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Scott Webb (Host): We all need to see our primary care doctors, at least once a year. And as we get older, we need to be screened for various types of cancer and men are no exception. And joining me, part one of a two-part series on Men's Health and Cancer Screening Guidelines and Treatment Options, is Dr. Jacob Andrade. He's a Radiation Oncologist at Coastal Radiation Oncology and Salinas Valley Memorial Healthcare System. This is Ask the Experts, a podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Doctor, thanks so much for your time today. We're generally speaking about men's health. We're going to talk about prostate cancer as well, in part two of our series. Before we get rolling here, just want to have you talk about the importance of men seeing their doctors every year for those yearly physicals or annual checkups and screenings as well.

Jacob Andrade, M.D. (Guest): Yeah, actually, that's a great question because a lot of stuff we're going to go through today, is really dependent on your individual risk factors. And a lot of people aren't really set up to identify those individual risk factors for disease, not just cancer, but other diseases as well. And so definitely going to your doctor regularly, getting an understanding of the diseases in your family, especially the risk factors that you're exposed to, and then the worrisome symptoms that you're concerned about is definitely important to get that figured out sooner rather than later. For instance, going to your primary care doctor, as opposed to ending up in the ER.

Host: Yeah, there's no doubt, and for most of us, you know, that sort of our portal into the medical system is through our PCPs, through our primary care physicians and most insurance covers annual checkups, yearly physicals. So, we know those are important. Speaking specifically about you, what are the types of cancer that really affect men the most? What do you see the most? Is it lung, skin, colorectal, sort of all the above?

Dr. Andrade: Yeah. When we talk about cancer there, there's really two classes we talk about. Let me just run through some the numbers here. The US 2020 census was just completed and there's 331 million people in the United States. So, skin cancer by far is the most common type of cancer. And that's because 90% of them are associated with sun exposure. And so running through some numbers, basal cell carcinoma, which is the most common cancer type affects about 3.6 million Americans per year. That's luckily a very indolent cancer. It grows locally. Doesn't usually spread like other typical cancers. So, it's usually taken care of relatively easily, not a lot of deaths or any at all. On the other hand, another type of skin cancer called squamous cell carcinoma acts more like the typical cancers we know that can start in the skin and spread to other parts. And there's 1.8 million cases and about 15,000 deaths per year for that.

When we started looking at all the other cancers that are non-skin cancers, which also include melanoma, which is a type of skin cancer, but it's a little bit different. And when we look at all the cancers, there's 1.8 million cases diagnosed per year in the United States and about 60,000 deaths. So, these kinds of cancers, the ones we commonly we talk about lung, prostate, breast and there's a lot of deaths associated with that. But specifically for men, we have about 893,000, about half of the total cases involve me, which makes sense. The most common being prostate affecting about 190,000 men, the next is lung cancer, then colon cancer. And then something rare would be like a pancreatic cancer that affects about 30,000 people per year. But something even more rare that is unique to men would be like a testicular cancer that affects about 8,000 to 10,000 men per year.

Host: Processing everything you're saying here. And I know that many of us after COVID-19, we're looking forward to getting outside. And of course we know that sunscreen is so important and reapplying. And I'm wondering, do you treat all of these types of cancers?

Dr. Andrade: So, I specifically am a radiation doctor. I use radiation to treat cancer. For all the listeners out there, whenever you have cancer, you should always be thinking, do I need chemotherapy? Do I need surgery? And do I need radiation therapy? It's actually an and or. So, usually the more advanced cancers, you probably need a combination, if not all, three of them, whereas more early stage cancers, you can probably get away with just a single modality treatment.

So, in the case of radiation alone, we can treat skin cancers, anal cancers, cervical cancers, head and neck, which we usually refer to as throat cancers and some of these lower grade lymphomas, which are a type of blood cancer that acts more like an organ cancer.

Host: Yeah, and I want to talk about when men should be screened. And I know that regarding colorectal cancer, that the guidelines have changed. It used to be 50 was sort of automatic, as soon as you get to be 50, you get screened for colon cancer. Now it's 45 in most cases is appropriate unless there's a family history or genetics are involved, but generally speaking, when should men start to get screened for these types of cancers and how important is it to know our family history?

Dr. Andrade: Yeah, absolutely. First I want to take a little sidestep because there's something that I commonly hear, especially now in the age of fake news and misinformation, but one of the things that you hear repeatedly is that experts constantly flip-flop. And it could seem that way when, as you said before is 50 and now it's 45, well what's gonna be next time. I think you have to take into account what exactly is an expert recommendation. When doctors look at expert recommendations, there is actually a government, a task force called the US Preventative Services Task Force that their job is basically to review all of the data and by data, I mean, clinical trials, and then they make the recommendations based on what the available data is.

So, as you said for colorectal cancer, there's actually a lot of data that indicates that a screening program for patients between the age of 50 to 75, not because that's what the results were, but that's what they looked at in that trial specifically. There's a lot of data that shows that screening for colon cancer can reduce cancer deaths. Now, subsequently after that initial trial was published, there's additional trials we're trying to look at. Well, maybe younger people should also be examined, but unfortunately there's not a lot of data to look at that. So, even though, as you said that the task force has changed the recommendation from 2016 to 2021, really, they don't have as a strong recommendation to screen people under 50.

And that's because the data doesn't show that, but definitely, when we do see screening in younger patients, that's typically because there is someone in the family that has a prior history of cancer. And as you said, you know, people with a history of cancer in the family are at increased risk of having cancer, but also at risk of having a cancer at an early age.

So, when you talk about recommendations, you assume the average risk, which is the general population. Most people don't have family members with cancer. That would be an average risk and 50 would be appropriate for colon cancer. Whereas if you had a lot of people in your family who had cancers, then maybe a little bit earlier, like 45 would be recommended.

Host: Yeah. And you mentioned earlier, what you do specifically, and you talked about radiation therapy. So, let's talk about that. Tell us a little bit about that. How successful is radiation therapy? How does it work? And so on?

Dr. Andrade: One of the words that I want you to understand when we talk about radiation therapy is organ preservation. What does that mean? It's kind of a hard thing, but it's exactly what it says. It's organ preservation. For instance, say a throat cancer or a cancer of the vocal chords. If you have surgery and you remove the vocal chords, you're going to lose your voice. And early stage throat cancers, losing your voice for a small cancer, doesn't really seem like a good deal, although, you're probably going to have a very high chance that this is not going to come back. On the other hand, if we treat this with definitive radiation, we have an almost equal chance of not having this come back as surgery, but the benefit is you're going to get to preserve your voice.

And so whenever you talk about radiation, the key there is it's going to allow you to preserve organs. Another example would be in breast cancer where traditionally treatment was mastectomy, removal of the whole breast, but now most commonly we're performing a lumpectomy, removing just the tumor and then adding radiation to help decrease the risk of recurrence.

Host: Yeah, so I get it, so organ preservation. And that does sound so key and so important for patients. So, generally speaking, how does radiation therapy work?

Dr. Andrade: One fundamental property of cancer is that it's always growing. And when cells grow, that means that they divide. And when they divide, they're gonna need an instruction book that basically tells them what they're going to do and that's the DNA. And so radiation specifically works by damaging DNA. And what ends up happening is that in normal cells, they get DNA damage as well. But since they're all normal and healthy cells, they have repair mechanisms in place to help repair those damages, whereas cancer on the other hand, is more concerned with growing and it doesn't have all of those repair mechanisms in place. So, often there's so many mutations that develop that the tumors die. And so the main idea is that we're targeting the division of cancers or the growth of cancer and causing them to die.

Host: Cancer in and of itself is very scary for people, but so is the treatment. And I've had some friends that have had cancers and you know, they tell me that, you know, that being treated for those cancers is difficult. It's a long process. It can be a painful process. It can make them sick and so on. So, I'm sure listeners might have some questions. When we talk about radiation therapy, what are the side effects? How long do the treatments take it? Does it vary by cancer? That kind of thing.

Dr. Andrade: I think one of the most common things to be concerned about is the side effects. Lots of our patients hear stories of complications from different treatments, but I'll reassure you that your doctor is an expert in knowing the data and knowing what the risk of each specific treatment is. And they are not going to recommend a treatment that is going to cause more damage than good. So, you know, one of my greatest feelings is when I can say to a patient, you don't need radiation. Not because I don't want to give radiation, but because potentially I don't want to have that patient deal with the side effects. And if it isn't necessary, then you don't want to do that. So, going with the side effects, you can think of it as basically radiation damage causes damage to the cell. And when cells are upset, it causes a stress which causes it to release different signals, which we call inflammation.

And so, inflammation is a systemic response mediated by the immune system. And usually say, if you sprain your wrist, the inflammation will involve some swelling, increased blood flow to that area to help in the repair process. On the other hand, if you have an infection, inflammation, again, may cause some swelling, it causes increased blood flow, which increases recruitment of immune cells to help attack that infection. When radiation treats a specific area, you get a lot of cell damage. And the immune system enters basically like a war zone where there's a lot of catastrophe and it's trying to figure out what's going on. So, the first step is to create these inflammatory signals that increase swelling, blood flow and probably pain and sensitivity to that area. And usually, after you complete treatment, those symptoms go away. However, there does remain a small amount of persistent irritation of the cell. Some of the cells don't act entirely normal and they continue to send out these inflammatory signals.

And I think, long-term side effects can be like pain in the radiation site or say if the intestines were treated, you know, it can have some diarrhea occasionally. Those are all kind of symptoms that things aren't working. Right. And every person, will react differently and have different intensity and duration of symptoms. And there are some people that have no symptoms or very minimal symptoms that go away. And there are, on the other hand other patients that receive the same radiation dose to have these long-lasting pain symptoms or diarrhea symptoms or other stuff like that. So, with side effects, you know, it is also related to the total amount of radiation that you receive, which we call the dose.

And then the dose is related to how many treatments we give. Just to explain in general, how long does the treatment last? For something where our goal is just to achieve some pain relief in say somebody that has an incurable cancer, then we don't want to keep that patient on treatment for very long. So, sometimes a single treatment, to a painful bony site, can be very effective. Whereas when we're considering more definitive treatment like for prostate cancer, nine weeks of daily radiation; we usually deliver radiation five days a week, Monday through Fridays. Weekends are off to give the patient a little bit of rest and, you know, nine weeks that's 38 total treatments, once a day and each treatment will take about 30 minutes. So, that is for prostate cancer, but most cancers can be treated with what we call standard fractionation, where we give a little bit of radiation every day, in about five to six weeks, again, with the daily, Monday through Friday treatment.

But what our field is looking into and the future of radiation is how can we decrease that treatment time? Because there is some evidence that the shorter the treatment time, the more effective the treatments. In cases like cervical cancer or head and neck, throat cancers and so there's been a long period where we've been looking at trying to give a little bit more radiation every day so that we can decrease the total amount of treatment time, however, still deliver the same or an equivalent dose. For instance, traditionally breast cancer was treated over five weeks.   Now most treatments can be less than four weeks, usually about three weeks or even less than that. And moving forward for example, in clinical trials, we're looking at trying to treat prostate cancer, not in 38 treatments over nine weeks, but just five treatments over two weeks.

Host: Wow. That's incredible. As you were speaking to earlier, you were talking about how, you know, it's not so much flip-flopping when experts change guidelines or when treatment, you know, changes. It's really more that medicine and science is evolving and changing so rapidly. And that's just amazing news for patients, to cut down both the amount of treatments, but the duration for each of those treatments. That's really amazing.

Dr. Andrade: That is really amazing. And the reason that this wasn't possible before is because you got to think about it. If we're doing multiple treatments, we gotta be absolutely sure that we're hitting the same target. So, when radiation was first being delivered, we had no CT scanners. It was all done on x-rays. And so knowing your bony anatomy and where the organs lie in relation to that bony anatomy, was really the main thing you had to do. And so fields were very large. A lot of organs were included and so most treatments usually lasts about 15 minutes because it was really easy to set up. And you wanted to give just a little bit of radiation every day, because you're potentially giving a lot of radiation to areas that didn't need it.

As medicine advanced, and CT scans became available, now we could see in three dimensions exactly where our target is and where all the organs of risk, which is what we call them, are in association to that. And so with these more condensed treatment schedules, treatments delivered over five single treatments that are equivalent to 38 treatments, you have to be absolutely certain that you're giving the very high dose radiation just to your target and not to the organs. So, traditionally these long treatments would take about 15 minutes a day. Whereas when we do five treatments, those usually take about 45 minutes to an hour.

And a lot of that, critical steps is imaging. We have a CT scanner on our actual treatment machine, so, we can visualize exactly where the organ lies just before we deliver the radiation. And we can be certain to millimeters of exactly that we're hitting our target and we're avoiding the organs that are dangerous. And that's very important when it takes, you know, 20 minutes of continuous radiation. You want to be absolutely certain that you're hitting your target. And that has only been allowed with this modern technology that we have available today. And so that is why we're continuing our investigations and moving onto the future, things are going to continue to change.

Host: Yeah, it sure does sound like they are. And I wanted to ask you about brachytherapy. How does that treatment work?

Dr. Andrade: Brachytherapy it comes from the term brachas, which is a Greek word that was used to describe short distances, a small amount of time or a small quantity. And specifically in radiation, brachytherapy means that the short distance. And what that means is, the radiation is only going to travel a short distance. So, what we use here most of the time is external beam radiation, or x-rays. The source of their x-ray is several centimeters away from your body. So, that's a long distance considering how small radiation, or just the size of the photon, which is the element that the radiation is delivered through is very tiny. It's energy and so it doesn't have to be very far, but on the other hand with brachy, the short distance is because you use a radioactive source that you could implant directly into the tumor and therefore the radiation is being generated intimately in contact with the source that you're targeting. So, as opposed to radiation coming from outside the body.

Host: Really fascinating stuff. So amazing. And it almost sounds sometimes like we're talking about science fiction, but the great thing is it's real, it's happening. You're doing it. Maybe later today. Doctor, I'm looking forward to speaking with you for part two of our series, when we'll discuss prostate cancer. Until then stay well and stay tuned for part two of our series and for more information, go to svmh.com and we hope you found this podcast to be helpful and informative.

This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.