Scott Webb (Host): For many years, the treatment of prostate cancer was sort of an all or nothing approach; surgery or radiation, or more of a wait and see approach. But there's actually a third option that my guest today is going to tell us about. And I'm joined today by Dr. Louis Liou. He's a Urologist with Emerson Urology Associates. And he's a proponent of a third option, which is a hybrid approach that he believes is a revolution in the treatment of prostate cancer.

This is the Health Works Here podcast from Emerson hospital. I'm Scott Webb. Doctor, thanks so much for your time today. I was just mentioning to you that I'm 53. And so anytime I get an expert on to talk about prostate cancer, that's a good thing, because as you mentioned, you know, we want to get the word out. We want to educate, talk about the latest advances, the importance of early diagnosis and treatment and so on. So a whole bunch of stuff to cover today. And as we get going here, who needs to be screened for prostate cancer and when?

Louis Liou, MD, PhD (Guest): Yes, that's a great question. And I would tell you that it's been an ever moving target. There has been some studies for sure, certainly in men that have actually ended up dying of causes outside of prostate cancer. And during those series, they looked at 50, 60, 70, 80 year old men and they found that as men age, their incidence of prostate cancer go higher. However, as they get older, because prostate cancer does grow at a slower rate, it appears that men have a better chance of not dying from prostate cancer as they get older. Age guidelines were set in place. And because of this it was started at anywhere between 40 and 50 years of age.

However, the United States Preventative Task Force a little while back actually did come up with their findings that potentially screening for prostate cancer may be more harmful to men than helpful. And this was their reasoning. We have two tools at our disposal. The first one is the PSA, which stands for prostate specific antigen. However, the PSA is not only not specific to prostate, but it doesn't really tell you exactly whether you have cancer or not. And as a screening tool, there's a lot of false positives, meaning it can be high and you may not have cancer. Our second tool at the time is a digital rectal exam. And that's when again the doctor puts a finger into the rectum and feels the backside of the process. The problem with this, is that again also a lot of false positives because there are lumps and bumps that may not be cancer.

Based on these two modalities, there's been referrals to urologists and then subsequently a lot of biopsies and the biopsies are let's just say not without side effects. So a final piece of this, is because as I mentioned, prostate cancer is a slow growing cancer. So if you are a person that has less than 10 years of life, prostate cancer in general, will probably not kill you. And just like in the autopsy series, you'll die with prostate cancer, but not because of prostate cancer.

So based on all of this, there have been many societies that have now come up with some guidelines and certainly they don't all agree. But the American Cancer Society, the American Urologic Association, which is the association that I belong to as a urologist; they have all recommended screening for prostate cancer starting at 50, and potentially with a strong family history of prostate cancer, a father and grandfather that had prostate cancer, maybe you should do it five years earlier at 45. Now they also have said as far as screening is concerned, if you've not had a diagnosis of prostate cancer and you're in your seventies, it may be a good idea to stop screening at that point, because again, if you have less than 10 years of life and the average life expectancy in the United States for a man is in their mid to late seventies.

So I think given all that it's a long answer to a short question, but I do believe that all men after an appropriate discussion with their doctor, men between 50 and 70 years of age are eligible to be screened.

Host: Yeah, they definitely are. And you mentioned a bunch of things there, a family history, genetics, our age and so on. So a lot to consider, but always good to speak with the doctors, speak with a specialist, if you have any questions. We know that early diagnosis is key. So let's get into that. What's new in the diagnosis of prostate cancer?

Dr. Liou: So the old way of doing this as I alluded to earlier, is that you get your initial screening of a PSA and a digital rectal exam. Then based on the suspicion of whether you may or may not have prostate cancer, you would go right to a prostate biopsy. Now the prostate biopsy was done, trans rectally, meaning you would have a probe inserted in the rectum, visualize the prostate. Then you would have a tiny needle sample the prostate about 12 times, and this was all random. So there's no target available. And of course there would be a lot of error in potentially diagnosing prostate cancer, because you would have sampling error.

And so things have changed. I wouldn't say recently, but within probably the last decade we've been trying to find better ways to look at the prostate in order to look at lesions. And we do this in a lot of areas like lung lesions, kidney lesions, and so we've actually started and adopted the MRI imaging of the prostate in a specific protocol. It's called multiparametric MRI.

And in this case, we're able to get a nice image of the prostate. See if we can see a lump or lesion, and with certain criteria, we can say there's a high chance that there is and what we call clinically significant cancer, meaning cancer that could kill you or not a high chance. And then based on that, we can actually do the prostate biopsy as I had described earlier, but now we know where to direct our needles. So it's a targeted biopsy.

Having said that, we've also changed an approach of going through the rectum and there is another option called transperineal biopsy. Now the old approach of going through the rectum really, the major complication was infection, because the rectum is not a clean place. And obviously with stool and with bacteria there, you could introduce bacteria into the patient's prostate or their bloodstream and make them very sick. And in addition, also you could have bleeding through the rectum and sometimes that can be pretty substantial. So based on these side effects of the biopsy, the transperineal biopsy has been developed and you go through the area between the anus and the scrotum. So that's the perineum and you go straight through the tissue, the skin, the muscle right into the prostate.

And obviously, if you cleanse or put antiseptic over the skin, there's a much less chance of having infection and certainly a much less chance of having bleeding. However the downside here is that you will need the numb very well, that whole area. And a local anesthetic is key here. However, once you've done the biopsy and a targeted biopsy, the feeling is that you're able to better distinguish the men that truly have cancer that is aggressive versus men that have cancer that is not aggressive or clinically insignificant cancer.

Now, another way to distinguish this, which has come about, is that a few companies have started looking at genes and genomics. Now, again, the DNA in general, dictates how tall we are, what hair color we have and really, to some extent, even how long we will live. And it certainly does dictate the behavior of disease and also the behavior of tumors, especially obviously cancerous tumors.

So that's another advancement that we actually will send the tissue from the biopsies, the cells, if we do find cancer and we'll get a deeper dive into their DNA composition. And through that, we can actually have some numbers and project how aggressive they really are. And I think that's a breakthrough that is still in evolution.

And so I do think that we are now at an era where we can better diagnose men with cancers that will kill them. And those are the patients that we need to of course, treat. And leave alone the men that have cancers that won't kill them. And in that way, we spare them the side effects of the treatments.

Host: Yeah. And as you've mentioned here, there are some men who die with prostate cancer and some men who die because of prostate cancer. And that's an important distinction in terms of the diagnosis and treatment. So let's get into treatment then, what's new in the area of treatment for prostate cancer.

Dr. Liou: Yes. I think the old way of treatment certainly is now people are looking at it because the side effects were pretty bad for men. And they ended up really crippled and their quality life was dramatically reduced even though potentially their quantity of life was extended. And it probably takes a place such as Canada, where they have socialized medicine and they're able to actually look outside of the box and potentially even less attorneys, that they were able to diagnose men with cancer, but not treat them and just watch them. Now, why did they do this? Because of the autopsy series. They knew that, by doing autopsies on men that had died of other things, heart attacks, strokes, car accidents, anything else; they knew that a lot of these men in their seventies and eighties already had prostate cancer, but never died from them. So they wanted to conduct a trial to see whether they truly needed to treat these men right away or whether they could give them time and spare them the side effects of the treatments.

Now they did this and then they dubbed it, initially was called Watchful Waiting, which means that you really didn't do anything. You just told them they have cancer. And then just see when the cancer comes back or if it spreads. But then that turned into something called Active Surveillance. So I use the analogy of criminals and doing a wire tap or doing surveillance on criminals.

What you want to do is you want to be active. So you do want to monitor these people and do repeat PSAs, do repeat biopsies. And so you're very active in their treatment. And then the idea would be if that cancer starts to get worse, then you can act and treat them just in time before it spreads and kills them. So that was the concept of active surveillance. And initially in the United States, there was a lot of pushback because again the idea was there is no good cancer, no good prostate cancer and every single prostate cancer needs to be treated. However, we started come to grips that potentially not every prostate cancer needs to be treated. And so a lot of men did go on active surveillance. However, it was looked at and about maybe 50% of these men on active surveillance eventually did need some sort of treatment. Now, when they need a treatment, what do we offer them? You know, and in most parts of the country, this is still the quote unquote standard of care.

We offer them the two old time treatments that we've always had. The first one obviously is a surgical approach called the radical prostatectomy. Now we don't call it radical for nothing. It is pretty radical because we are actually rearranging your plumbing. We are going to remove the prostate and reconnect the bladder to your penis. So I usually tell my patients it's really like if you had a pipe underneath the sink, we're really going to cut through the middle of that pipe and then reconnect the two ends. And when you do, of course, there's always a chance of leakage. And certainly, we've, I think been more and more honest in collecting the data after radical prostatectomies.

And we do find that there's a large amount of men that have to at least wear a small pad. And some of them are incontinent all the time and that really is a terrible quality of life. The second side effect of the radical prostatectomy is lack of erection or erectile dysfunction. And we also have found that a large percentage of men undergoing a radical prostatectomy also have that problem.

And many of them become impotent and are no longer able to engage in intimacy with their significant other. So based on these things, we decided that we would want to try and improve the radical prostatectomy and along came the robot. So now many surgeries that do the radical prostatectomy instead of a knife and a surgeon, they're actually a robotic arms that go into the patient and they are still controlled by the surgeon. But the idea was that you could see better. You couldn't touch the structures, but you could see better and you could actually potentially do a better surgery and have better outcomes.

Unfortunately, after many years of the robotic radical prostatectomy, the side effects of incontinence and impotence are pretty much the same. So that was not good. Now the second option that is routinely given to most people is radiation. And radiation comes in two forms. The first form is really the external beam where you lie on the table and they shoot the radiation beam to your prostate.

Now this takes up to a lot of times, it's a two months treatment, so eight weeks and you have to go every day and they give you a little bit of radiation at a time. Certainly it doesn't have any of the side effects, short term side effects as the radical prostatectomy. However, long-term radiation really creates tissue that does not heal very well.

And a lot of times, post radiation healing is terrible and in general, most surgeons will not operate on someone that's been radiated. In addition, we all know radiation, although it can kill cancer cells, it can also cause cancer because it breaks DNA structure. And so long-term effects, especially, years later, you can come up with cancers around not only within the prostate, but certainly cancers in the bladder and the rectum where that radiation had to pass through.

And so the other options for radiation, are the seeds. These are metal seeds that are implanted in the prostate and they give off radiation. The metal seeds stay there, pretty much forever. The radiation will go away, but the side effects are very similar to the external beam. So when men are given these options of either full treatment, take out the whole prostate or radiate the prostate, or the other option is do nothing; we're not going to do anything to your cancer. It's an all or none phenomenon.

And a lot of men get paralyzed and they say, why can't I have an option for somewhere in the middle? And so that's where I do think, I'm going to briefly touch upon focal therapy. And this is my area of expertise. I've been doing this for almost 15 years now, following patients, because like I said before, in the earlier discussion, we have better ways to localize the prostate cancer. And if we can localize it, we can go after just the cancer itself and leave the rest of the prostate alone. And that will certainly diminish side effects of any of these treatments and increase quality of life. And the other great thing about focal therapy is that of course, even if the cancer were to come back, we can retreat areas because again, we can find them again.

And so I do think that it is an option that I've given men. However, you really have to be very careful. I don't tell men that we are going for an absolute cure. We are going to control the cancer so that it does not kill you and that you have minimal side effects. So you're not going to die of prostate cancer, but yet you're still going to maintain your quality of life functioning, such as, urinating without issues and being able to be intimate with your significant other.

And so this has kind of taken off and there are now multiple centers throughout the United States that do it. And certainly we're one of them up in New England. And as far as I know in New England, there's nobody else doing this type of work or offering this to patients.

Host: You know, so much to unpack there, but I'm sure you're right. And so much great information and education today. And as we wrap up, Doctor just want to give you a maybe the easiest question you've had all day. What do you enjoy most about your job working with patients, whether it's related to prostate cancer or otherwise? What brings you just great satisfaction at work?

Dr. Liou: Obviously, I went into the medical profession to help people. And I think the greatest satisfaction is that when I hear patients who find me, either they find me through family, friends, word of mouth, other physicians, or even on the internet, they come in and they say, I didn't know I had this option. I really had no hope. I thought I was just destined to undergo one of these radical treatments and potentially suffer the side effect profiles. And when I hear that and I say, well no, you don't have to be destined for this and we can help you and their eyes light up. And they literally walk out of my office with hope. I think that's really the best thing that I experience while I'm doing my job is to give men hope and I've really made it a mission. And the good thing really is because I've also done a PhD in molecular biology in genomics; I have approached this in a little different fashion and I've gathered, I've been meticulous about gathering the data. And I can tell my patients after 15 years that the procedure is safe and efficacious and men do get to keep most of their day to day functioning and have really pretty good quality of life after this.

So that's really, I think my mission right now. It is very gratifying and it's, humbling and an honor for these men to entrust their life in my hands. And I work every day to earn that trust.

Host: Well, And just hearing you today, just your compassion, your expertise, you know, and knowing what makes you happy, seeing that look of hope, the hopeful optimism on faces of men and perhaps their partners too. So great conversation, so much education and information today. We hope listeners got a lot out of this as well. I certainly did so. Thanks for your time. You stay well.

Dr. Liou: Okay, thank you.

Host: For more information or to make an appointment to call Emerson Urology Associates at (978) 287-8950. Or visit Emersonhospital.org and search urology. And thanks for listening to Emerson's Health Works Here podcast. I'm Scott Webb. And make sure to catch the next episode by subscribing to the Health Works Here podcast on Apple, Google, Spotify, or wherever podcasts can be heard.