Scott Webb (Host): Though a majority of men who are diagnosed with prostate cancer survive, they often end up with side effects from the treatment, including urinary incontinence and sexual dysfunction. My guest today, Dr. Jaspreet Singh, Co-Director of Men's Health and Urology Services at Montefiore St. Luke's Cornwall, is here to discuss prostate cancer, the treatment options, and the resources that are available to help survivors deal with the physical and mental effects of their treatment.

This is Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Scott Webb. Dr. Singh, it's great to have you back again. I know we've spoken a few times. And today, we're going to talk about prostate cancer sort of broadly and treatment options, surgical options, prostatectomies, all of that. Before we get there though, who's at the highest risk of prostate cancer?

Dr. Jaspreet Singh: The men with the highest risk are the aging men above the age of 50. And also, Caucasian men tend to have a higher prevalence of prostate cancer, although African-American men tend to have higher stages and more aggressive prostate cancer. There's definitely a genetic risk to that. Men who have family history of prostate cancer are definitely at a higher risk. So, something that, you know, we should talk about so that instead of, I guess, keeping the problem in your pants, the more we talk about it, the more men will go out and talk to their physicians about.

Host: Yeah. One of the things I've learned in speaking with you with the various topics we've covered is that there generally tend to be the types of topics that men don't want to talk about. Certainly, you know, with just anybody on the street, so we need to get them in the office, get them to speak with experts like yourself. And just wondering, you say there's a strong family history genetic component. Is there behavior, lifestyle contributing factors when it comes to prostate cancer?

Dr. Jaspreet Singh: Yeah. I mean, nothing that's been concrete in reproduction of data and looking at. Retrospectively, patients. But in general though, Scott, I mean, healthy living is important. So, we all believe that the impetus for cancer tends to be some sort of an underlying inflammation. So, healthy living is important, exercising, keeping the weight off, not smoking. Whether there's direct correlation to prostate cancer, I can't tell you for sure.

Scott Webb: Yeah. Hard to know for sure. All right. So then, let's talk about the signs and symptoms. You know, we've talked before about things like male stress urinary incontinence. And as you said, like those certain things aren't life-threatening, they just really impact our quality of life, but prostate cancer is life-threatening. And so, we want guys to recognize the signs and symptoms and speak with the provider. So, let's go through what they might be experiencing.

Dr. Jaspreet Singh: Yeah. Unfortunately, as with most cancers, they don't present with any symptoms. For example, colon cancer, we have to get colonoscopies every 8 to 10 years. So, prostate cancer is very similar. Unfortunately, I think men tend to think that prostate cancer will present with symptoms of urinary changes, perhaps weakness of stream or getting up at night or frequency urgency. But that's not the case. Most of those urinary changes are associated with benign prostate growth, obviously, which occurs with aging as well. But with prostate cancer, the only way that's effective in screening for prostate cancer is the annual PSA level as well as a prostate exam, a rectal exam that should start somewhere on the age of 50 and should be up until about the age of 75 to 80.

Host: Yeah. And I'm in my mid-50s. So, you know, I'm checking the boxes as you're going through the things that men should have done. Yes, check, check, check. Right. And so, as someone who does have some of those issues, because I'm in my 50s, as you say, sometimes having to go to the bathroom more often than you'd like and so forth. And you mentioned in our last podcast, it's never a good idea, you know, to just basically stop intaking fluids, right? Don't just stop drinking fluids, especially I love coffee as we've discussed. You got to live your life and you need to stay hydrated and all of that. So, let's talk about then, if prostate cancer has been diagnosed or prostate cancer has been found, what are the next steps? What are the treatment options?

Dr. Jaspreet Singh: Yeah. So, there are like four main buckets, depending on the staging. So for most men that get diagnosed with prostate cancer tends to be early, and at a low grade or low stage. And many of them, we watch, something we call active surveillance. That allows us the opportunity to understand the cancer better. And that's one of the nice things about prostate cancer is that, for most men, it's fairly slow growing and perhaps we can monitor until it necessarily, you know, needs treatment. We can avoid some of the side effects to treatment.

What are the two main ways we treat prostate cancer? Either we're removing it, a procedure called prostatectomy, and/or radiation, and various types of radiation that we have accessible. But most commonly something called external beam radiation, which can be a daily thing from anywhere from six to eight weeks, as short as five to seven days depending on what type of cancer. So, those are the two main ways we are treating prostate cancer, is through surgery or radiation.

Host: Yeah. Surgery, radiation, and as you say, depending on the stage and some other factors and things would determine the course of action, a course of treatment. So then, let's talk about recovery time, you know, or survival rate. Maybe we start there. So, let's talk about survival rate. Regardless of the treatment, surgery or radiation, what's the prognosis, if you will, for survival?

Dr. Jaspreet Singh: Yeah. So, the one thing that, you know, as controversial as PSA is and, you know, often gets kind of poo-pooed in the media, and some doctors don't even offer their patients PSA screening at the fear of overdiagnosing. But the one thing that we cannot argue, which data has shown, is that over the last 25 years, the five-year survival rate for prostate cancer for all stages has gone up from 68% to 99%. And the 10 to 15-year survival rate is very similar, 10 years at 97% all the way up to 15 years at 91%. So, you know, there definitely has been a shift in the survival of prostate cancer with PSA, early screening. And now, we have tools that we're using, some urine studies, MRIs, things like that, to improve the survival rate.

Now, the downside to that, Scott, is because we have increased the life expectancy after the diagnosis and treatment of prostate cancer, many issues of survivorship come into play. And that's where we're taking out the time to kind of highlight so that now, you have most of men that get treated with prostate cancer living 15 years after the diagnosis, if not longer.

So, you know, what does that mean? That means changes after prostate removal, like urinary dysfunction, stress incontinence, perhaps changes as far as the need to urinate frequently. Sexual dysfunction is very big after prostate surgery. You know, you have a guy at the age of 55 gets diagnosed with prostate cancer who we still consider young and considering the average life expectancy of a male to be 85, that's a long time to live with side effects of prostate cancer treatment, with erectile dysfunction, this mental or psychological issues that also often are not talked about and get ignored, perhaps depression from ED or sexual dysfunction, orgasmic changes, shortening of penile length, and then just the embarrassment of urinary incontinence. How does that play on a man's psyche day to day where, again, not picking on women, but a lot of women understand leakage of urine as they get pregnant, and as they get older, learn to manage with that. Men don't in general have urine incontinence. And now, you have to manage with that after prostate removal.

And it's not only just men who have radiation are not immune to side effects either, the same way radiation therapy to the pelvis causes risk for scar tissue formation in the urinary tube, making it difficult to urinate; bowel dysfunction, the bowels are very close to the bladder and often get irradiated as we're trying our best to radiate to the prostate, but you have some of the adjacent organs that get involved. There's a risk of inflammation to the rectum, the bladder, you know, blood in the stool.

So, there's a lot of these issues that, I think, don't get addressed, and that's the nice thing about being part of Montefiore St. Luke's system is that we have a survivorship system. We have a nurse navigator that is easy to get a hold of who can hold a patient's hand and plug them in into the right area. Many doctors that I can tell you frankly, Scott, as a urologist, we don't get trained in helping men who are having depressive issues or anxiety issues. We're not really trained to do that or even perhaps even recognize it. So, I think patients tend to open up to other healthcare providers like nursing staff that can help patients to get them plugged in the appropriate area.

So, we recognize there's, these side effects. And then also, it's a long time, men who are diagnosed with prostate cancer are not necessarily dying from prostate cancer or dying from other medical issues. What does depression cause? Its effect on being able to have the energy to go out to the gym or to take care of your regular health or eat healthy. So, there's a lot of things that we're just kind of, I think, scratching the surface. And I think, as clinicians, as we are learning that we have, you know, patients for a lifetime, we need to be able to better recognize these issues.

Host: Yeah. And just taking all this in, it's like, "Congratulations. You've survived prostate cancer, whether it was radiation or prostatectomy, but you're going to live now 10, 15 years or longer, and you're going to be living with all these sort of side effects, if you will, of whatever you had done, as you say, urinary incontinence and some other things. Wondering if there are some resources. I know you said Nurse Navigator and this great survivorship program, but in general, like some resources you could point folks to.

Dr. Jaspreet Singh: Yeah. I think the American Cancer Society has a great website in helping patients out. If you go on Montefiore St. Luke's website, I'll get you plugged in the survivorship program. There are local chapters, Men-to-Men. Again, American Cancer Society has a Prostate Cancer Men's Group where men who are facing these challenges together can have discussions, have a support group, kind of encourage each other and also share resources. Perhaps something worked for one individual can help somebody else out. And somebody, you know, struggled with issues for several years may be able to share a resource that they discovered that helped them out. And then also, you know, I think primary care physicians, our primary care providers in general also are valuable in helping patients with survivorship, healthy living, weight control, avoiding things like smoking and, just in general, living a good, healthy lifestyle helps promote mental well-being as well. And actually, there were a couple of studies that showed that healthy eating effectively reduced the likelihood of prostate cancer reoccurring. So although we don't know what we can do to prevent prostate cancer, but let's say you get diagnosed and you're treated, what can we do to prevent this prostate cancer from coming back? And now, we have two studies. One is the MEAL study, which showed that men who abided by a healthier living and avoiding any sort of high-calorie foods tended to have a lower risk of recurrence. So, these are very important issues.

Host: Yeah. Well, as always, I appreciate your expertise and today, especially your compassion, as you say, you know, many doctors, surgeons like yourself aren't trained to spot the signs of depression, deal with depression in patients who are suffering. Yes, they've survived prostate cancer, but now they're suffering in other ways. So, this is a lot of layers here. As you say, we're kind of just scratching the surface a little bit, but we certainly hope this helps listeners and I appreciate your time.

Dr. Jaspreet Singh: Oh, it was my pleasure and thanks again as always for having me, Scott.

Host: And visit montefioreslc.org for more information about our Littman Cancer Center. And if you found this podcast to be helpful, please be sure to share it on your social channels and be sure to check out all the other Doc Talk episodes. This has been Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. I'm Scott Webb. Stay well.