Summary: This week, Dr. Ali welcomes a special guest to discuss prostate cancer including the latest treatments.
Male: Our Ask the Experts weekend continues with The Conversation with Dr. Ali Kasraeian and Carmela J. To join The Conversation, call 340-0690. This is News Talk WOKV.
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 and our guest, Dr. Dave Thiel. Good evening, gentlemen, how are you?
Dr. Ali Kasraeian: Good evening.
Carmela J: It’s a beautiful day out.
Dr. Ali Kasraeian: It’s gorgeous. This is the first beautiful day we have had in a while.
Carmela J: I know, I got to pull out the flip flops today and it’s not freezing cold when I leave the house.
Dr. Ali Kasraeian: Welcome to spring. So welcome, thank you for joining us on The Conversation today. I have Dave Thiel, a friend of mine. He has joined us before. He is a robotic surgeon at the Mayo Clinic.
Carmela J: He’s just uncontrollably smiling right now too.
Dr. Dave Thiel: Well, it’s fun to be on the radio. I do that when I’m around Ali, I smile. I smile and he makes me laugh.
Carmela J: That’s really cute guys.
Dr. Ali Kasraeian: We’re very close. We’re always sad because this work stuff keeps us from playing all the time.
Carmela J: I know, and you know I’ve been sitting in here and I’m sure the WOKV listeners are tired of my voice today because I’ve hosted the past three shows.
Dr. Ali Kasraeian: I thought you exclusively worked on our show. You’re cheating on us? I mean, should I be hurt?
Carmela J: No, no. This is my favorite, you’re still my favorite.
Dr. Ali Kasraeian: I mean, do you tell that to everyone?
Dr. Dave Thiel: She was telling that to Shannon Miller on the show before.
Carmela J: No, definitely not on the air, no.
Dr. Ali Kasraeian: Should I direct a counselor back here next week? I mean, am I going to be nursing wound care? Do you have a [inaudible – 0:01:38.7].
Carmela J: No, you’ll be fine, you’ll be fine.
Dr. Ali Kasraeian: So, today we’re going to talk about all the new things while I was at the European Association of Urology annual meeting in Milan, Italy. There are a lot of very interesting and exciting things and I have my good friend Dave here with me to kind of talk about these things. They are very exciting. I know we talked a lot about PSA screening and prostate cancer treatments and all the controversies, but this – Europe has done a nice job I think of following up some of the studies that they had from the mid-90s on to now for really long-term follow-up that seems to show some very nice advantages to the benefits of screening if they are done appropriately. So welcome, Dave, thank you for joining us.
Dr. Dave Thiel: Thanks, Ali.
Dr. Ali Kasraeian: So one of the things I want to start out with is I was kind of thumbing through the newspapers over the last week and I found a very interesting article. I know we have been talking about a lot of healthcare reform things and lean hospitals and all these kind of interesting concepts, but one concept that has come up that we will sometimes mention on the show when we’re talking about the healthcare economy aspect of things where some insurance companies and Medicare and Medicaid and things of that nature always look at ER visits as a big source of excessive cost to health care. And right before the show you and I were kind of talking about this, Dave, where we have got to kind of figure out how that stuff is going to be addressed so that we can get better at more efficiently treating everyone who needs healthcare. So this article out of the New York Times was talking about emergency room care. And over the past 50 years or so emergency rooms have been kind of looked at a major source of excessive health care costs. And a few years ago in order to decrease some of the excessive costs of Medicaid expenditures. Several states looked at potential unwarranted visits to the emergency room, meaning someone goes in with chest pain and it ends up being heartburn and they go into a very expensive emergency room visit and they leave the same without any particular need for an emergency room visit.
The challenge and the criticism for me, as a physician, is how are you expecting the patient to differentiate whether they are having a heart attack or whether they have heartburn and that is a big task to ask someone. So it’s interesting because if someone goes in with chest pain it could be heartburn, it could be a heart attack, there could be a rupturing aneurysm and within the first couple of hours from the onset of symptoms you could either be getting an anti-heartburn medication or going to the cath lab and getting a stent or you could be going to the operating room to take care of a ruptured aneurysm. And I don’t think it’s fair to have the patient be the one deciding this. So fortunately the Journal of the American Medical Association, JAMA, recently published an article looking at approximately 35,000 patient visits to the emergency room and they found that in only approximately 6% of these cases the patients were discharged and the disease process that brought them to the hospital could have been taken care of in the doctor’s office, per se. So elegantly they went back and looked at the inciting symptoms related to these diseases in that 6% and also that other 94% that had more emergent issues and they found that in nearly 90% of these cases the patients came into the emergency room with the same primary presenting symptoms as those more urgent cases that required treatment. So when you kind of look at this stuff it brought to the forefront the fact that asking the patient to differentiate between what their inciting symptom is for the sake of cost saving for the symptom, maybe a little bit of a bigger undertaking and over-glamorization and overuse of the personal responsibility aspect of healthcare savings. What do you think?
Dr. Dave Thiel: I think that’s an excellent point and also no matter how you shake it, when these symptoms happen say between 5 o’clock at night and 9 in the morning, what is the patient supposed to do? Where are they supposed to go?
Dr. Ali Kasraeian: And 5 p.m. to 9 in the morning, especially on the weekends, seem to be people’s most favorite time to go to the emergency room. But you’re right, how are people supposed to know? And whenever the primary care doctor’s offices close you can’t ask people to differentiate. I think people generally do that anyway for the most part.
Dr. Dave Thiel: I actually think that’s an overblown topic that gets brought up in the media, but the real issue is that not enough people have primary care doctors and too many people are going to the emergency room for their primary care, but then the argument gets confused that we have too many emergency room visits that don’t have an emergency diagnosis. But like you said, weekends, nights, how are you going to get around that?
Dr. Ali Kasraeian: And I think honestly if people have a severe, non-emergent finding they are going to end up in the emergency room over the weekend or a lot of these smaller clinics because they can’t differentiate. And I don’t necessarily think we should ask them to differentiate more severe symptoms. You know, if you have chest pain that needs to get checked out. That’s not something for you to figure out whether it’s a heart attack or heartburn.
Dr. Dave Thiel: And you and I see it all the time, people come in sick usually from a kidney stone or something like that. And you’re like, ‘How long has this been going on?’ And they say three days and you’re like, ‘What were you waiting on?’
Dr. Ali Kasraeian: I tell you, I think stones love Friday night.
Dr. Dave Thiel: Oh, Friday nights?
Dr. Ali Kasraeian: I think stones love Friday nights.
Dr. Dave Thiel: Or Monday morning at about 4:30.
Dr. Ali Kasraeian: At least on Monday morning at 4:30 you can put them on the OR schedule for Monday and they are usually eating right before you see them. So that was an interesting thing that I read in line with some of the things that we’re talking about, where I think everyone having some kind of coverage makes the most sense to avoid unnecessary ER visits but I think if you have something that has concerned you enough to even think about going to the emergency room it makes more sense to go there if you don’t have access to a primary care physician at that time. So that’s all we’re going to talk about for that and now we will get into the wonderful world of prostate cancer, which is near and dear to both our hearts. So what is new that you have heard that has got you excited or thinking in terms of what’s going on over the last six months to a year with prostate cancer?
Dr. Dave Thiel: Well, okay, it wouldn’t be just the last six months and as we know I have been about the same amount of time you have, about 12 to 13 years. And there are persistent themes that play out and we’re starting to see data emerge now from some of the watchful waiting series, the watchful waiting or active surveillance would be the proper term in younger men. Maybe safe and certain low-grade, non-aggressive tumors, and safe over a long term. And I know you’re very interested in focal therapy, which is just treating one part of the prostate, and we’re starting to see data on that. Again, that’s going to be controversial. And we will talk about that I think throughout the next hour.
Dr. Ali Kasraeian: Let me ask you – have you noticed that decreased and elevated PSA referrals and things of that nature out of the primary care physicians, since the recommendations from the US Preventative Service Task Force against prostate cancer screening?
Dr. Dave Thiel: I haven’t and most of my friends who are in primary care medicine still recommend screening for prostate cancer and I think one of the editorials you were pointing out actually mentioned it. It was a healthcare policy expert that said until these things are cleared up most physicians are going to screen for prostate cancer. We’ve made it so confusing now that it’s almost hard to not do it because the patients don’t understand the ramifications.
Dr. Ali Kasraeian: And I think the scary thing about that would be if the patients are not asking for it and someone doesn’t screen we can see some of the shift in terms of increase in incidents and also an increase in mortality from prostate cancer. At the AUA last year when they presented this at that town hall meeting there was an epidemiologist that was saying that if we stopped screening at that time as a US Preventative Services Task Force recommended, we would go from 28,000 deaths per year from prostate cancer to upwards of 68,000 per year.
Dr. Dave Thiel: And on the physician’s front there have been numerous lawsuits and physicians who weren’t screening the patient for prostate cancer. The patient gets prostate cancer and was never screened. They die from it or have bad disease and then they come back and say, ‘Hey, why wasn’t I ever screened for this?’
Dr. Ali Kasraeian: And the interesting thing I find in conversations I have with primary care physicians is that they really are confused and then the patients are a bit confused, but I’m beginning to see when I am presenting cases at tumor boards and things of that nature, internal medicine doctors and primary care doctors are asking whether they should screen or not. They are leaning a little bit towards not screening, which is a little bit scary for me.
Dr. Dave Thiel: And the biggest thing I think the patients come in confused about and the media doesn’t do a good job of covering is if you do have prostate cancer and it spreads, there is no cure for you. The only real treatment we have is castration, or cutting your testicles off, and we do that with drugs.
Dr. Ali Kasraeian: With drugs now, fortunately. So medical castration is basically the idea that testosterone serves as a bit of a fuel for prostate cancer, so if you have prostate cancer outside of the prostate the only thing that we can do to try to slow down the disease is to decrease that testosterone level, either with medication or with what is called an orchiectomy, where we remove the testicles, which are the biggest source of testosterone.
Dr. Dave Thiel: And I have talked to numerous patients about this and that is not conveyed to them. I think the message that gets conveyed is you don’t have to screen for it because there are some potential side effects to the treatment. But if you get it and it spreads then we can take care of you, and that’s not the proper way of looking at it.
Dr. Ali Kasraeian: That’s not at all the way because one thing that is very interesting that doesn’t get discussed too much in these articles and even with the media when they talk about prostate cancer screening is not only have we noticed between a 20% and 44% — most of the studies lean towards greater than 40% prostate cancer specific mortality decreases, with screening meaning screening programs decrease death from prostate cancer from in the family of 40% in some studies. It also decreases the risk of having metastatic disease, much like Dave was saying. We don’t have cures for it by more than 50% to 70%, and in some studies as high as 75%.
Dr. Dave Thiel: And another confusing points with patients is if you do develop metastatic prostate cancer, the significance of that. And we have seen it as urologists, and it is a very morbid thing. And dying of prostate cancer is very difficult. And when we talk about not screening patients, especially younger men, that message needs to be conveyed to them so they can make an educated decision as to whether or not to screen for prostate cancer.
Dr. Ali Kasraeian: And that’s the key to this, like you’re talking about, the educated decision where you know the ramifications of both starting a screening process but also if you decide not to screen what the implications of that decision are. Do you have any questions?
Carmela J: No, no.
Dr. Ali Kasraeian: We kind of went on there for you, didn’t we?
Carmela J: I think you answered absolutely everything that we could ask.
Dr. Ali Kasraeian: It would be like a boxing match if weren’t in agreement.
Carmela J: The thing is that you guys are just so well-versed and you just know everything there is to know. And I’m just sitting here and I don’t know anything about what you’re talking about, so I’m sitting here like – don’t let it go to your head.
Dr. Ali Kasraeian: You must not know us very well.
Carmela J: I’m just saying that I’m like all the other listeners perhaps that are sitting here listening to the show and I just enjoy listening and watching you back and forth and the smiles coming from over here.
Dr. Ali Kasraeian: What, my smiles don’t matter anymore?
Dr. Dave Thiel: She’s used to you.
Carmela J: I know you, I’m unaffected by your smiles now. Just kidding.
Dr. Ali Kasraeian: Wow, this is the [inaudible – 0:12:44.8].
Carmela J: I’m kidding, I’m joking. You should know I’m joking.
Dr. Ali Kasraeian: So the interesting thing when we come back from break, and I think we are close to break time?
Carmela J: We have about two minutes, a minute-and-a-half.
Dr. Ali Kasraeian: So when we come back through the course of the show I have a lot of recent studies that were just presented over in Milan. They kind of look at and expand upon the idea of screening appropriately and the benefits that we see and also a really interesting study that both Dave and I are very excited about as urologists who do prostatectomies, that surgery has better outcomes that they found in comparison to radiation therapy for both low-risk, intermediate-risk, and high-risk cancer. The only cancers that seem not effected or treated equally well were metastatic diseases and really advanced diseases. So for us that is really exciting data to talk about. The basic concept that we’re going to kind of reiterate through this is trying to facilitate that conversation for you to have with your doctor about the importance of prostate cancer screening and hopefully we can give you some important information today that you can take to that appointment with your doctor, whether that is your primary care physician or your urologist to discuss why or why not screening would be most beneficial for you, and that standpoint. And in one of the studies that will kind of lead into that and we will expand upon a little bit further is one that we presented at the European Urology Conference in Milan that looked at PSA screening and comparing that. They took about 20,000 men and approximately 10,000 of them who screened and 10,000 did not screen. And they followed them for a long period of time and they found upwards of approximately 50% benefit in the screening arm. And they also found that not only did they diagnose less cancer in the screening arm but they also found that people died less frequently of prostate cancer and upwards of 50% in this particular study. And that benefit lasted approximately 9 years and they followed these arms up to 9 to 12 years where it was arranged that at that point the screening arm met the control arm in terms of mortality specific to prostate cancer. So it’s interesting, again, that it shows the long-term benefits of screening seem to show their face with longer-term follow-up. So that was a very interesting thing that I found and we will expand upon that when we get back.
Carmela J: When we come back, all right. It’s 5:20 and today we will be talking about prostate cancer with our guest Dr. Thiel on The Conversation. Remember you can call us at 340-0690 if you have any questions. Stick around on 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. Tonight we’ve been talking about prostate cancer and remember, you can call us with your questions at 340-0690. I’m sure Dr. Dave Thiel and Dr. Ali Kasraeian would love to speak with you if you do have any questions.
Dr. Ali Kasraeian: Thank you for joining us on The Conversation today. Dr. Thiel from the Mayo Clinic department of urology is joining us. For anyone that I guess may not know, we’re both urologists and what we specialize in is disease of the urinary system which include the kidneys. The meat of the kidneys make urine and they dump it into this beautiful funnel-looking thing that pushes the urine from the kidneys to the bladder. The bladder does two things – it fills and it empties. You have your urine channel and the urethra that exits the body, and men you have the prostate that gets in the way. And we kind of specialize in the elegance of that system. And David and I – sorry to call you David.
Dr. Dave Thiel: No, you can call me David.
Dr. Ali Kasraeian: Him and I did an extra year or so of training, specializing in minimally-invasive surgery using telescopic cameras or the idea of keyhole surgery where we use things like robotic technology to do big surgeries through small holes with offer less morbidity after the operation and less blood loss. People bounce back from the operations quicker and they have smaller incisions. So today in the realm of that one of the things that we deal with a lot is prostate cancer. And prostate cancer is, in my opinion, one of those Normal Rockwell diseases where the relationship that you have with your patients and the conversations you have through the process from whether to screen, what happens with the diagnosis, and then what you do afterwards are very much ingrained in the personality of your patient and the relationship that you have with them to discover that. Would you agree that’s kind of true for prostate cancer more so than some of the other diseases that we deal with?
Dr. Dave Thiel: Yeah, I mean your first question is that we have confused the issue with should you screen or shouldn’t you, is there a benefit to screening? And then once you get diagnosed depending on your age, your condition, the type of cancer you have, the score of cancer, should you watch? Should you treat? If you treat there are multiple treatment modalities and it gets confusing.
Dr. Ali Kasraeian: And it’s going to change even more in the future as we’re getting more minimally-invasive and we’re actually getting a little bit more elegant in the diagnosis. Now, in terms of the screening if someone asks you what your thoughts are and why you would recommend one way or the other, what are some of the things and points that you consider?
Dr. Dave Thiel: The main thing I consider is if someone has over ten years of life expectancy I do think they should be screened for prostate cancer. And that includes say the 75-year-old guy that doesn’t take any medications, has no medical problems, and looks like he’s going to live ten years, I still screen that guy. I also screen an 80-year-old in the same situation who looks like he is going to live to 90. Now, none of us have a crystal ball but the flip side of that is true too. You have a 52-year-old guy who has had three strokes and two heart attacks, I tell them there may not be a benefit to screening for prostate cancer. And our primary care guys do a good job.
Dr. Ali Kasraeian: And I think the importance of that is you look at the patient in front of you and whether the benefits of screening are going to be beneficial for them. But in terms of the screening and in terms of the studies we are talking about some of the things that are coming out of Europe. Another study that looked at 21,210 men screening every four years versus non-screening, and again 12.6% of people were detected with prostate cancer versus approximately 7%, so it is almost a 50-fold increase in finding the cancer early while confined to the prostate. And then for people in the range that they followed from 55 to 74, they found 20% decreased risk of prostate-cancer-specific death for people in that age group. And then your point that you were talking about with the benefit, people 55 to 69 had approximately 32% decreased death from prostate cancer if they were screened and the people 70 to 74 did not.
Dr. Dave Thiel: Right, and I think if you look at most modern prostate cancer studies there is no doubt that prostate cancer screening saves lives. The only one that has thrown a loop in that is our American PCLO study and the reason for that I think is the design of the study.
Dr. Ali Kasraeian: It was very confounded.
Dr. Dave Thiel: It was, and we had a control arm that had numerous patients that already had a PSA. And obviously that PSA was normal or would have been acted on, so it’s not really a control arm. Like the European studies where the men in the control arm didn’t have a PSA in their life.
Dr. Ali Kasraeian: And that’s a big thing for this particular study, the PCLO or we have been confused if it’s the PCLO or PLCO, but I think it’s the PCLO.
Dr. Dave Thiel: We’ll stick with PCLO for tonight’s show.
Dr. Ali Kasraeian: It’s basically they look at the prostate cancer, colon cancer, lung cancer, and ovarian cancer in a big study and then a part of this was a prostate cancer screening versus not screening, among other things. The reason that us as urologists criticize this quite a bit is because the non-screening arm actually had a significant amount of patients who actually were screened and put into this other arm, so if you assume that they were in the screening arm after having a PSA they didn’t have cancer, so that makes this study a little bit flawed.
Dr. Dave Thiel: Yeah, they weren’t a true non-screened arm.
Dr. Ali Kasraeian: And so when we look at this stuff that’s whether to screen or not. The advantages are you find a prostate cancer early enough and again when you look at – my dad’s a urologist, probably when he was closer to my age or younger, they didn’t have the PSA test so prostate cancer at that point was found at a later age where people would die from it. And we will discuss this a little bit more when we get back.
Carmela J: We are getting ready for the second half hour of The Conversation. When we come back we will continue our discussion about prostate cancer with our guest Dr. Dave Thiel. News and weather are up 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 host Carmela J. and I’m here with our weekend expert Dr. Ali Kasraeian and our special guest Dr. Dave Thiel. Thank you for staying with us as we continue our discussion tonight. Remember you can call us at 340-0690. We do have a caller right now on the line. This is Max on the south side. Hi Max, how are you?
Dr. Ali Kasraeian: Hello Max, thank you for joining us on The Conversation. This is Ali and my good friend Dave Thiel is here. How can we help you?
Max: Well, I’m just going to a urologist who I have a great deal of confidence in but since you have this program I thought I would get your input on a couple of things. I was diagnosed with prostate cancer in January of 2012 but unfortunately it seems to be the early stages. It was detected with an in-office biopsy, the 12-gun salute, I call it.
Dr. Ali Kasraeian: That’s great, I’m going to have to use that. Well done.
Max: But then November 29th we had one of those comprehensive 36 blood samples in the outpatient in the hospital and that came out with out of 36 samples only 2 had cancer. And they surmised it was less than 10%. So I’m on the monitoring phase right now. And hopefully I can just keep on monitoring it because I do have a complication here. My wife is an invalid and I lift her many times a day. And so if it gets to the point where the situation changes and I have to have some type of treatment, I obviously would not want the – what do you call it? The prostatectomy?
Dr. Ali Kasraeian: The surgical option?
Max: Yeah, because of the recovery. That would put me dead in the water with taking care of my sweetheart. And the external radiation, I understand that has side effects. Now my question is because it sounds like there are two – the radiation seed implants, which has a very quick recovery time. The only problem is I have a BPH, oversized prostate, and I’ve been taking this. They had me on Avodart for a long time but that’s not doing anything. So my question is, after giving you that history there, is what about this, what do you call it? Cryo something.
Dr. Ali Kasraeian: Yeah, cryotherapy.
Max: Well what’s the deal on that? Can that be done even if your prostate is oversized? Or do you know? Is that your area?
Dr. Ali Kasraeian: Great question. So basically you are bringing forth in a very elegant way – it’s almost like we planned this, but thank you for calling in. The way to deal with prostate cancer in terms of from diagnosis to what to do, the thing that you’re talking about in consideration – one, I applaud you for having so much good information and foresight to dealing with the disease process. There are a couple factors to kind of think about. One is how significant is your disease? You look at a couple things. One, we look at your PSA. A PSA less than 10 seems to be a very, very important factor for most of the criteria – we’re looking at act of surveillance. We are not quite sure whether the difference between 10 and 20 may be in terms of long-term implications, but if your PSA is above 10 that is one thing that makes our red flags a little bit higher and we need to monitor things a little bit closely and maybe entertain the idea of doing treatment. Two, what’s your Gleason score?
Max: My Gleason score was 6.
Dr. Ali Kasraeian: Perfect. So Gleason score, basically, the pathologists take a look at the cells under a microscope and they assign a number of 1 to 5 to the most common area, add it to the second most common area and give you a total score. And the most common things we tend to see, and tell me agree Dave, are 3s and 4s, equaling 6s or 7s. Seven is kind of a fence that divides aggressive cancers, like 8s, 9s, and 10s, from less aggressive cancers like 6s, 5s, and 4s. And within the 7 family, if the 3 number is first it is a less aggressive cancer, kind of the side of the fence leaning towards the less aggressive cancers, like the 6s, 5s, and 4s. Where if the 4 number is first it is kind of the side of the fence facing towards the more aggressive cancers like 8s, 9s, and 10s. And so for you it looks like you have a low-risk, Gleason 6 cancer, and 2 out of 36 biopsy cores, so it’s a low volume of disease. And for most screening criteria you look at one to two to possibly three cores that are positive. So it seems like you meet all the criteria for active surveillance. How old are you?
Max: I’m 75 and holding.
Dr. Dave Thiel: Very good. The one thing that bothers me about you, and I will play devil’s advocate. Ali is being nice. When you look at side effects from prostate cancer, and I look at ablative therapies – I don’t know how Ali looks at them, but I look at radiation, cryotherapy, HIFU, as ablative of therapies. You either remove the prostate or you ablate it. If you ablate it you use radiation, cryotherapy, which is freezing, or sound waves, which is HIFU – all of the disastrous complications we have seen from ablative therapy usually start with men with big prostates and voiding symptoms who get these ablative therapies, and that’s where you’re set up for sometimes drastic complications that we really don’t have good medications or treatments for, so the concerning thing about you to me is that you’re having voiding symptoms on Avodart, and Avodart didn’t work. You need to be very careful about picking any type of ablative therapy, whether radiation, cryotherapy, or HIFU.
Dr. Ali Kasraeian: And I think the important thing that Dave is mentioning is the size of the prostate and how you are urinating are important factors to consider when you’re thinking about doing some kind of treatment that uses energy to destroy the prostate cancer because most of the initial side effects, and even some of the long-term side effects, involve difficulty and challenges with urination. And you mentioned in one of your questions about cryotherapy – there are size requirements and size limits to ablative therapy. So for example, for cryotherapy most people recommend having a prostate that is smaller than approximately 45 grams. For brachytherapy or the seed implants that you mentioned, again, one thing that is important for people to realize is seed implantation or brachytherapy is a form of radiation therapy. You’re just using small, radioactive pellets that are approximately 4 mm in size to deliver that radiation in a focal manner. So the upper limit of recommendation for that is 50 grams. For HIFU, or High-Intensity Focused Ultrasound, where you use sound waves and ultrasound to destroy the prostate, it has very low side-effect profiles – 2% or less incontinence, about 20% to 30% erectile dysfunction; however, your prostate needs to be less than 40 grams with some specific consideration for the size of that. So when you’re looking at the possibility of undergoing a treatment option, your urination and the size of your prostate are very important. One thing Avodart does is it tries to shrink your prostate. So for people who are on Avodart, it may not immediately decrease your urination symptoms but over time studies show that it should help, especially when added to a medicine like Flomax, Rapaflo, or Uroxatral, which tries to relax the prostate. So tell me, what are your thoughts in terms of the direction you feel like you’re heading with your prostate cancer?
Max: Well, let’s see, I took the Avodart for a long time, for about nine months, and it was not working. It did make my skin peel. It looks like I’ve got leprosy on my legs. It makes your skin peel but it was not shrinking at all. So I talked to the oncologist and after two tests it was not shrinking and they just kind of said –
Dr. Ali Kasraeian: Can I ask you what kind of test they did to see if your prostate was shrinking? Was it the different biopsies that you had done?
Max: Yeah, ultrasound and that time I had that 36 thing, you know, 36 samples.
Dr. Ali Kasraeian: Do you recall what the size of your prostate is?
Max: It was 63.
Dr. Ali Kasraeian: So 63 is a pretty good-sized prostate.
Dr. Dave Thiel: Yeah, you need to be careful of ablative therapy in my opinion at this particular time.
Dr. Ali Kasraeian: Now one thing that sometimes some people can do with the consideration of this is a potential of doing what’s called a TURP, a transurethral resection of the prostate, where you go in and open up the channel portion of the prostate, that surrounds the urine channel, to open it up to alleviate the obstruction. And in your case it may do a couple of things. One, it may decrease some of the difficulties you have with urination and two, it also decreases the size of your prostate which may in turn decrease some of the side effects you have.
Max: Now, that leads me to another brief question. I’m taking two supplements – one is called, I’m sure you heard it advertised, super beta prostate, and the other is called prostate essentials. I’m taking one of them in the morning and the other one in the evening, and it has definitely helped my urination. I was getting up like four times during the night and now I’m only getting up like twice. So I don’t know if it’s doing anything about the shrinkage but it’s definitely helping the urination part of it.
Dr. Ali Kasraeian: Now, let me ask you – are you taking anything like Flomax or terazosin?
Max: I’m taking absolutely no medicine and I’m in excellent health except for this disease. And I have withdrawn from the Avodart because it was not working. So I’m taking nothing right now. I guess the good news is that I seem to be very early stages, so I may outlive it. I may outlive the prostate cancer since it is so low with out of 36, only two of them, and less than 10% cancer in those two. So I’m hoping that I don’t even have to have treatment, but of course they are going to be checking me periodically to see. Now the main reason I called was to get your feelings on cryotherapy. It sounds like you all really don’t care much about that.
Dr. Ali Kasraeian: No, cryotherapy is a good treatment, it’s just that your prostate is a little bit too big for it. Your prostate is approximately 20 grams too big for cryotherapy. And with that one you can’t effectively treat the cancer as well unless you do a focal therapy, and then your side effect profile may be a little bit higher.
Dr. Dave Thiel: And then one thing Ali, I don’t know how you feel about cryotherapy of the prostate, but the one drawback to cryo-ablation of the whole prostate is the erection return rate is miserable. There is no erections when you have cryotherapy to the whole prostate. And that’s why most younger men do not entertain cryotherapy. Cryotherapy, when you look at the data, is mostly used either following radiation failures or in older men who aren’t having erections as it is.
Max: Well, I’m still not over yet. I’m getting there pretty quick, but –
Dr. Ali Kasraeian: Well, I’ll tell you Max, I think you’re doing a wonderful job in addressing it. The only thing that I, as a urologist, would entertain, is possibly staying on a medicine like Avodart and then potentially adding something like a Flomax or Uroxatral or Rapaflo, which would relax your prostate a little bit and entertain the possibility of doing some kind of resection to your prostate if you’re considering any kind of ablative therapy like cryotherapy, HIFU, or any kind of radiation therapy.
Dr. Dave Thiel: But to the general public out there, beware when you are on Avodart, especially if you have prostate cancer, it’s going to lower your PSA 50%. So any PSA you get you need to double when you get it. So for example if your PSA is 3, it’s really 6 in our mind.
Max: Well, thank you very much. And by the way, have you all had any experience with these supplement that I was telling you about? The super beta prostate and the prostate essentials?
Dr. Ali Kasraeian: I will tell you, that’s an interesting point. When I was in Milan at this conference actually they looked over a lot of different supplements that have been associated with prostate cancer and unfortunately none of them have really been shown to have any kind of durable, reproducible benefit with helping either in urination or prostate cancer. For example, for prostate cancer specifically some people said vitamin E may have been helpful, and it was actually found to be detrimental to those with prostate cancer. No effects with selenium, which is an active ingredient in a lot of these prostate healthy vitamins that are advertised. Nothing with multivitamins, no effect with lycopene, no effects with soy and phytoestrogens.
Dr. Dave Thiel: And most American studies with vitamins and herbs have not shown any benefit with regards to prostate cancer. And there is a little known study last year that show that men who took more than six doses of vitamins per week actually had higher-grade and more aggressive prostate cancers than those who didn’t take vitamins, so supplements and vitamins, the jury is still out.
Max: Yeah, okay, well thank you very much.
Carmela J: Thank you, Max.
Max: All I know is it definitely has helped my urination at night, so I don’t know what the explanation there is. All right, well thanks a lot.
Carmela J: All right, bye Max.
Dr. Ali Kasraeian: Now, it’s interesting, with active surveillance – a study in the European urology journal this week actually looks at the PRIA study, in which they follow a lot of people along for active surveillance, and one interesting thing that they found is that they found it be very effective if it is done appropriately; however, one thing that I keep finding in these articles is that I think they are oversimplifying the effects of active surveillance because even in this age 77% of people were able to be continued on active surveillance at two years. That means the rest of those people, 28% of the people that they looked at were reclassified. Meaning at that first biopsy of the year their cancer became more aggressive that you couldn’t monitor anymore. And most of the studies that look in that two to three year range is about as far as people go with active surveillance, so monitoring closely is incredibly important.
Dr. Dave Thiel: Yes.
Dr. Ali Kasraeian: What do you think about that in terms of active surveillance?
Dave: I’m an active surveillance fan in the right candidates and for me it has to be guys with low PSAs and you broached the topic of PSAs under 10, but I like to see them lower than that in younger guys and I like to see one core positive, under 5% of that core. Anybody over that needs to be carefully looked at; however, I can tell you my experience with active surveillance and this is my seventh year at Mayo. I have very few younger men continue it out. Usually the biopsy changes over time or their PSA goes up where you have to do something. And some of the trials are showing that in 20%, 30% of the men where you are on active surveillance, when your prostate biopsy score changes or your PSA goes up, your stages change. You are no longer a clinically-localized cancer, you are a stage III.
Dr. Ali Kasraeian: And it’s very important to kind of monitor that, so if people are doing active surveillance – which I think in the appropriately-selected patient makes a lot of sense – you’re not essentially avoiding treatment forever but you’re just delaying the treatment with a lower side effect profile during the time whenever you’re monitoring it. So I think reading some of these studies for active surveillance adds another tool in our belt, but people should really understand that this doesn’t mean that you have a low-risk cancer and we never follow it. I think the importance of close follow-up is very important and the data – and as urologists, we’re still trying to figure out what’s the best candidate to maintain on active surveillance and how to follow it more closely.
Carmela J: Okay, well, we have to take another quick break but we still have a few minutes left to finish our discussion on prostate cancer. Stay with us on News Talk WOKV.
Carmela J: Welcome back, we’re wrapping up on The Conversation on News Talk WOKV. Thank you again for listening. Dr. Kasraeian, what are we closing with tonight besides you making me laugh right before I start talking?
Dr. Ali Kasraeian: Oh, you’re noticing me making you laugh?
Dr. Dave Thiel: I thought that was me that made her laugh.
Carmela J: It was, actually. You made me laugh, Dave, but it was about him. I’m kidding.
Dr. Ali Kasraeian: If I was a comedian I would drop my headphones and make it make a sound and then I would walk out, but we don’t have time in this last segment.
Carmela J: Lost for words, I’m sorry.
Dr. Ali Kasraeian: It’s tough to speak with a lump in your throat.
Carmela J: So the last thing I want to finish up with my good friend Dave Thiel, and apparently your new sparring buddy against me, I want to talk about a study that [inaudible 00:49:03] was presented in Milan that looked at the differences between surgery and radiation therapy for localized prostate cancer, meaning prostate cancer confined to the prostate, and this one was done at the Karolinska University in Stockholm, Sweden. One of the premier surgeons out of that group is Peter Workland, who not only is an amazing surgeon, he’s one of the most charming people you’ll ever meet. And he’s very kind and very mentoring to the world of urology, in my opinion. What they did is they took approximately 21,000 men who underwent surgery and compared them to approximately 30,000 men who underwent radiation therapy for localized prostate cancer and just kind of followed it along to see what would happen. And interestingly they found with approximately 6 years of follow-up, as the median follow-up range, meaning kind of the in-between years of follow-up, some more, some less. They found an approximately threefold increase in the risk of death in the radiation therapy group compared to surgery. And I found this to be incredibly interesting and that followed suit for both low-risk cancer, intermediate-risk cancer, and high-risk categories, meaning that surgery offered a better cure and better survival. And the only category that they seemed to be equal was in the risk of metastatic disease outside of the prostate, where neither one of these are aimed to cure because the cancer is already out of the prostate. So what do you think about that? And that’s a follow up of 34,515 men.
Dr. Dave Thiel: Well, my simple take on that, and I am biased because as you said I’m a surgeon, but I’ve seen a lot of prostate cancer and I’ve seen a lot of complications, side effects from prostate cancer and it’s therapies. And what I still tell younger men is I do believe that surgical removal of the prostate and experienced hands is the best long-term care for prostate cancer with the least long-term side effects. And I think that trial, and there are similar ones in the United States that are coming out that will demonstrate that same thing over the last ten years, that I believe in younger men who are candidates you are better off having your prostate out in the long term than ablative therapies. Now, that’s not to say that men aren’t candidates for radiation therapy because they are. And in most cancers, especially low-grade and intermediate-grade cancers, their survival is going to be the same at the five-year mark.
Dr. Ali Kasraeian: And it’s interesting. We talked about a study out of the New England Journal that looked at side effects from the treatments and some of the advantages that are afforded with radiation therapy in the first five years and they equalize from year five to fifteen. So after a period of time the side effects are approximately the same, if not favoring the surgical realm.
Dr. Dave Thiel: And let’s be honest, the main side effects that people are after are whether or not they are going to leak urine, incontinence, and erections, are they going to be able to have sexual intercourse or not. And when you look out from the therapy, as you mentioned, five years there is not much difference between the two. I think that has however more to do with the age of the patients involved. I think 65-year-old men, as they get into their 70s, are going to have erectile function, a high percentage of them are, whether they have prostate cancer therapy or not.
Dr. Ali Kasraeian: And it’s interesting in terms of the side effect and the cancer cure, people younger than 65 tend to do better across the board with both the cancer cure and the benefits from surgery and treatment in general than people who are older and have less side effects by the nature of the fact that they are younger and healthier, meaning again, the age-appropriate treatment and looking at your overall picture and how healthy you are and how your life span seems to be playing out, depending on your comorbidities is an important fact to consider. And again, I think the important thing is catching the cancers early.
Carmela J: All right, well thank you so much Dr. Kasraeian for another great show and thank you for being with us Dr. Thiel. Thank you everyone for listening, please join us again next week on The Conversation on News Talk WOKV. I’m Carmela J. We’ll see you next Saturday at 5 pm for more talk on your health and wellness.[End of Audio]