Dr. Andrew Wilner: Welcome to GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm your host, Dr. Andrew Wilner. I invite you to listen in, as we discuss advances in prostate cancer treatment. My guest today is Dr. Michael Whalen, Associate Professor of Urology at The George Washington University School of Medicine & Health Sciences, and Chief of Urologic Oncology at The George Washington University Hospital. Welcome Dr. Whalen.

Dr. Michael Whalen (Guest): Thanks very much for that.

Dr. Andrew Wilner: Dr. Whalen. Thanks for joining us to get started. Can you tell us a little bit about yourself? I read in your bio that you majored in neurobiology at Harvard. Is that correct?

Dr. Michael Whalen: That's correct. So right up your alley. And then I transitioned over to the dark side as it were.

Dr. Andrew Wilner: yeah. It's like, how did you stray from the brain, which is my specialty to the prostate.

There's gotta be a story there.

Dr. Michael Whalen: To the second brain. Yeah. It's interesting. You know, I was interested in neuroscience as a student and did some neuroscience research. Actually my senior thesis in college was on Alzheimer's disease and electroencephalographic way form potentials and response to a paradigm of familiarity versus recollection and for in memory.

And during my. Clinical rotations in medical school. in preclinical rotations, even I became interested in oncology and cancer care. And as much as a lot of developments had been made and an infectious disease and the early experience of medicine, and then even in HIV research and treatment and successes there, it still seemed that cancer care, despite all the advances had a lot more to do and a lot more.

To develop from a cookie cutter approach to a more personalized and precision medicine. And, you know, being in the midst of that was exciting. And using surgery to treat cancer also grew to excite me and to have a proactive impact on patient care and is as much as known there was even more to understand.

I got immersed in that and in grew interest in that and sort of deviate it away, I suppose, from neurology, what's interesting is that during prostate cancer surgery, you know, one of the ways to maintain good functional outcomes is to preserve the neurovascular bundle. You know, basically the cavernous nerves that allow for patients to have a functioning erections after surgery.

So I suppose I haven't completely deviated from, you know, from neurology altogether, because that is, you know,

A fundamental component of a well-done surgery. And one of my mentors used to say, Dr. Tiwari who does high volume robotic prostatectomies at Mount Sinai in New York used to say that this is one of the few operations where we are judged, not by what we take out, but by what we leave in, we want to leave the nerves alone, basically.

So

Yeah, I think it was in, you know, it sort of dovetails with Biden's moonshot to cure cancer. And it's a huge impact, not only on patients, but also their families. I mean, one in three men will be diagnosed with cancer. One in two women in three of the six, most common cancers in men are your allotted.

Prostate bladder and kidney in that order. So in terms of using my knowledge set to treat cancer and cure cancer in general urology poises me at the forefront to be able to do that.

Dr. Andrew Wilner: Yeah, well, that's fantastic. And that was my second question is how common is prostate cancer?

And it's one in three men. I mean that

Dr. Michael Whalen: Well, exactly. So one in three men in general will be diagnosed with any cancer in their lifetime. I mean, think that's a statistic from the American cancer society. Not urologic cancer necessarily, but prostate cancer is common. It happens in about one in five or six African-American men, about one in seven or eight Caucasian.

Ends up being around, you know, 17 or so percent of the population. A lot of the cancers that are diagnosed are indolent and it's, you know, in, can be managed, meaning they're slow growing because it's such a common disease. We have a lot of experience treating it. Many men these days can be monitored through what's called active surveillance.

There's also been studies reported for men who pass away from unrelated causes, heart attacks, strokes.

Thing, you know, things that car accidents basically, you know, not from any kind of cancer, but looking at autopsy in the prostate, it's been reported that 80% of them have trace amounts of prostate cancer that might not have been fatal or has it had any impact on their quality of life or quality of life.

So, you know, it's a very common disease and there is this notion of, well, if you live long enough, you'll get prostate cancer and it's not likely to be any kind of clinical deficit or meaning

But it is also true that prostate cancer is the second leading cause of cancer deaths in this country. Behind lung cancer and ahead of colorectal cancer.

And actually it switched places with colorectal cancer a couple of years ago, per statistics provided by the American cancer society. And that's partly because of the prevalence of the disease. Only about 3% or so of men will succumb to prostate cancer. But because of the number of patients, we diagnose the total number of people who die actually ends up being the second most.

Who die of cancer in this country, you know, so it's a big public health issue. You know, and from patients and their families issue, you know, also a very important thing to, to to address.

So.

Dr. Andrew Wilner: absolutely, One of the reasons we're talking about this is because when I researched this myself in fact years ago, I think there was a friend who had prostate cancer, and I started looking in.

And there just seemed to be so many approaches. Well, you can do nothing. You could do radiation, you could do surgery, you can do a hormonal therapy and it's like, gee, you know, why is this? So. I mean the prostate isn't all that big or complicated in Oregon. Seems to me. So a few questions. In fact, I'll just mention anecdotally, I remember reading a book about Michael Milken.

And you know, the junk bond king and at a relatively young age, I think he was in his late forties or early fifties. He got prostate cancer. And I remember that he was just personally, just a be fuddled is like, Hey, how come this shot a treatment for this? You know, everybody gets it. What's the deal. And I believe he created a foundation to pursue prostate cancer research.

Are you familiar with.

Dr. Michael Whalen: Yes, kind of peripherally. I mean, there's a lot of nowadays community support and a lot of foundation. I mean the prostate cancer foundation, the Movember foundation, there's something called us to which is another kind of patient advocacy organization. So there's a lot of interest, you know, which has grown up because of the prevalence of the disease and people that are thinkers and doers being affected personally.

And then kind of jump-starting.

Research and development outside of academia, or even industry or PR or partnering with these domains to make more rapid change.

Dr. Andrew Wilner: Let's jump back to the science for a second, because I'm curious, and I don't know if we have an answer to this, but what is it about the prostate that.

Enables it or allows it or gives it this proclivity to to become malignant. Do we, what is it about the organ itself? I mean, we don't see a liver malignancies or even kidney malignancies, as often as we see prostate malignancies, what's going on down there?

Dr. Michael Whalen: Sure. That's a good question. I mean, the same might be asked about breast cancer and I don't know that there's necessarily a smoking gun. You know, there's a lot of hormonal prostate cancers, hormonally sensitive to the male hormone testosterone. There's likely a multifactorial etiology with genetics and also nutrition.

The, you know, there's a fair amount of cell turnover. I mean, it is producing you know, secretions and there, you know, various chemicals that enter the body, you know, through nutrition or oxidative stress over time, you know, it can be concentrated there perhaps. And so oxidative damage can accumulate over time.

There is proliferation of the cells over time as well. And this is in response to. Hormones intrinsic and also per perhaps, you know, things that people encounter, you know, I don't want to be too conspiratorial about it, but there are associations between prostate cancer, risk and red meat and dairy, for example.

And you know, there may be antibiotics or hormones in this meat, you know? So is it inherent to the red meat or the way that the meat is processed? That's not completely known and it's difficult to study in a way. That's not a big population based study where the. Limitations and methodology with patients remembering how much they've eaten and, you know, not knowing exactly, you know, how the meat was treated, these kinds of things, but it is true that prostate grows over time.

You know, it's called benign prostatic hyperplasia. And so there's constant cell growth and turnover. And in these, you know, in these cells that are turning over and growing there is a possibility that this oxidative stress will lead to DNA damage that forms to.

Dr. Andrew Wilner: All right. So let's move to your particular area of expertise, which is surgery. When do we turn to surgery for prostate cancer?

Dr. Michael Whalen: It's a good question. And there's been a lot of advances in surgical technology since the operation was done back in the 1990s. I mean, Dr. Patrick Walls from Johns Hopkins pioneer. The radical retropubic prostatectomy.

An enhanced understanding of anatomy of the neurovascular bundle to afford better outcomes in terms of continents and potency.

It used to be that, you know, being dies with the prosecutor, prostate cancer. If you had surgery, you were basically permanently wet, you know, incontinent and permanently impotent these days because of advances in robotic technology and minimally invasive surgery, we have more sophisticated tests. To not only cure the cancer, but allow a much higher quality of life after the surgery.

So about 95% of men re retain their urinary control in our continent. And you know, there's very high rates of sexual performance preservation. After the surgery, as well, after a period of, recovery, you know that number, you know, that you didn't hear me give a number. I mean, that depends on many factors.

You know, as well as, you know, the patient's function beforehand and where the cancer is, you know, we don't want all the cancer behind. But because of that, you know, the surgery is less morbid, meaning it has less of an impact on the body.

There's less complications with the newer technology using the DaVinci robot less blood loss, faster recovery, shorter hospital, stay less pain.

Patients are usually up and walking around either the same day or the next day. I tell people they feel like they've done about 500 sit-ups so it's like sore, but not overwhelmingly painful. And would that magnification afforded by the robotic surgery, we're just really able to appreciate nuances in the anatomy.

As far as I'm concerned, just were not appreciated previously. I mean, there's been a lot of work in the neuroanatomy of the prostate done by people, such as Dr. , who I was fortunate enough to train with during my fellowship about understanding, you know, what's important to spare, you know, and what needs to go or what needs to be excised surgically.

So because of that we are able to do sort of more precise. Anatomical dissections and, you know, preserve the neurovascular bundle. If it's safe, really understand the mechanism of continents. There's been even worse.

And different approaches something called ritziest sparing approach. So even, you know, even these days is much as has been developed, even more innovation, kind of coming down the pike about ways that we can optimize the surgery.

It's probably one of the most common operations that I do. And in fact, because of the prevalence of the disease is one of the most common operations that we do at the house.

Dr. Andrew Wilner: Wow. help me understand a little bit about the robot, you know, everybody's saying we got a robot, what does the robot do?

Dr. Michael Whalen: Sure. So, so the robot is not autonomous, you know, it's not doing anything on its own. It's not like a self-driving car. You know, kind of put us out of a job. Maybe that's coming down the pike, but the robot is just a tool that uh, that is controlled. Completely by the surgeon. So it allows more precise control of the surgical instruments.

You know, the scissors, the forceps, the things that we use to manipulate the tissue. It is a free-standing machine that is attached to instruments that go through small incisions in the patient's abdomen. And then sort of through almost like a gaming console. The surgeon will control the.

Tools and these instruments originally, the idea was for the military to use the robot in bed, battlefield telemedicine to keep people out of harm's way.

I mean, that was one thing.

Or one approach. And then in terms of doing telemedicine and long distances, I think there is still a delay in maneuvering of the instruments versus, you know, the vocal commands. I mean, there is an assistant that is required to stand at the patient's side and help to change instruments and afford suction and, and help with that.

So it hasn't really taken off, you know, it's true telemedicine, but for use.

Urology surgery. It's been really a game changer and I was training during the era where it was just starting to come online. the first robotic prostatectomy I think was done in the early two thousands, if not 2000 itself.

Dr. Manny Menin out of the

urology Institute in Detroit was one of the pioneers of this. And I was fortunate to train under Dr. and Dr. Tiwari who trained under him. So I'm sort of third generation and that kind of. And it's, you know, so I tell patients it's by no means experimental it's been around for the last 20 years and has really kind of upped the ante in terms of how we can get patients through the surgical period safely and, you know, with better outcomes.

It's a little controversial in the literature, whether the robot Fords, you know, better continents or or rectal dysfunction, I suppose, you know, some of that is based on the patient population, the methodology, or there is some suggestion of that. And as I said, based on our understanding of the anatomy, I mean, it makes sense of why that would be the case.

Dr. Andrew Wilner: Sure. And it probably depends a lot on who's driving the robot.

Dr. Michael Whalen: Yes. Yeah, exactly. There's a certain learning curve that happened. I mean, you know, there has been concurrent with our experience as the general urology community with sort of doing a better job at the surgery. There has been less surgery performed overall for prostate cancer because a lot of men are opting for and rightly so active surveillance.

They used to be in the early or.

Time of the robot or mid era of the We were doing surgery on anyone who was diagnosed with prostate cancer, the idea being, we didn't want to watch it, let it grow and potentially grab the control. But now we understand that a period of active surveillance or close monitoring for low grade what would be termed as national comprehensive cancer network, very low and low risk disease is safe.

And in fact, you know, more than 50% or so of patients that are. With the very low and low risk diseases can safely be monitored. There are a proportion of patients that will progress to treatment, but that is about 20 to 30% over five years or so. You know, it's kind of actively being studied. I mean, we need longer follow-up to know, you know, how many people are going to progress, you know, in 10 and 15 years, because certainly if you're diagnosed in your sixties, you know, you're going to be around, hopefully God willing in, you know, 15 years.

So you know, more to come, but as we're, you know, as we've sort of gotten better with the robot, you know, less people are having surgery. But recently, you know, there's been another kind of stage migration where people who do go to surgery, you don't have more aggressive disease, you know, so we're having to react to that because we're doing active surveillance on the less aggressive disease these days.

So that cumulative experience for the last 20 years is really paying off now, as we are operating on more aggressive cancers, because in, especially in that setting, we really want to make sure that, you know, all of it.

Dr. Andrew Wilner: Well, absolutely well doctor, well, and this has been a really a great discussion.

Jay, just to finish up if I'm an internist or a family practice physician, and I have a patient and I don't know, I do actually do a physical exam and the prostate's in large, or I have an elevated PSA, or I think this guy has prostate cancer. What's my next step. What do I do? How do they get to you?

Dr. Michael Whalen: Exactly. So the fastest way, you know, is to make a urology consultation, right? You do to seek us out. Not only is the PSA is a good screen tool, but as I tell people, it kind of catches some dolphins in with the tuna. You know, it raises a flag of concern that may not actually be there. And in the past it used to be that we would automatically biopsy people with an elevated PSA these days.

We're a little more we're able to be more refined in who we. Determined would benefit from a biopsy by doing other ancillary testing through blood based or urine based biomarkers, to look for different kind of gene alterations that are associated with more aggressive prostate cancer to really justify who's going to that next step.

And then also we have advances in MRI technology that can basically see if there's a tumor in the prostate. The prostate is a small organ, you know, tumors within it are often less than a centimeter. So we have a. Suspicion score called the PI-RADS a system that we use to grade lesions within the prostate to determine whether they should be biopsied.

But the point is that these days we can be more sophisticated about, you know, who needs to have a biopsy. And those tests are well within the armamentarium of this, of the urology specialist to be able to offer these. And I, And I work hard to be on top of the cutting edge things that are available for our patients, so that, you know, we don't have to be doing unnecessary, invasive testing. For people who don't need it.

Dr. Andrew Wilner: Well, Dr. Whalen, I want to thank you for this. A terrific discussion of approaches to the treatment of prostate cancer.

Dr. Michael Whalen: You're very welcome. Thanks for the.

That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. To refer your patient please call 1-888-4GW-DOCS. If you have a question for one of our specialists please email physicianrelations@gwu-hospital.com

Disclaimer: Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. 

Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if robotic surgery is right for you.