Dr. Ali welcomes two special guests — Dr. Matt Cooperberg and Dr. Dave Thiel — to discuss the latest in prostate health.
Carmela J: Welcome! It is now 5:06. Time to get some good tips on the Conversation on News Talk WOKV, where health and wellness are explained. I’m your host, Carmela J., and I’m also joined by our weekend expert, Dr. Ali Kasraeian. We also have our guest, Mr. Dave Thiel, in the studio. We love having him in.
Dr. Ali Kasraeian: Dr. Dave Thiel.
Carmela J: Dr. Dave Thiel. We love having him here. I don’t want to give him more credit, sorry.
Dr. Dave Thiel: Already tongue tied again.
Carmela J: Shut up. So we have Dr. Dave Thiel in the studio with us. We also have Dr. Matt Cooperberg, is that correct?
Dr. Ali Kasraeian: Yes.
Carmela J: Joining us over the phone, so we will have him here in a minute. This is a very exciting day because it’s also Dr. Ali Kasraeian’s birthday today, and he’s really old.
Dr. Ali Kasraeian: Thank you very much. I’m very old.
Carmela J: He’s very old. We have that and also, very exciting, in five days we will be strictly on 104.5, so we will have a stronger signal. More people will be able to hear us without having to switch from our AM to FM, so it’s very exciting for us here.
Dr. Ali Kasraeian: I can’t tell you how excited I am about that.
Carmela J: I can tell that you’re really excited about it.
Dr. Ali Kasraeian: I mean, I have lost sleep.
Carmela J: I see it, under your eyes.
Dr. Ali Kasraeian: Well, thank you everyone for joining us on The Conversation, moving to the new 104.5. I’m here with my good friend Dr. Dave Thiel and Carmela J., Roxanne. Do we need to change your name when we move to the new station?
Carmela J: No, it’s still going to be Carmela, sorry.
Dr. Ali Kasraeian: And also we have Matt Cooperberg from UCSF, University of California San Francisco, joining us. And he is a urologic oncologist over there and very – he does a lot of work on risk stratification, which is a very interesting concept of looking at disease and being able to predict how your disease of diagnosis may materialize in the future in terms of is it going to be aggressive, is it going to be not aggressive, is it going to move fast? And there are a lot of interesting things going on in prostate cancer specifically that I am very excited about and Matt does a lot of the research and lot of investigation to see how that can be used to help us negotiate and navigate the world of prostate cancer, which has been dealt a new controversial guideline change by the American Urological Association. Matt and I spoke a lot about the recent American Urological Association’s national meeting in San Diego, and so Matt, welcome. And thanks for joining us to talk about this very interesting topic. So what are your thoughts on all of this?
Dr. Matt Cooperberg: So, this is sort of – it’s probably just the next chapter in an ongoing, longstanding controversy about what we should be doing with prostate cancer and with PSA screening. At the root of the problem is the fact that we – in this country, we use the word cancer for a lot of different things in life and one end of the spectrum has things like pancreatic cancer and lung cancer that move very quickly. Prostate cancer is at the other end. Men diagnosed with prostate cancer typically live for decades and many of the prostate cancers that we find never come to any sort of clinically meaningful state. So if you live long enough in the U.S. you’re almost guaranteed to grow a couple of prostate cancer cells somewhere in your prostate but the majority of these never amount to anything. They never cause any symptoms, they never kill anybody. They never cause any loss of life.
The flip side, though, is that because it is so common there are a minority of prostate cancers that we call high risk and even though it is a minority of prostate cancers, because it is so common, those high-risk prostate cancers still kill more men than any cancer except lung cancer in the United States. So our challenge is really finding the ones that need to be treated and treating them appropriately and aggressively while trying to minimize over-treating low-risk prostate cancers that really don’t need to be treated. Now, we haven’t done a great job of that in this country – of matching treatment to the patient’s that need to be treated, and we know that there is a lot of over-treatment of low-risk disease.
Now, one of the proposed solutions to that, which is the one that the U.S. task force has been advocating, is just to stop PSA screening. And most of us that actually understand the data and understand the disease all agree that it would be a public health disaster. And really the folks on the task force are well-intentioned epidemiologists who have no real experience in prostate cancer research and frankly just don’t understand the disease. So their guideline that came out last year said to stop PSA screening all together. And that is clearly the wrong thing to do to.
The AUA’s new guideline – basically, there is what the guideline said and then the way it was interpreted in the media and there are some important differences. And most of the media coverage sort of had these statements that AUA is now backing off on screening and is closer to the task force and that sort of thing, and it’s really not actually true. So the new guideline, and the disclaimer here is that I’m not part of the AUA’s guidelines panel, I have had some great conversations with people that were on it at the meeting. You know, what the new guideline really tried to do was to be more evidence-based. They really wanted to really only make statements that they could clearly base in high level evidence, basically coming from randomized trials. And most of those randomized trials, those are situations where you take men and really split them down the middle and say you guys get screened and you don’t. Those trials were really only done well in Europe and they really only looked at men in their 50s and 60s at time of diagnosis. So the AUA’s new guideline really focuses on men between ages of 55 and 69. It makes a statement that these are the men who most clearly stand to benefit and should be discussed the option of PSA screening during their primary care visits.
The controversy though, the point that is a little bit more controversial is they then said that for men under 55, between the ages of 45 and 55, they cannot recommend screening. And that’s based on the fact that there is really no high-level evidence. The randomized trials didn’t include younger men. It doesn’t mean they said don’t screen, or we recommend against screening. They said we can’t recommend screening. And I know that sounds like kind of a semantic difference, but it is an important difference.
Dr. Ali Kasraeian: It’s a very important difference.
Dr. Matt Cooperberg: It is a very important difference.
Dr. Ali Kasraeian: They do mention that there is no evidence that screening below the age of 40 makes a big difference, which I think all of us can agree on except for, you know, being mindful of people that have high-risk disease – obesity, people with excess weight, have a slight increase in risk. Family history for sure, people that are African-American population.
Dr. Matt Cooperberg: Absolutely, absolutely.
Dr. Ali Kasraeian: And then for the people between 40 to 54, you know, I think that’s where as a urologist we get a little bit concerned about the perception of these recommendations because we have all had people we have done prostatectomies done. They are in their mid-40s, early 40s, have high volume Gleason 7 disease and if you don’t do anything for that, that cancer is going to get out of their prostate and that cancer is going to kill a young man when they’re in their 60s. And so with that, I think the challenge here becomes that people really need to take the new guidelines which specifically say there is no evidence for screening for men below 40, there is no evidence that the American Urological Association can cite that shows a benefit in terms of the assessment of risk and benefits of screening with a PSA and rectal exam for people between 40 and 54, except for a high-risk population that we mentioned. They do recommend every other year screening for people between 55 and 69, after having a discussion of the risks and benefits with their primary care physician or their urologist, with a shared decision-making discussion. And they also don’t recommend screening for people above 70, which if your life span or life expectancy is less than 10 to 15 years. What do you think about that last aspect of it?
Dr. Matt Cooperberg: I think it’s an interesting point and again, the main motivation for that statement was based on the trials to stop the screening, on the ESRPC trial. The European trial that they really focused on, that was what was done in that trial. So again, kind of from this randomized trial standpoint, they are just trying to fit that mode. Now, we know there is a lot of over-screening in older men. There was a great VA study done where they saw that 30% of men in their 80s were getting PSA screening even when they had multiple other health problems. They had heart disease and all these other things that were going to kill them long, long before prostate cancer ever would. So we know there is a lot of over-screening in the older populations; however, we need to be careful because men diagnosed with high-risk prostate cancer, even at older ages, will die of prostate cancer quite a significant proportion of the time when they are not treated. So when you talk about someone who is over 70, you absolutely have to think about life expectancy. There are men that are 70 going on 60 and there are men that are 70 and are lucky to have made it that far because they’ve got diabetes, heart disease, obesity, and all the rest of it.
So you really need to look at the person’s health, not just their age. And the other thing is their prior PSA history. So I think the assumption from the way the AUA kind of phrased the guideline, I think the idea is that if your PSA has been low the whole time from 55 to 69, you can probably stop if your PSA is still 1 or whatever at that point. But if you’ve never been screened before and you are 70 years old and healthy, or 72 years old and otherwise healthy, I think it absolutely makes sense to screen with the understanding that what we’re screening for is high-risk prostate cancer. And that’s probably the most important point that none of the guidelines are stressing sufficiently. The reason to screen, the reason to do PSAs is not to find more prostate cancer. We find too much prostate cancer already. The point is to find high-risk prostate cancers, high-grade prostate cancers.
Dr. Ali Kasraeian: We’re trying to find the cancer that will kill people.
Dr. Matt Cooperberg: Exactly. And one of the other false statements you will hear all the time from the task force and others is that we can’t tell the good ones from the bad ones and that sort of thing. That’s just not true. It’s just a ridiculous statement. We can tell which ones are low-risk, we can tell which ones are high-risk. We need to do a better job of that, but we can already do a pretty good job. The problem is we need to do a better job than taking the next step and not over-treating the ones that are low-risk.
Dr. Ali Kasraeian: Now Matt, some of the interesting things we will talk about in the next half hour – there are some tests that may make us a little bit smarter in terms of differentiating between this low-risk disease and the high-risk disease. Dave, what do you think about all this?
Dr. Dave Thiel: Well, I think Matt has done a good job here of summing everything up in 15 minutes, but there are a couple issues that I think get lost in the message to the media and to the public, and obviously we see a skewed population as urologists but one thing that can’t be forgotten – we do see a skewed population, but we see people in their 40s and early 50s dying of prostate cancer often. The one thing that can’t be lost in the message through the media is that dying of prostate cancer is an awful death. It’s not a quick death. It’s not like pancreatic and your lung cancers which can be very rapid. Dying of prostate cancer is a very morbid thing and that does get lost because you hear patients say all the time, ‘Well, if I get it and don’t do anything once it spreads I will do something.’ And that is the message that is being sent out with some of this. And it’s our fault. We have made this message confusing.
Dr. Ali Kasraeian: The problem for us, and think about this, most of the studies besides talking about a 44% decrease in prostate cancer specific mortality – some of the studies that don’t get mentioned in this is that prostate cancer screening decreases metastatic disease that will kill people by, in some studies, up to 75%.
Dr. Dave Thiel: And it’s morbid. And Matt hit on this briefly –
Dr. Matt Cooperberg: One of the gray lines of research that has really been kind of lost in the guidelines is that all this work is being done by modelers, by the statisticians, in the last few years. I have had the opportunity to work with some brilliant people at the University of Washington and Memorial [inaudible – 00:11:32] and others, and you can basically take these missing data and do some very good statistics on it and figure out – again, the problem is the trials only included men over 55. But you can extrapolate pretty reliably and say, okay, what if we screened at 40? What if we screened at 45? What if we screened every second year or every fourth year, etcetera? And there have been a number of good studies out recently that suggest that the best way to do it is to probably think about this more like a colonoscopy model where you get a baseline at 40 or 45 and if your PSA is very low you don’t need to check again for another five years or more. Where as if it is high then that is somebody that needs more attention in the next few years. And it is absolutely true that there are high-risk prostate cancers that are already incurable by the time somebody is 55. So there is a gray kind of rationale for doing this differently. The problem is again the AUA was really intent on really kind of being so-called evidence-based and being driven by the randomized trial data. And I think that is these other types of research got a little bit undervalued in the final cut.
Dr. Ali Kasraeian: I tell you, we will talk about a really interesting study when we come back from break that kind of highlights the importance of that first PSA in your 40s, and one thing Matt and I agreed on when we were talking back in San Diego, not screening to me is like putting your head in the sand and Matt has a great slide actually that if you send him I haven’t been able to find it and it broke my heart a little bit when I saw you put it on there because it was fantastic, where it shows an ostrich putting his head in the sand. And not screening to me is essentially doing that. The cancer is not going to not materialize, pardon the double negative, but you’re going to miss being able to catch it early on. So what we don’t do a good job of in the prostate cancer ward is differentiating and separating diagnosis from treatment. I think we need to get better at doing more active surveillance. I know your program at UCSF is very aggressive and appropriate act of surveillance and you’re doing some studies to see how to appropriately and effectively do active surveillance where you treat the cancer when it needs to be treated in the people that it needs to be treated in. And we’ll be back.
Carmela J: Perfect timing. It’s 5:20 and today we have our guests Dr. Dave Thiel and Dr. Cooperberg on the conversation with us. I do want to say to everyone that if you do want to call in our phone number has changed. It’s now 340-1045. So if you have any questions or you want to comment please give us a call. That’s 340-1045. We’ll be back right after this, News Talk WOKV.
Carmela J: Welcome back. This is Carmela J. and you’re listening to The Conversation on News Talk WOKV. Thank you for staying with us today. We’re talking with our guests about new guidelines for prostate cancer screenings. And I have to say, I really like the music change, Dr. Kasraeian.
Dr. Ali Kasraeian: I have to say, I like myself the more hard stuff that we put on like the Killers and things like that we had before.
Carmela J: It sounds more like you, yeah.
Dr. Ali Kasraeian: This stuff I don’t like so much. It’s a little bit soft for my taste. But if you like it that’s important and Dave is batting his eyelashes because every time you say something it’s fine. So I will go with it.
Carmela J: Smart man.
Dr. Matt Cooperberg: I hope you guys are staying dry, by the way. Hearing these weather updates, I shouldn’t’ tell you what the weather is in San Francisco, but hail in May, that’s not something I hear too often.
Carmela J: We actually have – we’re under a severe thunderstorm warning. Actually those tones that you hear in the middle of us talking, those really annoying beeps, that’s actually our severe weather tones that are active right now. So if you do hear that, don’t be alarmed.
Dr. Dave Thiel: I was wondering. I thought that was like a tone to stop talking.
Carmela J: You were hitting wrong buttons and I was like, somebody shut him up.
Dr. Ali Kasraeian: I thought we were doing something wrong.
Carmela J: No, no.
Dr. Ali Kasraeian: That’s why it go quiet all of a sudden. So welcome everyone. Thanks for joining us on WOKV and our new number, 340-1045, or 1-0-4-5, or however we’re supposed to say it. And I can’t tell you how excited I am that we’re moving to the new station.
Carmela J: Yes, it’s very exciting. Static-free.
Dr. Ali Kasraeian: But it makes me a little bit sad, 106.5 is going to be a little sad hanging out by itself without a new station.
Carmela J: You know, 104.5 is making us better.
Dr. Ali Kasraeian: I guess, I guess. So today we’re talking about the new AUA guidelines for prostate cancer screening. I’m joined with my good friend Dr. Dave Thiel from the Mayo Clinic and Dr. Matt Cooperberg, my new friend from San Francisco. And one study I want to talk about is we’re talking about what to do with PSA screening and Dave has some amazing questions he’s going to throw at us in a second which has me a little bit nervous, but there is a great study from Andrew Vickers, who is a brilliant statistician from Memorial Sloan Kettering and in this study, I don’t know how they actually thought about doing this – they went to Malmo, Sweden, where there was a population of about 21,000 who they had blood stored in the refrigerator somewhere. And they followed them through their life and they went back and looked at their first PSAs in their 40s and saw how the natural course of these men’s prostate health developed through time and they found very interestingly that men who were in the upper tenth percentile of PSA, meaning that in their 40s they had the highest PSAs of this population, and these numbers were actually more than 1.5, and by the time they reached 75 they accounted for more than approximately 50% of the prostate-cancer related deaths. So based on this elegant study they thought that if men had those first PSAs in their 40s you could do very, very elegant prediction of how often they needed to be screened. So you could essentially personalize their screening based on a prognostication of those first PSAs. And they actually recommended that if someone has a PSA of 1 or less at 45 then they could be screened a little bit less frequently, maybe at 50 and then again at 55 and then make assumptions on how often they need to be screened based on the trajectory of their PSA through time. And if people had a low PSA, less than 1, then you can check another in their 50s, another one in their 60s, and if it remains low then you can make predictions based on that and that’s for average-risk people, of course, people without family history, without African-American race.
Dr. Dave Thiel: Yeah, we have an American population with a similar study and Matt can probably talk about I think from 2007, [inaudible – 00:21:34] maybe, from Northwestern did the same thing. And they looked at if your PSA was I think 0.7 or 0.9 under the age of 50 you were 10 to 12 times more likely to have prostate cancer through your lifetime. So I think that initial PSA does tell you a lot. Matt, what do you think about that?
Dr. Matt Cooperberg: It absolutely does. And I mean, both of these studies really fall under this concept of smarter screening. And what’s a little bit frustrating for all of us in the business is the media constantly presents this as a black-and-white issue – either screen everybody or screen nobody. And the truth is that prostate cancer is all about shades of gray and that the right answer, the correct answer, is clearly in the middle. There is no question that some people get over-screened and that some prostate cancers are over-diagnosed and over-treated, but the answer is to do it all better not to stop doing it. And frankly it’s not as easy as saying don’t screen anybody until the age of 55 either. And to be clear, again, that’s not exactly what the AUA said. I think studies like this really do kind of light the way as far as giving us better indications of how we should be doing all this. It just takes a long time for something like Vicker’s study to percolate its way into clinical practice but I think it is absolutely the right thing. The problem is that if you look at it from a strict evidence basis, which again is how these guidelines panels tend to look at it, well – there’s no proof that doing it this way saves more lives, right? It’s a brilliant statistical plan and personally if it were up to me this is how I would run my practice if I were a primary care doctor. It would be to screen early and screen less often. And don’t forget the majority of men who get a PSA test have a very low PSA and can basically stop worrying about prostate cancer. And that’s actually a point that is really overlooked constantly, when people talk about the harms of screening one of the things they always talk about is the anxiety.
Carmela J: I’ve got to cut you off real quick, I’m so sorry. We’re getting ready for the second half hour of The Conversation. When we come back we will continue this discussion. News and weather are next. Stay with us on News Talk WOKV.
Carmela J: Welcome back, you’re listening to the second half hour of The Conversation on News Talk WOKV. I’m your hose Carmela J., here with our weekend expert Dr. Ali Kasraeian, our special guest Dr. Dave Thiel in the studio, and also joining us over the phone is Dr. Matt Cooperberg. Thank you for staying with us as we continue our discussion.
Dr. Ali Kasraeian: So Matt, one thing you were saying as our weather alert comes in, you were talking about an interesting point that a lot of people mention, the anxiety with PSA screening and the anxiety of dealing with prostate cancer. And Dave, you had an interesting question.
Dr. Dave Thiel: Yeah, so all this talk we do about guidelines and one thing that drives me crazy is I think one of the biggest healthcare discrepancies we have in the United States is not socioeconomic but what we do as physicians compared to what we offer to the general public. And one thing I am always into is we spit out all this data and we spit out all this info, but then you ask another urologist and I will ask you, today is your birthday, you’re close to 40 but not quite. You’re the same age as me, and I will ask Matt this too, and I’m sure Matt is in his 30s – when are you going to get a PSA?
Dr. Ali Kasraeian: I mean, I will tell you from my standpoint – a lot of evidence that I think is very interesting and very smart is getting a PSA at 40 and seeing where you are at to make predictions of where it is going to be. If the PSA was very low I would probably sleep better than if it wasn’t but then I would want to check more frequently if it is was in the 1 to 2.5 range. And I would probably go with some of the European studies that show that in your 40s if you have a PSA velocity of more than 0.35, which is again a PSA that changes over a period of time, I would pay attention to it. That being said, there are some studies that show there may not much be much validity to a PSA velocity, but at least in my mind I would have an idea of whether I just need to watch it is a little bit more closely. If you have a PSA of 2.5 and you’re in your early 40s I think that warrants a biopsy.
Dr. Dave Thiel: So you’re going to get a PSA next year at the age of 40.
Dr. Ali Kasraeian: And the exciting thing is you and I being the same age is we may be able to do each other’s prostate cancer screening.
Carmela J: Aw, isn’t that sweet?
Matt: You can really feel the love, even over the phone.
Dr. Dave Thiel: Now Matt, how about you? I mean, knowing what you know – you’re exposed to one of the biggest prostate cancer databases in the world. When are you going to get your first PSA?
Dr. Matt Cooperberg: I’ve already had a baseline before 40, actually, believe it or not. I tell you why, there was a great editorial – you talk about this disparity between what doctors say and what they do. There was a brilliant little editorial that came out last year in JAMA by a guy by the name of Allen Detsky who was an internal medicine doctor and a decision analysis guru, so he was one of these guys that really looks at models and tries to figure out does it make sense to do various things. And he wrote back in 1994 one of the first papers that really came out against PSA screenings, saying this is not cost-effective, it doesn’t make sense, and it’s causing more harm than good. Well, you know, time passed on and Dr. Detsky turned 60 and he decided to go ahead and get a PSA check. And he wrote this article about – he tracked down one of his former trainees, former med students, who was now a urologist and he talked to him about what to do and he decided to go get a PSA test. And it came out under 1 and he was very reassured. And he talked about this point that we always focus on the downsides of screening, of the anxiety from having a high PSA, of having to go through biopsies and that sort of thing. But we always ignore the fact that for the majority of men who get a PSA test – the majority of men are going to have a very low value and can basically take prostate cancer off the list of things we need to worry about in life. And there is value in that. You know, the notion that your quality of life is better when you’re in this unknown state, that you haven’t had a test, then it is when you know that you just don’t have to worry about prostate cancer, it’s just not true.
Dr. Ali Kasraeian: Absolutely.
Dr. Matt Cooperberg: So we help most men by checking. Now, the major caveat to all this, and I do want to make this point – when we talk about screening men at younger ages, the major caveat is that we do a terrible job as urologists and radiation oncologists and everybody else of not over-treating young men in particular when they have low-risk disease. And I always make the point that we really can’t screen young men until we are willing to put young men on active surveillance when we find these low-risk tumors. Because there are a lot of urologists out there that I think are increasingly comfortable with the idea of surveillance for low Gleason, low PSA type tumors, but you will frequently see this guy who has 5% of a single biopsy core involved with low-grade cancer, but somebody will tell him yeah, it’s all well and good, but you are 53 years old and you better get treated right away. And that is kind of the dark side of screening earlier, is there is still this propensity to treat more progressively the younger men. And we don’t necessarily need to do things that way.
Dr. Ali Kasraeian: So that leads us right into, beautifully I might add, risk stratification. Both of you, I’m a big believer in the excitement that is surrounding some of the new genetic testing that is allowing us to risk stratify within low, intermediate, and high-risk prostate cancer to let us know which cancer may act in a more indolent nature and which cancer may be more aggressive and needs us either to watch it more closely if you’re going to do active surveillance or whether we need to jump the gun and kind of treat that quicker to avoid the prostate cancer getting out of the prostate. With the caveat that when you do active surveillance there are studies that show that approximately 38% of prostate cancer that is monitored over a period of time, within 5 years, may not meet the criteria for active surveillance anymore that requires us to treat. That being said, in my opinion, that means that we are treating appropriately at the correct time for a cancer that requires treatment. So what do you guys think about some of these tests?
Dr. Dave Thiel: Well, I mean, these tests are in their infancy and the big push will be in the future. Now, whether it’s 10, 20, or 100 years from now is individualized medicine. And essentially what you’re getting at is every 50-year-old with prostate cancer with regular Gleason score of 6 prostate cancer is not a 50-year-old with Gleason 6 prostate cancer. They have multiple genetic markers that may predict how they do. The problem I have is I don’t want people to get too excited about this. And Matt can talk about this – it’s in its infancy and its beautiful technology looking for a home, and that’s exactly what it is. And where that home is remains to be seen and who is going to pay for it, how much they will pay and when do they decide to pay. What number benefit are you going to say, hey, here’s the number where we figured out we will pay for this or we won’t. Because right now it’s a free for all and all these genetic tests are hey, pay for us. And by pay for us I mean Medicare and that’s taxpayer dollars. Hey, we have this beautiful test, pay for it. We don’t quite know what it says or what it means, but pay for it. So Matt, what do you think about genetic markers?
Dr. Ali Kasraeian: So how do we interpret these tests?
Dr. Matt Cooperberg: I call the field more in its childhood at this point than infancy. I think a lot of progress has been made literally in the last couple of years. We just did a study out at the AUA meeting last week which is in the process of hopefully being published soon, looking at one of the marker sets. And there is definitely progress being made in this area. And don’t forget that part of the challenge is that the bar is actually pretty high because we can actually do a reasonably good job now with the information. With the PSA and with the Gleason grade, which is how the cells look under the microscope with the stage and how much of the biopsy is involved with cancer. You know, standard information like that, that every single patient diagnosed in the U.S. has available, and we can – we’re about 75% accurate using information like that in terms of predicting how the cancers are going to behave. So to do better we actually need very good tests. And we’re starting to see them. I agree that we don’t know how to use them yet. We just got a big grant from the Department of Defense actually to do exactly that, to take somebody’s markers to the next step and say now what do we do with these exactly to start to really change practice? But the cost question is interesting because these are expensive tests, but the treatments are much more expensive. You are talking about tests that range probably around $3,500 and surgery is probably about $25,000, external radiation is $50,000, and proton beam is $100,000. You can buy a lot tests to avoid one unnecessary round of IMRT. And if we really do get more men to accept surveillance and stay on surveillance and maybe even be able to do surveillance a little less intensely eventually. There actually is huge potential for cost savings. And the deal with these is not just to say who needs treatment and who doesn’t, but don’t forget active surveillance is actually fairly active. You need biopsies every year or two, you need a lot PSA tests. It would be great to say you’ve got low clinical features and your genetic signature is low. If we put all this information together we can tell you that you don’t need another biopsy for five years. We’re not there yet but I don’t think it’s going to be ten years until we get there. I am hoping in the next two to three years we will be able to start figuring out exactly how to use these tests in that and along those lines.
Dr. Ali Kasraeian: I tell you, from my perspective, Matt –
Dr. Matt Cooperberg: And [inaudible – 00:37:59] but how intensely we need to survey these low-risk ones.
Dr. Ali Kasraeian: I think from my perspective, Matt, the place where these tests shine, I think, one in terms of – it fuels the discussion with your patient to make both of us smarter, where you can look at their cancer and give a little bit of a prediction as to what their cancer may do in terms of the time frame with which you have to – whether you need treatment or not. And so when – in terms of one thing with the anxiety, if they know that their cancer has some genetic susceptibility for getting out of the prostate more so than a test that has a lower signature on some of these genetic testing, I think it helps guide them into a decision-making process. But right now it’s very challenging. If someone is diagnosed with prostate cancer and they look at all the different options they go on the website. The website for surgery makes radiation seem like it’s the spawn of the devil. The radiation site make surgery seem like it’s medieval torture, and then you have all these ablative options which makes it seem like it’s a walk in the park. So I think it allows the conversation for whether a cancer can be actively surveilled well. It gives us a little bit of information about how often you need to screen them, and you know, you can even use it – there are new PSA tests that are always being researched like prostate health index and things like that and as those things emerge I think we can do a better job of figuring out exactly who needs to be treated and when they need to be screened to allow us to treat them when we need to.
Dr. Matt Cooperberg: Absolutely. That is absolutely right. And the anxiety – don’t forget a lot of the anxiety is driven by the fact that when you biopsy the prostate you are sampling it, right? And part of the reason people are anxious about surveillance is always the question – well, you found the cancer. What if your biopsy missed something worse hiding somewhere else in the prostate? And we know that if you look at men who we think meet all our criteria for surveillance but they choose to have their prostates out immediately, we know that we will find something worse – higher-grade, more cancer than we expected – in about 25% to 30% of cases, depending on what you read. So the whole point of the tests as they’re being launched right now anyway is to try to do a better job of predicting the true nature of the cancer, to do a better job predicting which cancers are truly low-grade, low-risk, and confined to the prostate. And the evidence really suggests that they do help. They’re not – it’s not – everybody wants a test, and if it’s a plus take it out and a minus leave it in. It’s never going to be that easy but we definitely are seeing additional independent information here that we do believe are going to help men and their doctors make better decisions.
Dr. Dave Thiel: Yeah, and you get on that and we have taken – prostate cancer screening and treatment are complex as it is, and as Matt is saying now you’re going to throw in genetic markers and so on which is going to raise the complexity of the discussion.
Dr. Ali Kasraeian: And I believe that I think we are moving in wonderful areas in terms of imaging with multiparametric MRI and things of that nature, which I think over the next few years all of this stuff hopefully will grow in a place that will allow us to put them all together to make smarter decisions, both in terms of screening and in terms of who needs treatment.
Dr. Dave Thiel: And interesting, Matt used the 30% number and you talked about what you’re getting as focal therapy. Can you just treat the tumor and not the whole prostate, maybe decrease the risk of some side effects, but some of the newer papers that were at the meeting this year were basically saying hey, if you re-biopsy guys after they have had focal ablative therapy guess what, 30% of them have higher-grade disease than what you were going after and will have cancer on the other side of the prostate.
Dr. Ali Kasraeian: Sure, and I think that’s where us getting better at doing MR beforehand in the future as it gets smarter and we are able to read it better, I think it allows us to maybe look at this stuff like kidney tumors, where we find a lesion and then in this case we can either be focused in terms of where we do the biopsy with more impunity and also with how we follow these people.
Dr. Dave Thiel: And another thing, the genetic markers are going to help with and what we don’t know is if a Gleason 6 tumor, say at the age of 45, it’s low-risk, and as Matt said you probably don’t have to worry about it, is that going to turn into a 7 or 8? Or is it going to be more 6? I mean do all 8s start at 6 and come to 8?
Dr. Matt Cooperberg: Well you know what it’s probably both. There are probably some 8s that started off 6s and there are probably some 8s that were born bad. But I think as Ali was saying earlier, even if you have a 6 at age 50 that eventually is going to become a 7, it doesn’t mean you need to take it out when it’s a 6 because the point is that the – the point of active surveillance again is not watching and waiting. It doesn’t mean go home and forget about it, it means we are going to watch this closely and if and when it shows signs of progression we will treat then with every intent to cure. And we know there are some great papers coming out now. The number of men who will potentially die because we missed a window, because they had a curable cancer that we missed and we watched it, and it became incurable, that number is not a zero, but it’s very, very low. And the number of men who will be harmed by surveillance because of that lost opportunity is far, far lower than the number of men that are going to be harmed because they get over-aggressive treatment for low-risk disease. It’s not perfect yet. We need to do surveillance better but there is no question that it really needs to be part of the discussion, even for young men.
Dr. Ali Kasraeian: I think in my personal opinion some of the new things we are doing in imaging and some of these genetic testing as they mature will help us make those decisions better.
Dr. Matt Cooperberg: That’s absolutely right.
Carmela J: Dr. Cooperberg, thank you. We have to take another quick break. We still have a few minutes left though to finish this discussion. Stay with us on News Talk WOKV.
Carmela J: We’re wrapping up on The Conversation on News Talk WOKV. Thank you again for listening. If you’re not already, you will be in five days listening to us on our new frequency 104.5, very exciting. Yes, a stronger frequency. You won’t have to change from AM to FM anymore, no static. It’s going to be great. We’re excited about it.
Dr. Ali Kasraeian: It’s actually great. It does have a bigger reach so that’s fantastic news.
Carmela J: More people will be able to hear your beautiful voice.
Dr. Ali Kasraeian: Oh, well you’re sweet, you’re sweet. Well, will Matt be able to year it in San Francisco?
Carmela J: Probably not, no. I don’t think it reaches that far. But you can always go to WOKV.com and you can go to our link and listen to all of our shows.
Dr. Dave Thiel: Well played, Carmela J. I’m sure he’s going to be doing that.
Dr. Matt Cooperberg: Plus they are on Twitter too.
Dr. Ali Kasraeian: Actually we are on Facebook at theconversationjax, where we put all this stuff up.
Carmela J: Nice little plug, there it is.
Dr. Ali Kasraeian: It’s www.theconversationjax.com, where this will be podcast for all our west coast fans to listen in.
Carmela J: You’re welcome for that.
Dr. Ali Kasraeian: To be honest with you I think this has been an interesting conversation which is the kind of conversation we need to have about prostate cancer where you look at the reasons to screen and how to screen appropriately and as Matt put it, screen smartly so that we don’t miss the cancers that require treatment but we also don’t overly treat cancers that don’t require treatment at that particular time. So by all means the American Urological Association did not recommend against prostate cancer screening. I think they are trying to advocate smarter PSA screening and I think it is up to us, the general public, our primary care physicians, and for the patients to go in and ask about why they should or should not screen. And do not ignore family history of prostate cancer. Any parting words, Matt?
Dr. Matt Cooperberg: No, I think you summed it up well actually. I think the one point I would make is that this is hard for us to wrap our heads around as urologists and it’s even worse for the primary care world. They are ultimately the ones that make the screening decisions with their patients, so it’s really to a large extent up to us in the business to be educating the primary care world and ultimately for better or for worse for the next couple of years at least it’s going to be up to men to advocate for their own health. And men who are otherwise healthy really should think hard about having the PSA test with the understanding that what we’re looking for is the high-risk prostate cancers and if we find low-risk disease along the way that doesn’t necessarily mean – just because we call it cancer doesn’t necessarily mean it’s something that needs aggressive treatment.
Dr. Ali Kasraeian: Well thank you everyone for listening as we end. I want to thank my friend Dave Thiel who actually will be joining us next week to talk about kidney tumors.
Carmela J: I won’t be here, though. I’m going on vacation.
Dr. Ali Kasraeian: Is it because of the new music?
Carmela J: No, actually that was the only reason I was going to stay but I don’t know.
Dr. Matt Cooperberg: You’re running from the hail storm.
Dr. Ali Kasraeian: Oh it’s gone.
Dr. Matt Cooperberg: Come to San Francisco, it’s 70 and sunny.
Carmela J: Thank you Dr. Kasraeian for another great show. Thank you Dr. Thiel and thank you for being with us Dr. Cooperberg. And join us next week on Saturday at 5 p.m. on our new frequency 104.5, that’s where you’ll find us for more talk on your health and wellness.[End of Audio]