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Prakash Chandran (Host): Prostate cancer is the second most common cancer in men after skin cancer. And for the men who get it, the diagnosis usually comes later in life. But there are several warning signs, noble risk factors, tests, and treatments for prostate cancer. And today we're going to learn all about them. Joining us to discuss is Dr. Timothy Averch, Fellow of the American College of Surgeons and Urology Specialist at PRISMA Health and Dr. Patrick Kuhlman, Medical Oncologist for PRISMA Health. This is Flourish, a podcast brought to you by PRISMA Health. My name is Prakash Chandran. So Dr. Kuhlman, I'd love to start with you. What exactly is prostate cancer?

Patrick Kuhlman, MD (Guest): Great question. And it's an honor and privilege to be on the podcast. To understand the abnormal, I think it's helpful to understand the normal prostate gland and its location is just below the bladder. And it functions to produce seminal fluid, which nourishes and transports sperm. In prostate cancer, the cells that make up the prostate become abnormal and they proliferate or grow to involve local structures or spread elsewhere in the body.

Host: So Dr. Kuhlman, sticking with you, I think for the lay audience, maybe just talk a little bit at a high level about what a prostate is.

Dr. Kuhlman: Yeah, good question. So, a prostate is a gland that is located just below the bladder and it's function is to produce seminal fluid, which nourishes and transports sperm. In, in prostate cancer, those cells, that tissue become abnormal and they proliferate and grow to involve local structures or sometimes spread other parts of the body. In the United States, one out of every nine men will be diagnosed with prostate cancer at some point during their life.

Host: So Dr. Kuhlman, one more question. Can you describe the types of malignancies that could potentially arise in the prostate?

Patrick Kuhlman, MD (Guest): Yeah, the most common one. You know, usually when I talk to patients about cancer, one of the things I highlight is good to know is what kind it is in. The way that it's gotten is with a biopsy. When that happens, that piece of tissue is sent in front of a pathologist and they describe the kind of cancer that it is.

And most commonly in, in the prostate, it's adenocarcinoma. Rarely there can be other forms of prostate cancer such as small cell carcinoma or ductal carcinoma, but the overwhelming majority is prostate adenocarcinoma.

Host: So Dr. Averch, I wanted to move over to you. Do we know exactly what causes prostate cancer?

Timothy D. Averch, M.D., F.A.C.S. (Guest): That's a great question. And I too am so happy to be here sharing some of our information with your listeners. So what causes prostate cancer? Ultimately, we don't know. We do know and can identify those who have a higher risk of developing prostate cancer, but ultimately we don't know what causes it or what has contributed to its presence in those who are diagnosed with it.

Dr. Kuhlman: Just to piggyback you know, rarely in somewhere estimated about to five to 10% can be thought of as hereditary. So, patients that have family members who were diagnosed at a young age, less than 60, or if they have relatives with other cancers like breast, ovarian or pancreas cancer that could be a signal of having a genetic mutation that increases the risk for prostate cancer, but overwhelmingly I agree the vast majority of causes are unknown.

Host: Now Dr. Averch, Dr. Kuhlman touched on this briefly, but is there any more information that you can share with us around who's at risk or the different risk factors that might lead to prostate cancer?

Dr. Averch: Absolutely. And this is a really important thing to note for your listeners is who is at risk really, initiates, begins the next step for the potential diagnosis. So, who's at risk as Dr. Kuhlman already mentioned there is a genetic component likely with this disease. So, if there is a strong family history, such as a brother, uncle, father; those patients are at greater risk of developing prostate cancer as well.

We also know that there are some genetic diseases that can have higher occurrances of prostate cancer. So those are key. This is also important for men who are older. It is a disease of the aging male. So, we know the older you get, the more likely prostate cancer can show up. The other very key risk is race. Unfortunately, African-American men have a greater risk of developing prostate cancer throughout their life. So we know that in, in those three categories of risk, those are definitely individuals who should be talking with their doctor about getting screened for prostate cancer. There's been other work that's looked into folks who are overweight and their environmental contributions but overwhelmingly those three major categories are the things that should propel someone to asking the question should I be screened.

Host: Now, just to clarify, you mentioned aging men. Can you give us an age range of men that this affects?

Dr. Averch: Sure. So in general, we're talking about men over 50 and as they get older if you're at a higher risk category, as I just mentioned with strong family history or genetics, then even over 40, some men should be considered to be screened for prostate cancer. We also know that because of the fact that the older you get, the more likely you might develop prostate cancer, we generally don't recommend screening in men whose life expectancy is less than 10 years or in general, a category of patients over 75, because there is the screening for prostate cancer really doesn't benefit the individual as much as it would if you were 50.

Host: So Dr. Kuhlman, I wanted to shift over to you. Can you talk about some of the symptoms that would tell someone that they might have prostate cancer?

Dr. Kuhlman: Absolutely. It's a good question. So, most patients when they're diagnosed are asymptomatic and are picked up on screening. But when men do have symptoms, things to be on the lookout for are changes in their urinating ability or symptoms related to urination. And that can be things such as urinating more frequently, feeling the urge to urinate, waking up in the middle of the night multiple times to urinate or maybe problems starting or initiating their urinary stream. Other symptoms to be on the lookout for would be seeing blood in the urine. That's called hematuria or seeing blood during sexual activity in the ejaculate and rarely, if a patient presents with prostate cancer, that's traveled to the spine or the back, they can have back pain as the presenting symptom.

Dr. Averch: And can I just add that, you know, as Dr. Kuhlman mentioned the vast majority of patients who get diagnosed with prostate cancer, it's because they've been screened. And the screening tests, as I'm sure we'll discuss in a minute, have identified a question and then the disease is then diagnosed.

But fortunately those symptoms that Dr. Kuhlman mentioned are rare or rather unusual in presentation. So I don't want everybody just running out to the urologist or their doctor to say if they have some trouble, but it's at least it should start the discussion with your physician to say, heh should I be screened? Is that appropriate? Where are we with that? And, you know, it opens the conversation to have screening.

Host: Yeah. So Dr. Averch, let's stay on that line of discussion. You know, let's talk about the different types of screenings or tests that are available, if someone, you know, wants to start this conversation or might suspect that they have something that needs to be looked at.

Dr. Averch: Yeah. So as I was mentioning most of the direction now for screening men for prostate cancer starts with either a risk and then a discussion with their physician about the benefits and risks of screening for prostate cancer. The first thing that's usually done is a blood test. It's called a PSA or prostate specific antigen. And that's the primary tool that we have in our toolbox for screening for prostate cancer. It doesn't tell us, unfortunately, if it's abnormal, that someone has prostate cancer, it just suggests that patient needs a bit more workup. The other thing that we still do is a rectal exam, a finger in the bottom, if you will, to feel the prostate and look for abnormalities. So in general, those two things are the primary tools that we'll use. When we talk about the screening, those individuals are the ones that I mentioned, anybody over 50 to 70, 75 years of age are in that screening age group. And then down to 40, if there's a strong family history or even African-American. Once that screening is performed and if everything is normal, then the question becomes screening, you know, when do you get screened again. That's a great discussion to have with your doctor based on the findings of your blood work and your physical exam as well.

Host: Yeah. So you mentioned the PSA and the DRE which is the physical exam. But are there any other screenings or types of tests that are done? Like for example, is there ever a case where a biopsy needs to be taken?

Dr. Averch: Absolutely. That's a great point. So if the PSA or the physical exam is abnormal, then usually the discussion of the next steps would be proceeding with a biopsy. And these days a biopsy is performed through the bottom where samples are taken of the prostate tissue and sent to the pathologist to be reviewed. When that's performed that turns around and lets us know if there's potentially prostate cancer. Now, when that biopsy is done, only about four out of 10 men will actually become positive or show positive for cancer, but it is our best test. Currently, there is also work being done to see if an MRI might actually help individuals, but that work is early yet. So for most men, when they're suspected of having prostate cancer based on their screening tests, they'll go ahead with a biopsy.

Host: So Dr. Kuhlman, I wanted to move over to you. Let's say you're diagnosed with prostate cancer. Can you talk to us a little bit about how prostate cancer is treated?

Dr. Kuhlman: Great question. So treatment after designing treatment is warranted most men receive a local therapy. What I mean by local therapy, meaning either a surgery by a urologist like Dr. Averch or sometimes radiation can be used to cure the prostate cancer. And as a Medical Oncologist, I become involved when the prostate cancer has spread to other areas of the body and tools in my toolbox consist of medicines that lower testosterone because prostate cancer most often grows in the presence of testosterone. And when we lower the testosterone, that's called androgen deprivation therapy. We can also utilize chemotherapy and some other newer treatment modalities.

But really the risk of dying of prostate cancer is one out of 41 or two to 3%. And so, for more on the local therapies, I'd like to get Dr. Averch's input on perhaps more traditional and maybe more novel approaches to providing local therapy for men with prostate cancer.

Dr. Averch: Sure the key here, I think as you stressed, is that even with a diagnosis of prostate cancer, it's very treatable and most men will just live with their disease or live with the cure. At five years, 98% of men diagnosed with prostate cancer, are still around and still flourishing. So, the local treatment options on the surgical side is the removal of the prostate gland, what we call radical prostatectomy and that's traditionally, or when I say traditionally, I mean, it's certainly the last 10 years has converted over to robot surgery, done laparoscopically and patients do very well with the quick recovery. And then there are some more focal therapies out now where we can freeze or burn just the cancer right within the prostate. And those are modalities we certainly offer through PRISMA Health. So we have a lot of options and treatment of prostate cancer. As I mentioned, it's very treatable.

Host: So Dr. Averch, just staying with you here for a minute. If people are listening to this and they want to be as proactive as possible and they want to get screened, where should they go?

Dr. Averch: So for most men starting with their primary care doctor and family practice physician, you know, whoever they see on a regular basis. Those are usually the best first folks to go to and have that discussion about screening, have a physical exam, have their PSA checked. If it's identified that they're abnormal then those patients usually get referred over to a urologist to have the discussion on whether biopsy would be appropriate and what the risks and benefits of the biopsy.

So, here in the Midlands, the urology offices are located in the center of the state here around Columbia. And certainly can provide a phone number, 803-434-4790 and our access is online of course, too. But that's where we start the discussion, biopsy. And then based on those biopsy findings can have conversations about what the best option for treatment. And we frequently pull in our wonderful colleagues in medical oncology and radiation therapy, radiation oncology to, to help in the management of these patients.

Dr. Kuhlman: And as far as the upstate is concerned I would echo what Dr. Averch has said as far as initiating a discussion with the primary care provider. I would also like to highlight an opportunity to participate in clinical trial we have here in the upstate called Prevent Cancer Greenville. And this is a 90 minute assessment focused on cancer prevention and will help guide discussions on prostate cancer screening. And the telephone number if listeners are interested is 864-455-2279. And so that's an opportunity that's that's available here in the upstate.

Host: Well, Dr. Averch and Dr. Kuhlman, I truly appreciate your time today. This has been a hugely informative conversation. Dr. Averch, I'll start with you. Is there anything else that you would like to leave our listeners with before we sign off today?

Dr. Averch: Well, I think certainly when one thinks of the word cancer you know, the thoughts that spin around with that are certainly troublesome and burdensome, but the good news, the silver lining in this cloud certainly, is that prostate cancer, even if identified, is very treatable and men tend to do very well even with treatment. So, we're there to help and and try and answer any questions that we can.

Host: And Dr. Kuhlman, I'll give you the last word.

Dr. Kuhlman: Yeah. I appreciate the opportunity and would like to highlight that while prostate cancer screening, if one Googles, it, you might find a lot of different messages and it can be a little bit complex. But I'd like to just encourage men to be an advocate for their own health. And just because the discussion may be nuanced, not as straightforward as many other screenings, just because it's complicated does not mean that it's not important. And I would say that this is important and we'd like to encourage men to bring up the conversation with their primary care providers and ask questions, ask family members about your family history and be informed. And there's a great team here to help. And if the opportunity arises, it'll be our honor and privilege to play an important role in helping patients with prostate cancer.

Host: Well, thank you both again. I really appreciate your time. That was Dr. Timothy Averch, Fellow of the American College of Surgeons and Urology Specialist at PRISMA Health and Dr. Patrick Kuhlman, Medical Oncologist for PRISMA Health. For more information, visit our website at Prismahealth.org and to listen to other podcasts, just like this one, you can head to prismahealth.org/flourish.

This has been Flourish, a podcast brought to you by PRISMA health. My name is Prakash Chandran. Thank you so much. And we'll talk next time.