Transcription:
Movember- Importance of Prostate Screenings

Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I’m Melanie Cole and I invite you to listen in as we discuss the importance of prostate screenings.  Joining me in this panel are Dr. Douglass Scherr, he’s the Clinical Director of Urologic Oncology and the Professor of Urology at Weill Cornell Medicine, and Dr. Jim Hu, he’s the Director of the LeFrak Center for Robotic Surgery and a Professor of Urology at Weill Cornell Medicine. Gentlemen, thank you so much for joining us today. Dr. Scherr, I’d like to start with you. Tell us what the prostate does. Give us a little lesson.

Douglas Scherr, MD (Guest):  Sure, well thanks for having us Melanie. The prostate interestingly is unfortunately known for more of the problems it creates rather that its function. But the prostate in fact, does have a function and that’s involved in male reproduction and fertility and so the prostate secretes enzymes that affect the viscosity or the thickness of seminal fluid and is involved in sperm transportation and fertility. So, really, for the reproductive ages of men, it’s quite important, the prostate’s functionality but once men are done having children, the prostate really serves no further function.

Host:  Well Dr. Scherr, why don’t you expand a little. What happens to the prostate as men age?

Dr. Scherr:  So, as men get older, one of the few things that gets larger in the man is the prostate. And prostates tend to grow in almost all men. And enlarging the prostate as you can imagine, creates health problems as it could partially begin to obstruct the flow of urine and the other issue or problem that could occur within the prostate as men get older of course is prostate cancer. But from a public health perspective, obviously, enlarging of the prostate or what we call BPH, benign prostatic hyperplasia is one of the biggest health problems that occurs in men as they get older.

Host:  Dr. Hu, I’d like to start with some of the risk factors for prostate cancer and indeed, BPH as Dr. Scherr just said many men experience this. It’s quite common. Please tell us about the risk factors for prostate issues and specifically prostate cancer. Is there a genetic component to this? And if so, is there a genetic test that men can have that would alert them, so they know?

Jim Hu, MD, MPH (Guest):  So, the risk factors for prostate cancer just starting with your question about genetics; there are familial cancers, not necessarily just limited to men but those with mothers, sisters with breast cancer, ovarian cancers may be at an increased risk for prostate cancer particularly if they have a BRCA mutation. And other risk factors for prostate cancer include African American race, higher body mass index has been associated with having prostate cancer and more aggressive prostate cancers as well as exposure to Agent Orange. Now, it is also of note that as men get older, they also have an increased risk for prostate cancer. For instance, there’s autopsy studies that have been done that showed that in men who died in their 80s, they looked at the prostate and 50% of them had prostate cancer. As far as a genetic test that may be done; certainly there are some commercially available tests like Color Genomics and the Color test is one that you can actually go online. You can order the test to be sent to your home. You swab within your mouth and that looks for germline mutations such as the BRCA mutation. But there’s not specifically a genetic test that’s FDA approved for prostate cancer.

Host:  Dr. Scherr, tell us about some of the symptoms that men experience and as long as we’re talking about symptoms, is it true that men often don’t seek treatment until these symptoms become quality of life limiting; because as a woman, with a partner, it’s not easy to get our men in to see you guys as we’re going to be talking about the screening methods and there are certain ones that the men just really don’t want to have. So, speak about the symptoms that would send them to see you in the first place.

Dr. Scherr:  So, most men of course, are resistant or reticent to go visit a doctor for a variety of medical problems and the prostate is really one of them. Symptoms of the prostate relate to the ability of the prostate to obstruct the outflow of urine. So, what a lot of people don’t realize is the urethra which is the tube that allows urine to exit the bladder that runs through the penis, a segment of the urethra just below the bladder is in fact, the prostate. And so as the prostate enlarges, it can compress and impede on urinary flow and as a result, a lot of men begin to experience symptoms of BPH. And these symptoms can include waking up several times at night to urinate, a slow urinary stream, some men fell like they can’t empty their bladder completely and exhibit what’s called postvoid dribbling or leaking a little bit of urine when they are done urinating. Sometimes the prostate can grew to a point where it can cause some bleeding. So, blood in the urine sometimes can be a measure of prostate problems. And so, having said that, there are men who have very small prostates who can also have trouble urinating. So, it’s not only the size of the prostate but the muscular tone of the prostate that can compress the urethra and also cause difficulty for men to empty their bladders.

And so, it’s these issues, these quality of life factors, particularly waking up at night and men often have to find bathrooms wherever they are going and sometimes you’ll know when two men are going to the bathroom in a urinary stall, some men get in and out of there very quickly, other guys could be there for five minutes trying to empty their bladder and that’s often a sign of enlarged prostate. So, it’s typically when men reach these points that they’ll ultimately seek help but it’s the asymptomatic men that often are not coming to the doctor.

Host:  Then Dr. Hu, let’s talk about the screening. We are hearing more and more about the importance of men getting screened. I’d like you to tell us the screening methods, at what age, when they should start doing them, how often. Give us kind of the summary of the screening methods that you use to determine whether a man has enlarged prostate and or prostate cancer.

Dr. Hu:  So, Melanie, the guidelines for screening for prostate cancer that is the opinion of experts is largely based on one study and that’s a European large randomized controlled trial. In that trial, the entry criteria for men in that trial was those that were age 59 to 69 years old. And so, if you’re looking to evidence, that’s really the only age group that had the screening versus non-screening and looked at long term outcomes such as death from prostate cancer. So, when you look at screening guidelines, recommendations again, is to do screening PSA testing every two to three years for men aged 55 to 69 years. However, there is the thought that those at higher risk for prostate cancer and we talked about risk earlier; that is those of African American race, those with family histories of prostate cancer, breast cancer, other cancers, pancreatic cancers undergo screening at an earlier age, not before the age of 40. There’s also evidence that shows that getting one PSA test in your 40s what’s called a baseline PSA can also determine the frequency of future PSA testing, that is if you have a PSA done in your 40s and it’s less than 1, then you have a low lifetime risk of having or developing prostate cancer whereas if that PSA in your 40s is greater than 1, then that needs to be monitored more closely.

Host:  Well Dr. Hu, I’d like you to expand a little bit more. Is this for screening, do men and this will be an answer for women too or their partners who love them who want to get them into the doctor; do they go to their primary care provider for these screenings or do they go right to a urologist for these screenings depending on how often they need to have them?

Dr. Hu:  So, this remains a very controversial issue and what I mean by that is the large task force, the US Preventative Services Task Force in 2012, recommended against PSA screening in men regardless of age. And really, just two years ago, that decision against PSA screening was moderated to say that it’s an individual choice. Now unfortunately, this has caused a lot of confusion amongst those who have general medical practices, that is primary care doctors, general practitioners or internists and so, although we used to get PSA tests, I think many physicians did in the general practice every year, I think there is some confusion because of the recommendation from some of these professional guidelines. And so, certainly if you see a urologist for the conditions earlier that Dr. Scherr described such as BPH, it’s going to be pretty routine to get a PSA test. But whether you get a PSA test routinely when you see an internist for instance may vary based on their beliefs or how up to date, they stay with the current research and guidelines.

Host:  I find that so interesting. And thank you for that answer. So, Dr. Scherr, let’s talk about BPH first. You already mentioned how common it is, people might worry that cancer is next. Tell us a little bit about some treatment options, the goal, really of treatment if you do any for an enlarged prostate.

Dr. Scherr:  Thanks Melanie. So, BPH and cancer really are unrelated to one another. So, the fact or that any kind of a man has an issue with BPH and bladder outlet obstruction it does not necessarily mean that they have cancer and in fact, an enlarged prostate can also cause one’s PSA to become elevated. So, it’s important to understand and differentiate between a PSA elevation that’s a result of BPH versus a PSA elevation that could be resulting from prostate cancer. One of the things we look at nowadays are prostate MRIs which can be very beneficial to distinguish which individuals with elevated PSAs are from BPH and which may be for something more concerning or cancer.

BPH symptoms should be treated for two reasons. One of course is quality of life. I think a lot of men when they are getting up four or five times a night to urinate or they can’t empty their bladders completely or they are leaking urine; these are major impediments to their quality of life so medical therapy can often improve upon that and sometimes when medical therapy doesn’t work, we move towards surgical therapy. And the second reason is that if someone is walking around with a full bladder, it ultimately can begin to damage their kidneys and their bladder so if the bladder begins to back up and it starts going backwards towards the kidneys; this could actually be a very serious medical problem where people can develop kidney failure from chronic bladder outlet obstruction or BPH. So, it is important to seek some medical care for this because I think it can have more long lasting side effects beyond quality of life as well.

Host:  Well thank you for that. Now Dr. Hu, I’d like you to tell us a little bit about prostate cancer and you can mention surgical treatments that have the most beneficial effects, or really what’s exciting in the field of prostate cancer and you’re in robotic surgery so tell us what you do and tell us a little bit about prostate cancer.

Dr. Hu:  So, with the treatments for prostate cancer really, I think what’s become more popular in the last five to six years is really not treatment. That is, there’s a large proportion of men diagnosed with prostate cancer that have what we term low risk disease, low grade prostate cancer with a PSA less than 10 or they have favorable intermediate risk disease. And so, in these men, it’s been showed that they may be safely followed with monitoring with a curative intent that is, they get PSA testing annually, a prostate exam and they get a biopsy as well, although that interval is getting longer and longer and so, that’s active monitoring or active surveillance for those with low risk favorable intermediate risk disease.

For men with what we term clinically significant cancer, that is, higher grade cancers or they have significant cancers at an earlier age, treatments like surgery that you mentioned, there’s also radiation treatments; those are the two conventional treatments that guidelines recommend because these have been around for 30 or 40 years and therefore there’s long term outcomes. There’s also partial gland ablation or focal therapy that’s a newer treatment option that really has been more popular overseas. However, there’s very limited data beyond two to three years and very few centers have published outcomes for focal therapy but the treatment goals of all of these are the same, that is to preserve quality of life, that is preventing urinary incontinence, maintaining erectile function and cure of cancer.

Host:  Dr. Scherr, let’s talk about – I think this is a really important topic here and a lot of men have questions about herbal treatments that they see. They hear about saw palmetto and they hear about all of these things that they can try. Do any of these work? Is it a myth? Do they help men at all with some of the symptoms of prostate issues?

Dr. Scherr:  So, Melanie, the herbal remedy, nutritional supplementation, vitamin market obviously is a multibillion dollar industry and of course, prostate is a big focus of that. When you go on television, you’ll often see these commercials about different prostate health medications. Saw palmetto is probably been around the longest and it’s an herbal remedy that comes from the fruit of a type of palm tree and although there have been some small scale NIH studies that showed some benefit, most of the larger studies conducted really showed that there’s no benefit above placebo for saw palmetto. There was another study recently done called the Select trial which looked at selenium and vitamin E and really found no benefit to preventing prostate cancer. There’s phytoestrogens, there’s ryegrass pollen extract, there’s a whole slew of different herbal remedies for prostate health but really, on most of the larger studies, I think that they haven’t really shown to be better than any placebo trials. I think the recommendation that most of us would agree to is heart health tends to correlate with prostate health so, diets low in red meat and low in saturated fats are probably helpful.

If you look at prostate cancer for example, back in the China of say 20 years ago, we saw very low rates of prostate cancer but then when most of those people either moved to the US or began to adopt Western diets within China; we’re seeing prostate cancer rates go up. So, clearly diet has a huge impact on prostate health, but I don’t think there’s any one specific herbal remedy right now that we could recommend other than a heart healthy diet, low in red meat and low in saturated fats.

Host:  Dr. Hu, do you have anything you’d like to add to that because really, this is an important issue is healthy prostate. Do you have some recommendations of things that men can do to keep their prostate in good health and Dr. Scherr just mentioned diet? Are there any other things that you would like to mention that really can help men with overall health and the importance of this continuum of care anyway?

Dr. Hu:  So, I think Dr. Scherr answered the question very comprehensively. I would just add that for instance, what may lower your risk of prostate cancer. We talked earlier about obesity as being a risk factor and certainly, things that maintain good cardiovascular health I think overall is good for lowering the risk for prostate cancer. It’s also thought that lycopene’s which are available in tomatoes, tomato paste, that may have some benefit in terms of lowering the risk of prostate cancer. That said, there has been a recent randomized control trial multi-center that was published that didn’t demonstrate that a dietary modification for those men who had already been diagnosed with low risk prostate cancer on active surveillance had an effect although follow up was not past ten years. And so, diet wise, I think one just wants to maintain a heart healthy diet because again, cardiovascular factors are still the higher risk for death in US men.

Host:  It is a great topic and so important for men and their loved ones to hear. Dr. Scherr, I’d like to start with you and I’m going to give you each a chance to kind of do your final thoughts. Many men worry that if they come to see their doctors, and they’re told they have an enlarged prostate or anything else; they worry most about those quality of life and side effects like erectile dysfunction and incontinence. Will you please, as your final thoughts, let men know what you do for them as far as those side effects and how you can help them in ways so that they have a better quality of life.

Dr. Scherr:  I think the dictum right now in medical care particularly as it relates to prostate and prostate cancer is shared decision making. And I think that’s really been adapted by both primary care doctors and urologists and what I mean by that is that it’s not a unilateral decision. It’s not like as a physician we’re going to tell someone that they need to have x, y, or z; but it’s a conversation and it’s one that I think both parties need to participate in. And quality of life has certainly taken center stage in prostate cancer. Of course, cure always comes first but I think we’re fortunate now to live in an era where we have treatments that men can maintain sexual function and urinary function and still be cured from their prostate cancer.

I think there’s been an incredible advance in our ability to perform nerve sparing surgeries with robotics improving upon visualization. I think even procedures for BPH now have gotten far less invasive. We’re using laser therapy to extract prostate tissue and create greater flow of urine. We’re now even using sort of something called aqua-ablation which is a novel treatment that’s using high powered water jets to ablate prostate tissue. And so, I think we’ve learned a lot more over the last two decades in terms of the neural anatomy involved in sexual function and the anatomy of the external urinary sphincter where we’re able to really preserve quality of life issues to a much larger level than we had once been able to do, but at the same time, effectively treat prostate cancer and BPH symptoms. So, I think patients should understand that through shared decision making, and really improvements in technology and understanding of the disease, so I think it’s a very different set of symptoms and diseases we’re looking at right now than we did say two decades ago.

Host:  I certainly agree with you and Dr. Hu, last word to you. What would you like to tell men and please reiterate and reassure that in this time, these unprecedented times, that it’s safe to come in for their screening and what Weill Cornell Medicine is doing to keep the community safe and that this is so important that men discuss these issues with their doctor, they don’t put it off and they tell somebody.

Dr. Hu:  Absolutely. I think obviously, this is a great forum to raise awareness about the value of PSA screening. So, starting by asking their primary care doctor, internist whether or not they are getting a PSA at their annual visit or when they get a blood drawn. Second thing I think is just to echo what Dr. Scherr mentioned, when you think about prostate cancer treatment and the goals; the priorities usually for most men are cure of cancer, preservation of urinary function, that is no incontinence and then preservation of sexual function or the absence of erectile dysfunction. Now if your priorities are in a different order, that is if you value preservation of sexual function over cure of prostate cancer; then you may delay treatment, you may opt for active surveillance or be interested in some of these focal therapies.

Now both of us being surgeons, we didn’t spend a lot of time on radiation therapy. There are some newer radiation therapies. It’s common for patients to come in and ask about the Cyber knife which is just a brand name for what’s called stereotactic body radiation therapy, newer delivery of radiation that is over two weeks, five treatments. I think some of the trade offs of radiation therapy while there may be a convenience factor that is you don’t have to stay in the hospital. There isn’t general anesthesia. I think it’s important for patients to understand that if radiation therapy doesn’t work, there typically isn’t a second opportunity for a cure. It’s more difficult to do surgeries after failed radiation. The diagnosis of recurrent prostate cancer even persistent prostate cancers is often delayed because of the somewhat nuanced definition of failure depending on the PSA being in a gray area.

So, I would just conclude by saying that we’re learning something new every day. We didn’t talk a lot about some of the genomics test once you’ve been diagnosed with prostate cancer to more accurately predict it’s behavior and of course, I think Dr. Scherr mentioned earlier, the MRI which has really been transformative in terms of avoiding biopsies in some men with an elevated PSA if their MRIs are not suspicious.

And finally, here at Weill Cornell, we have the advantage of being very deep in all areas of treating prostate cancer such as doing active surveillance, during MRI targeted biopsies, radiation therapies. For those with advanced disease, we have medical oncologists. Dr. Scherr has a lot of clinical trials as do others. We have a first rate basic scientist translational research as well as surgeon scientists and Dr. Barbieri who is also on the cutting edge of looking at molecular behavior for prostate cancer. And so I think it’s very uncommon to have that expertise all in one campus setting.

And in addition, given the recent national and international pandemic in terms of COVID, we certainly at Weill Cornell, we were obviously the flashpoint or epicenter as they called it for the COVID pandemic in the United States and at the world at one point. However, more recently, our positive testing rate is under 1%. At Cornell, we’ve been doing surgeries for prostate cancer and other more urgent medical issues certainly since June and I can say and Dr. Scherr may want to chime in, that certainly I’m unaware of any patient whose come in and had some COVID related issues because of the stringency of the measures that we’ve taken to take temperature testing, to have COVID testing in our patients who need surgery 48 hours prior. So, I think it’s certainly very safe to come in for treatment of prostate cancer and BPH currently.

Host:  Thank you gentlemen so much. What great information. Such an informative segment. Thank you very much for joining us today. And Weill Cornell Medicine continues to see our patients in person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today’s episode of Back to Health. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back to Health on Apple podcasts, Spotify and Google Play Music. For more health tips go to www.weillcornell.org and search podcasts. Parents, don’t forget to check out our Kid’s Healthcast. I’m Melanie Cole.