Smilow Shares with Primary Care: Prostate Cancer

September 15, 2022

Information

September 6, 2022

Hosted by: Anne Chiang, MD

Presentations by: Erin Culbert, DO Bruce McGibbon, MD, Daniel Petrylak, MD, and Gerald Portman, MD

ID8062

To CiteDCA Citation Guide

00:00Oh, it's really exciting.
00:05Super, super exciting.
00:07Thank you guys for being the kickoff.
00:12Yeah, and who knew
00:13that September 6th was the
00:15day after Labor Day? OK.
00:21Karen, I didn't tell you yet.
00:23I got covered over the weekend,
00:24so I'm COVID recovering now. You
00:30are in the ranks of the proud
00:33who who held out for that full 2
00:361/2 years before going down now.
00:40With a really, really long Oh my goodness,
00:43OK, we are live actually. OK.
00:49Well, welcome everybody tonight to
00:51to Smilo shares with primary care.
00:54It's our kickoff. Wait just a few
00:58minutes so that people can join.
01:51Before we get started,
01:52I see we have about 14 people did did.
01:55Maybe you can answer the
01:57question and the answer.
01:59Did anybody have a difficult
02:01have difficulty logging on?
02:03Through the zoom link.
02:06If anybody did, please please just give
02:08us this the the feedback in the Q&amp;A.
02:18And then if you might be asking the
02:20wrong people, I know. They got on.
02:27Is 16126 and
02:30Dan, can you go on mute please?
02:33Thanks. OK. All right, well,
02:35let's get started because we
02:38have a lot going on tonight.
02:41My name is Anne Chang.
02:42I'm a medical oncologist
02:44and deputy CMO for Smilo,
02:47and I've been working very closely
02:49with Karen Brown and Ryan O'Connell.
02:52I'll let you guys introduce yourselves.
02:55Good. So I'm Karen brown.
02:56I'm the medical director of primary
02:59care for Northeast Medical Group and
03:01thrilled to see this series get Off.
03:04Ryan O'Connell, General Internist
03:06at NE Medical
03:07Group know I think most everyone,
03:10but for those I haven't met, thank you.
03:13And really a special shout out to Ann
03:15Karen and to all the panelists who have
03:18really worked hard to make this really
03:22meaningful and highly educational.
03:23I'm really excited.
03:25Great. And Kevin Billinsley,
03:27who's also our course director
03:29but is unable to attend today.
03:31So first just to opening slide,
03:36if you can pull that up, please?
03:39Telling you what this series is,
03:41it's a monthly series.
03:43It's called smilo shares.
03:45Actually. It's called with
03:47primary care for primary care.
03:48I think we ultimately decided with with
03:51primary care and this month is focused
03:53on prostate cancer and each month
03:56it's going to be a different topic.
03:58These are topics that both Karen
04:00and Ryan chose for primary care,
04:03not only for themselves,
04:04but thinking about and talking
04:06to other people.
04:07The designated audience is.
04:10Primary care clinicians.
04:12And our faculty,
04:13we tried to choose people from
04:15a specific geographic region.
04:18So today, we're in Greenwich really,
04:19and focusing on prostate cancer.
04:22And the idea is really to link
04:24up and build relationships
04:25between primary care and smilo
04:28physicians and EMG physicians.
04:30And and this is going to be a
04:32monthly series just like that.
04:33Trust your gut so you can get used
04:34to it and put it on your calendar.
04:36It's going to be the first Tuesday
04:39of the month from 5 to 6 virtually.
04:41And hopefully maybe this year we can
04:43do a few of these in person as well.
04:46And the the Big Y is really as
04:48we were talking about this that
04:51there there's just there's an
04:53explosion of information around
04:55cancer even for oncologists and
04:57I think for primary clinicians.
05:00This is an area where,
05:01you know,
05:02understanding the updated recommendations
05:04and some of the new approaches are
05:06really important to hear about and
05:08while there are lots of different,
05:10you know.
05:11Lectures around cancer,
05:13specifically this this format is
05:16really focused on primary care.
05:19And those questions that are most
05:21most important to you and it'll be
05:23case based tonight we have three
05:25cases that are really going to
05:27highlight those what we thought would
05:30be very topical or very important
05:33questions that you run that you come
05:35across in clinic and to highlight
05:38the clinical pearls from our our faculty.
05:41So let's go to the next slide.
05:43Ohh,
05:44this is the agenda.
05:46So we're going to do the the
05:47three case presentations.
05:48We will have some time for
05:50for a question to answer.
05:52Each one will take about 15 minutes.
05:55So we'll encourage you guys to
05:57put your questions in the chat.
06:00Some of those may be answered as we go along.
06:02Some of those if if you want
06:04to hold them to the end,
06:05we will hope to have hope to have
06:08a little bit of time at the end.
06:10And then our our terrific faculty is here.
06:16Or you wanna introduce Aaron?
06:21Or we have Aaron Culbert, who is an
06:25internist in the Greenwich region,
06:28well respected by her colleagues and
06:31her patients, and turns out to be quite
06:35knowledgeable about prostate cancer.
06:39How she's a mother
06:41as well as a physician and has all sorts
06:44of athletic activities as well as well.
06:49And and next is Bruce Mcgibbon.
06:51He's already he's been a radiation
06:53oncologist at Yale for 13 years,
06:55and he is the medical director of Rad
06:57ONC at Greenwich for the past three.
07:00And he's particularly
07:01interested in prostate cancer,
07:03also very active and and an owner of
07:06a new kitten he informed us last week.
07:10And then my colleague Dan Petrovac,
07:12who's a medical oncologist,
07:14he's a professor of medicine and leads
07:17the Gu cancers for Yale and Smilo.
07:20Uh, in New Haven.
07:21He's been in Greenwich for for
07:24practicing for 10 years as well he is.
07:27Do you expert these develop new drugs
07:31he's brought them to FDA approval
07:34really just known internationally
07:37and and an amazing clinician and
07:41and a clinical researcher and also
07:43very active in tennis and golf.
07:45And then finally Jerry Portman who
07:48has been a urologist at Yale for 10
07:51years in Greenwich for a year and he
07:53is you know he does generally urology
07:55but really focuses on urologic.
07:57Ecology and he loves to travel.
07:59In fact,
08:00he was participating on his vacation
08:02last week in planning of this event.
08:04So we're going to get going and
08:07turn it right over to Aaron to
08:10start us off on the first case.
08:12Thanks,
08:12Karen.
08:13All
08:13right. Thank you so much and
08:14thank you so much, Karen,
08:16for that kind introduction.
08:17We're going to start with our first case,
08:21pretty typical primary care,
08:23bread and butter.
08:24We have our 47 year old white male.
08:28Nonsmoker patient who presents
08:30today for a routine physical exam.
08:34When asked, he notes no urinary symptoms,
08:37unless of course he has coffee
08:39at night right before bedtime,
08:41which results in one to
08:43two episodes of nocturia.
08:44When we questioned him about family history,
08:47he relates his father was diagnosed with
08:49prostate cancer at the age of 61 and
08:52notes that his paternal grandfather was
08:54also diagnosed with prostate cancer.
08:56Not sure of the age for that.
08:59Uh, so he uhm,
09:01unless we count that coffee is
09:05asymptomatic for urinary symptoms.
09:08He expresses concern to us about
09:11his family history of prostate
09:15cancer and says DOC,
09:17can I get screened for prostate cancer?
09:20So we are going to talk uh to him.
09:24I think it's easier to go through
09:29some of the screening recommendations
09:31utilizing our care signature pathway
09:34for prostate cancer screening.
09:36This was a collaboration between
09:40our clinicians also involved
09:42review of a lot of the evidence
09:45that's available as well.
09:49Consideration of the
09:51national recommendations,
09:52I think Mike Lehman was involved as
09:55well as our other affiliated urologists
09:57were involved in developing this pathway
10:00and keeping it as up to date as we
10:02can with the change in recommendations.
10:04Certainly since 2018 there's
10:06been a lot of changes,
10:09especially with the Class C recommendation
10:13for prostate cancer screening for
10:15patients 55 to 69 and a lot of debate.
10:19Revolve revolving around the
10:20prostate specific antigen as
10:21well as digital rectal exams.
10:23So we'll go through that as if you were
10:26in the room talking to your patient,
10:29going through the pathway to
10:31evaluate his prostate cancer risk
10:34and go through the screening.
10:39So we have our test patient here.
10:42Karen's kind enough to drive for me,
10:43so she's going to open up that pathway.
10:46So this is how it would look
10:47if you were in doing your note.
10:51If you type in prostate,
10:53not prostate, uh, it will come up
10:56with the prostate cancer screening.
10:59Pathway or you wanna click on
11:01that initial screening pathway?
11:05And it will open up.
11:08Obviously the entire pathway,
11:10she's gonna fit it to our screen here.
11:13So we're gonna go through uh and see our,
11:16our our case,
11:18uh for today was 47 years old.
11:21Karen, if you want to open up the authors,
11:23I think you want to give full credit to
11:26the contributors for the pathway content,
11:28because I know this took a lot of work.
11:30Uh, so there's our list.
11:32Mike Leitman up at the top,
11:33an extra bacus who's from
11:35the Greenwich region as well,
11:37Jerry Portman, who's with us today,
11:39Karen Brown who's with us today,
11:42as well as a host of others.
11:44So thank you very much for making this
11:46easy to use on the primary care side.
11:50Alright. So we're going to
11:52go through the pathway.
11:54We're going to spend a little
11:56bit of time here because it
11:57does open up into some detail.
11:59We're going to talk about some risk factors.
12:01We're going to go through as well,
12:04OK, if we check the PSA and it
12:06comes back at a certain level.
12:08So we'll give you a whole
12:11pathway overview here.
12:12So our patient is 47,
12:14he meets the criteria being above 40.
12:18So we'll consider prostate
12:20cancer screening for him.
12:21It's important to note this does not
12:24apply to patients who have a prior
12:27prostate biopsy with a high grade
12:29neoplasia or atypical cell proliferation.
12:32We also want to double check that our patient
12:34has a greater than 10 year life expectancy.
12:38Our patient is healthy,
12:39has no other medical comorbidities
12:41that we know of.
12:42Uh, and he is younger than 75 years old.
12:45So we're gonna proceed down that pathway
12:47and then we go to risk factors which
12:50I want to spend a little bit of time
12:54about certainly African American descent,
12:56we need to note.
12:58So on our initial case presentation slide,
13:00you know if he were African American
13:02that would be an additional risk factor
13:05on top of his family history and it
13:07gives you the incidence rates as as well,
13:10but it it's quite elevated.
13:11So they.
13:12That population should definitely be
13:14screened at an earlier age greater
13:17than one or one or greater first
13:19degree relative within the history of
13:22prostate cancer on either side actually.
13:25So maternal and paternal
13:27diagnosed that less than 65.
13:30Family history of other cancers is important.
13:34You want to consider not
13:36only prostate cancer,
13:37but you do want to consider breast
13:40cancer either male or female colorectal.
13:43I think Melanoma is on that
13:45list or it was ovarian,
13:48pancreatic,
13:49uterine and then it expands down
13:52at the bottom if you have two
13:54or more first or second degree
13:57relatives with cancer at any age,
13:58so if you have multiple relatives.
14:02They will also count for you.
14:04So he does have a family history
14:07of prostate cancer and his father.
14:09So we're going to say, yes,
14:11he's a high risk patient and then we'll
14:15initiate shared decision making for him.
14:18I'm going to come back to that.
14:20Thank you.
14:21There's a bunch of resources there.
14:23I did want to touch on the germline mutations
14:26and the genetic testing that's available,
14:29so not.
14:32Not very common to talk about.
14:34It's something that Yale offers
14:36for our patients, which is great.
14:38If you click that hyperlink that
14:40says referral to cancer genetics,
14:42it'll automatically bring up to sign
14:45off on that ambulatory referral to genetics,
14:48type in the referral reason,
14:49send it off.
14:51There's also a Yale Generations project
14:53which you can offer to your patients,
14:56which is a DNA sequencing project
14:59that's free to participate in,
15:01provides a lot of genetic screening.
15:03Uh, opportunities?
15:06And Karen just pull and pull
15:08up our our flyer for that.
15:10So that is definitely available to our
15:14patients either blood or saliva testing.
15:16And then patients will get that
15:19results and have a nice QR code they
15:21can scan to get involved with that.
15:24So we can print that and give that to our
15:26patients or just click on that link and scan
15:28the QR code in the visit, which is nice.
15:32In terms of genetic testing,
15:34BRCA gene testing is important.
15:37And then there's additional.
15:41Remind mutations that if you
15:42Scroll down and click on,
15:44that germline mutations line
15:46up right above Karen.
15:50There's also additional testing
15:52related to Lynch syndrome.
15:55I think the ATM gene,
15:56there's a few genes that we know are
15:59linked to higher risk of prostate cancer.
16:02So when it comes to shared decision making,
16:06while I'm in the room with my patients,
16:09you can open this up.
16:11I know everybody has a different
16:13report with their patients,
16:14but basically the important thing
16:16is to let the patients know.
16:19What the recommendations are,
16:21uh, what the testing is,
16:25as well as the risks of the testing.
16:29So there's a lot of great handouts
16:31from the American Cancer Society
16:33resources from up to date that provide
16:36a great informational overview,
16:38especially with patients 47.
16:40He's probably never had prostate
16:42cancer screening before.
16:43Would give them a great overview to
16:45know exactly what we're getting into
16:47because once you start screening.
16:49It's going to be continued most
16:52likely until they're 75 based
16:54on the current guidelines.
16:56So I would take this patient through, OK.
16:58Yes, we should talk about
17:00prostate cancer screening.
17:01Your dad had a history of prostate cancer.
17:05These are the ways that we would screen.
17:08PSA is is the most commonly used.
17:11We'll come back to other methods.
17:14There are risks of false positive.
17:16Uh, if you Scroll down,
17:17there is a list of the acute factors.
17:19Yep, you got it.
17:21That may alter PSA results.
17:24So we'll get into that.
17:25But there is a nice smart phrase
17:27you can put in your note.
17:28It's dot prostate cancer screening,
17:31SDM's shared decision making.
17:32So you can put that into your note.
17:34Get full credit for having that
17:37lengthy shared decision making
17:39conversation with your patient.
17:40So you want to let the patient know,
17:44you know, hey.
17:45PSA is not a perfect test.
17:47If you have some urinary
17:49retention instrumentation,
17:50vigorous physical activity or perineal
17:54trauma can sometimes raise the PSA.
18:00So if they say, OK,
18:01I understand they're the
18:02risks involved with PSA,
18:04I want to proceed.
18:05You would then click on the screening
18:07PSA order either through Yale or
18:09LabCorp or through Quest and it's
18:11going to look exactly like that if
18:13you see on the upper right hand side.
18:16So you can just hit accept and it will
18:18sign off on that screening PSA order.
18:21Yeah, there you go.
18:23Perfect.
18:26Alright. So say we sign off that our 47
18:31year old male is otherwise pretty healthy.
18:33It's a week or two later, depending on
18:36whether he went to Quest or LabCorp,
18:38he should have gone to Yale. And then, uh,
18:42as you go through the pathway, there's Umm,
18:45if you go down to that 3rd result,
18:47that PSA interpretation?
18:51Normal result discussion.
18:52You can then go through that pathway and it
18:55literally takes you through step by step.
18:57So Umm, we're going to go through,
19:02we're going to come back to
19:03the digital rectal exam.
19:04I have a couple slides on that.
19:05Umm, we'll talk about that in a minute.
19:10If the PSA is greater than 10.
19:13It should be repeated in
19:15about four to six weeks.
19:17Uh, you want to make sure we
19:19weren't missing part of our history,
19:21some unknown instrumentation or unknown
19:24symptoms that they didn't realize they had?
19:27Uh, we also, uh,
19:29wanna review what that repeat lab is.
19:33If it's still elevated,
19:35then that generates a reflex.
19:37You can hit that refer to urology
19:40hyperlink up there on the right.
19:42Yeah.
19:43And at that point,
19:45we need to get your urology involved
19:48because that indicates more of a
19:50high risk probability if our young
19:5247 year old has a PSA less than 10,
19:55which thankfully most of them do.
19:58We need to consider.
20:01Other factors so say he was 47 and on
20:05finasteride to help prevent hair loss.
20:07Umm, that's your 5A reductase inhibitor.
20:11So there actually is a correction
20:13factor for that,
20:14something which I had to brush
20:16up on for this.
20:18So not that I have a lot of patients on it,
20:20but if you do have a patient
20:22that's already on it,
20:23you really should double your PSA value.
20:28If the PSA increases while they're
20:30already on a 504 reductase inhibitor,
20:33that also should be evaluated by urology.
20:36The reason for that is because higher
20:39grade lesions are more common when
20:41you're on a 5A reductase inhibitor.
20:43So assuming he's not on finasteride,
20:46which our patient was not,
20:48you can go by age category,
20:51even though the lab cut off will
20:53be 4.0 nanograms per milliliter.
20:55It really does go by age so
20:58that first decade.
20:5940 to 49,
21:01if it's greater than two
21:03is considered abnormal,
21:05then 50 to 59 greater than
21:07three also considered abnormal,
21:09and then 60 and above.
21:10You can use that upper limit
21:13normal of the lab cut off at 4.
21:16So you can go through based on all of that.
21:22If his PSA was less than 2.0
21:25nanograms per milliliter,
21:27then you would go to the right
21:29and he would have a normal PSA,
21:31and actually it'll break it down
21:33even further into when you should
21:35be repeating the PSA numbers,
21:37and you can actually go into
21:39your health maintenance screen.
21:42And you can update the modifier and
21:45select the frequency that you want to.
21:48I think you might have to hit edit modifier.
21:51Yep.
21:54Yeah, there it is.
21:59Wonderful. And it should pop up.
22:02Although. For us, it's not.
22:07So you should be able to edit that
22:09modifier to be specific for the time
22:12interval that you want to repeat.
22:14You do not have to do it every year,
22:17uh, but for higher risk patients,
22:19uh, like our patient you should.
22:21And then for lower risk patients
22:23you can do every two to four years
22:26depending on how low their PSA is.
22:29And I think that about covers the
22:31more important points of the pathway.
22:35Just Scroll down, make sure
22:36I didn't miss anything.
22:41Yeah. And then it's all the same.
22:44If PSA is abnormal again, then you
22:46would refer to urology at that point.
22:50Thank you, Karen.
22:53All right. Hopefully that the
22:56health maintenance didn't
22:57work because of the age.
22:59So we just looking at that we just
23:01problem solved and that will get fixed.
23:06Yeah, we picked an older patient for testing.
23:09All right. So I just want to draw
23:11some attention to the smart phrases.
23:13There's that shared decision
23:15making smart phrase.
23:16And then if you want to,
23:17rather than clicking on the
23:19hyperlinks in the pathway,
23:20if you felt like you wanted
23:21to do the prostate resources
23:23in your after visit summary,
23:25there is a smart phrase for that as well.
23:26At the bottom, another key update,
23:30we need to circle back to
23:33the digital rectal exam.
23:34It is no longer recommended
23:36for screening purposes,
23:38but it absolutely should be done.
23:39For diagnostic purposes,
23:40if our patient maybe didn't drink the
23:43two cups of coffee before bedtime and
23:46still had those episodes of nocturia,
23:48you know,
23:49we may want to consider
23:51evaluating what's going on.
23:53But for average screening purposes
23:56is not recommended in terms of
23:59when to start PSA screening
24:01for prostate cancer screening,
24:03if it is elevated risk,
24:04you need to tell the patient
24:06that there are higher risk engage
24:07in that shared decision making.
24:09I know it takes a little bit of time,
24:10but it's worth it.
24:11Because then they understand what
24:13they're getting into and have
24:15better follow-up going forward.
24:16If there's really no increased
24:18and that'll start at 40 to 45,
24:21if they really don't have
24:22any increased risk factors,
24:24you can start at 50.
24:26If we go to the next slide,
24:28I wanted to spend a little bit of time
24:31talking about that digital rectal exam,
24:33everybody's favorite test.
24:36So I, I, you know,
24:38kind of had some trouble adjusting
24:40to this and and probably still do
24:43because I was kind of trained in medicine.
24:45If if you could see it and touch it
24:46and it was right in front of you,
24:48you should check it.
24:50But with the digital rectal exam
24:52that's not necessarily the case.
24:55As I mentioned,
24:56definitely for symptoms,
24:57not so much for screening.
24:59It does have a low sensitivity
25:01and low specificity.
25:03The most generous estimate that
25:04I could find was that it had a
25:0641% positive predictive value.
25:08But that was out of a meta analysis
25:10where when you broke it down into
25:13the individual studies did not have
25:15such great evidence backing it up.
25:17So that was probably overgenerous.
25:20They think the OR have shown that
25:23the digital rectal exam will
25:25increase the PSA a bit, you know,
25:27up to .4 nanograms per milliliter.
25:29And of course,
25:30just because of anatomy and physics.
25:33You can only detect that that
25:35back surface of the prostate,
25:37making the earlier stages of
25:39prostate cancer undetectable
25:40based on just the Dre alone.
25:43So for that reason.
25:45You know,
25:46up to 1/3 of cancer is detected
25:48by a digital rectal exam alone or
25:51advanced versus less than 10% or
25:53advanced stages when you use the PSA.
25:57So there is an advantage there.
25:59There have been additional comparisons,
26:02you know,
26:03looking at positive predictive
26:04value using abnormal digital
26:06rectal exam with a normal PSA,
26:09that's about a 10% positive predictive value.
26:12And then there were additional
26:13studies looking at OK,
26:14well, if you.
26:15Have a normal digital rectal exam
26:17but then you have an abnormal PSA.
26:20Positive predictive value goes up
26:21to you know 25% a little bit more.
26:25So there was you know,
26:27an advantage to using the PSA over
26:30just the digital rectal exam.
26:32Certainly if you're using the
26:35Dre for evaluating symptoms
26:37or if the patient says Doc,
26:39I can't sleep tonight unless you
26:41check my prostate and you find
26:44something nodule and duration.
26:46It's asymmetric.
26:47Regardless of what the PSA level is,
26:50you're going to refer that patient
26:52to urology to have that evaluated.
26:54Alright, I think that's all of my slides.
26:58All right, Jerry, onto you.
27:01All right.
27:02Good evening, everyone.
27:04So my patient is more your
27:08average patient that usually gets
27:11diagnosed with prostate cancer.
27:12So it's a 57 year old
27:15asymptomatic man with PSA of 5.6.
27:18We always try to get a repeat PSA to
27:20make sure that it wasn't an aberration.
27:23Re PSA's basically the same.
27:26And for almost all our patients at Yale,
27:30we try to get an MRI.
27:33Before any biopsy because it
27:35increases and improves detection
27:37and if we're we have technology that
27:41helps target the specific areas on
27:43the MRI to make it a better biopsy.
27:45So target biopsy was performed and
27:48it shows Gleason 3 + 4 prostate
27:50cancer and five out of 17 cores.
27:53And these biopsies can be performed
27:55in the office under local,
27:56which most of us do,
27:58but also a lot of patients
28:00have anxiety about this.
28:02So we do offer to do it in
28:04the OR under sedation as well.
28:06I would say 80% of my patients
28:09tolerated very well in the office
28:12because we could do a good prosthetic
28:15nerve block and about 20% have it
28:18done in the OR in terms of so the
28:21Gleason 3 + 4 prostate cancer and.
28:24Go into the risk groups in a second,
28:25but it's considered intermediate
28:27risk favorable.
28:28The two main treatment options that we offer.
28:32Active surveillance is usually for
28:33low risk and we offer radiation
28:35and robotic surgery,
28:36which are standard of care treatments.
28:39There are also focal therapies that
28:42are considered newer treatments and
28:44don't have as much data behind them.
28:46Prostate cancer is a very
28:48slow growing disease,
28:49so a therapy has to be
28:52around for 1510 to 15 years.
28:54Before we know how well it works
28:55in terms of recurrence risk and
28:58then this question always comes
29:00up in terms of staging.
29:02For patients with prostate cancer,
29:04CAT scan and bone scan is recommended
29:06for grade Group 3 or higher,
29:08meaning Gleason 4 + 3 or higher.
29:11And there are instances where we
29:13use a newer PET scan called PSA PET,
29:16which Bruce Mcgibbon will go
29:17into a little bit in his slides.
29:22If we could go to next slide,
29:25so I just wanted to go over the
29:27risk stratification because we
29:28throw around these terms, low risk,
29:30intermediate risk, high risk.
29:31What do they mean?
29:32So very low risk is a small amount of
29:35leasing 6 basically with a low PSA.
29:38Gleason, Six is considered a very.
29:43Unaggressive and the chance of
29:45it spreading outside of the
29:47prostate is extremely low.
29:50In most studies,
29:51it's actually believed to be 0.
29:54So both very low risk and low risk
29:57patients we usually recommend
29:58for active surveillance.
30:01Intermediate risk patients are split
30:03up into favorable and unfavorable
30:06and that's basically how much of the
30:09Gleason 4 component that they have.
30:11Also, it can be based on PSA.
30:13PSA is above 10.
30:14It's also falls into intermediate risk.
30:17High risk is usually Gleason 4 + 4 or higher.
30:20So great Group 4-5 and very high
30:24risk if there's evidence on MRI,
30:26if someone vascular invasion,
30:27noble disease, metastatic disease,
30:29or if the the top.
30:31Component of the Gleason score
30:32is the Gleason 5.
30:35So in terms of treatment
30:38for intermediate risk,
30:40robotic surgery and radiation
30:42are considered equally effective
30:44in prostate cancer treatment.
30:46We haven't been able to prove that
30:48one is better than the other,
30:49so we usually go over the side
30:51effect profiles of each one and the
30:54benefits and risks of each each
30:56one and let the patient decide.
30:58Robotic surgery,
30:59usually it involves A1 day stay in the
31:01hospital and a catheter for one week.
31:03You it's we we do a robotically,
31:06but it's still a three to four week
31:08recovery radiation treatments,
31:10usually 5 or 28 treatments
31:14depending on the patient and
31:15cancer characteristics or let Bruce
31:17go over that a little bit more.
31:19The main effects of both radiation and
31:22surgery are on urinary and erectile function.
31:26Newer less proven therapies are the
31:29focal therapies and there are four
31:32or five of these that depending
31:34on the institution.
31:35And I'll go over one of the newer
31:38ones that we have here at Yale.
31:40Prior to radiation,
31:42patients usually undergo a procedure
31:44which is similar to a biopsy
31:46where we place gold markers into
31:48the prostate to help target the
31:50radiation and we place a space or
31:52gel and Bruce will have some slides
31:54on that and then the important thing.
31:56To know is patients who are getting
31:59radiation treatment even for localized
32:02cancer, if it's grade Group 3,
32:04the NCCN guidelines recommend four
32:06to six months of androgen deprivation
32:09therapy and for great Group 4 to 5,
32:12the NCCN guidelines recommend
32:13at least 18 months for androgen
32:15deprivation therapy.
32:16This used to be two to three years.
32:18They've decreased it in the last two,
32:21two years.
32:23To make it a little bit more tolerable,
32:26next slide,
32:27so to just go over some newer technologies,
32:30we have a. Yo.
32:35We,
32:35we have been using for the last
32:3710 years the Artemis system to
32:39help target MRI lesions.
32:41We've just upgraded to the exact view,
32:43which is a very powerful ultrasound.
32:48It's 300 three,
32:49100% more powerful than standard ultrasound,
32:51which is 7 megahertz.
32:53And on this ultrasound we could
32:56actually see prostate cancer
32:59lesions and that's what the bottom
33:01right hand corner is showing.
33:03It's the ultrasound is so powerful
33:06that the the slide on the left
33:09is actually showing that you can
33:11actually see the previous needle
33:12tract through the prostate.
33:16You can still do MRI fusion on these
33:19machines, which is very important
33:21because most of our patients
33:23get the MRI before the biopsy.
33:25OK. Next slide.
33:28And then one of these newer
33:31technologies that's also available
33:33at Yale is the Tulsa Pro.
33:34And what this is is transurethral
33:37ultrasound ablation of the prostate.
33:38So the top device of the patient is
33:41asleep under anesthesia and it gets
33:44inserted into the urethra like a catheter.
33:47And the bottom device gets inserted into
33:50the ****** uh for cooling the rectal area
33:53and if you could go to the next slide.
33:56And basically what this device does,
33:58it rotates and under MRI guidance it ablates
34:01the prostate in a circumferential fashion.
34:04Within 1 millimeter of the capsule,
34:06it's very precise.
34:10You can do focal therapy as shown on
34:12the slide on the left where you could
34:14just do 1/4 of the plot prostate,
34:17you could do 1/2 of the
34:19prostate or the entire thing.
34:20So there are two clinical trials
34:22right now at Yale investigating this.
34:25One is comparing it to surgery
34:27and one is just comparing.
34:30Is just the observational
34:32study to see the the.
34:34It's believed to be that the side
34:36effects with this are significantly
34:38lower than with surgery or radiation.
34:41Another area of interest for this
34:43treatment is in salvage treatment for
34:45patients who have undergone radiation
34:48and now have recurrence.
34:51And now I'll turn it over to
34:53Bruce to discuss radiation
34:54treatment. Thanks, Jerry. So
34:59just want to break down some of
35:01the different scenarios where we
35:02do radiation and and give some.
35:04Some of the core details I think would
35:06be most interesting to you guys.
35:08So for intact prostate
35:10basically the two options,
35:11one is external beam radiation where
35:13patients lying on a table machine
35:15moves around at the distance and
35:18shoots X-rays and the others breakey
35:20therapy usually with with seed implant.
35:22The vast majority of the of the
35:25gentleman these days in the US and
35:27really I think internationally get
35:29external beam breaking therapy
35:30still quite effective but in a much
35:32smaller percentage of the cases.
35:34Uh, and it's less commonly available.
35:37So within external beam you have what's
35:40really considered traditional IRT,
35:42which is intensity modulated
35:43radiation therapy that I think
35:44most people are familiar with.
35:45That's the nine week course,
35:47which is 40 to 45 treatments.
35:49We kind of rarely use that anymore.
35:52That's really for guys who have
35:54very large process or have a lot
35:56of urinary issues where we're
35:57trying to be very gentle per day.
35:59So most guys don't need that.
36:01We're mainly doing like Jerry referring
36:02to either the 28 treatments or the five.
36:04Treatments 20 actually can be 20 or
36:0628 in the Yale system we we followed
36:09the data most closely from the
36:1128 fraction or treatment regimen.
36:13So that's what we'll see.
36:14It's official title is moderately
36:16hypofractionated IRT,
36:17but for us it's 28 treatments.
36:21The other is the five treatment option.
36:22This one has a lot of nicknames.
36:24There's a lot of advertising around it.
36:26So I think it's important to know
36:28that the core technique is SBRT or
36:31stereotactic body radiation therapy.
36:33This is the technique that the cyber knife.
36:35Sheen does, but other machines do as well.
36:37So our machine here at Greenwich
36:39is the true beam, for example,
36:41and a lot of machines like that,
36:43they're high end machines that
36:44are capable of this,
36:45but Cyber net does it also sometimes called
36:48Saber in the Sloan Kettering system,
36:51excuse me,
36:51it's referred to as precision RT.
36:53But anyway,
36:54important to know that a lot of
36:56machines do this technique.
36:58It is very focused.
36:59The cure rates are the same between
37:01these options.
37:02The bowel issues and urine issues are very,
37:05very similar.
37:06There is some thought or or hints
37:08that the five treatment option
37:09because it's more intense per day
37:11might have a little more of an
37:13acute urinary side effect profile
37:15in the data that's out there that
37:17actually looks very, very similar.
37:18But anecdotally I think some
37:20physicians especially urologist who
37:22who follow the complications the most.
37:24Mostly feel like maybe there are
37:26sometimes some extra issues with that.
37:28For us,
37:29I think the big distinguisher is
37:32prostate size and baseline urinary
37:34issues if you have a prostate size
37:37under 60CC's and really fairly
37:39low urinary issues.
37:40And I think these guys tend to
37:41be a good candy for either one.
37:43But if you're anything beyond that,
37:45I really strongly caution guys that
37:47they kind of asking for trouble with
37:49five and we should really do the 28,
37:51which is a very solid track
37:53record in terms of.
37:54Pure and and toxicity breakey therapy
37:57briefly mentioned that's the seed
37:59implant or sometimes temporary
38:00catheters that are put in and then a
38:02radioactive source is placed in and out.
38:03I think this technique again very
38:05good especially for the low risk
38:07and favorable intermediate the
38:09jury was mentioning probably is
38:11the worst of the urinary staff
38:12profiles and can also be combined
38:15with external beam for high risk guys.
38:17But that's a bit of a of a nuance
38:20that it's probably not not so
38:22important for this this chat.
38:25For post prostatectomy.
38:27You're sometimes asked to give
38:28radiation within about 6 to 12
38:30months as adjuvant treatment.
38:31There's some very risky looking
38:33features that surgery pelvic nodes or
38:35the PSA does not go to undetectable.
38:37But most of what we're doing these
38:39days is called salvage radiation
38:41therapy and that's where the PC's
38:43gone undetectable and subsequently
38:45risen typically to something like
38:47.2 is our our most common cut
38:50off and we see the guys there.
38:53It's about a 37 to 39 treatment course,
38:55it's about 8 weeks and.
38:58There's some developing data about,
38:59including four to six months,
39:01usually six months of engine
39:02deprivation for these guys as well,
39:04especially if they're coming to
39:06us with a little bit higher PSA
39:08or some other feature that's
39:09a little riskier for Gleason.
39:11And the third category which is I
39:13think definitely the new kid on the
39:14block and you know is really not as
39:16well known but it's becoming really
39:17important is oligo metastatic.
39:19So these are the guys who have,
39:21they do have metastatic disease
39:23based on whichever imaging we'll
39:24talk in a later slide about that.
39:26But let's say they have in the
39:28prostate and they have two bone sites.
39:30Should we treat this guy the same as
39:32a guy who has 17 bone sites and some
39:35nodes in his in his chest and you
39:37know the the most recent data says
39:39that really we should treat these
39:41guys differently if they have all of them.
39:43That disease we should treat the
39:45prostate as part of the case is not
39:48replace hormone therapy and other
39:49things that that Dan will talk about.
39:51But in addition to that,
39:52treating the prostate has a survival benefit.
39:55And if we have again a limited
39:57number of bone sites,
39:58actually going after those bone
40:00sites can help to prevent additional
40:02bone sites from coming up and
40:05create a longer PSA control.
40:07Next slide please.
40:09Just give a little more detail,
40:11Jerry's mentioning.
40:11We put in the the gold markers and
40:13the gel refer to the gel first.
40:14So this is called the main product that's
40:17available these days is called space or gel,
40:19and this is a biodegradable gel.
40:21So it goes in,
40:22it lasts for three months and
40:23then dissolves back to water
40:25over another three months and
40:26just absorbed by the body.
40:28And as you can appreciate in the
40:29upper left in the cartoon and then
40:32the real MRI pictures on the right,
40:34it's really trying to create this pad of
40:36gel between the prostate and the ******.
40:38And as I tell patients, it's not.
40:40It's not a shield, it's not absorbing
40:42radiation in some magical way,
40:44but it's creating with that gap that's
40:46allowing us to drop the dose very quickly
40:48between the process and the ****** and
40:50it helps to reduce rectal side effects.
40:52So not every guy is a
40:54good candidate for this,
40:56but most guys are.
40:57And if there's a a nuance to it,
40:59then we work with the urologist about,
41:00you know, who's a good candidate versus not.
41:02So some guy who has posterior extension of
41:05of cancer on MRI that's pretty pronounced,
41:07may not be a good candidate for example,
41:09but most guys are.
41:12And so I think you'll be hearing more
41:14and more about guys who got gel on with
41:17their markers with definitely a big helper.
41:19Next slide, please.
41:22There are different
41:23fiducials that are possible.
41:24I say the most common ones
41:25and that we use are gold and
41:27you can see a zoomed in view.
41:28They they have a little bit of a
41:30texture or rifling to them to help
41:33stick in the prostate not migrate.
41:35But there there are ceramic
41:36versions of these.
41:37There are long coiled versions.
41:39There's another one that has a a called
41:43Calypso that has an electromagnetic.
41:46Frequency is like an RF powered device that
41:48can be checked multiple times a second.
41:50So there are multiple types,
41:52but I think you know the goal ones are
41:54the most standard work really well.
41:56The imaging on on the lower right is
41:59what's called a cone beam CT you know
42:01when when patients are asking us,
42:02you know, how do you know that,
42:04that the treatment is accurate?
42:05You can't see my prostate,
42:06but the treatment say,
42:07well every day before we treat you,
42:08we spin the machine around and we
42:10take an image that's a cone beam CT
42:12that looks very much like a CAT scan.
42:13We overlay it with the real CAT
42:15scan that we get for planning.
42:16Services.
42:17So in this view here with this
42:19kind of quartered view,
42:21the upper left and the lower right is
42:23from the real CAT scan and the cone
42:25beam is the upper right and the lower left.
42:28You can see that there's some slight
42:29differences in how the tissues appear,
42:31but they're really,
42:32it's really very robust and you
42:34can see with the this red arrow
42:36what the gold markets like.
42:37So the gold markers are are very
42:40easily distinguished and this is
42:41what helps us to have a high degree
42:44of confidence that we're on target.
42:46Now some guys are not a candidate for this.
42:47They, you know,
42:48they're on blood thinners and they.
42:49If we feel from primary care that
42:51you're for their cardiologist that
42:52that's just not going to be safe
42:54to go off blood thinners again
42:55or they simply don't want another
42:56procedure or whatever it is.
42:57So we do have an option to not
43:00do gel and not do markers.
43:02If we're going without markers,
43:03then the margins that we use around
43:05the prostate are a little bit larger
43:07because we don't have quite the same
43:09degree of confidence about the alignment.
43:11We can still take this comb beam
43:13image and see the soft tissues.
43:15So we we can get very, very close,
43:16but the markers even even nicer.
43:19Next slide please.
43:21Uh,
43:22just a quick word about better
43:23imaging for prostate.
43:24So if we're moving into that intermediate
43:26or high risk prostate cancer and
43:28above where we're trying to staging,
43:30you know, convention,
43:31we're getting an MMR and usually
43:33getting a CAT scan, abdomen,
43:34pelvis and bone scan.
43:36These are still good,
43:38still highly supported.
43:39Some insurance companies will still insist
43:41on getting those instead of a pet scan,
43:43but I think that the that
43:45the trend is definitely
43:47to allow PET scans.
43:48The first PET scan that we had access
43:50to around here was called Axemen.
43:52The newer one, I think we have
43:54a little more confidence in.
43:55It has some trade names like Polara 5,
43:57but it's really a PSM, a pet CT,
44:01another slide about this in a moment,
44:03but currently for the PSA pet,
44:07we're having a gentleman go up to New Haven,
44:09but later this month it will be
44:11available at Greenwich as well.
44:12We'll see this popping up I
44:14think in other places over time.
44:16Next slide please.
44:18Just a little little bird
44:20I'm going to focus on,
44:21on the mid and bottom part of the slide.
44:22So this this PSM, a pet can be
44:24used for gentleman with an initial
44:27diagnosis prostate cancer or if
44:29they're post treatment either post
44:31prostatectomy or post radiation.
44:33We're seeing a PSA rise and we want to
44:35hunt down where the spot is or spots are.
44:37This is a a great study for that.
44:40PSA is prostate specific membrane antigen.
44:43So this is a little more specific
44:45to prostate cells is overexpressed
44:46and over 90% of prostate cancer
44:48cells and that's really the magic
44:49of how we can make this work.
44:51So this is not a regular
44:53pet scan with glucose.
44:54This is really targeted to to PSA and
44:57interestingly and hopefully it is has
44:59a high degree of expression with those
45:02higher leasing score, nastier tumors.
45:04Next slide please.
45:07Are you OK?
45:13Turn this over to Dan.
45:23Hi, Dan, I think you're on mute still.
45:29I think it's important to note that
45:31we've made a tremendous amount of
45:33progress in metastatic disease,
45:35not only in the earlier treatment
45:37of prostate cancer when we call
45:39the hormone sensitive state,
45:40which is what this patient is,
45:42but in the hormone resistant
45:44or castration resistant state.
45:46In fact, in 1991, my esteemed Lake colleague,
45:51Alan, you go to my published paper
45:53saying that patients only lived
45:54about a year with chemotherapy.
45:55Well, we've extended that out with
45:57all of our other treatments to
45:59about three years at this point
46:00and with good quality of life
46:02and for metastatic patients such
46:03as this five year survival to 7
46:06year survival is not unexpected.
46:08So this 82 year old male,
46:11very active develops lower back
46:13pain while playing tennis.
46:14He goes to see his internist,
46:16who does a series of L spine films,
46:18which demonstrate sclerotic bone metastases.
46:22He has a PSA of 1200.
46:23He's referred for a biopsy of his prostate,
46:26which demonstrates at least
46:28nine adenocarcinoma.
46:29Imaging detects multiple bone
46:31metastases in the ribs and thoracic
46:33as well as lumbar sacral spine.
46:35So this is not the patient that
46:37Doctor Mcgibbon spoke about before.
46:39This patient would not benefit from
46:41receiving radiation therapy to his
46:43prostate or to the metastases but.
46:45Would really require systemic therapy.
46:48So this patient goes on androgen
46:51deprivation therapy with a drug
46:53called degarelix which rapidly
46:55reduces the testosterone levels
46:57within 24 to 48 hours to less than
47:0050 nanograms per deciliter which is
47:02considered to be castrate and also he
47:05starts a drug called enzalutamide.
47:07Which is in next generation and antigen,
47:09which is originally,
47:11which was originally approved for
47:12patients with resistant disease,
47:14but now is being moved up front
47:16to these patients.
47:17So all these patients really deserve
47:20the chance of having what we call
47:23the best next generation agent.
47:25And drugs such as enzalutamide,
47:27apalutamide,
47:28abiraterone are all given to these
47:32patients in the early stages of
47:33metastases rather than the late
47:35stages where they originally approved.
47:37And we see that there's more of a survival.
47:38Benefit in these patients with
47:40this treatment,
47:41chemotherapy is also administered
47:42in this area as well,
47:44so common complications that an internist
47:47may see in this disease include hot flushes,
47:51osteoporosis, anemia.
47:53Impotence, fatigue,
47:55and weakness, muscle wasting.
47:58That's something we can do something about.
48:00All of my patients with prostate cancer,
48:03I recommend that they maintain
48:05an active exercise program,
48:07including lifting weights.
48:08They have to maintain the muscle mass
48:11because of course without testosterone
48:13we can have issues cardiovascular side
48:15effects of being newly identified.
48:17And these include a higher risk
48:19of a second myocardial infarction
48:21within six in a patient who's had
48:23a myocardial infarction within
48:25six months of starting an engine
48:28deprivation therapy.
48:28And the guidelines for managing
48:30cardiovascular patients are really
48:32not as clear as we would like them
48:34to be at this particular point.
48:37Next slide. Hot flushes occur
48:39at about half to 80% of men.
48:42It's usually a sudden perceived
48:44increase in temperature,
48:46accompanied by reading of the
48:47skin and profuse sweating.
48:48Next slide, please.
48:51And this is usually spontaneous,
48:54changes in body position or
48:55ingestion of hot liquids can also
48:58cause this particular problem,
48:59environmental changes as well.
49:01So what do we do about hot flashes?
49:03We generally will ask the patient
49:05try to try soy products because
49:07they do have phytoestrogens and
49:09that tends to counteract that.
49:11Additionally, drugs such as effects Effexor,
49:14Clonidine are also effective
49:15in these patients.
49:17We generally will reserve
49:18that for severe hot flushes.
49:21Osteoporosis is really a more recognized
49:24problem in men over the last several years,
49:27and about 25 to 30% of all osteoporotic
49:30hip fractures do occur in men.
49:33By 2025 we expect about 1.1 million cases,
49:36and as one would expect with a patient
49:38zoning going ancient deprivation therapy,
49:40the major causes hypogonadism.
49:43Women can also experience this who are
49:46on LHRH agonists for endometriosis,
49:49and that's why.
49:50The use is usually limited
49:52to about six months.
49:53Next slide please.
49:56So generally a man will lose,
49:59after age 35, zero .5 to 1% of their
50:03bone mineral density per year.
50:05That's accelerated in the patient
50:07on androgen deprivation therapy
50:09to 1.4% to 2.6% per year and
50:12compared to age matched controls.
50:16Men on energy deprivation therapy
50:17have a 6.5% to 7070.3% risk of
50:21higher bone loss and the rates
50:23of fractures are higher.
50:25So in the hormone sensitive state
50:28the patient we would consider
50:30giving calcium and vitamin D2.
50:35And we see this is in a patient who's
50:37head does not have bone metastases,
50:40who's treated for more than six months.
50:43This is 218 patients.
50:45A 6% fracture rate is seen and the median
50:48time to fracture is 28 months. Next slide.
50:52So we we generally as I said
50:54before in a metastatic patient,
50:55I generally don't do dexa scans.
50:57But in a patient that we're treating
51:00with the urologist as well as
51:01radiation oncologist who may be
51:03on Angie and deprivation therapy
51:04who don't have metastatic disease,
51:06we we do do dexa scans and then
51:08treat the patient accordingly
51:09depending upon the level of bone
51:11metal density loss at baseline.
51:19Great. That was terrific.
51:21Dan, really, can we stop sharing?
51:27This means we actually have a a decent
51:30amount of time for for questions and
51:32the Q&amp;A which which is wonderful.
51:35So folks who are listening,
51:37please type in your questions in the Q&amp;A.
51:41And as we were discussing this initially,
51:45I know that there are a number of people
51:47who had questions already for each other.
51:49So I'm going to allow Aaron to start off.
51:54Alright. I guess dance,
51:55since you finished most recently,
51:57uh, I wanted to ask if there a
51:59recommendation for how often to check,
52:01uh, bone density testing on
52:04those patients who receive
52:06androgen deprivation therapy?
52:10I think you're on mute, Dan. Sorry.
52:14It's usually every two
52:15years we we check it, OK?
52:17OK, I figured that with the, uh,
52:19I guess the 28 month marker there
52:21that you gave the average bone loss.
52:23OK, and have you had any experience
52:27with gabapentin helping with hot
52:28flashes for your patients with?
52:32But I've not really tried it.
52:33I've used predominantly Effexor.
52:35But anyway some literature
52:37that that does use it.
52:38You know, The funny thing is that that
52:41the soil products do actually work.
52:43Not. Soy milk, which has very
52:45little soy but tofu soy cheese.
52:47It will least reduce the the
52:50frequency or actually the intensity
52:52of the hot flashes may make not
52:54make them go away completely,
52:55but makes it a little more tolerable.
52:59Do you have any soy products you recommend?
53:00I have a lot of patients who
53:02like supplements, tofu, tofu.
53:06Sounds tasty to me.
53:08Here's a question from Beth Allard.
53:10Can you address PSA testing and
53:13patient on on testosterone replacement,
53:16the frequency and cut offs for referral?
53:21Yeah, that's a great question.
53:23UM, to my knowledge,
53:24when I looked at the most recent guidelines,
53:28there was not a strong relationship
53:32between testosterone and worsening
53:35of prostate cancer outcomes.
53:38So I think the guidelines
53:39are still the same for.
53:41Those patients.
53:42But Dan, correct me
53:43if I'm wrong.
53:45Uh, it. At Harvard, they've actually
53:48been looking into that question.
53:50They do have a number grammar 7 adjustment.
53:54And I'm blanking on the author's name.
53:57I can. If if I think of it,
54:00I'll put it in the chat but
54:01but they but they have it.
54:02Looking at this particular issue
54:04interestingly I thought the other
54:06question would be should a man with
54:08prostate cancer go on androgen,
54:09androgen supplementation.
54:10That's one of the more
54:12controversial areas right now.
54:14And in fact we're actually using
54:16high dose testosterone in some
54:18patients for right with resistant
54:19disease and about a third of those
54:21patients will respond to that.
54:23So that testosterone is a very.
54:26Poorly understood hormone.
54:29And you know, again,
54:31I think you really should consult with
54:33your physician before embarking on
54:34any of those particular supplements.
54:38Ryan, were you going to add to that?
54:42No, sorry, I was just
54:44responding. I was since the best
54:46question was answered, I just
54:48took it out of the queue. I'm sorry.
54:53Let's see another question from the chat.
54:54If a Dre is abnormal and the
54:57PSA within normal, what is the
55:00next step maybe going to Jerry?
55:03Yeah, so I would have probably recommend.
55:06Referring to the urologist at that point.
55:10Because I think we, you know.
55:18It's rare for me to call a Dre
55:22abnormal unless I, you know,
55:24truly, truly feel something.
55:27Because of the the sensitivity and
55:30specificity that Aaron quoted,
55:32so you know if if there is
55:35something real on the Dre,
55:37usually the PSA is 15 to 20
55:40and those patients as well.
55:43There are rare instances
55:45when that's not the case.
55:47And there are some instances
55:49where the patient is older
55:50and doesn't have a PSA level.
55:52So if the Dre is abnormal
55:54and we were very concerned,
55:56I would get a PSA on that patient and.
56:01There have been patients that have
56:02been diagnosed that way who have
56:04stopped PSA screening because of their
56:07age and the Dre was very concerning.
56:11Yeah, but I think it's important.
56:12If the DVR is abnormal it
56:14it needs a second opinion.
56:19I agree.
56:24Nope, and I think you're on
56:25mute. Having an epidemic of mute.
56:29Any data on acupuncture for
56:31hot flashes and flashes?
56:32Keep these questions coming in.
56:34They're fantastic.
56:38No, not that I found. Dan anything?
56:41I've not found that either. I found
56:44mixed mixed mixed experiences with it.
56:51And then why stop PSA at 75 years old?
56:59How proud here this
57:01is actually. Pretty controversial, uh?
57:07The AUA guidelines actually
57:09recommend 55 to 70.
57:11I I did have a discussion
57:14with my patients at age 75.
57:16And we discussed the harms
57:18of continuing to test.
57:21The problem is when you can.
57:23When you tell a patient to
57:25consider life expectancy,
57:26that's not something that
57:27they want to consider.
57:29So it's it's it's it is difficult to stop
57:32testing at 75 because most patients will.
57:36I I've had, I've had a lot of patients
57:38who've come to see me who were
57:41told by their previous urologist.
57:43You're you're going to die anyway.
57:45Why? Why test your PSA?
57:46And they don't like hearing that, so, uh, it.
57:49I usually look at their
57:52medications and comorbidities.
57:55If the patient is on Plavix and
57:57aspirin and has had three stents,
58:00you know,
58:01the chance that you're gonna
58:03increase their lifespan with
58:04PSA testing is pretty low.
58:06Most prostate cancer that's intermediate
58:09risk probably takes anywhere from 7
58:12to 10 years to actually metastasize.
58:15So.
58:15That's why the 10 year life
58:17expectancy is a good rule as well.
58:24Got it. We were talking about Dre
58:26also earlier in in the planning and
58:29it is something that many of us are
58:32have grown up in a certain way and
58:35it it marks their dates us I guess.
58:38Karen Ryan, any thoughts on on on
58:41the Dre and and how things have
58:44changed recommendations over time?
58:48So
58:48I was going to ask a different
58:50question, but a quick story.
58:52Remember, I once told the patient,
58:53this is 20 years ago, back when it was,
58:55I think, still a standard of care about
58:58to do a digital rectal exam. And he said,
59:00oh, they're digital now.
59:03True story, true story.
59:05No, I think you know what. What we
59:07find, and I'll be really interested
59:08in Karen's perspective as well, is
59:10that, you know, old habits
59:11die hard and,
59:12you know, it's hard to convince
59:15people that the evidence is evolved. And,
59:19you know, we
59:19find that, you
59:20know. Conversations like this
59:22or presentations like this are
59:25ways in which we can share best
59:28evidence and evolve practice.
59:31But you know for the record when I
59:33trained it was the standard of care
59:35and I'm wrapping my head around it.
59:37So Karen, I don't know
59:38more thoughtful answer than mine.
59:42I mean the answer that
59:45I mean Aaron presented some of the
59:48statistics we we do get a lot of false
59:52positives and urology consultation I
59:53still consider a precious resource
59:55and so you know I want to make sure
59:58that most of the people who most need
01:00:01to get there do and and the reality
01:00:03is and and it's kind of funny because
01:00:05ten years ago we weren't saying this,
01:00:07but the blood test does work remarkably well.
01:00:11It's not perfect,
01:00:13but I think most of us have really.
01:00:16At the same time,
01:00:17we decreased our our rectal exams,
01:00:19we increased our PSA and and
01:00:21so on a kind of summary level,
01:00:24you know, my,
01:00:25my guess is that we're finding more
01:00:28prostate cancer and being more sensitive.
01:00:30I mean I, I,
01:00:31I offered every man, I said,
01:00:33you know, I don't, I'm not required to
01:00:36do a rectal exam anymore, but I'm happy
01:00:38to do one if you would like.
01:00:39And I find that actually most patients
01:00:41are far more happy to give it up than
01:00:44if I phrased it any other way. Uh, but
01:00:48you know. I mean, everything we do,
01:00:51there's always a risk of missing something
01:00:53and and so everything we do just has to
01:00:56be with the greatest good in mind and and
01:00:59what we can do routinely for everybody.
01:01:03Just want to make one point.
01:01:05I think it's great that you
01:01:07having that discussion.
01:01:08Going back to the preventative task force,
01:01:10there was a study that was done at
01:01:12ASCO presented at Asco Gu this year
01:01:15where they look state by state at the
01:01:19incidence of prostate cancer and the.
01:01:22The development of metastatic disease
01:01:24and there's been a 28% increase in
01:01:27metastatic disease since that task
01:01:29force made that recommendation.
01:01:31So I'm glad that we're getting back
01:01:33to having shared discussions because
01:01:35clearly we want to move to a curable
01:01:37situation rather than incurable situation.
01:01:41And that's go ahead, Chris.
01:01:44I was just going to add to that that
01:01:46you know Jerry and Dan and I are.
01:01:48Are managing these days really a really
01:01:50high number of gentlemen in their late,
01:01:53mid to late 70s to early 80s who have
01:01:55great longevity in their family,
01:01:58relatively few comorbidities and they
01:02:00have Gleason 8-9 disease and no Mets
01:02:02on on advanced imaging and I think
01:02:04these guys are are gentlemen where they
01:02:07don't all need treatment but I think
01:02:09quite a few of them really do benefit
01:02:11from treatment you know they and and I
01:02:13what the this part of the discussion
01:02:14I have with guys is that you know
01:02:16long before prostate cancer kills you.
01:02:18If it spreads it creates a considerable
01:02:20reduction in your quality of life
01:02:23and so you know the the offer
01:02:25treatment is trying to help survival.
01:02:27But as maybe even before that with
01:02:28that older gentleman it's hey can
01:02:30I can I keep you from being on long
01:02:32term manager deprivation having
01:02:33bone Mets with pain a fracture.
01:02:35And I think these are all really important
01:02:38discussions to to have so I think.
01:02:40You know being more flexible and you
01:02:42know individualized with PSA screening
01:02:44these things and maybe going a
01:02:46little longer I think is paying off.
01:02:48We're just seeing a lot of these
01:02:50guys these days who fit that that
01:02:51description and and if we pick some
01:02:53up and it's released in six or seven
01:02:55and like Jerry's referring to they
01:02:56don't all need treatment.
01:02:57But again there are a lot of these guys,
01:02:59the higher grade disease that I
01:03:01think need need attention.
01:03:02I think that actually
01:03:04that attitude that's allowed us
01:03:06to feel more comfortable with more
01:03:08PSA screening, I mean it there.
01:03:10There was a point where it felt a little bit
01:03:13like if you had an elevated PSA, you know,
01:03:15the people may be getting unnecessary care,
01:03:17some component of the care was under.
01:03:19And with the better risk stratification
01:03:22and attention to the kind of geriatric
01:03:25and comorbid medical concerns that,
01:03:28you know, I feel like even if there
01:03:30is a PSA that's mildly elevated.
01:03:33People get the right care, you know,
01:03:35on both ends of the urology
01:03:37primary care spectrum.
01:03:38And have you had that same
01:03:40kind of ability to let go and
01:03:41feel more comfortable doing it?
01:03:44No, it's it's definitely added to,
01:03:46I think my comfort as well as my
01:03:49patients knowing that there's you know,
01:03:51a procedure, there's great
01:03:53specialists who are highly involved.
01:03:55There's so much to offer these patients
01:03:58now versus you know 20 years ago we we
01:04:02just haven't had this explosion in.
01:04:05And tech and and options.
01:04:08I think it's a great development.
01:04:10And I think that shared decision making is
01:04:13employed is it's what we're doing today too.
01:04:16So in the Smiler shares with primary care.
01:04:18So we have run out of time unfortunately.
01:04:21It's been fantastic discussion,
01:04:23a few more questions that maybe
01:04:25we can answer after the fact,
01:04:27but really appreciate all of the panelists.
01:04:31Karen Ryan are really pleased
01:04:33with the attendance and tell your
01:04:35friends we'll be back next month.
01:04:37Thanks so much. OK.
01:04:39Thanks, everybody. Thank you.