Jaime Lewis (Host): Prostate cancer is the most common cancer and the second leading cause of cancer death among men in the United States. But surgical procedures for prostate cancer are becoming more sophisticated and less invasive. Today, we'll speak with two experts about how medicine is advancing in the field of prostate health.

Alison Sachs specializes in oncology social work and she is the Community Outreach Director for the Eisenhower Health Lucy Curci Cancer Center. And Dr. James Hendricks is a Board Certified Urologist specializing in laparoscopic urology and robotic urology. This is Living Well with Eisenhower Health. Healthcare as it should be. I'm Jaime Lewis. Welcome, Alison Sachs and Dr. James Hendricks. Thank you for joining us.

James Hendricks, MD: Thank you.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Thank you for having us.

Host: Alison, you are the Community Outreach Director for the Lucy Curci Cancer Center. So let's start with an overview. Can you tell us a little bit about the Eisenhower Health Prostate Cancer Program?

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Sure, I'd be happy to. You know, at the Lucy Curci Cancer Center, we have a, a tagline that really fits us and the whole team that we work with across the healthcare system for Eisenhower. And that's a healing place like no other. So along with board certified exceptional physicians, like my colleague sitting next to me, Dr. Hendricks, we also recognize the needs of patients when it comes to their, what we like to call, psychosocial needs of them and their family members and loved ones. So our program is all encompassing. It's the medical aspect, but we don't forget the emotional and supportive and spiritual aspect of helping patients walk that cancer journey.

Host: How prevalent would you say prostate cancer is in our population?

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Wow, well I think I'm going to punt that over to Dr. Hendricks. I mean, certainly in the desert, we skew a little older here and prostate cancer tends to be diagnosis of older gentlemen, but I'm not really sure, Doc. I don't have numbers.

James Hendricks, MD: I mean, it's one out of six men in the U.S. will get prostate cancer at some point in their lifetime. Clinically significant prostate cancer remains, meaning it can affect their lives, usually that's, like, Alison, is correct, it's usually in the older generation, usually most people are in the 70s, 80s, but we see it earlier, as well, but it's more prevalent the older you get.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: And also, I understand, Doctor, it seems to be more prevalent in the Black community. Is that, or do we see some higher numbers with African American men?

James Hendricks, MD: It's a little bit more prevalent and especially it's more aggressive with African American men.

Host: Alison, does Eisenhower provide prostate screening?

Alison Sachs, MSW, LSW, OSW-C, FAOSW: We absolutely do. That's what, again, Dr. Hendricks and his colleagues, what they do. Also understand family medicine, primary care doctors, the screening for prostate cancer has guidelines, that they follow. And again, that's a, that's a medical decision. I'll let Dr. Hendricks share what those screening guidelines look like.

James Hendricks, MD: So yes, the primary care doctors and the family doctors, they're the gatekeepers, they're the ones who do the primary screening based on what we recommend. And if there's anything, if anybody has an abnormal screening, then they usually refer them to us. So but the guidelines are changing. Just recently, basically, anybody with a high risk of prostate cancer, meaning an African American, or strong family history, we recommend screening with a blood test, the PSA, starting at the age of 45. Some can even do one PSA test at the age of 40 if they want to, it's up to the doctor and the patient, and then for the general population, we recommend start screening at the age of 50.

And when screening is generally a PSA, which is a blood test, you go to the lab and you just do a routine blood test, as well as a physical exam, which involves a digital rectal exam, which is where you palpate the prostate with your, with your finger.

Host: So Dr. Hendricks, some more information. Once a patient is diagnosed with prostate cancer, what are the treatment options?

James Hendricks, MD: So, prostate cancer is sort of, very complex disease that we have. There's different risks. It all depends on what the risk category is and the age and general health of the patient. You know, there's, there's low risk prostate cancer, which is slow growing. The general treatment for that is much different than somebody with high risk cancer.

So low risk cancer means basically that there's low risk this is going to affect how long you live. So the recommendation generally is what we call active surveillance, where we don't actually treat it, but we watch it very closely. If things change, and it looks like the cancer is growing over time, then we, we're more aggressive about recommending some form of treatment. Intermediate risk and high risk prostate cancer, those generally, we offer treatments with the, with curative intent, meaning we want to cure them of their cancer. So, in general, the two main, there's many, many different treatments. The main two treatments are either surgical therapy, or some form of radiation therapy.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: And you know, I want to jump in here too, Jaime. I think the doctor hit on something that there's really been a change in the verbiage that's used. You know, I often joke with our patients and our physicians that they speak doctorease and we need sometimes to do some communicating, Doctor used the term active surveillance, and then he's absolutely right. And for those listening, they may have heard the term watchful waiting in the past. And that is what it was called years ago. But you can imagine the anxiety just that term brings. Watchful waiting. What are you waiting for? And so, they see change in the use of the words important. Now it's called active surveillance.

They're not just sitting back and waiting. They're actively surveying these patients, whether that's repeat PSA blood tests at a certain level. I mean, at certain intervals, there's very different ways now that they're actively following patients to see has anything changed? Do they need to move from the active surveillance stage into the treatment stage? I think that's an important point.

Host: Yes, that's an important distinction. I would love to talk about robotic surgery, Dr. Hendricks. So how is robotic surgery different or better than traditional surgery?

James Hendricks, MD: Just like most other surgeries that general surgeons do and gynecologists and us, it's, basically, doing surgery through smaller, much smaller incisions, so that there's quicker recovery time, and less trauma to the patient overall. The traditional form of surgery is to do, make a incision, in the lower part of the abdomen and remove the prostate. That way, now we, we started doing it laparoscopically in the early 2000s and then the da Vinci system came out in about 2001, 2002. And since then, you know, back then, even up until 2006, 2007, 95% of prostate cancer surgery was done open and 5% was done robotically. Now it's completely flipped.

So it's over 95% are done robotically and less than 5% are done open. And the reason for that is it's, in general, it's just that it's a better operation. The main two advantages are; there's less blood loss by far, used to transfuse probably a third of people that had a radical prostatectomy needed to have a blood transfusion.

Now it's practically zero. And they get out of the hospital, much quicker, you know, one night, sometimes home the same day. We usually stay in the hospital one night, which used to be three or four nights in the hospital, and they have a urinary catheter in the bladder, which stays in for, usually five to seven days. Robotically, open surgery, they need a catheter, which is a tube that goes through the penis into the bladder to drain the urine. They need a catheter for two or three weeks after open surgery. So, the recovery is faster, have a catheter in for longer, they're in the hospital shorter. In terms of cancer cure and complications, the main two complications being, or side effects being urinary incontinence and erectile dysfunction.

They're pretty equivalent between the two types of surgery. I can tell you in general, I can tell you as a robotic surgeon now, I'm able to better spare the nerves to the penis that are behind the prostate that save erections. I'm better able to do that robotically than I was open just because it's a more accurate procedure and you can see much more detail and you can better save the nerves. Some people say they do just as well open, but I don't, I do it better robotically, so. But those are the main advantages. I think I covered the important ones.

Host: Well, also for you, Dr. Hendricks, do all prostate cancer patients require surgery?

James Hendricks, MD: It's always a discussion with the patient, and it depends on, surgery is not the only option, but radiation obviously is also an option. You can do radiation in either external beam, or you can do intense, IMRT, they call it, or they can have brachytherapy, which is where you put seeds in the prostate, or a combination of both.

So a lot of candidates, that people that are candidates for surgery are also candidates for radiation. It depends on patient preference and what side effects they're willing to accept because the side effect profile is different for radiation than it is for surgery. Radiation patients tend to have not as much problems with erections after right away, like after surgery, but they can get worse over time. Urinary symptoms can get worse with radiation more so than with surgery. The leakage and incontinence is less, but people can have trouble going to the bathroom, they go more often, they have a weaker stream, things like that.

So, but a lot of it is patient preference. A lot of patients have friends or family that have had one or the other, and they had a bad experience, and they go, no, I don't want to do that, I'd rather do the other, so.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: You know, Dr. Hendricks in the prostate cancer information and support group, I often hear the gentlemen and their significant others, talking about the fact that, if they're, they're younger, they skew younger age, and if they have radiation up front, should there be a recurrence or an issue down the road, it kind of takes surgery out of the picture because it's very difficult, if close to impossible, to operate on radiated tissue. So is it fair to say that surgery for younger men would tend to be the better choice?

James Hendricks, MD: Again, it depends on their overall health and their other medical issues, prior surgeries, things like that. But, yes, in general, especially if they have aggressive disease, it's better to do surgery. Especially up front. We always tell people sometimes, especially if they have aggressive disease, sometimes you need more than one treatment, sometimes you need a combination of treatments.

So you take the prostate out and they have a positive, say there's a positive margin, meaning there's cancer left behind or if the cancer comes back locally in the future, they can always have radiation added on to that. It's not a problem. If you have radiation first, what she says is absolutely true, it's very difficult to do prostate surgery, it's like operating on cement, so the risk of erectile dysfunction is basically 100%, and the risk of having urinary incontinence is as high as 50%, which is leaking urine, having to wear diapers, so that's really that's a very important point.

So, yeah, for younger men, more aggressive cancer, especially, we push more towards surgery than radiation because of that.

Host: What are the potential risks and complications associated with robotic prostatectomy?

James Hendricks, MD: Just like any other surgery, the main risks are bleeding and infection. There's a risk that you could have bleeding, which would require a blood transfusion, which is very low. There's the risk that you can get, anytime you have to make a incision in the skin, there's a risk that you can get a skin infection, or you can get a urinary tract infection from the catheter going in and out. And then there's a risk, like any other surgery, there's a risk that anything close to the prostate or any abdominal cavity could be injured during the procedure, which is extremely rare. I don't think I've ever had to deal with that ever, in the past. Sometimes, if you injure something during surgery, we can repair it during surgery.

For instance, like, there's a small chance you could put a hole in the rectum. We give patients a bowel prep. If we put a hole in the rectum and we see it, we can close it right on the spot. Not a problem. I've seen that. I've done that a couple of times. Rarely, rarely do you need to have a colostomy to divert the stool away if that happens.

But again, these complications are all rare. The main, biggest ones that we see more frequently is the risk of blood clots in the legs. We do things to prevent that. Those are easily treatable. And then it's just the risk of general anesthesia.

Host: How long does a robotic prostatectomy typically take?

James Hendricks, MD: It's completely dependent on the surgeon. But generally between, I'd say, overall time asleep, anywhere from an hour and a half to six hours. It depends on how, actually, how aggressive the cancer is too. Some surgeons, some prostates are, very easily operated on. Some are very, very difficult.

So, I've ranged anywhere from an hour to seven hours. But the patients that have it are very difficult anatomy or prostate. So, but the recovery time is the same regardless of how long the surgery is and the outcome, the cancer cure rate, the blood loss, everything else is equivalent.

Host: What is the recovery time?

James Hendricks, MD: Generally, like I said, out of the hospital, the next day. Sometimes the same day, there's actually new techniques coming out where we actually can do prostatectomy through a single port, not just multiple ports. Hopefully we'll do those soon here at Eisenhower. Only a few big medical centers in the country are doing that and those patients can go home the same day.

And generally they're up walking the next day. A catheter comes out in a week and they do full activities. Usually tell them to wait a month, but a lot of people, are fully active in two weeks. I had one patient who was a big game hunter, and he went hunting elephants in Africa two weeks after his surgery.

Host: Oh my goodness. Not typical.

James Hendricks, MD: Not typical. He's a very healthy, energetic fellow.

Host: Well, are there side effects or changes in bodily function after the procedure? You touched on this, but what about on an average level?

James Hendricks, MD: The main risk that people worry about the most is erectile dysfunction, and that's, you know, if you spare both nerves, the chance of them having an erection sufficient for sex, with or without the use of Viagra or Cialis is about 80%. If they have aggressive disease and we have to take one or both nerves out that go to the penis, then that goes down dramatically.

But we also treat that. The other risk is obviously urinary leakage or urinary incontinence. Usually, when you cough, sneeze, you can get a few drops leaking out. The risk of that long-term, is less than 5%. Most people within six months are either wear one pad that they rarely, hardly ever have to change, or zero pads.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Dr. Hendricks, is it common or do you recommend Viagra or Cialis prior to surgery to ensure good strong erections that are use so that you have full or hopefully have full use?

James Hendricks, MD: If they have, if patients have normal erections before and they're sexually active, then we don't recommend that. But if they are having trouble getting erections and if Viagra helps them, then yes, I would treat them with that beforehand. But if they don't get erections beforehand, they're definitely not going to get erections after.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Right.

James Hendricks, MD: But we treat that also, and we have ways to get men the erections back, regardless.

Host: Are there specific guidelines to determine if someone is a suitable candidate for robotic prostatectomy?

James Hendricks, MD: Generally it's just the, the age, the life expectancy of the person. So the age, obviously you don't want to do somebody who's overly obese. Surgery is much more difficult in obese patients, but generally a life expectancy of more than 10 years, and they need to be a good candidate for general anesthesia.

If they have a heart condition or something, they're at risk of having a heart attack, we're not going to do surgery on that patient. So those patients are more, we recommend more radiation than we do, surgery. If their life expectancy is less than 10 years, then again, we wouldn't offer it.

Host: What kind of training does performing the procedure require?

James Hendricks, MD: Nowadays, most residency programs for urology, the doctors in training with the robot these days. When I was in training, it was all done open, so, and we started doing laparoscopic prostates without the robot, in the late 1990s, uh, when I was in the Navy Medical Center in San Diego, and then we just, I just trained on the robot, and did a cadaver, and started doing cases.

 But we had done, many laparoscopic prostates before that. So a lot of residents, residents all get trained. A lot of them will be part of cases, but they don't actually do much of the case during their training. So depending on where people go, the training is very different. Some people come out of residency, being able to do this very easily.

Some of them uh, it's more challenging because they did not do that many cases.

Host: What are the pre op and post op requirements for, for a robotic prostatectomy?

James Hendricks, MD: The pre op requirements is that they're a healthy patient, that's going to, that's going to benefit from the surgery and that's willing, obviously. The after, I don't know how to answer that question.

Host: Well, any instructions for when you, when the patient is discharged?

James Hendricks, MD: Other than taking care of their catheter and, you know, not doing anything overly strenuous for about a month, they can generally go on with their lives. And we just, instruct them if they have any, any leakage at all when the catheter comes out, we train them to do pelvic floor exercises too also come similar to Kegels to increase the rate at which they become no longer incontinent or dry, get off pads.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Very little pain.

James Hendricks, MD: Pain wise most people maybe take some pain pills for a day or two at the most. But I say the average number of pain pills people take like Norco or Hydrocodone is less than 10 tablets total after surgery.

Host: Fantastic. Okay. What is the long term prognosis and what's the success rate of the procedure in treating prostate cancer?

James Hendricks, MD: It all depends on how the patients are selected. If they're a good candidate for surgery, they're, the chance of them being cured is very high. High risk patients with a very aggressive disease, we tell them there's a good chance there's going to be, there might be some cancer left behind, you might need radiation afterwards. So, let's all discuss with them. I think did that answer your question?

Host: Yes. Yes.

James Hendricks, MD: Okay.

Host: Okay, back to Alison. So, is Eisenhower Health part of any clinical trials?

Alison Sachs, MSW, LSW, OSW-C, FAOSW: I'm unaware of any clinical trials we're offering in prostate cancer right now. We do collaborate and work closely with our affiliated partners at UC San Diego Moores Cancer Center, UC Health, UCSD Health, as well as some other cooperative clinical trials that we're part of. But presently, no, we are not engaged in any prostate clinical trials that I'm aware of at this time.

Host: Why is support so important for prostate cancer patients and the people who love them?

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Well, sure, that's a, that's a big question. Let me start with the fact that there are three words no one ever wants to hear their physician utter. And you know, that's, you have cancer. It's one of those diseases or diagnoses where we automatically go cancer death for whatever reason, even if that's not the case.

And certainly as Dr. Hendricks has already spoken to and can speak much better than I about, when caught early, prostate cancer is a very treatable and curable disease. And we have lots of ways to do that. Cancer can be a sneaky disease, so you're not going to hear a doctor say, yeah, you're cured 100%. That's great. But, for prostate cancer caught early with regular screening, yeah, you have a very, very good life expectancy and very good outcomes for your treatment. However, you're still dealing with the term cancer, which is very frightening, not just for the patient, but for their loved ones. Add into it again, the side effects that Doctor spoke about.

Those can create issues. Certainly. I mean, that's, the intimacy is how we show connection and love for each other. And this is a very serious issue, and the treatment and side effects of prostate cancer can lead to impotence, the inability to have an erection, and that causes fear, concern, a lack of feeling of manlihood.

There are so many issues. You know, semi joking, but not really, because as a male, often sex is intercourse. Showing your closeness with someone and your love is intercourse. So being able to work with men and explain, even if it's a temporary side effect, sometimes it isn't. But what does it mean if you lose the ability to have an erection? How do you have intimacy with your partner? And it doesn't always have to be about intercourse. All of that's intertwined in the discussion around how can we support you through this journey. How can we give you good information? How can we let you know we hear you and we're here for you?

You and your partner as well. So, lots of things to support around. And those are two big ones. The issue of, wow, am I going to survive this? And if so, what's going to happen with my sex life and how I interact intimately with those I love.

Host: As far as your center goes, you mentioned support groups. What kinds of support are available for prostate cancer patients?

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Well, now you've hit on what I'm extremely proud of. Thank you very much. Because we have one of the bigger programs for supportive care in the country. And that's impressive to say about a community cancer center. Our donor support for this non profit hospital is extraordinary, and I am talking about everything from a 50 dollar donation and up. Those donations support our prostate information and support group, which meets bi-weekly here, as well as four or five, I'm sorry, five other support groups, breast, colorectal, bereavement support, Spanish language support. We have exercise classes, Tai Chi, yoga, strength training. We do nutrition counseling. We do genetic counseling. We do stress management. We provide survivorship classes. Oh, my treatment's now over, now what? Who's taking care of me? How do I cope with any treatment side effects? All of those programs are offered free of charge to our community members and, very important, very much a part of cancer care and treatment.

Host: Yeah, fantastic. And how does education play into it? How does it benefit prostate patients?

Alison Sachs, MSW, LSW, OSW-C, FAOSW: Well, I am sure our listeners have all heard, an informed consumer is a good consumer. And you know what? Patients are consumers. They're consumers of medical care. So an informed patient is extremely important. There's a reason we call it your health care team, and we mean it. You need to be a part of the team. Just like any other team, to be a part of it, you need to be educated. You need to understand what's being talked about. We like to say to everyone, hey, we have physicians such as Dr. Hendricks, who's going to be speaking, September's Prostate Cancer Awareness Month. He's going to be presenting a very informative lecture.

 Education is key. He's going to be talking about PSA screening, robotic prostatectomy, all of the issues that men in general should know about if they don't have prostate cancer or if they do. So we're excited about that. Some of his colleagues are going to be talking about radiation treatment for prostate cancer as well.

So we have a lot going on around education. I would be remiss not to point out that there's some really good education on the internet, because we can tell you all you want, don't go on the internet, people are going anyway. So if you're going to do that, let's go to the places that aren't selling you something.

The places that don't have a personal interest in doing it their way. Let's go to legitimate sites such as zeroprostatecancer.org; the largest, largest, non-governmental, prostate cancer information site in the world, literally. Run by experts in prostate cancer. Great information, great support. That's a website to go on.

The Prostate Research Foundation, Prostate Cancer Research Foundation, another great site. Cancer Care, Cancer.org, the American Cancer Society site. These are reputable, fact based sites run by experts with oversight on what's being offered and given to folks. So I really, really encourage our listeners to use these sites and reach out to us here.

We're here for you at Eisenhower Lucy Curci Cancer Center. You have a question, you're not sure where to go, you need some support, you need some guidance, call us, email us. We're very easy to get hold of.

Host: Excellent. Well, thank you both so much for your expertise and your care in this field, and thank you for joining us.

Alison Sachs, MSW, LSW, OSW-C, FAOSW: It's been a pleasure, thank you.

James Hendricks, MD: Thank you for having us.

Host: September is Prostate Cancer Awareness Month, and Eisenhower Health will offer lectures on topics such as robotic prostatectomy, late stage treatment, and radiation oncology approach. To stay on top of these events and more, go to EisenhowerHealth.org/calendar. I'm Jaime Lewis, and this is Living Well with Eisenhower Health. Health care as it should be. Thanks for listening.