 Joining us now for our Your Health segment is Dr. Minaj Siddiqui, Associate Professor of Surgery at the University of Maryland School of Medicine and also Director of Urologic Oncology and Robotic Surgery at the University of Maryland Medical Center. Doctor, thank you for being with us. Thank you for having me. Refresher, of course, on the prostate, part of the male plumbing for whatever reason becomes cancerous fairly frequently but thankfully many times is not fatal. Is that about right? That's exactly right, yeah. So this is a part of the reproductive system and it is part of the urinary tract. And so it's very important in younger ages, in younger ages it allows men to be fertile. Later ages it doesn't have as much a function but can cause problems both in the sense of causing urinary problems with ability to urinate, with blockage as it grows, but also a large percentage of the time it can also get cancer. Something called enlarged prostate. Yes. Is it related to cancer? No, they're thought to be part of similar processes but BPH, benign prosthetic hypertrophy which is essentially enlarged prostate, is something that happens in parallel with the possibility that some of the cancer, some of the prostate actually becomes cancerous itself. And so they're separate processes but they can both cause problems for men. Is it those kind of symptoms that lead to a diagnosis that leads to somebody becoming your patient? Yeah, yeah, that's exactly right. So what happens is that someone will often come in with urinary symptoms. Often they will come in with inability to urinate or difficulty urinating and that leads to kind of working up their prostate. But then the other thing that can happen is men undergo screening for prostate cancer from an early age often, from their fifties often and the blood test that's used for screening can be high both because of cancer but also because of enlarged prostate. Let's talk about the screening but maybe to start with who ought to be screened? At what age should the average person start worrying about this? The normal recommendation is around the age of 55. The conversation should take place between the primary care doctor and the patient about screening for prostate cancer. And the peak incidence of prostate cancer, the peak time that people get prostate cancer is about the age of 65. But about a third of people would get the prostate cancer before the age of 65. There are some subsets of people who should consider getting screening done before the age of even 55, somewhere up downwards of 45 or 40 years old. Is that because it runs in the family or different demographic groups, higher incidence? Yeah, exactly. Both. So African Americans are at higher risk. They may well consider getting a screening at a younger age. Men who have first degree relatives such as fathers or brothers, they should consider also because they are also at higher risk. There's actually emerging research showing that men with female relatives with breast cancer might actually be at higher risk too. And although this is not a proven thing yet, but there's some thought that they might actually benefit from earlier screening too. Let me remind our viewers if you have a question about prostate cancer treatment or screening, give us a call. We'll have the number up on the screen. You could also email your questions, the email address, livequestionsatmpt.org. I can think of two major screening tests for this. One is fairly old school, digital exam, which does not involve ones and zeros. And the other is the PSA, and can think of some downsides to both of these. The PSA has particularly been at times particularly controversial. That's very true. So the PSA blood test, PSA stands for prostate-specific antigen, and it is a protein, a compound that is made by the prostate. And it's only made by the prostate, and so it floats around in the blood. And prostate makes it, but prostate cancer makes more of it. So if it's high, it's high because of one of two reasons. Either the prostate's making too much, such as an enlarged prostate, and that's where that kind of initial conversation comes into play, or cancer's making it, and that's usually when it's high. We're trying to make sure that it's not that the cancer's making it and that it's for some other reason. The controversy has been that it can be falsely elevated, and so people have a high PSA and it kind of sets into play a sequence of events such as the need for a biopsy, the need for some concern by the people that they might have cancer, and they don't really have cancer. And so there are downsides to having a false positive test. But the benefit is that prostate cancer in the early stages is a disease without symptoms. So you have no idea that you have it. You feel totally fine. And so the only way to really catch it is by this blood test. Interesting that you want to catch it early, but many times when you have a patient with an early stage prostate cancer, you don't do anything, right? Yeah, yeah, yeah. So it turns out that the majority of the time, you know, this is a very common cancer. This is about three million men in the United States are living with this cancer. And the key to that is that they're living with the cancer. This is a cancer that more often than not, you die with the cancer rather than of the cancer. You know, and so the majority of men can just be watched carefully and monitored with something such as active surveillance rather than needing active intervention or treatment. Let's get to the phones. A bunch of calls for you. Lisa in Allegheny County. Lisa, thank you for the call. Go ahead. Thank you for taking my call. Real quick, I actually have a dual question because I have a friend who's in his 80s who has an enlarged prostate and refuses to go through the biopsy, but there's a new technique using steam treatment for the prostate to reduce that enlargement. Can you discuss that a little bit more? And why should anybody in their 80s even bother with the process? Great questions. Thank you very much. Yeah, so that is a very good question. And so, you know, age does come into play. This is a cancer. It's a great question because it touches on a couple of key things. This is a slow-growing cancer usually. And especially if it's just localized to the prostate, someone in their 80s is very unlikely to really face significant harm in the course of their natural life. That is why we often will counsel patients as they start approaching their 70s and 80s on whether there really is any benefit at that point to trying to find the disease because we end up finding out that we put patients and the physicians in a tough situation that if you find something, you almost feel compelled because it's cancer to treat it. But it may actually be better to not treat it. And so if you know that you're not even going to treat whatever you find, then why look for it? Because sometimes it's just, you know, mentally tiring to be diagnosed with cancer. But I know, obviously, you can't comment on Mr. Miller's case, but it's been described as an aggressive cancer. Yeah. There's a difference? There is. So there is, and this is the challenge with prostate cancer. The majority of prostate cancers are local prostate cancers. These are curable. These don't even need treatment sometimes. But about 12% of prostate cancers are these advanced prostate cancers. These are aggressive. These can spread. These can actually cause harm to people. You know, prostate cancer is still the second leading cause of cancer death in men. And so there are people who face the very real impact of prostate cancer. And the key is to kind of differentiate the ones with these aggressive cancers and offer them the appropriate treatments while not overtreating everyone. Full call. Howard County, this is Bill. Bill, thank you for the call. Go ahead. Thanks for taking my call. I would like to know the answer to question of whether is it normal for the prostate to produce less fluid, the older you get, and is that related in any way with prostate cancer? Thanks for the call. Yeah, that's a good question. That is within the range of normal. And in terms of its relatedness to prostate cancer, I'm not aware that that would be related. So I think that that's just one of those things that the body changes with time. We introduced you as head of robotic surgery. One of the things you do with robots is prostate operations. What's the state of the art there? So there's a lot going on in the field of robotics. I mean, robotics really started emerging in prostate cancer in pelvic surgery. So when robotics was first introduced as a surgical tool, the prostate was one of the first applications. And in its early applications, 2006, it was still relatively crude, but new robots have come out. Now they're even using robots that go through a single incision. So right now, the benefit of the robot is it uses small incisions. You know, my hands are this big. So to do surgery, I have to make an incision big enough for my hands to fit in. The robot hand is about this width of my finger. And so an incision the width of my finger can get in. And that helps with recovery. Now the robot is capable of actually putting all its hands through one incision and remove the prostate. Is it harder as the surgeon to use the technology or do it the old way? Does it take longer in the operating room? No, there was a time when it did. I think surgeon skills have improved. And you're actually hitting a new generation of surgeons now. The technology has been around for about 12 years now. And you're finding a whole generation of people who've trained with robotics as their first language, if you can think of it that way. And so I'm probably in that first generation of people who actually came through learning surgery. Not scared of it at all. Yeah, it's actually a basic tool for me. And it's a very familiar thing for me. So I am as fast robotically as I am open. And I feel the surgery that we do now actually is better in these types of situations robotically. There are situations where open and still important and useful. No doubt in that robotics cannot do. But in most cases actually robotics has really become the go-to tool. Here's an email question. Might be a little complicated. A writer was just diagnosed with a Gleason 3 plus 4 a couple of weeks ago. 55 years old, had an elevated PSA about 10 years. Last PSA was between 6, 5 and 8. Father had prostate cancer at 78. Question is how urgent is it to have treatment? Gleason is a scale? Yeah, let me break that down. It actually hits on a lot of key points. So the key takeaways from that is versus the Gleason score. The Gleason score is an aggressiveness scale. And Gleason score is what's historically been used over the last 30 years. There is actually a new scale that is coming up now, which is more, I think, patient-friendly, frankly. And so the Gleason score system goes from 6 through 10, and it's the sum of two numbers from 3 to 5. And so you get like 3 plus 3 equals 6, or all the way up to 5 plus 5 equals 10. The new system goes from 1 to 5. And so on the new system, this would be a 2. This is an intermediate-risk prostate cancer. So it's probably aggressive enough that it needs treatment, but it just barely is. The PSA is the other thing we use for part of kind of figuring out how aggressive and how urgent this is. Less than 10 is a low-risk category. Between 10 and 20 is intermediate risk. 20 and higher is high risk. How do people respond psychologically to that conversation? Where you tell somebody you have this cancer, and you can't definitively say it's slow-growing, minor, forget about it, nor can you say it's aggressive, we need to go to surgery, it's sort of in the middle, we need to watch it. How do people handle that? You know, remarkably well. People are very robust. Being in the role as a provider that I've been fortunate to be in, I've come to appreciate how much people can adapt to these situations. This is often the first major medical diagnosis for men. They've been diagnosed with blood pressure or cholesterol, but this is the major thing. Because it's a slow-growing cancer, and actually that's the point to make about the other patient too, because it's a slow-growing cancer, you have time to actually learn about the disease as a patient. And that's something I really emphasize with patients. This is read about it, get second opinions, talk to a surgeon, talk to a radiation oncologist, talk to a medical oncologist, learn about the disease and be an active participant. And by doing that, you can take a few months to learn about it, and when they do that, I think that they start to like then, in the beginning, it's overwhelming. But then, once the dust settles... You're taking some control, awesome. Yeah, yeah. And so having these options for treatment, often there are a lot of options. To some patients, it's a little overwhelming, and some patients just need a little guidance, and they appreciate that. You don't mind when people talk to Dr. Google as it's called? Yeah, I don't mind it. I really appreciate and informed a participating patient. I think that the challenge with Dr. Google is when it scares the patient themselves because they see the worst case scenario on Google of people dying from the disease when that may not apply to their situation at all. Here's a quick email question. It's a colonoscopy connected in any way with prostate cancer. No, fortunately. But one thing that is interesting is a colonoscopy is a good opportunity for a rectal exam. And so a colonoscopy is at a time... I've had many patients who came to me because they said that my GI doctor was doing a colonoscopy. When they were doing the colonoscopy, they did a rectal exam. They felt a spot, they felt a lump, and they said I should see a urologist. Back to the phone, St. Mary's County. This is Kevin. Kevin, thank you for calling. Go ahead. Yes, I'm concerned. I got a week ago through my prostate exam, and I'm kind of worried about... I mean, what kind of symptoms can I look for? I mean, if there's any symptoms you've got to look for before you go see the doctor? Kevin, thank you very much. We'll get you an answer. So that is a great question. I think that that is one of the challenging things with prostate cancer, but there really are very few symptoms. Some degrees of challenges with urination might be early symptoms, but the reality is that for the vast majority of prostate cancer, this is a cancer that it's really important to see your doctor and get the rectal exam and get the blood test. Is there anything people can do to prevent this? This isn't one of those where you don't smoke, you stay out of the sun. No, it's not. The chief risk factor for prostate cancer is age, and there's not much you can do about preventing age from happening, so... Working on that one. We're continuing our conversation with Dr. Minaj Siddiqui about prostate cancer. Back to the phones. Howard County, this is Steve. Steve, thanks for the call. Go ahead. You're quite welcome. I'd like to know the interaction of different cancers. I had to have a kidney removed this summer because of the cancer growth on top of it. They couldn't take the growth away because it was all mingled in there. All the cancer... the best of everyone's knowledge, all the cancer has been removed. But I was just curious if there's any concern about... since it's all part of the same system down there, if there was any concerns about developing prostate cancer from this. Steve, thank you. Best of luck. Yeah, I mean, that's a great question. It comes up often. To the extent that's known, prostate cancer is not really known to be related to any other cancer, even though it's part of the same urinary tract. Kidney, bladder are probably not related to prostate cancer. It does turn out, though, that because it's such a common cancer, because there's about a 1 in 7, 1 in 8 chance of getting the cancer, that many people who have had these cancers, precisely 1 in 8 men who have had kidney cancer, for example, will end up having prostate cancer. So it is important to kind of keep on follow-up for that. Let's take a call from Baltimore. This is Will. Will, thank you for the call. Go ahead. Yes, I wanted to ask if the PSA fluctuates quite a bit, is that indication that there's no cancer? And I have a second question as to whether is there any dietary habits or practice which would be good in preventing prostate cancer? Will, thanks very much. Related email question, 74-year-old, this PSA has been around 2. Last exam it went to 3.5. How alarmed should that person be? So how much do these bounce around? Yeah, PSA is notorious for bouncing around. It can bounce around in the course of a day. It can bounce around in the course of a few hours. It's very frustrating, actually, both to the physicians trying to provide care and then the patients, obviously, who are getting these conflicting messages. Generally speaking, an aggressive cancer will show in steadily increasing PSA, but a high PSA may be indicative of cancer even if it's fluctuating. I wouldn't say that a fluctuating PSA is a rule out for cancer. It still needs appropriate work up. With the 70-some-year-old patient with the PSA less than four, I would not be worried about it. Second part of the caller's question about diet we sort of covered, but is there anything that you'd recommend? This is a real interesting area of study right now, and so there is no definitive answer. What is clear is that not having a lot of body fat, so obesity is related to poor outcomes with prostate cancer, and so to the extent that a healthy lifestyle and healthy diet can lead to healthy body mass. Whatever diet that is for you, there are a lot of healthy diets. There are studies we're doing with special diets. We're doing a study with a ketogenic diet, for example. A ketogenic diet is a diet that's very... I'm not on that one. That's one of the catchphrase diets, too, nowadays, but it's more than just that. It's a diet very, very low in sugars. And it turns out that this is a whole area of cancer metabolism where we're looking at how cancer cells convert nutrients into energy, and cancer converts nutrients into energy differently than normal cells. And that's part of your research. We're telling you in terms of the process of being able to look in there maybe a little bit less invasively. Exactly. And that's a major interest of mine, is figuring out better ways to diagnose and actually maybe even treat prostate cancers. And so we're looking at whether we can study it in the cells, whether we can look at it through metabolic imaging. That's an emerging area we're trying to develop now. But understanding cancer metabolism, and that's where diet comes into play. So there is research being done on what diets may work. Right now, there's no optimal diet. But what I tell my patients is that if they're overweight, they have to be underweight by any means. But if they're overweight, any diet that works for you to lose. Doctor, we're going to leave it right there for time. Dr. Menage Siddiqui, University of Maryland. Thank you, sir. Thank you for joining us for Direct Connection. Your health segments are a co-production of Maryland Public Television and the University of Maryland Medical System.