Early Stage Prostate Cancer: Know Your Treatment Options

Dr. Diane Reidy-Lagunes:

Prostate cancer: 1 in 8 men in the United States will be diagnosed during their lifetime. For black men, the risk is even higher. They are 50% more likely to develop prostate cancer and twice as likely to die from it. Understanding what kinds of treatment are needed, if any, can be very confusing for patients. What do you need to know about prostate cancer and what's the best treatment for you? Let's talk about it.

Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier, healthier lives. For more information on the topics discussed here, or to send us your questions, please visit us at mskcc.org/podcast.

Today we are pleased to be joined by my colleagues and friends: Dr. Dana Rathkopf, a medical oncologist, Dr. Sean McBride, a radiation oncologist, and Dr. Behfar Ehdaie, who is a urologic surgeon. They're all part of MSK's multidisciplinary urology care team, and I'm so proud to say that the urology team is ranked number 1 in the nation by US News and World Report this year. Dana, Sean and Behfar, thank you so much for joining us and welcome to the show.

Behfar, I'd like to start with you. Knowing your risk for prostate cancer can clearly help us decide who is the right person to be screened in the first place. Can you start us off to understand what those risk factors might be?

Dr. Behfar Ehdaie:

Absolutely. Thanks for having me. Prostate cancer really is a cancer associated with age. As you get older, your risk increases. Obviously race, including black men are at an increased risk of being diagnosed with prostate cancer. These are the two main issues, including family history as well – patients who've had a family member, especially a first degree relative who's had prostate cancer. Having said that, prostate cancer is very common in our population. So our screening practices not only take into account these risk factors, but we also try to broaden the amount of men being screened by including men at a younger age.

Dr. Diane Reidy-Lagunes:

I think some people may be a little intimidated by the screening process itself. Could you walk us through what goes into actually being screened?

Dr. Behfar Ehdaie:

Screening actually has never been easier. In the past we used to include a digital rectal examination as part of our screening. We have since not included that and relied predominantly on a blood test. And that's the prostate-specific antigen, also known as the PSA test, which is a normal enzyme produced by the prostate gland associated with seminal fluid and easy to obtain through blood.

Dr. Diane Reidy-Lagunes:

Dana, we know regular screening is important because it can increase the cure rate when we find the cancer earlier. But we have some confusion sometimes since some of these tumors can be quite slow growing and may not need treatment. So how do you know what's the right approach for you?

Dr. Dana Rathkopf:

As a medical oncologist, I typically see patients who have what we would call intermediate- or high-risk disease. When you're screened by your urologic surgeon who does a biopsy and finds prostate cancer, the pathologists look at the cancer cells under the microscope and give it a grade that translates into the risk of prostate cancer. We call it the Gleason grade. Typically a patient who has a Gleason grade 7 would be considered intermediate-risk. A Gleason grade 8, 9, 10 would be considered high-risk. There are always modifications to that. Sometimes somebody might have an elevated PSA or features on imaging that don't quite match the biopsy, and we take that into consideration as well.

So when we think about which patients need treatment, we're looking at the actual biopsy, the Gleason grade, we're looking at the PSA level, we're looking at their risk factors, often we get imaging, and we're really trying to get a sense if there's something there that's more aggressive that needs treatment.

Dr. Diane Reidy-Lagunes:

Behfar, for those patients that don't need to go to Dana or Sean yet, and could potentially be in that bucket of active surveillance, what does that actually mean? Who are those patients and what do they have to do while they're undergoing that surveillance?

Dr. Behfar Ehdaie:

It's called active surveillance and what that entails for men with low-risk prostate cancer (in which we've also now expanded the criteria to some men with low-volume, intermediate-risk prostate cancer), is that we follow them every 6 months with a PSA exam, a blood test and exam in the office or through telemedicine. Every 18 months we obtain imaging, specifically a multiparametric MRI. And we do biopsies every 3 years throughout their lifetime to make sure that there aren’t any even small changes to the cancer while they're being monitored.

Dr. Diane Reidy-Lagunes:

For those that do require active treatment, how do you know when surgery is the best option for those folks?

Dr. Behfar Ehdaie:

For patients who are on active surveillance, which I do consider a treatment for prostate cancer, we think approximately 50% of men within 10 years may need some form of treatment.

Our criteria is quite selective and our thresholds are low, meaning we don't want to miss any patients without them being in our window of cure. So we look for patients in which their Gleason grade – which Dana referred to, which basically is how organized or disorganized the cells look under a microscope after a biopsy – or any changes on MRI that we would find concerning (which would be enlargement of the tumor or expansion beyond the capsule of the prostate gland) would then be an individual that we would approach about treatment. It's at that point that a patient then is really told to not only visit with me and discuss surgery but meet with our radiation oncologist like Sean to talk about radiation treatment.

Dr. Diane Reidy-Lagunes:

Sean, when you do meet a patient for the first time and you're thinking radiation therapy would be appropriate, any advice on why select for radiation?

Dr. Sean McBride:

There's a variety of radiation options. There's internal radiation called brachytherapy. There's external radiation called external beam radiation therapy. And within external beam radiation there's a variety of different radiation regimens that can last for a few weeks or as short as a week and a half or 2 weeks.

And there finally are different radiation modalities - something called protons versus photons. So there's a lot of different radiation treatment techniques that are available to men, and the factors that we look at when we're trying to determine which radiation technique is most appropriate for a guy are his urinary function, the size of his prostate, and his general medical conditions.

Dr. Diane Reidy-Lagunes:

So that's kind of a decision that the clinical team is making. It's not that the patient needs to decide if they should do external beam versus seeds, for example.

Dr. Sean McBride:

Well, the patients also have sort of some subjective preferences about what kind of radiation they may want to pursue. Some men want something that's as minimally invasive as possible, so they choose the external beam radiation, which doesn't involve any needles or cutting. And some men want to choose radiation options that may improve the probability of erection preservation or improve the probability of urinary function preservation. When a guy has options between the different radiation choices, we really try to tease out what's most important to him from a quality-of-life standpoint, whether it's sexual function, bowel function, urinary function, sort of the inconvenience of the treatment. So there's a variety of subjective factors that guys bring to the table that helps us hone the recommendation we might make to them.

Dr. Diane Reidy-Lagunes:

Let's hear from a patient named Larry, who received brachytherapy from MSK.

Larry:

My name is Larry Scott Blackman. I was diagnosed with prostate cancer back in 2021. It was early stage and my urologist and the team of doctors that I saw all agreed that we should move to cure based on where I was. So I wound up pursuing brachytherapy at Memorial Sloan Kettering and I came in and it was the same day treatment, and I was able to go home later that afternoon. The care I received was second to none. Awesome. I was in and out in one day, seeds permanently implanted in the prostate that attacked the cancer cells and took care of it. So no side effects other than some light fatigue and I’m ready to rock and roll.

Dr. Diane Reidy-Lagunes:

Rocking and rolling. Let's dive down a little deeper into those side effects because I think that's really what our listeners are trying to understand. So you said some of them may be able to preserve sexual function, for example, better than others. Some are a little bit more invasive. Could you share with us the different radiation techniques and approaches that you could do that may, for example, help with the urologic function and urinary continence, as well as sexual health?

Dr. Sean McBride:

In general with urinary radiation side effects, it tends to result in a temporary increase in urinary frequency and some urgency. For about 10% of men that can translate into a permanent change in their urinary quality of life. So for guys who come in with a lot of baseline urinary issues, frankly for a lot of those men, assuming they have minimal or acceptable medical comorbidities, we’ll oftentimes steer them towards surgery with Dr. Ehdaie and his partners.

But for guys who may not be surgical candidates who have significant urinary issues, believe it or not, the longer course radiation treatments – the treatments over 5 weeks or so – may be a little bit more tolerable for them from a urinary quality-of-life standpoint.

I think from a sexual quality-of-life standpoint, in general, radiation's fairly good at potency preservation and the radiation impact on a man's erection function doesn't tend to manifest itself for a year or two after the treatment, if it's going to happen. And it happens in probably about a third of men.

As to whether or not specific radiation treatments are better at potency preservation than other radiation treatments, I think what matters the most is the degree of precision of the radiation you're going to be delivering in terms of potency preservation. Over the past 10 years, we've made a lot of advances in delivering more precise radiation with less exposure of the normal tissues. I think that progress, more than any particular radiation modality, is what has allowed us to minimize to the best of our ability the risk of erectile dysfunction.

Dr. Diane Reidy-Lagunes:

Got it. It certainly sounds like from a convenience perspective the seeds are a little bit more invasive, as you're putting the seeds in, right?

Dr. Sean McBride:

Yep. That's always been true. Brachytherapy has always had that advantage of being one of the more precise forms of radiation, because instead of the radiation coming outside-in, as it has to do with external radiation, you're literally putting the radiation directly into the prostate. So that has always, in my opinion, had a precision advantage.

Dr. Diane Reidy-Lagunes:

Does that have any adverse disadvantage as opposed to the external beam? The seeds themselves?

Dr. Sean McBride:

The guys who undergo this procedure are under general anesthesia so there's the attendant risk associated with that. The seeds themselves, there's two types of seeds: Either seeds you put in and they stay there and release their radiation over about a month, or temporary seeds you put in for about 15 minutes and withdraw before the man wakes up from the procedure.

I think the permanent seeds that was referenced by the patient that we just heard, there tends to be a little bit more in the way of urinary irritation in the short term, meaning a little bit more burning with urination, a little bit more urgency in the short term, compared to maybe the temporary seeds or some of the external beam radiation options.

Dr. Diane Reidy-Lagunes:

Behfar, obviously every patient needs to be personalized and think about these options. And options are always good, but they can be overwhelming. So could you give me, in summary, who an ideal patient would be for a surgery over radiation?

Dr. Behfar Ehdaie:

I think there's some known reasons that radiation would not be an option, including any bowel issues regarding Crohn's disease or inflammatory bowel issues. There may be patients who've already had radiation to their pelvis for other conditions, patients who've had difficulty with urination or irritated urinary symptoms, sometimes very young patients in which a surgical approach may have a long-term reduction in treatment burden.

Ultimately our goal is to really sit with patients, not only once, but as many times as they need to not just describe the procedure. Initially, we focus on what's your risk, what does the prostate cancer mean? And that might be enough for the first visit because all of this information is so overwhelming. We connect and reconnect patient with our nursing team, myself, and then after we've laid out what the expectations are, the recovery plan, we can then help guide them to align their preferences with the outcomes they want to achieve.

Dr. Diane Reidy-Lagunes

We talked a little bit obviously about the radiation side effects. What about the surgery side effects?

Dr. Behfar Ehdaie:

We've had significant advancements in the technology with surgery in the past decade. Specifically, we've moved from open surgery, which was an incision the size of your hand in the lower abdomen, to now minimally invasive procedures involving either robotic assisted procedures or laparoscopy, in which a dime size incision above the belly button is utilized. We do these cases in the outpatient setting. Patients go home the following morning. Frankly, we expect our patients to be up and walking the evening after surgery, eating regular food, drinking fluids.

Patients have a urinary catheter for one week after surgery. That catheter is placed under anesthesia during the surgery, so patients wake up and are able to tolerate the catheter and walk. Our expectation is about a mile per day after surgery.

Having said that, with surgery there are side effects associated specifically with urinary function and sexual function similar to radiation treatment. With surgery, the transition or recovery period can last up to 2 years. With recovery, a lot of what we do happens before surgery. We expect all of our patients to do Kegel exercises before surgery, which is strengthening the muscle that's required to hold the bladder in the absence of the prostate gland. We also start patients on a penile rehab program to help with nerve recovery after surgery to help with erections.

In general, I tell patients that in the first 6 weeks to 3 months after surgery, expect to have some leakage when you cough or sneeze. That'll improve into 12 and 18 and 24 months after surgery to hopefully achieve full continence. Similarly, with erectile function, we are hoping to start erections 6 to 8 weeks after surgery. If not, our sexual health experts really help recovery of erectile function as well.

Dr. Diane Reidy-Lagunes:

Dana, when do we have to use hormone therapy? Patients don't usually love that one so much.

Dr. Dana Rathkopf:

I think that's a major fear of many patients with a diagnosis of prostate cancer, is that at some point they will need hormone therapy. We're specifically talking about the hormone testosterone, and we give medications that either stop the testosterone from being made or block the testosterone from getting to the cancer cells and feeding those cancer cells and allowing them to grow.

For a patient with a high-risk localized prostate cancer who's thinking about radiation, we often recommend hormone therapy with the radiation because there is a synergy between the hormone therapy and radiation, such that when you have damaging effects of radiation on the cells, the hormone therapy prevents those cells from repairing themselves. So for a patient considering radiation with curative intent who has a high-risk tumor, hormone therapy is certainly something that they need to think about, and that can impact outcomes and side effects quite a bit.

We certainly think outside the box sometimes. It's not one size fits all and we refer patients for clinical trials when we think it's appropriate. Some of those trials include hormone therapy or hormone therapy in combination with other agents to try and improve outcomes.

Dr. Sean McBride:

Over the past few years we've become much better at determining who really needs hormone therapy, and then amongst that group of men who we think need hormone therapy, who benefits from just having a shorter course of hormone therapy versus a longer course. In the future, I think we'll look at the pathology slides with AI technology that'll allow us to eliminate the need for hormones in a good portion of men, especially with intermediate-risk prostate cancer, and really identify those who are going to truly benefit from it.

Dr. Diane Reidy-Lagunes:

I think that's so critical because obviously quality of life is so important to all of us, and these hormone therapies can be disruptive. Let's hear from Michel, who shares his experience with hormone therapy that was short-term.

Michel:

My name is Michel. I've had hormone therapy for prostate cancer and then I had radiation at the same time. I think the biggest complication from the hormone therapy, in my opinion, was hot flashes every 2 hours. It was difficult to get a night's sleep, so I usually just kept my bedroom at 65 degrees. They last about 3 or 4 minutes and then you cool down. In the daytime when it would hit, if you're driving in your car in the wintertime, 20 degrees outside, I would just roll down all my windows. Number two, your sex drive is just gone. You don't even know it's gone. Only your partner or wife will know that it's gone. And then the last one that comes on slowly but surely is the weight gain. For me being a thin guy, I had to think about it and work on it.

Dr. Diane Reidy-Lagunes:

I just want to give a shout out to our sexual health clinic because they can really help with exercises and/or other interventions that can really help when it comes to the sex drive. Dana, anything else our patients should know about hormone therapies?

Dr. Dana Rathkopf:

Absolutely. When men are on hormone therapy, it's very similar to women going through menopause. For women, our ovaries stop making estrogen and then we can have a continuum of symptoms like hot flashes or weight gain. For men, it's similar in that we're artificially shutting off the male hormone testosterone in this setting.

When that happens, you can have quite a number of side effects. Some men have really debilitating hot flashes. Some have fatigue, bone loss, sometimes you don't necessarily gain weight, but the weight can shift to the breast tissue, for example. There are a lot of ways to prevent these side effects of hormone therapy or to be proactive about them.

At Memorial Sloan Kettering, we have an integrative medicine program, and I'm a huge proponent of this program. They focus not necessarily on the cancer, but on the patient and on the side effects of the cancer treatment, with an overarching goal of quality of life. There are any number of ways that they do that. They have acupuncture, massage, physical therapy, nutrition, and exercise.

There's also an “About Herbs” on MSK’s website, which tells you a lot about different supplements. I find that patients are often asking about different supplements that they can take to help with hot flashes. On this website, you can actually put in different supplements and get some information about them. I feel that being proactive is important.

Another side effect of hormone therapy that we haven't touched on is a possible metabolic syndrome. There's a question about how hormone therapy affects blood pressure, insulin resistant cardiovascular disease. There's a lot that we don't know about that, but we know that patients in general – for all diseases – when they feel better, they do better. So I really encourage patients starting on hormone therapy to be proactive about their lifestyle, and we try to offer them the tools they need to do so.

Dr. Sean McBride:

I was just going to say – just to piggyback on what Dana says about side effect mitigation – one of the things that we do have here that I think is helpful is the men's sexual health clinic here. Oftentimes we'll start guys prophylactically on medications like Viagra, Cialis, Levitra to mitigate the risk of erectile dysfunction, especially if they're getting radiation and hormone therapy.

The one other thing I would mention about hormone therapy is that there are two ways to administer hormone therapy: one is through a shot the other through a pill, and the pill is a relatively new version of hormone therapy. Oftentimes guys who are getting short-course hormone therapy will actively suppress their testosterone for 4 to 6 months when they're getting radiation. But with the shot version, that testosterone suppression would extend well beyond the 4 to 6 months, up to an additional 6 months. With the pill version, what's called Orgovyx, the testosterone tends to return much more rapidly. That doesn't change the intensity of the side effects the guy experiences while he's on the hormone therapy, but it definitely reduces the duration of those side effects.

Dr. Diane Reidy-Lagunes:

What's on the horizon for treating prostate cancer in terms of radiation oncology, surgical techniques and/or medical therapies?

Dr. Dana Rathkopf:

I'm a medical oncologist so we look at systemic therapies and there's a great desire to look at treatments outside of just hormones. We have drugs that target something called PSMA, now we have drugs that target DNA damage-repair alterations. We have immunotherapies for a small population of prostate patients. We also are looking at intermittent hormone therapy. There's an opportunity to de-escalate and escalate therapies as well when needed. I think that there's any number of things on the horizon and it's quite exciting.

Dr. Behfar Ehdaie:

We also found that patients who were on active surveillance, who we've seen subtle changes in their cancer, their only options were to meet with myself or Sean to get radical treatment with radiation or surgery. And we really brought to the fore this concept of focal therapy, which was a new concept when I finished my training and really unexplored. What we realized is with our advancements in our biopsy techniques, using MRI prior to biopsy to guide our biopsies, we were able to map the prostate and the tumor within the prostate better than we have in the past. So the next question was, why not just treat inside the prostate the area where the tumor is located, or where the tumor burden exists? We partnered with some really exciting technology to treat tumors within the prostate gland using sound waves in which patients have no cuts, no bruises, no pain, go home the same day, and have had a treatment that burns or ablates the tissue within the prostate gland. We're continuing to do studies and providing it as an option for our patients, although selective, to really continue to push the envelope in treatment options.

Dr. Sean McBride:

On the radiation front, I would echo one of the things that Dana mentioned. There are men with newly diagnosed low-volume metastatic prostate cancer, meaning prostate cancer that spread to the bone or spread the lymph nodes outside the pelvis, who I think with aggressive treatment can enjoy long and durable remissions. This is called oligometastatic prostate cancer, and frankly, I think it's been a sea change for men who find themselves in that situation. The other big thing – we're constantly, in radiation oncology, trying to design our treatments to minimize side effects – and one of the most exciting new treatment techniques that we have is MR-guided radiation. Typically radiation is guided using a CT scan, but MR-guidance is much more precise and gives us much higher resolution pictures of the prostate. There's now randomized data – the highest level of evidence that we have in medicine – that shows that compared to older radiation techniques, MR-guided radiation reduces short-term urinary and bowel side effects. And we have one of those machines here at Sloan Kettering that we're increasingly using, especially for guys who might have a little bit more in the way of urinary side effects. The benefit of this treatment is that it is as minimally invasive as it can be.

Dr. Diane Reidy-Lagunes:

That's great stuff. I can't thank the three of you enough. I learned so much. Any final thoughts before we leave today?

Dr. Dana Rathkopf:

As you can hear, there's so many options. It can really be overwhelming for patients, especially a patient that's newly diagnosed and trying to sort through all of this. It's very rare that there's a quote “wrong” option. A lot of times we choose treatments not because one is better than the other in terms of how long a patient's going to live or what their chances are of being cured, but more so based on what the side effect profile might be and how it might affect their lifestyle. I think it's important for patients to understand that and to ask as many questions as they need to feel comfortable with the treatment that they choose.

Dr. Diane Reidy-Lagunes:

Terrific. Thank you again for joining us today.

Dr. Dana Rathkopf:

Pleasure. Thanks Diane.

Dr. Behfar Ehdaie:

Thank you, Diane.

Dr. Diane Reidy-Lagunes:

Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us your questions, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing it on Apple Podcasts or wherever you listen. Any products mentioned on this show are not official endorsements by Memorial Sloan Kettering. These episodes are for you but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes, Onward and upward.