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Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care. Keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And Joining me today is Dr. Timothy McClure. He's an Assistant Professor of urology at New York Presbyterian Weill Cornell Medical Center, and an Assistant Professor of Urology and Radiology at Weill Cornell Medical College Cornell University. And he's here to highlight less invasive treatments for prostate issues for us today.

Dr. McClure, thank you so much. This is a great topic. So as we get into this, for men and the partners that love them, what are some of the most common issues with the prostate that you see? What kinds of conditions are we talking about here today that might warrant less invasive treatments?

Dr Timothy Mcclure: Well, thanks for having me. It's a real privilege. The main issues that I see patients for is elevated PSA, which is a chemical in our blood that helps give us an estimate of whether or not a patient may or may not have prostate cancer. And that can cause a lot of anxiety and stress with patients. And that's really the main topic that I see patients for.

And then, other things that we see patients for are for lower urinary tract symptoms due to an enlarged prostate. And one of the minimally invasive approaches we can help patients out with that is prostate artery embolization, which helps shrink and reduce the size of the prostate to improve a patient's lower urinary tract symptoms. So those are the two main reasons why we see patients in our clinic.

And then, we also see patients for image-guided therapies for prostate cancer or focal therapy. There's a big interest in prostate cancer treatment now, which will offer patients good cancer treatment, but also minimize the side effect profiles that can happen when you have more traditional standard care of treatments such as radiation or surgery. And focal therapies are new approaches that allow us to kill the area of the prostate that has the prostate cancer, but allows you to preserve the nerves and the muscles that surround the prostate to help keep man's urinary health intact and unaffected by treatment.

Melanie Cole (Host): Focal therapy is a fascinating field of study right now and very exciting time in the field of urology. Now, as we're thinking about screening and you mentioned PSA, I'd like you to speak about screening right now for us. Tell men what it is when they're supposed to be screened, because Dr. McClure, let's face it, it's the partners that are getting these guys in to get these screenings. Men don't want to go, they don't want to get the digital, they don't want to have anything to do with any of it. So why and when should they be screened?

Dr Timothy Mcclure: So PSA screening has historically been controversial and part of that reason was because we really didn't have much with regards to treatment options for patients who were diagnosed with prostate cancer, and there was a significant amount of concern that we were over diagnosing and overtreating patients with prostate cancer.

The general guidelines now are that for men between the ages of 55 and 70 would undergo prostate screening with what's called shared decision-making. And shared decision-making is where you have a conversation with the patient and the physician about the risk and benefits of undergoing a prostate biopsy and what could happen if you were diagnosed with prostate cancer. And it can be a stressful point in one's life. But those are the general recommendations. And then, patients who have high risk factors, so if your father or your brother had prostate cancer, then those patients should undergo, screening at an earlier age.

The general workup for a patient with an elevated PSA is first you ensure that it wasn't just a spurious lab value, and that it is truly, in fact, elevated. And if it is elevated, then usually we get additional workup, which includes a prostate MRI. And the prostate MRI is an imaging technique that helps us identify patients who are at risk of having what we call clinically significant cancer.

So there's various types of prostate cancer and easiest way to divide them up is cancer that we don't really care about, that is unlikely to cause problems in the future of that man's health, and that's called clinically insignificant cancer. And then, clinically significant cancer, which is this is probably a cancer that may impact someone's life and should be evaluated and potentially treated. And so, prostate MRI helps us identify those patients who are at higher risk of having clinically significant cancer when compared to those who have clinically insignificant cancer.

Melanie Cole (Host): So you mentioned shared decision-making. So if someone is found to have that elevated PSA. And you also mentioned enlarged prostate, BPH, which is something that so many men, especially as we're seeing this aging population have, can you tell us about your work at Vascular and Interventional Radiology, some of the most exciting and innovative? You mentioned focal therapy, but what are you doing for men with BPH? You mentioned ablation. Tell us a little bit about what's exciting in your field. And if someone comes to you with this elevated PSA, what are you doing for them?

Dr Timothy Mcclure: Sure. The first question is to determine if this elevated PSA is because of the fact that they do in fact have prostate cancer, or if it's just due to an enlarged prostate. If the workup is negative, meaning that we don't detect prostate cancer, and we find that the elevated PSA is because of an enlarged prostate, then I work with my colleagues in men's health where they do the full workup for patients with enlarged prostates, and if they think that they're a good candidate for prostate artery embolization, that's something that we do here.

And what prostate artery embolization is, is it is a procedure where instead of having a procedure done to open up the prostate channel to make it easier to empty your bladder, what we do is we take a small little catheter through an artery in either your leg or your wrist and bring that catheter down into the pelvis and then identify the prostate artery. And then, once we identify the prostate artery, we embolize that prostate artery, meaning we put small little particles in the blood vessels. And what that does is that shrinks the prostate. And by shrinking the prostate, that opens up that prostatic channel that you can empty your bladder easier. And the advantage of this procedure is it's a procedure that's not done through the urethra. It's an outpatient procedure. So you come in the hospital, you go home the same day, and you don't need a Foley catheter either. So that's something that we offer here at Cornell that really helps out our patients, who we find are good candidates for it.

Melanie Cole (Host): So there's some really cool things, and you've mentioned just a few of them like prostate MRI, PSMA, there's all these cool diagnostic and therapeutic imaging modalities now. Can you speak about some that you really feel have changed the landscape for you, Dr. McClure, that can kind of give men hope as we're talking about these less invasive treatments. And we mentioned that shared decision-making because many men are worried about treating any of these issue for fear of the complications that arise from them, which could be incontinence or could be erectile dysfunction. Can you speak about some of these advances in imaging that have really helped you to make these less invasive?

Dr Timothy Mcclure: Prostate MRI probably has been the biggest impact in kind of imaging that I can think of during my training and my career. And PSMA is just starting and I think it's going to be just as impactful. Prostate MRI itself has been huge in helping us identify men who need to have a full workup for the elevated PSA, and it really has helped us avoid overtreating patients with prostate cancer and help keep patients on what's called active surveillance, which is where rather than treating prostate cancer, we watch patients closely with PSA values, MRIs, repeat biopsies when necessary. And what we do with active surveillance is we help avoid overtreatment with prostate cancer because what we're doing is we're following men who've been diagnosed with low risk prostate cancer, whose life expectancy is likely to be unaffected by this prostate cancer because the prostate cancer that we've identified, this low risk prostate cancer, is so indolent and so slow-growing, it's safe to watch and avoid definitive treatment.

And then, PSMA Imaging has just recently been FDA approved for the workup of patients with metastatic disease. I see it becoming more and more involved in potentially the evaluation of men with elevated PSA and potentially its role will increase likely with men on active surveillance for prostate cancer. And hopefully, we might be able to use a PSMA study instead of a biopsy to help follow patients who are on active surveillance.

Melanie Cole (Host): It's a pretty exciting time. And Dr. McClure, you mentioned active surveillance. And before we wrap up, I'd like you to speak about the importance of this multidisciplinary approach to a man with prostate issues. Because when you say things like active surveillance, watching and waiting, or whatever, we're calling that, that can cause anxiety, a lot of it, especially for the partner, the spouse, anybody who loves this man. Sometimes more for them than him. And so when we look at all the different providers that you might involve to help them with any of these complications or no complications, but the anxiety that could come with it, tell us a little bit about who might be involved and how those kinds of things, those anxiety, those side effects, any of those things, tell us how they're managed and tell us about your team.

Dr Timothy Mcclure: I think the easiest way to look at that first is to divide it into either issues that are not cancerous and issues that are cancerous, because the treatments vastly different. So for patients who have urinary symptoms due to an enlarged prostate or a bladder that is overactive, that's what we consider a non-cancerous prostate issue. And that's really where I work very closely with men's health, which is Dr. Alex Te, Bilal Chughtai, and Rich Lee. And we really work the patient up thoroughly, so we understand the etiology of where their urinary symptoms are from, because sometimes it's not due to an enlarged prostate, sometimes it is.

And during that workup, if the team feels that the patient may benefit from a procedure to shrink the prostate, like prostate artery embolization, then that's when I get involved with the patient care. And I think that really helps us identify the true reason for a patient having their symptoms and really help them get back to a quality of life that they are comfortable with again. So the fact that we have a team that's true experts in management of men's health from that perspective is great.

With regards to prostate cancer, the best care I think is something that is going to be multidisciplinary and that's going to include the surgeons. It's going to include radiation oncologists. It unfortunately may need to include medical oncologists and radiologists as well, because there are so many aspects to the evaluation and the management prostate cancer that require these cross specialties to talk with one another. And the key thing with prostate cancer treatment is education, so patients understand what treatments options exist and what side effect profiles may happen if those patients decide to go down that route.

With regards to just managing patients on active surveillance, patients also want to know that they have the best imaging possible and the best followup. And that's something that we have here. We have phenomenal imagers at Cornell. Dan Margolis is on the International Committee for Prostate Imaging. And we work closely with him to identify patients who need to have a thorough MRI and appropriate analysis of that MRI. And we've improved the workflow for patients who are on active surveillance, where historically they would get an MRI, they would wait a week or two to get the results and have the doctor make a decision if they need to do a biopsy or not. And then, that whole process might drag on for a week or two or even longer. I understand that that causes a lot of stress for both the patient and the spouse or their partner and it's important to try to streamline that.

So, the beauty of Cornell is we can do this all in one sitting, so where a patient will come in in the morning, they'll get an MRI, they'll get it interpreted, we'll look at it together and we'll make a decision if we do a biopsy that day or not. And so, that's one of the things that we are really doing our best to try to optimize patient care for prostate cancer patients. The second thing we do is with identifying and helping educate patients who do need treatment, what those treatment options are.

And so with our multidisciplinary team, we work with the surgeons and radiation oncologists to explain what options they have available. And then, we also bring and highlight the potential treatment options we have for focal therapy if it's something they are interested. And part of the problem with focal therapy is that it's not yet in guidelines. And so, it's not yet well-defined what patient and what type of focal therapy is best for the patient. So having this multidisciplinary approach helps us identify patients who may truly benefit from this.

Melanie Cole (Host): Thank you so much. What an interesting podcast. You covered so many of the exciting advancements and imaging modalities and innovations in prostate cancer and prostate issues. Thank you so much, Dr. McClure, for joining us today and sharing your incredible expertise.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

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