Bob Underwood, MD (Host): Welcome to UK HealthCast, a podcast presented by UK Healthcare. I'm your host, Dr. Bob Underwood. Today, we're talking about prostate cancer, and to help us understand all of this, we are joined by the Chair of the Department of Urology, Dr. Steven Strup. Dr. Strup, welcome to the podcast.

Stephen Strup, MD: Thank you. Pleasure to be here.

Host: Lots to talk about. Of course, this is a really big deal in men's health. So can we just start with an explanation of what is prostate cancer and why is it so significant?

Stephen Strup, MD: Cancer of the prostate obviously, starts in the prostate, which males have. It's significant because it's the most commonly diagnosed cancer in men, and it's one of our leading causes of death and if you look across the US, there's roughly 280 or so thousand cases diagnosed every year, and as many as around 34,000 deaths, so clearly many more with it. But it's still a deadly disease, so it's something that men need to know about for sure.

Host: So are there risk factors that increase the risk of a male developing prostate cancer?

Stephen Strup, MD: Well, we know some, obviously being male. There are genetic factors. We know that family history plays a big role. There are certain groups that have a higher risk, black men have a higher risk of having prostate cancer. We're getting more information about specific gene abnormalities that may track through families.

 Breast cancer actually through the BRCA genes actually translate to higher risk for prostate cancer, in men. If mom had a family history of breast cancer, you may have gotten a gene that may impact you.

Host: So, at what age do you recommend starting screening, PSA, testing, things like that?

Stephen Strup, MD: It's been interesting. There's been a lot of change and controversy through the years about prostate cancer screening and, briefly to hit the history highlights; PSA testing, which is our standard now, actually started many years ago, and, and we weren't sure how to use it. And so there was a lot of learning about how often do you check it, what's a normal value and so forth.

There've been a couple large trials that have been done, some controversy over those, but I think the dust is settling and different groups will have different recommendations. But our AUA guidelines would suggest that if you're a man of average risk, meaning that you don't have any strong family history or other risk features, somewhere in that 45 to 50 years of age, you should consider starting with PSA screening.

Host: Is that an annual test?

Stephen Strup, MD: Well, the timing of it, again, you, should start out at least getting it done every year for a year or two, and then we're learning a little bit more, that if you have a very low number, you could probably stretch that out to every couple of years more just to get a history because there's really no set value that works for everybody. So you, as your own internal control tends to be, the best way to look at this. So, establishing a baseline and then depending on where that baseline is, history and so forth, you can do it yearly or stretch it out to every couple years if everything looks good.

Host: Sure. Now let's talk about prevention. Do diet and exercise and some of the other things that we consider to be healthy activities, play into prostate cancer and the risk?

Stephen Strup, MD: To some extent. The way I tend to phrase it to my patients is, if it's good for your heart, it's good for your prostate. So things like low fat diet, avoiding obesity, those are sorts of things that can impact it. But again, there's not a specific diet recommendation that's going to be, take this, you will prevent prostate cancer.

So really heart healthy, healthy diet is good for you. Exercise, actually, there were some studies that we actually even looked at here at UK years ago that showed exercise had a positive impact on prostate cancer. So again, eating healthy and exercise is not going to hurt you and it's certainly not going to hurt your prostate.

Host: So going back to the testing and the screening, what role does early detection actually play in the treatment of prostate cancer if it is early detected?

Stephen Strup, MD: Well, it gives us more options. So I remember back in my training, which was too many years to comment on, I guess. But, we didn't have PSA testing and so the patients that we would treat often came in, you diagnosed them just with a rectal exam and they would have bulky disease. And so, not shockingly, they didn't do as well.

It was harder to control that disease. Many more people presented with metastatic disease and so forth. So, by screening, it's not perfect, but you can at least have a chance of finding that cancer earlier when we have options and have more options for local control and so forth. Some men still present with just metastatic disease, so, we know there's value in screening. We just have to do it carefully and smartly.

Host: As a urologist and an expert in oncology, what to you are some of the most promising things that are out there for treating a patient who's recently been diagnosed?

Stephen Strup, MD: So I think there's several exciting things. A lot of the development recently, has been in the more advanced disease state, and so that's really where things really started shaking out several years ago. Before it was hormonal control for advanced disease, and we didn't really have much beyond that. And then there's just been an explosion in research and drug development on ways to help control prostate cancer once it escapes that baseline hormonal control.

There's been newer options as well. And really it seems silly, but it's actually a, an important option is to observe, not treat. So active surveillance for low risk cancers is something that really has changed our management dramatically. Because we know that not all prostate cancer is the same.

And if you have a low volume, low risk tumor, we can carefully surveil that and avoid the potential side effects of therapy in properly selected patients, they do just fine. Doing nothing seems like a crazy treatment, but it really is an excellent choice for low risk cancers. For active treatment options, there's been a surge in interest in focal therapy, which is really targeting the cancer and ablating it by either ultrasound, energy, heat, electricity and so forth. It's attractive, but the problem is, is prostate cancer tends to be multifocal. We're still learning who might be the right patients for that disease. There's some emerging data now to say, well, in the properly selected patient we can consider that. We certainly do other standard treatments such as surgery and radiation better. I think we are better at targeting with radiation, combining it with tools to help improve targeting and also decrease impact on the rectum.

For surgery, we're doing it robotically and people are looking at other surgical adjuncts and I think they're just becoming more refined. It doesn't eliminate side effects, but it sure helps control them a little bit.

Host: I know that that's been one of the big things that I've learned over the years. You talked about how long it's been since our training, and I'm with you on that. But the whole implementation of robotic surgery around the prostate and being able to really target a lot better, compared to the radical prostatectomy when we were going through our initial training, it's just been huge. So how does UK Healthcare really kind of personalize that treatment the patient?

Stephen Strup, MD: What we try to do is take a multidisciplinary approach. So when we talk about what's right for the patient, we really, I would try to talk about all therapies. So we have a multidisciplinary clinic for prostate cancer. And so you'll come in and, and you'll talk with me about the surgical options, about any focal ablation, if that's something that would be reasonable for your particular disease. At the same time, we'll have you talk to our radiation therapy team about the different options, whether it's brachytherapy, which is a seed implant therapy we do here. We also have SBRT, which is a shorter course radiation or standard radiation, about the pros and cons of each of those approaches and if appropriate, active of surveillance.

 So we try to talk about all of those things and we talk about it from different perspectives and help the patient come to the realization that they have a big role in this. The old shared decision making which starts at screening has a huge impact when it comes to choosing your treatment because, you're going through that and there's risks no matter what you do, whether it's observation, radiation, surgery, or et cetera.

So you gotta be on board with those, understand them and decide sort of what makes sense for you and what you want to accomplish.

Bob Underwood, MD (Host): And that I think kind of gets around to really the next thing I wanted to ask about is, what advice do you give to somebody with a new diagnosis? It doesn't matter. When a patient hears cancer, they get concerned. So a new patient with a recent diagnosis of prostate cancer, what advice do you give them and, and how do you try to advise?

Stephen Strup, MD: So first thing is take your hand off the panic button. Cancer's a scary word and nothing I say or do, is going to take that away and I don't want to because it is a huge threat. But with prostate cancer, it's far better to say, let's make a good decision and understand our treatment choices. We don't need to treat you tomorrow, generally, sooner is better than later, but later can be weeks or months even depending on the risk of your disease.

Secondly is to make sure that we understand your disease. And so with modern imaging, PET imaging and so forth, we can really go a long ways to our understanding what do you have, and then make sure the patient understands that not all prostate cancer is created the same. Yes, you may have one that's super high risk and you may die of your disease, or hey, you're at the other end of the spectrum and we have time here and we can talk about surveilling this and this is what that entails.

So I think really educating the patient in this cancer is paramount because to make a good decision, you've gotta understand where you are on that spectrum and what choices make sense for where you are. And I think patients get that and I think they can understand that and make good choices.

Host: Yeah, I think that that's absolutely critical. And, I like your position on take your finger off the panic button, because it is emotional. So what are you excited about? What's on the horizon around treatment and diagnosis for UK Healthcare and for the Markey Cancer Center.

Stephen Strup, MD: I think really across the spectrum of the disease; for early disease, it starts with do we need to biopsy you, you have an abnormality of PSA or MRI and so forth. I think we really have all those diagnostic tools where we're learning more about genetic markers, urine tests, and so forth, where we can better understand whether we need to really chase down whether you have a risk of cancer or not. So it starts there. Once you have that cancer, we're starting to understand better about looking at the genetic expression of the tumors and understanding who might be even safer to observe or who maybe is at risk, and we really should be potentially more aggressive. Working to continue to refine our treatments, really make them a personal fit.

We have a focal ablation program with IRE, which is using electricity. Sounds crazy, but it actually is it's a pretty cool way to attack an area of the prostate. So again, there it's all about selection, right? So getting the right patient. And then working to refine our robotics program, our radiation therapy technologies.

And then the other end of the spectrum is advanced disease. And, we have a great medical oncology team, and, and they work with us as part of our whole Markey team, looking for trials, whether it's just simply, we have a trial looking at Artemis T, so it's, it's a fairly low risk thing, but PSA is rising a little bit.

So having something for somebody at every phase of their disease, whether, hey, we're failing everything, or we're sort of in this watch and wait phase, I think that's where Markey adds a strength. We can, we can look for trials and keep people focused on their therapy and living their lives too, so.

Host: That's phenomenal that you've got all of those assets and a view and vision of the future for this kind of treatment. Anything else you'd like to add?

Stephen Strup, MD: I think it's really about the importance of starting with the screening. If you have a healthy, asymptomatic male, you need to have those discussions. Because it's always frustrating when we see them too far down the pike and, oh, I would've screened, you know, some men that for that discussion say, no thanks, I don't care to, that's okay.

 You can make that choice. But bringing that discussion early in their healthcare, I believe in that. I've had my PSA checked, so, I do what I preach. So I think that's the first thing and very important because that's across all healthcare, right? And then, making it really a educational journey as well as just a treatment journey.

I think those are the things that I try to focus on and, you know, I'm excited about the future. We've made a lot of progress in the last few years, so.

Host: Yeah, huge, huge. Thank you for being on. We really do appreciate it.

Stephen Strup, MD: Well, I very much appreciate your time and thanks for getting the message out. Appreciate it.

Host: Yeah, you bet. And to our audience, thanks for listening to UK HealthCast, a podcast from UK Healthcare. For more information, visit UKhealthcare.com and be sure to subscribe and catch our latest episodes for more informational interviews.