Prostate cancer is one of the most common types of cancer affecting men, with one in six American men receiving the diagnosis in their lifetime.
In most cases, the disease grows slowly and causes no problems.
But some prostate cancers are fast-moving and lethal, causing more than 29,000 deaths annually because the disease wasn't detected and treated in time.
One of the latest advances in prostate treatment is robotic surgery.
With this minimally invasive surgery, patients often recover faster, experience less blood loss, decreased positive-margin rate and sometimes better nerve preservation.
Jennifer A. Linehan, M.D is here to discuss prostate cancer and all the latest developments in diagnoses and treatments.
Selected Podcast
Prostate Cancer Update
Featured Speaker:
Jennifer A. Linehan, MD
Dr. Linehan is a clinical assistant professor in the Division of Urology and Urologic Oncology at City of Hope. She works primarily at the City of Hope Antelope Valley multispecialty clinic in Lancaster, Calif., but also sees patients at other City of Hope locations. Her expertise and interests are minimally invasive approaches to urologic oncology and reconstructive urology, with a particular emphasis on robot assisted procedures. She also practices general urology, including both male and female voiding dysfunction and treatment for kidney stones. Transcription:
Prostate Cancer Update
Melanie Cole (Host): More than 230,000 men will be diagnosed with prostate cancer this year, and about one in seven will be diagnosed with this disease at some time in their life. But thanks to improvements with surgery and radiation, chemotherapy, and other treatments many prostate cancer patients can overcome prostate cancer to lead long, productive lives. My guest today is Dr. Jennifer Linehan. She’s a clinical assistant professor in the division of Urology and Urologic Oncology at City of Hope. Welcome to the show, Dr. Linehan. So tell us a little bit about prostate cancer screening. Is there anything new and different going on? PSA, is it still the gold standard?
Dr. Jennifer Linehan (Guest): Melanie, thank you for having me today. So what I like to really remind my patients about PSA screening is that the PSA test, which is the prostate-specific antigen, is really a risk assessment. The PSA blood levels are not always a direct correlation of prostate cancer. Both inflammatory diseases of the prostate, enlarged prostate, and prostate cancer can cause elevation in the PSA. So you have to put together what I call the PSA kinetics, or watching the trend of the PSA to interpret whether those patients have cancer. Now, in recent years, they added something called “the free PSA,” and the free PSA was again another biomarker that helps us risk-stratify the patient who are at risk for prostate cancer and those that needed biopsy. But it wasn’t always a direct correlation. So PSA and free PSA are still the gold standards as far as screening. About a year ago, they added another test called the Prostate Health Index, and in the Prostate Health Index, you actually have three biomarkers. It was PSA, free PSA, and p2PSA, and using these in combination and using those values to, again, assess what patients were at risk for prostate cancer and which were those that needed biopsy. So I think the gold standard is still PSA and we’re adding biomarkers to that that are still somewhat investigational and learning to really focus on our diagnostic technique for PSA screening.
Melanie: So where do you think genetics and genetic testing, PCA3 and such, are going to come in to this screening? Do you think that they will be a part of screening?
Dr. Linehan: I think PCA3 does have a role in screening, but I don’t think it is first-line screening technique. I think the PCA3 is for patients who had had histories of elevated PSA or even previous biopsy where the PSA is still elevated and you’re trying to make a decision on whether to re-biopsy this patient or figure out what the next step is. But I don’t think at this point the genetics test, the PCA3, has a front-line role in general screening of the population. I think those are patients that are more complex, that are already being evaluated by a urologist because they’ve had a history of PSA, or again, like I said, even previous biopsy.
Melanie: So what do you see in treatment in the next 10 years? We’ve got hormone treatments; we’ve got radiation, external beam seed implantation. There’s chemotherapy, and there’s surgery, which seems to be going down a little bit, Dr. Linehan. It seems to me that less men are having their prostates removed and more are having this combination of radiation and hormone treatments or various combinations thereof. What do you see happening in the next 10 years?
Dr. Linehan: Prostate cancer is a very unique cancer, because first of all, early detection is curable. And second, there’s a large population that have indolent cancers that don’t need to be treated immediately. So I think, really, the last several years we’ve focused on necessarily not treating the cancer but not treating the cancer in cases where the patients can be watched. I think City of Hope has really done a good job of pursuing active surveillance protocols, where you’re monitoring the patients’ PSA, you’re monitoring their pathology and focusing on prolonging treatment in very specific cases. So in this instance, it’s not treating that’s been the focus instead of treating. I think the other thing that we’ve started to look at as a urologic community is what we call focal therapy for prostate cancers. So as our diagnostic techniques have gotten better, we’ve been able to localize the cancers and have focused on treating just that local area. Again, these are still investigational, but they are newer techniques that are starting to rise. And I think because there are more options for patients, you’re seeing the number of surgeries decrease. But I think if you look at the overall outcome, especially in patients with aggressive prostate cancers, surgery is really still a first-line therapy.
Melanie: Speaking of surgery, with the advent of robotics surgery everywhere, where do you see that for prostate cancer? Is that coming into play as a big part and partial for you to be able to use all of these different advances to make this a much less invasive surgery with less side effects?
Dr. Linehan: Yes. I think robotics has really helped our understanding of the anatomy of the nerves, which are important for both impotence and for incontinence with patient’s prostate cancer, and I think robotic surgery has helped us reassess that anatomy so we can better understand it and better preserve those nerves. I also think that in the next 5 to 10 years, that robotics will improve in several ways. One, the surgeries will actually become more minimally invasive. They are now looking at doing one-port surgeries where you have one incision, and the arms actually extend from what’s inside the body of the patient so the patients will only have one incision. The other thing is better visualization, better visualization of the anatomy, magnification, understanding of the tissues. And the third thing is that soon we’ll be able to incorporate some of our radiologic images into our robotic surgery at the time of surgery, which will help us identify cancers if it’s extending outside the prostate or going to the nerves or even going into the lymph node. So I think those things are also going to change robotic surgery, which is going to give patients a lot more options with surgery and help them recover faster and help them recover from both impotence and incontinence as well.
Melanie: Well, speaking right, you segued beautifully into this. So as that progress and these surgeries become more minimally invasive the risk of impotence and incontinence, following prostate cancer treatment, it seems to be what men worry about the most. So do you see that that’s going to be something that we’re not going have to deal with quite as severely?
Dr. Linehan: Yeah. I think there’s been a lot of new research, especially within the last year, regarding impotence and incontinence, which is very harrowing for the patients postoperatively. And because surgery offers such a good chance for lifelong care for these patients, I think that we focus more on preserving the nerve. One of the newest things they’ve been doing is actually wrapping the nerves in an amniotic wrap to help protect the nerve, nurse the nerve, and to improve the circulation to the nerves, which will eventually help them regenerate. So there are newer medications coming out that we are going to apply both intraoperatively and that the patients are going to be able to take postoperatively to help boost nerve function, which will improve continence as well as erectile function.
Melanie: In just the last minute—and it’s such fascinating information and such exciting hope for men suffering with prostate cancer—give us your best advice about the future of this, your best hope, and why they should come to City of Hope for their care.
Dr. Linehan: I think City of Hope has always focused on treating the patients as a whole, and my advice to my patients always is no matter what the PSA number is, find a urologist or a doctor who is going to evaluate all the factors in your life—your age, your life expectancy, your family history of prostate cancer, the symptoms that you’re having, your previous PSA—and put all of these things together very specifically for just that patient to have a risk assessment for the, and to focus on the patient as a unique and whole patient instead of just treating a number. And I think City of Hope has really focused on doing that as well as providing patients both surgery, radiation, active surveillance roles, and many options for treatments.
Melanie: Thank you so much. What great information. You’re listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Prostate Cancer Update
Melanie Cole (Host): More than 230,000 men will be diagnosed with prostate cancer this year, and about one in seven will be diagnosed with this disease at some time in their life. But thanks to improvements with surgery and radiation, chemotherapy, and other treatments many prostate cancer patients can overcome prostate cancer to lead long, productive lives. My guest today is Dr. Jennifer Linehan. She’s a clinical assistant professor in the division of Urology and Urologic Oncology at City of Hope. Welcome to the show, Dr. Linehan. So tell us a little bit about prostate cancer screening. Is there anything new and different going on? PSA, is it still the gold standard?
Dr. Jennifer Linehan (Guest): Melanie, thank you for having me today. So what I like to really remind my patients about PSA screening is that the PSA test, which is the prostate-specific antigen, is really a risk assessment. The PSA blood levels are not always a direct correlation of prostate cancer. Both inflammatory diseases of the prostate, enlarged prostate, and prostate cancer can cause elevation in the PSA. So you have to put together what I call the PSA kinetics, or watching the trend of the PSA to interpret whether those patients have cancer. Now, in recent years, they added something called “the free PSA,” and the free PSA was again another biomarker that helps us risk-stratify the patient who are at risk for prostate cancer and those that needed biopsy. But it wasn’t always a direct correlation. So PSA and free PSA are still the gold standards as far as screening. About a year ago, they added another test called the Prostate Health Index, and in the Prostate Health Index, you actually have three biomarkers. It was PSA, free PSA, and p2PSA, and using these in combination and using those values to, again, assess what patients were at risk for prostate cancer and which were those that needed biopsy. So I think the gold standard is still PSA and we’re adding biomarkers to that that are still somewhat investigational and learning to really focus on our diagnostic technique for PSA screening.
Melanie: So where do you think genetics and genetic testing, PCA3 and such, are going to come in to this screening? Do you think that they will be a part of screening?
Dr. Linehan: I think PCA3 does have a role in screening, but I don’t think it is first-line screening technique. I think the PCA3 is for patients who had had histories of elevated PSA or even previous biopsy where the PSA is still elevated and you’re trying to make a decision on whether to re-biopsy this patient or figure out what the next step is. But I don’t think at this point the genetics test, the PCA3, has a front-line role in general screening of the population. I think those are patients that are more complex, that are already being evaluated by a urologist because they’ve had a history of PSA, or again, like I said, even previous biopsy.
Melanie: So what do you see in treatment in the next 10 years? We’ve got hormone treatments; we’ve got radiation, external beam seed implantation. There’s chemotherapy, and there’s surgery, which seems to be going down a little bit, Dr. Linehan. It seems to me that less men are having their prostates removed and more are having this combination of radiation and hormone treatments or various combinations thereof. What do you see happening in the next 10 years?
Dr. Linehan: Prostate cancer is a very unique cancer, because first of all, early detection is curable. And second, there’s a large population that have indolent cancers that don’t need to be treated immediately. So I think, really, the last several years we’ve focused on necessarily not treating the cancer but not treating the cancer in cases where the patients can be watched. I think City of Hope has really done a good job of pursuing active surveillance protocols, where you’re monitoring the patients’ PSA, you’re monitoring their pathology and focusing on prolonging treatment in very specific cases. So in this instance, it’s not treating that’s been the focus instead of treating. I think the other thing that we’ve started to look at as a urologic community is what we call focal therapy for prostate cancers. So as our diagnostic techniques have gotten better, we’ve been able to localize the cancers and have focused on treating just that local area. Again, these are still investigational, but they are newer techniques that are starting to rise. And I think because there are more options for patients, you’re seeing the number of surgeries decrease. But I think if you look at the overall outcome, especially in patients with aggressive prostate cancers, surgery is really still a first-line therapy.
Melanie: Speaking of surgery, with the advent of robotics surgery everywhere, where do you see that for prostate cancer? Is that coming into play as a big part and partial for you to be able to use all of these different advances to make this a much less invasive surgery with less side effects?
Dr. Linehan: Yes. I think robotics has really helped our understanding of the anatomy of the nerves, which are important for both impotence and for incontinence with patient’s prostate cancer, and I think robotic surgery has helped us reassess that anatomy so we can better understand it and better preserve those nerves. I also think that in the next 5 to 10 years, that robotics will improve in several ways. One, the surgeries will actually become more minimally invasive. They are now looking at doing one-port surgeries where you have one incision, and the arms actually extend from what’s inside the body of the patient so the patients will only have one incision. The other thing is better visualization, better visualization of the anatomy, magnification, understanding of the tissues. And the third thing is that soon we’ll be able to incorporate some of our radiologic images into our robotic surgery at the time of surgery, which will help us identify cancers if it’s extending outside the prostate or going to the nerves or even going into the lymph node. So I think those things are also going to change robotic surgery, which is going to give patients a lot more options with surgery and help them recover faster and help them recover from both impotence and incontinence as well.
Melanie: Well, speaking right, you segued beautifully into this. So as that progress and these surgeries become more minimally invasive the risk of impotence and incontinence, following prostate cancer treatment, it seems to be what men worry about the most. So do you see that that’s going to be something that we’re not going have to deal with quite as severely?
Dr. Linehan: Yeah. I think there’s been a lot of new research, especially within the last year, regarding impotence and incontinence, which is very harrowing for the patients postoperatively. And because surgery offers such a good chance for lifelong care for these patients, I think that we focus more on preserving the nerve. One of the newest things they’ve been doing is actually wrapping the nerves in an amniotic wrap to help protect the nerve, nurse the nerve, and to improve the circulation to the nerves, which will eventually help them regenerate. So there are newer medications coming out that we are going to apply both intraoperatively and that the patients are going to be able to take postoperatively to help boost nerve function, which will improve continence as well as erectile function.
Melanie: In just the last minute—and it’s such fascinating information and such exciting hope for men suffering with prostate cancer—give us your best advice about the future of this, your best hope, and why they should come to City of Hope for their care.
Dr. Linehan: I think City of Hope has always focused on treating the patients as a whole, and my advice to my patients always is no matter what the PSA number is, find a urologist or a doctor who is going to evaluate all the factors in your life—your age, your life expectancy, your family history of prostate cancer, the symptoms that you’re having, your previous PSA—and put all of these things together very specifically for just that patient to have a risk assessment for the, and to focus on the patient as a unique and whole patient instead of just treating a number. And I think City of Hope has really focused on doing that as well as providing patients both surgery, radiation, active surveillance roles, and many options for treatments.
Melanie: Thank you so much. What great information. You’re listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.