Intro: It's your health radio, a special podcast series presented by Henry Mayo Newhall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And today, we're talking about detecting and treating prostate cancer. Joining me is Dr. Kian Asanad. He's a urologist with Henry Mayo Newhall Hospital and Keck Medicine of USC. Dr. Asanad, it's always a pleasure to have you on.

Before we get into the topic, can you just tell us a little bit about the prostate itself? What does it even do? What happens to the prostate as men age?

Kian Asanad, MD: Sure. Glad to be back, Melanie. So, the prostate is a deep-seated organ in men that really only plays a role in semen production, the volume of the ejaculate. And as men get older, the prostate can enlarge. And when it enlarges, it can cause urinary symptoms for some men, trouble urinating, difficulty emptying their bladder. This is known as BPH or benign prostate hypertrophy or growth. And sometimes prostate can develop a cancer. So, prostate cancer can develop as well.

Melanie Cole, MS: Is prostate cancer pretty common among men? Because I've heard some statistics that men, as they get older and as our generations are getting older and living longer, that more men will get prostate cancer and that many men also get BPH as they grow older.

Kian Asanad, MD: Yep, prostate cancer is incredibly common. There's a one in eight lifetime risk. It's the second most common cause of cancer-related death in men in the U.S. And so, we have lots of guidelines to screen men for prostate cancer, just like we screen for other types of potential cancers like colonoscopies and colon cancer. Prostate cancer screening is one of the recommendations as well.

Melanie Cole, MS: Well, then, let's talk about that. Let's talk about the screening, Dr. Asanad. First of all, as we think about getting our partners in to get screened in the first place, how do we get them to come see you? Because I know that many men, my husband included, does not want to go to the doctor at all, much less a urologist to have the digital exam and the PSA. I'd like you to speak about screening and your best advice to the partners out there to get their men to come in to get screened in the first place.

Kian Asanad, MD: Sure. Yeah. So, to see a urologist, many of the patients I see haven't seen a doctor, as you mentioned, since they were 18, maybe they haven't had a physical. Some of the first signs that bring them to a urologist's office is trouble urinating, waking up at night to urinate, maybe there's blood in the urine, or commonly they'll come in for erectile dysfunction and sexual side effects or sexual health concerns. And when I see men and if they're of the appropriate age, I always talk about prostate cancer screening. So, that's the more common approach.

PSA screening is routinely done by primary care physicians with annual physicals. For patients who see their primary care physician on a regular basis, PSA screening is routinely done. So, that's really one of the main approach. But yeah, definitely shedding light on the importance of PSA screening, it's super important. So, the AUA guidelines, or the American Urologic Association guidelines recommend screening for prostate cancer at the age of 50. And all that nowadays is actually just a blood test for your PSA, which prostate-specific antigen. The digital rectal exam is actually found to be optional at this point. So, we only just start with a PSA test. You can begin prostate cancer screening to get a baseline test for men if they wish, starting at the age of 45. And in men who have a risk factors for prostate cancer, maybe they have a brother or a father who've had prostate cancer, if they have any family history suggestive of a genetic predisposition to certain cancers or African-American race, we do recommend prostate cancer screening even earlier at the age of 40. Again, that's a PSA test or a blood test as a first step.

Melanie Cole, MS: There's numbers involved in that PSA, Dr. Asanad. Tell us what those numbers mean.

Kian Asanad, MD: Yeah. So, we use an absolute cutoff of 4 for the majority of men. If the PSA is less than 4, we generally consider that normal. If the PSA is over 4, that's considered abnormal. There are some nuances to that. The PSA may be less than 4, but maybe a man has been checking it every year and it's rising. We look at changes in the PSA as well. That's an important information to have. Was it 0.5? Now it's one, now it's two, now it's 3? That's something worth investigating. We also calculate something called PSA density. So when we look at a PSA, we determine information about the prostate as well. And if a patient has a really large prostate and it's secreting a lot of PSA, the density is also an important parameter to determine whether this is something that needs further investigating or not, or can give us more reassurance.

Melanie Cole, MS: Thanks for explaining that because not everybody always understands what those numbers mean when they see them come back after the test itself. Now, you mentioned a few symptoms earlier. You mentioned getting up in the night or blood in the urine. Can you expand a little? Because I think this is important because it is what helps get these men in, whether it's primary care where they start or off to Urology, where they will end up if they do have some of these symptoms. Can you kind of go over those again for us?

Kian Asanad, MD: Sure. So, urination for men is a very complex process. The bladder and the prostate are really intimately involved. So for a man to urinate, few things happen, right? The bladder muscle squeezes, the sphincter muscle for men relaxes, the muscles of the pelvis relax. It allows flow of urination and emptying the bladder.

The prostate sits at the base of the bladder or the neck of the bladder. And as men get older, the prostate can enlarge and it can cause a blockage or obstruction of the bladder. I commonly refer to men as a donut. Men have a prostate the size of a donut. As men get older, that hole in the middle closes down. It can impede the flow of urine. And so, that can cause symptoms like trouble urinating, a weak stream, hesitant to start the stream. And as a result, the bladder doesn't empty as well. There's retained urine. And so, men get the urge to urinate more frequently, so they go to the bathroom more often or they wake up at night more frequently because their bladder is not emptying fully.

Other symptoms can include blood in the urine. So, the prostate is a very vascular organ. There's lots of blood vessels around it. As the prostate enlarges, a vessel could ooze and bleed and have blood in the urine. That doesn't mean that there's cancer there, it just means it warrants evaluation. So, those are some of the more common symptoms. But the size of the prostate, interestingly, does not correlate with severity of symptoms. I have patients with huge prostates and have no symptoms. There's no blockage. Some patients with moderately enlarged prostates with severe symptoms, so just because you have a big prostate doesn't mean you're going to have severe symptoms. But the PSA test is just a blood test that we also look at for ruling out cancer.

Melanie Cole, MS: So if the PSA is questionable or high, what is next? Tell us a little bit about diagnosis and staging too. Because we've heard this term, Gleason score. Can you tell us a little bit about what that means?

Kian Asanad, MD: Absolutely. So if the PSA is abnormal or over 4, let's say commonly, the first step is actually to repeat the PSA guidelines. Recommend a confirmatory PSA test to make sure it's not a spurious result. There's many reasons why a PSA could be elevated despite cancer. You could have a big prostate, secretes PSA. If you had a recent urine infection, the PSA could be high. If you had recent instrumentation, like a catheter in the bladder or you had a camera procedure done, that can cause the PSA to be elevated. So, you want to confirm it on a repeat test.

The second step is now I do recommend digital rectal exam to feel if there's any lumps or bumps, areas of firmness in the prostate. Once we confirm that or the prostate exam is abnormal, the next step is an MRI of the prostate. There's been some landmark papers in the New England Journal of Medicine a few years ago now, back in 2018. We do imaging of the prostate via MRI to see if there's any areas of the prostate that is suspicious for a tumor or a malignancy.

 And so when we talk about biopsy as the next step, we biopsy the prostate throughout the entire prostate, as well as take extra biopsies of those specific areas or targets. So in summary, PSA comes back abnormal, meaning over 4. Second step is to repeat the PSA to confirm it's still elevated; digital rectal exam, to check the prostate for any lumps or bumps. And then, I'll send patients to get an MRI of the prostate to discuss those findings and the MRI of the prostate comes back with a different risk category. It's scored on a scale of 1 to 5. One and 2 means that there's no areas in the prostate that look suspicious. Even in those cases, there could be a cancer in 10-15%, even if there's no areas on MRI that we can see. And then, score of 3, 4, 5. And the higher up you go and score, the more suspicious it is for a prostate cancer. So, those are kind of the next steps. Then, I'll see the patient, we'll review the MRI. We'll review the PSA, and we'll talk about doing a prostate biopsy to determine what you mentioned, the Gleason grade, if present.

Melanie Cole, MS: You're such a great educator, Dr. Asanad. You explain everything so well. And really, you make it understandable. Now, let's talk about those tools in your toolbox because, wow, for your field, this is a very exciting time. So much happening. So many ways and modalities for you to help men with prostate cancer. So, speak about some of those, some of the more exciting ones, ways to keep track. I mean, there's focal therapy and there's watching and waiting. And then, are we still doing prostatectomies? Tell us what's going on in your field.

Kian Asanad, MD: Absolutely. Let's start with biopsy actually. So, even biopsy has new modalities. So traditionally, biopsy of the prostate was done transrectally, meaning through the rectum, through the feces, to biopsy the prostate typically done in the office under local anesthetic. It could be done in the operating room under a light sedation. Nowadays, we commonly perform transperineal prostate biopsy, meaning we're not going through the rectum anymore, we're going through the perineum, which is the skin between the rectum and the scrotum. Why do we do that? Because of risk of infection. So, there is about a 1% risk of infection if we went transrectal, and this is a severe infection. I mean, fevers, chills, hospitalization, prostate infection, it's not a routine infection. Transperineal technique has been studied and published by many researchers recently, European Urology, that have found 0% risk of infection with no antibiotics. Really, a novel technique that's been demonstrated to be equivalent to transrectal in terms of diagnosis, but also did not carry the risks of infection and other issues. So, transperineal technique of prostate biopsy is now what I completely do for patients who need a prostate biopsy.

Second, so we move over to treatment. I think the important point, Melanie, is the majority of patients that are diagnosed with prostate cancer are commonly diagnosed with very low risk or low risk prostate cancer, meaning these are not cancers that are likely to progress spread or cause death to the patient. They are commonly just found and we don't even treat them. We perform what you mentioned, active surveillance. We just monitor them with repeat blood tests, PSAs, repeat prostate biopsies, repeat MRI, and we want to make sure that it's not progressing. And the majority of these patients stay on active surveillance for quite a while before they even need treatment if they do.

The prostate cancers that do require treatment are the groups known as Group 3, 4, and 5. These are the more aggressive types of prostate cancer where active surveillance is not typically recommended. In these patients, options, if there's no cancer throughout the rest of the body, nowadays still include radical prostatectomy, which is almost universally done through a minimally invasive robotic approach. We use a robotic console that we control as surgeons. Make tiny openings in the abdomen, and very precisely and meticulously can remove the prostate from its connection to the bladder and urethra. Avoid injury to the other organs, like the rectum and the blood vessels completely preserve the nerves around the prostate that are important for sexual function. Radiation is also a well-established and equivalent treatment option for patients that has the same efficacy to radical prostatectomy in terms of overall survival and treatment that's done by a radiation-oncologist.

And finally, focal therapy, which you mentioned. So, focal therapy nowadays is a modality that we can treat just the area of the prostate that has the tumor. There's specific inclusion criteria required for this. Typically, the prostate cancer or lesion is only on one side of the prostate. It's not in the entire prostate. And it's really reserved for men who really want to prioritize their sexual function, urinary function that could be changed with radiation and prostatectomy.

So, here at USC, we do have focal therapy experts who do a lot of that sort of work. And we commonly refer patients to them for candidacy of those procedures.

Melanie Cole, MS: How often is hormone therapy now a part of this? Are we doing these targeted, and hormone? All these words get thrown around, and we hear them as exciting ways for treatment.

Kian Asanad, MD: Yeah. So, hormone therapy is typically combined with radiation for the intermediate risk cancers known as the group 3 cancers, typically for about six months, six to 18 months. It's a temporary combination with radiation. Patients with higher risk cancers require sometimes two years of hormonal deprivation therapy or androgen deprivation therapy known as ADT.

What does that do? It's a medicine that basically shuts down testosterone production in men. And that can treat the systemic side of prostate cancer in addition to radiation. And in the less common cases of metastatic prostate cancer, meaning if the prostate cancer has spread throughout the body, usually those men require lifelong hormonal therapy or on androgen deprivation therapy for life. And that's to minimize the testosterone to levels that are undetectable or less than 50 or known as castrate levels to treat the prostate cancer throughout the entire body. That's what ADT or hormone therapy refers to. And it's not a one-size-fits-all. Sometimes it's a short course, sometimes it's about two years, and sometimes it's lifelong.

Melanie Cole, MS: As we said, there's so much going on in your field. And Dr. Asanad, one of the things that I've heard over the years when it comes to prostate cancer, that men, one of the reasons they don't even go to the doctor is because they don't want to discuss the side effects. The cancer is one thing, but the side effects are another. And you and I have talked about incontinence before, erectile dysfunction. There are these side effects. Can you speak about how you work around with those while you're dealing with somebody with prostate cancer?

Kian Asanad, MD: Absolutely. I mean, I saw a patient in the office today. This discussion comes up all the time, right? And so, prostatectomy has risks, has benefits. Radiation has risks and benefits. And there's different factors that can kind of elude a patient to be a better candidate for prostatectomy versus radiation, right? If a patient in general is not a good surgical candidate, maybe they're older, have a lot of medical problems, I'm worried about anesthesia for them, radiation seems to be a better approach, but from a radical prostatectomy side, I talk about openly with patients that there is a significant decrease of erectile function that occurs after prostatectomy, especially in the beginning.

 The good news is even in the bilateral nerve-sparing approaches and the best approaches, recovery of erections can take up to 18 months to two years. We don't wait that long. And the good news is we have lots of different treatment options, as we've discussed previously for erectile function to optimize blood flow to the penis and optimize erections. But I have to be very open and honest in those conversations that the erections will change. Some men are older, right? This is a typically a disease of older patients. Many patients are not prioritizing their erectile function. Maybe at baseline, they have poor erections. And so, doing a surgery for them, it's not going to make anything worse or better. It's at their baseline. So, that's a non-issue for some patients, right?

Leakage is always an issue. Nobody leaks usually prior to surgery. Nobody wants to leak. The good news is incontinence is pretty uncommon after a year from prostatectomy. Over 90-92% of patients are continent after a prostatectomy at a year. The majority of patients are continent after even six months. So, I tell all patients immediately after surgery, when the catheter comes out, you will leak urine. It is going to happen. That's why we work with pelvic floor specialists and pelvic floor exercises to regain continence for the majority of patients. And for the 10% of patients who are incontinent after a year, we also have treatment options for those, including slings or prosthetic sphincters that can help improve quality of life.

Melanie Cole, MS: Wow, Dr. Asanad. Those are very encouraging words you've just given. Really letting listeners know that when you're managing those side effects, that there are treatment modalities that work, and that it is very encouraging and hopeful. Wrap it up for us with your best advice about navigating those emotional challenges for the couple when someone is diagnosed with prostate cancer, but the importance of getting in, getting screened, knowing those symptoms, and going in to see your doctor.

Kian Asanad, MD: Absolutely. I would say prostate cancer is incredibly common in men. And the evaluation and screening is easy, right? It's not even a colonoscopy to go under sedation and put a camera inside. It's just a routine blood test, PSA test. It's done with your annual physical starting at the age of 50 for the majority of men.

As a take home point, if you have a family member, like a brother or father with prostate cancer, or anybody in your family diagnosed with metastatic prostate cancer or African American ancestry, African American race, I do recommend starting screening earlier at the age of 40. And you want to monitor that every few years. Getting those data points is important. And once we can get that data information, always see a urologist if you have any concerns about urinary symptoms or blood in the urine so that can be investigated. And the good news is there's so many different treatment options available. And if things are caught early, it's curative in the majority of patients.

Melanie Cole, MS: Thank you so much, Dr. Asanad. You're just such a great guest as always. And for more information, you can visit our website at henrymayo.com. You can also visit the free Henry Mayo Newhall Hospital online library. So much great information there at library.henrymayo.com. That concludes today's episode of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Thanks so much for joining us today.