The Basics of Prostate Cancer



Kristie L. Kahl: Can you discuss the signs and symptoms of prostate cancer?

Dr. Charles Ryan: Prostate cancercan present in many different ways. Infact, I would say the most common waythat a man with prostate cancerpresents with this condition is with nosymptoms. For most men actuallyit's detected by their primary caredoctoror a urologist by doing a digital rectalexam and doinga PSA test.

There are some patients whopresentto their physicians with signs orsymptoms ofmore advanced urological process, suchas difficulty with urinationor perhaps even pain in the pelvis. Andthen a minority of the totalwilldemonstrate symptoms frommetastatic disease at the time ofdiagnosis. It might be bone pain, weight loss, etc., but that fortunately isa relatively rare phenomenon.

Kristie L. Kahl: What are some of the risk factors for the disease?

Dr. Charles Ryan: The most common risk factor for prostate cancer is a family history of prostate cancer. Although not all patients who have prostate cancer do have a family history, it is part of a genetic familial risk related to the BRCA genes. But that's again the minority of the patients with prostate cancer.

For the most part, patients have unknown risk factors. It’s a common disease in aging men – somewhere between one and six and one in eight men will get this disease over the course of their lifetime. There have been a number of dietary, lifestyle and other risk factors that are associated with it, such as a high fat diet, a western diet, obesity is slightly associated with a risk of prostate cancer. But for the most part, we don't point to simply one risk factor when we think about this disease, like we might, for some other cancers.

Kristie L. Kahl: Can you discuss the recommended age and testing guidelines?

Dr. Charles Ryan: That’s a fluid topic and something that does change from time to time. For the most part, men who are at the age of 50 should be having a conversation with their doctor about whether they should be screened for prostate cancer. That is the general time when screening has started. In some guidelines it's as low as 45.

For gentlemen who have a family history of prostate cancer in their father or a brother, they should think about getting screened for this disease at an age that is about 10 years prior to the age of onset for their family member. So, if dad was diagnosed at age 52 maybe you should start at age 42, for example.

Kristie L. Kahl: Why is early detection so key?

Dr. Charles Ryan: As with many cancers, prostate cancer is a disease that can stay localized to the prostate and could actually exist as a low-grade entity for many, many years before becoming something. That is a little bit more challenging or perhaps life-threatening. Many men who present with this disease actually have a form of prostate cancer that doesn't need treatment right away and they can be followed through active surveillance. But there are some patients who are followed on active surveillance who do go on to develop clinically significant disease. Discovering that and intervening when appropriate and following them expectantly and appropriately is key in order to prevent a conversion of a low-grade prostate cancer, for example, to potentially a higher grade and even a metastatic prostate cancer.

Kristie L. Kahl: Can you discuss the different grades and the different stages of prostate cancer?

Dr. Charles Ryan: With regards to grade, when I refer to grade, we're referring to what is seen by a pathologist under the microscope when a cancer is diagnosed. If there's no cancer, there's no grade. So, all prostate cancer is assigned what's called a Gleason grade. The Gleason grade has two components – a major component and a minor component. That grade range goes from 3 to 5. So five is the most aggressive and three is the lowest. There really isn't a 2 or a 1 anymore because those have been sort of done away with because they were considered to be not really cancer. So, the lowest grade prostate cancer that one would be diagnosed with in the current era would be a 3 plus a 3, or a grade 6. The highest grade then would be a grade 10, or a 5 plus 5. So, we see everything in the middle from a 3 plus 4, which equals 7, to a 4 plus 3. And as those numbers go up as the grade increases. That roughly corresponds to the likelihood of aggressiveness of the disease, meaning the likelihood of a recurrence after treatment with surgery or radiation or perhaps even the likelihood of the development of metastatic disease ultimately showing up in the bone or the lymph node or some other organ.

Kristie L. Kahl: How can patients find a specialist and the right health care team so that they get the right treatment?

Dr. Charles Ryan: Prostate prostate cancer is a fairly good example of a multispecialty or a multidisciplinary disease. There are three modalities of treatment for prostate cancer: surgery, radiation therapy and systemic therapy. Systemic therapy has a whole host of different options ranging from hormonal therapy to chemotherapy to immunotherapy to targeted therapies. In general, many men may be diagnosed and may never leave the care of a urologist because they have, for example, low-grade disease that doesn't require treatment and is put on active surveillance.

Many men may be diagnosed by a urologist but may be treated by a radiation oncologist or a combination of a radiation oncologist and an oncologist for patients who develop systemic disease who recur after surgery or radiation. For the most part, those patients are treated by oncologists. That's what I do. I’m a medical oncologist. The typical patient that I would receive into my care would be somebody who may have already undergone local treatment but it's an experience of relapse or his cancer has already left the prostate at the time of the diagnosis.

Kristie L. Kahl: What are the types of treatment options that men have for prostate cancer?

Dr. Charles Ryan: I’ll put these into two different categories. For men with localized disease, which is the disease that is confined to the prostate gland, that person could be potentially cured either through surgery or through radiation therapy with or without concurrent hormonal therapy. Then when we get into the systemic therapies, what I mean by that is treatments that really go all over the body not just to a local spot in the prostate gland, we would be talking about hormonal therapy, which is really guided towards blocking the effect of testosterone on the cancer. Chemotherapy, which is typically a drug injected by vein that has activity against rapidly growing cells in the body. We have new therapies such as androgen receptor targeted therapies, which are really hormonal therapies but are kind of in the next generation. We have a new class of therapies that have just been approved by the FDA here in the United States, and those are the PARP inhibitors and those block the mechanism by which cancer repairs defects in DNA. There’s many others coming in here as well: Radioisotopes, for example, are injected by vein. It’s essentially a radiation delivered by intravenous injection. We have an immunotherapy that is a cellular therapy that's a product called Sipuleucel-T, or Provenge. You can see there's a lot of different modalities of treatment and there are more coming. We’re likely to see, for example, targeted radio isotopes developed and will become available in the coming years, as well as other modalities of treatment.

Kristie L. Kahl: Why is it key for men to be their own best advocate when it comes to treatment options?

Dr. Charles Ryan: As I’ve stated, there are a lot of different treatment options. There are a lot of different types of doctors who treat this disease and there's a whole range of treatment necessities ranging from observation or surveillance to chemotherapy. So, it's always advisable for a patient to ask appropriate questions and to think about whether or not they are the full spectrum of physicians who might be able to treat them.

I would break this conversation down into two aspects. Number one is the person who has focal or localized prostate cancer, where the question is: How can I get this cancer cured with the most effective and efficient means possible, whether that be surgery or radiation? And if I’ve already talked to a urologist, should I also talk to a radiation oncologist to get a different perspective on my case? Then, for the patient who has recurrent disease or a systemic disease, the question is: The doctor who is treating me, are they a specialist in systemic cancer? Medical oncologists, that's what we're trained on. That's what our fellowships are in is the systemic therapy of cancer. Many medical oncologists will treat a whole host of cancers, ranging from lymphoma and leukemia perhaps even to prostate cancer. Some urologists, in addition to doing surgery will administer some systemic therapies.

So, I think it's important for the patient to know what tools their doctor has in his or her tool kit in terms of the available treatments that they have in their office.

Kristie L. Kahl: What would you say is your biggest piece of advice for someone who's newly diagnosed with prostate cancer?

Dr. Charles Ryan: I would say my advice for newly diagnosed patients would be to understand the extent of the disease that they have, the grade of the disease they have and the risks of their disease that they have. One of the interesting things about prostate cancer is there's almost hardly ever a time when there's only one way to do something. I would urge patients to ask the question of what would be the alternative to what's being recommended to me? So many men are perfect candidates for surgery but some of them choose to have radiation instead and vice versa. Asking the question of what if I did it this way, what's the downside? What's the upside> That is a good question.

Just a couple of practical pieces of advice: If somebody's diagnosed with a prostate cancer and they're going to get information and they're going to see perhaps many people and have a couple of different conversations, buy a pad of paper and get a folder. Label that folder and take that pad of paper with you everywhere you go. Take notes and you'd be surprised. That's really, really important. In addition, maybe even more important than taking notes yourself, would be to bring a loved one along with you to help you to take notes. If you're not getting the answers that you need from your doctor, then ask the questions yourself. And if you're still not getting the answers you need or the time you need to make decisions, get a second opinion.

Transcription edited for clarity.

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