At the Forefront Live: Prostate Cancer
February 28, 2019
UChicago Medicine prostate cancer experts answer questions about the latest prostate cancer treatments, hereditary factors that increase the risk for prostate cancer and advanced research under way to improve the diagnosis and treatment of prostate cancer. Hear from medical oncologist Russell Szmulewitz, MD, radiation oncologist Stanley Liauw, MD, urologist Scott Eggener, MD, and genetic counselor Sarah Nielsen, MS, CGC.
Today on the program we will talk about clinical trials and various treatment options. We'll discuss the launch of our high risk and advanced prostate cancer clinic. We will also learn about genetic predispositions and what you need to be aware of. We will introduce you to one of our patients who found he had prostate cancer, went through treatment, and now lives a very active healthy life. All of this coming up right now on At The Forefront Live.
And welcome to At The Forefront Live. Over the next half hour, we will take your questions live. So start typing in the comments section. We'll get to as many as possible. We want to remind everyone that today's broadcast is not designed to take the place of a consultation with your physician.
Now, joining me today in our first segment are physicians Russell Szmulewitz and Stanley Liauw. In our second segment, we'll have physicians Scott Eggener and genetic counselor Sarah Nielsen. They will be on the program to discuss more things involving prostate cancer. First, let's start off with the basics.
Welcome to the program. We appreciate you being here. And please describe, if you can, prostate cancer, exactly what is it? And what kind of things do people need to be aware of and possibly look for?
I can start. Well, prostate cancer is a cancer that affects men. The prostate gland is considered a male sexual organ. The purpose of the prostate gland is to make some seminal fluid that's involved with sexual activity. So what men need to know is that prostate cancer is very common. It's the most common cancer that affects men in the United States, affects about one in seven men.
There are screening tests available for it and is a very treatable condition with good cure rates.
And I think, again, part of the key to this is early detection and early treatment, I would imagine, like with most cancers.
So can we talk a little bit about PSA tests? Because that's something that I think many of us have heard of and probably don't know exactly what that is. And Dr. Szmulewitz, if you wouldn't mind.
So PSA test is a blood test. Basically, it's a test that patients can get at their physicians visit. And it is a protein that's made exclusively by prostate tissue. And it's made, both by normal prostate, and even to a greater extent, by prostate cancer. And basically, it's one of the ways in which we can screen and detect for prostate cancer.
Basically, there's a normal range for what a normal sized prostate would make with respect to this PSA. And if it's elevated, that gives us a clue that perhaps we should do a biopsy to look for prostate cancer within the gland itself.
And if you do see those elevated rates, you mentioned the biopsy, and there are other tests as well that probably your physician will put you through if you are in that category, correct?
Sure. Screening for prostate cancer is controversial, but in addition to this PSA blood test, it would be standard to have a physical examination, including a digital rectal examination. And then if it is elevated, your primary care physician will likely send you to a urologist for a consultation. That urologist might do other physical examination, might order a CT scan or MRI in addition to a biopsy.
Now, I think prostate cancer is more prevalent in men as they get a little bit older. Would that be a fair statement? I would think. And as people get older, what kind of things should they look for? What kind of things should they be aware of as we experience changes?
It is true that prostate cancer is more common with age. Some estimates are that it's as high as 70% in men who are age 80 and higher. One thing about prostate cancer is that PSA screening can be valuable because most men who are newly diagnosed don't have any symptoms. So there isn't necessarily a set of symptoms that men should necessarily be looking out for related to having a cancer diagnosis.
Now, we already are getting questions from our viewers, which is great. And we want to remind our viewers, please type in the comments section. We'll try to get to as many of your questions as we possibly can over the next half hour. The first one that we have is, I've heard that there are some experimental treatments involving laser ablation of prostate tumors.
Is this true? And where does the treatment option stand in the continuum of care?
So Dr. Eggener, who will be speaking in the second segment of this Chicago Medicine At The Forefront Live, can speak more to this, as he's been involved in the development of this type of therapy. But basically, there are new technologies, including laser, that allow you to ablate a certain portion of the prostate, but not the entire prostate. And it's a device that has been cleared for use.
But to be honest, the long term results from a cancer standpoint are not entirely clear as of yet.
So how dangerous is prostate cancer? One of the things that I've seen actually online, that prostate cancer isn't fatal and, again, as I always say on this show, believe-- be careful with what you read on the internet, because it's not necessarily very accurate. So can you address that as how is the danger of prostate cancer?
Sure. Well, we certainly see a spectrum with prostate cancer diagnoses. Fortunately, most men are diagnosed with low risk features. So a significant proportion of men may not actually need treatments and can undergo something called active surveillance, whereby the disease is monitored with certain parameters. And when you get nervous about it progressing, in accordance with a man's life expectancy, only then would you consider treatment.
But we certainly do see the other end of the spectrum, unfortunately, where men can present with very high risk features that can be lethal. So it's important to get as much information as you can when you're diagnosed and make the appropriate treatment decisions with all the information that you have available.
And so to kind of go with what you were talking about earlier, more at the beginning stage, you just kind of keep an eye on it and you watch it and make sure that it doesn't get worse and people can kind of go ahead with that, is that how it works?
Well, I would say that-- what Stan was mentioning is that there are features that we can really only tell by the biopsy that-- and by perhaps the MRI and the total PSA that help us determine whether or not the prostate cancer is a low risk prostate cancer or a higher risk prostate cancer. It is true that with a lower risk prostate cancer, surveillance is very reasonable. But when you have higher risk features, which you can really only tell from the biopsy, that is where treatment is likely necessary.
And in what types of treatments are we talking about at that point?
Well, men who present with higher risk features that therapy is warranted for will often consider two of the mainstays of local therapy and that would be surgery or radical prostatectomy and radiation therapy, which comes in two forms, external beam radiation and prostate seed brachytherapy or HDR brachytherapy. So these are probably the two most common therapies with long standing follow up for men who have higher risk features that haven't spread to other parts of the body.
And can you kind of describe those therapies for us in layman's terms, if at all possible.
Sure. Radical prostatectomy is a procedure where a urologic surgeon will have the patient undergo general anesthesia and do an operation to remove the prostate, seminal vesicles, and occasionally sample pelvic lymph nodes. The goal is to remove all of the areas that are at risk. It does have favorable success rates. And new technologies have allowed functional outcomes to become better over time.
Radiation therapy is another form of local treatment that has similar rates of cure. External beam treatment is usually done as an outpatient over several weeks of time where a patient will come Monday through Friday, lay on a table, and a machine called the linear accelerator will treat them with high energy x-rays that are painless. The patient undergoes a treatment in a matter of a few minutes each day and comes back repeatedly and is followed for their PSA. The prostate brachytherapy is another version of giving radiation using a radioactive source.
In some cases it's a seed implant to give low dose implants or brachytherapy, and in some cases it can be a high dose rate exposure. This is usually done under anesthesia. In our university it's done in conjunction with our urology colleagues. And the patient wakes up and is done with the treatment and we surveil them.
And these are pretty targeted treatments, correct?
They are targeted treatments.
So because I think that a lot of times people get worried when they hear radiation and things like that and with today's technology and the advances that have been made. You want to put people's mind at ease when you talk about things like that, so that the targeted treatments are obviously important.
Absolutely. One of the goals in radiation oncology is to treat the area of disease that's only at risk and try to minimize the amount of normal tissues. And we take great care to try to use our technology in order to do that.
And Dr. Szmulewitz, it's amazing how things have changed over the years with technology like that to make that possible, because I think if you went back a decade or two, it was a very different story.
Well, it's an exciting time for medical care in general and for cancer care specifically. And in prostate cancer we do have newer technologies, including robots that can help our surgeons operate with less side effects and with a shorter hospital stay and with radiation techniques that allow more precision and allow the normal tissues around the prostate to be spared. So it definitely-- and these technologies keep getting better and better. And we pride ourselves on being at the leading edge of that.
Perfect. Who is the most at risk for prostate cancer?
Well, men. Men are more at risk than women.
Other than it is more common with age, so the older you get, the more at risk you are. I would say some of the major risk factors are a family history. So if you have a first degree relative with prostate cancer, you're at much higher risk. If other cancers also co-segregate with prostate cancer.
So if you have a strong family history of, for example, breast cancer or ovarian cancer, then you might be at increased risk for prostate cancer. And we'll get to some of the genetics of that in the second segment. And then finally, it is worth pointing out that African-American men are at much higher risk for prostate cancer than Caucasian men.
And that's interesting. I'm sure there's been plenty of studies done trying to determine why that is, but certainly a valuable piece of information. At what age-- if you do have some of these factors, do you get screened? You get tested? Is it something you do when you're 50?
I know there's a bit of controversy around screening for prostate cancer. How much time do we have? We can go on all day if you want to, but--
No. Stan, you want to--
Yeah. It is a controversy. I think most people would agree that shared decision making is the right avenue to take, which means that a patient and a physician, which is usually a primary care physician will have a discussion about the benefits and risks of PSA screening. But there are studies that show that there are benefits to PSA screening, which means that you can save lives, especially in the age ranges of 55 to 74.
But I think it's appropriate to have these discussions earlier, especially if you have risk factors and a family history.
So talk to your physician. That's probably the best piece of advice from that standpoint. We've got another question from a viewer asking, how long are the radiation treatments? Does it depend on the severity of the prostate cancer? How long do they go on?
Yes. It really does depend on the characteristics of the cancer and also on the health of the patients involved. But there have been some recent trials that have shown that giving shorter courses of radiation are actually very safe compared to the historical standards, which would give men eight to nine weeks of radiation treatments. So it really depends on the situation.
But we've adopted shorter courses. And four weeks is a very common length of time for men who have intact prostate cancer.
What are some of the current innovations that you're seeing take place in the treatment of prostate cancer?
So I'll speak to the innovations for therapy once the disease is spread. Unfortunately, that is a common occurrence, especially for the more aggressive disease. And the patients that I treat in my clinic have disease that has spread. And I would say that over the last 10 years we've really seen an explosion of new medications to subdue and to treat that advanced, what we call metastatic prostate cancer.
There have been very exciting treatments in novel hormonal therapies that are both well tolerated and very, very effective. We have new immune therapies that are FDA approved for prostate cancer. And we have new combinations of therapy. And so I think that one of the greatest innovations is that we're realizing that the earlier we treat prostate cancer with more aggressive therapies, the better our chances of success are.
We were talking a little bit before the program. And one of the things that I think makes UChicago Medicine very special is the clinical trials. We do a lot of work here that's unique, because we are a research institution, an university that also couples with the hospital on work like this. And I think that is a huge advantage to the patient. Can you speak a little bit to that?
And what do the clinical trials mean? And how important is that for the patient?
Sure. So thank you for that question. So clinical trials is a blanket term and there are multiple different kinds of clinical trials. What we're talking about is a way to advance the field of prostate cancer through research. And we pride ourselves on having clinical research opportunities for our patients throughout the course of their disease. We have clinical research trials that patients can participate.
And even before they're diagnosed, when they're at risk and we think that they may have prostate cancer, we have biomarker based studies, so studies looking at the diagnosis and trying to refine the diagnosis. Then we have clinical trials that are testing new therapeutics for early disease, for a disease that recurs, for advanced disease. And we're really talking about having a clinical trial opportunity that will push the field forward for all of the patients no matter where they are in their disease spectrum when they come to see us.
Great. Dr. Liauw, we have a question from a viewer. And it is, what are the options for someone if the cancer actually does indeed return? Which I'm sure is a common fear for people.
Sure. It does happen, unfortunately. But there are a lot of treatments. Some of them very effective. It really depends on the circumstance. For men who have surgery and then have a PSA rise, it is common for us to see them and think about doing radiation treatment, just because the source of the PSA recurrence is most commonly within the pelvis. And that is an area that we can fairly safely treat with external beam radiation.
So there are also other types of recurrences, of course. Those that occur after radiation, or external beam radiation, can sometimes be salvaged with surgery or repeat radiation. And then, of course, there's a lot of systemic therapies that Dr. Szmulewitz and his colleagues would administer for people who might have metastatic recurrence. More and more we're seeing that aggressive treatments to metastatic sites, especially if there are very few of them, may actually help to improve outcomes.
So we are interested in that at the University of Chicago to try to extend the use of our therapies for more advanced disease.
Fantastic. I'm excited. We get to meet one of your patients here right now. Dave Hicks is a triathlete who has always kept himself in good shape. He was surprised when he found out that he had prostate cancer. After treatment at UChicago Medicine, Dave is proof that prostate cancer doesn't have to slow you down.
It was a surprise to me. I never had a clue that I had any kind of condition going on. I was doing fine. Went in for an executive physical and just as part of the normal screening process. It was just sobering. Just looking at life and suddenly being faced with something that has a potential to impact your future in such a significant way.
Well, we immediately kind of connected in terms of his triathlon experience and everything. And he just struck me as a very sharp, outstanding physician who covered all the bases and had excellent answers and seemed to be right up to date and current on research and clinical studies. It was very impressive.
You know, there's really a couple of goals as we go through treatment. But the main two are that we hope that the disease doesn't come back, that it's successful to eradicate any cells of activity. And the second is to try to protect the normal tissues so that patients can maintain a high quality of life in the long run. Radiation for prostate is typically done using linear accelerators. The courses of treatment usually last for several weeks at a time. In Dave's case it was about 8 and 1/2 weeks.
I started to feel the effects of the radiation therapy just in the last few weeks before the marathon. I mean, I could just watch my performance deteriorate. And it dropped off by 20% over a year period of time there. And then I gained weight. I gained like 40 pounds. It significantly affected training and affected my races. I mean, it became a focus as well to just finish the race and keep going and keep doing the exercise and everything.
But certainly the fact that you continue to stay exercising and doing strength training is a huge help.
It means that patients are also more invested in their outcomes. And that's always a great thing. You have a sense that you'll have an easier time getting people through treatment when they're invested.
So that certainly was a big win. And it felt good to achieve another milestone.
Yeah. We're pleased with how Dave's done. It's a testament to himself to really try to keep his body in great shape and be very fit, because I think that does play a part in his ability to recover well from the treatment. Dave is a special guy.
Mental standpoint, this isn't a death sentence, this isn't the end of my current kind of view on things, this is just another speed bump in life and we'll get over it.
That was a nice story. And it's good to see that he's doing so well. So joining us for our second segment of the program is Dr. Scott Eggener and genetic counselor Sarah Nielsen. Welcome to the program. Thanks for being here.
So let's just talk-- let's jump right into it. And I think people are kind of curious of the big question. And this was asked earlier as well, is, how critical is the genetic history or heredity when we talk about prostate cancer? Because I think we see this in a lot of diseases, in particular, cancers.
Yes. So we know that prostate cancer is one of the most familial diseases, meaning that it runs in families often. And we're now starting to pay more attention to the particular genes we can test for that are related to hereditary or genetic prostate cancer. So family history is definitely one of the big parts of determining what people's risk for prostate cancer is and could they potentially carry one of these genetic causes or one of these genes that we'll talk about as well.
So if you do have a family history, would you suggest that somebody get tested at a specific age? Or what would you tell them? Either one of you can jump in on that one.
Yeah. That's very actionable information. And there's very strict criteria on who might benefit from genetic testing. But in essence, it could directly benefit that man in how we decide to screen aggressively or loosely. It can often alter the management options if he is diagnosed with prostate cancer.
And then what most people don't realize is if a man has an identifiable genetic mutation, it can have profound impact on other family members, siblings, parents, children, both males and females, so it's incredibly important. And that's why we're fortunate to have Sarah and her team at our disposal.
Can you talk to us a little bit about the program here at UChicago Medicine? Because this is very interesting to me. If you have, again, the family history, people, I think, are, and very understandably, they're concerned. So talk to us a little bit about the program and how you deal with and treat patients or perspective patients as they come in.
The good news for people that might be at risk for prostate cancer or diagnosed with prostate cancer is we have a really comprehensive team of folks, all with their special area of expertise that have spent most of their adult life learning about prostate cancer. So it's really comprehensive, really multidisciplinary. There's a few of us on the urological oncology side. We have a couple folks on the radiation oncology side. A number on medical oncology.
We have Sarah Nielsen and her team in genetic counseling. We have some world class radiologists, pathologists. And we'll basically pull in anyone, including scientists and clinical trialists to try to do everything possible to provide for patients.
And I'm glad you brought that up and you're talking about that, because one of the things that I've seen time and time again as I do this program for UChicago Medicine is this team approach when it comes to dealing with patients. And I think this is so important and it's such a benefit to the patient because we do have experts across many, many fields and world renowned experts, so it really is-- in my opinion, the way to get care. And I think it's the way to do it. And you guys do a wonderful job of it.
And one of the things were recently very enthusiastic about is we had a very generous, but anonymous donor, give us a large chunk of money to start, what's called the UCHAP Clinic, U-C-H-A-P, which is the University of Chicago High Risk and Advanced Prostate Cancer Clinic. And to your point, it's a multidisciplinary approach where we meet from multiple different disciplines all in one clinic setting, and it's a genetic counselor, a urologic oncologist, a medical oncologist, a radiation oncologist if needed.
And men can-- sometimes they come in and they need only one or two of us. Sometimes they would see all of us, but it's sort of one stop shopping for screening and treatment for what can often be a complex and worrisome situation.
And I can also just add that we-- so we do get an extensive family history for every patient we see pretty much. And so that's kind of part of the package too, it's a personalized risk assessment like we talked about, not just asking about prostate cancer in the family, but asking about breast, ovarian, pancreatic, Ashkenazi Jewish ancestry, all these components of risk assessment to decide if that patient should go through with the genetic testing. And the process of that is not as scary as it sounds. It's essentially just a simple blood draw, but we do spend some time talking with the patient at that time to talk about the implications for both themselves and their family members.
So the clinic allows us to have that conversation in conjunction with a conversation with the rest of the physicians as well.
And that's very interesting. Can you expand a little bit on the genetic testing? Because obviously, I can see the impact that if I went in for, potentially, and me, but for family members as well, how important is that for children, other family members?
Right. So once we identify, or if we do identify a genetic cause, that allows us to do targeted testing for other family members. So if we can determine what's causing the cancer in that family, then we can use that genetic information to determine who in the family is at risk and who actually may not be at as high risk anymore. And like we also mentioned earlier, it's not just prostate cancer, we can also assess risk for women in the family.
The highest risks when we talk about the most common genes for prostate cancer are BRCA1 and BRCA2, which are historically known as the genes we would test for women for breast and ovarian cancer, the BRCA genes, or the Angelina Jolie genes, as we've heard them. There's some rebranding to do, if we should be calling them the breast ovarian prostate genes. And so those genes actually have the highest risk for breast and ovarian cancer in women.
And in terms of ages we start thinking about testing. I think you already asked that earlier, what age should we do testing? These are adult onset cancers, so we don't-- we are not typically testing children. We think about young adulthood. Primarily the early or mid 20s for women. And for men, if they do carry these higher risk genes, we talk about screening their prostate around age 40.
Well, that is great information, because I think most people probably don't even think about that. If you're male and you're going in and getting tested for potential prostate cancer, you're probably thinking maybe your son, but your daughter you could also give some very valuable information for her as well. So that's great information.
So what is the process for getting genetic testing? If I want to do this, what would I do? And how do I go about it?
Well, we do recommend, if you-- to come in for an appointment to talk about it in more detail. We also recommend talking to your family members ahead of time. It's really important to get a good family history. So gathering as much information as you can about the ages that individuals are diagnosed, the specific types of cancer, helps us kind of decide what genetic tests we might order.
We tend to do kind of broader genetic testing these days, where we're not testing just prostate cancer genes, but like we've said, we test genes that can also increase the risk of other cancers. But having a better idea of what cancers are going on in the family helps us then to make management and screening recommendations after that genetic test results are back, because even if genetic testing is negative, we still may actually change how we manage individuals in the family. Particularly, if there's a strong family history of prostate cancer, then we still treat people as high risk for prostate cancer even in the context of negative testing.
So family history is important. But like I mentioned, it's just actually a blood draw. We can take one tube of blood and test as many as 80 genes at the same time.
That's very interesting. So you talked a little bit about the high risk and advanced prostate cancer clinic, our new clinic. How long has that been in existence?
Yeah. We've been going for about six months.
And there's many of us that staff that clinic. And it's really two distinct populations that we offer it to. One is the man who might be at high risk of developing prostate cancer based on ancestry or family history or an identifiable genetic mutation. And then completely separate, but often overlapping, are a group of men newly diagnosed with a type of prostate cancer that has a legitimate threat of either spreading to other parts of the body or it already has spread to other parts of the body. And we're really proud of the fact that we have a lot of really new innovative clinical trials and screening protocols to offer these men.
And obviously one of our goals at any academic center is to provide top notch cutting edge care, but to also move the needle and come up with newer better ways of treating these men.
And, again, we were talking in the first segment just the fact that we do have so many options available here. We do the clinical trials here as well. Just a huge benefit to the patient. So I think, probably, if we want to leave somebody with a thought, because we are just about out of time.
And I know men don't want to go talk to the doctor about prostate cancer, that's an uncomfortable conversation to have. But it's a good thing to see your physician on a regular basis. Get your checkups. That sort of thing. And if have a concern in this area, obviously, you want to talk about it. You guys were great.
Thanks for having us.
We appreciate you being on. That's all the time we have for At The Forefront Live. I want to thank our viewers for their great questions today. If you want more information about some of the health topics that we discussed on today's program, please visit our website site at UChicagoMedicine.org or you can call 888-824-0200.
And please make sure to check out our Facebook page for future At The Forefront Live dates and subjects. Thanks for watching. Have a great week.
Prostate Cancer Care
The UChicago Medicine prostate cancer care team is highly skilled in the most up-to-date, technologically advanced methods for the diagnosis and treatment of prostate cancer. We offer the full range of treatment options, including robotic surgery, clinical trials of new therapies, sophisticated radiation oncology care, genetic testing for hereditary risk factors and more.Prostate Cancer Care Services
High Risk & Advanced Prostate Cancer Clinic
The UChicago Medicine High Risk & Advanced Prostate Cancer Clinic (UCHAP) provides focused care for men at high risk for developing prostate cancer due to hereditary risk factors as well as those with advanced disease. Services include customized screening plans, genetic testing and access to new treatment options available through clinical trials.Learn More About UCHAP