Prostate Cancer Panel 2019
Our recent Ad Hoc with a Doc brought together an expert panel to discuss new developments and treatment approaches for people with prostate cancer. Below is the entire video as well as a full transcript of the discussion.
Hi, I’m Dr. Dan Rubin and this is another edition of Ad Hoc with a Doc.
We’re here at Naturopathic Specialists with some wonderful colleagues; Dr. Vershalee Shukla a radiation oncologist who you’ve seen before on Ad Hoc with a Doc, Dr. Amber Flaherty, a medical oncologist, who has not been a guest yet, but we’re so excited that she’s here and we’re talking with her, and of course, Dr. Larry Bans, a urologist with a focus on prostate cancer who has joined us on Ad Hoc with a Doc.
We all practice in the Scottsdale, Arizona area, and today we’re going to be talking about prostate cancer, we’re going to be talking about some new trends, or rather, some new treatments, some new diagnostic methods, and if we’re lucky we’ll get into dispelling some myths that may be out there that patients come in with.
So, Dr. Flaherty, thanks for being here. I’d love to ask you some questions about some of the newer treatments that are out there in the medical oncology world for people with prostate cancer.
Well thanks for having me, and usually we treated men in the past with prostate cancer with just Lupron alone or some kind of hormone blockade. And in the last couple of years, we’ve realized that if we moved some of the treatments that we used later in the disease process up-front, that seems to give patients longer time without worsening tumors and symptoms, and then that also translated into more survival data as far as patients were living longer.
So let me ask you a question about that then. So if you were using certain treatments later on…later on usually means maybe after something didn’t work at first, or was it as the disease was progressing when people may be getting sicker, maybe not as vital…using some of those treatments up front, are you seeing that they’re tolerating them better?
Correct. So usually it was, you know, one treatment, they’d progress as far as getting new tumors, or their PSA was going up, then another treatment, then another treatment, and you’re right, those patients would be very sick by that time. Now that we’re using the treatments in an earlier stage, the patients are doing better longer, and we can, basically, get them through more therapy if needed. So they, yes, in getting worse there’s PSA going up and also tumors growing.
Got it. And so, with those newer treatments, can they stay on those treatments longer? And then another question would be, Do those treatments interface with say, radiation therapy, and can they, now that you’re using some of those medical treatments up-front, do they compliment radiation therapy differently than they may have had in the past? And that may be a question for both Dr. Shukla and yourself.
Yeah, we’re finding that a lot of the treatments can go very well together and they don’t increase toxicity which is the biggest concern for patients and doctors, is we don’t want them to have more side-effects, and a lot of patients think well, more treatments are surely going to give me more side effects, but I haven’t seen that really.
And the type of radiation that we’re using nowadays, stereotactic radiation –
Yeah, what does that mean, what is stereotactic radiation?
Stereotactic radiation is a very precise type of radiation, so we use image guidance, sometimes we have implanted fiducials inside so we can –
Wait, hold on…an implanted fiducial? So that means you’re putting a marker inside the lesion so you can see it on an image which guides your treatment?
And so that’s the newer type of stereotactic.
Well, so that’s the concept of stereotactic, so you can see the tumor while we’re treating it, and because we can see it and we’re so precise, we can give a very high dose in a few fractions. So stereotactic is usually one to five fractions.
Well, that’s fantastic.
So that lessens the amount of time that they need to take time out of their day and come to the treatment center and it sounds like if you’re more precise and you see it on the picture you’re, especially around critical areas then, you’re lessening the side-effects of the radiation. But I know, I know this may be more lay terminology but, the beams kind of come in and they have to go out of the body – Right, right – So when they go out, I know they go out in a precise manner, but that’s where some side-effects can happen, right?
Right, exactly, but then there’s also newer things that we have to prevent those as well.
We have something called a SpaceOAR. So, something we always worry about with the prostate is the rectum, because the rectum is adjacent to the prostate. So what we can do is insert this gel that separates the space between the prostate and the rectum.
Is that by an injection?
It’s by injection, and that decreases the amount of radiation to the rectum – It’s like a protective barrier – Yeah, it decreases the amount of radiation to the rectum, it decreases radiation to the bladder, and the nerves. And so it’s…erectile dysfunction is maybe like ten percent with radiation using SpaceOAR.
Dr. Bans, with some of the newer technologies Dr. Shukla was discussing, are you seeing fewer people that you consult with moving toward surgery, and maybe opting more for primary radiation therapy for their prostate cancer?
I think it’s changing, I think the data on 10, 15, 20 year outcomes has become more comparable with radiation outcomes as opposed to surgical outcomes; and I think depending on the patient’s age and their disease status radiation options are becoming more attractive to patients for fear of a slight risk of urinary incontinence long-term with surgery and the erectile dysfunction issues. So I think that with better radiation techniques, higher doses, and less toxicity on the rectum and the bladder-side, I think people are electing radiation more commonly than they used to.
Dr. Shukla, with the technologies that you’re talking about and the advances in radiation therapy as primary with the intention to cure men with prostate cancer, are you seeing equal rates as to surgery?
Yes, pretty much so. So if you look at low-risk disease, intermediate-risk disease, and high-risk disease, survival comparatively for all stages is pretty equal with surgery or radiation. I always tell my patients it’s just about choosing which side-effects they’re willing to live with.
How would you describe somebody who’s high-risk compared with somebody who’s low-risk? Especially for our listeners out there, so they know the difference.
We clinically stage prostate cancer, so when we feel the gland, we feel the amount of disease there, and if it’s going to both sides of the gland if it’s invading into the seminal vesicles, that puts you at high-risk. We look at your PSA if that’s above 20, that puts you at high risk. And then we look under the microscope and if you have a Gleason of 8 or more, that puts you at high-risk.
Got it, so the Gleason is a score that goes up to 10 correct?
Okay, so anywhere 8, 9, or 10 would be considered at least part of the criteria for high risk.
And then you also I assume use when you were talking about looking at the seminal vesicles, if the prostate cancer has grown into, or invaded that, and you would see that on a scan?
Yeah, an MRI.
Okay, so you use radiology, lab diagnostics, the pathology diagnostics, and the clinical diagnostics all wrapped into one to determine. Got it.
What about the generalized, published rates of success for people with high-risk disease for surgery Dr. Bans? Have you seen any changes in the rates of success or cure with maybe newer surgical techniques? I’m not aware of the data.
Yeah, I think the rates are not that great with surgery alone –
Yes, for high-risk. At least 50% of those people tend to fail long-term and that’s called biochemical failure with a rising PSA in the future sometime. The promising point though is that with multi-modal therapy, with the addition of radiation therapy after surgery, with the addition of medical oncology interventions, whether it be chemotherapy or advanced hormonal therapies, I think the outcomes are much better than they used to be.
Got it. And nowadays, in our clinic, in our naturopathic medicine clinic, for people with prostate cancer, we do a lot of assays for people of what’s called circulating tumor cells, which there are United States based labs that can assay the blood, literally; I know we’ve discussed this before, to classify a cell, or if they find a cell they classify it as something that’s not supposed to be in the blood. And they consider that a circulating tumor cell, and I know in terms of some of the published data in men with prostate cancer, in some of the more advanced disease, or high-risk, or the higher Gleason grades, sometimes circulating tumor cells could actually be a better indicator of disease burden, or disease status than PSA. And we do, we see quite a few people who are undergoing conventional treatments and have also wanted to engage, whether they’re high-risk or medium-risk, engage in the integrative stuff and the naturopathic stuff with us, and it’s been nice to be able to interface with you all, I have to say that, so thank you.
What do you think accounts for biochemical failure for somebody who underwent either primary surgical resection or primary radiotherapy with or without medical oncology intervention who then, I’m assuming, have hopefully a PSA of down to undetectable, but then have a return, which would be called biochemical failure? Is it that disease had escaped that local, primary area prior to that treatment? Or is there a residual disease that may have been resistant to whatever treatment was given?
Well, on the surgical side, I mean, if there’s only cancer in the prostate, and the entire prostate is removed, in theory, we should not have biochemical failure. When we do have biochemical failure, it can mean that there’s residual disease, where we took the prostate out there could be microscopic cells that have escaped the prostate, and they were not removed at the time of surgery; or perhaps some cancer cells had escaped the local area completely and spread to bone or lymph nodes or other parts of the body, and sometimes we don’t detect that for months or years, sometimes even decades later when the PSA starts to rise.
Got it, so PSA can rise decades later…
It’s not necessarily very quickly, or the first year following treatment; which I would assume, Dr. Flaherty, they start to be referred to you at that time…Or do you start to see people earlier than that?
Generally speaking, it’s in that setting where they’ve gone through primary treatment whether it was surgery, radiation, or they’ve been on Lupron, and then it’s sometimes months to years that I see them after a rising PSA, a new set of scans may or may not show tumors, but we have medication to use in any case, so in that space, if the PSA is rising, but their scans are negative or normal still, a lot of times we didn’t know what to do with those men in the past. You know, we knew something was going to happen at some point, but we didn’t have anything really, or any action to take, and nowadays we do have more therapies that we’re using at that space, or if a man has a tumor that’s gone to a bone or wherever, we do use a lot more like I said, upfront treatment at that time.
And so, it sounds like you have more to offer your patients at different parts or different stages of their journey in the prostate cancer continuum.
Absolutely, in the last three years, so much has happened in prostate cancer for treatment of stage four metastatic disease, and it’s great because it used to like I said, be Lupron, chemo, and that was it. And now we’re doing more up front, and we have more therapies to offer. We’re doing genetic testing for men that have disease that has spread –
And that guides your treatment options for them too?
It does two things; it guides treatment because we know that a lot of prostate cancer grows or misbehaves by using DNA mismatch repair, so that’s something that we don’t have great targets for now as far as treatment goes, but in the future, we will have approved therapies for that.
It’s on the horizon.
Yes, in clinical trials. And then the second thing that genetic testing does is it basically tells men if they have any familial cancer syndromes that they may not have been aware of. BRCA mutations are associated with, most commonly, breast cancer and ovarian cancer, but prostate cancer is amongst those genetic mutations. So I’ve had men who’ve been tested, they have a BRCA mutation and then their siblings and then their children are tested as well.
So, are these people who are tested because they may be at risk or they’ve already been diagnosed, or what do you see kind-of on the horizon with that?
So the guidelines say that any man with stage four prostate cancer should be seeing a genetic counselor, and that was within the last year that our guidelines changed, just because they’re kind of seeing the new therapies come on the horizon, and because of the awareness of the genes for prostate cancer.
Fair enough, well Dr. Bans, that would be a question for you then about BRCA testing. Are you seeing any data or any patients consulting with you saying ‘I’ve been tested, or my father has it and I’ve been tested’ and they’re looking at prophylactic prostatectomy, or having their prostate taken out before it’s been deemed cancerous…and maybe – a second part of that question is – if they’re having prophylactic prostate removals, on pathological examination, are they finding occult cancers?
Yeah, well, I’ll answer the last question first, you know, it’s very difficult to justify removing a prostate prophylactically just because of the potential side-effects and risks –
Are we not there yet? Do you think that may be on the horizon?
I don’t think so, I don’t think so. And you know, until recently, very few men were tested for BRCA. I have one physician in town who because of a strong family history of ovarian and breast cancer he checked himself and he was positive. And that does increase his risk of certain cancers including prostate cancer. So we have stepped up his screening to six months rather than annual. But you know, I think, the people that I’m looking to test are the people with the really high-grade, aggressive cancers, and/or a family history that really goes along with it.
Good; thank you for that because I was about to ask – Does BRCA seem associated with a certain risk of disease, or a certain Gleason grade that you’ve seen in the literature?
I don’t think so, I don’t think they’ve teased that part out yet. Because we’re just now testing a lot of the men. So we just probably don’t have enough of the data yet. I wouldn’t be surprised because BRCA tends to be more triple-negative aggressive breast cancer, but we’ll see, over time as we test more men I think.
Excellent. Well, let’s talk about integrative oncology too. As a medical oncologist, are you seeing an increase in the number of people who are changing diet or asking about fitness or taking supplements, or maybe asking you for a referral or seeing naturopathic physicians or naturopathic oncologists, is that in your practice?
Yes, absolutely. I think part of it is because we’re in a state that has naturopaths, and so, other states that I’ve practiced in it was very uncommon. Here it’s more common for that reason, but I also think because most men, when you tell them ‘you have prostate cancer’, they know we’re going to take away their testosterone and they panic. So they want to do anything on the back-end of things to feel good because generally speaking, fatigue is going to be one of their side effects – muscle strength – exactly. And so, a lot of them already have established with one, or do want to see someone, and I’m very open to that because, generally speaking, none of the treatments kind-of…negatively affect each other, and if a patient is helping manage side-effects and feeling better on treatment, they’re going to do better.
Yeah, and we see quite a few people who have maybe the lower-risk, lower-Gleason grade, are on observation and we’ve done some dietary manipulation with them in the past, and one trend that we’ve found, which has been interesting is; it’s always kind of been our knee-jerk reaction I’d say for at least decade to say ‘Alright, vegan plus a fish add-back. High plant-based diet with marine lipids, which are anti-inflammatory’ you know, removing things that are potentially inflaming the person, making sure they’re on a fitness program, making sure that their body fat percentage is where it should be, not too high, especially their visceral fat; checking their blood sugar, you know making them more fit and healthy, and that reduces inflammation because a big component of prostate cancer is inflammation. But, what we’ve found through a lot of what we do, we look a lot at the onco-metabolic milieu and a lot of serological testing for our patients and surprisingly we found, especially with the, sort of, the newer quality of meats and foods, that we’re able to have some people respond well on less of a plant-based diet. And we’re especially watching something called IGF-1, or insulin-like growth factor 1, which is a known growth factor for many types of solid tumors, but especially prostate cancer. And you know, we thought ‘oh if they were going to be consuming animal meats that are rich in omega-6 fatty acids, especially arachidonic acid, and especially those that may have been treated with some type of growth hormone that that would…that we have seen has increased the IGF-1 circulating in the patients’ body. But we were afraid that even the more consciously raised, or humanely raised animals would too, and we see even people, men with prostate cancer who are on observation from the medical side going on a more ketogenic diet which includes high-fats and meats, but if they’re careful we will actually see decreases in the IGF-1, and I just thought that was really fascinating, I wanted to share that with you because we’ve seen that clinically.
Yeah, I think the data is getting stronger and stronger on exercise, on good aerobic interval training in terms of cancer outcomes; I don’t know if you see that across the board with other malignancies, but we hear a lot about it with the prostate. I’d like your opinion, and the panels’ opinion on statin drugs and metformin because there’s a lot of positive reports that those agents might be beneficial for people with prostate cancer.
Yeah, I know that there was a lot of retrospective data that looked to see men, you know as they were taking the metformin for diabetes and incidentally, did they have a lesser incidence of prostate cancer, and I think they’re, you know, it’s going to be hard to prove, but it’s something that I’m not against patients being on if it’s not negatively impacting them at all. Because I think that there is, you know, it goes along with inflammation and things like that with a statin as well, so I think it’s going to be hard to tease out, but I don’t think it’s adding any negative components to the men that are on other prostate cancer drugs, or in that kind-of preventative phase, I think it’s a good idea.
Yeah, excellent. I think that the world of repurposed pharmaceuticals is burgeoning. I mean we look at it, we use naltrexone in our practice, and we’ve been writing more and more metformin prescriptions; in this state, we can prescribe that, and so not only is it looking at blood sugar regulation, but there is known sort-of onco-metabolic or pathway regulation with that. Same thing with berberine which is an herb that has sort-of like a mini-metformin if you will. Um, in terms of the statins, I think that the anti-neoplastic and cancer pathway control mechanisms have been known for a long time…not one that I prescribe in my practice per-se…I have, and of course, we do some Coenzyme Q10 and making sure we’re exercising them et cetera, and we’re also watching cholesterol. As an ND I’m concerned that if cholesterol, certain types of cholesterol go too low, then they may not be having the fluidity of the cellular membrane that we need them to; but that doesn’t happen too often. And certainly in terms of prostate cancer, we – well in terms of all humans – we know that our steroid hormones are derived from cholesterol, and so I think that there may be some additional benefit from that.
You also mentioned circulating tumor cells; Amber, are you using any for genetically evaluating a patients’ tumor and looking for potential interventions down the road?
We’re not using them, only because there’s not a lot of support with the insurance companies. And so, for example in the space kind-of like we were talking about before with a high-risk patient, you say ‘Well how do we know they’re going to recur? Not all high Gleason scores recur.’ So at that time point, if we had a circulating tumor cell assay to then know going forward what would happen. But the problem is if there’s one, could that turn into more aggressive disease versus…we don’t know exactly how to use it in our practice yet, and it’s not well supported by insurance. So I don’t use it, but I think in the future it will be more useful. For now, the PSA is enough of an indirect measure and it’s usually pretty reliable for most men to kind-of tell us what’s going on with their disease; that and using radiographic changes.
So as the last topic we should examine is the notion of undertreatment. Dr. Bans, in your practice, are you seeing an increase in the number of people coming to see you that are diagnosed – like their initial diagnosis – but it’s with more advanced stage disease?
Well, as a prostate cancer specialist, right now I am seeing more patients – younger patients in particular – who are coming in with advanced disease initially.
What’s a younger patient?
Younger patient, to me, is someone in their 40’s. And I’m seeing a number of people who may not have been screened for prostate cancer with examinations and PSA screening. With what’s going on in the community in the last five to ten years with the question of whether or not screening is helpful in terms of survival…I definitely think it is. I think the European studies have proved that now, but unfortunately, there are people that present with advanced disease, which means they’ve got very high PSA’s, they’ve got high-grade cancer, and a lot of these young people – 40’s, early 50’s – are coming in with disease that has already spread outside the prostate.
Most likely to a lymph node or a bone?
Lymph nodes and bone. And in the past, you know, our only treatment option was to put them on hormone therapy for the most part…sometimes give them radiation for relief of pain et cetera, but now with aggressive therapy, which Dr. Flaherty can address, with some of the newer studies, we’re giving people up-front chemotherapy, very aggressive hormonal therapy, and we’re even treating these patients with radiation and surgery where in the past we would not have; and I think the outcomes are much better than we’d seen in the past.
And clinically too I’d assume as we talked about before, they’re probably able to tolerate something a little bit more aggressively. In those situations, Dr. Shukla, do you use a more aggressive form of radiation or treatment planning? Is that possible, or newer techniques? I know you talked about some of the blocking agents that allow you to give a higher fraction.
We don’t…we treat more comprehensively, so we treat the entire pelvis as well as the prostate, but the doses that I’m treating – we’ve maxed out on what we can give at that point to that area, and so that’s why I’d give what I’d give in a high-risk prostate.
What does it mean to treat the entire pelvis?
Sometimes we treat the prostate only because the risk of the disease going to the lymph nodes isn’t very high, but someone with very aggressive disease it’s higher, so then we’ll treat the lymph nodes in the pelvis – prophylactically – yes, along with the prostate and then kind-of halfway through treatment, we’ll come off those lymph nodes and just increase the dose to the prostate for the last couple weeks.
And if there’s somebody who does present initially, like Dr. Bans was saying, somebody who has metastatic disease to not only a lymph node, or instead of a lymph node, a bone in the pelvis which advances their stage, do you do any prophylactic bony pelvic treatment aside from just treating the lesion that’s been identified?
No, that’s where she (Dr. Flaherty) comes in.
So how has your practice changed with people being diagnosed younger, with more aggressive disease?
Well, the benefit of the patients that are diagnosed younger is that you can be more aggressive with them, and you know, you can give them up-front chemo, they can tolerate that well, along with Lupron, and they handle side-effects beautifully. We had a patient that did treatment while he was working and went on to have a prostatectomy, and he was now in his early 50’s and is doing really well. And that changes his life expectancy dramatically, probably on the order of years. So the younger the patients are when they’re diagnosed, even though that’s an aggressive form of disease, they can handle more aggressive treatment up-front.
Excellent, and I see that younger people seem to be more aware of their body composition, the health benefits, maybe they’ve already changed their diet – generally, at least I see in my practice, they’re living a healthier lifestyle, and maybe that might contribute to some of the successes as well. It’s all about awareness.
Well thank you, everybody, for joining ‘Ad Hoc with a Doc’, I really appreciate it, this has been a great learning experience for all of us, and me. Thank you.