Dr. Trushar Patel, Associate Professor of Urology at the University of South Florida Department of Urology, speaks on the incidence of prostate cancer, modalities for screening, and available treatment options.
Visit cme.tgh.org for other CME opportunities, including live webinars, on-demand videos and local events offered to you by Tampa General Hospital.
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Selected Podcast
Prostate Cancer Screening and Treatment Options
Featuring:
Trushar Patel, MD
Dr. Trushar Patel joined the USF Department of Urology after completing a fellowship in Robotic and Minimally Invasive Urologic Oncology at Columbia University Medical Center. Prior to his fellowship, he completed his urology residency at Columbia University Medical Center. Dr. Patel is committed to providing patients with the highest level of urologic care in an environment that fosters a strong patient-physician relationship. He is currently offering a full array of advanced robotic procedures for prostate, bladder, and kidney cancer.
Transcription:
Prakash Chandran: After skin cancer, prostate cancer is the most common cancer among men and can sometimes be slow-growing or aggressive. With testing and treatment, it can be managed successfully. But there's more than one type of test to discover prostate cancer and more than one way to treat it. Here to educate us and to tell us more is Dr. Trushar Patel. He's the Associate Professor of Urology at the University of South Florida Department of Urology, Residency Program Director and Director of Robotic Surgery.
Welcome to MD cast by Tampa general hospital, a go-to listening location for specialized physician to physician content and a valuable learning tool for world-class healthcare.
I'm your host, Prakash Chandran. Dr. Patel, thank you so much for joining us today. I truly appreciate your time. Just starting with the basics here, maybe you can talk to us about how common prostate cancer is.
Trushar Patel, MD: Thanks, Prakash. Prostate cancer is actually fairly common. About one in eight men will be diagnosed with prostate cancer during their lifetime. And there are some, you know, geographic and racial risk factors that go along with that. The most cases, six out of ten are usually found in men who are above the age of 65. It's actually very rare to be diagnosed with prostate cancer under the age of 40. But we know certain patients such as African-American men, patients from Northern Europe, North American men and patients from the Caribbean islands are at more risk for prostate cancer.
Prakash Chandran: Yeah, it's been on my mind lately. I just turned 40 and I was wondering, what age do you actually start screening for prostate cancer?
Trushar Patel, MD: You know, if you look at the guidelines, especially from the American Urological Association, they state that men should start screening for prostate cancer between the ages of 55 and 69. And there's different guidelines out there from Europe and different societies. And there's been evidence to suggest that if you are at risk, so if you have family history, you're African-American, that you should potentially get a PSA screen test done in your mid-40s. And based on that level, it'll give you an estimated risk for the future. And you don't necessarily need to get the testing done every year in your 40s. But there is some good evidence to say if you're an at-risk patient, to consider getting it done in your 40s, but otherwise guidelines would state at the age of 55.
Prakash Chandran: When we say screening for prostate cancer, what exactly does that mean?
Trushar Patel, MD: Prostate cancer screening is really done by a blood test. It's a simple blood test that you can get from your primary care or your local urologist or any physician. And it's called a PSA test, which which means prostate-specific antigen. And it's a marker in your blood that could rise over time. And that number can give you a risk of estimate of what your prostate cancer risk is.
Now, PSA is not perfect. There are other reasons why that blood test can be elevated such as an enlarged prostate. Certain men can have infections in their prostate. Trauma, so if you fell off a bike and got kicked in the groin, things of that nature can cause your PSA to become elevated. So it's not cut and dry depending on the blood test whether you have prostate cancer or not. It will give you a risk estimate. Over time, your doctor will follow your PSA numbers and he can track the rate of change and how fast it's rising. And those are other indications that potentially may indicate you're at more risk for prostate cancer or not.
Now, if your PSA is of a certain level that is concerning to your physician, he may end up ultimately recommending an MRI of the prostate, which is magnetic resonance imaging, to take a picture of the prostate. And then from there, you may ultimately need a biopsy of the prostate which can be done in the office or in the operating room.
Prakash Chandran: Okay, understood. And so you kind of talked about people in the at-risk category, getting screened potentially earlier than 55. But how about people that aren't, are there like symptoms or things that happen in their lives that tell them, "Hey, maybe I should get this PSA screening done"?
Trushar Patel, MD: Yeah, that's another great question that people have looked at. And there really aren't any significant symptoms of prostate cancer, unless it's almost too late where it's metastatic, and it's kind of spread to the bone and different organ systems. Typically, prostate cancer is asymptomatic. You won't feel it. It should not cause any urinary symptoms or where you have difficulty peeing or any of that nature. And so really you're truly going by what the blood test tells you and then going from there. So there's not really many symptoms we tell patients to look for. But we do have patients, who haven't had access to care and haven't seen doctors in a long time and they present with metastatic prostate cancer, and those patients do have pain, they can have weakness in their lower extremities and their legs, and then those patients could also have difficulty with urination, but that's usually in the advanced stages.
Prakash Chandran: Maybe talk a little bit about the benefits and pitfalls of prostate cancer screening. I know you've mentioned that sometimes it may not always be accurate, given certain scenarios like an enlarged prostate or trauma. But are there other things people should be considering when it comes to prostate cancer screening?
Trushar Patel, MD: Yeah. And I kind of touched on this a little bit here. The PSA can rise for a lot of benign conditions that are not related to cancer. And so unfortunately, the reason why PSA is not perfect is it can lead to many unnecessary biopsies. And so a biopsy, you may say, "Well, who cares? It's just the biopsy," but, you know, there are certain risks with biopsy. Typically in this country, the majority have been done transrectally. So that's an ultrasound probe that goes in the rectum. And then we do a biopsy of the prostate. There's about a 1% to 2% risk of sepsis with that biopsy. And then you do need to potentially need an ICU stay for that. So the biopsy is not completely benign. And so you are subjecting a lot of men to potentially unnecessary biopsies with the PSA.
And then furthermore, if you are diagnosed with prostate cancer from a biopsy, many of these cancers are potentially low-grade, slow-growing and are not going to impact your life. And so what happens is though lot of fear, there's a lot of pressures for patients to get treatment and there's been a lot of unnecessary treatments with either surgery or radiation for patients with disease that was not going to ultimately kill them. So based on the risk of a biopsy and the potential risk for overtreatment, PSA screening and evaluation for biopsy is something that has to be discussed and the patient needs to understand what they're getting themselves into.
Prakash Chandran: Understood. So given what you've just said, are there additional tests or measures that can be ordered to actually help improve the screening to really find out whether what is found is something worth pursuing and treating?
Trushar Patel, MD: Yeah, so I kind of touched on it, MRI over the last decade has really come to the forefront in helping us evaluate patients for elevated PSA and prostate cancer screening. So the MRI allows us to identify lesions within the prostate that potentially could harbor significant disease, and that can dictate patients who need biopsy and versus those who don't. And there's been plenty of studies that have come out over the last five years that have shown that MRI does reduce the risk of unnecessary biopsies and does improve the accuracy to identify high risk disease. So from that standpoint, MRI is a really good tool that most urologists are now using to help them. There are other adjuncts with biomarkers, with different kinds of urine and blood tests that are out there. There's been mixed results with those. Some have shown improvements, some have shown mild improvement. They're not as widespread as MRI. There's a lot of considerations with cost and insurance coverage with them. So, many of those tests have not really become widely available, but they're out there and certain people are using them. But typically, it's the MRI that has really helped us in trying to reduce the risk of PSA screening.
Prakash Chandran: So, if it is found out that someone does have prostate cancer and it's worth pursuing treatment, what are some of the available options?
Trushar Patel, MD: Yeah, it really depends on, again, the type of cancer we find. Not all prostate cancers need to be treated and we place many men on active surveillance where we just kind of monitor those patients over time with PSA, MRI and repeat biopsies. And if the cancer is stable and the patients are doing well, we just leave them alone. Depending on if they are intermediate or high risk patients or they're more aggressive, the patients will undergo a staging evaluation to make sure there's no cancer outside the prostate, so it hasn't spread to other organs, lymph nodes, or bone. And if not, then the patient potentially is eligible for treatments such as removal, surgical removal, so prostatectomy. There's radiation available to the prostate. There's cryotherapy, where you put probes in the prostate to freeze them. There are other ablative technologies that have come out in the last three to five years such as high-intensity focused ultrasound. There are other modalities using laser and different kinds of energy probes that can be there to focally ablate, you know, focal lesions within the prostate. So it really depends on, number one, the type of cancer you have and the volume of cancer. And then whether it's spread outside the prostate, which will dictate which one of these treatments will be ultimately best for the patient.
Prakash Chandran: Okay. Understood. And so, just as we start to close here, you clearly have lots of experience kind of evaluating and dealing with men with prostate cancer. What's one thing that, you know, to be true that you just wish more men knew about prostate cancer or prostate cancer screening?
Trushar Patel, MD: The biggest thing is to get over the fear. A lot of men don't want to have a screening. It's a sensitive topic. They don't want to discuss it. They don't want to bring it up. And it's something that they don't know about. I mean, I think really part of why we're talking and why we're out there is to kind of get men more comfortable talking about the disease understanding that it's not anything to do with them as a person. They didn't do anything that caused this disease. It's just that it becomes more common with age. And then as you age, it's going to be part of your normal kind of health evaluation as you get older and kind of just trying to break that barrier to just kind of make this more of a common conversation.
Prakash Chandran: Yeah, absolutely. And let me just ask a more broad question as a lay person. You know, we're told to go see our primary care physician once or twice a year, and we get our blood workup, but how should we start thinking about prostate cancer screening in general? Is this something that we bring up to them? Do they bring it up to us? Maybe talk a little bit about that.
Trushar Patel, MD: Well, I think, at any age, you know, obviously the more you know about it, the better you are to have a discussion with your primary care doctor about it. I mean, obviously all your physicians will know about this. They'll know about the screening. They'll know about the guidelines. And they'll kind of give you a more nuanced discussion on the pros and cons of screening. And if you want to have a further conversation, you kind of would kick that up to a potentially a urologist who will go over with you the risks and kind of the protocols for the biopsies on that side. Really, it's just kind of informing yourself and just being proactive about it. If your primary care is doing blood work, it's just simple as that, "Hey, do I need a PSA?" And then having that discussion. Not every guy needs a PSA. You don't need it at every age. And so it's just having a simple conversation that a lot of guys don't have is what we're trying to move along here.
Prakash Chandran: Dr. Patel, really appreciate your time. Thank you so much for joining us today.
Trushar Patel, MD: Thank you very much for having me.
Prakash Chandran: That was Dr. Trushar Patel, Associate professor of Urology at the University of South Florida Department of Urology, Residency Program Director, and Director of Robotic Surgery.
Thank you for listening to MD health cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars, on-demand videos and local events offered to you by Tampa general hospital, please visit C M E dot T G h.org.
My name is Prakash Chandran. Thank you so much. And we'll talk next time.
Prakash Chandran: After skin cancer, prostate cancer is the most common cancer among men and can sometimes be slow-growing or aggressive. With testing and treatment, it can be managed successfully. But there's more than one type of test to discover prostate cancer and more than one way to treat it. Here to educate us and to tell us more is Dr. Trushar Patel. He's the Associate Professor of Urology at the University of South Florida Department of Urology, Residency Program Director and Director of Robotic Surgery.
Welcome to MD cast by Tampa general hospital, a go-to listening location for specialized physician to physician content and a valuable learning tool for world-class healthcare.
I'm your host, Prakash Chandran. Dr. Patel, thank you so much for joining us today. I truly appreciate your time. Just starting with the basics here, maybe you can talk to us about how common prostate cancer is.
Trushar Patel, MD: Thanks, Prakash. Prostate cancer is actually fairly common. About one in eight men will be diagnosed with prostate cancer during their lifetime. And there are some, you know, geographic and racial risk factors that go along with that. The most cases, six out of ten are usually found in men who are above the age of 65. It's actually very rare to be diagnosed with prostate cancer under the age of 40. But we know certain patients such as African-American men, patients from Northern Europe, North American men and patients from the Caribbean islands are at more risk for prostate cancer.
Prakash Chandran: Yeah, it's been on my mind lately. I just turned 40 and I was wondering, what age do you actually start screening for prostate cancer?
Trushar Patel, MD: You know, if you look at the guidelines, especially from the American Urological Association, they state that men should start screening for prostate cancer between the ages of 55 and 69. And there's different guidelines out there from Europe and different societies. And there's been evidence to suggest that if you are at risk, so if you have family history, you're African-American, that you should potentially get a PSA screen test done in your mid-40s. And based on that level, it'll give you an estimated risk for the future. And you don't necessarily need to get the testing done every year in your 40s. But there is some good evidence to say if you're an at-risk patient, to consider getting it done in your 40s, but otherwise guidelines would state at the age of 55.
Prakash Chandran: When we say screening for prostate cancer, what exactly does that mean?
Trushar Patel, MD: Prostate cancer screening is really done by a blood test. It's a simple blood test that you can get from your primary care or your local urologist or any physician. And it's called a PSA test, which which means prostate-specific antigen. And it's a marker in your blood that could rise over time. And that number can give you a risk of estimate of what your prostate cancer risk is.
Now, PSA is not perfect. There are other reasons why that blood test can be elevated such as an enlarged prostate. Certain men can have infections in their prostate. Trauma, so if you fell off a bike and got kicked in the groin, things of that nature can cause your PSA to become elevated. So it's not cut and dry depending on the blood test whether you have prostate cancer or not. It will give you a risk estimate. Over time, your doctor will follow your PSA numbers and he can track the rate of change and how fast it's rising. And those are other indications that potentially may indicate you're at more risk for prostate cancer or not.
Now, if your PSA is of a certain level that is concerning to your physician, he may end up ultimately recommending an MRI of the prostate, which is magnetic resonance imaging, to take a picture of the prostate. And then from there, you may ultimately need a biopsy of the prostate which can be done in the office or in the operating room.
Prakash Chandran: Okay, understood. And so you kind of talked about people in the at-risk category, getting screened potentially earlier than 55. But how about people that aren't, are there like symptoms or things that happen in their lives that tell them, "Hey, maybe I should get this PSA screening done"?
Trushar Patel, MD: Yeah, that's another great question that people have looked at. And there really aren't any significant symptoms of prostate cancer, unless it's almost too late where it's metastatic, and it's kind of spread to the bone and different organ systems. Typically, prostate cancer is asymptomatic. You won't feel it. It should not cause any urinary symptoms or where you have difficulty peeing or any of that nature. And so really you're truly going by what the blood test tells you and then going from there. So there's not really many symptoms we tell patients to look for. But we do have patients, who haven't had access to care and haven't seen doctors in a long time and they present with metastatic prostate cancer, and those patients do have pain, they can have weakness in their lower extremities and their legs, and then those patients could also have difficulty with urination, but that's usually in the advanced stages.
Prakash Chandran: Maybe talk a little bit about the benefits and pitfalls of prostate cancer screening. I know you've mentioned that sometimes it may not always be accurate, given certain scenarios like an enlarged prostate or trauma. But are there other things people should be considering when it comes to prostate cancer screening?
Trushar Patel, MD: Yeah. And I kind of touched on this a little bit here. The PSA can rise for a lot of benign conditions that are not related to cancer. And so unfortunately, the reason why PSA is not perfect is it can lead to many unnecessary biopsies. And so a biopsy, you may say, "Well, who cares? It's just the biopsy," but, you know, there are certain risks with biopsy. Typically in this country, the majority have been done transrectally. So that's an ultrasound probe that goes in the rectum. And then we do a biopsy of the prostate. There's about a 1% to 2% risk of sepsis with that biopsy. And then you do need to potentially need an ICU stay for that. So the biopsy is not completely benign. And so you are subjecting a lot of men to potentially unnecessary biopsies with the PSA.
And then furthermore, if you are diagnosed with prostate cancer from a biopsy, many of these cancers are potentially low-grade, slow-growing and are not going to impact your life. And so what happens is though lot of fear, there's a lot of pressures for patients to get treatment and there's been a lot of unnecessary treatments with either surgery or radiation for patients with disease that was not going to ultimately kill them. So based on the risk of a biopsy and the potential risk for overtreatment, PSA screening and evaluation for biopsy is something that has to be discussed and the patient needs to understand what they're getting themselves into.
Prakash Chandran: Understood. So given what you've just said, are there additional tests or measures that can be ordered to actually help improve the screening to really find out whether what is found is something worth pursuing and treating?
Trushar Patel, MD: Yeah, so I kind of touched on it, MRI over the last decade has really come to the forefront in helping us evaluate patients for elevated PSA and prostate cancer screening. So the MRI allows us to identify lesions within the prostate that potentially could harbor significant disease, and that can dictate patients who need biopsy and versus those who don't. And there's been plenty of studies that have come out over the last five years that have shown that MRI does reduce the risk of unnecessary biopsies and does improve the accuracy to identify high risk disease. So from that standpoint, MRI is a really good tool that most urologists are now using to help them. There are other adjuncts with biomarkers, with different kinds of urine and blood tests that are out there. There's been mixed results with those. Some have shown improvements, some have shown mild improvement. They're not as widespread as MRI. There's a lot of considerations with cost and insurance coverage with them. So, many of those tests have not really become widely available, but they're out there and certain people are using them. But typically, it's the MRI that has really helped us in trying to reduce the risk of PSA screening.
Prakash Chandran: So, if it is found out that someone does have prostate cancer and it's worth pursuing treatment, what are some of the available options?
Trushar Patel, MD: Yeah, it really depends on, again, the type of cancer we find. Not all prostate cancers need to be treated and we place many men on active surveillance where we just kind of monitor those patients over time with PSA, MRI and repeat biopsies. And if the cancer is stable and the patients are doing well, we just leave them alone. Depending on if they are intermediate or high risk patients or they're more aggressive, the patients will undergo a staging evaluation to make sure there's no cancer outside the prostate, so it hasn't spread to other organs, lymph nodes, or bone. And if not, then the patient potentially is eligible for treatments such as removal, surgical removal, so prostatectomy. There's radiation available to the prostate. There's cryotherapy, where you put probes in the prostate to freeze them. There are other ablative technologies that have come out in the last three to five years such as high-intensity focused ultrasound. There are other modalities using laser and different kinds of energy probes that can be there to focally ablate, you know, focal lesions within the prostate. So it really depends on, number one, the type of cancer you have and the volume of cancer. And then whether it's spread outside the prostate, which will dictate which one of these treatments will be ultimately best for the patient.
Prakash Chandran: Okay. Understood. And so, just as we start to close here, you clearly have lots of experience kind of evaluating and dealing with men with prostate cancer. What's one thing that, you know, to be true that you just wish more men knew about prostate cancer or prostate cancer screening?
Trushar Patel, MD: The biggest thing is to get over the fear. A lot of men don't want to have a screening. It's a sensitive topic. They don't want to discuss it. They don't want to bring it up. And it's something that they don't know about. I mean, I think really part of why we're talking and why we're out there is to kind of get men more comfortable talking about the disease understanding that it's not anything to do with them as a person. They didn't do anything that caused this disease. It's just that it becomes more common with age. And then as you age, it's going to be part of your normal kind of health evaluation as you get older and kind of just trying to break that barrier to just kind of make this more of a common conversation.
Prakash Chandran: Yeah, absolutely. And let me just ask a more broad question as a lay person. You know, we're told to go see our primary care physician once or twice a year, and we get our blood workup, but how should we start thinking about prostate cancer screening in general? Is this something that we bring up to them? Do they bring it up to us? Maybe talk a little bit about that.
Trushar Patel, MD: Well, I think, at any age, you know, obviously the more you know about it, the better you are to have a discussion with your primary care doctor about it. I mean, obviously all your physicians will know about this. They'll know about the screening. They'll know about the guidelines. And they'll kind of give you a more nuanced discussion on the pros and cons of screening. And if you want to have a further conversation, you kind of would kick that up to a potentially a urologist who will go over with you the risks and kind of the protocols for the biopsies on that side. Really, it's just kind of informing yourself and just being proactive about it. If your primary care is doing blood work, it's just simple as that, "Hey, do I need a PSA?" And then having that discussion. Not every guy needs a PSA. You don't need it at every age. And so it's just having a simple conversation that a lot of guys don't have is what we're trying to move along here.
Prakash Chandran: Dr. Patel, really appreciate your time. Thank you so much for joining us today.
Trushar Patel, MD: Thank you very much for having me.
Prakash Chandran: That was Dr. Trushar Patel, Associate professor of Urology at the University of South Florida Department of Urology, Residency Program Director, and Director of Robotic Surgery.
Thank you for listening to MD health cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars, on-demand videos and local events offered to you by Tampa general hospital, please visit C M E dot T G h.org.
My name is Prakash Chandran. Thank you so much. And we'll talk next time.