Scott Webb (Host): There are a variety of treatment options for metastatic prostate cancer, and one of the most promising that's being offered to patients at the Maimonides Cancer Center is Pluvicto. And joining me today to discuss the importance of screening and early diagnosis and the various treatment options is Dr. David Berlach. He's the Chair of Radiation and Oncology at Maimonides Health.

This is Maimo Med Talk. I'm Scott Webb. Doctor, thanks so much for your time today. We're going to talk about a serious topic, metastatic prostate cancer and the options that folks have. I know it's a really a terrifying diagnosis. So, glad to have your expertise today. Let's just start here. Let's have an overview of metastatic prostate cancer and who's at the highest risk.

Dr. David Berlach: Prostate cancer is the number one cancer diagnosis for men. That's in the United States and around the world. In the U.S., about 288,000 men every year get diagnosed with prostate cancer. It is one-third of all new cancers for men, but it only accounts for about 11% of all cancer deaths for men.

So, while a lot of people get prostate cancer, fortunately, few of them, relatively speaking, actually die from prostate cancer because we are very, very successful in treating early stage prostate cancer. Now, a large proportion, roughly a third of men who get prostate cancer, will develop metastatic prostate cancer. So, these are the patients that we're really going to be talking about today. And those are the more challenging cases to treat. Because once the cancer has spread beyond the prostate, it can cause all sorts of problems. And not only does it result in death, but it could also affect quality of life. And, you know, we're trying our best to improve everyone's quality of life while keeping them alive as long as possible.

Host: Sure. Yeah, we're going to talk about screening and diagnosis and Pluvicto, and lots of important stuff today. Before we get there though, what are some of the symptoms that folks and men especially would be experiencing if they had prostate cancer or perhaps even if it had spread and become metastatic prostate cancer?

Dr. David Berlach: So, a lot of men who get diagnosed with prostate cancer are diagnosed through screening. There's a blood test that you can test that tells us that men are at risk of having prostate cancer and then you need additional testing to confirm that. So, the majority of people who find out they have prostate cancer don't have any symptoms. But when we're talking about metastatic prostate cancer, one of the most common symptoms is actually bone pain because prostate cancer frequently travels to the bone and it can cause pain. So, that is a common symptom. Other symptoms that can occur are difficulty with urination, difficulty with ejaculation, or even difficulty with bowel movements.

Host: Okay. Yeah. So, let's move then to screening and diagnosis, both the importance of screening and early diagnosis and how you do that.

Dr. David Berlach: Screening is an interesting question, because up until 2012, it was pretty routine for all men to get screened for prostate cancer later in life, usually starting around 50 or so. And then in 2012, the United States Preventative Services Task Force decided that we were treating too many people with prostate cancer that probably didn't need treatment at all and so, recommended against routine screening. And during that time, actually the great improvements that we had in cure rates for prostate cancer actually started to decline. And so by 2017, they revisited that and made it a much more kind of nuanced discussion that you're supposed to have with patients about how you're going to do the screening. And so for men now, the current recommendation are for men from ages 55 to 69 should have a discussion with their physician about whether or not they are at risk for prostate cancer and should they have screening. So, we're starting to see, you know, increases in the number of people being diagnosed again with prostate cancer and also improvements in survival.

Host: Yeah. And of course, with all cancers, but especially trying to catch prostate cancer before it becomes metastatic is so key, so the screening or early diagnosis. Let's move in now and talk about, as I mentioned earlier, this is really a terrifying diagnosis. I'm 55 years old. I'm a male. So, you know, I'm a bit terrified of being diagnosed with prostate cancer. So, for folks who've been diagnosed, let's talk about the treatment options and especially Plevicto.

Dr. David Berlach: First of all, I mean, understandable that you're terrified, especially when you're getting into that age where, you know, you fit right in in that group that I just mentioned. And also, you know, probably have had some friends or relatives or acquaintances that have been diagnosed with one cancer or another. So, I'm getting to that age also where these things just start happening more frequently. And I guess as an oncologist, I get that call a lot from people I haven't heard of in years or decades even. And they're like, "Oh, I just got diagnosed with cancer. Can you help me?" So, you know, it is something that is scary. But the truth is that expression, "You have nothing to fear about fear itself," really ties into this. Because you can't be scared of finding out that you have cancer. What you should be scared of is having cancer and not knowing about it, because that's when you really run into problems. So, I cannot over express how important it is to undergo screening as recommended by your physician.

Now, in your particular case, you might not have a family history or other risk factors that put you at high risk for prostate cancer, so maybe screening is not important for you. But if you do have a family history, it is really important. And just one more thing I want to mention, prostate cancer disproportionately affects African American men. And so, that is, you know, by about a 3:1 margin. And so, that in and of itself is a risk factor. So if you're an African American male, you know, over the age of 55, you certainly should be talking to your physician about whether screening is right for you.

To get back to the actual question, which was treatment, there are so many treatments for prostate cancer. Because it is the most common cancer in men, there's just been an enormous amount of research that has been done to try and treat and not only treat the cancers, but also to improve the quality of life, like I said.

So, the three main ways we treat cancer in general are surgery, systemic therapy, and radiation therapy. So, surgery definitely has a role in the earlier stages of prostate cancer and could be curative. Systemic therapy is a term that encompasses, you know, most people when they think of cancer treatments and drugs for cancer treatments, think about chemotherapy. But in fact, there are many, many things beyond chemotherapy. So, one of the mainstays of treatment for prostate cancer is something called androgen deprivation therapy or hormonal therapy. Prostate cancers love testosterone, they eat testosterone for breakfast. And by giving medicines that adjust the levels of testosterone in the body, you are able to suppress kind of the food supply for the cancer and get rid of the cancer. So, these hormonal therapies, major treatment modality for prostate cancer.

Chemotherapy is used usually only in the metastatic setting where the cancer is spread. And then, there are newer therapies like immunotherapies and targeted therapies that are very, very specific to cancer. So, you can get really good results in terms of cancer control with much less side effects than traditional chemotherapy. So, that is kind of a newer modality being used, but it's extremely effective across a wide range of cancers, including prostate cancer.

And then, radiation treatments, which is actually what I do. I'm a radiation oncologist. Radiation can be used in the curative setting, so you can get rid of prostate cancer with radiation. Or if prostate cancer has spread to other parts of the body, you can use radiation to palliate the symptoms, you know, whether it's bone pain or compression of something or other. You can shrink those tumors with radiation and relieve the symptoms. For a few years now, we've been using injectable forms of radiation that can travel throughout the body. In the older versions of this, it would actually just target the bones. Like I said, prostate cancer tends to travel to bones when it spreads. So, you give the form of radiation and radium that would kind of attach to all of your bones and kill off any prostate cancer wherever it was. And that was very effective in reducing bony pain related to prostate cancer, but it wasn't super targeted. It would go everywhere you have bones. You got a lot of bones in your body.

Pluvicto, it was approved by the FDA in March of 2022, is a targeted form of injectable radiation. So instead of just going everywhere where there's bones, it actually seeks out a specific antigen or a marker on the cell surface, on the cancer cell surface. It's called PSMA, that's the marker. And It attaches to that and delivers the radiation right to the cancerous cells. And I mean, it does treat some nearby normal stuff like bone or whatever is nearby, but it is much, much more targeted than the previous generation. So, this treatment has been shown to not only help get rid of the symptoms of prostate cancer, but has actually been shown to improve survival for men with metastatic prostate cancer. So, this is a really new and an exciting product that we're super happy that we have to offer to our patients. Because like I said, all we're trying to do is keep people alive as long as possible and living as healthy as possible. And these treatments, very effective, but at the same time also have pretty limited side effects and are pretty easy to deliver. So, it really is a great thing. And Maimonides, first place in Brooklyn to offer this treatment. So, we're more than happy to get it to whoever needs it.

Host: Yeah. Yeah. Of course, we don't want anyone to be diagnosed with prostate cancer. We definitely don't want metastatic, you know, for folks. But the reality is, as you say, that lots of people are diagnosed, but because of all these treatment options and the limited side effect profiles and so forth, you know, folks are living and they're living well and they're living longer. So, that's encouraging, of course. I just want to give you a chance here at the end, final thoughts, takeaways, when we think about metastatic prostate cancer, Pluvicto, and mainly how you and the Maimonides Cancer Center can help folks.

Dr. David Berlach: You know, I say this often to my patients and I feel a little bit bad saying it because it's kind of flippant, but it's true. There's never been a better time to be diagnosed with cancer. We have more treatment options than ever before. People are living longer and, just as importantly, I feel, is that they're living well, that these people, you know, with these treatments, Pluvicto, and there's other forms of systemic therapy that are coming online for prostate cancer, people are able to treat these diseases that were once considered catastrophic as kind of like diabetes or high blood pressure. They're just something that you live with, as opposed to something that defines your life. And it's really an exciting time that we're able , to really offer these amazing treatments to patients.

And I agree, I would love to prevent prostate cancer in everyone, so nobody needed any of these treatments. Unfortunately, you know, it's not like those who smoke get prostate cancer, those who engage in illicit drug use get prostate cancer. It's really just being a man is the risk factor for having prostate cancer, so you can't really change that, so we have to do our best to kind of detect it early, treat it when we can, and help people live their lives.

Host: Right. All you experts, you doctors, you went to medical school, no one's trying to put you out of business. But the reality is, as you say, there's never been a better time to be diagnosed because of the treatments and therapies all this encouraging news. So, thank you so much for your expertise today and fighting the good fight and you stay well.

Dr. David Berlach: All right. Well, thank you for having me.

Host: And to make an appointment with the Maimonides Cancer Center, call 718-765-2700. That's 718-765-2700. To learn more about Maimonides Medical Center, please visit maimo.org. This has been Maimo Med Talk. I'm Scott Webb. Stay well.