Scott Webb (Host): Prostate cancer is common and highly treatable when diagnosed early and today we're gonna discuss prostate cancer, signs, symptoms, diagnosis and treatment options with Urologist Dr. Emily Kelly and Radiation Oncologist Dr. Jaymin Jhaveri, both of whom are with Health First. 

This is Putting Your Health First, the podcast from Health First. I'm Scott Webb. So it's really nice to have you both here today. We're gonna talk about the prostate, diagnosis, signs, symptoms, treatment options, all of that. Just wanna welcome you both to the podcast.

Emily Kelly, MD: Thank you for having us Scott. 

Jaymin Jhaveri, MD, MS, DABR: Scott, excited to be here. Let's talk about prostate cancer today.

Host: Yeah, let's do that. There's probably never a bad time. So it's good to have you both here, good to have your expertise and we're gonna kind of break things up a little bit. Talk to Dr. Kelly first about diagnosis, signs, symptoms and then Dr. Jhaveri we'll come to you about treatment options. So let's start there Dr. Kelly. What is the prostate exactly and why is a healthy prostate so important? 

Emily Kelly, MD: The prostate is one of the main organs of the male's urological system and not only aids in sexual function, urination, but it also produces vital enzymes with, which help to mature the sperm and allow for proper ejaculation and fertility. 

The prostate is very important to overall urination, ferility and is vital in a male's quality of life. It is roughly about the size of walnut however it can fluctuate based on the individual male. Also as one ages, it increases roughly about 1.4% annually. Thus a younger male will have a smaller gland and as that gentleman ages, it will increase in size which can affect both urination and ejaculatory function.

Host: Yeah Doctor and I'm definitely in that age when a male might begin to notice that the prostate is enlarged a little bit you know and all of that implies when I have three cups of coffee during the day so I can do these podcasts. What are some of the most common symptoms or early warning signs of prostate cancer?

Emily Kelly, MD: So, unfortunately prostate cancer's early signs are very silent. That is why early screening with blood test and physical exam are extremely important. Most males will come to me saying I think I'm worried about prostate cancer because it's affecting their urination where that's more the size of the prostate.

It's not until very late in prostate cancer that it actually affects urination and produces symptoms. Rarely do we see blood in the ejaculate or in the urine caused by prostate cancer, however this could occur. So if you ever see blood in the ejaculate or the urine, it's 

definitely important to let your provider know so additional testing can be performed. However most prostate cancer is diagnosed on screening tests alone and not based on symptoms.

Host: I see what you mean. Yeah, it's one of those dreaded thingsin medicine where it just isn't obvious until unfortunately it is obvious. So, I'm assuming then screening is important as you were saying there. So at what age should we consider prostate cancer screenings and what does that usually involve? Is that just a blood test how does that work?

Emily Kelly, MD: Yeah so there's actually been a huge shift over the years of when we should start prostate cancer screening and if you look at different medical groups, each one's gonna say a different recommendation. But based on the American Urological Association's most current recommendation, which was produced in 2023; we start by assessing the patient's risk for prostate cancer around the age of 40.

If a patient has high risk findings such as multiple relatives, or a single first degree relative having prostate cancer or of the 

African American race that would place them at the high risk category and we would recommend screening starting at age 40. Based on the first baseline PSA, we would then determine an interval surveillance or screening protocol from there. However, if there's no family history of prostate cancer, they are not in an elevated risk because of race, then we start somewhere between the age of 45 and fifty and that's done predominantly with a blood test.

Host: Okay.

Emily Kelly, MD: Based on the blood test, we then determine the screening protocol. Most of the PSA's in this age group are going to return less than 1.0 And if that's the case, then we resume on a bi-annual basis at age fifty. If the PSA returns greater than 1.0 but less than 2.5; then we continue on an annual to bi-annual basis, meaning every one to two years.

And if the PSA is greater than 2.5, then we discuss additional testing or biopsy. It's super important to note though, that sometimes the PSA is not always accurate and can be affected by different things such as retention of urine, infection, prostatitis, being an avid cyclist, spin or Peloton participant. Those things can put a lot of pressure on the prostate and increase the PSA. So if the initial PSA comes back elevated, oftentimes the provider will look, take a history, make sure we're not missing an infection or some urinary retention symptoms, recheck the PSA. About 30% of PSA's  

will actually normalize back down to an appropriate baseline. However, if it remains elevated, then that will prompt additional testing.

Host: Yeah and you mentioned some of risk factors that we can't escape of course. Genetics, family history that kind of thing. Wondering if there's also behavior, lifestyle choices that maybe increase the likelihood of developing prostate cancer?

Emily Kelly, MD: So we always recommend a healthy diet, staying away from tobacco use. Ah that can definitely be a risk factor. I get a lot of patients who ask me are there any supplements that I can take, any male health products that I can take that can decrease my risk of prostate cancer. And there really hasn't been anything clinically significant that you can take over the counter that can decrease your risk. So, really just making sure that we have a healthy lifestyle. The most common risk factors can be family history and genetics so making sure that you talk to your family members, talk to your father, uncles, grandfathers; getting an accurate family history so that way we can appropriately assess the risk and when we should be performing screening.

Host: Yeah it would be great. I wish we lived in that world. I know there are some things that there's just like a magic pill you can take and then you know you don't get a thing or it helps you not get the thing but not the case with prostate cancer, at least not yet. I just wanna finish up this first part here with Dr. Kelly. Let's talk about staging for prostate cancer, how that's determined and why it's important when it comes to treatment. 

Emily Kelly, MD: A lot of times staging at first is a clinical stage based on the pathology from an actual biopsy. I, more of a time, talk to my patients in risk. Meaning are we low risk, intermediate or high risk when we get the pathology back. That's based on a variety of different factors. So on a path report that your provider would talk to you, they would tell you what your Gleason score would be. A Gleason score is based on two numbers added together and is on a scale from six to ten.

So breaking it down just very simplicity, six would be low risk, seven would be intermediate risk, eight, nines and tens would be high risk or very high risk. Other things do factor into play, meaning the PSA. What was your PSA at baseline. Was It less than ten,    

greater than ten. If you had imaging performed, an MRI before the biopsy, any additional staging? Is it confined to the prostate? These are all things that can affect the risk stratification and then based on the risk we then talk about different treatment options. I will say that it's actually gaining a lot of popularity in the news recently where's there's been a lot of news articles saying that we're over diagnosing prostate cancer. Most prostate cancers don't need hear about it all the time. Patients bring me copies of articles that they find in Male Health Magazines and that the low risk prostate cancer. That's what we're finding early and we're saying lets keep an eye on it an monitor very frequently to make sure that this doesn't progress rapidly. frequently And that would be more of your Gleason six disease versus intermediate and high risk that we more likely offer upfront treatment options and hopefully of curative intent and I know we're gonna talk more about radiation specifically in a few minutes, but most of those would entail some sort of radiation, possible hormone management or surgery.

Host: Right. Yeah and that leads perfectly into our section here you if you will, with Dr. Jhaveri. I wanna bring you in now Doctor and talk about diagnosis right. So once prostate cancer is diagnosed what are the primary treatment options?

Jaymin Jhaveri, MD, MS, DABR: The primary treatment options for prostate cancer there's two different ones and very simple. One is surgery where a urologic surgeon like Dr. Kelly or other surgeon will uh take you to the operating room and remove the prostate gland itself. That's one form of curative treatment option. The other is radiation treatment, which is a painless x-ray treatment usually given in the office as an outpatient. Sometimes it can just be five treatments or it can be daily for up to nine weeks for a prostate cancer radiation. So those are the two main treatment options, surgery or radiation therapy.

Host: All right so surgery or radiation therapy and obviously you're a radiation oncologist so a good person to have on to talk about this. So let's talk about radiation therapy a little bit. What is it exactly? When is it recommended? That kind of thing.

Jaymin Jhaveri, MD, MS, DABR: Radiation therapy is recommended for all different types of prostate cancer low risk, intermediate risk, high risk, all varieties of prostate cancer. Even cancer that's spread to some of the lymph nodes we even offer treatment or curative intent treatment. Radiation is a simple thing. It's an x-ray. Kind of like you get an x-ray at your dentist's office or an x-ray for a broken bone; except this time, these x-rays are, the energies are cranked up a thousand fold higher and they're pinpointed to the prostate gland with extreme precision. And every day a small radiation dose is given that slowly over time kills the prostate cancer cells.

Host: Yeah, just want to get a sense of how radiation therapy has advanced in the last few years and ultimately you know how the improvements how are they benefiting patients.

Jaymin Jhaveri, MD, MS, DABR: Yeah we were able to over the last decade or two, we were able to advance technology in a form that allows us to deliver radiation very precisely. So for instance with our radiation treatment machines here, our precision's within three to five millimeters so we can pinpoint high energy x-rays up to five in precision ah and by doing that that affords us the ability to increase the radiation dose to the cancer itself while minimizing radiation dose to the adjacent organs. That reduces side effect and increases, cure so improving the overall outcome of the patient.

Host: I can even a lay person like myself and get a sense of you know you obviously want to really narrow the field and really target the prostate you know and not the things around the prostate of course. Are there some side effects of radiation therapy? And how do you recommend that patients manage them? 

Jaymin Jhaveri, MD, MS, DABR: There are side effects of radiation and they can be usually visualized instead of memorizing them. The prostate gland anatomically, sits deep in the pelvis. And it's near two main organs. One is the bladder which it sits right in front of the prostate gland and the other is the rectum which sits behind it. So when we give radiation to the prostate gland, we maximize radiation dose to the prostate but some of the radiation does inadvertently get delivered to the bladder and the rectum and as a consequence patients can have side effects from the treatment. The most common side effect is urinary frequency.

So that means, during the day peeing more often and at night, waking up in the middle of night to pee more often and that's a common side effect. The other is also urinary urgency which is the sensation that you got to go, you gotta go to the bathroom all the time. That's another common side effect that pertains to the radiation that's given to t bladder area. And finally, there can be some loose stools and diarrhea that can happen during radiation treatment.

As far as how to manage them, usually we see our patients every week during the radiation treatment course individually face-to-face to talk about the side effects they're having. We give them medicines to help calm those side effects down. The majority of patients, I would say ninety nine percent of the patients are able to complete the radiation treatment course successfully with minimal to no side effects.

Host: Yeah that's always encouraging you know side effects unfortunately are part of life, part of medicine, but good to know that you can help manage them and that they make it through most of them pretty successfully. Just uh finish up with you here Doctor just, typical prognosis for patients who undergo radiation therapy? You know I don't know if you start weighing the options of treatment options but limiting it to just radiation therapy, how does that usually go?

Jaymin Jhaveri, MD, MS, DABR: I know patients often scared when they get diagnosed with cancer and they want to know will I live, will I get to see my granddaughter graduate from high school?

Host: Of course, yeah.  

Jaymin Jhaveri, MD, MS, DABR: Or important events like that. The important thing that dictates prognosis is the stage of prostate cancer. For example someone who has low risk prostate cancer, with radiation, the cure rate they measure at five years is anywhere between ninety five to ninety nine percent. As opposed to someone on the other side of the spectrum, or a patient who has high risk or very high risk prostate cancer with radiation the five year control rate could be seventy percent. That's just in general the, the gist of the, the statistics but it obviously varies individually with each patient.

Host: Yeah exactly right. That's just kind of the broad picture, it's a patient sort of specific kind of thing working with their doctors and specialists all that. It's been really educational. Good stuff today. I just wanna give you both a chance you know kind of final thoughts and takeaways. Dr. Kelly I'll start with you.

Emily Kelly, MD: Thank you. So I think we talked a lot a about prostate health, prostate cancer, possible treatment options. I think the big take home message is make sure that we're being screened, make sure that we're being screened at least biannually and also being accurate with our risk factors especially because a lot of primary care providers may not prostate cancer discussions and screening until age fifty five where if you know you have a really strong family history of prostate cancer in your father, brother, uncle, grandfather;then that really needs to be to bestarted and initiated at age 40. So we could be missing a really vital window.

So I think it's really important to get the message out to say make sure this is done, that it's being done appropriately and not to be scared by it because even if we are diagnosed with prostate cancer early and we're able to intervene early, then the survival rate is very high.

Host: Right.

Emily Kelly, MD: So I think the big take home message is make sure that were having appropriate screening.

Host: Yeah that's perfect. All right Dr. Jhaveri, last word to you. 

Jaymin Jhaveri, MD, MS, DABR: My take home message for the listeners is try not to be scared. I know cancer is a scary thing to be diagnosed with. But go meet with your urologic surgeon and radiation oncologist to talk about treatments. Our technologies advance tremendously both surgically and from the radiation standpoint we're able to cure these cancers with very little to no side effects. So try not to be scared and go meet with your oncologist.

Host: Yeah great words of advice from experts here today. You know as you both say you know it is scary of course but with all of the advancements and especially stressing Dr. Kelly the importance of screenings, early diagnosis, early treatments. Dr. Jhaveri, I get a sense of how when we think about survival rates, how important all of those things will be to all of us surviving prostate cancer. So I just want to say thank you for your time, expertise, all that good stuff. Thank you so much.

Jaymin Jhaveri, MD, MS, DABR: Thanks Scott.

Emily Kelly, MD: Yeah thank you for having me.

Host: And if you're experiencing any concerning symptoms, please consult your urologist or primary care provider to learn more about prostate cancer visit HF.org.

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