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PROSTATE PROS

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by Mark Scholz, MD

4.8(37 reviews)

10 episodes

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Podcast Overview

Prostate cancer is complex. Patients often struggle to find accurate, stage-specific information. Listen as prostate specialist and author, Mark Scholz, MD guides you through the 15 stages of prostate cancer, recent updates, and all possible treatment options. Avoid prostate cancer pitfalls and take control of your diagnosis with the PROSTATE PROS podcast.

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8/3/2020

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Recent Episodes

May 3, 2021

That’s a Wrap

PROSTATE PROS Series Finale On the last episode of the PROSTATE PROS podcast, Dr. Scholz and Liz recap important themes and talk about what’s new in prostate cancer, including Lutetium-177 and Orgovyx. Dr. Scholz:  [00:03] We’re guiding you to treatment success and avoiding prostate cancer pitfalls.  I'm your host, Dr. Mark Scholz.  Liz:  [00:09] And I'm your cohost, Liz Graves.  Dr. Scholz:  [00:13] Welcome to the PROSTATE PROS podcast.  Liz:  [00:15] We have a bit of a sad announcement to make, as this will be the last episode of the PROSTATE PROS podcast.  Dr. Scholz and I have really enjoyed working on this project and we've covered so many important topics surrounding prostate cancer and men's health.  So for this last episode, we're going to recap some important themes and talk about some promising new therapies.  So Dr. Scholz, on our very first episode, we talked about how important it is to find the right treatment team.  This is something that's come up again and again and again.  What are some tips you have for newly diagnosed men trying to find their doctors?  Dr. Scholz:  [00:53] I think what's confusing is how much of the responsibility falls on the shoulders of patients.  The prostate industry is a very powerful multi-billion dollar industry, and there is a lot happening really fast.  When patients are diagnosed, they're not in a thoughtful perspective, they're in an action mode, they're frightened.  It is hard to sort out who to listen to and who to stay away from. This process can be aided by family members, primary care doctors, oncologists, and of course, online resources and books.  I try to provide some of that information in the book, The Key to Prostate Cancer, but the process, if it was easy, we could give you one simple answer.  It is not a simple process.  Liz:  [01:46] One thing that we've talked about is to get a quarterback.  So this is a doctor that isn't the treating doctor necessarily, but it’s someone that will oversee the treatment and work with the other teams of doctors.  This is something I hear you doing Dr. Scholz, you're always talking to other doctors about patients and kind of networking with them to make sure that the patient is getting the best care, even when they're not in our office.  Dr. Scholz:  [02:12] I think the issue that you're relating to is that many of these physicians have a conflict of interest.  You're asking them, what should I do?  But they're a surgeon or they're a radiation doctor.  And as a medical oncologist, I'm neither of the above.  This is somewhat uncommon, but you can recruit your urologist or your radiation doctor to help you by explaining at the outset that, “you, sir, will not be my treating doctor, but I definitely need your aid and your assistance in picking the right doctor.”  Liz:  [02:43] Now you may be thinking that you have cancer and you don't have time to see all these people, but as we've mentioned, prostate cancer is slow growing.  So really taking that time to find the right doctor for you is crucial.  Dr. Scholz:  [02:56] Just yesterday, I saw a very sophisticated new patient who was feeling the rush job, the sense that the clock is ticking, and he did have a Gleason 9.  We consider that the High-Risk category of prostate cancer.  But, the idea that you have to make a decision within days or weeks is never substantiated by the literature and the science.  Patients can take several months to sort out what they want to do.  This sort of careful thoughtful process pays off in the long-term with better results.  Liz:  [03:29] So patients really need to take it under their control.  One of the things is to educate themselves.  In the past couple of years, there's been a huge shift towards imaging.  So we've had the approval of the PSMA PET scan and using 3T MP MRIs and color Doppler to help men diagnose their prostate cancer and watch it.  Dr. Scholz:  [03:51] What Elizabeth is referring to is that if you don't have a clear picture of where the cancer is and whether it's spread outside the gland, what part of the gland it's located in, it's not feasible to tailor treatment to the specific needs of the individual.  Some men are fortunate enough to have prostate cancers residing on one side of their gland.  This opens the door to something called focal therapy, enabling men to undergo treatment with less risk of erectile dysfunction.  There were a lot of things we could have covered in this last podcast and the reminder that quality imaging and not only MRI and PSMA PET scans, but scans done at centers of excellence that are read by experts are going to help men be light years ahead in their selection of treatment, because they'll have a clear picture of what they're really treating.  Liz:  [04:43] So we've actually gotten emails from people all across the country saying, you know, my doctor's never heard of the PSMA PET scan or my doctor doesn't do 3T imaging.  So it is really important that you take the time to educate yourself and bring these questions to your doctors.  Finding the right treatment team and doing your due diligence to make sure you're choosing the right treatment is all important because of where the prostate is located.  Treatment related side effects can have damaging effects on quality of life.  Because prostate cancer is so slow growing, hopefully you'll have a very long life, so it's important that that can be lived to the best of your ability.  Dr. Scholz:  [05:25] That's so, so important.  And these functions, sexual, urinary functions are something that people face every day of their life.  In the hustle bustle to get treatment quickly, the fact that if the treatment is not done in an ideal way, that men can be left with permanent issues unnecessarily, certainly if there was no other option, we would live with these negative consequences. But, in most cases now with skillful care, these things can be avoided. Liz:  [05:58] Over the past two years, Dr. Scholz and I have covered all the treatment options from active surveillance to surgery, radiation chemotherapy.  These episodes will still be available even after the podcast ends, you can go back and re-listen and keep sharing with friends and educating yourself.  Dr. Scholz:  [06:16] One thing about this information provided in the podcast is not only the idea of which treatment is best and what kind of things to look out for, but the step by step process, the thinking process, the procedures, and how you can come to get the right doctors and the right treatment is implicit in the whole podcast system that we have provided.  So you can also just learn from the thought process that leads to successful outcomes.  Liz:  [06:49] While there are a lot of challenges that newly diagnosed patients face, patients with advanced prostate cancer also are missing out on some tools like Xgeva and Prolia.  Dr. Scholz:  [07:01] These medicines are to help compensate for men who have disease that’s spread to their bones or men who've been on hormone treatment and the calcium is leaching out, a process called osteoporosis.  The number of times this is overlooked and people coming to us for second opinions is really quite surprising, as they are FDA approved to help compensate for these problems.  So simple second opinions can be so valuable for men, even if they have advanced disease.  Liz:  [07:35] As we segue into what's coming up and what's new in prostate cancer, we wanted to quickly mention that there are a lot of new drugs and things being tested for FDA approval through clinical trials.  Clinical trials are a great way to get access to these new medications, if you have a specialist on your team who is constantly looking out for these and keeping tabs on what's coming up. Dr. Scholz:  [08:03] Every new medicine or treatment goes through a process of being researched. Once it's validated as a treatment, it gets FDA approved.  And then after that, it becomes commercialized and broadly available across the country.  The things that succeed through that process are very valuable.  And we'll be talking about a Lutetium-177 and a new pill called Orgovyx.  These medicines have been available, but now are commercially available.  If your physician is not staying abreast of all the new developments, men who could benefit from these treatments will be denied access simply through unawareness.  Liz:  [08:43] Lutetium-177 is something that we've talked about on past podcasts.  And it's not even FDA approved yet, but you've actually had some patients who have had it, is that correct?  Dr. Scholz:  [08:57] Lutetium-177 a was purchased by a Novartis pharmaceuticals for $2 billion prior to all the testing being completed because all the preliminary data looks so favorable recently, they released the code for the large clinical trial that was performed confirming that it does prolong survival. This is a medicine that was evaluated in men with very advanced prostate cancer who had already had chemotherapy who had been on other powerful hormone treatments and they'd stopped working.  The man who got treated with Lutetium-177 lived longer, statistically significantly longer, than the men who got an alternative, placebo-type approach.  This medicine is well tolerated.  It can cause some dryness of people's mouths.  It can lower blood counts a little bit, but it's a simple injection every six weeks.  And it is a potent treatment for men with advanced disease.  It may even be a useful treatment for men with earlier stage disease.  This will probably be commercially available within a year.  Liz: [10:05] To learn more about this medicine, we covered it in <a href="http://podcast.prostateoncology.com/podcast/dont-reject-radiation/" data-type="podcast" data-id="266" target="_blank" rel="noreferrer noopener">Episode 10, Don't Reject Radiation</a>. So you can go back and listen to that. At the end of 2020, there was a new FDA approval Orgovyx. This is an oral anti-androgen, so it works kind of like a Lupron, but instead of it being an injection, it's just a daily pill. Dr. Scholz:  [10:28] So how much do we really need a new pill?  When if you could take an injection that lasts three to six months, and you don't have to remember taking pills every day, but Orgovyx may have some other advantages when compared to head to head with Lupron and the other medicines like Lupron, such as Firmagon and Trelstar, Eligard, and Zoladex.  These medicines all work by shutting down the production of testosterone in a man's testicles.  Orgovyx is interesting for two reasons.  One is that the recovery of testosterone when treatment is stopped, seems to be much more predictable and consistent medicines like Lupron, and the others that I mentioned, can have a very protracted and prolonged effect even after they're stopped, and it's hard to predict when testosterone is going to return.  Another thing that came out in Orgovyx trials was a lower incidence of cardiovascular complications.  For years, I've made a strong argument that Lupron and other drugs do not cause cardiovascular problems directly, but indirectly in men who have a lot of weight gain, blood pressure goes up, blood sugars start to go out of control.  Of course these things can lead to cardiovascular problems, but for some reason, in that randomized trial Orgovyx had a lower incidence of cardiovascular related issues.  This is certainly an interesting and potential advantage for this medication. Liz: [11:56] Technology and medicine around prostate cancer is improving almost daily. And one of the things that's really promising is immunotherapy. We talked about this on <a href="http://podcast.prostateoncology.com/podcast/the-intelligence-of-immunotherapy/" data-type="podcast" data-id="262" target="_blank" rel="noreferrer noopener">Episode 9, The Intelligence of Immunotherapy</a>, and we cover all sorts of different things that will benefit men with prostate cancer, like KEYTRUDA and OPDIVO YERVOY. So if you're interested in learning more about immunotherapy <a href="http://podcast.prostateoncology.com/podcast/the-intelligence-of-immunotherapy/" data-type="podcast" data-id="262" target="_blank" rel="noreferrer noopener">Episode 9</a> is a great place to start. Making this podcast has been such a rewarding experience for Dr. Scholz and I, and we really hope that it's helped you on your prostate cancer journey. And we've left you with a little more education and knowledge and empowered you to take control of your prostate cancer diagnosis and spend time really learning about it and understanding, so you can have your medicine personalized to you. You can find the right doctors, seek second opinions, and then take everything you've learned to spread awareness about prostate cancer. Remember prostate cancer is a silent disease and it affects so many men and families and loved ones. This really needs to be something that people are comfortable talking about. So we hope our podcast has helped give you some points to talk about with your friends and family members and help them make those treatment decisions. Dr. Scholz:  [13:26] So Kaili, my business manager and myself are very grateful to Liz for all the hard work she's done in compiling these episodes and helping us reach the things that really count.  It's been quite a bit of work along the way, which has been a delight to participate in for me.  Liz, can you just share a couple of sentences of where you think you're going to be going with your own professional career as you're moving on?  Liz: [13:51] Yes. I am actually pursuing higher education to become a professional writer. I am looking forward to it, but I'm definitely sad that I won't be working with you and bringing this podcast to everyone. I know I've had so much fun learning about prostate cancer and hopefully being able to help all of our listeners navigate this subject. Again, these episodes have been archived, so you can go back and listen to all twenty-four of them on <a href="http://podcast.prostateoncology.com" target="_blank" rel="noreferrer noopener">podcast.prostateoncology.com</a>, or <a href="https://podcasts.apple.com/us/podcast/prostate-pros/id1460174904" target="_blank" rel="noreferrer noopener">Apple Podcasts</a>, <a href="https://soundcloud.com/prostate-oncology" target="_blank" rel="noreferrer noopener">SoundCloud</a>, wherever you like to listen. Another good tip is that the PCRI’s YouTube videos come out every week. These are awesome videos that talk all about prostate cancer. Dr. Scholz is a very frequent guest on there, so I would highly recommend you check that out. You can find them at <a href="https://www.youtube.com/channel/UCPYrfTJMCTfhBNZxb31Z1tg" target="_blank" rel="noreferrer noopener">youtube.com/thePCRI</a>. Thank you for listening and supporting us.

April 5, 2021

Friendly Reminder: Replace the Random Biopsies!

For decades the random 12-core biopsy has been the standard of care for diagnosing prostate cancer. What most men don’t know is that random biopsy can be dangerous and its results misleading. Fortunately, there are now better ways to interpret a high PSA that are less invasive, safer, and more accurate. The tragedy is many men don’t know this. One million men continue to get random biopsies each year despite having better options. This episode discusses the dangers of random biopsy and the best steps to take when facing an elevated PSA. If you’ve already been diagnosed with prostate cancer, share this episode with your friends and family! There are better, safer ways to interpret high PSA. Dr. Scholz:  [00:03] We’re guiding you to treatment success and avoiding prostate cancer pitfalls.  I'm your host, Dr. Mark Scholz. Liz:  [00:09] And I'm your cohost, Liz Graves. Dr. Scholz:  [00:13] Welcome to the PROSTATE PROS podcast. Liz:  [00:16] A lot of our listeners are men who already have prostate cancer.  This episode is for those people's friends who have a high PSA and are wondering what to do.  Do they get a random biopsy?  Is that dangerous?  Are there any alternatives?  Dr. Scholz:  [00:32] Yeah, Liz, I come across this all the time after I have a face-to-face meeting with one of our patients and we're helping them with their prostate cancer.  They mention “Oh, by the way, my friend Sam called me up and his PSA is running high, and his urologist wants to do a 12-core biopsy.  Can I run his case by you, Dr. Scholz?”   Liz:  [00:52] This episode, Dr. Scholz and I are going to talk through some easy points that you can share with men going through this, and we'll also post a flow chart on our blog, prostateoncology.com/blog. Dr. Scholz:  [01:06] One thing that really motivates us is the concern that too many men are getting random 12-core biopsies.  We've talked before about the wonderful advances in imaging for prostate imaging that have been developed over the last few years.  If 12-core biopsies were harmless, they certainly provide accurate, useful information, but they can cause complications.  Imaging is actually more accurate.  Unfortunately, the industry is sort of stuck in the past and 12-core biopsies are still being done with great frequency.  Hopefully we can give you some idea of when this may or may not be indicated.  Liz:  [01:47] Yeah, this is one of those things in prostate cancer, where there are better options, but men are really just hearing about random biopsy.  It's the option most people get.  Almost everyone knows someone who has had a random biopsy.  There are about a million of these done each year, so it's kind of public knowledge that when you get a PSA, you'll likely get a random biopsy.  Dr. Scholz:  [02:10] It's been this way for historical reasons.  The random biopsy was a big breakthrough in 1987.  It was approved the same year PSA came on the market.  So when the PSA was high, everyone would get a 12-core, round-the-clock, needle sticking in their prostate.  Really there was no other alternative because imaging for so many years, really wasn't adequate to see prostate cancer inside the prostate.  Liz:  [02:38] When you're comparing this to a different type of cancer, let's say liver cancer, they're not just taking random samples of the liver.   Are they expecting that there'll be imaging?  And why is the prostate something that's handled so differently?  Dr. Scholz:  [02:54] I think it's because historically the cancers that come from the prostate, aren't very malignant, thank God, and they tend to have a similar background appearance to the prostate gland itself.  So, very specialized techniques had to be developed for the cancers to light up to an adequate degree, to be visible on these scans.  Liz:  [03:15] Before we get into imaging, let's address some of the risks of random biopsy.  The first risk is something that I know you're very passionate about and actually wrote The Invasion of the Prostate Snatchers about, and that's the over-diagnosis of low-grade cancer.  These are the Gleason 6 cancers.  Dr. Scholz:  [03:33] We now know that Gleason 6 cancers don't spread and to call them cancers is an egregious overstatement.  They still do call it cancer however, and this creates confusion.  It's really better for men if this isn't diagnosed.  It doesn't spread and it doesn't need treatment.  12-core biopsies are much more likely to find Gleason 6 cancers than an image guided biopsy.  This is one excellent reason to avoid a 12-core biopsy.  Liz:  [04:07] This is something that we're kind of in an uphill battle against.  You said that Gleason 6 cancer doesn't need to be diagnosed.  And I think a lot of men think, well, if I have cancer, don't I want to know about it? Dr. Scholz:  [04:20] Yeah.  Not only do men think they should know about it, but they think they should be treated for it.  Cancer is an action word.  And the idea of sitting quietly and doing nothing with a cancer seems totally ridiculous.  It's the problem with the naming of this entity, which really isn't a cancer, but it's called a cancer.  The best analogy I've ever come up with is the difference between melanoma and squamous cell carcinoma of the skin.  The melanomas are the type of cancers that can spread, and the squamous cells stay put and don't spread, yet they're both called cancers.  Liz:  [04:56] So a biopsy can diagnose men with Gleason 6 prostate cancer, and then they'll rush into treatment.  They'll get surgery, they'll have terrible side effects that will be lifelong.  So it's really dangerous to be over-diagnosed with a low-grade cancer.  Dr. Scholz:  [05:11] Yeah, really, if there was no other option, we'd keep quiet about random biopsies.  I saw a patient just yesterday in the office; a sweet eighty-five year old man came to me because his urologist wanted to do another biopsy.  His PSA is running high, around 10, and his 20-core biopsy that was done in 2018 caused him to bleed three and a half units of blood.  How frightening!  If it was necessary to take these risks, one can certainly understand doing another biopsy, but imaging, now we know, is much better.  Liz:  [05:49] Beyond over-diagnosis, biopsies are dangerous.  There's a risk of infection, erectile dysfunction, rectal bleeding. The list goes on.  But I think a lot of patients don't have this conversation with their urologists or if they do, they think it's just kind of what needs to happen to figure out the cause of their PSA.  Dr. Scholz:  [06:11] I mentioned a patient who had a bleeding problem, but the real fear is that 1% of the time men develop infections that are so serious that they have to go to the hospital.   For otherwise healthy men to be hospitalized with really life-threatening infections is a tragedy.  When we know we have other approaches that can be just as effective, or even more effective than doing a biopsy.  Liz:  [06:34] The other thing too, as we talked about in the last episode, PSA can be from multiple different things, including just a big prostate.  So sometimes men with big prostates will have biopsy after biopsy and they're not finding cancer, but their PSA's are still high.  Dr. Scholz:  [06:52] This becomes more common in the men with larger prostates.  So a man with a very small prostate that has multiple needles stuck into his gland is most likely going to get a good, clear sampling.  But doctors know that with big prostates, sometimes they have to do more and more biopsies to get a good chance at finding all the cancers.  Liz:  [07:13] A 1% infection rate may not seem that big, but considering that one million men get prostate biopsies each year, that means about ten thousand men are going to the hospital with infection. Random biopsies can also miss high-grade cancer.  This happens about 20% of the time.  Dr. Scholz:  [07:32] So the first step to consider is a blood test called OPKO 4K.  This test is more useful than PSA because it clues the doctors in when there's a higher grade cancer present, a Gleason 7 or above.  Unfortunately it's not a perfect test.  It gives a percentage likelihood that a higher grade cancer is lurking in the gland.  This is certainly useful, if the percentage is very low, say less than 5% likely such individuals could consider then skipping doing a biopsy and just continuing on their PSA monitoring.  Liz:  [08:09] So a lot of our listeners may have experienced random biopsies and obviously they're uncomfortable.  They're dangerous, and they're not necessarily something you'd want to tell your friend to go do.  So what are some options that men with high PSAs have that allow them to avoid the random biopsy, but still get accurate results and understand their PSA?  Dr. Scholz:  [08:35] Yeah.  This is really the big breakthrough for over the last few years.  The imaging in particular with a multiparametric MRI is truly more accurate than a biopsy and studies have proven this.  Of course MRIs are non-invasive.  If an MRI shows a spot it's graded from 1 to 5 on a system called the PI-RADS system.  If the spot is graded a PI-RADS 4 or 5, some doctors say level 3, then a targeted biopsy to see what's in the spot is necessary.  So in certain situations you can't avoid doing a biopsy, but a targeted biopsy would involve possibly two or three biopsy cores rather than a dozen or more cores.  Liz:  [09:21] In our office, OPKO 4K is the most used, but there are competitors like SelectMDx and ExoDx, which do kind of the same thing.  So the OPKO 4K report will come back and it will give a percent likelihood that you have a Gleason 7 or higher prostate cancer.  If the likelihood of having one of these consequential cancers is low, patients should go back to annual PSA monitoring.  If the likelihood is high, patients should consider getting scanned with an MRI or a color Doppler ultrasound.  So before we get into targeted biopsies, I wanted to mention that it's very important about where you're getting your MRIs done.  These can be tricky things to read and tricky things to perform, so going to a center of excellence will give you the best results.  Dr. Scholz:  [10:14] Yes, in fact, if patients bring MRI reports to my office for interpretation, and I don't recognize the place where the MRI was done, I routinely asked for those images on a disc and forward them to a center of excellence like UCLA, Cornell, UCF, and have the images over read by a valid expert.  Liz:  [10:36] Where does the color Doppler ultrasound fit into this?  Dr. Scholz:  [10:41] Not very many doctors see enough patients to get skillful with color Doppler ultrasound.  We, however, find it very handy because it's a simple office procedure and it gives us information as to whether there is a suspicious area on the gland, just as the MRI does.  It also tells us how big the prostate gland is, which allows us to get a sense of why the PSA might be elevated.  For example, if the prostate is particularly large and the PSA is only minimally elevated, it's quite likely that the high PSA is merely from the big prostate, rather than coming from a cancer. Liz:  [11:19] Just as it's important for people to get scanning at centers of excellence, it's also important to note that targeted biopsies require that same level of expertise.  Dr. Scholz:  [11:31] Another thing to be aware of is that a lot of the doctors that are doing so-called targeted biopsies don't trust their skills.  Sometimes they don't trust the MRIs that they're looking at, and they feel obligated to do a random biopsy on top of a targeted biopsy.  In fact, that's almost routine.  Those of you that are seeking a targeted biopsy need to have this discussion before you're on the table in that vulnerable position, and the doctor starts hammering away with biopsy after biopsy.  I personally would express clearly to my physician, prior to the biopsy, that I only want a targeted biopsy and to not include the random portion.  Liz:  [12:11] So we're starting with something nonspecific, which is the PSA test.  Then we're using tests like the OPKO 4K, like MRIs, and targeted biopsies to figure out where that high PSA is coming from.  Dr. Scholz:  [12:25] What Liz says is exactly right.  The ambiguity of PSA creates a real challenge as to what the next step should be, and people need to be patient with themselves, even with the doctors.  Technology is changing quickly and some doctors get on board early with things, others don't.  We're looking to these physicians as our authority figures, and some of them are still kind of locked in the past. So the take-home message here is to go slow, do your research, talk to a lot of people, and familiarize yourself.   Thank God that prostate cancer is a very slow process, and of course it may not even be present, that is to be determined, but the go slow approach is essential in this whole process of figuring out what to do with a high PSA.  Liz:  [13:21] This can all seem overwhelming and confusing, especially during a time that can be filled with fear and experiencing a lot of different pressures, so we've posted a flow chart of PSA screening on our blog.  You can find it at prostateoncology.com/blog.  Before we close, we wanted to address some listener questions we got from our last episode “The Brief on PSA.”  We had a listener email this question in: “What is the difference between a standard PSA test and an ultrasensitive PSA test?” Dr. Scholz:  [14:02] When you're reading a PSA on a report, you'll notice sometimes that (this is only relevant when the PSA is very low) the numbers to the right of the decimal point may read 0.1 or in another report, it might read 0.11, or even in a more ultrasensitive report, 0.111, three digits to the right, indicating very small changes can be measured with what are called ultrasensitive PSAs.  So in men who have had previous surgery and their PSA should be undetectable, ultrasensitive PSA can detect a recurrence at an earlier stage than other technologies can.  Ultrasensitive PSA should be used in almost all cases.   For men with higher PSAs, say above 1 or 2, it's really not that important whether the PSA has ultrasensitive technology or not.  Liz:  [15:05] So besides standard PSA and ultrasensitive PSA, another listener was curious if there are other types of PSA tests and which of these are the most beneficial?   Dr. Scholz:  [15:17] There are actually quite a few there's something called free PSA or percent free PSA. There’s something called complexed PSA.  These have all been attempts to try and further refine the question that I believe OPKO 4K answers best.  They’re trying to sniff out which individuals with high PSA have a consequential type of prostate cancer that is a cancer that has a Gleason score of 7 or higher.  The complexed PSA, the percent free PSA had some utility, but it's not as useful as OPKO 4K, or perhaps the SelectMDx that Elizabeth mentioned earlier, or the ExoDx test.  So these other PSAs, which are available are just giving you the same information that any old PSA provides.  Liz:  [16:07] So when a patient comes to our office, Dr. Scholz isn’t ordering five different types of PSA, he just uses the ultrasensitive PSA test.  Thank you for sending your questions.  If you have further questions, please send them to podcast@prostateoncology.com.  Thank you for listening.  Please remember to rate, review, and subscribe on Apple Podcasts.

March 1, 2021

The Brief on PSA

PSA (prostate-specific antigen) is essential for prostate cancer screening and monitoring. This episode explores the PSA controversy, explains why annual PSA screening is crucial, and talks about the importance of PSA testing for monitoring prostate cancer treatment. Understand the benefits and drawbacks of PSA, and use this incredible tool to your advantage. Dr. Scholz:  [00:03] We’re guiding you to treatment success and avoiding prostate cancer pitfalls.  I'm your host, Dr. Mark Scholz.  Liz:  [00:10] And I’m your cohost, Liz Graves. Dr. Scholz:  [00:13] Welcome to the PROSTATE PROS podcast. Al Roker:  [00:16] I've been feeling great, but my doctor discovered I had an elevated PSA level in my blood work, PSA standing for prostate-specific antigen.  It's the first line of defense when detecting possible prostate cancer. Dr. John Torres:  [00:32] Today, an influential medical task force is changing those screening guidelines.  Now, urging all men ages fifty-five to sixty-nine to talk to their doctor about getting a PSA test.  Men ages seventy and older should not get screened. Dr. Kirsten Bibbins-Domingo:  [00:46] This should really be a personal choice that a man makes together with his doctor, and the goal of these conversations is really to understand benefits and harms. Dr. John Torres:  [00:57] Previously experts…  Liz:  [00:58] There's a lot of confusion and hesitation surrounding PSA screening.  What are the proper steps?  What do you do if the PSA test does come back abnormal?  This episode, Dr. Scholz and I are going to talk about the importance of PSA testing, what a high PSA actually means, and what the best steps to take are to further investigate. Dr. Scholz:  [01:21] The PSA blood test has been around since 1987, about the time my career started it up.  I can't tell you how revolutionary this blood test has been.  Really, we don't have another blood test like this for other cancers.  In some ways, PSA makes prostate cancer a much easier cancer to treat.  In other ways, like any powerful tool, if it's misused, it can create confusion and problems.  I hope we'll be able to bring some clarity to why this blood test can be controversial.  Liz:  [01:57] Everyone knows that PSA tests for prostate cancer.  PSA stands for prostate-specific antigen.  And when this is screened annually in men, it is to look for prostate cancer, but that is not all that PSA does. Dr. Scholz:  [02:15] The problem with PSA as a screening tool and PSA is used for other things besides screening.  But, as a screening tool, men still have a prostate gland.  Typically if they have a small tumor in their prostate, the lion's share of the PSA is actually coming from the gland, the benign prostate, not the cancer.  This is where the confusion comes.  Men will have inflammation of their prostates, and the PSA will be high.  Men will have enlarged prostates, and their PSA will be high.  Or, of course, they could have a low-grade, or a more consequential cancer, and their PSA could be high.  One savvy patient once told me, tell your patients to think of the PSA as a check engine light on the dashboard of your car.  Something's going on in the prostate, it could be cancer, and it could be one of these other causes.  Liz:  [03:12] When a PSA comes back elevated, taking time to understand what that means is crucial.  PSA can be a great tool to tell people they have prostate cancer, but it also has all of these other possible complications.  In 2011, the US Task Force advised against PSA testing.  Why was this Dr. Scholz? Dr. Scholz:  [03:35] Small cancers that don't spread are the root difficulty we have.  There have been active discussions about renaming certain types of prostate cancer as something non-cancerous.  That would be appropriate.  Of the 200,000 men diagnosed every year, about 100,000 have a condition that was named cancer back in the 1960s, that we now know never spreads.  But, that word cancer is so motivating that many people, to this day, are rushing into unnecessary surgery and radiation.  So the Task Force, realizing this problem of overtreatment, thought that quite possibly PSA screening was causing more harm than good.  Men were having treatments, making them impotent and incontinent for a condition that would never hurt them.  They later realized in 2016 that the men who have high-grade cancers were getting a short end of the stick.  People were coming in with more advanced cancers.  So they rescinded their recommendation to forgo PSA screening.  But you can imagine what confusion has ensued when you have a large task force arguing for, or against this powerful and useful test. Liz:  [04:54] Low-grade cancers, which are also called Gleason 6, never spread.  So this PSA testing can lead to unnecessary treatment.  So there's been a lot of controversy about the PSA testing.  What's your policy, Dr. Scholz?  Dr. Scholz:  [05:10] Well, I'm a big believer in doing PSA testing, at least in patients who are informed.  I get concerned about PSA testing just as the Task Force got concerned.  If you have uninformed patients that are like sheep, just doing what the industry tells them to do, those men are at risk of getting unnecessary surgery and radiation, which has all the consequences we mentioned.  Liz:  [05:34] This is something we come back to again and again, it's how important it is to advocate for yourself.  This means educating yourself, this means having conversations with doctors.  PSA screening should begin at forty for people who have family history and at forty-five for people who do not.   Dr. Scholz:  [05:54] Be aware that when you go in for an annual physical, many of you are assuming that your doctor's simply going to add a PSA to the blood test section that isn't always happening.  Some doctors still are following the 2011 Task Force recommendations, and it doesn't come up in conversation.  I have seen patients come in with high PSA, say from an insurance exam, and when they look back at their annual physicals, their doctor wasn't doing PSA.  So you need to make sure that PSA is part of the blood screening during the annual physical.  Liz:  [06:31] What happens if someone isn't getting annual PSA tests?  Dr. Scholz:  [06:35] Well, hopefully they don't have a bad prostate cancer, in which case they'll be fine.  But the incidence of prostate cancer is somewhere around one in seven men.  This means that a significant number of men could end up with advanced cancers that could have been prevented.  Liz:  [06:52] When most people think about PSA, they attribute it with screening.  Men with prostate cancer know that PSA is used for more than just screening.  Dr. Scholz:  [07:03] So when we were naming our clinic, Prostate Oncology Specialists, we actually considered calling ourselves the PSA clinic.  PSA for men who have already been diagnosed with prostate cancers is a very accurate test.  Why is this?  Well, as I stated before, one of the problems we have with screening is that men's prostate glands are intact.  The prostate gland makes a lot of PSA, which is unrelated to cancer.  Most men that have been treated for prostate cancer have had their prostates, either surgically removed or they've undergone radiation, which dramatically reduces the amount of PSA production from the gland.  So, if we are monitoring someone going forward who's been previously treated, if the PSA starts going up, we know that it's almost certainly coming directly from the cancer.  It gives us a speedometer to tell us how much cancer is present and how fast it's growing, which we can tell by how quickly it rises.  Liz:  [08:03] So, men with prostate cancer will get very familiar with their PSA numbers because they're being monitored, they're being discussed in terms of treatment options and staging.  Dr. Scholz:  [08:14] Many of my medical oncology colleagues are very jealous when I tell them that I specialize just in prostate cancer because of the accuracy of the PSA test.  We don't have as much ambiguity about the status of the cancer.  We can tell so much about how the cancer is behaving just by checking a PSA.  Liz:  [08:35] How often are men with prostate cancer having their PSA's checked during monitoring?  Dr. Scholz:  [08:41] Well, they’re certainly different situations.  The men who've had surgery or radiation typically will get their PSA checked every three months for a couple of years after the treatment, then maybe every six months out to about five years after treatment, then annually thereafter.  Men with advanced cancers, who are undergoing hormone treatments or chemo treatments, will often have their PSA checked every month to determine how effective the treatment is.  Is it working and whatnot, because we want to know if we need to switch treatment or strengthen or reduce the intensity of the treatment.  Liz: [09:18] PSA is a great tool for men with prostate cancer, whether it be for screening or for gauging treatment success. There is so much to learn about PSA screening, DREs, OPKO 4K. We've discussed this in past podcasts, but we'll always keep you updated on what the latest is on these topics. For those of you who love to learn about prostate cancer, the Mid-Year Moyad and Scholz Update with the PCRI is on Saturday, March 27th. It's free registration and it's virtual this year. So we're really looking forward to joining in on that. You can register at <a href="https://pcri.org/" target="_blank" rel="noreferrer noopener">pcri.org</a> and submit any questions to the experts. This year Dr. Tia Higano will be joining, she is a brilliant oncologist from the University of Washington. She will be talking about hormone therapy and its side effects. The new PSMA scan will also be talked about by Thomas Hope. Dr. Scholz, what are you looking forward to with the PCRI Mid-Year Conference? Dr. Scholz:  [10:28] Both the topics are so relevant, but the new PSMA PET scans, which we've talked about extensively really can't be talked about enough.  They're going to have relevance for men with advanced disease and men who are dealing with early stage disease.  This information is going to be very helpful, but it is so new, I don't even know all the things that are going to be coming.  Liz:  [10:52] My personal favorite part is always when you and Dr. Moyad talk.  So I'm looking forward to hearing some great questions and seeing what you have to say.  Thank you for listening.  You can email any questions or topics to podcast@prostateoncology.com.

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What is PROSTATE PROS?: Prostate cancer is complex. Patients often struggle to find accurate, stage-specific information. Listen as prostate specialist and author, Mark Scholz, MD guides you through the 15 stages of prostate cancer, recent updates, and all possible treatment options. Avoid prostate cancer pitfalls and take control of your diagnosis with the PROSTATE PROS podcast.
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Does this podcast accept guests?: No, this podcast does not typically feature guests.

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