Transcription:

Melanie Cole (Host): According to the American Cancer Society, prostate cancer is the most cancer among men after skin cancer, but it can often be treated successfully. More than two million men in the United States count themselves as prostate cancer survivors. My guest today is Dr. Matthew Young. He's urologist with Greenville Health System. Welcome to the show, Dr. Young. What happens to the prostate as a man gets older?

Dr. Matthew Young: Well, Melanie, as men get older the prostate will tend to enlarge. That's why many men will start to experience some urinary symptoms which are very commonplace; more difficulty between the bladder; slower stream--those sorts of symptoms. But, many men will show no symptoms at all, despite the fact that the prostate will enlarge over time.

Melanie: And this is quite common, yes? A lot of men experience the enlargement.

Dr. Matthew Young: Absolutely and some have very significant symptoms and may have to ultimately undergo an operation or some other procedure for urinary symptoms. Of course, many of those men will be managed with medical therapy successfully, and that's been a big transition over the lasts 15 to 20 years, moving away from so much surgical therapy for that. Many men are managed with medicines quite successfully without having to undergo any other operation or procedure.

Melanie: And when it enlarges or BPH this does not mean cancer, yes?

Dr. Matthew Young: No, it does not mean cancer at all. Certainly, BPH and cancer can co-exist. They can be present simultaneously but the urinary symptoms almost are always benign in nature. By far and away, the vast majority of men which are diagnosed with prostate cancer in the contemporary era are done so through routine screen measures such as PSA or digital rectal examination.

Melanie: So, let's talk about PSA and the digital examination because we women, we work hard to get our man into see you for those examinations and tests. Tell us about them.

Dr. Matthew Young: Well, PSA has been in the press a good bit lately and certainly there has been some good news and bad news about it. Many men will come in and ask if PSA has any utility at all any longer and I would say that by no means has PSA been thrown or done away with. PSA is an acronym which stands for “Prostate Specific Antigen”. It's a protein which is made in the prostate and not made in any other part of the body, but it can be elevated for a number of reasons such as age, enlarged prostate inflammation and, of course, cancer. So, it's a useful tool to help screen men for prostate cancer, particularly, if they have a family history of prostate cancer. It is not the end-all-be-all, but it is a useful weapon and armamentarium in fighting and protecting cancer.

Melanie: What do the numbers mean?

Dr. Matthew Young: The numbers will vary a great deal. It depends on the individual really. So, if the patient has a PSA, usually established at a baseline when they get to about 40 years of age and if they have a family history of prostate cancer, we would want them to obtain a baseline PSA. Then, they would follow that over time. So, some men will start out with a much lower PSA, which is a reflection of the size of the prostate, but as the PSA number goes up it can be an indication that other testing is needed.

Melanie: And when you do a digital exam what are you looking for?

Dr. Matthew Young: You’re trying to see if you can palpate any discrete abnormalities. The vast majority of patients will have a normal prostate exam. You can get a sense of the size of the prostate. That's a very subjective evaluation. You don't actually have an actual measurement with the digital rectal examination, but it does give you a sense of how large the prostate is. What you're trying to see is if there are any obvious lesions or nodules which are can be palpated. If a nodule is palpated, typically that will prompt prostate biopsy at a later time.

Melanie: Dr. Young, urologists at Greenville Health System are the first in Carolinas equipped with the new 3-D imaging device used to detect prostate cancer. Tell us about the Artemis.

Dr. Matthew Young: The Artemis is a very exciting tool that we've had to work with very recently. Really what this ties back in with, though, is the advance of technology and imaging with MRIs. Historically, MRI was not used very much for the detection of prostate cancer, but as with all other technologies, the software is better, the resolution is better, and there are other advances. So, there is a more powerful MRI. It utilizes a 3 Tesla magnet which can allow a very discreet differentiation of different structures within the prostate and early detection of abnormal lesions. So, typically, what we've been using it for are patients that have previously undergone a prostate biopsy and prostate biopsy did not demonstrate any prostate cancer and yet have continued to have an elevated or rising PSA. So, you really have a dilemma. What do these patients need next? Do they need another biopsy? Is there some means of detecting an abnormality? And so, MRI has been done and, if there's an abnormal lesion which is found, then what we will do is, at a later date, they return for the procedure in the operating room where an ultrasound is performed. And then, those images from the ultrasound and the MRI are fused together and that's essentially what the Artemis does. It fuses those images together, creates a 3-dimensional map of the prostate and the abnormal areas that were seen on the MRI, you can then target those lesions very discreetly and obtain targeted biopsies of those. So, it's been a real tool moving forward in diagnosis of prostate cancer and likely in the future, it will also be used in the treatment. There are some new, minimally invasive modalities that will be coming down the pike several years along which will also be able to allow for very targeted and focal therapy for prostate cancer.

Melanie: Are the biopsies that you perform are done at the same time as you're using the Artemis?

Dr. Matthew Young: Yes, the MRIs are usually done first. You then would discuss that with the patient and make a decision on what needs to be done and then, when the Artemis is done, the biopsy is done at that time.

Melanie: That's a nice way to set it up for men. Now, tell us if you do diagnose prostate cancer. Depending on the age of the man and the situation, what treatments are available now?

Dr. Matthew Young: It's really going to depend upon the patient's age; it's going to depend on their other medical conditions; it’s going to depend on their desires. There are a lot of different ways to treat prostate cancer and some men will elect not to treat their prostate cancer at all. Particularly, for a man that may have many other medical issues and is concerned that a prostate cancer has been found but perhaps it’s a very low-risk disease. The biopsies may show a very small volume of cancer or very low risk, and they don't want to go through a significant treatment. So, some of those men will be followed. I think you've mentioned it earlier that watchful waiting is one technique where you are essentially following a man along, and he may never need to have any treatment at all. Of course, other men will elect to have surgical therapy. Really, we would describe that as the gold standard because it has been around for many many years, and it's changed over time in that the vast majority of prostate removals are done now with robotics. I have several partners, that's their area of expertise. They've done many thousands of such cases to remove the prostate with a robotic device.

Melanie: And then, what about things like hormone therapy? Or, is chemotherapy used in prostate cancer?

Dr. Matthew Young: Hormone therapy and chemotherapy are used in prostate cancer. I should say radiation therapy is additionally an option for some patients. When the patient comes to discuss biopsy results, we sort of lay out all the options. Those would include things like watchful waiting, surgery, radiation therapy, cryotherapy, which is freezing of the prostate. And then, some patients are treated with medications. Really, as I would describe to the patients that I've worked with, all cancers in the human body are really treated with 1 of 3 modalities. Whatever you're talking about, it's either going to be treated with surgery, radiation or chemotherapy, right? And so, chemotherapy is typically used on cells that are very rapidly dividing. That's why sometimes people have side effects from chemotherapy like having low blood counts where they lose hair or different things like that. That's for most chemotherapies. Prostate cancer is rather different in that the cells divide very slowly. So, most of the time, chemotherapy is not used except in very advanced prostate cancer or patients that have failed other therapy. Now, hormone therapy is a form of chemotherapy but not in the normal sense of what people think of. It does not cause very significant side effects, but what it does is it removes the male hormone from the system and causes prostate cancer to die back. You would not exclusively use hormone therapy to treat prostate cancer, but it can be used in conjunction with other therapies to improve the response or in patients that are at a different stage of their disease management.

Melanie: So, if you're trying any of these treatments and you say it's a slower growing cancer, then do you typically then have to recheck? Do you use the Artemis to recheck? How do you keep track, Dr. Young, of whether prostate cancer has either spread of come back?

Dr. Matthew Young: Well, this is one of the ongoing uses of PSA and people will ask if whether we use it anymore. I talked earlier about how it's used, still, very much as a screening tool, but it's also used as a follow-up tool. The great thing about it is that it is a simple blood test. It’s not very invasive. It does not cost a great deal and the results are available very rapidly. We even have machines in our office where we have point of care testing. A patient can come in, they can be seen and evaluated, and we can give them a PSA result, really, in less than about 30 minutes and much the discussion will hinged upon that PSA result. So, typically, patients that have had prostate cancer and have been treated, you'll continue to follow their PSA at routine intervals over time and as the PSA begins to rise or has a particular concerning trajectory, that may prompt additional evaluation and possibly lead to other treatments in the future. Some patients that would get a follow-up Artemis biopsy, say they had an Artemis biopsy, demonstrated prostate cancer, and maybe they elected not to have treatment; and then, at a later time, sometime much in the future, perhaps the PSA were to continue to rise. In that situation, you might use Artemis again to find discreet areas.

Melanie: What great information. Wrap it up for us, Dr. Young. Tell men listening and the women that love them what you want them to know about prostate cancer, the importance of screening and why they should come to Greenville Health for their care?

Dr. Matthew Young: I think that one of the things about Greenville Health is we really offer a wide variety of options for treatment and really some leading edge tools. The Artemis procedure and the machine that we have here is one of the very few devices in the Southeast and, to my knowledge, it's the only device in South Carolina. We see patients from all over the state and from out of state that are referred in for this exciting technology. But, prostate cancer is a huge issue in America. It affects many millions of men and early detection is better. Certainly, there are things that can be done to treat this that are not going to have a significant impact in one's life, but I would certainly encourage any patient with a family history of prostate cancer, in particular, those men should be screened or other individuals that would be high risk.

Melanie: Thank you so much for being with us today. You're listening to Inside Health with Greenville Health System. For more information, you can go www.ghs.org. That's www.ghs.org. This is Melanie Cole. Thanks so much for listening.