Transcription:
Detecting and Treating Prostate Cancer

Melanie Cole (Host): According to the American Cancer Society, about one in eight men will be diagnosed with prostate cancer during his lifetime. But what are the current best practices for detecting and treating prostate cancer? It's such a growing field now. Welcome to Its Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Joining me today is Dr. Edward Forsyth. He's a urologist on the medical staff of Kec Medicine of USC and Henry Mayo Newhall Hospital, and he's here to share how Henry Mayo Newhall Hospital in Kec Medicine, our collaborating to bring world class cancer care to the Santa Clarita Valley.

Dr. Forsyth, it's a pleasure to have you with us today. As I said in my intro, I mean, this is just such an exciting time to be in your field. So many tools. We'll get into prostate cancer itself in just a minute, but before we do, can you tell us how Henry Mayo Newhall Hospital and Kec Medicine of USC are collaborating to bring that world class cancer care to the Santa Clarita Valley? Tell us how this came about and what's happening?

Dr Edward Forsyth: Well, it's my pleasure to be here and thank you for having me, and it's a very exciting time both to be a physician in this field, but also to be working for these great institutions. So I did my training and then I went through my fellowship at USC, and then when I was brought on to stay on the staff, I had to interview not only with all of the faculty in the whole department of USC, but the same thing with Henry Mayo, because these two institutions have gone in on a venture together to provide cancer care locally through Henry Mayo to the Santa Clarita Valley.

So both institutions have full buy in as far as making this the most successful treatments available for the patients and specifically not to diagnose them here and then bring them somewhere else for their treatment, but to treat them here at Henry Mayo. And so, I get to work with both institutions and I get to have the benefits of both, but it also means I have a lot of extra bosses. But that's been okay so far.

Melanie Cole (Host): How cool. And they're lucky to have you as well. So tell us a little bit about prostate cancer, the incidents and the prevalence and then I'd like you to speak about screening because that seems to be a little bit of a confusing spot for people about the recommendations, when it starts. So speak about prostate cancer for.

Dr Edward Forsyth: Absolutely. So it is the most common cancer in men, and it is a very high cause of cancer. Death in men. Lung cancer and prostate cancer kind of switch off as the two most lethal cancer killers in men. And as part of the joint venture up here, we had a symposium. Back to screening. because of covid, so many patients have fallen off on their cancer screening. So we just had an event up here and I spoke at this to discuss. All the different cancers and how to screen for them etcetera. So, specifically prostate cancer you've heard of some of the controversy and that is exactly what we were hoping to address with this symposium.

So the foundation of prostate cancer screening for the last 30 years has been the PSA blood test. Before then it was either physical exam or there would be symptoms or blood in the urine. But this was a blood test that was able to detect cancer at a very early stage. And so the incidence of cancer went up a lot because it was being discovered. And then the cancer death ended up going down throughout the nineties, which was very good. But the controversy arose because Although we were saving lives by treating all these prostate cancers, maybe some of them were not gonna be the cause of death in that patient, meaning there was overtreatment going on.

So when you order a test to find something, sometimes you'll find it and. At all those patients were being treated. And therapy for prostate cancer does have side effects. So we've been trying to seek a balance in finding the right cancers and treating the right cancers while trying to make sure that the less dangerous ones are not overtreated.

Melanie Cole (Host): That's a great point because I have heard that before. So because of that, some of the treatment options are active surveillance. Watchful waiting. Before we get into that, explain PSA because you mentioned that as the test, people don't really know what those numbers mean. Can you explain that a little bit and how PSA doesn't always mean cancer, because it could mean BPH as well?

Dr Edward Forsyth: Absolutely. And part of the, part of the controversy is that it can be difficult to interpret the PSA, which is why it's so important to talk to your doctor both before you get it checked, but then afterwards to help interpret it. Because it can be different in every person. So overall, in a very course fashion, a high PSA could indicate cancer, cancer cells. Not normal, and PSA stands for prostate specific antigen, and those cancer cells make more PSA than others, so that's why that blood value would be higher.

However, simply having a large prostate, inflammation, infection, these are all things that can elevate the PSA for non-cancerous reasons, which is why if you do have an elevated PSA, usually the first step will be to check it again as well as have a physical examination with a urologist or with your primary care doctor. And then make sure that that's truly an elevated number before you would go into the next steps. And then furthermore, what's considered a normal value goes up as you get older.

So in the very young, in those under 50, under one is considered extremely safe. And that kind of trend will then continue if you're in the low ones, by the time you're 60 or below one still, by the time you're 60, that's also considered very safe. But then depending on which guidelines you look at; it can get a little more confusing.

Melanie Cole (Host): That was a great description, Dr. Forsyth. So there's so many tools in your toolbox these days. You and I were even discussing a few of them off the air and some of the exciting advancements. Any of these advancements in treatment, whether we're talking about like focal therapy for just within the prostate or systemic, metastatic, whatever. There's all these different treatments that you've got and some of them include imaging, and radiotherapy. Some are medication, some are active surveillance. Just watching and waiting.

Can you speak about some of these treatments that are out there? The ones that you see that have the best outcomes with maybe the least side effects? Because I think for men, one of the biggest fears of this type of cancer is those side effects, erectile dysfunction, incontinence, those kinds of things. Speak about what's exciting and going on right now.

Dr Edward Forsyth: Well, you hit the nail on the head because as far as treatment goes, it's all about balance as it is with screening. And all these treatments have side effects, and it's about finding what ends up working for each individual patient. So when we have a diagnosis of prostate cancer we will first figure out how dangerous it is or put it into a risk group. So those low risk groups, That's where we can do active surveillance, which watchful waiting includes actually just watching and waiting.

Whereas active surveillance, we get frequent PSAs and we would also get more biopsies. So that's the active side of it where we're monitoring not just the blood test, but even the pathology by getting those repeat biopsies to make sure that the cancer doesn't change into a more dangerous form while we're watching it. The imaging side of things is also very exciting because you'll probably come across prostate MRI, and I use this a lot because that can be helpful both in the screening phase and in the treatment phase of prostate cancer.

So with MRI there are areas that can be identified as suspicious, and then we can target our biopsies at those areas. Once we're able to localize the tumor to maybe one side of the prostate that can help guide the next phase in treatment. Treatment would be broken into broad categories of surgery, radiation, or focal therapy. And they all have pros and cons. So with surgery, we're able to use that imaging the information from the MRI to help tailor when we're doing nerve sparing, which trying to preserve the erections as best as we can during the prostatectomy.

To maybe be more or less aggressive with how much cancer we're trying to take versus, well, rather how wide we go when we're resecting the prostate. Because the wider you go, you might be better at getting the cancer, but you'd be losing some of the nerve sparing. So the MRI data can be used to help guide that treatment. Furthermore, in the focal therapy realm, that's really the newest thing. And we are bringing that to the Santa Clarita Valley, but it's available to our patients as well at Kec.

That uses the information we learned from the MRI and the prostate biopsy to destroy the tissue of the prostate in place while trying to completely avoid those nerves and certain patients or candidates for that and certain are not. And right now it is still considered an alternative therapy. So you make sure you have a good conversation with your doctor before pursuing that. But it's very exciting in that there are certain patients who are able to have treatment for their prostate cancer and really avoid a lot of those side effects.

The third category is radiation, which involves destroying the prostate also while it's in place using energy. And surgery and radiation both are very good, and it's important to have a conversation with both the urologist and a radiation oncologist. And to balance the pros and cons of each. And some patients end up needing both as well. So it's important to have those relationships in place. But that's the grand tour of treatment for localized cancer in a nutshell.

Melanie Cole (Host): That was an excellent description. So, I mean, we could really go on and talk about this for a long time, but these podcasts are not that long. But before we wrap up, When you're speaking about all of these different therapies, and again, I go back to those side effects that, really do concern men, how do you discuss those with your patients, and look at all these tools that you have and say, Okay, we can manage this, whether it's ED or incontinence, or any of these things. How do you weigh those pros and cons with your patients?

Dr Edward Forsyth: Well, it starts with a very honest conversation up front because both surgery and radiation are going to have side effects and we do everything we can to reduce them, but we want to be honest with what to expect. The great news is with robotic surgery and sort of the modernization of the radical prostatectomy. The rates of incontinence have gone way down. So really about 90% of men will end up with zero pads or maybe leaking a few drops of urine when coughing or sneezing or doing heavy activity. But lots of men, including my father, haven't had to wear pads for a very long time.

The erections, we often say, well, they are going to get worse even if we do a perfect nerve sparing. But the most important predictor is how good they are to begin with. So the stronger the tissue ahead of time, the better the recovery can be. And we also offer what is we call penile rehab, which is after the prostatectomy will often, as soon as the catheter comes out, start some medications to help enhance the erections and help to maintain the blood flow to the area. So that those, the penile tissue is still getting fresh blood flow and hoping to reduce some of the scar tissue formation that can occur as a result.

We try to be as aggressive as we can to maximize our potential for preserving and recovering those erections. As far as radiation, those side effects also occur. And their rates end up being about similar, but they end up starting off slow and getting worse over time, whereas a lot of the side effects from surgery start off more severe and then can recover as time goes by and the body heals.

Melanie Cole (Host): Well, it certainly is that honest discussion to have. And so as we get ready to wrap up, I'd like you to speak about the multidisciplinary approach that's so important for these patients and anything exciting, future directions in prostate cancer, and really this collaboration between KEC Medicine of USC and Henry Mayo Newhall Hospital?

Dr Edward Forsyth: So the multidisciplinary approach is critical with prostate cancer, especially with the more dangerous and high risk diseases. It's so important that the patient knows they might end up having surgery and radiation and medication. So each of those fields has had tons of advances. And so you really want a specialist from each realm to be available to take care of everything. So the high grade cancers might need surgery followed by medication with radiation and or more medication going forward.

So that's very intimidating and it sounds like a lot, but what we've been able to do is really enhance the survival of even the dangerous and most aggressive prostate cancers. And on the frontier, there's new imaging like PSMA scanning, which is helping us to detect recurrence at a very, very early stage, as well as maybe treating radiation to areas where the cancer has spread. Our colleagues in radiation oncology are available up here at Henry Mayo Newhall, and our colleagues in medical oncology as well.

We are all in close touch, so there's always new medications, new scans and new therapies coming out, and we're just very excited that we're being able to bring that to the local level here because I think a lot of people can benefit.

Melanie Cole (Host): Thank you so much Dr. Forsyth, for joining us today and sharing your incredible expertise. You know, I say it again. They're very lucky to have you. And thank you again for coming on the podcast. And if you need to see a specialist in prostate cancer detection and treatment, or for any other urological conditions, please call 661-839-1800. You can also visit our website at henrymayo.com for more information and to get connected with one of our providers. And we also have the free Health information library at library.henrymayo.com. That concludes this episode of It's Your Health Radio, with Henry Mayo Newhall Hospital. I'm Melanie Cole. Thanks so much for joining us today.