Joey Wahler (Host): It's a common but treatable condition, so we're discussing the future of prostate cancer. Our guest, Dr. Mark Siegelbaum. He's Chief of Urology and Director of Urologic Oncology at University of Maryland St. Joseph Medical Center. Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. Thanks for joining us. I'm Joey Wahler. Hi, Doctor. Welcome.

Marc H. Siegelbaum, MD, FACS: Good morning, Joey. Thank you for having me this morning.

Host: Same here. First, give people an idea, if you would, please, just how common is prostate cancer in the United States?

Marc H. Siegelbaum, MD, FACS: Prostate cancer is exceptionally common. It's the second most common cancer killer in men in our country. So it is very prevalent and one in every five to ten men are going to have prostate cancer sometime in their lives.

Host: And lung cancer remains number one, right?

Marc H. Siegelbaum, MD, FACS: It still remains number one. It's holding strong.

Host: Gotcha. So what recent advancements in prostate cancer screening technology would you say are improving early detection these days?

Marc H. Siegelbaum, MD, FACS: Well, the screening for prostate cancer mostly still depends on a few very basic things. We're still recommending that men have PSA checks. Most men are pretty familiar with the PSA that's included with all their other blood work usually that they get by their primary care doctor and a rectal examination, which unfortunately is not performed by all primary doctors.

But usually if patients get sent to us, we certainly perform that. Those are two very important tests for screening, despite all the other advancements that we have. Having said that, these days, in addition to those things, there's various and sundry kind of additional tests we use to screen for prostate cancer and decide then if men should have a prostate biopsy or not.

Some of those tests are blood tests, called PHI tests, which basically looks at various forms of PSA fractions, the protein of PSA, and depending on what that number is, that might prompt a biopsy. There's a urine test called the PCA 3 test. which basically looks at voided urine for certain kinds of RNA biomarkers of a few different genes that have been known to be prominent in prostate cancer.

And there's another test called the exosome test, the XODX test, which also is a urine test that we use for men that have PSA elevations between 2 and 10. That urine test has been found to be pretty helpful to decide if we should do additional biopsies or not as well.

Host: And the recommended frequency for the PSA testing has changed in recent years, right? So what are those new guidelines?

Marc H. Siegelbaum, MD, FACS: Essentially, for men who have a family history of prostate cancer, they should be screening at the age of 40. So, earlier screening with a family history is still the recommended guideline. As far as African American men as well, those too should be screened early and the age of 40 is very appropriate for them.

If you're not in either of those two categories, you could begin screening at somewhere between the age of 50 to 55. And you should have at least an annual to semi annual PSA and rectal exam.

Host: Gotcha. And then can you explain the importance of early detection in treating prostate cancer, because it can be lifesaving, right?

Marc H. Siegelbaum, MD, FACS: Completely life saving, and that's the key, and that's probably going to be my takeaway point at the very end of this whole conversation today. Early detection is still key. That probably applies to every single other cancer as well. But if you can find prostate cancer early in its development, number one, we may not necessarily have to even treat it.

But number two, if you do have a medium to more aggressive kind of prostate cancer, the earlier we get at it, all the different treatment options are highly, highly effective.

Host: Absolutely. So switching gears a bit, we mentioned we're mainly focusing on advancements in treatment. How are new treatments like immunotherapy and precision medicine changing the outlook for prostate cancer patients?

Marc H. Siegelbaum, MD, FACS: Right. So all of that is valid. And some of the newer treatments, and we'll talk about immunotherapy in a second, but robotic surgery is still considered a relatively new precision treatment, although honestly it's been around for about 20 years. But it's precision surgery treatment for those men who are deemed surgical candidates for prostate cancer surgery, meaning that their surgery can be cured that way.

And by using precision visualization and precision microscopic instrumentation you can very carefully remove the cancer without causing too much disturbance. An alternative to that treatment is radiation treatment, and that, those treatments have become more precise as well. Some of those radiation treatments include the IMRT radiation, it's called intensity modulated radiation therapy, where the radiation beam is very precisely focused on the cancer itself without causing too much treatment outside of the cancer itself.

We do radioactive seeds or pellets, which are highly focused on the cancer. And, when they do the radioactive seeds, there's a lot of computer pre planning for exactly where those seeds should be placed to make sure that there isn't any kind of scatter radiation. And as far as the immunotherapy is concerned, the place for that really is more with advanced prostate cancer, or prostate cancer that has already spread beyond the prostate, and we'll probably talk about that a little later.

Host: And so, the preciseness that you alluded to, Doctor, simply put, why is that so important and beneficial to both doctor and patient compared with more traditional methods of years gone by?

Marc H. Siegelbaum, MD, FACS: Well, I think there is a word on the street that if you have prostate cancer, and you opt for treatment for prostate cancer, you're doomed to a life of incontinence, which means you'll never have control of your urine anymore, and doomed for a life of impotence, where you'll never be able to perform sexually anymore. And because of those misconceptions on the street, but also some truisms as well, there has been an effort to, to fine tune the treatments to make sure that neither of those things are true.

While both of them are true temporarily, they don't have to be true on a permanent basis, and by doing more and more fine tuning and focus of our treatment, we actually can accomplish what we want to accomplish with minimizing treatment and side effect. So, the purpose of focal treatment and minimal treatment, is to avoid the side effect while still trying to cure the cancer at the same time.

Host: And so having said that, I presume patients remain concerned about potential side effects when considering treatment and treatment options. So how do you walk them through those factors?

Marc H. Siegelbaum, MD, FACS: So we walk them through by, first of all, seeing if they're a candidate for curative treatment and whether they qualify for that. And then you have to go through all the different treatment options that are out there for that and really specifically telling them what to expect from side effects and what we do to minimize them.

So if we talk about robotic surgery first, which is the mainstay of the surgical option, we tell them that, you know, looking through the microscope to treat their prostate cancer surgically, their prostate is magnified 10 times. So, we can really see well. We know exactly where those special nerves are located that control sexual function, and we have the ability to spare those nerves because we know where they're located, and we see them better.

We also tune in to the whole issue of urinary leakage, and because we can reconstruct the urinary tract once the prostate is removed in a very hi at a very high level, we can minimize the chance of getting incontinence postoperatively, or if they get incontinence, it's not going to last that long.

And also with radiation techniques, because we can pinpoint where the radiation beam is going, we can try to do some nerve sparing as well, and we can try to minimize the scatter of the radiation to other organs that might also contribute to incontinence and impotence. There are also additional treatments that are called targeted treatments that are out there. They're not necessarily sanctioned by the American Urological Association just yet, or sanctioned by the National Cancer Cooperative Network organization yet. That's the body of cancer treaters that basically sanctions what is appropriate for prostate cancer treatment or not. And those treatments though are still in the developmental stages and they may become a more significant part of our treatment paradigm in men who have very small prostate cancers.

And we can then very focally treat just that cancer itself without treating the whole organ. We use ultrasound for that, they use radiotherapy for that, they use steam treatment for that, we use injectable medications for that. So, so all of those things will eventually come more into the mainstream for focal therapy of prostate cancer. And the less you have to treat of the prostate, the less chance of side effects.

Host: Gotcha. So how about things like genetic testing and biomarkers that have come into play in so many different areas of medicine nowadays, what role do they play in a more personalized prostate cancer treatment?

Marc H. Siegelbaum, MD, FACS: Yeah, that's a good question. And they are taking a big place in prostate cancer as well. It may not be quite as prevalent as some of the other cancers. I think breast cancer is probably the most mature cancer in terms of utilizing some of this technology. So we actually learned a lot from them. But when prostate cancer is diagnosed, we use multiple different types of genetic biomarker tests to help us figure out not only how aggressive the cancer is, but it might help us with our decision making in what we should use to help treat this cancer.

Some of those testings are called the Prolaris testing, which looks at the actual prostate biopsy tissue itself. We use Oncotype DX testing, which is a genomic classifier, which looks at all kinds of very involved things like RNA expression from 17 different genes, and that helps us figure out how aggressive this prostate cancer is going to be.

A similar test is called the Decipher test, which also looks at the biopsy specimen to help us figure out and help us tailor our treatment options; either before you actually treat them or sometimes after you've even removed their prostate, we can reanalyze all the prostate tissue and decide if they need additional treatment.

We do know that prostate cancer is genetic. We do know that there are genes out there like the BRCA gene 1 and 2, which if detected, the chance of getting prostate cancer is exquisitely high. And if you do get prostate cancer, it's probably going to be a more aggressive version of it. So we do use genetic testing, especially in the higher grade cancers or with people that have a family, a strong family history of prostate cancer.

So we're using all of this stuff. We still use our most basic paradigms for deciding how to treat men. But sometimes it's difficult to know which direction to go in terms of aggressive treatment or not, and these additional genomic tests are incredibly helpful in pushing us in one direction or another.

Host: It certainly sounds like it. A couple of other things for you. First, you touched on the use of robotics. When it comes to robotics, artificial intelligence, machine learning, things that are cutting edge at the present time, how will those do you think shape the future of prostate cancer diagnosis and treatment?

Marc H. Siegelbaum, MD, FACS: Yeah, I think AI has a place in all of this. There is no getting around it. For the average treating urologist, it doesn't have a mainstream place just yet, but in the field of prostate cancer in general, and in the field of research and development of drugs, and in the field of trying to figure out proper treatments for prostate cancer; AI can be used in multiple different scenarios.

They are used, for instance, AI is used in the biopsy material itself, so once you do a prostate biopsy, you can digitize an image of what the biopsy looks like under the microscope, and you can use AI to better understand validate what the grade of that cancer is, meaning if it's a higher grade, it might require more aggressive treatment.

If it's a lower grade, it might not require any treatment. So they're using AI in the actual analysis of the biopsy tissue itself. They're also using AI in looking at MRI images. We use MRI scans a lot in prostate cancer in men who have an elevated PSA. It's becoming kind of almost a standard to get an MRI scan to look for any abnormal lesions on the MRI scan, and then based on that, we kind of fine tune where our biopsy actually is taken from.

So any suspicious lesion on the MRI scan is targeted during our biopsy. Well, the AI can assist in figuring out which of those areas are more suspicious than others so that when we finally do our biopsy, it becomes a cleaner, more accurate biopsy. I think also AI is used, as I said, in, research and development for lots of different drug therapies, and it's also used quite a bit in radiation, where they're deciding if patients should have additional treatment to the radiation itself, such as anti hormone therapy. And AI can be very helpful in helping them decide if they should give additional treatment to the radiation itself.

And as far as the robotics is concerned, it, it's not exactly meshed into the robotic platform just yet but it's probably coming. The robotic platform is advancing itself. We're doing all kinds of advancements in terms of when you're doing robotic surgery, you can't really feel the tissue or feel what exactly you're getting into, but it's sort of being changed now, research and development wise, so that you can actually feel the tissue, even though your hands are not in the body, and that will be helpful for us. And, other technologies that are meshed with the robot are just being able to visualize where exactly the cancer is when you're actually removing it. So you can do, again, more precision surgery and avoid the structures you want to avoid during the surgery.

Host: Wow, that does sound advanced indeed. And then finally, in summary, Doctor, you touched earlier, you mentioned immunotherapy. Touching on that, how would you say that emerging therapies like immunotherapy can help with advanced prostate cancer?

Marc H. Siegelbaum, MD, FACS: Yeah, thank you. That's a great question too, but advanced prostate cancer is kind of a completely different animal. And what that means is for patients that have already received treatment for their prostate cancer, either with surgery or radiation, or for those men who opt, for those men who have opted to not receive treatment and now the prostate cancer has advanced and spread to their bones for instance, that is sort of a different animal.

Those patients aren't treated with surgery or radiation therapy except in very specific situations and a lot of their treatment depends on what some of their genetic makeup, so to speak, of the tumor looks like. Every single one of those men are going to be treated with hormone therapy, which is an anti testosterone therapy, meaning that prostate cancer grows because it's under the influence of testosterone.

If you can eliminate the supply of testosterone in the body with certain drugs, you can starve this cancer out, and it's a highly sensitive treatment for men who have advanced prostate cancer, and furthermore, there are other drugs you can give orally that are anti androgens, meaning if there's any other floating testosterone around somehow in the body after those other drug treatments, those will basically counteract any and all remaining testosterone in the body. But of course there are many side effects to that, but nonetheless, it is very powerful in keeping advanced prostate cancer treated initially, but despite all that the prostate cancer will eventually progress, and when it does progress, then, there is a treatment called Provenge, which is an immunotherapy that is actually mixed with the patient's own blood or plasma and then infused back in the patient, and that has been shown to control even more advanced prostate cancer.

We give radiopharmaceutical infusions in patients who already have bone metastasis and can actually float into the body and direct itself right to the, to the hot areas in the bone, if you will, and treat metastatic bone cancer in those situations. And we also use chemotherapy, too, in the, in these situations.

But what has been an explosion in the last five years or so are these PARP inhibitor treatments, which are basically various medications that are given specifically for those men who have the most abnormal genetic makeup, including the BRCA gene, the HRR gene, etc. And those PARP inhibitors have been shown to be very active in the most advanced cases of metastatic prostate cancer.

And it's all based on the genetic makeup. And you have to prove a genetic etiology to all this, because otherwise you wouldn't even qualify for the medication. But genetics play a big role in these PARP inhibitors for the most advanced cases of prostate cancer.

Host: Well, folks, we said you'd find out about the future of prostate cancer treatment, and the doctor has certainly delivered, telling us about many options out there right now. We trust you're now more familiar with the future of prostate cancer treatment. Dr. Mark Siegelbaum, very comprehensive. Thanks so much again.

Marc H. Siegelbaum, MD, FACS: Very welcome.

Host: And you can find more shows just like this one at umms.org/podcast and on their YouTube channel. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks again for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.