Episode 10: Prostate Cancer: Part A) Detection, Diagnosis and PSA, Part B) Surveillance and Treatment

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Episode Summary:

Learn what guys ought to know about prostate cancer, including some surprising risk factors (related to female relatives), in this frank discussion by prostate cancer experts. Hear about standard detection and treatment methods, as well as newer tools and protocols that enable smarter screening and treatment. Lastly, get a glimpse of what the future holds for individualized, precision medicine for combatting prostate cancer.

Episode Guest:

Daniel W. Lin, M.D., Professor Department of Urology, University of Washington School of Medicine, Chief of U.W. Urologic Oncology, and The Pritt Family Endowed Chair for Prostate Cancer Research.      

During This Episode We Discuss:

  • Prostate Cancer in detail, Part 1A Comprehensive Review of Diagnosis, Testing. (PSA Prostate-Specific Antigen)
  • Prostate Cancer is not just one entity. Learn how to distinguish less active from more active and dangerous diseases.
  • Symptoms of Prostate Cancer. (most men who can be cured present without symptoms)
  • When and who should be evaluated for Prostate Cancer.
  • What is screening for Prostate Cancer, what does that mean?
  • Review of Treatments for Prostate Cancer in Part 2.
  • Does everyone require treatment? 
  • What does Active Surveillance mean? Who is a candidate?
  • What are the best treatments for Prostate Cancer when it’s confined to the Prostate?
  • What are the best treatments for advanced (metastatic) Prostate Cancer?

Quotes (Tweetables):

“The main target population (based on recommendations from national governing medical associations) usually entails men over 50 or men with a family history.”

“I always look more at life expectancy rather than age by itself … perhaps some 70-year-olds will live 15 or 20 more years and men in their 70’s should be screened.”

“If there is a strong family history of Prostate Cancer, Breast Cancer, and Ovarian Cancer, those individuals should consider some form of (genetic) testing.” 

Daniel W. Lin, M.D.

Recommended Resources:

Episode Transcript: 

Introduction (00:00:06):

A baseball game, a day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures. Whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health is presented by the Washington State Urology Society to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body after all, it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body. If you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast as we explore men’s health with renowned experts and embark on a journey towards better health.

Dr. Richard Pelman (00:01:30):

Prostate cancer, what every man needs to know about detection and treatment of prostate cancer. This is Dr. Richard Pelman, your host for the Original Guide to Men’s Health. Today, we’re going to be interviewing urologist, Dr. Dan Lin, at the University of Washington. Our first segment will be about the diagnosis of prostate cancer and prostate specific antigen. Our second segment will be about treatment for prostate cancer. Stay tuned for information every man needs to know. On the Original Guide to Men’s Health podcast today, we are fortunate to interview Dr. Daniel W Lin. Dr. Lin is chief of urologic oncology and a professor of urology at the University of Washington. He also is the Pritt Family Endowed Chair in Prostate Cancer Research, and the director of the Institute for Prostate Cancer Research. Dr. Lin is a urologist, surgeon, academic, and a truly amazing person. I’m fortunate that he was able to give time today for this podcast, as he’s exceptionally busy. Truly one of the finest surgeons and people I know. Welcome Dr. Lynn. 

Dr. Dan Lin (00:02:43):

Well, thank you Rich for having me. I’m happy to discuss a topic obviously of everyday interest in my practice on prostate cancer, and the management of the man who has just been diagnosed.

Dr. Richard Pelman (00:02:57):

So Dr. Lynn, we have an overview of a significant disease that concerns men and there’s always a discrepancy of patient understanding of prostate cancer from those who come in who are concerned that their friend has it – it’s advanced, to other men who come in and go, “I guess you don’t have to worry about it, I hear you’ll die of something else.” So first we should look at prostate cancer and an overview as a spectrum of disease. Give us some ideas about when we have to be concerned about prostate cancer in the sense, and when we shouldn’t.

Dr. Dan Lin (00:03:34):

Great, Rich. Definitely no doubt that there’s a wide spectrum of prostate cancer. And there’s a disconnect between the men who are diagnosed with prostate cancer, and those who might eventually suffer from prostate cancer in terms of spread of disease or death from disease. So when we think about men in general, the statistics that we have now is that something like one in seven men will actually be diagnosed in their lifetime with prostate cancer. But certainly, most of those men will die of other causes. In fact, it might be more like one in forty men will die of prostate cancer. Obviously it’s the leading cause of cancer death in men, second to lung cancer. So it’s a very significant issue. Although, as you said, not all men who have prostate cancer need to get treated. And certainly, most men who are diagnosed with prostate cancer do not die of it.

Dr. Richard Pelman (00:04:31):

So this of course is the dilemma for patients. And it’s even a greater dilemma for practitioners. If we look at the issues of prostate cancer, we would be first interested in who is a target population and who’s most at risk. And then we’ll talk about some of the tools we have for detection. But talking to an audience that we might have 20 year olds listening to 80 year olds, who should we tell they should be aware of prostate cancer and be interested in potentially being screened?

Dr. Dan Lin (00:05:06):

So the main target population, and these are based on recommendations from national governing medical associations, usually entail men over fifty or men with a family history. So not particularly for men in their twenties or thirties, unless of course there’s a very strong family history. So who we’re really talking about targeting for screening and being concerned for prostate cancer is mostly men between the ages of fifty and seventy. And that is the national government recommendations in that age frame. At the same time, I would say that I always look more at life expectancy rather than age by itself. We know now that men and women are living longer because we have better healthcare and perhaps some seventy year olds are clearly going to live fifteen or twenty years. And I think men in their seventies who are otherwise healthy should be screened and should be concerned about prostate cancer. And so I’m hesitant to draw a line just at an age rather than a life expectancy.

Dr. Richard Pelman (00:06:08):

So we have a seventy-seven year old who’s playing tennis, active, running, has family longevity and tells me his dad passed away at ninety-eight, and wishes to have an understanding of whether he might be at risk for prostate cancer. Would you tell him no? Or would you say, “fine we can pursue investigations.”

Dr. Dan Lin (00:06:31):

That’s a unique situation, but I think having seen many men, and I’m sure in your own practice, Rich, you see those types of people fairly frequently. If it truly is a man in his late seventies that’s that healthy that has fifteen, twenty years to live, I certainly think at least some screening for prostate cancer initially, and that might not be every year PSA’s, but that is some form of screening is appropriate. 

Dr. Richard Pelman (00:06:56):

So that of course leads us into a further conversation about, are there some populations who are known to be at risk, for instance, there’s been some data about men who have mothers with breast cancer, ovarian cancer, the BRCA gene*, should they be screened genetically? Lynch syndrome. These are very sub-populations, very small segments, but just what comes to mind that you would alert people to be aware of?

*The BRCA genes are tumor suppressors, in that they normally function to keep breast, ovarian, and other tissue types from growing too fast. Mutations in these genes can increase one’s risk of certain cancers. https://www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer/index.htm

Dr. Dan Lin (00:07:26):

Well, great question. Now, here we are in the year 2019, and I think that the genetic tests and what we call germline inherited mutations, what you receive from your parents, is at the forefront of all research clinical trials. And it is no doubt true that we know men who inherit the BRCA mutation or something related to that are at higher risk of being diagnosed with prostate cancer. And not only that, the prostate cancer that they are diagnosed with is usually worse prostate cancer. And lastly, and perhaps most interestingly, which we might get into later in this podcast, those individuals with the BRCA mutation and prostate cancer are more susceptible to chemotherapy and other agents, which usually are ineffective in prostate cancer. So getting to the bottom line, certainly if there’s a strong family history of prostate cancer, breast cancer, and ovarian cancer, those individuals should consider some form of testing. Of course, within the confines of a medical geneticist, and maybe counseling.

Dr. Richard Pelman (00:08:37):

So now this of course brings us back to the general population and to the question of screening versus detection. And I know we tend to sometimes have a controversy. Do you want to address, first of all, what we mean by screening?

Dr. Dan Lin (00:08:54):

Screening is in general, referring to healthy individuals who have no indication of prostate cancer, no family history of prostate cancer necessarily, but as part of their normal health care evaluation by their primary care provider, would be recommended to undergo screening. And screening, at this point in time should be a combination of a blood test for PSA and a digital rectal examination together.

Dr. Richard Pelman (00:09:20):

So now we’re talking about one of the more controversial tests, PSA, prostate specific antigen.* And when we look at PSA over time, we have seen an evolution from many men getting PSAs when it was first brought out into the marketplace in the late eighties and early nineties, to then a review of PSA by primary care specialties, family medicine, internal medicine, and a review by a government panel, the United States Preventive Services Task Force about the efficacy of PSA. The USPSTF ended up degrading the test around 2011-12. And we as urologists were not comfortable at that time that it was downgraded. Do you want to just give a little background in why there’s controversy about PSA and some of the history of PSA? 

*PSA, or prostate specific antigen, is a protein produced by the prostate and found in a patient’s blood. PSA is often elevated in patients with prostate cancer. https://www.cancer.gov/types/prostate/psa-fact-sheet

Dr. Dan Lin (00:10:20):

Well certainly, and I would think it’s safe to say that the wheel has gone full circle in many ways, and I think that it started out, as you said, to put it simply, we found this test that detected prostate cancer and we used it to blanket across the whole population, whether the man was young, old, sick, or healthy, and we detected many prostate cancers that would simply never harm a man. And that then led to treatments such as surgery or radiation, which led to side effects such as urinary issues or sexual dysfunction or erectile dysfunction. This was then reviewed by many governing bodies, including the USPSTF, and then the pendulum swung towards maybe not screening at all based in part by a couple of flawed studies across the world. And that was in, as you said, the year 2012. Since that point in time, that’s been seven years now, there has been multiple other reviews finding that perhaps screening was appropriate, and now the recommendation has changed back to what we call a C-rating, which is an individualized decision, a structured discussion, between a primary care provider and a patient. So I think that at the end of the day, now we’re screening smarter. I think the message should be, screening with PSA in those individuals who are healthier screening by PSA, perhaps not every year, but maybe even every other year, and maybe even using other biomarkers such as free PSA, MRI, and other tools, which are emerging.

Dr. Richard Pelman (00:11:56):

So let’s just go back to PSA for a moment for our listeners who aren’t aware of what the PSA actually represents. So it stands for prostate specific antigen. It’s an enzyme that actually functions to keep sperm from clumping together. It’s concentrated in an ejaculate. And I always tell patients, if we wanted to have fun with a lab, we’d send ejaculate for PSA, and they wouldn’t be able to register the test. They’d have to dilute it and dilute it. So then patients go, well, how does something that’s in the ejaculate end up in the bloodstream? Well, it seeps through the cell wall and there’s various conditions that can elevate the PSA. And I remind patients that it’s a prostate specific entity, but it’s not a cancer specific entity. So PSA in its own manifestation of an enzyme being made only by the prostate picked up in the bloodstream is something that is specific to entities that are diseases or issues, prostate growth, prostate inflammation, inflammation from infection, or inflammation not from infection, instrumentation, and possibly prostate cancer.

Dr. Richard Pelman (00:13:02):

So it then falls on the urologist to sort out which of those issues is the PSA elevated from if it’s abnormal. The other knock against PSA is when it’s normal, it doesn’t necessarily mean that you don’t have prostate cancer. And I have to remind patients that there are a subset of prostate cancers that are so aggressive, so dedifferentiated, they don’t contribute much PSA. And that’s where the digital rectal exam helps to find those. But for the most part, the PSA becomes a useful test in detecting prostate cancer. Give us a little more background. then if you have an abnormal PSA with a normal digital rectal exam, the prostate feels it might be enlarged, but it feels okay. There’s no hard firm area on it. Where would we go from there?

Dr. Dan Lin (00:13:45):

Well, we usually make sure that the elevated PSA was indeed true, hopefully given previous PSA’s. But I do, like you, tell my patients that there are three primary reasons that the PSA goes up. One of course is prostate cancer, which we want to avoid. The second is benign prostate growth which happens with age. And the third is a prostate inflammation or infection, some sort of prostate inflammation, most call it prostatitis, being the three primary causes of elevated PSA. If I don’t think a man has prostatitis for an infection, of course, we would go down the path towards some form of evaluation. And usually that is in the case that you presented of a elevated PSA in a normal digital rectal examination. That would be a prostate biopsy. The prostate biopsy is a very well tolerated procedure that we do right in our clinic, no anesthesia needed.

Dr. Dan Lin (00:14:40):

We provide antibiotics at the time to avoid an infection. And that infection risk is probably in the one or two percent range as far as a serious infection. And we try to have our patients stop any blood thinners or aspirin use to prevent bleeding, which again, is probably a one or two percent chance of bleeding with a biopsy. And again, it’s very well tolerated and we perform the biopsy in a way that distributes the biopsies around the prostate gland to try to fully sample the prostate and try to diagnose the prostate cancer if it’s there.

Dr. Richard Pelman (00:15:17):

Now you mentioned no anesthetic, no general anesthetic, no spinal, but we do use local, and we’re very, very, very good at making the procedure a non-painful event. The local anesthetic is something that was described back in the early two thousands for a decade. We did it without even injecting local and men did fine. Now they do really well. And I ask all patients after if that was painful and they go, “no, it’s annoying, but it didn’t hurt.” And when we look at the aftermath of the biopsy, people worry, “well, can you spread prostate cancer cells?” And I think that’s been answered that that is not an issue. There are some papers on the web, but the vast amount of research shows that you do not distribute prostate cancer by a needle biopsy. And as you mentioned, it’s very well tolerated. Very minimal risks. And it’s a now designed biopsy to decrease what we call false-negatives. So you said we sample in a very specific way. This is really based on scientific evidence of a template that was derived, so that we maximize our true-negatives and try to avoid the false-negatives. What would be the general false negative acceptable now? That means we call patients and “say you don’t have cancer, but we missed something.” What would that rate be?

Dr. Dan Lin (00:16:37):

When one looks at the literature with transrectal biopsies, which is the normal way we do these, the false negative could be in that fifteen percent range, somewhere in that range, maybe even as much as twenty percent. But we also know that those cancers that are missed are probably very small cancers, are very likely low grade cancers, and are very likely non-lethal or non-threatening cancers. I will say that we have discussed in multiple settings, what to do to improve on that. And the major one that has been promoted for the last approximately five years is using MRI technologies. And so we would do what’s called a multi-parametric MRI. That’s not the same as if you might have an MRI for your knee or for your back, but it’s a different type of MRI of the prostate where we can pinpoint possible lesions in the prostate, and then at the time of biopsy, specifically target those lesions to make sure that they don’t have cancer. And that definitely has brought down the false-negative rate quite a bit.

Dr. Richard Pelman (00:17:42):

So patients who do a lot of reading are aware of the technology of MRI and they go, “well, why don’t you do my MRI before my biopsy?” And that really comes to the question of screening with the MRI. Certain countries may. Certain institutions may. But we here have not been screening with the MRI. We think the algorithm works better if we do the initial biopsy, say it comes back negative, but the PSA continues to rise, see the patient back to make sure they’re not in that fifteen to twenty percent. That’s where the MRI would come into play.

Dr. Dan Lin (00:18:15):

That’s definitely true. I think that the reason that some other countries have picked up MRI perhaps more than the United States is in part a cost issue. That the MRI of the prostate in the United States costs quite a bit still and in other countries, it might be one quarter of that cost or even less. The other major issue about MRI is it’s at the mercy of the radiologist who reads it, and there is some variability between radiologists when they look at these MRIs. I still think, and most people in this country still think, that doing our traditional, well done, well distributed, transrectal biopsy by ultrasound is the first step. And then again, as you said, if the PSA is still going up, or if there’s still some suspicion, then proceeding with an MRI,

Dr. Richard Pelman (00:19:01):

So besides the MRI, do you use any other tools? Have patients come in who have heard about the PHI test, PHI, sorry, it’s the PHI test. Liquid biopsies are advertised. There are tools that can be used actually on the tissue itself from the biopsy to tell us whether maybe we miss something or not. Do you want to elucidate a little bit about that? 

Dr. Dan Lin (00:19:24):

Yeah, there are now multiple blood tests. There’s the 4k score, the PHI test, there’s a urine test that’s been used in Europe called the Select MDX. That’s coming towards the US. And then there’s a tissue based test, what’s called the Confirm MDX, which looks at molecular signatures. It’s really methylation signatures. I think those all clearly add to the data that we have. However, they are really reserved for certain situations. Again, multiple negative biopsies, or very high suspicion, maybe want to get more data before deciding whether to do another biopsy. At this point, they are on national guidelines, but they’re not standard of care and they’re not required.

Dr. Richard Pelman (00:20:07):

I like to tell patients that really, what we’re trying to do, is to get all the pieces of the puzzle to fit. And if we have a negative biopsy, the PSA is still elevated, or there’s concern in a negative MRI, then what else can we use? And as many things as we can do to reassure them that we’re not concerned about prostate cancer.

Dr. Dan Lin (00:20:25):

Yeah, I think that’s a fair amount of it because each incremental bit of data usually improves what we call the negative predictive value* that they don’t have cancer. And to avoid a biopsy is really what we’re after. To avoid and to assure the patient that we haven’t missed something on a previous biopsy.

*Negative predictive value refers to the “probability that subjects with a negative screening test truly don’t have a disease.” https://sphweb.bumc.bu.edu/otlt/mph-modules/ep/ep713_screening/ep713_screening5.html

Dr. Richard Pelman (00:20:42):

Now the biopsy yields information, either positive or negative. But when we have positive, we also get information as to the spectrum of the disease. It really helps us decide who can we watch and offer surveillance. Maybe there’s a better form of treatment based on the pathology. So the biopsy gives us an idea how aggressive the cancer cells are and the volume of cancer. And it really helps us determine treatment planning. Do you want to just review a little bit about the actual pathology? People have done a little web search and they have some names, and they’re not sure about what all this means.

Dr. Dan Lin (00:21:19):

Sure, I think that is probably the core of the issue in newly diagnosed prostate cancer, which is, “how bad is it doc. Do I need to get treated?” And you mentioned two areas that are very key, which is, what is the grade of the prostate cancer, and perhaps what is the volume? The last parameter we use is sometimes, well, what is the PSA, because the higher the PSA, in general, means the worse off the cancer. But let’s start with the grade of the cancer and the volume of the cancer. The grade, traditionally, as many listeners might have looked on the web or heard from their physicians, is called the Gleason Grade. And the Gleason Grade traditionally was a number score that was basically between six and ten. So it was six, seven, eight, nine, ten, and the lower the number, the better. The sixes did better than the sevens and so forth. We’ve since changed it to be Gleason Grade groups.

Dr. Dan Lin (00:22:13):

And I think it’s a little bit easier for all of us to manipulate, which is a grading scale now from one to five. So now we call it Gleason Grade Group one, two, three, four, or five. And in general, the ones are the ones that when we look at it on the microscope, it’s prostate cancer, but it looks fairly well behaved. Orderly cells, slow growing, not threatening, not lethal. And as you go up to Gleason Grade Group five, you might look at it under a microscope and it’s very chaotic looking, dividing cells, big cells, small cells, aggressive cells. Those are the lethal cells. And so we give patients biopsies a grade between one and five. Again, one being the slowest, five being the fastest. And I will say the ones and twos really are at least half of prostate cancer that’s diagnosed today, are a grade group one or two.

Dr. Dan Lin (00:23:02):

The second factor is volume. So as we said, we divide the prostate up into a grid, let’s say of six areas of the prostate, and we ask ourselves, is it just in one area or is it in two or three areas maybe, or is it in five or six areas, like really spread through the prostate? And we can get a very good assessment of how much cancer is in that prostate by how many areas that are involved. And even within that area, how much of that little piece of tissue we took out had prostate cancer in it? So with the combination, it’s a very important combination of what the grade is, what the volume is, perhaps what the PSA is, we can have a good understanding of what the predicted behavior of this newly diagnosed prostate cancer will be.

Dr. Richard Pelman (00:23:49):

So we have reviewed an at-risk population, a general population of men who should consider looking for a potential of prostate cancer, reviewed some of our tools that we use to find it, and we’ve discussed the prostate biopsy. That’s substantial information and I think the first segment we’ll just call a detection and overview of prostate cancer, and our next segment we’ll talk about treatment. So stay tuned for the next segment of the Original Guide to Men’s Health podcast on prostate cancer, where we address treatment. Thank you, Dr. Lin.

Dr. Dan Lin (00:24:26)

Thank you, Rich. It’s my pleasure.

Narrator (00:24:49):

This is Dr. Richard Pelman for part two of our segment on prostate cancer with Dr. Dan Lin, a University of Washington urologist. Previously, we discussed an overview of prostate cancer as a disease, and detection. 

Dr. Richard Pelman (00:25:13):

Now once we have centered on having found prostate cancer, we will discuss various treatment options. We’re lucky to be interviewing Dr. Daniel Lin, chief of urologic oncology and professor of urology with the University of Washington Department of Urology. He is the Pritt Family Endowed Chair in Prostate Cancer Research and is director of the Institute for Prostate Cancer Research. So as we previously had reviewed in our last segment on prostate cancer, we have utilized a transrectal ultrasound guided biopsy in some instances and MRI directed biopsy to determine pathology of prostate cancer. And now we have a patient who is sitting in front of you with newly detected prostate cancer. Understanding it’s a spectrum of disease, how do we offer advice?

Dr. Dan Lin (00:26:06):

Oh, great Rich. This is clearly one of the most common situations that we deal with in urology being a man with newly diagnosed prostate cancer. And the question again is what should we do? I think to recap a bit from the last episode of the podcast regarding prostate cancer biopsy and how we determine what to do. It certainly is a combination of what we see under the microscope, what the PSA is, the age of the patient, perhaps how sick or how healthy that patient might be, and of course the patient’s desires and expected outcome of treatment or no treatment. But again, to step back, let’s step back and say a man with newly diagnosed prostate cancer comes to my office and I see them. The very first thing I do is look at their biopsy and their clinical information. And on that biopsy, particularly what the grade of the prostate cancer is.

Dr. Dan Lin (00:27:01):

And again, we reviewed this on the last podcast, but it’s either, essentially we call it, Gleason Grading. For those of you who have read online about grading prostate cancer, the Gleason Grade is traditionally run from six to ten. Six, seven, eight, nine, and ten, with ten being the highest grade and six being the lowest. And now we’ve revised that to be called Gleason Grade Groups, which is a one through five score, a much easier score to work with. That being grade one is a very slow cancer. When we look at that on the microscope, it’s a very orderly cancer, very well behaved. It is cancer, but it’s very slow growing. Or a grade five, which would be very chaotic looking under the microscope, very fast growing, very aggressive. So the very first thing we determined is what the grade is. And the next thing is, how much of the prostate has the cancer?

Dr. Dan Lin (00:27:53):

Is it in multiple areas of the prostate or just one area? And then even in those areas, is it a fair amount of the needle biopsy or is it a little bit of the needle biopsy? And again, we use all those things in combination first to determine, is a man what we call low risk prostate cancer, being slow growing, very early prostate cancer that very likely will not harm a man even if left untreated. Is it intermediate risk prostate cancer, being a little faster prostate cancer, unpredictable. What will happen with that prostate cancer over time? Or is it a high risk prostate cancer, meaning a high grade high PSA, lots of the prostate involved. We know those prostate cancers grow quickly, aggressively, can threaten a man’s life in a short period of time, and deserve treatment as soon as possible.

Dr. Richard Pelman (00:28:46):

It’s fair to say that our understanding of prostate cancer has evolved since we have had PSA and had transrectal ultrasound guided biopsies. Even in my career, I remember what would now be a group one, very slow growing, back in the early nineties, we would counsel patients, “good.” We found it and we’d treat it. And I think that was a part of the reason that PSA was downgraded. The consequences of finding an inactive cancer leading to treatment lead to distress in some instances, and a potential quality of life issues, though most men successfully did well but probably didn’t need to be treated at that point. So we have really evolved in our understanding of the disease based upon a number of the issues that you just spoke about. Let’s say that we have a man now who previously we would have treated in the nineties, who we go, “you know, this is a slower growing tumor. You don’t have high volume. Your PSA is fine.” And we now have something that is not called watchful waiting. It’s actually called active surveillance, which is a distinction. Let’s address active surveillance.

Dr. Dan Lin (00:29:49):

First, I would make that distinction between what we used to call watchful waiting, and still do, versus active surveillance. Watchful waiting is certainly a strategy by which treatment is avoided. Perhaps in an older man or a person that doesn’t have as long of life expectancy. Maybe not even monitoring their PSA or not doing other biopsies for sure, and watching until they become symptomatic, and if the band becomes symptomatic, then to treat in a palliative way. Active surveillance on the other hand is quite a bit different. It’s taking younger and healthier patients who are fit for treatment such as surgery or radiation, which we’ll get into shortly, and instead watching them and doing surveillance, which entails PSA’s every six months approximately, doing a biopsy perhaps every year or two, and monitoring them quite closely. And if there’s any evidence that the cancer is getting more aggressive than we treat early. We treat for cure.

Dr. Richard Pelman (00:30:51):

Yeah, prostate cancer is a scary word. And when we tell a man he’s got cancer and then tell him we’re not going to treat it, we’re assuming a lot of responsibility. So I think it’s important to review that the surveillance protocols were fairly strict about who could be in them so that we didn’t end up telling somebody two years later, “too bad we didn’t treat you back then.” So some of the criteria for being in surveillance are…?

Dr. Dan Lin (00:31:18):

The primary criteria for being in surveillance are a Gleason Grade Group one, or Gleason as we call it, we use to call it Gleason Grade six, a PSA of less than ten, and a normal digital rectal examination. That’s sort of the high bar or the blunt criteria for those patients who are eligible for active surveillance. And I would say that when one looks at all the active surveillance groups of patients over fifteen or twenty years, and much of this has been published by the University of Toronto, by Johns Hopkins, by University of California, San Francisco, and even by our group, which we’re called the Canary Pass Group, has shown that it is safe to follow men on surveillance, serially do biopsies and PSA’s, and treat if it looks like it becomes aggressive. And there does not seem to be any higher chance of prostate cancer, death, or higher chance of prostate cancer spread if indeed a patient follows the schedule and the doctors follow a schedule, serial biopsies and repeating the PSA’s and really monitoring them very closely.

Dr. Richard Pelman (00:32:27):

Is there a threshold by which you wouldn’t let somebody in surveillance with a PSA that was too high?

Dr. Dan Lin (00:32:31):

Most of us use a PSA of ten, certainly twenty, but some would use a PSA of ten. Now there are some unique situations, such as a man with a very large prostate from BPH. PSA’s over ten most likely because of the enlarged prostate, and multiple biopsies are done and there’s only a little bit of Gleason Grade Group one disease. But with a PSA of over ten, we might watch that patient very closely and allow them to be on active surveillance.

Dr. Richard Pelman (00:33:01):

The other area in surveillance that I think varies from institution to institution is the allowance of any Gleason Grade four. We have two types of seven. Gleason primary pattern three plus a minority pattern four. Or those who have a majority pattern four with a minority pattern three. They’re both total sevens, but I’d rather have a majority pattern of the lower acting three than the more aggressive four. Do you have patients with Gleason seven in surveillance here at the University of Washington? 

Dr. Dan Lin (00:33:38):

We do have some. I think that is a bit of a controversial area. So those that we call Grade Group two, being three plus four. We have some of those. We do not allow or typically recommend at all anyone that has a four plus three, or what is called Grade Group three, in active surveillance. So we do have some that have a little bit of three plus four, but we also have a very little bit of the four component, first of all. Secondly, it’s typically men that have been on active surveillance for a few years, mostly with Gleason three plus three, that they have a biopsy at some point in time, two or three years later, and there’s a little bit of a Gleason seven with a stable PSA. We’ll allow them to stay in. I would say there are some groups across the country, like let’s say Johns Hopkins, who are from and fast and they say, “no, almost no Grade Group four or Grade Group two,” which has Gleason three plus four. But by and large, if it looks like a minimal little bit, then certainly we have some of those men in our program and they’re doing quite well.

Dr. Richard Pelman (00:34:44):

So you had mentioned they are allowed to stay in surveillance. What would move a man out of surveillance? And what is your general approach as far as repeating biopsies? Every six months or yearly?

Dr. Dan Lin (00:34:58):

Great. So our protocol is a biopsy at the year, one anniversary of their diagnosis, at the year two mark, and then every other year if those biopsies look stable. So there are some groups around the world and country that are trying to have men do a biopsy once a year. That’s a lot of biopsies. And then there are other groups that are every three to four years and we think that’s not enough biopsies. And so we are basically splitting the difference and we’ve done some work with Ruth Etzioni at the Fred Hutchinson Cancer Research Center, and others who have clearly shown that it appears biopsies every other year are frequent enough and not too frequent, and detect the cancer when it needs to be detected. So that’s how we do our protocol. To answer your question about what would move a man out from surveillance to me recommending treatment. Primarily it would be an increase in grade.

Dr. Dan Lin (00:35:54):

So any increase in grade, we consider that so-called grade progression. Also, there are some patients who have gradually increasing PSA’s that will eventually get over ten or more and we know that those people will probably need treatment. And then the last is if they started out with maybe one or two biopsies that are there, twelve that had cancer, and then now they have four or five biopsies. They’re clearly having some growth, even though it’s the same grade, then that might trigger us to recommending treatment. I will say at this time that there are many men that start on surveillance for a while, their biopsies all look the same, low grade, a little bit of cancer, their PSA’s are still the same, yet they still want treatment later for some reason. Sometimes it’s just anxiety or concern. Sometimes it’s just that time of life. They’re maybe just retired and they’re ready to [Inaudible] have their prostate removed or have radiation or something like that. So there are a fair number of patients that despite the fact they’re on surveillance and still look to be completely stable, indolent disease that might never bother them, still want therapy. And I think that’s still allowed and we will do that.

Dr. Richard Pelman (00:37:09):

And just before we leave the subject on surveillance, the biopsies that provide us the information that we make the decision on, if you were to do what’s called upgrading another set of biopsies, or a man says, “I don’t care, I know I could be watched, but I just wanted out,” what percentage of the time do we find more cancer lying in the prostate, or a higher grade than we found on the biopsy?

Dr. Dan Lin (00:37:36):

I think that’s pretty well-established now that at least a third of the time when we take a man’s prostate out, we actually find a little bit worse cancer, a little bit higher grade, and that’s mostly because we can sample the entire prostate. We don’t think that necessarily is unsafe because when we look at large populations of men, particularly in Europe and Scandinavia, that have untreated prostate cancer, they still do quite well even with the knowledge that there’s a little bit of worse cancer in there if we had taken their prostate out and looked at the entire prostate,

Dr. Richard Pelman (00:38:10):

And then before we move on to treatment options, I just want to emphasize that we certainly have patient preference as part of the shared decision-making and that patients sometimes come in with preconceived ideas and our idea of what we think should be done may be an opposition to what they think should be done. We, as urologists, want to educate our patients. But we also certainly want to have them be comfortable with the decision.

Dr. Dan Lin (00:38:39):

There’s no doubt that this is a shared decision making process because there are upsides and downsides. And I tell all my patients that at any time during surveillance, at any time, if they change their mind, even if there’s absolutely no indication of worsening clinically by the biopsy or PSA, that they can change their mind and go any which way with regards to treatment. And again, most of this is expectation management and making sure that there’s an education about the pros and cons of treatment versus no treatment.

Dr. Richard Pelman (00:39:10):

So let’s take a patient whose grade volume gives us a concern and we review with the patient that we think that they shouldn’t necessarily be a surveillance patient, that we think that they should really consider treatment. What options are there? And I know this is a significant issue for many patients, as far as “invasiveness versus something that’s noninvasive,” but let’s just touch on each of the known treatments that are accepted for prostate cancer.

Dr. Dan Lin (00:39:40):

Yeah, the known treatments that are accepted in prostate cancer, and these aren’t necessarily University of Washington or Seattle Cancer Care Alliance treatments of choice. These are the national guidelines for the treatment of prostate cancer. So these are a national governing body, the so-called NCCN guidelines. And really the treatment of localized prostate cancer only falls into two families, surgery or radiation. You will hear a fair amount and we will read a fair amount and there’s a lot on the internet about heating the prostate or freezing the prostate or herbal remedies. There may be other non-traditional ways, but I’ll be first clear in stating that I look at it fairly simplistically, that it’s either surgery, remove the entire prostate, or some form of radiation. And radiation comes in multiple forms. There are the implantable little beads that are like the size of a grain of rice that are radioactive that we plant in there, so-called, like brachytherapy is what it’s called, or seed therapy.

Dr. Dan Lin (00:40:44):

Then there’s the family of beams. And there are all sorts of beams. There’s their traditional photon or radiation beams. And then there’s the proton beam. And I lump those together in the beam family because there’s no clear winner in the beam family. And I think that it’s either an external beam of radiation or it’s an implantable seed of radiation. And there are some radiation specialists that use the combination of a beam and a seed when they treat their patients. But in general terms, Rich, it’s either surgery, it is invasive and we’ll go through all that, or radiation as the two families of treatment.

Dr. Richard Pelman (00:41:21):

So let’s start with surgery. In my era, I was trained as an open surgeon, as were you. And then we had, I think in Europe, the first prostates that were taken out with a laparoscope. Most patients are familiar with having a gallbladder taken out with a scope and people were doing that by hand, and then a robot was developed. And I tell patients the reason there’s a robot is because it would be hard to direct five assistants who were doing different things through scopes, with a surgeon trying to direct everybody. What the robot does is it puts one brain in charge of the five different instruments. Now, the robot has significantly altered the recovery and the success and the minimization of complications of the surgery. Why don’t you address, first of all, what robotic surgery is about and how it has helped.

Dr. Dan Lin (00:42:12):

Yeah, it’s true that you and I both did train doing the standard open surgery and then transitioned now to where I’m ninety-five plus percent doing them robotically as is the rest of the nation. And there’s nothing necessarily magical about the method of taking the prostate out with the robot, as opposed to open. The incisions on the prostate itself and how we actually remove the prostate is fairly similar, but just the approach is different. There’s no doubt, as you said, that use of the robot has less blood loss, has less pain after surgery, has a faster recovery, and maybe has slightly faster return to continence, maybe, and less strictures that occur after the surgery. I will say that most of the data, and of course at the university we spend a fair amount of time looking at the worldwide data, but the data on cancer control and erectile dysfunction look to be equal between the way you and I learned how to do it with the open and with a robot. So there are some advantages primarily in recovery and pain to the patient with a robot. And it is now the state-of-the-art way of doing it.

Dr. Richard Pelman (00:43:27):

Speaking of some of the known side effects, potential side effects, the spectrum of urinary incontinence and erectile dysfunction. I always make it clear to patients that when they have heard from a friend who had surgery and said he never had an erection after, I always ask them to go back and ask a friend, “didn’t they tell you that they had no intention of sparing the nerves?” The reason I think it’s important to address this is some of the higher grade high volume cancers might have cancer cells that creep around the outside of the prostate. And it wouldn’t be wise to attempt to save the erection nerves that hug the very edge of the prostate due to the fact that you might be preserving cancer cells. So it’s a known issue before surgery, that those patients are going to seek alternate therapies to help them have erections. They won’t have spontaneous ones, but they can still have sex. Still have erections. These are not sensation or orgasm nerves. But it wasn’t that they “were ruined because of the surgery.” It was the way the surgery was intentionally done.

Dr. Dan Lin (00:44:25):

Yes. I think those are good points. I say to my patients that there are two major side effects of surgery. One of them is temporary, and one of them could be more than temporary depending on how the surgery is performed. So I tell them that the temporary, almost always temporary, side effect of the surgery is incontinence. And so almost all men, when we remove their urinary catheter, leak urine. And they don’t leak like when we’re sitting like we are now. But they usually are leaking when they do stressful activities like coughing or sneezing, laughing, or lifting something heavy. And what I mean by temporary is something around ninety percent of men get their control back. Like full control. No need for pads, no diapers. After six months, or maybe as long as a year, I’ve had, of course, as you have had, many patients that come back a month later and they’re pretty much dry. But the norm is usually a few weeks of incontinence when they strain that they recover, and I say that it’s temporary because it’s at least ninety percent of men that get their full control back and do not have any urinary leakage issues. 

Dr. Dan Lin (00:45:21):

The second one which you mentioned, which is sexual dysfunction, erectile dysfunction, can be definitely more impacting. And I would say it’s about expectations, as you said, of how the surgeon will approach the preservation of the nerves that control erections. I tell patients that there are two nerves that control erections. They’re lying around the prostate and we peel them off the prostate during the surgery. And just the process of peeling the nerves off can stun them and they go to sleep and they need to recover. Sometimes often we will not spare the nerves because the cancer is very aggressive. But even when we do, the nerves get stunned and it takes them a while to recover. There are various ways we can help with that recovery, for sure, during the process after surgery.

Dr. Richard Pelman (00:46:13):

I tell patients again to realize that the issue is spontaneous erections, but not giving up being intimate. We can help patients who have difficulty with erections achieve erections. And again, it’s not sensation, it’s not orgasm. So a man can still have a satisfactory sexual life after radical prostatectomy even if the nerves are not spared. Now let’s go to the patient who elects to have surgery, has the prostate removed, and recovers. How do we know we’ve been successful?

Dr. Dan Lin (00:46:43):

So the primary way we deem success after surgery is the PSA result. That’s one of the great benefits of PSA. In fact, historically back when PSA was first approved for use, it was really approved first for monitoring disease after treatment. That was its first use. And after surgery, the PSA should be undetectable. It should be below the limits of detection in a laboratory assay. And so that’s how we primarily determined whether the surgery has been successful in terms of cancer. Of course, in terms of erections and continence, time tells.

Dr. Richard Pelman (00:47:21):

Yeah. Success incorporates all quality of life measures and we continue to work with patients in that regard. So the patient wants to, first of all, feel comfortable that they have had successful cancer surgery. So the PSA becomes an absolute surrogate for cure. As long as we don’t see PSA activity, we’re happy that we have done a good job of cancer control. Now, if a man has a PSA that starts to reoccur after having the prostate removed, what can we do?

Dr. Dan Lin (00:47:47):

Well, typically when the PSA is rising, if it rises after it becomes detectable and rises after the surgery, there is prostate cancer somewhere. Typically in those settings, we will administer radiation right where the prostate used to live. Right down in the pelvis and near the bladder. And we call that salvage radiation therapy. And that’s a beam of radiation that’s delivered daily, five days a week, Monday through Friday. And it’s usually for somewhere between four and six weeks, and depending on the patient and the disease, a third or a half the time the PSA goes down and stays down. And so typically, if the PSA starts to go up, we would recommend salvage radiation therapy. I will say now, and take this time now to make note of newer imaging that’s emerging, and one of them is called an Axumin PET scan, or there are other types of PET scans. One’s called a PSMA PET scan. And in patients that have rising PSA after treatment, even if it’s radiation treatment, sometimes these fancy PET scans can find the cancer even with a PSA of less than one. Maybe even less than 0.5. And so we’ve been incorporating these PET scans into our workup of patients who have a rising PSA after surgery or radiation.

Dr. Richard Pelman (00:49:09):

That’s a great point because previously the traditional bone scan and CT scans were really only able to find evidence of disease when there was a significant amount. We’re now talking about micro-metastasis in the lymph node or in bone that we might seek. That’s what we call distant metastasis versus localized cells that might be laying around where the prostate used to live, that the radiation would be successful. What do you do for the patients who have evidence of disease that spread out into lymph nodes or into bone.

Dr. Dan Lin (00:49:39):

Typically for these patients, the cornerstone of treatment is hormonal ablation. And again, for those listeners who have read about hormonal ablation, I can tell you that the way I think about it is that the prostate cancer is an animal. It needs food to grow, and the food that it grows on is the male hormone, testosterone. We now have medications that can turn off the body’s production of testosterone called medical castration, and certainly slow the cancer down. It’d be like feeding you bread and water. You would get weak and feel tired, go to sleep, but you wouldn’t necessarily die. It certainly puts the cancer into somewhat of a remission status and puts it to sleep. And of course there are side effects to that. And the typical ones are things like hot flashes. Like all of a sudden sweating with kind of a hot flash. Also some fatigue. And then what men don’t know what’s going on, but it is, is some degree of bone loss. And then some men notice muscle mass loss as well. But that is if it’s spread to the bone, that is the traditional therapy, which is what we call hormonal ablation.

Dr. Richard Pelman (00:50:45):

And the other side effect would be loss of libido since testosterone is what drives guys’ sexual desire. They can still have erections but they just may not care to. The other issue for newer drugs is that they tend to promote and prolong this effect that you’re talking about that puts the cancer to sleep. It’s not a cure because there’s always going to be cancer cells that don’t need the male hormone and they start to emerge. So in a sense, we’ve set the clock back on the cancer, but we haven’t cured it by this technique. New novel drugs and therapies are aimed at keeping that effect more long-lasting.

Dr. Dan Lin (00:51:20):

Yes, we’ve been fortunate maybe in the last ten years to have many new medications. The majority of them are aimed at keeping the hormonal levels even farther down or keeping the hormones that we have still in our body from doing their job. So most of them are in that domain. However, there are new chemotherapies that are being worked on and approved for prostate cancer. And there’s even one immunotherapy that is approved for later stage prostate cancer, and that is called Sipuleucel-T, which is a prostate cancer vaccine. So there are emerging medicines, and I think that every year, we’re having even more of them come along with the progress and research that we’re doing in prostate cancer.

Dr. Richard Pelman (00:52:07):

So again, we use these in the situation of a recurrence of prostate cancer or persistence after initial treatment, either radical prostatectomy or radiation, or in a patient who first presents with advanced disease with a very high PSA and imaging studies that show it’s in bone or in lymph nodes. But let’s go back to the man who we hope has localized cancer and says, “well, I want to go talk to the radiation oncologist.” These are the doctors who treat the cancer with radiation. So tell us a little bit about the radiation that you previously referred to.

Dr. Dan Lin (00:52:39):

Yes. I think that prostate cancer is clearly a disease that we work in teams in our university hospital. Of course, we have an excellent staff of radiation oncologists that we work with together and see patients. And I’ve been there during their consultations and I can tell you what I tell my patients about radiation. As I said before, the radiation can come in two forms: the seed therapy or the beam of radiation. And what I tell patients is that just like with surgery, having two possible side effects, radiation also has two possible side effects. One side effect, again, I think is temporary, which is the irritation of radiation. And so I tell patients that radiation is delivered to the prostate, but inevitably the radiation will hit a little bit of the bladder, hit a little bit of the rectum, and thus cause irritation of those two areas.

Dr. Dan Lin (00:53:35):

What does that manifest in a patient? Well, I tell patients they might feel like there’s more urgency to urinate. Like when they have to go, they have to go right away. Same with their bowels. And they might have to actually have more frequent urinations due to the radiation. And that’s, I think, temporary. It certainly occurs during the radiation and for perhaps a few weeks or months after that, but it usually goes away. It usually resolves. Not always, but it usually does resolve. Likewise, I say to them, the other side effect is loss of some sexual function. And there’s no doubt that radiation also causes decreased erectile function. It is a bit more gradual than with surgery. In other words, it takes several months for the effects of radiation to affect the nerves that control sexual function. And so it might be a gradual dwindling of erections after radiation. But again, it’s very similar to surgery having a major effect on sexual function.

Dr. Richard Pelman (00:54:33):

And I like to emphasize to patients that again, this is a shared decision. They have the opportunity to speak to surgeons who may want to talk about the robotic technique, and then go talk to the radiation oncologist who will tell them and educate them more about radiation, and then we can help them make a decision. I like to emphasize to patients that sometimes there’s a better decision than not. And even with the radiation, people who have vast experience agree with me that a large prostate with a man who is having trouble urinating is not going to be the best candidate for radiation even if the patient says what they want. I look at patients and go, “well, you could have radiation. It’ll take care of your cancer but it will make it harder for you to urinate. Or you may be unsuccessful in urinating. Why don’t you have a treatment that takes care of both your cancer and your blockage, that’s removal.” Then there’s other patients who we look at and the choice is theirs so as long as they are educated and have the ability to have full knowledge of side effects and successes.

Dr. Dan Lin (00:55:33):

Yes, those are all great points. I should lead with the fact that it does seem that surgery and radiation does cure the patient in about the same amount of time. So I say to my patients that there is no evidence that surgery is necessarily better to cure you or radiation is necessarily better to cure you. There does seem to be some equality of cure rates. It’s just how to get to that cure and what they’re willing to go through to get to that point. And I very much agree with, there are certain patients that I do tend to steer one way or the other. Most of the time I’m giving them the choice in what they want to do. But there is that patient, such as the one you mentioned, the man with a large prostate, a fair amount already of urinary symptoms, who will not do well with radiation. Likewise, there’s a patient that might be not as healthy, multiple abdominal surgeries, not being able to withstand a surgery, and we might steer that patient towards radiation. And so there definitely is a shared responsibility between radiation treatments as well as surgical treatments.

Dr. Richard Pelman (00:56:44):

There are a subset of patients with the more aggressive cancers and higher volume that I personally feel do better by first removing the prostate, and then might need radiation. And as surgeons, we all would rather operate on non-radiated tissue. So we’d rather have things go through a sequence where the available second treatment doesn’t cause significant morbidity or side effects. Meaning if you radiate and then do surgery on patients, the incontinence rate is significantly higher and other complications arise.

Dr. Dan Lin (00:57:16):

Yes. In general, I would say that if a man has what we call low risk prostate cancer or earlier prostate cancer, that the need for a secondary therapy is probably low enough that it does not play into the decision of what to do first. However, you’re exactly right. If a man comes to me with a very aggressive prostate cancer that either surgery or radiation will unfortunately fail that patient, maybe not as much as half the time if not more, then it does cross my mind to say, “perhaps start with one of the therapies and allow the second one to come in later.” And that would be to start with surgery and have radiation as a possibility later, because in that patient, starting with radiation basically blocks surgery for later, because surgery, as I said before, if I do surgery on a man that’s never had radiation, his incontinence is temporary. Ninety percent of the time he gets it back. Gets control back. But if I say to a man that’s had radiation, I’m going to do surgery, I say more often than not, the incontinence is permanent.

Dr. Richard Pelman (00:58:23):

And I would also emphasize that in the high risk patient, there may be an eighteen or twenty-four month period of that “turn-off male hormone drug,” the anti-androgen drug, in combination. I also think it’s important in this spectrum of looking at these cancers just to go through some of the newer tests that we have to reassure a patient who is in surveillance that genetically his tumor is not going to be aggressive and there are some tests that can be done on the tissue of the cancer itself. And patients go, “can I do something to actually check the tumor?” If a patient has decided to have treatment, either radiation or removal, there’s no reason to do that. But if the patient’s on the border about surveillance versus treatment, what tests do you use that are useful?

Dr. Dan Lin (00:59:12):

So great question. I think that what you said about using the test, if someone already has decided, I think is the key point. In other words, I have always said that I only order tests that might actually change what I do. So if I know a patient is going to have treatment or if they know they’re going to have surveillance and want to go down those paths, then I’m not really sure a test is even needed. In those patients that want more data or I think that more data would help them, then there are a variety of tests that are available. There’s one called Prolaris, there’s one called Oncotype, and there’s one called Decipher. And those are their commercial names. And we’ve used all of them. In fact, they all work and they all work in doing one thing. Basically, they say that they take the tissue that’s already been in your biopsy, so there’s no need for extra biopsies or extra tissue. 

Dr. Dan Lin (01:00:05):

It’s the biopsy tissue that’s already been obtained, and that biopsy tissue is sent to a company, and then they give you the answer of genetically or molecularly what that tumor looks like that’s independent of what we already know about it. In other words, we know the grade of the cancer under the microscope. And what the test will tell you is, of men that look exactly like that grade of cancer, what this patient’s tumor really is. In other words, if a man has Gleason Grade Group one cancer with a PSA of six and you do the test, it will say that this patient is at the 50th percentile. In other words, that cancer molecularly looks just like it does under a microscope. And most of the cancers fall in that middle range. But they might come back and say, “this cancer is the 90th percentile.” In other words, almost all the cancers that look like this under the microscope, this one genetically or molecularly is the top ten percent in the worst. And that might change your mind from surveillance to doing treatment. And so I do it for those reasons, but only in the select patient that really will add to their risk score.

Dr. Richard Pelman (01:01:20):

And just going back to something you said earlier that I was thinking about, the patients who have high grade aggressive disease where you say they may fail, they may say, “why go through anything then?” they actually do end up with a better outcome having primary surgery and radiation then just ignoring it and going directly to an alternate therapy.

Dr. Dan Lin (01:01:37):

Yeah, that is a very good point as well. There’s never been a clinical trial where we flipped a coin and said heads in the higher risk patients, the really bad cancer, flipped a coin and said, heads you get surgery, let’s say, and tails you get nothing. There’s been one in Scandinavia. But it did show that we do think that just observing men with high-grade or high-risk disease, or just giving them hormonal therapy alone without giving them radiation on top of that or taking their prostates out with surgery, there is enough evidence to show that we should actually do something interventional there rather than just wait.

Dr. Richard Pelman (01:02:18):

And as we’re wrapping up, as you are a director of prostate cancer research, a whole full note for patients who are suffering from advanced prostate cancer in the research world?

Dr. Dan Lin (01:02:28):

I think that the most hopeful research, and again much of this is at the University of Washington, Peter Nelson, Colin Prichard, Heather Chang, and others that are doing it, which is what we call precision medicine. And I think that’s been a buzzword for quite a while. But we take men’s cancers, now these are men who have spread of cancer, maybe in their bones, and we’ve been biopsying their cancers and then sequencing them, the DNA, sequencing the DNA, and actually finding very unique signatures that suggest that those cancers might be susceptible to drugs that are not even approved in prostate cancer. And we’ve had some remarkable examples of patients who their PSA is going up, their PSA is fifty or a hundred, or maybe even literally two hundred, and we find they have a mutation, let’s say in either BRCA 1 or 2 or some mismatch repair gene, we call it MSH, and that makes them susceptible to other medications. And we’ve been giving them either novel chemotherapies or targeted agents and these men’s PSA’s are going from two hundred to two, or to one. And it’s been very remarkable in the progress that we’re making into individualizing cancer care for the advanced prostate cancer patient. It’s our group and many across the country that are doing this really novel, emerging, and very hopeful cancer research.

Dr. Richard Pelman (01:03:48):

Well, I think we’ve covered more than people want to know about prostate cancer, but hopefully it’s helpful to the population who have questions or concerns. We’ve been lucky to spend a significant time with Dr. Daniel Lin, the chief of urologic oncology and professor of urology here at the University of Washington. Dr. Lin, thank you very much. 

Dr. Dan Lin (01:04:10):

Thank you, Rich.

Narrator (01:04:10):

This completes another podcast chapter of the Washington State Urology Society’s Original Guide to Men’s Health. This is Dr. Richard Pelman reminding you to take care of yourself. Washington State Urologist Society wishes to thank all contributors who volunteered their time and knowledge. The information presented is the opinion of the speakers. The society also wishes to thank Sean Fox for his invaluable technical assistance. The music theme, San Juan Bells, was written and performed by Dr. Dave Whiting. The podcasts are the property of the Washington State Urology Society. Reproduction and use without the express consent of the society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.

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