According to the American Cancer Society, it’s estimated that one in eight men will be diagnosed with prostate cancer in their lifetime, making it one of the most common cancers in men. Despite its prevalence, prostate cancer is often slow to progress, which makes screening and early detection key for effective treatment.
The Experts
What You’ll Hear in This Episode
- 00:00 Opening and Introductions
- 00:55 Prostate cancer, risk factors and prevalence
- 2:09 Diagnosis and Gleason score
- 4:13 Symptoms/warning signs
- 5:15 Screening (PSA)
- 6:40 Further testing for elevated PSA
- 8:23 Life expectancy for somebody diagnosed with prostate cancer
- 11:17 Treatments for prostate cancer
- 16:30 Hormone therapy
- 21:09 Additional therapies for prostate cancer
- 23:37 Clinical trials at Stony Brook Cancer Center
- 25:26 Closing Remarks
Full Podcast Transcript
00:00 Opening and Introductions
Announcer
Welcome to HEALTH Yeah!, where experts from Stony Brook Medicine come together to discuss topics ranging from the complex inner workings of an infectious disease to tips and tricks for staying safe and healthy all year long.
Michael Hung, MD
Welcome to HEALTH Yeah!. My name is Dr. Michael Hung and I’m a surgeon that specializes in the management of complex urologic cancers. I’m joined today by my colleagues, Dr. Judy Huang and Dr. Joanne Wu, and we’re going to be discussing prostate cancer today, including how it’s diagnosed and treated.
But before we get started, I’d like to ask each of our experts to introduce themselves. Dr Huang, why don’t we start with you?
Judy Huang, DO
Hi, I’m Dr. Judy Huang. I’m a medical oncologist, and I treat prostate cancer along with my
colleagues here.
Joanne Wu, MD
Hi, my name is Dr Joanne Wu. I’m a radiation oncologist here at Stony Brook. I’m happy to be on the team here today.
00:55 Prostate Cancer, Risk Factors and Prevalence
Michael Hung, MD
So we can start with, what is prostate cancer? What are the causes and how prevalent is it?
Joanne Wu, MD
So prostate cancer develops when changes in prostate cells allow them to keep multiplying when they normally wouldn’t. There is no main risk factor for prostate cancer that we can concretely say. But we’ve known that men who are older in age, most commonly, maybe after 50 years old, race and a family history of prostate cancer can sometimes be our “risk factors.”
The prevalence of prostate cancer is that it’s about one in eight men in their lifetime can develop prostate cancer. It’s the most common cancer after skin cancer for men. And the good news is that usually, prostate cancer is something that grows very, very slowly. If we catch it early, and we can treat it, most of the time, it would not change a patient’s quality of life or quantity of life.
2:09 Diagnosis and Gleason Score
Michael Hung, MD
Yeah, definitely. And I know the incidence of prostate cancer is increasing over time, so it’s kind of more important that men get screened earlier and earlier. And when we talk about screening and things like that, I guess we should probably start with, how is prostate cancer graded? How we detect it and things like that.
Judy Huang, DO
Prostate cancer is diagnosed by biopsy, and usually that’s a prostate biopsy performed by your urologist, like Dr Hung’s team. And most prostate cancer is diagnosed in the earlier stages, when it’s localized and confined to the prostate itself.
And you may have heard of the Gleason score when we’re talking about prostate cancer. So the Gleason scoring system is very important in helping us risk stratify localized prostate cancer and determine the appropriate treatment.
So after your biopsy, the pathologist will look under a microscope, and they will assess how aggressive the cancer cells appear. Your Gleason score is determined by the two most common patterns, and that is added up. So for example, if your most predominant pattern is graded at three, and your second most predominant cancer cell pattern is graded at four, then your Gleason score is three plus four, which equals seven. And this grading helps us categorize whether your localized prostate cancer is low risk, intermediate risk or high risk.
And that then dictates how intensive treatment needs to be. For higher grade cancers, we do tend to be more intense with our treatments. Overall, it is important that patients get screened for prostate cancer so that we can catch this at an earlier stage and have better outcomes. So usually patients are referred to urologists when there’s an initial suspicion for prostate cancer.
4:13 Symptoms/Warning Signs
So Dr Hung, would you be able to tell us what symptoms or warning signs to be aware
of?
Michael Hung, MD
Yeah, so, you know, I think it’s very hard. You know, as men get older, they typically have a lot of symptoms, so maybe a slower urinary stream. They may be straining a little bit to urinate. These could be signs of just normal aging for a lot of men. So I think the scary thing, and the thing to know about prostate cancer is that generally, in the early stages, in the local stages where it’s confined to the prostate, there generally aren’t many signs or symptoms.
So some people can have absolutely no issues with urination, no pain at all, and can still have prostate cancer. So that’s kind of why screening is super important.
And you know, I think you bring up a very good point about the Gleason score, there’s a huge range of prostate cancer. Not all prostate cancer is the same. And that’s kind of where we work as a multidisciplinary team to treat patients who have low grade, low risk cancers, all the way up to high grade, high risk cancers, and we can really tailor treatment to them.
5:15 Screening (PSA)
So we talked about what prostate cancer is. I think for most patients, they want to know how we can detect prostate cancer, how we do that screening. And typically the screening is in the form of PSA. It’s that blood test prostate specific antigen that’s made by normal prostate cells and also abnormal prostate cancer cells. And that’s usually a test that you start getting with your primary care physician.
You can get that test as early as age 40-45, based on the risk factors. And it’s a simple blood test that you can have collected by your primary care physician, and gives you an idea of where you stand, you know, in that scale for PSA.
6:40 Further Testing for Elevated PSA
When do you think is a time where we should start working up patients for an elevated PSA or a number that’s very high?
Joanne Wu, MD
Yeah, that’s a good question because PSA can range. And I think normally they say four is normal, but actually, as a patient ages, the PSA changes. It can increase over time. So there is no normal for a specific patient. So then elevated PSA would be around two to four, maybe above four, we would say you should probably see a urologist to see if there’s a need to get a biopsy.
Michael Hung, MD
And I think that’s important to know that everyone’s number is a little bit different. So you know, it’s hard to ask your friend, to ask their neighbor, “Hey, what is your PSA,” because it is a very individualized lab result, and really you should have that discussion with your primary care physician.
Joanne Wu, MD
So Dr. Hung, can you tell us more about any further testing for someone with prostate cancer?
Michael Hung, MD
Sure. Yeah, so during the workup for elevated PSA, urologists like myself or even your primary care physician can do a couple of things to see if that elevated PSA is a result of something like prostate cancer, or if it’s just a normal enlargement of a prostate gland.
So most practitioners will start with the digital rectal exam, where they feel the prostate, they feel for any lumps, bumps or nodules that may be suspicious for abnormal growth within the prostate.
More and more nowadays, there are some advanced imagings that we can get so things like multi parametric MRIs, which is a very great test, and one that gives us an idea of the size of a prostate for a patient, and let us know if there are any specific areas within the prostate itself that could be suspicious, that may warrant something like a prostate biopsy.
And prostate biopsy we talked about a lot earlier. It’s really the only way to definitively say if there’s prostate cancer there or not, and it’s also very important to see the architecture if it is cancer, and we can give it a Gleason score and a grade group like we talked about earlier.
And prostate biopsies nowadays, especially here at Stony Brook, we’re moving towards, we call it transperineal biopsy. So it’s a biopsy that’s done in the office. It’s an in and out procedure. Doesn’t need any anesthesia. But the transperineal route definitely has a bunch of advantages, where the infection risk is significantly lower and there’s less of a preparation for that.
And I think detection of prostate cancer very early is very important. That’s why we should continue to talk to our patients about screening and things like that.
8:23 Life Expectancy for Somebody Diagnosed with Prostate Cancer
So the big question is, once we detect prostate cancer, if we do a biopsy or detect prostate cancer, patients always ask, what is the life expectancy for someone who is diagnosed with prostate cancer?
And Dr. Huang, you could probably talk to us a little bit about that.
Judy Huang, DO
So this is a very difficult question to answer in the oncology world. Overall, the life expectancy for prostate cancer is very favorable compared to other solid cancers, especially when we’re able to detect prostate cancer early. And at that point, with the appropriate treatment, we have very high cure rates, and so then the life expectancy in these patients can be very similar to someone without prostate cancer.
Now, when we talk about advanced or metastatic prostate cancer, at which point the disease is no longer curable, unfortunately, life expectancy is reduced, and it’s estimated at median survival in a ballpark of three to five years. And there are a lot of factors that go into life expectancies, such as the extent of the disease, how aggressive the cancer is, and the response to treatment. We do also have to keep in mind that prostate cancer is diagnosed more prevalent in older men. And so there may be other medical conditions that limit life expectancy as well in these elderly gentlemen.
But we do have multiple therapy options and metastatic prostate cancer can still be very treatable, and with these therapies, we hope to increase life expectancy and provide and maintain a good quality of life.
Michael Hung, MD
Yeah. So I think it is definitely important what you brought up that prostate cancer is very different than other solid organ tumors. And a lot of our patients, especially those who we detect prostate cancer very early, have very long life expectancies.
And you know, I like to tell patients, you probably say the same for patients, that especially with low risk, intermediate risk cancers, if you have the right treatments, you go through the surveillance that most men will die with prostate cancer, and from prostate cancer. I think that’s really an important point, because, you know, cancer is always a very, very scary word, but we definitely have a lot of great treatment options available from the surgical side, from the radiation side, from the hormone side, to really help patients get through that diagnosis.
11:17 Treatments for Prostate Cancer
So I guess the next thing is probably, you know, once you detect prostate cancer, how we treat it. And you know, we know that not every prostate cancer is the same, especially for these low risk prostate cancers, where these cells may be slightly abnormal, but not really types of cells that we would anticipate would grow very quickly or metastasize.
A lot of patients who are detected very early with very low risk cancers, we know that something like active surveillance is very safe, and we know that patients who are in active surveillance have very, very good life expectancy. As long as we keep a very close eye on things, there are all the treatment options available in the future for these patients, and we know they do just as well as folks who get any sort of treatment earlier and then.
So that’s one of those modalities of treatment. The other things are things like surgery. So that’s something that we do here at Stony Brook Hospital, myself and our team here, the urological oncologist here.
Surgery nowadays is very different than what it was back in the day. We do it laparoscopic, robotically. Most of the incisions are about one inch long, so they’re all very, very small. It is an outpatient procedure for us here at Stony Brook Hospital as well. So most folks don’t need to spend the night. They can relax at home. We know it’s a very effective treatment option to remove the prostate. In order to get rid of that cancer, we remove and sample some of the lymph nodes in the area as well to confirm that cancer hasn’t spread outside the prostate.
A lot of patients do very well after surgery. Everyone’s a little bit different in kind of how they decide to treat prostate cancer. If we think that surveillance may be not the best option for those patients, especially those with intermediate risk prostate cancer, a lot of patients also want to explore things like radiation therapy. There are a lot of big advancements in different types of radiation therapy, things like CyberKnife therapy, and Dr. Wu, you probably have a lot of experience with that and talking to patients about that.
Joanne Wu, MD
Radiation therapy uses basically very high energy X-ray beams to kill cancer cells. There’s two main modalities to doing it. One is what we call external beam radiation, and the other patients call or people call it internal radiation, and that’s called brachytherapy.
So let’s start with external beam radiation. External beam radiation feels like going through a CAT scan. A CAT scan also uses X rays, but instead of taking images, we’re using higher energy X-rays to kill these cancer cells in the prostate. It’s like a CAT scan. You don’t feel it, you don’t see it, it’s painless. As surgery has gotten better, it’s moved into laparoscopic robotic, like you said, there’s been much, much better radiation has evolved now than it was maybe 30 years ago.
And when I say that I’m talking about something called stereotactic radiation therapy. And so there’s a lot of commercials about CyberKnife. CyberKnife is essentially the name of a machine that delivers stereotactic radiation therapy, and that’s something that we deliver here at Stony Brook.
What it is is basically you are able to track the prostate in real life motion, even while the patient’s breathing. And so while it tracks that prostate, it’s able to deliver high radiation beams, high energy radiation beams at the same time. And because we’re able to do that so well and so precisely, radiation can be done in five days.
And so that’s five days every other day for two weeks, and that’s the external bean radiation part of it. Not everyone’s a candidate for that stereotactic radiation treatment. And when that’s the case, then we can kind of go back to the more historical way of doing radiation, which is everyday radiation for maybe four to six weeks.
But even when I say that’s a historical way of doing radiation, we’re still able to track your prostate in real time, and we’re still very precisely delivering the radiation beams to the prostate, just as we would with the CyberKnife version. It’s just that we’re doing it a little slower, a little more gently on the prostate.
So I’m going to segue into internal radiation, which is also something we offer here at Stony Brook, and it’s using a method called brachytherapy. So brachytherapy is more of delivering radioactive sources right where the cancer is, destroying the cancer in that area and sparing the local tissues around it. And I’m talking about the bladder, the rectum, etc.
These two modalities, depending on your prostate cancer risk group, you can choose one or the other. Sometimes in higher risk patients, we recommend combining them together to treat the prostate cancer. It’s a very high dose of radiation. All to say that radiation has gotten a lot better. It’s much safer. I think it’s more akin to surgery in that it’s a local treatment, so we’re really delivering treatment to just that area. Sometimes we do add hormones for patients who are a little bit of a higher risk of prostate cancer.
16:30 Hormone Therapy
Can you tell us more about hormones?
Judy Huang, DO
Yeah, it’s amazing. The surgical and radiation advances in the treatment of prostate cancer. Hormone therapy or androgen deprivation therapy has been around for many, many years, and it remains the core of systemic treatment in prostate cancer. So I will refer to it as ADT for short and more casually, we refer to it as hormone therapy. It comes in the form of injections or oral pills.
ADT is very effective in treating prostate cancer because prostate cancer cells are highly dependent on androgens such as testosterone for growth and survival. So the way ADT works is that it brings down testosterone levels to a castration level, and that cuts off the fuel to these prostate cancer cells.
Now I have patients who like to joke with their wives that, you know, it’s their turn to experience menopause now because of the symptoms of ADT, such as hot flashes, fatigue, irritability, sexual dysfunction. And while it’s good that they still have a sense of humor about it, it is understandable that these side effects can affect their quality of life quite significantly.
So there are other side effects, such as increased risk of bone loss, muscle loss, cardiovascular disease, especially with long-term use. And like you said, ADT can be given as a short duration with radiation to enhance the cancer killing effect of radiation and increase the chance of cure in localized prostate cancer.
When we talk about advanced or metastatic prostate cancer, ADT serves as the backbone of treatment to which other treatment modalities are added to. And unfortunately, prostate cancer can become castration resistant, which means that these prostate cancer cells, they adapt and they acquire mutations that allow them to survive, allow them to grow, despite low testosterone levels.
And in these situations, we do have to intensify treatment. So we have agents that can further inhibit testosterone use by these prostate cancer cells, such as by blocking receptors or by blocking synthesis pathways.
We also have chemotherapy that may play a role in extensive metastasis or castration resistance. We have radioactive drugs that target and deliver radiation directly to cancer cells, and as oncology treatment is moving towards a more personalized method, this also is the case for prostate cancer treatment. So we have immunotherapy that modifies the patient’s own immune cells to help fight the cancer. And we can also send tissue for next generation sequencing to identify targetable mutations which may open new lines of treatment and it may also help to identify patients who have certain mutations that are eligible for clinical trials.
Michael Hung, MD
Yeah, you know, I think you bring up a lot of advances, especially in the management of advanced prostate cancer and high risk prostate cancer. I think it’s also important to know that not all patients will need a lot of these medications, but they are available for folks you know, who may develop prostate cancer that spreads outside the prostate, or those that are resistant to hormone therapy.
And you know, it’s a really wide range of options. Especially in the treatment for advanced prostate cancer, we have more and more tools nowadays to manage advanced prostate cancer, even if it’s spread outside the prostate. I know there’s very exciting radiotherapy options like radio ligand therapy. And I know, Dr. Wu, that we have those options available here at Stony Brook too.
21:09 Additional Therapies for Prostate Cancer
Joanne Wu, MD
Yeah. So for patients with metastatic prostate cancer, as Dr. Huang said, there’s a lot of systemic therapies, and that could be in the form of ADT or chemo or immunotherapy. Radioligand is kind of like that in that it is systemic. So one example of that therapy is something that we have called PLUVICTO® (lutetium Lu 177) which is a radioactive source. It binds with PSMA. And what it does, it finds PSMA antigens in the body. And someone with prostate cancer, they can have PSMA with metastatic prostate cancer, they can have PSMA antigens, kind of in different parts of the body that are difficult to access with, you know, just radiation alone, because it’s hard to access to kind of treat the entire body.
But with this infusion, what happens is it goes to wherever there is a PSMA antigen and destroys the cancer cells in that area. And so PLUVICTO® is kind of one of the newer technologies in terms of the radiation in the radioligand world.
In addition to all the systemic therapy options that medical oncology offers, I think that when we combine these modalities that we have in the radioligand radiation world with the systemic therapy options that we have in the medical oncology world, we can really tackle metastatic prostate cancer, which is can be very advanced and very devastating for some patients, but at least there’s there’s still options to offer.
Michael Hung, MD
Yeah, you know, and I think with those growing technologies, like the radioligand that you talked about kind of builds upon the PSMA scans that we have, which are really fantastic scans that look for small, very, very small amounts of prostate cancer that can be outside the prostate.
So we have these scans available at Stony Brook. We do these PSMA PET scans for patients who may be considering radiation therapy, surgery therapy. If on their biopsies, they’re found to have higher grade types of cancer, we can find out very quickly, very early, whether that is one confined to the prostate, so still in the prostate, or if it’s, God forbid, spread outside the prostate.
So that we know we’re giving patients really the best treatment option, whether that’s surgery, radiation, if we need hormone therapy, that PSMA skin is really integral in helping us make those decisions.
And you know, Dr Huang, you talked about a lot of the different chemotherapy, immunotherapy options we have available here. We also have a fantastic line of clinical trials available, one with our medical oncology colleagues over here, we have some clinical trials available with our radiation oncology colleagues, Dr. Wu, I think there’s a couple you may want to talk about.
23:37 Clinical Trials at Stony Brook Cancer Center
So I think what separates, you know, Stony Brook, which is an academic center, from the rest of Long Island, is that we offer several national clinical trials to our patients, and that just kind of adds to this extra layer of a personalized treatment for someone with prostate cancer.
So a lot of these clinical trials look at the prostate cancer’s genetic and molecular biomarkers, and depending on how that looks like, other than just what it looks like on a biopsy, we can tailor our treatments to say, hey, do we want more hormones or less hormones depending on what their cells look like on a genetic or bio or molecular test?
And there’s some experimental therapies that urology has some experience with here at Stony
Brook.
Michael Hung, MD
Yeah, I think clinical trials are very important about pushing the edge of science so that patients can really have all the options available to them. And besides things like radiation and surgery to remove the prostate, we have a number of very cutting edge technologies to do what we call focal therapy, where we treat just very small specific portions of the prostate that might have prostate cancer. We can preserve a lot of the rest of the prostate and preserve things like the nerves that are in charge of erections. And we really see these patients have very minimal or very low rates of side effects that you may see from something like surgery. So like something like radiation, where we would focus typically on the entire prostate, focal therapy is really fantastic for folks who want to explore some of these other options. And we have all those available here at Stony Brook.
25:26 Closing Remarks
Yeah, so that’s all the time we have today. Thank you to our experts for your time and expertise, and thank you to our viewers and listeners. If you have a loved one who has a question about prostate cancer screening or diagnosis or treating the disease, please don’t hesitate to reach out to our multidisciplinary team at Stony Brook Cancer Center, and they will direct you to the correct resources. If you found this conversation interesting, don’t forget to like and subscribe for more informative health related content.
Announcer
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