Melanie Cole, MS (Host): Prostate cancer will affect one in nine American men and is the second leading cause of cancer deaths. Welcome to Bryan Health Podcast. I'm Melanie Cole. And today, we're joined by Dr. Haris Zahoor. He's a board-certified medical oncologist with Cancer Partners of Nebraska. Dr. Zahoor previously served as an Assistant Professor at the University of Southern California where he specialized in urinary system cancers. So, he's really familiar with this topic.

Dr. Zahoor, thank you so much for being with us today. This is a really, really important topic. Many men and their families are facing prostate cancer. I'd like you to speak a little bit about who is at risk for this disease. Is there a genetic component? Is it sort of a natural part of aging? Speak a little bit about some of these things.

Dr Haris Zahoor: Yes. Hi. Thanks, Melanie, for having me. It's a pleasure to be on this podcast. This topic is close to my heart. So coming to your question, yes, in terms of patients or folks who are at risk for prostate cancer, first of all, I like to tell patients that prostate cancer has a very strong relationship with age. So as we grow older, our risk of developing prostate cancer increases. And it mostly occurs in patients who are above age 50. So, that's one thing to remember.

It's also more common in African American men as compared to white or Hispanic men. And this, perhaps, is related to a combination of dietary and/or genetic factors. In addition to this, African American men also tend to develop prostate cancer at an earlier age and more aggressive or advanced disease. There are many potential explanations for this observation, which I think are maybe beyond the scope of this podcast. But important to remember is that there are some data to suggest that if African American men with prostate cancer receive appropriate treatment, their risk of dying from prostate cancer is similar to white men.

And finally, as you alluded to, yes, there is a strong genetic or inherited component as well. So, I remind patients that if they have a family member with prostate cancer, particularly first-degree relative diagnosed at an age less than 65, they are at increased risk of prostate cancer. And I think it's a good time for a reminder that we should talk about pros and cons of screening with our doctors because that's a very nuanced discussion. And also, keep physicians and their primary care doctors updated about their family history.

Melanie Cole, MS (Host): That's so important, Dr. Zahoor. Now, I would like to touch on screening for just a minute so that people listening know when they're supposed to be discussing this because there are cancer screening guidelines. But the first question that I have for you, Dr. Zahoor, is how can partners get their men in to get the screening? Because this is something that many men do not even want to think about, and therein lies one of the reasons that some men don't get diagnosed until late.

Dr Haris Zahoor: I think, as I mentioned, it's a very nuanced discussion. There are certainly pros and cons of screening for prostate cancer. And my general recommendation is talk to your doctors, discuss about your potential risk factors, as we discussed. There's a family history and other risk factors, maybe some symptoms. So whether it's your urologist, your oncologist or your primary care doctors, I think getting in touch with them, discussing potential pros and cons and finding out if getting screened for prostate cancer is the right thing for you based on your goals of care.

Melanie Cole, MS: So then, tell us a little bit about some of the latest treatments. What's exciting, Dr. Zahoor, in your field? Are they helping men live longer with fewer side effects? Because again, for men, many of the things that they are wary of or frightened of are the side effects of these treatments.

Dr Haris Zahoor: Right. So, this is very exciting times to be alive and seeing the progress of prostate cancer treatments. They have significantly evolved over the last few years, leading to better patient outcomes. And I think due to this, our patients are living longer. If we look at the most recently reported studies, the average survival of stage 4 prostate cancer has improved to more than 5 years and, in some cases, reaching close to 8 years. This was almost unheard of almost 10 years ago.

So, what I tell patients is that we should always remember that we got to this point because of medical research and clinical trials. So, the best treatment for a prostate cancer patient is, in my mind, always a clinical trial, if available and if feasible. And that's why our robust clinical research department, screen every patient who walks into our clinic for a potential research study.

Outside of a clinical trial, there are a few exciting treatment options or treatment paradigms, so to say, which I think I would like to highlight. The first one is treatment intensification. Many years ago, patients with advanced prostate cancer were treated with hormone shots alone. However, the current standard of care is to intensify treatment by adding a novel hormonal agent at minimum, or perhaps adding chemotherapy upfront as well. This treatment intensification has shown to make patients live longer in many randomized phase III clinical trials. Unfortunately, there are studies from real world indicating that this practice has not been adopted still for many reasons. So, that's the first thing.

Now, on the other end of the spectrum, there are some patients who have what we call as oligometastatic prostate cancer, which is slow-growing prostate cancer, may have only spread to one, two or three spots outside of prostate. And these select patients could potentially be spared from treatment intensification. And maybe we can do focused radiation treatment to these cancer spots, if you have the right technology and the expertise from radiation oncology, which we do.

And I would also like to add another treatment option here, and that is PSMA-based treatment. PSMA stands for prostate-specific membrane antigen, which is a protein expressed commonly on prostate cancer cells but typically, not on other body cells. Now, this is actually a very exciting field of theranostics, which is a two-pronged approach to diagnose and treat cancers through radiotracers, generally speaking under supervision of a radiation-oncologist.

The way I explain to patients about this treatment option is that our radiotracer consists of two pieces. One half is a carrier, which travels through the blood to bind to a unique designated target, in this case PSMA and prostate cancer cell, and the other half is a radioactive component. During the diagnostic scan, the radioactive component emits a low amount of radiation that allows us to take pictures of the cancer cells. This is called PSMA PET scan, is FDA approved for select patients and studies have shown to outperform conventional imaging in appropriate setting. And during the treatment phase, that carrier is almost identical. But the radioactive component is different, which releases more powerful kind of radiation that kills cancer cells. And this treatment is called Plovicto and is also FDA approved for advanced prostate cancer patients. We have been providing our patients these advanced novel imaging and treatment options at our clinic.

Melanie Cole, MS: Then, tell us a little bit about that multidisciplinary approach, Dr. Zahoor, because you just mentioned radiation and you're a medical oncologist. There's a lot of people involved when a man has prostate cancer and certainly if he's in a clinical trial or doing different forms of treatment. Tell us a little bit about the importance of this multidisciplinary approach so that you're not just treating the cancer, but you're treating the whole person because also there could be erectile dysfunction, there could be incontinence. Any of these other things means there's a lot of people involved. Tell us about that importance.

Dr Haris Zahoor: Absolutely, yes. So, treatment of prostate cancer has become very complex. It's nuanced, and it does require multidisciplinary input. We actually, in collaboration with Bryan, have a monthly genitourinary tumor board, where we review these cases, let's say, about prostate cancer cases who need this multidisciplinary input.

When I see patients in clinic, I tell them we need all hands on deck. There are many physicians involved in a patient's journey of prostate cancer. For example, a urologist who will perform surgery if that's the route they want to take for their localized prostate cancer treatment; a radiation-oncologist is typically involved in various stages of prostate cancer, and they treat cancer with radiation; medical oncologists like myself are involved in most stages of prostate cancer and we treat patients with systemic treatments like hormone therapy, pills and targeted therapies and chemotherapies. Most prostate cancer patients should see a genetic counselor as well. Because as we discussed earlier, there is a strong genetic component. Up to 10% of patients with high-risk localized prostate cancer or advanced prostate cancer will have a germline mutation, which can be transmitted from one generation to another. And it has implications for both patient and family members.

And you mentioned about the erectile dysfunction and urine incontinence. So, I think that brings us to our physical and occupational therapists, which also play an important role. These patients need pelvic floor therapy, rehabilitation treatment for their neuropathy if they're on chemotherapy and stuff like that. If they are struggling from weight loss and need nutritional support, I send them to our dietician. And finally, social workers also play an important role.

So, I think you can appreciate that a big multidisciplinary team is usually required to treat prostate cancer. And we're fortunate to offer all these services to our patients through our clinic. And when we move into our new cancer center next year, I think we'll be able to offer all these services in collaboration with Bryan under one roof, which is quite exciting.

Melanie Cole, MS: That is quite exciting. So, how can someone with prostate cancer get more information, Dr. Zahoor, or find support? I'd like you to speak about some of the support groups and tell us a little bit about that.

Dr Haris Zahoor: Yeah, it depends on what type of support or information patient is looking for. If they want to look up on any websites, I recommend them to use reliable medical websites. I like Prostate Cancer Foundation. They have good information for patients. Bryan has a Prostate Cancer Support Group, which I think is an excellent resource. They meet every second Thursday of the month at Bryan West Campus. I'm one of the speakers, and I really enjoy speaking to them about new treatment options once a year. And finally, if there is a specific medical question, we're always available for second opinions.

Melanie Cole, MS: This is great information. And as you said, Dr. Zahoor, it's an exciting time for advancements in your field. Wrap it up for us. What would you like listeners to take away? The key messages. Give us your best advice for men that are either worried about prostate cancer or have been diagnosed and what you would like them to know about what you can do for them.

Dr Haris Zahoor: You know, I think my message is every prostate cancer patient should be seen at a place where they can obtain a multidisciplinary input. They have the resources, they have the research, clinical trials, and all the ancillary services which we discussed. I think that will be my key message to the patients.

Melanie Cole, MS: Thank you so much, Dr. Zahoor, for joining us today. And for more information, I'd like to encourage the listeners to visit bryanhealth.org/prostatecancer, where you can learn what you need to know and who to contact. I'd also like to thank our Bryan Foundation partner, Sampson Construction. And to listen to more podcasts from our experts, you can always visit bryanhealth.org/podcasts. That concludes this episode of Bryan Health Podcast. I'm Melanie Cole. Thanks so much for joining us today.