Joey Wahler (Host): One in eight men in the U.S. will be diagnosed with prostate cancer. So, we're discussing how it's diagnosed and treated. Our guest is Dr. Jaspreet Singh. He's Co-Director of Men's Health and Urology services at Montefiore St. Luke's Cornwall and Physician Liaison for MSLC's Littman Cancer Center.

Welcome to DocTalk presented by Montefiore St. Luke's Cornwall. Thanks for listening. I'm Joey Wahler. Hi there, Dr. Singh. Thanks for joining us.

Jaspreet Singh, DO: Thanks for having me, Joey.

Host: So first you say that you and yours are seeing of late, a higher number of advanced stage cases of prostate cancer. Is it safe to say that that's because still today, not enough men are heeding the warnings about early detection and screenings on a regular basis?

Jaspreet Singh, DO: Joey, that's a very good question and point that you bring up. I think there's multiple reasons why we're seeing what we refer to as stage migration of prostate cancer. And by stage migration, meaning seeing higher grade prostate cancer. Historically, the US Preventative Task Force came out with their recommendation back in 2010 that stated that prostate cancer does not need any screening.

And they made their recommendations based on the fact that they felt that the treatment and the issues that men go through for the diagnosis of prostate cancer or the difficulties through that outweigh the benefits of treating prostate cancer. And what that did was that changed the primary care's approach, the primary care physicians and nurse practitioners and PAs to limit their ability to offer PSA and prostate cancer screening.

And so what happened over a period of time, is we had started seeing less and less men being offered screening for prostate cancer and less men even coming to the doctors asking for prostate cancer screening. Now fast forward to 2018 and what happened with their update, the U.S. Preventative Task Force came up with an update kind of retracting the original statement and saying, well, perhaps in the right fitted individual after discussion, that between the ages of 55 and 75, one may be offered prostate cancer screening.

So they kind of took a step back and I think they realized that there were going to be men who were going to miss the opportunity to appropriately diagnose early prostate cancer and to treat prostate cancer. Now, I don't have to tell the listening audience, in 2019, the world stopped. COVID-19 had come out in March 2020.

Things had shut down. Hospitals had shut down. Offices had shut down. And unfortunately, what the result of that was, that less and less patients came to their doctors for preventative care once the offices opened up. It allowed a break in the continuity of care for our community. And so when that had occurred, in general, less men were now coming to the doctor's offices for the routine preventative care.

And so that's the second issue that we're dealing with is some of the results of what COVID-19 had caused in routine preventative care. The last thing I think also has to take into consideration in the stage migration is the fact that we have recognized and fortunately that most prostate cancers are early and low grade disease.

In fact, 80 percent of prostate cancers as diagnosed in the U.S. is low grade and we have learned in the last two decades of research that most low grade prostate cancers do not need treatment. And so we've been able to selectively offer patients monitoring rather than treatment in low grade disease.

And what this has now allowed is to filter out higher grade disease, or I should say patients that need treatment. So patients who fall under intermediate to high risk disease. And so what happens is there's somewhat of a bias because when you look at prostate specimens that are removed after prostatectomy, we'll tend to find a higher grade, higher risk disease.

Host: So, to be clear on that last point, when you say some cases of prostate cancer are early enough and minimal enough, if you will, that they don't need to be treated right away, does it mean that they'll likely need to be treated at some point or maybe not?

Jaspreet Singh, DO: Yeah, so low grade prostate cancer in general, and by definition that falls under men whose PSA level is less than 10 and or with a Gleason score less than or equal to 6, fall under a low grade disease. And what the data shows is that 80 percent of these men who fall under low grade disease will not necessarily need any future treatment.

Meaning you can keep an eye on this because those men will most likely die with the disease rather than from the disease. Now, of the 20 percent of men who fall into low grade disease may eventually need treatment, whether it be radiation or prostate surgery. So they fall out of what we call an active surveillance protocol.

How do we know that you are going to be the 20%? And this is what the cutting edge technology is allowing us to do. And this is what's so exciting about providing prostate cancer treatment care with Montefiore St. Luke's system is we're able to look at genomic studies on the tissue samples at the time of prostate biopsy to help understand the RNA sequencing and the expression of these genes to then reassure us that, you know what, this is a low grade disease, and we're comfortable with keeping an eye on this, versus something that needs treatment, or perhaps, Joey, if I can put it, what we're trying to do is identify the wolf in sheep's clothing. And that's what these genomic studies have allowed us to do. So we're really providing kind of a molecular level understanding of prostate cancer.

Host: Gotcha. So before we move on to talking about treatment, since you just addressed how there have been some of these mixed messages out there about screening; in your view, from your particular experience, how important is it for the average man to go, say, on a yearly basis for either a blood test to check their PSA level or even to get a physical digital exam to go a step further?

Jaspreet Singh, DO: The current guidelines, and we follow as a Board Certified Urologist, I follow the American Urology Association guidelines. Their recommendations for an annual PSA screening should start at the age of 55 and should go to 75, in the average male who does not have any family history of prostate cancer.

Now, what's interesting, Joey, is that the digital rectal exam has been inspected and recent data is saying that the DRE, or digital rectal exam, may not be necessary. But, I tell patients that the DRE allows an understanding, perhaps gives me an idea what the feel of the prostate is, whether it's symmetric, how large it is.

So it does provide information about the prostate that a PSA level may not. In any individual who has a family history of prostate cancer, the screening should start earlier, and the recommendation is to start anywhere at the age of 45 to 50 in men who have family history. Black men, Joey, are at higher risk of developing prostate cancer and not only developing it, but at a higher grade at the time of diagnosis and unfortunately have a higher mortality rate in the United States from a diagnosis of prostate cancer. So although not quite adopted by the AUA, but there was a recent meeting at the American Society of Clinical Oncology, the ASCO meeting, which put together a panel of specifically evaluating our black men, and what should we do as far as specifying our ability to screen these men.

That included, earlier PSA screening, which should start at the age of 40 to 45. I suppose in general, 45 is a good year for black men to start, but if there's a family history, specifically if the first blood relative, a father perhaps was diagnosed with prostate cancer before the age of 65, that screenings should start at the age of 40.

Host: So as for treatment, Doctor, what is the most commonly used and most effective means these days for prostate cancer?

Jaspreet Singh, DO: The two main ways if a man needs treatment for prostate cancer include the surgical removal, which we call a prostatectomy, or the use of radiation therapy. Most prostate cancers that are being treated in the United States are undergoing a surgical removal. We've been doing the prostatectomy procedure for over three decades, but at this time, the most common way is through a robotic assisted laparoscopic approach, which we are doing at Montefiore St. Luke's Hospital. Alternatively, radiation therapy, and there's many ways to radiate the prostate, whether it's seed implants or external beam radiation therapy. In general, seed implants have fallen out of favor. The data for seed implants revolved around treating lower risk disease, which we've learned don't necessarily need treatment.

And the technology in providing external beam radiation has gotten so much better that we can fine tune and kind of hit the prostate with limiting any sort of injury to surrounding tissues has gotten better, that we're offering patients image guided radiation therapy. We also have a program now at St. Luke's that's going to be starting that offers patients a quicker condensed treatment option, that the radiation is given over five to seven days to help prevent any sort of interruption which may occur in the traditional way we treat prostate cancer through radiation, which can be up to 40 days worth of treatment.

Host: And as you well know, side effects are such a concern when this condition is treated because men worry about urinary function, sexual function. So generally speaking, what can they expect there?

Jaspreet Singh, DO: Yeah, I think that's probably the number one reason, Joey, why men don't come for prostate cancer screening is the fear that if they do need treatment, what that treatment may entail. Now, with the robotic approach and this has been also published data that it has allowed men to recover quicker and sooner after prostate removal, the blood loss is significantly lower, and also the return of urine control is expedited.

And in my experience, as a surgeon who offers patients robotic prostatectomy, most men, I would say close to about 85 to 90 percent of men do recover their urine control. And that's usually a process that takes about three to six months after prostate surgery. And in those men, about 10 to 15 percent that are experiencing urine incontinence, it is usually a mild degree where they may have to wear a pad a day as a safety, or if they're unexpectedly coughing heavy or lifting something heavy, they may experience a couple of drops of urine.

The other thing that the robotic approach has allowed us is to identify some of the neurovascular structures that are surrounding the prostate that are important in erectile dysfunction. And so we're able to really pinpoint with the zoom factor to spare these nerves, and that advancement in technology has allowed our patients to recover erectile function at a higher rate.

In regards to radiation therapy, we have another opportunity to spare the injury to the rectum. Remember, the bladder and the rectum are very close to the prostate, and can experience a scattered dose of the radiation. And what that means to patients is an irritation to urination, perhaps need to urinate more frequently, with urgency, or some bowel changes that may include some blood in the stool. We have ability to protect the rectum. There's a procedure that our patients undergo called the peri rectal spacer or the space OAR that helps protect the rectum. So several advancements in being able to recognize some of these side effects and minimize them; we're really employing and offering our patients in our community.

Host: So in summary here, what would you say to our listeners, Doctor, about the prospects for a healthy, and good quality of life after prostate cancer.

Jaspreet Singh, DO: I think more than ever, we've gotten better at both surgical approach and the radiation approach. And, the nice thing about working with a urologist in the community, such as myself, is that even if you're experiencing some of the untoward side effects from treatment of prostate cancer, we can manage those.

We can manage leakage of urine after prostate removal. We can help manage some of the irritative symptoms that can occur after radiation therapy. So, you know, I don't want patients to feel discouraged. There are various treatment options to even help with some of the quality life changes that occur after prostate cancer treatment.

Host: Well folks, we trust you're now more familiar with prostate cancer and its treatment. Dr. Jaspreet Singh, thanks so much again.

Jaspreet Singh, DO: Thank you, Joey.

Host: And for more information, please visit MontefioreSLC.org. Again, that's MontefioreSLC.org. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts as well. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler and thanks again for listening to DocTalk presented by Montefiore St. Luke's Cornwall.