in terms of men’s willingness to advocate for themselves.  It was a big deal, if you remember, when Senator Dole years ago talked about his prostate cancer treatment and that raised a little bit of awareness but men as a group have not done a great job at this and if you have watched an NFL game this month then you see the guys all wearing the pink gloves and the equipment with pink and so on for breast cancer awareness and you realize how women have done such a great job advocating for themselves and what it also emphasizes in comparison is how poor a job the guys have done and notable is that the Affordable Care Act has over 130 mentions of women’s health issues and 2 about men’s health.  Funding as far as women’s cancer outstrips men’s cancer funding research by a factor of 15 or more and so part of the idea of this campaign is that through awareness and through men’s willingness to speak up and advocate for themselves, that these things begin to turn around, but again, guys being less willing to speak up about these issues, they hold them a little closer and that is what this is important for.

Higgins I see the correlate in women’s health community in that I treat gynecologic cancers and some of this I think is human nature for men and women.  If it is below the belt, then we do not talk about it, it is private and so when we think about urology, people’s minds automatically goes to sexuality and intimacy and erectile dysfunction and all of these things that even though we have the people in the bathtub on the Cialis commercial, people still do not want to talk about it.

Martin And that is the idea.  I have a patient who is actually a pastor here in New Haven who talks with the men in his parish about it and says that there are more things to being a man than just that part of it and you have to put them in the perspective of saying, part of being a man is taking care of yourself so you can take care of others and there is help for those more personal issues that go along but you have to keep yourself alive and healthy in order to do those other things and it is an effective message that he uses and so I think that those are the kind of things that we try on a bigger level to emphasize to the guys to get out there and be advocates for each other and for those issues as a whole.  

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Higgins And I think by putting it in the context of men’s health helps people, it is not just prostate health, there are other issues and it is more of an encompassing topic that you can engage the patient in and I think there are other things, like low testosterone and we talked a little bit about testicular cancer.  These are all important health issues that also go into this Movember campaign concept right?

Martin That is right.  Low testosterone is an issue that affects nearly every man as they age. Our testosterone will pretty steadily in almost every case decline as you age at different rates for different men, but it can provoke a variety of symptoms, sexual dysfunction being one that perhaps the guys notice the most, but there are a bunch of other things, muscle mass, energy level, things of that sort which also can be affected and so awareness of those things, we think, helps give the guys the kind of gumption to get up and get those things checked out.

Higgins What about testicular cancer? People I think are still in the dark about that issue and I wonder what people are doing about screening and do they encourage self-exam, what is the current state-of-the-art management?

Martin It is definitely something in this campaign that we try to emphasize because again, it fits that population of guys where they start to fall out of their health care system for a period of time based on their age.  It is after they leave their pediatricians and before they maybe hook up with a family doctor when they are in their 40s, that is when testicular cancer has its highest incidence and so campaigns like Movember, which have tried to be aimed at the younger guys a little bit, sometimes you will see their emphasis on that age group and it strikes home for those guys and it really has its potentially greatest impact on those guys because they are in that spot in the healthcare system and that is a bit of a gap for them and so if they are aware of it and checking themselves periodically and can receive information about how to do that, it is an important step.

Higgins Especially in regard to testicular cancer, it is highly curable especially at an early stage and I think initially a lot of men are not aware that catching it early, treating it early, have very well tolerated treatments that are really very effective.

Martin It is very treatable and in fact, such a highly curable disease, and it was one of the things that obviously Lance Armstrong pointed out, all of the issues otherwise aside in terms of the competitive things that he has been accused of, but this guy had testicular cancer in a pretty bad way and is living a life that is a high quality achieving life and did so because he was very well treated and had the problem found and dealt with it and that is I think a good example for people to know about, all of the other scandalous things aside is that here is a guy who is healthy and well because he got on the problem and took care of it at a young age.  

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Higgins My understanding was he even had relatively advanced disease, so it was a real success story in terms of cancer treatment.

Martin Testicular cancer in a lot of ways is one of the miracles of modern oncology in the sense that patients who had disease as advanced as he had it are cured and it is something that we do not want guys to be afraid of, that their first instinct is a death sentence and it need not be.

Higgins And when someone as famous as Lance Armstrong or some other celebrity steps up to the plate and talks about something as personal as that, it seems like that was a real turning corner for testicular cancer in terms of its global awareness, or at least in the United States.

Martin No doubt, it is helpful to see someone step up there and show that and be willing to share the fact that they have had a problem, that can be a sensitive one obviously and they have confronted it in a public way which kind of takes away some of the sensitivity issues and it is an enormous help I think in terms of how the average person likely gets it.

Higgins And again the Movember campaign hopefully will be getting people to talk with their doctors about this.  I did want to talk about the fact that you are going to be part of the lecture series that Yale-New Haven Health is sponsoring and you will be discussing on November 16, 2015, advances in prostate cancer diagnosis and care and there are 4 talks by Dr. Honig, Dr. Hess and Dr. Walker who will all be discussing various topics and that will I believe be held at the hospital, correct?

Martin They are throughout New Haven County. Actually, it is Old Saybrook, Hamden, New Haven and around the entire area.

Higgins They will be basically going over all these issues that men want to know about and I see one of them is called, everything men want to know about male urology but are afraid to ask, and that is almost the summary statement for our discussion because a lot of this is starting a dialogue.  Now what about people who are outside of this system, you talk about this gap, how can we get men engaged with their doctors? Do the primary care doctors need to refer them, how do we get them engaged with you?

Martin There are a variety of different ways to access the system.  The hospital has been very generous over the years in terms of doing free screenings for a variety of different things and I think if you keep your ear to the ground you can very readily become aware of those things.  I think again some of it comes from patient initiative.  You have to be willing to step up to your primary 

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doctor or urologist if you have one and identify the problem.  I think we have to make sure we do a good job listening when patients are trying to give us a hint that something is going on and so I think we all have to do a job, I think it is incumbent on us to be welcoming in terms of the discussion and hopefully efforts like this on a big scale do a good job communicating with patients that we’re ready to listen to what they have to say.

Higgins I am just curious, how many primary care people are actively engaged in doing PSA screening? Is that something that has kind of been in their domain and you are struggling with how you divide that responsibility up?

Martin Most of our patients who we evaluate, for instance for PSA screening issues, PSA especially, come to us from their primary doctors and I think that it is a difficult problem for the primary doctors because it is such a complex issue and yet in a course of a yearly physical you have got a limited amount of time and we have talked about PSA now for 15 minutes and at the same time, the primary care doctor has to talk to you about your cholesterol, your heart disease and every other thing, so it is difficult for them, and in a lot of instances, it is something that we want them to be able to address, the primary care doctors, with patients, but we also want the patients to know that it is something they can ask about and if they are not being screened, why, and if they are being screened, is it something they really want to do and so it has got to be a little bit of a two way street in the sense that both parties have to be plugged into it.

Higgins Let’s say they come to you with a slightly elevated PSA, it sounds like if you are able to open up the conversation, they will start talking about things that I think for many men are even more personal, like erectile dysfunction.  I would imagine that is not necessarily the first thing that comes up, but you get to that after maybe going through some levels of other healthcare issues. How does that get discussed and what types of therapies do you have for that?

Martin You are right.  It oftentimes comes up in the context of a bigger discussion and hopefully you have developed enough of a rapport with patients that they feel comfortable bringing it up and then in terms of evaluating it, it is a pretty intensive evaluation in the sense that it involves talking about their history and what is involved in terms of the actual symptoms.  It involves looking at the patient’s history of other problems, diabetes, heart disease, neurologic conditions, all have an impact on erectile function, so each of those has to be considered.  We have to look at things like a physical exam that may provide clues as to why the patient has erectile problems and then oftentimes there is a series of laboratory work that has to be considered and the treatments are very far flung.  They can range from the things that your audience knows well from just watching again those NFL games, and all those commercials that come on during the games or the evening news in terms of the pills, to treatments that are a little bit more 

28:01 into mp3 file https://az777946.vo.msecnd.net/cancer/2015%201108%20YCC%20Answers%20-%20Dr%20Martin_237053_5.mp3sophisticated in terms of medications that can be given by routes that are different than pills to ultimately surgical treatments and so there is a big spectrum, but again, it is a process and you have to walk the patients through it in terms of understanding what they want to accomplish.

Higgins And obviously it sounds like partnering with their primary care doctor to address these what we call comorbidities is an important part of that.

Martin Absolutely, it is the guy who comes in to see you and has erectile problems but really poorly controlled hypertension or elevated cholesterol or things of that sort, that is a guy that we have got to pay attention to and actively enlist the primary care physicians to help us with and so yeah it is definitely a team game to a significant degree.

Higgins And I think one of the things that we as Americans are always walking around with and what we do not want to think about is vascular disease and that is a big part of this and it is really total health means total body care.

Martin It does, we try to be aware especially in some of the patients who come in without diagnoses of coronary disease, heart disease or vascular disease that their erectile dysfunction may well be a tip that there is some other maybe bigger problem and so we have to do a good job being aware of that and make the appropriate referral for evaluation.

Dr. Thomas Martin is a Clinician in Urology at Yale School of Medicine.  We invite you to share your questions and comments, you can send them to canceranswers@yale.edu or you can leave a voicemail message at 888-234-4YCC and as an additional resource, archived programs are available in both audio and written form at yalecancercenter.org.  I am Bruce Barber hoping you will join us again next Sunday evening at 6:00 for another edition of Yale Cancer Center Answers here on WNPR, Connecticut's Public Media Source for news and ideas.