Amanda Wilde (Host): Prostate cancer is not uncommon and risk increases over a lifetime. So we'll address what you need to know about prostate cancer with Dr. Marcelo Bigarella, Urologic Oncologist at UAMS. Dr. Bigarella specializes in the diagnosis and management of urologic cancers. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences.

I'm Amanda Wilde and I'm so glad to have you here, Dr. Bigarella. Welcome.

Marcelo Bigarella, M.D.: Thank you so much for having me here. It's a pleasure to talk a little bit about what we do in clinic and the operating room and to share this information with everyone to raise awareness about this condition.

Host: Yeah, so many questions because either you will get it in your lifetime or you will know one or more people that will get it in their lifetime. So what is the prostate and can you explain exactly what its function is in the body?

Marcelo Bigarella, M.D.: Mm Perfect. That's a very good thing you asked first. And then one thing you mentioned is very important. I think prostate cancer is very common. So that's why I think that we can share with people that is at one point in your life you'll get to know someone that will have prostate cancer.

It's one of the most common cancers in men and almost one out of eight or sometimes one out of nine men will have this prostate cancer during their lifetime. But I like explaining exactly what the prostate is and where it's located. The prostate is a very small organ that is the size of a walnut, is located below the bladder and in front of the rectum in men.

Okay. The main function for the prostate is to produce seminal fluid, which nourish and transport sperm during ejaculation. And the prostate also helps controlling the urine inside the bladder to avoid leakage. So that's why I think that we can say the two most important things is to help with this, the nourishing, transporting sperm during ejaculation and controlling urine inside the bladder.

Host: And what is prostate cancer?

Marcelo Bigarella, M.D.: Any type of cancer is when the cells within the organs, they start to grow uncontrollably. Meaning that they evade the capacity of the immune system to stop the growth and to kill that abnormal cells. Prostate cancer it's when that growth happens within the prostate.

And sometimes it will grow and by growing it might invade the surrounding structures. And sometimes it also, during the late phases of the disease it can go to other parts of the body. Not just within the prostate or the prostate around it, but it can go into bones, to the liver, to the lung, and they are known as metastases.

So I think there are two entities. Everything starts within the prostate, but then prostate cancer can also be present in different organs once it gets to the metastatic space.

Host: So with all cancers, there are many stages to the cancer. And you want to get it as early as possible. I want to talk about screening and if that exists. But, before we get to that, you mentioned prostate cancer is quite common. 

Are their specific risk factors for prostate cancer? For example, hereditary factors or lifestyle factors?

Marcelo Bigarella, M.D.: That's a very good question. I ask very often in clinic also what one can do to prevent the risk from getting prostate cancer in the future. And if we know the modifiable risk factors, we can work around that question. So one that it's something that is completely difficult to control, is the age.

We know that prostate cancer is more common as man age. So that's something we cannot control. But we know that the risk increase substantially after age 50, once someone is around 50. We know the average age for prostate cancer in the United States is around 66. So that's why I guess we have a lot of patients around 60 and 70 years old having prostate cancer found.

There are also family history. So if you have like a close relative, father, brother with prostate cancer, you have a somehow higher risk because we might find mutations in your genetics that might contribute to this elevated risk for prostate cancer. We also know that race plays an important role.

We know African Americans, they tend to have higher risk and also more likely to develop aggressive disease. So that's why we have specific recommendations for this race group. And we also know that genetic factors that it, we even sometimes the genes associated with other cancers like there's a very common, the BRCA, the BRCA gene, Angelina Jolie breast cancer gene that was famous a couple of years ago, can also play a role in prostate cancer and you can pass through generations, not necessarily from just the father, but also coming from the mother. So we know that genetic is also plays a role but one thing that you asked during your question, the what we can change the lifestyle factor is also they we think they play a role in developing prostate cancer. So diet, obesity and smoking may contribute to this risk. So that's something we advise patients to really pay attention because they can control those things.

Host: You mentioned that as men age, there's a higher risk for this cancer. And you have mentioned some other risk factors. So what are some of the specific recommendations you have as far as screening?

Marcelo Bigarella, M.D.: That's exactly what we try to do as your oncologists and as urologists to bring these age recommendations because in the earliest stages of the disease, we don't have symptoms. So someone should seek the prostate cancer screening, even without symptoms, that's why it's called screening.

It's something that someone would do asymptomatic in order to detect. It won't change the risk of developing cancer, but it will detect your cancer much early on. So, the recommendations right now in the United States by the American Urological Association is to start your PSA, your prostate cancer screening with a PSA test.

We will talk about that a little bit later. But around the age 45. Okay. In all men. But if you have those risk factors, I've just mentioned African American, family history or any genetic mutation that predispose you to have more aggressive or earlier prostate cancer than we would recommend starting the screening at age 40.

There is the main difference between everyone 45 and then risk factors 40 years old. 

Host: You mentioned you can be asymptomatic. Can you also have symptoms?

Marcelo Bigarella, M.D.: Yes, you can. So, most men once they or elevated PSA, elevated PSA is a blood test we do to detect and that's how we start prostate cancer screening for asymptomatic. But I think we can also do PSA in the setting of symptoms and the symptoms are related to more frequent urination, sometimes patients, they have urgency, they complain, they cannot empty their bladder.

They feel that once they went to the bathroom, 15 minutes later, they feel that they need to go again. Sometimes they start having leakage or incontinence where they didn't have that before. And in more advanced cases, you can even have some blood in your urine. So, I think those are the symptoms to look for that can be a part of the prostate cancer scenario. Symptoms related to urination and also blood in your urine.

Host: And the tests you will get done. It sounds like the PSA blood test is an important one for screening.

Marcelo Bigarella, M.D.: Correct. So, for asymptomatic patients, PSA really revolutionized the way we do prostate cancer screening for a long time since the nineties has been there for a long time. It's not perfect, but it provides us with a good estimate if someone is more likely to have cancer. And of course, the PSA is not just the one test we do, but that's the test we start.

And then if we found someone with elevated PSA, meaning above the normal limit for that age group, then we might order different tests such as MRI or even other molecular tests or even other blood tests to make sure we understand if this is prostate cancer or if this PSA is elevated because the prostate's big but it's not related to a tumor. It's just because of the big size of the prostate.

Host: But you get an answer either way.

Marcelo Bigarella, M.D.: Yes. So elevated PSA, there is an overlap in between prostate cancer because they produce a lot of PSA, those cells that are growing in a very rapid way but also there is elevated PSA in the setting of what we call benign prosthetic hyperplasia, which is just the complete benign enlargement of the gland that is much more common the prostate cancer that almost 70 percent of men will have around the age of 70.

So it's very common and there's this overlap in between elevated PSA from like a benign condition and also from a oncological condition. So we have to make sure once we have that elevated PSA, we do a further workup, to understand exactly what's going on, if the patient has prostate cancer or is just having issues with urination because the prostate is very large.

Host: And if cancer is found, how is prostate cancer treated?

Marcelo Bigarella, M.D.: There's a lot of things we have to consider before offering someone treatment. The first thing that mentioned early on is to get a good sense of where the prostate cancer is at this point. So it's a staging, a good staging with sometimes we rely on PET CTs we have a very specific for prostate cancer. Sometimes we do prostate MRIs to understand if the prostate cancer has spread to the surrounding organs or to the lymph nodes. But if the prostate cancer is only located inside the prostate that we call this early disease or localized disease, then there are two most common treatments for prostate cancer we call active treatments.

And they involve either removing the prostate surgically, most commonly we do robotic surgery, we call radical prostatectomy, or giving the patient radiation to the prostate in conjunction with hormone therapy to prevent the cancer from growing back. Those are the two most common active treatments modalities we have for localized prostate cancer.

Host: And what is the success rate of those two modalities?

Marcelo Bigarella, M.D.: So if we consider someone got an elevated PSA at the age of 45 and it triggered the biopsy, we found prostate cancer and the patient is around 60 years old, 62 and just have very localized lesion; we are talking about like a very good success rate in 15 years, 20 years down the road.

Okay? Because again, once we remove the tumor that hasn't spread, we are talking about cancer free options for treatment. So I think our goal both delivering radiation or getting a patient to surgery is to make sure like we provide cure. We do that with a curative intent. So very good success rates. They usually once we see more aggressive tumors or tumors extending outside the prostate, those success rates, of course, they decrease, but still we can offer good things to patients and also to make sure they preserve the quality of life.

Host: In terms of quality of life, you mentioned there are ways to reduce risk of prostate cancer in some lifestyle areas. On the other side, what are you looking at in terms of the latest advancements in prostate cancer treatment?

Marcelo Bigarella, M.D.: Prostate cancer, since it's the most common cancer in man, there's a lot of research looking into it and we had good things coming from all different stages of the condition from the diagnosis, from imaging, from treatment and also for surveillance.

So I think right now a couple of things I can say related to diagnostic, we have molecular testing that we can predict a little bit better if the patient will have some sort of recurrence or if the patient harbors mutations that we can give them more tailored and more specific individualized treatments. 

We have tests for that right now. In terms of imaging, we have better resolution for the MRIs that we know for sure now where the prostate cancer is so we can try to preserve more nerves that have better functional outcomes in terms of erectile function. We have this very specific PSMA pad that is approved in the last couple of years for prostate cancer that only look into prostate cancer specific molecules.

So we know exactly very, very tiny nodes that harbor micrometastatic disease, this pad will light up because of that sensitivity. And in terms of treatment, I think both treatments we have available, surgery and radiation; they got much better in terms of reducing the side effects. And the radiation, they have better technology. They are able to deliver radiation to the prostate instead of the scatter. The radiation that was delivered to surrounding organs was lowered. So this scattered radiation is a little bit better.

In terms of surgery, we have robotic surgery in the past couple of decades in past two decades that minimize the length of stay here in the hospital and also maximize the functional outcomes for the future because we are able to see a little bit better the structures inside the cavity.

Host: That's really exciting that you have treatments that progressed to lower impact, which means faster recovery.

Marcelo Bigarella, M.D.: That's right. And I think we're always trying to push towards more minimally invasive surgery and procedures and definitely, I think, robotic surgery, in that sense, it started with prostate cancer because the location of the prostate is very tricky. It's within the pelvis. So having a better instrument to get access to a very hard location, it was crucial.

So that's why I think robotic really came and stayed for that reason.

Host: And affected all these other medical areas as well.

Marcelo Bigarella, M.D.: Correct. So once I think the first robotic surgery really started within urology, because we needed something better to see the pelvis. That's where the prostate is below the bladder. So it's a very challenging area because we don't have a good visualization. And once the technology was approved and it was, every urologist started using them for prostate cancer; you really had a widespread use for all different surgical fields. So now everyone now is trying to use the robotic surgery for different reasons. 

Host: And that makes the recovery rate higher than ever.

Marcelo Bigarella, M.D.: Correct. Correct.

Host: Dr. Bigarilla, thank you so much for your insights and explanation of prostate cancer from diagnosis to treatment and beyond.

Marcelo Bigarella, M.D.: Thank you. It's my pleasure. Thank you so much for having me today. If you have any questions or any other discussions, I'm more than happy to answer those. I think one of the important things about being a provider, not only we have to provide care to our patients in an individual basis, but we have to educate the entire population in a broader sense. So I'm happy to have joined the program today.

Host: That was Dr. Marcelo Bigarella, Urologic Oncologist at UAMS. To make an appointment at the UAMS Urology Oncology Clinic, call 501-296-1200. If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for other topics of interest. Thanks for listening.

This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences.