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Melanie Cole (Host):  Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we examine how prostate cancer impacts gay and bisexual men. Joining me is Dr. Channa Amarasekera. He's an Assistant Professor of Urology at Northwestern Medicine. Doctor, I'm so glad to have you join us today. And as you're new to Northwestern, please tell us a little bit about yourself and your background.

Channa Amarasekera, MD (Guest): Thanks for having me, Melanie. And thanks for giving me the opportunity to talk to you about this important topic. I am a urologist specializing in andrology and in men's health. I'll be starting at Northwestern in August. I finished residency at Northwestern in 2020, and then took a year to do a Fellowship in Andrology at Rush before coming back. My interests are survivorship after prostate cancer and to helping men regain sexual function and urinary function after prostate cancer treatment, but also just men's health in general, in terms of erectile dysfunction, Peyronie's disease and any other health issue that arises.

Host: Thank you for sharing that. So, Doctor, this is a fascinating topic and I think it's not one that gets a lot of discussion. So, you're in a niche situation here. Talk about screening for prostate cancer in gay and bisexual men. Can sexual activity affect PSA levels? Tell us a little bit about what you found out and really how you started finding these things out.

Dr. Amarasekera: That's a great question. So, the screening criteria for gay and bisexual men are the same as for straight men, in terms of the age of screening. It's between 55 to 69, it should be a joint decision between provider and patient. In terms of sexual activity, PSA level can go up with any kind of sexual activity. So even for a heterosexual, ejaculation can increase PSA level and falsely elevate it. However, what's different with gay and bisexual men or anyone that engages in anal intercourse would be with anal intercourse there can be trauma to the prostate. And that could release some more PSA than you would ordinarily see with sexual activity.

So, it can really elevate the levels of the enzyme leading to a biopsy that may not have been done. So, when I counsel patients in terms of abstaining from sexual activity, I tell all patients to refrain from any kind of sexual activity for 48 to 72 hours. And I pay particular attention when talking to gay and bisexual men bringing to attention that anal intercourse should potentially be avoided for maybe even a little bit longer, just because there's direct trauma to the prostate there.

Host: Well, Thanks for that. So, as we're talking about this, research suggests that some gay and bisexual men receive less healthcare than heterosexual men. And they face a number of barriers to getting the healthcare and cancer screening tests they may need. And that people from these groups are less likely to receive preventative health care and across the board have faced a disproportionate health burden. Can you talk to us about the unique challenges these communities have faced in terms of healthcare disparities?

Dr. Amarasekera: Yeah, I think it's important to look at the historical context of healthcare that's been provided for this community. So if you look at the HIV AIDS epidemic of the 1980s, there was a lot of hesitancy within the medical community, in approaching these patients and treating them appropriately. There wasn't much government funding for AIDS research. In fact, the president at the time, didn't acknowledge that this was a problem for a very long time and the medical community didn't seem to get behind LGBT patients with HIV. So, I think there's a little bit of distrust when it comes to older men who've experienced that time of going through the HIV crisis.

And that has led to perhaps not seeking care within an establishment that you don't feel like you're welcome. I mean, that's just one example. Another example, until 19, I think it was 1973, people who were homosexual were considered to have a mental illness if you look at the DSM manual, the psychiatrists classified this as a mental illness and alienating gay people. So, there's been a history, I think of marginalization that hasn't been forgotten yet. So, I think, you know, there's been a sea change in public opinion when it comes to gay and bisexual patients or LGBT patients in general.

But that's been very recent. A lot of the patients that we see there, they're older, if they have prostate cancer and they didn't grow up during this time when society was this accepting or embraced people that, you know, were different.

Host: Certainly true. And hopefully we're seeing the tides change a little. So, what do you advise your gay and bisexual patients after a prostate biopsy?

Dr. Amarasekera: After a prostate biopsy. That's a great question. I would first inquire as to what kinds of sexual practices they engage in. And if they do engage in receptive anal intercourse I would say abstain from a receptive anal intercourse, until there's no bleeding, perhaps for a couple of weeks, just to ensure that there is no trauma to the area and you don't predispose yourself to an infection, which is one of the, the most feared complications of that procedure.

Host: Tell us a little bit about the additional side effects. Most men, Doctor are afraid of any kind of prostate cancer and surgery and even treatments because of the side effects. Are there different treatment options that would impact all men? Side-effects that gay and bisexual men may experience differently or it's pretty much across the board for men. Do they treat it differently?

Dr. Amarasekera: Yeah. So if you look at the treatments for prostate cancer, there's surgery or radiation. It can be a very devastating diagnosis to get just because treatments associated with it can impact very intimate parts of people's lives. Side effect profiles of treatment are experienced, the actual side effects are very similar between gay and straight men. However, they can mean different things to these populations. There's good data showing that gay men are much more bothered by erectile dysfunction after a prostatectomy compared to straight men. And there are many reasons that could be and some of those reasons are cultural. A lot of gay men have non-traditional relationships where they may not be in a monogamous, committed relationship. And they might have the expectation of having sexual relations much later in their lives compared to straight men. So, that disappointment of losing erectile function may hit them a little bit harder.

The other things that we've found are gay mentend to place more importance on ejaculatory function and losing ejaculate, which happens with surgery and radiation seems to have a much greater impact. And the reasons for this are again, are not quite clear, but it appears to be cultural.

And the third and less obvious potentially, reason is for gaming that engaged in receptive anal intercourse,after prostatectomy or a prostate cancer treatment, currently, the way we follow these patients in terms of sexual function is asking them what their erectile function is. But if you're a gay or bisexual man that doesn't have penetrative intercourse in terms of being the insertive partner, but you're the receptive partner, that may not matter so much for you. And you may feel a little bit left out that you're not being asked questions that are appropriate to you. This also matters with both treatments that we talked about. Because if you think about the prostate as a sexual organ, as a source of pleasure, removing that with a surgery, may be devastating to that man. And if you didn't counsel him about it, they may feel a little resentful that this wasn't discussed. And then with radiation, there could be fibrosis in about 20% percent of cases where there's rectal fibrosis, making it impossible for them to have anal intercourse. And this is something that you also need to make them aware before they proceed with treatment.

Host: So interesting. So, you and other Northwestern Medicine investigators recently published a study, assessing the areas of sexual function predicted to be important after treatment. And you were just speaking about that a little bit. Can you tell us a little bit more about the study and what you sought to find? Give us a brief overview if you would Doctor. Tell us about your findings and some of the meaningful end points of the study.

Dr. Amarasekera: Yeah, thanks for bringing that up. So, the reason we did this study is because we had patients after prostatectomy in clinic where their sexual activities weren't being recorded by the instruments we had to measure sexual function. So, if this again were patients that didn't need erections for sexual function, but rather were the receptive partner in a relationship where they had, anal intercourse. This is an area where it's hard to follow these patients, given the current clinical questionnaires we have, because there's not a validated questionnaire that assesses this kind of function. We wanted to first see if this was something that was important to patients outside of the patients that we were seeing in clinic.

So we sampled 56 men that were gay with prostate cancer after treatment and asked them if they felt erectile function as measured by one of the currently used questionnaires, the Epic questionnaire was important to them. And over 75% said yes, it was important. But then over half of them said that they wish there were another questionnaire where they could, where we could assess functioning as it relates to anal intercourse. And this was much more prevalent as you might expect with someone that actually did engage in receptive anal intercourse. Over 90% of those men said there should be one of these questionnaires.

It's just something that we don't have at the time. And we're working on building a validated questionnaire just to help these men feel more included in help track their recovery after

Host: What about transgender women and their risk?

Dr. Amarasekera: Yeah. So there's not a, there's not a whole lot of literature on transgender women and their risk of prostate cancer. The literature that exists, it comes in the form of case reports. I think there are maybe 11 or 12 different case reports. What is known is prostate cancer feeds off of testosterone. And in these women, they're on estrogen therapy and their testosterone levels are typically very low. So, in a sense it can be a little bit protective in terms of prostate cancer risk. However, about 60% of these women that have prostate cancer, when they present, they present with metastatic disease, which means that they weren't being screened or they just weren't getting the healthcare that they needed. Because PSA's can be depressed artificially on estrogen therapy, the cutoff for screen should in theory be lower than four, which is what we use for men who have physiologic levels of testosterone. There is a, there's no clear data on what this cutoff should be, but there's some consensus that perhaps it should be one. If their PSA is greater than one, you should proceed with either an MRI or s biopsy.

The other thing with trans women is transgender. The transgender population in general, is particularly underserved by the medical community. They have a great deal of trouble finding medical care and a great deal of trouble with finding some, finding a physician they're comfortable with. Just because there's a lot of discrimination and it's a historically marginalized. So, these patients may not be screened because they're not seeing a doctor very often. And even when they do get screened, a lot of these patients and the doctors that see them may not remember that they have a prostate, just because it's typically they look like they're women.

Host: That leads very well into my next question, Doctor. So, working with people from different backgrounds and cultures presents a unique opportunity for collaboration and creativity. In your personal experience, how have you seen this materialize at Northwestern? How do you envision it and thinking about longterm solutions, how do you think the healthcare industry can be reformed to better serve gay and bisexual men with prostate cancer?

Dr. Amarasekera: I think a lot of it is visibility and the willingness of the hospital system to say, Hey, we welcome LGBT patients. That goes a long way. And I think Pride month is a great month because at Northwestern we're very active in welcoming LGBT patients and celebrating these patients and just letting them know that they should feel comfortable here just because we're all about taking care of this population.

In terms of ways we can get better, one of our studies looked at particularly in urology, one of our studies looked at over a hundred urologists and they were queried on whether they felt comfortable talking to straight men about sexual health issues, if they felt as comfortable with gay men and it turned out as you might expect physicians were much more comfortable talking to straight men as opposed to gay men.I don't think that's a result of homophobia. I just think it's a lack of education. So, part of what we need to do is educate physicians and give them the tools that they need to feel more comfortable asking gay and bisexual men about their sexual habits.

And even before then, asking every man about sexual orientation, because it would help tailor their care based on this very simple question. Not asking, a lot of times you hear physicians say well, I treat all patients the same, so I don't really need to ask that question, but then unfortunately sets up a don't ask, don't tell dynamic, which can be troublesome and difficult for particularly older gay men to navigate, because they're not sure if they can tell the doctor about what it is that they want to say, because there's no indication that they're welcome.

Host: And that's what we're doing here today is really discussing this and getting it out there. And as a wrap up, what's next, when it comes to this area of study and how will you apply this work to your clinical practice? How will this research you're doing translate into patient care? And what other considerations would you like other urologists to know when caring for gay and bisexual patients with prostate cancer?

Dr. Amarasekera: I think as we moving any field forward, I think collecting data is the very first step. So, getting SOGI data or sexual orientation, gender identity data in Epic and being able to figure out how these patients did with treatment or what, what happened what worked, what didn't that's an important start.

I also think advocating for these patients to be included in national registries so that we have large data sets that allow us to see what the disparities, if any, are for these, for this population, not just with prostate cancer, but with other kinds of health issues too. So getting data is very important.

Dr. Amarasekera: The other part of the solution is education for physicians and the hospital system in general to create ways in which we can engage this population and bring them in. And just let them know that yes, historically, like this has been a very marginalized community, but we've come a long way as a medical community. And we are very invested in taking care of this population.

Host: Thank you so much Doctor for joining us today. What an interesting and eye-opening topic. Thank you again. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.