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Scott Webb: Hello and welcome to Checkup Chat with Evergreen Health. I'm Scott Webb and I'm here today with Dr. Jessica Dai physician at Evergreen Health Urology care to discuss the prostate, some common conditions and the treatments you can expect if you experience these conditions. The prostate is an important part of not only the male reproductive system. But can also be an important part of overall health with prostate cancer being the second most common type of cancer in men. So Dr. Dai, thanks so much for your time. It's great to speak with you again. As I mentioned in my intro prostate cancer is extremely common among males, but I don't think that many men know what the prostate is, me included perhaps. So what exactly is the prostate and what role does it play?

Dr. Jessica Dai: So the prostate is an organ unique to biological males. It is a walnut shaped organ that sits between the bladder and the urethra, which is the tube that you pee out of. And it has several functions. One is a kind of physiologic function. It produces a protein called th PSA which we can talk a little bit more about, but that helps liquefy semen. It also serves an anatomic function and that it comprises part of the urinary sphincter for men. So it helps maintain continence, prevent us from leaking with urination. Also place some hormonal roles in that it is responsible for the conversion of testosterone to a different form of testosterone called dihydro testosterone. So a lot of functions for little.

Scott Webb: Yeah, that is a lot for a little organ, and I'm 54, so I definitely know how the prostate is examined, but wanna have you walk us through that process. Also, let listeners know, when should men begin to have the prostate examined? How often should it be checked and so on?

Dr. Jessica Dai: Yeah, that's a great question. And I'll start by saying there's a lot of controversy over prostate cancer screening. Who to do it in, who not to do it in, when to start, when to stop. And so those are things certainly that are worth an informed discussion with your physician and is a really individualized choice in a lot of cases. Generally speaking, most of the guidelines tend to agree that prostate cancer screening should start for men kind of in their middle ages. And depending on which guidelines to kind of follow mid fifties is pretty common overlap. Continuing all the way through about age 70 or in some folks who are very healthy and older can continue even longer.

The typical prostate cancer screening is comprised of two things. One of which you mentioned, which is the prostate exam that's called commonly digital rectal exam or a DRE. It's not something that can be done at your primary care office, certainly at your urologist's office, but essentially is a finger exam by which the prostate is measured through the back wall of the rectum. So a finger in the bottom lets us feel the backside of the prostate and feel for any abnormalities, lumps, bumps, hard areas that shouldn't be there, that can raise our concern for prostate cancer.

So the other component of prostate cancer screening, in addition to the digital Recal exam is that th t PSA, which you may have heard about. And that's a blood test again, checking for that, protein that's normally produced by the prostate. And this kind of gives us an indication of when we need to be concerned. It's not perfect by any means, meaning normal prostate produces PSA and other things can make the PSA level high infection, inflammation, trauma, having a catheter placed. But it's really following the PSA trend over time.

And the PSA in the context of everything else, including the rectal. And the decision about when that PSA triggers concern enough to do further workup is really somewhat individualized. And again, depends on a lot of different factors that are of taken together and looked at over time.

Scott Webb: Yeah, there are a lot of factors and we're gonna come back to PSA as we move through this podcast today. And wanted to ask you, you know, beyond cancer, other conditions could affect the prostate like inflammation or enlargement. So how common are those conditions and can you tell us what happens to individuals who experience those conditions and the ways that they would be treated?

Dr. Jessica Dai: Yeah, definitely. I would say prosthetic enlargement is very common. And I would wager to say that most men, by the time they're hit, their middle-aged or fifties, sixties, seventies almost everybody has a little bit of enlargement. Whether or not that causes the symptoms is certainly a different story. And so prostate size alone doesn't always correlate with symptoms. Some men can get inflammation of the prostate. That's sometimes triggered by bacterial infections, sometimes viral infections. And sometimes it's inflammation that can result in discomfort or prostate issues. But we don't really have a clear ETI ideology for.

Many of those are treated similarly. There are medications that first line treatment options that help relax the smooth muscle in the prostate, which helps us urinate a little bit better and minimizes symptoms from that perspective. And then there are also medications that help shrink the prostate. Something called finastinite or five alpha reductase inhibitors. Finastrenite is one of those examples of those that over time helped shrink the prostate by about 20 to 30% its size. Decreasing the size of the prostate and helping the prostate relax through those two medication options can help urination symptoms significantly.

Scott Webb: Yeah. When we think about prostate cancer, how common is it among individuals in the US and when in life are males most likely to be diagnosed with prostate cancer?

Dr. Jessica Dai: Yeah, it's actually the most common diagnosis of cancer among men in the United States. About one in eight men over the course of their lifetime will be diagnosed. It tends to be diagnosed in older men, so the majority about 65 or older. It's very rare in younger men under 40, but certainly there are men. Particularly those with risk factors like a family history of prostate cancer that we do check and sometimes diagnose prostate cancer earlier.

Scott Webb: Yeah. And as we know we can't outrun family history and. So for some earlier screening and you mentioned the different screening options and how individualized that is, but earlier screening might be the answer or might be the right path for some, and I know a physical exam isn't the only way, right. We've talked about the blood test, PSA test can, offer some clues as to the presence of cancer. So what other symptoms, might trigger someone to speak with their primary or ask for a referral? When we think about prostate cancer?

Dr. Jessica Dai: So, it's really interesting that you asked this question, before we did PSA screening which was this blood test. a lot more men, were being diagnosed with prostate cancer related to actually symptoms. And these symptoms are typically urinary symptoms often, which can overlap with just having a, normally enlarged prostate symptoms of obstruction, weak stream, not being able to urinate. Feeling like you have to go really frequently or unable to urinate, sometimes blood in the urine. And occasionally in really advanced stages where there's prostate cancer that's spread outside the prostate, some men can develop bone pain, joint pain which again is tricky because some of that can overlap with just normal aging.

In this day and age with prostate cancer screening, we actually tend to diagnose fewer men at those more advanced stages. And the vast majority of prostate cancers that are picked up, particularly by PSA screening and the rectal exam screening tend to be asymptomatic. Again, occasionally you can have obstructive symptoms like the urinary symptoms that we were talking about, or blood in the urine. But again, when it's picked up at these early stages, it's typically not advanced enough to be causing a lot of those symptoms. So that's why screening is really important?

Scott Webb: Yeah, I really see the benefits of the PSA test. So beyond symptoms and the blood test is prostate biopsy. Is that something that's always necessary to determine if cancer is present? And as for the operation, maybe you can walk us through the preparation, procedure, what are you looking for exactly? Sort of take us through that. I'm sure when folks listen to this and we think about prostate cancer immediately the alarm bells start to go off. And as you say, so many things are like other things. It could be this or it could be that. It doesn't mean cancer, but it might. So maybe you could just kinda walk us through all of this.

Dr. Jessica Dai: Exactly. And you know, I talk to my patients about this all the time. There's a lot of gray area and there's no slam dunks other than the prostate biopsy, which in and of itself isn't perfect. Is the only definitive way we have to diagnose prostate cancer and then it gives us tissue and gives us a reflection of what's going on in the prostate. Before you get to that, especially in this day and age, we're using more and more imaging studies to help us risk stratify folks or even look for spots of suspicious areas that could be prostate cancer.

So prostate MRI is a step many of us use to help better target any areas to biopsy. I can identify areas that are suspicious of prostate cancer it's not perfect. It certainly can miss, up to 10% of high grade prostate cancers, even if it's totally negative. But it does help us increase the accuracy of diagnosing prostate cancer and in particular, diagnosing the type of prostate cancer we care about, which is the fast, aggressive rapidly progressing type. The prostate biopsy itself is typically an outpatient procedure. And many folks often do it in the office.

It's done with ultrasound guidance. Typically if we do it through a transrectal approach, which is how we do it here an ultrasound probe is put in the bottom, in the rectum, and then we use that to directly visualize the prostate, see if there's any abnormal areas and then we biopsy it and we typically biopsy it systematically. So we take 12 needle samples, typically six from each side. And obviously if there's anything that's abnormal appearing on the ultrasound, that area is sampled.

So I like to tell patients it's almost like sample in the haystack looking for the needles. So it's certainly not possible, but it gives us a representation of really what's in the prostate. If we do get an mri, which is again becoming more and more common, we often will take additional biopsies or additional tissue from the areas that look abnormal or concerning on the MRI. That just helps us target it. And that's called an MRI fusion targeted biopsy. I will say there are some centers in the United States, and this is probably more common globally that do this biopsy through the perineum or kind of the taint area rather than going through the rectum.

And there are risks and benefits with both approaches. But I would say probably the vast majority of practices in the United States currently are still doing this trans rectally in the way that I described.

Scott Webb: Yeah. And I know that recovering from a biopsy is important in the healing process. So maybe you can tell us, what patients can expect after the biopsy. What are some steps they should take to ensure their healing properly and how long does it take before they would know, before we would know if we have prostate cancer?

Dr. Jessica Dai: You raise a good question about healing after the prostate biopsy. Now I counsel every patient who has a prostate biopsy about a couple of risks, and there are many things that are normal. Bleeding in the blood, in the urine, blood in the stool, and blood in the semen is very normal. And that can take a couple weeks to resolve, particularly the blood in the semen. I have folks where we have to remind them this is normal and this is something that we will expect from the procedure.

A small percentage of men develop a urinary tract infection or difficulty urinating after the procedure. I see. That's fairly rare. The biggest thing that I worry about in healing is a risk of infection that progresses or is pretty severe, potentially life-threatening sepsis. The rates of those are low in our institution in about one to 2%, and we do give, before the procedure, we have them do an enema before the procedure to kind of minimize that. I give IV antibiotics at the time of the procedure as well. But those are things that I think are important for everybody who's thinking about having a prostate biopsy to be aware of.

In terms of healing properly, I usually have folks take it easy. Again, there's very minimal discomfort after the procedure and most men actually don't need any medication afterwards. But I do think it's important that they avoid straining making sure the bowel movements are stopped because any sort of straining, pushing in that area can make it harder for that bleeding to stop. In terms of how long it takes to know the prostate cancer, it takes about five to seven business days for that sample to be interpreted and run by our pathologist.

So typically that's the turnaround And We always have a sit down face to face in my office to go over the results because not all prostate cancers are the same. And we treat different types of prostate cancers very differently. And so I think it's important that we sit down and we kind of interpret those results together.

Scott Webb: Yeah, I'm sure patients, family members appreciate that. So let's talk about that. You mentioned the treatment options. What are the treatment options and how does maybe prostate cancer differ from other cancers?

Dr. Jessica Dai: The treatment options are very much determined by, your risk category. And I talk to patients about this a lot. This is kind of ways of thinking about how aggressive do we and should we be about treating your prostate cancer. And that's dependent on a number of factors, a combination of what your PSA level is. Combination of what's in your biopsy, how aggressive the disease is in the pathology, and how much of it there is And to whether there's any concern that there's disease elsewhere. And how things feel on the rectal exam, for example, does it feel like this is prostate cancer that's maybe outside the prostate or involving the seminal sicle?

And sometimes those at MRI beforehand will give us some information about that. So for low-risk prostate cancers, and these are often cancers that are picked up on just routine. Prostate cancer screenings that don't tend to be very aggressive or what we call grade group one out of five in terms of aggressiveness. Those are cancers that our standard of care right now is actually to surveil and not to of jump in and treat, because there are a lot of side effects and risks of treatment. And so that typically surveillance just means that we watch the cancer closely and we rebiopsy usually about within the first year to make sure that there's no change or no progression over time.

And that, for a lot of men, allows us to defer even, not have to do surgical or radiation treatment, which we'll touch on in a minute and might allow them to avoid treatment over the course of their lifetime if this is not a cancer that grows or progresses or becomes a threat to their livelihood. Treatment options for intermediate and high risk cancers tend to be focused more on either surgeries I touched on, or radiation. And radiation comes in a couple different flavors. There's external beam radiation, there's brachytherapy, which are seed implants.

And I typically have all my patients meet with the radiation oncologist to, learn a little bit more about those options of detail from the radiation oncologist. The prostatectomy would be what I and my partners do, and that would be removing the prostate itself, removing the seminal vesicles, which are the structures behind the prostate. And also depending on risk factors, removing the lymph nodes which are areas where prostate cancer might spread even in microscopic amounts even if we can't see it on a CAT scan or an MRI.

I guess I should add in particular for high-risk patients who have high-risk prostate cancer, sometimes treatment is a combination of these things, surgery plus radiation or sometimes radiation. Systemic therapy, which is typically in the form of hormonal therapy. it really depends on what the risk factors are, what risk categories you fall into. And then a lot of it depends also on patient preference. We know for localized prostate cancer, so prostate cancer that hasn't left the prostate. And this could be intermediate or high risk prostate cancer.

We know that the kind of treatment outcomes or cancer survival is equivalent out to about 10 years, which our studies have looked at. And so oftentimes patients are not then choosing between what's the more effective treatment option, but what's the treatment option that has the side effect profile long term that I'm okay with? So it's very individualized.

Scott Webb: Yeah I see what you mean? And you mentioned prostatectomy there and you know, wondering, how common that is how effective it is to remove the prostate. Maybe you can touch on the side effects, are there some methods to limit the side effects? Maybe you can kind of hit on all that.

Dr. Jessica Dai: So prostatectomy definitely, as you mentioned, carries a lot of side effects, many of which are long-term or even potentially lifelong. The biggest things that I counsel folks about in addition to just the standard risk to surgery, bleeding, infection, injury to, surrounding anatomy are longer term risks of potential urinary incontinence in erectile dysfunction. Now, I always tell people I can't make you better than where you start. But in particular, again, as I mentioned, the prostate is a continent mechanism, particularly for men.

And so when we remove that, a lot of men have issues with urination. There are things we can do in the surgery to try to minimize that which we make every effort to do, but sometimes because of a cancer perspective, we have to do it first and foremost. Good cancer surgery. Things that can help are certainly pelvic floor exercises like Kegels and for men. Once the prostate is out, that becomes a primary continent mechanism. And so sometimes doing a lot of Kegel exercises before and after can help with recovery from a continent perspective. And then erectile dysfunction is the other one.

And oftentimes, again, if you're not starting with great erections, it's really hard to preserve a lot of erectile function, but we do do nerve sparing prostatectomy meaning that, do our best to, as long as it's, say from a cancer perspective, preserve all of the neurovascular bundles that supply the nerve and the blood vessels that are required for a good erection. So with that we work on kind of rehabilitation afterwards as well, and we work with patients to try to manage any incontinence or erectile dysfunction that may persist after surgery.

Scott Webb: Well, Doctor, as always as I mentioned before we got rolling here, you're really good at this in getting a lot of information, important information out in a timely fashion So great to have all this information. Great to have your expertise and time today. Thanks so much. You stay well.

Dr. Jessica Dai: Yeah. Thank you. Appreciate it Scott.

Evergreen Health Urology Care provides expert evaluation and treatment for prostate conditions to help you improve your quality of life. To schedule an appointment, please visit the Evergreen Health Urology Care website at evergreenhealth.com/urology- care, or call 425-899 5800.

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