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Prakash Chandran: Despite the wide availability of advanced modern medicine, many men today are simply deciding not to visit the doctor at all. What pressures are causing men to turn away from seeking medical treatment, and what are the consequences of this phenomena? We're going to talk more with Dr. Angelo DeRosalia, a board-certified urologist and chief of the urology service at St. Joseph's Hospital.

This is St. Joseph's Health MedCast from St. Joseph's Health. I'm Prakash Chandran. Dr. DeRosalia, I really appreciate your time today. Thank you so much. I wanted to get started by asking how common this phenomenon is, you know, for men to simply just deal with the issues they're having or live with it versus not coming in to see a doctor.

Dr. Angelo DeRosalia: Thanks, Prakash. I appreciate you taking the time to sit down with me today. It's much more common than you think for men not to seek attention for health problems and as well as just routine healthcare maintenance, for lack of a better word, or wellness visits. We have a number of factors that contribute to that.

Life gets busier and busier as the years go on. People have less free time in their schedule. They're putting more on their plate at the workplace, in home life, and people are more apt to self-diagnose themselves online than they were years before. So, men especially are vulnerable to some of those pressures that keep them from seeking medical attention. Men don't do nearly as good a job as female counterparts with routine healthcare. It's very common for women to go and have routine visits with the gynecologist, mammograms, general cancer screening, general wellness. And additionally, there's a barrier that exists more in men than women where there's just a hesitance or reluctance to raise topics that are difficult to deal with with a healthcare provider.

Prakash Chandran: Think another piece of this is something around masculinity, because I think about my dad and sometimes my dad just deals with pain just because he feels like that's the masculine thing to do, rather than going in to see someone. Is that something that you also see?

Dr. Angelo DeRosalia: That's such an interesting point, Prakash. Women in general do better dealing with pain and are also better with bringing it up with a healthcare provider. So, there is this kind of stoicism that exists amongst men to kind of block it out, pretend it's not there, hope it'll go away. Kind of like if you're driving your car and your car makes a certain noise, you kind of hope it'll just stop. And if it stops, you assume everything's okay. That's definitely behavior we see more out of men. Especially we're going to talk a little bit more about prostate cancer and prostate screening, that elderly generation is more so I think to have those viewpoints than some of our younger men that we see in the office.

Prakash Chandran: And you touched on this, but why is it so important for men to kind of take charge and advocate for their own health?

Dr. Angelo DeRosalia: Well, you can only rely on somebody else to do it for you to a certain degree. Women, as I mentioned earlier, are much better than men at taking care of themselves from the health maintenance and routine healthcare standpoint. And often, I don't like to make generalizations, but women often take the role with their children's health and taking care of routine healthcare for their children. So often, the men tend to be an afterthought. And as a result, the men are just much less likely to go seek medical attention when needed. And there are real risks and repercussions to waiting for things to advance, waiting until you have a symptom, waiting until you say, "Hey, wait, something's wrong here." And at that point, often things are more in an advanced stage or further on down the line and now much more difficult to treat, if at all.

Prakash Chandran: Totally makes sense to me. I am curious, like I think about my dad and kind of the other men in my life that maybe are a little stubborn, like my father-in-law as well, I'm curious as to like the people in a man's life, like their support system or whoever's noticing that, "Hey, look, it might be time for you to take care of yourself and go see someone," what can the family or support system do to help?

Dr. Angelo DeRosalia: First, be aware of what should be done because if you don't know what should be done, you're not going to know what questions to ask that man in your life. So, educating yourself on prostate cancer, on mental health screening, diabetes, high blood pressure, obesity, smoking, being aware of what to ask is the first step because if you don't know how often someone should be screened or what screening looks like, it's going to be very difficult to make sure that the person, your loved one, is getting the appropriate care at the right time.

Prakash Chandran: Okay. So, that kind of leads us into the generalized best practices around screening. And I definitely want to dive deeper into things like prostate cancer. But in general, is there a framework or a certain rule of thumb that you tell men around screening cadence or how often they should be coming in to get their well visits?

Dr. Angelo DeRosalia: Sure. So as a urologist, I'm very in tune with prostate cancer and some other aspects of men's health. Sexual dysfunction, low testosterone, amongst other things. Voiding dysfunction, meaning difficulty urinating. So, those are things that I deal with day in, day out. And as part of your primary healthcare visit, that's one small segment of a long list of items to be covered on a regular basis. So, you can imagine just what I just named from a urologist standpoint four or five items off the top of my head can take a fair amount of time. So when a man goes to his primary care provider, that's only one small part of the whole picture. You still have to deal with obesity, smoking, depression, anxiety, high blood pressure, high cholesterol, diabetes, I can go on and on. So if you're not going to see your healthcare provider at least once a year, you're missing out. And obviously, it goes without saying that if there are other conditions at play, that frequency is going to be increased, maybe perhaps for routine blood work, for blood pressure monitoring, blood sugar monitoring and whatnot.

Prakash Chandran: Such a good point. Let's talk about prostate cancer. Especially as a urologist, I want to kind of get into the details of this. Talk to us about how common prostate cancer is, and also the current recommendations for screening.

Dr. Angelo DeRosalia: Great question. So, prostate cancer in general has been the number one solid tumor diagnosed in men. And I say solid tumor because skin cancers are more frequent, but generally don't fall under that ranking, for lack of a better word. And in general, depending on the year, between one in seven and one in six men will be diagnosed with prostate cancer and between one in seven to one in six of those men will ultimately die from prostate cancer. So, those are just kind of the real numbers, but prostate cancer screening is a much more complex topic. And it depends on who you ask and what year you ask regarding what answer you would get for how often someone should be screened. And there are a number of reasons for that.

Prostate cancer is very prevalent, meaning it's very common in the population, but the chances from dying from prostate cancer are much, much lower, meaning in general, it's not as lethal, and that's in general for our exceptions, it's not as lethal as other cancers can be. So lung cancer, while not nearly as common, has far higher mortality or chance of dying compared to prostate cancer.

So that being said, prostate cancer screening has gone through a number of iterations over the years. In the 1980s, a blood test called PSA, prostate-specific antigen started to become popularized, which led to a much higher detection rate than we had ever seen historically. So with that higher detection rate, you started to find cancers at a much, much earlier phase. And what we found was that a number of the cancers that were detected were behaving indolently or not as significant as other cancers, and many of them may never have turned out to be anything. When I say be anything, I mean cause and impact to a man's life. So, what we found was there are other cancers that were being diagnosed and ultimately being treated, some of which may never have become a problem over the course of a man's life. The reason I mentioned this, Prakash, is that we started to see a stage migration where cancers are being detected at a very, very early phase, which led to some recommendations about a decade ago in 2012, which really confused the medical community.

In 2012, the US Preventative Task Force came out with some recommendations. This is not a government agency, but it gave recommendations to primary care providers that prostate cancer screening was not beneficial. As a result from 2012 on, we started to see a stage migration the other way where we were finding cancers at a later phase, the chances of finding an advanced prostate cancer increased and the success rate of treatment for those advanced cancers started to decrease, which is exactly the direction we did not want to go. So in 2018, that was revisited and the US Preventative Task Force changed their recommendations to say that men between 55 and 70 clearly should be screened after a discussion with a primary care provider if it made sense for the patient.

Additionally, we know that patients with a family history of prostate cancer, meaning your father, your brother, your grandfather, were at higher risk for prostate cancer, they need to be screened more often, which I can get into in a minute, as well as African Americans need to have a different screening protocol than non-African Americans because we tend to see more aggressive prostate cancers in African Americans than we do in non-African American men. So, those screening recommendations are different.

We know to distill it down. We know that if you have a family history or you're African American, you want to get screened at a younger age. But at a minimum between 55, at 55 years of age, all men should have a discussion with their healthcare provider about the merits of prostate cancer screening. And that should be performed every one to two years with the screening, including PSA testing, which is a simple blood test, as well as a rectal exam to check for any nodules or irregularaties on the prostate gland itself.

Prakash Chandran: That's very helpful. Now, you mentioned that, for example, if someone with a family history, they need to be screened maybe more often or earlier, but you said that minimum age was 55. At what age should someone start screening if they have a family history?

Dr. Angelo DeRosalia: Between 40 and 45 years of age.

Prakash Chandran: Okay, gotcha. And could you just expand for our audience on why it's so much better to catch prostate cancer early?

Dr. Angelo DeRosalia: The earlier you catch a cancer, the higher the treatment success rate. And that's especially important with prostate cancer for a number of reasons, because the main part of success is making a man cancer-free. But there are other parts of that as well, namely side effects. It's important to treat the cancer and limit side effects and maintain quality of life. So for men surrounding prostate cancer, if more aggressive treatment is required to treat a cancer, there's a higher risk of seeing side effects surrounding urinary incontinence and sexual dysfunction, both of which are extremely impactful to men of any age.

Prakash Chandran: Yeah. So, one thing I've been curious about is prostate cancer for elderly men, especially around kind of screening. Is this something that you can speak to?

Dr. Angelo DeRosalia: Such an interesting point and a great question. So, prostate cancer in many men is an indolent cancer, as I mentioned before, that is a cancer that may not develop into anything that's significant. It may not impact quality of life or duration of life. So, we've been educated as providers to have a discussion with a man and say, if your life expectancy is less than 10 or 15 years, you shouldn't screen for prostate cancer. Sounds straightforward, right? Well, that's not an easy conversation to work through with folks because it's hard at 72 or 73 years old, if you say to a man, "How long do you plan to live?" I don't have the answer to that question, and most men who come to my office don't know either. So, we're seeing more men live into their 90s than we ever did before.

So when I was in medical school, if you were over 70 years old, there was no need to screen for prostate cancer, because in general, most men weren't living too far into their 80s. Now, as men are starting to live 90, 95, even 100, there is benefit and utility to screening men in that age bracket.

So, that's a conversation that I have with my patients on a regular basis and it's really an individualized conversation that we tailor to the person as I'm in the room. Some men are very active in sports, very active in health maintenance and taking care of themselves, and those men want to make sure that they get screened well into their 70s, if not 80s and beyond. So, that's an important distinction for listeners out there today.

Prakash Chandran: Okay. Yeah, that makes a lot of sense and it kind of leads me to the other health problems that are affecting men, erectile dysfunction as mentioned is one of them. Can you talk a little bit more about what you see as a urologist? Some of the most common things that are affecting men, they should be aware of.

Dr. Angelo DeRosalia: Probably three things come to mind immediately when you talk about complaints surrounding quality of life of men as you get older. And we all know as a population, men are living longer than they did in our parents' generation. I'm seeing more men now hitting their 95th or even 100th birthday than I ever saw before. And along those vines, 70, 75 is still a relatively young age for many men. Many men still have a very active life, in general and sexually. So with that, we tend to see men come in and complain about difficulty with erections. People are staying sexually active more into their 70s and 80s than we ever saw before. And there's a higher comfort level discussing this with a doctor than there was a generation ago. And I'd like to thank Viagra for that. I think the advertising that came around 20 years ago for Viagra and other pills like Levitra and Cialis really put this in the spotlight and made it less of a taboo topic. And I find that patients are much easier able to bring that up with me than they were years ago.

Along those same lines, low testosterone level is something that has been advertised heavily on television by pharmaceutical companies and supplement companies, and that has really kind of exploded in my office in terms of patients being able to bring that up and just attention to that issue. Women really have been pursuing youth and vigor for years, and men were a little slow to bring that on. And now with testosterone, we have men in their 70s living a much more active life. How many men do you know now in their 70s playing pickleball and tennis and remaining active in the community. And as that goes on, people are looking to make sure the testosterone levels stay high.

And the last thing that I would bring up would be difficulty urinating. That's a very common complaint I get. As many age, at least half of men experience symptoms of a large prostate beginning at 50. It's higher as you get older. So, that might include more trips to the bathroom at night, disrupting your sleep pattern, making you more tired during the day. It might mean being more sensitive to coffee as you get older. You used to be able to drink a couple cups of coffee and not have to stop and run to the bathroom. Now, that's changed. Additionally, some men even experienced leakage, which clearly impacts life. So, these all become issues, particularly coupled with the fact that I have many of my patients in their 70s who were still actively working a regular work week and aren't home with easy access to the bathroom. So, I would say those are the main issues that I see in my practise.

Prakash Chandran: Yeah, this is all fascinating, Dr. DeRosalia. Just as we start to close, I always like to ask, you know, you have helped a lot of men throughout your career as a urologist. What is one thing that you absolutely know to be true that you wish more men knew before they came to see you?

Dr. Angelo DeRosalia: Early detection and early treatment leads to better outcomes all around. So said differently, when you ignore something that just doesn't feel right, you're not doing yourself any favors and there could be harm, if not irreversible damage being caused. So if something doesn't feel right, there's a good chance that it's not right. And if you don't tell someone about it, there's no way that you can be helped. So, don't be afraid to bring it up. Make a visit if you have a problem with your provider. Make a visit with me if you have an issue. And also, go for your routine wellness health visits. Early detection is key.

Prakash Chandran: Dr. DeRosalia, I think that is the perfect place to end. Thank you so much for your time.

Dr. Angelo DeRosalia: You're welcome. Thank you.

Prakash Chandran: That was Dr. Angelo DeRosalia, a board-certified urologist and Chief of the Urology Services at St. Joseph's Hospital. For more information, you can visit sjhsyr.org. That is sjhsyr.org. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been St. Joseph's Health MedCast from St. Joseph's Health. My name is Prakash Chandran. Thank you so much and be well.