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Scott Webb (Host): Welcome to part two of a two-part series on Men's Health and Cancer Screening Guidelines and Treatment options. Today, we are specifically discussing prostate cancer, with Dr. Jacob Andrade. He's a Radiation Oncologist at Coastal Radiation Oncology and Salinas Valley Memorial Healthcare System. This is Ask the Experts, a podcast from Salinas Valley Memorial Healthcare System.

I'm Scott Webb. Doctor, it's great to have you back on. We're discussing prostate cancer today. And I know it's one of the most common types of cancers. It's the second leading cause of death after lung cancer for men in this country. So, just as we get started here, do we know what causes prostate cancer?

Jacob Andrade, M.D. (Guest): That's a good question. And the main risk factor is being a male. So, if you have the organ, the chances are you can get cancer in that organ. But we really don't know what causes cancer to occur, specifically. We know of certain risk factors that cause cancer, to say specifically what caused prostate cancer in a specific person, it's hard to say, but just some general ideas you should think of is, like I said, cancer cells are abnormal cells and usually your body and the immune system is very good at eliminating these abnormal cells. One theory would be that the abnormal cell gains an advantage to proliferate very rapidly, or that means to grow very rapidly. And the immune system doesn't have a chance or the body doesn't have a chance to stop it from growing. On the other hand, there are some very interesting cancers, that could evade the immune system using signaling. So, basically harnessing the immune systems properties to make the immune system not recognize that the cancer is abnormal. And so the future of, I think cancer research is immunotherapy and we're actively looking at immunotherapy in all cancers and how cancers evade the immune system.

Host: Let's talk about who's at the greatest risk, right? You said you can't really say exactly how prostate cancer is caused, but we know who's at the greatest risk and there are probably certain groups that are more effected by prostate cancer than others. Right?

   Dr. Andrade: You have to be male to get prostate cancer. And then usually it's a disease of the older age people. So, elderly usually will have prostate cancer, but interestingly, patients with a family history or even African-American race, usually end up having a higher incidence of cancer. Which means there's more people in that particular subgroup that have cancer, but another interesting fact is not only do they have more cancer, they also seem to have it at an earlier stage. So, with the family history, it kind of makes sense that there's some genetic component that is causing you to have cancer or be more susceptible with cancer at an early age, but also the African-American race again, that was contributing to maybe some genetic component of the African-American that is very similar to patients with family history.

Host: I'm just curious. What's the youngest prostate cancer patient you've had.

Dr. Andrade: I think the youngest I've had was in his forties, like 45 years old.

Host: Yeah, so definitely outside the norm. And there's some things, you know, we were talking about melanomas and skin cancer earlier, and so we can recognize some changes in things, a mole, whatever it might be, but are there signs and symptoms that might indicate to us that we have developed something like prostate cancer or we need to rush in to be screened.

Dr. Andrade: Actually no, unfortunately, prostate cancer, is usually very slow growing. So, one thing I wanted demonstrate is the total number of prostate cancer cases in a year is about 190,000, which is the most common cause of cancer in men, but only about 33,000 men die per year. So, that makes prostate cancer, the second leading cause of death due to cancer and that's because most of the patients that have prostate cancer actually live a really long time. And, if you find prostate cancer in young people, usually you're identifying it an early stage and one of the acceptable treatment modalities for early stage prostate cancer, because a patient can live 10 years before even having a problem with it or a side effect from it, is that you can just watch and you can wait and you can follow that patient and see if the cancer becomes more advanced. And then you could say, okay, you need earlier treatment. Whereas some patients, they can go on for 10 years and not have it change. But usually in the older patients, they have those more slow indolent cancers, but the younger patients will have a cancer that usually advances a little bit more quicker. On the other hand, once the prostate cancer has spread outside of the prostate and it has, started to affect your bones, you know, usually we'll see patients that have back pain. It's an insidious back pain. It gets worse. It doesn't go away. You can kind of control it with a pain medicine, but it's just going to get worse and worse. And eventually it could result in a loss of function. But the way we see most prostate cancers is usually patients will have some kind of urinary symptom that is not associated with prostate cancer, but it's usually associated with a different condition called BPH, benign prostatic hypertrophy, which we usually call enlarged prostate.

But even though the prostate is bigger, it isn't really a risk factor for prostate cancer. What ends up happening is whenever you have urinary symptoms that prompts a urologist to do a workup and usually that starts with a PSA, which is a blood test looking at prostate specific antigen, which is a protein that's made by the prostate gland. And it spills out into your blood. Now cancer makes a lot more of that protein. And so when you have higher levels in your blood, then that is an indication of possible cancer. So, usually if somebody has some kind of urinary symptoms, and we look at a PSA to see if there's a problem with the prostate, if the PSA is elevated above the normal level, then that would prompt the biopsy. And that's usually where we identify these early stage cancers.

Host: Yeah, and is the PSA the only means of screening for prostate cancer or are there other means as well?

Dr. Andrade: Usually the PSA is also associated with what we call a digital rectal examination. And that's where the physician actually palpitates, or feels the prostate through the rectum. And even though most of the cancers we find are early stage, if you do just a palpation and there's no nodules and you're not having any urinary symptoms, then potentially you don't have to do a PSA, but just because you don't feel a tumor on the prostate does not mean that the cancer is not there. So, usually it's a combination of PSA and digital rectal examination.

Host: Yeah, so sort of a combo of the two, and I know you sort of indicated and maybe I'm over simplifying, but kind of a, a wait and see with a lot of patients, but let's just say it progresses to the point where treatment is necessary. What are the treatments available for prostate cancer? Is radiation therapy, an option, that kind of thing?

Dr. Andrade: And I want to just clarify, you mentioned this wait and see and that is a term we did used to use for prostate cancer, which meant okay so you have prostate cancer, most likely it's not going to cause a problem. Let's wait. If you start having symptoms, we'll treat you for it. On the other hand, nowadays, what we're doing is something called active surveillance. So, if you do have a diagnosis of prostate cancer, we're not going to wait until it becomes so widespread. You start developing symptoms from it. We should be checking you pretty regularly. And that involves a PSA every six months and digital rectal exam or a biopsy no sooner than once a year.

And especially if the PSA starts to elevate indicating that may be a more aggressive cancer. And so when somebody is diagnosed with prostate cancer, if it's very early stage, we would recommend active surveillance as opposed to wait and see, which is another option for somebody that says is much older, is maybe a little bit frail. Maybe doesn't have a long life expectancy. And again, like I said, if somebody is 85, 90 years old and this cancer may not cause a problem for 10 years then, yeah, that makes sense. We were not going to regularly do biopsies and blood tests to follow the cancer. So, it's kind of adapted. But once you're diagnosed with prostate cancer, again, just like all cancers, you gotta think surgery, you gotta think radiation.

And in this case you don't use chemotherapy, but we use what's called androgen blockade, which is blocking the testosterone function because prostate cancer, like breast cancer is very hormone dependent and we don't really need to use chemotherapy. We just need a block of the hormones present in the male body.

Host: And doctor, what if the cancer returns, let's say you treat prostate cancer and it seems that the treatment was successful. What if it returns and has metastasized, what types of concerns then what would doctors and patients have?

Dr. Andrade: I think maybe traditionally, doctors would have a lot of concern, but we're currently living in an age where there's so many options available. And usually even patients with metastatic prostate cancer can live a very comfortable life for many years. So, when somebody does have metastatic disease, then that's when we could consider chemotherapy. Remember I said primarily androgen blockade is definitely the mainstay of treatment, but in some patients, they do benefit from having actual chemotherapy delivered. And then additionally, like I was saying, the nine weeks of radiation to the prostate gland is a traditional treatment, but there is recent data showing that if say a patient has a metastatic tumor in the bone that if we use this, very highly sophisticated, specialized radiation, which is equivalent to several weeks of radiation delivered in a short interval, that's specifically called stereotactic body radiotherapy; that's where I was talking about the treatment itself lasts a little bit longer, but the whole treatment can be completed in a shorter time because we're giving so much more radiation and actually prostate cancer patients with limited disease burden, if we target a few of these lesions with SBRT radiation, then potentially those patients can live longer without need of androgen blockade. There's a lot of different options that we can use depending on the circumstances, even if a patient has already been treated.

Host: Yeah, it does seem like there are a lot of options that it is patient centered, patient specific, but just so many options available. Not that anybody wants cancer. What have you tell us a little bit about your new clinical trial in conjunction with SVMH.

Dr. Andrade: This is the ENERGY trial. And specifically this involves patients with confined prostate cancer, which means it hasn't spread outside of the gland. And specifically we can subdivide that further, which is even more complicated, but let's just say for the sake of simplicity that this particular trial is looking at only patients with intermediate risk prostate cancer and that intermediate risk means what is the risk that the cancer is going to be spread to other parts of the body. And so patients with low risk, will have lower risk and patients with higher risk will have high risk, but really this intermediate risk is important because it suggests that maybe your cancer is going to be a little bit more aggressive or it's going to be advancing a little bit faster than a low grade cancer. And so what this trial entails is using a standard short course radiation treatment as the standard arm, which is a five and a half week course. And we're going to compare that to a course that only takes five days.

Host: And I'm sure that for patients who are eligible for this trial, it probably saves them some travel, right? They don't need to go to the Bay area. They can do it right there, close to home, which is great for them.

Dr. Andrade: I mean this is a very specific trial and it's not going to include everyone, but absolutely having a trial locally is so important for the community to be able to have these modern technologies, because like I said, these short five day treatments with very high doses of intense radiation are only possible if the technology is available in your area.

Host: Right. Which obviously it is. And you working in conjunction with SVMH is great. As we wrap up here, is there anything else you would like to add about men's health in general or prostate cancer? You know, we know it's so important not to delay medical appointments, even because of COVID and to get in for those screenings and care and treatment and all of that. But in your own words, what would be your takeaways today?

Dr. Andrade: I want to mention another organization that I didn't mention earlier. And that's the American Academy of Family Physicians. And I think really they're charged with understanding the message from the US Preventative Services Task Force, to understand how to guide you as a patient and what to do. Whether you suspect you have cancer, you're worried you might have cancer, they can do an evaluation of your family history and determine what is an appropriate age for you to get screened. So, I think even though there's a lot of anxiety and potentially mistrust in experts, it's really these organizations that help keep all the doctors informed so that they are up to date on the most current information. So, definitely I recommend all patients to see their doctors regularly, especially if they have something weird going on, you want to get it checked out sooner rather than later, and trust in your doctor. May not have all the answers upfront, but if you ask, that will prompt them to look into it and they will help guide you in what you need to do for your specific situation.

Host: Yeah that sounds right. Trust the doctors, trust the science, know that experts can change their minds, change their opinions based on new research, new science, new trials, and so on. So, thanks so much for your time today and you stay well.

Dr. Andrade: Thank you very much.

Host: And we hope you enjoyed this two-part series on men's health. For more information, go to svmh.com and we hope you found this podcast to be helpful and informative. This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.