Breaking the Stigma Around Prostate Cancer

Advances in detection and treatment for prostate cancer has improved so much that it's possible that patients are left with less dramatic side effects than those of past years. The key to this is early detection. Pranav Sharma, M.D., division chief of urologic oncology and clinical medical director, tells us who should get tested and when, who is at greater risk for prostate cancer and he explains what treatment is available and why sometimes not treating it is an option.

Transcript

Melissa Whitfield  00:09
Hello and welcome back to Texas Tech Health Check from Texas Tech University Health Sciences Center. I'm your host. Melissa Whitfield, we want you to get healthy and stay healthy with help from evidence based advice from our physicians, healthcare providers and researchers, detection and treatment for prostate cancer has improved in the past few decades. Likewise, advances in treatment have left patients with less dramatic side effects than those of past years, the key to this is early detection. Our guest for this episode is Dr Pranav Sharma, Division Chief of urologic oncology and clinical medical director. Dr Sharma tells us who should get tested and when, who is at greater risk for prostate cancer. And he explains what treatment is available and why sometimes no treatment is an option. Welcome to our podcast, Dr Sharma, thank you. Thank you for having me. Thanks again for coming and talking to us about a topic that's been in the news a lot lately, prostate cancer. So why don't you just start off by reminding our listeners about your background and what you do here at the Health Sciences Center.

Pranav Sharma, M.D.  01:26
My name is Pranav Sharma. I'm a associate professor in the Department of Urology. My clinical focus and area of interest is in all forms of cancer involving the genitourinary tract, so that would include bladder cancer, prostate cancer, kidney cancer, testes cancer and penile cancer. But of course, the most common cancer that I see and deal with on a daily basis and treat is prostate cancer.

Melissa Whitfield  01:57
Again. Thank you for coming. So let's start what is the prostate

Pranav Sharma, M.D.  02:01
so the prostate typically is a it's a small, walnut sized organ that sits just below the bladder and in front of the rectum, and its main purpose is for fertility. It provides important accessory fluid to the semen to prolong the life of the sperm in the ejaculate makes the semen more alkaline, less acidic, and that kind of combats the acidity of the vaginal tract as the sperm pass through For ultimately, insemination. The other important function of the prostate is it actually serves as a muscle, as an almost an ejaculatory duct, to force the semen out of the pedal urethra so the tip of the penis, so it creates that forceful ejaculation out the end of the penis during orgasm to kind of push the sperm into the female genital tract, again for fertility.

Melissa Whitfield  03:04
Well, as I said, prostate cancer has been in the news recently. Can you just tell us what is prostate cancer?

Pranav Sharma, M.D.  03:11
So prostate cancer is basically like other cancers. It is an abnormal growth of cancerous cells initially that begins in the prostate. They usually begins in the glands of the prostate. The prostate has both smooth muscle, what we call stroma, and it also has glands, and typically we see prostate cancer in the glands of the prostate. The prostate also has three main zones. It has the central zone, which wraps around the urethra, which is where the urine comes out of. It has a transitional zone. The transitional zone is again a central zone in the prostate, and that's where you typically see prostate enlargement. That's where you see prostate enlargement as men age. And then the peripheral zone, which, as it sounds, is on the edges of the prostate surrounds the transitional zone. That peripheral zone is where, most commonly where prostate cancer comes from and starts. And typically it's an abnormal growth of those glands in the peripheral zone, most commonly that can, unfortunately, like other cancers, can then subsequently spread outside the prostate, into other organs, most commonly the bones or the abdominal lymph nodes, and subsequently, from there, can spread to even more further, the lungs, liver, and ultimately, without treatment, can cause loss of life.

Melissa Whitfield  04:39
Who is at risk for prostate cancer, and what are the symptoms?

Pranav Sharma, M.D.  04:43
So definitely, the family history plays a huge role in prostate cancer, and we're learning more and more about even inherited genetic mutations that can put you at higher risk for prostate cancer. So family. History plays an important role, and not only family history of prostate cancer, so such as prostate cancer in first degree, male relatives, such as your brother, your father, but also looking at the female side of your family, breast ovarian cancer, they can carry these same genetic mutations that may put you at higher risk for prostate cancer. So even if you don't necessarily have a family history of prostate cancer in male relatives, if you have a significant family history of breast and ovarian cancer in your female relatives, you may carry certain genetic mutations that put you at higher risk for prostate cancer. So definitely, family history is one of the biggest things that we ask about, we also see prostate cancer more commonly in African American men, which is typically why we screen those men sooner. And then we also can see prostate cancer specifically in our veteran population who have been exposed to chemicals during, maybe during a overseas tour, such as Agent Orange, which was used commonly during Vietnam, we can see that exposure increased risk for prostate cancer in that veteran population. And then, for your second part of your question, the symptoms Now, unfortunately, when you start experiencing symptoms from prostate cancer, you're looking at a much more advanced stage, because you typically don't have symptoms. You may not necessarily have any symptoms when it first starts, so symptoms are typically seen in a more advanced stage, and that would include blood in the urine, troubles urinating, or even inability to urinate altogether, troubles urinating blood in the urine, and in severe cases, bone pain or kidney failure, but that's definitely in much more advanced cases.

Melissa Whitfield  06:57
So then, when should screening start?

Pranav Sharma, M.D.  07:00
So the American urologic Association, which is kind of the leader of my specialty urology, recommends screening men with a standard PSA blood test. Basically starts screening men at age 55 every other year until they're age 69 so the AU a recommends screening men age 55 to 69 every other year in high risk cohorts, as what we mentioned before, so people with significant family history of either prostate cancer in male relatives or breast ovarian cancer in female relatives or African American population, we recommend screening at age 45 starting at 45 every other year to 69 and the reason we stop at 69 is prostate cancer in general, is a very slow growing disease. It's one of the slowest growing cancers in the human body, which is a good thing. So for it to start out in the prostate, to eventually spread to other organs or metastasized to other organs, can take sometimes 10 to 15 years. So going off the average life expectancy of an American male, that's why we recommend stop screening at 69 because the chances at that point that they would die from prostate cancer are much lower, and they're more likely to, I know it sounds morbid, but more likely to pass away from something else, rather than prostate cancer after age 70. Of course, patients have the option, you know, sometimes with those life expectancy you may have a you know, we always take a nuance into each situation. So you may have an older gentleman that may be 75 but maybe his grandfather has lived to 105 maybe his father has lived to 100 and so his average life expectancy is going to be a lot longer than the average American male. And so you may want to continue to screen that patient even up to age 8590, so there is some nuance to screening as well. And on the flip side, if you have maybe a 60 year old, but he is in very bad shape, you know, he's got congestive heart failure, he's on dialysis. He's got a lot of other competing comorbidities, where, realistically, we don't think his life expectancy is 10 to 15 years, then, you know, probably don't have to screen that patient. So there is some nuances there. And sometimes it's hard to TR hard to tell, you know, it's very hard to predict life expectancy, you know. But in general, the AU A says that if your life expectancy is less than 10 to 15 years, you probably don't need to screen for prostate cancer.

Melissa Whitfield  09:48
So how do you screen for prostate cancer?

Pranav Sharma, M.D.  09:51
The gold standard right now is a simple blood test called PSA. PSA stands for prostate specific antigen. It. Is secreted by the glands of the prostate into the bloodstream, and higher levels of PSA can indicate prostate cancer. Now there's a lot of nuance here, because there are a lot of other things that can make your PSA high. And this is where we got into some controversy from before, where about 510, years ago, the US Task Force actually recommended against screening for prostate cancer because a lot of these PSA elevations ended up leading to over diagnosis and over treatment of prostate cancer. So there is some nuance. And really, as you get an experienced urologist, they'll kind of know how aggressive and when to really be concerned about a PSA level. Because yes, prostate cancer can make your PSA high, but there are other things that can also make your PSA high, such as having an enlarged prostate, prostate inflammation, what we call prostatitis, can also make your PSA high. Recent sexual activity or ejaculation within the last 72 hours can also make your PSA high, and some people genetically just run at a higher PSA. And so we not only use just the baseline level, we also look at PSA trend, or PSA dynamics, very closely to determine risk of prostate cancer. So it is a very nuanced test. You can't just judge it on one level. You really need a trend of two or three values to make a really a clinical judgment on whether you're concerned about prostate cancer, but definitely the gold standard is the PSA blood test, which can be done with routine blood work, and you don't need to be fasting for it can be done at any time.

Melissa Whitfield  11:51
That was one of my questions was, do you need to see a specialist to get test set? Or is this something?

Pranav Sharma, M.D.  11:57
It would depend on the I would say how comfortable your primary care physician is with PSA testing. So definitely, a lot of primary care physicians refer to us, and we're definitely much more experienced in tracking PSAs, because we do it day in and day out. Pretty much every day in a career of a urologist, they're seeing 1000s and 1000s and 1000s of PSAs. So it would depend on how comfortable I would I would say definitely. If you're seeing back to you know, if they check a PSA, it's high, they check it again, maybe six, four to six weeks later, and it's still high. Usually, that triggers a referral to specialist, and we're happy to take those cases. So I would say definitely, two or three persistent high PSA levels usually triggers a referral to a specialist.

Melissa Whitfield  12:47
So then, how do you treat prostate cancer?

Pranav Sharma, M.D.  12:50
So prostate cancer, again, this takes a lot of nuance, and this is why experience plays a role here. It's highly dependent on how aggressive the prostate cancer is there was a period of time 10 to 15 years ago where we used to treat every prostate cancer, and we probably did over treatment, and subjected men to side effects from over treatment. Nowadays, though, we use a much more nuanced approach, taking into account the patient's age, their other medical problems and the aggressiveness of the prostate cancer. Now, most what we call low risk prostate cancer nowadays, we just do surveillance. In other words, we've just watched the cancer. We are not necessarily treating it, because we understand that this low risk prostate cancer can take upwards of 10 years to really impact life expectancy. Now we cannot just forget about this low risk prostate cancer, so we are still doing periodic testing for it, because about 60% of these low risk prostate cancer will become more aggressive over the next 10 years. So about 60% will become more aggressive over the next 10 years. So even you may be diagnosed with the low risk prostate cancer that you're watching, but it would still require periodic blood tests and repeat biopsies of the prostate every one to two years, or even MRIs of the prostate to re image the prostate every one to two years, to keep on top of it, and to keep make sure it's not getting more aggressive, but you can safely watch them. As long as you're doing your PSA blood tests and as long as you're doing your periodic biopsies or MRIs, you can safely watch them, and a good percentage of them may never change. And so you can avoid all the side effects of treatment for low risk disease. Now, when you get into intermediate risk disease, you really have to take into account the patient's life expectancy, their age, their comorbidities. If it's a young, healthy patient with intermediate risk prostate cancer, a lot of those patients, we do recommend treatment. So if it's an older patient with a lot of other medical problems, such as heart failure, dialysis, etc, etc, where their life expectancy is limited to less than 10 years, you could make the case of watching those patients, because again, even with intermediate risk disease, it takes upwards of seven to 10 years to affect their life expectancy. And high risk disease, which is much more aggressive cancer, we do recommend treatment now, the two standard forms of treatment are surgery or radiation. Surgery involves removal of the entire prostate, and here at UMC at Texas Tech, I would say 100% of these surgeries are done using robotic technology, or what you call a laparoscopic or minimally invasive fashion. I would say almost all prostatectomies are done robotically here, and I would say 95% in the country are done robotically through minimally invasive or laparoscopic surgery, which helps patients recover quicker and go home the next day, and usually are back to normal activity within four weeks. Now there are some both short term and long term side effects of removing the prostate. One of the long term side effects that we always struggle with is erectile dysfunction, because the nerves that control sexual function run behind the prostate, and there is some, even in the best of hands, some damage to those nerves during surgery that can take upwards of a year, year and a half, to recover. The other short term side effect is loss of urine control, or what we call urinary incontinence, and that's because part of the sphincter muscle that gives a male their control is located in the prostate, and it is removed during the prostate surgery, when we remove the prostate. Now there is another sphincter muscle that's located in the urethra, the membranous urethra, which is located just distal to the prostate, and that membranous urethra muscle will compensate and help recover that control. But sometimes that can take six to nine months, and most of our men who have prostatectomies go through extensive physical therapy about six weeks after surgery to help recover their control by strengthening that remaining sphincter muscle to help recover their control. And they also go through penile rehabilitation with very potent erectogenic medicines that they self inject in the in the penis to help them recover their sexual function, but that can take much longer. That can take up to a year and a half, sometimes two years. And in older men, definitely above 70, they may never recover spontaneous erections and may be dependent on the medication for the rest of their life. So those are two major side effects with the surgery. Now, the counter to that is radiation, and that's what we call external beam radiation therapy, where basically it's fancy X rays delivered to the prostate to kill the cancer cells within the prostate, and usually not all the radiation is given on one day. It's given in small amounts over a 40 to 45 day period, but it is. There's no recovery process. Since there's no surgery involved, they walk in, walk out on each radiation session. Now there's still that sexual dysfunction aspect of it, even with radiation. And radiation does have some unique side effects, such as, you can get radiation damage to the bladder, which sits above the prostate, you can get radiation damage to the rectum, which sits behind the prostate, and either radiation damage to the bladder of the rectum can cause urgency frequency or bleeding of the urine or bowels, depending on where the damage is, now with advanced Radiation Technology, luckily, the risk of permanent damage, radiation damage to the rectum or the bladder is very low with our advanced targeting techniques. Now with radiation so in general, that risk of permanent radiated damage to the rectum and bladder is pretty low. Now, one of the newer options, also that we are going to have here soon, that is kind of on the forefront of treatment for prostate cancer, is something called focal therapy. So we are realizing that for these intermediate risk cancers. So these ones that are kind of in between, not low risk that we're watching and not high risk. Because high risk cancers, you definitely have to either do removal of the entire prostate or radiate the whole prostate, what we call whole gland treatment. We got to treat the whole gland because they're so high risk that if you only treat a portion of the prostate is a very high risk of it coming back somewhere else. But for these intermediate risk patients, especially these patients that only have cancer in one small portion of their prostate, let's say it's just at the right side, just at the left side, just at the base or just at the apex, we're realizing that we can actually. Go in and just treat that one area of the prostate, spare the rest of the prostate, and that dramatically minimizes the side effects of Ed and urinary incontinence, or loss of urine control. That's called focal therapy. And so we use something called High Intensity Focused Ultrasound. HIFU is abbreviation or high intensity focused ultrasound. We do it under anesthesia, so it is a surgery, but we put special probes into just that area of the prostate that has the cancer. And again, this is for intermediate risk cancer, not low risk, not high risk, but intermediate risk, and we put these special pros in just this area, just the area that has the cancer, and we can actually deliver high intensity, focused ultrasound, thermal energy to kill just that area of the prostate, to kill those cancer cells, spare the rest of the prostate, and that can result in just as good cancer control, but minimize side effects, especially for younger men, whose sexual function is very important to them, it's a great treatment option that we are going to be able to offer here within the next six months. But I want to again reiterate, it's for intermediate risk patients, and there's still a risk in those patients that the cancer could come back somewhere else, so they have to be aware of that. And so we still need to monitor those patients with, you know, repeat biopsies and PSA levels after that focal treatment. So it's not a one and done kind of thing, but it is a good option for patients with small amounts of cancer who want to preserve

Pranav Sharma, M.D.  21:43
as high as possible their potency and their urinary control, both in the short term and long term, and then obviously for advanced prostate cancer. So we're talking about metastatic prostate cancer. Once it's spread outside the prostate, then you really need the that's where the role of the medical oncologist comes in. And so we're looking at chemotherapy. We are looking at advanced, what we call androgen blockade. So testosterone is kind of the food for prostate cancer. It helps prostate cancer thrive and grow. So once we start seeing prostate cancer outside the prostate. We do, we have various formulations to bring the testosterone level down to zero, what we call castory levels, almost like, you know, having your testicles removed, and so that bringing that testosterone level down to zero can dramatically reduce the growth and the ability of prostate cancer. Just to survive, and so once you get to metastatic or advanced prostate cancer, you are using a lot of androgen blocking agents to bring the testosterone level down to zero in combination with chemotherapy. And that's again, for kind of stage four disease, advanced stage disease, which, yeah, involves the role of both the urologist and a medical oncologist. And there's a lot of different agents that we have now available to bring that testosterone level down to zero. And sometimes we use more than one agent in combination. So sometimes we can use a first generation anti androgen. With a second generation anti androgen, there's a lot of what we call androgen blocking agents now that we use for advanced prostate cancer in combination with chemotherapy, and we're also starting to use what we call theranostics in advanced prostate cancer. So for example, when you get a PET scan, you know, your cancer lights up. The reason it lights up is because there's a what we call a radio nucleotide isotope that makes those cancer cells light up in your body. And we could see that on a PET scan. One of the newer agents that we have is actually linking that isotope with a therapeutic agent. So not only it makes those cancer cells light up, but then it delivers that therapeutic agent to those cancer cells that light up. That's called theranostics, and the newest one on the market is called Lutetium. Lutetium is used for much, very advanced prostate cancer. So this is what we call castrate resistant prostate cancer this. So this is when prostate cancer gets so advanced that it no longer responds to blocking the testosterone anymore. It's become resistant to that, and it keeps growing despite having your testosterone at a castrate level. And so the lutetium, this theranostic lutetium, is now being used in those patients who really are running out of options to not only make their cancer cells light up on a PET scan, but also deliver this it's actually a microtubule kind of modifier to kill the cancer cells. But again, that's much more advanced disease. But I suspect that Lutetia will be now tested in earlier stages. Disease, potentially even when they're first diagnosed as metastatic. So that, yeah, that was a long answer, but obviously prostate cancer is a very complex disease.

Melissa Whitfield  25:11
Well, it was a very long answer, but I think it's very necessary, because I think that people who are coming up to the age of being screened remember just the worst case or the poor scenarios, and would just rather not know or not be tested. How can we how do you encourage somebody to get tested?

Pranav Sharma, M.D.  25:28
Well, I would say, tell them the number one cancer in males in this country is prostate cancer. It is the most commonly diagnosed cancer in a male in this country, and we are only going to see more of it because we have an aging population, without screening, we're going to see a higher percentage of patients that are diagnosed with advanced prostate cancer, stage four, metastatic prostate cancer, and we don't want to see that, because those patients have a lot of pain, have a lot of urinary problems, can develop kidney failure, and have to take very intense treatment such as chemotherapy and hormone blocking agents that can completely shut off their sexual drive. Because the good news is, when you block your testosterone, it makes the prostate cancer better. The bad news is, when you block your testosterone, you lose all sexual desire. Not only that, you can get hot flashes. You can lose muscle mass, you can get chronic fatigue, be tired all the time, and you could even get some breast enlargement and breast tenderness. So blocking the testosterone does have significant side effects in males, and so we don't want to see more men that have to be on that agent, you know, which typically we only use for advanced prostate cancer. So that's why it's so important to screen, because diagnosis early. There are so many options for effective treatment with minimal side effects nowadays, and again, a lot of these low risk cancers we just watch anyway. So that's why a lot of you know men may be scared, because they're worried that, you know, if I screen, then I get diagnosed, I have to have my prostate removed, and then I'll be impotent, and then I'll lose all my urine control, and I'll leak all the time, and I won't be able to have sex. That fear is is outdated when patients get appropriately screened. Most of the cancers that be diagnosed either in low risk or intermediate risk groups. It's very rare to see someone who has had appropriate screening be diagnosed with a high risk or an advanced stage four prostate cancer. The ones that we see that are high risk or stage four metastatic are usually patients that were never screened or weren't appropriately screened, or maybe they started screening way too late. They started screening, you know, in their late 60s or mid 60s, when they should have started screening at 55 but most of the patients that are appropriately screened again 55 to 69 every other year. Or if you're high risk, starting at age 45 most of those patients, I would say 95% of those patients, when they are diagnosed, are low risk or intermediate risk. And so those patients have plenty of options. Don't necessarily need their whole prostate removed or radiate their whole prostate. We either watch those patients or can do what we call focal therapy now, where we just treat that area of the cancer with very minimal side effects, both of their urinary control and their sexual function, so they can still feel like a male. And again, there was a lot of stigma 10 to 15 years ago, where they felt that if they got screened, they would have to have their prostate removed or had to have radiation, and then they would not stop being a male, because they would lose all their control or not be able to have sex. And so that stigma we and as urologists, we do have to educate males more about that, that nowadays, hey, just here because you're diagnosed doesn't mean that you are going to lose your male sexuality. We have so many other options now to preserve that and still treat your cancer, or watch your cancer or treat your cancer effectively. And so I think that was a lot of the stigma that you know as urology community that we're hoping to change. And so screening is important, because if you are not screened appropriately, or you're screened too late, and you do end up with a high risk disease, or, God forbid, stage four disease or metastatic disease, then the side effects of treatment will be 10 times worse. And yes, that could involve removing your prostate or having radiation, or having your testosterone level down to zero, or even having your testicles removed. And so the repercussions of that are so much worse than if you get screened appropriate because, again, appropriate screening most of the patients are diagnosed. Early with low risk or intermediate risk disease. It's very rare, if you are screened appropriately to end up with a high risk cancer or of an advanced cancer. Most of these patients are diagnosed low risk, intermediate risk and can really avoid a lot of the side effects that maybe men are afraid of when they get their PSA checked,

Melissa Whitfield  30:22
is there anything else that you'd like to add?

Pranav Sharma, M.D.  30:25
It's mostly a reiteration of you do want to get checked for prostate you know you need your prostate checked. It can be devastating to be diagnose someone with a high risk or advanced prostate cancer, knowing that if they they simply had their PSA checked 10 years earlier, they could have avoided a lot of the situation that they're in now. And I would reiterate even to primary care docs, that I strongly advocate for PSA screening appropriately. And it doesn't necessarily mean that we're just because you check a PSA, that your patient is going to end up with it, losing their prostate. That that is not true. We are much more nuanced. Now in when we offered that kind of aggressive treatment, and especially in my practice, as I said, 70% of the patients that are diagnosed with prostate cancer were not removing their prostate. We're either doing surveillance, or we're offering vocal therapy or we're watching them. And so we are much more nuanced in which men, we offer more aggressive treatment and we cater it to the aggressiveness of the disease, which hopefully, if you get screened appropriately, you'll never need to worry about, because, again, most advanced diseases seen in patients who don't get screened well.

Melissa Whitfield  31:47
Thank you so much for all this information and for educating us really on the advances for screening and treatment of prostate cancer.

Pranav Sharma, M.D.  31:54
No problem, no problem. Thank you for having me.

Melissa Whitfield  31:59
Thanks for listening to Texas Tech health check. Make sure to subscribe or follow wherever you listen to podcasts. This information is not intended to be a substitute for professional medical advice. Always seek immediate medical advice from your physician or your healthcare provider for questions regarding your health or medical condition. Texas Tech Health Check is brought to you by Texas Tech University Health Sciences Center and produced by Tr Castillo, Suzanna Cisneros, Mark Hendricks, Kay Williams and me,Melissa Whitfield.