 Dr. Brian Dickstein, Clinical Assistant Professor in the Department of Surgery at the University of Maryland School of Medicine, Chief of Urology at the University of Maryland Baltimore Washington Medical Center, also with Chesapeake Urology, Dr. thanks for being here. Thank you, Jeff. We want to talk about prostate cancer which is quite common and sometimes very serious. Let's start with the basics. Sure. The prostate is a walnut-shaped gland. It sits way down deep in the pelvis, just below the bladder, and it contributes the majority of ejaculate for the purpose of male reproduction. And the idea that it becomes cancerous, somebody told us once that if we lived long enough we would all get it, all men. What happens that makes it such a common cancer? Absolutely. It's well known that as you get older the incidence of prostate cancer increases, and it is the second most common cancer in men behind skin cancers. How is it in your practice when you see patients with this, how does it first come to their attention? Is it through a test? Is it through surveillance? Is it through some symptom that they experience? Yeah, absolutely. This day and age, it's most commonly detected incidentally, meaning patients are asymptomatic. This is typically on a screening test. Usually the most common things that we do are DRE, or digital rectal exam, and PSA, which is a prostate-specific antigen to blood test. Back in the day, people were diagnosed when they had symptoms, when they had lower urinary tract symptoms, frequency, urgency, difficulty, voiding, or even when it was advanced they had bone pain, pain from metastases. Okay, and the first set of symptoms you mentioned could be other stuff? Absolutely. These are non-specific symptoms, or symptoms that are commonly found for men with BPH or benign enlargement of their prostate. It's also commonly found in patients with overactive bladder, so they're not very specific to prostate cancer particularly. So I guess there's two things to focus on. Whatever the latest advice is on screening, and I know it's been a little bit controversial, who needs what and when, and then the treatment side has also changed a bit. So let's start with the screening. Average person, what do they need, when do they need it? The different governing bodies have different guidelines, so we have the American Medical Association, the U.S. Preventative Task Force, and the American Urologic Association. So obviously as urologists I'll speak from the AUA perspective. So in men under the age of 40, we do not recommend screening. In men between the ages of 40 and 54, we recommend screening only for those with high-risk features. So either African-American men, or men with a family history of prostate cancer. Just being African-American raises your risk of this. Yes, sir. Okay. Men between the age of 55 and 69, we do recommend discussion, shared discussion, shared decision-making process with men about the risks and benefits of screening. And men over the age of 70 or men with a less than 10 to 15 year life expectancy, we don't necessarily recommend routine screening. Okay. Now once something has been identified, there's something suspicious. What do you do? So if you have worrisome signs or symptoms, or if you have an elevated PSA and or abnormal digital rectal exam, the next step would be a prostate biopsy. So getting a tissue diagnosis is the way to confirm the prostate cancer. Does it tell you anything else? It gives you an information about the grade of the cancer, meaning the ugliness of the cancer cells. So that sort of implies how aggressive the cancer is. Okay. Let me remind our viewers, if you have a question for the doctor about prostate cancer, give us a call. The number will be on the screen. You can also email us at livequestionsatmpt.org. What is the range of treatment and how has that changed over the last decade or so? Absolutely. For a wide range of treatment, for localized disease, we have something called active surveillance where we just monitor very carefully. We have radiation treatments, and these include external beams, shooting beams of radiation from the outside, and something called brachytherapy where we implant seeds or pellets of radiation into the prostate. We also have surgical therapies. We have ablative therapies where we freeze the prostate or use ultrasound ablation, and then we have surgery to remove the prostate. For men with more advanced disease, when they become metastatic, we do use hormone therapy, where we call it androgen deprivation therapy. We're cutting off the supply of testosterone to the cancer cells, and then we also have newer therapies, chemo therapies, immunotherapies, and all kinds of new drugs that have come about in the last 10 to 15 years. And patients have to make that choice, right? You can just rattle off half a dozen or more possibilities. Absolutely. It's a complex decision-making process that involves the patient age, the patient's morbidities, the patient's preference, and then obviously disease-related features. Let's take a phone call at Baltimore City. This is Jerry. Jerry, thank you for the call. Go ahead. Yes, my PSA is high, and I wanted to know, what can I take to bring you down? Thanks very much. PSA by itself, what's high, by the way? Absolutely. So the common misconceptions that we used to use the cutoff of 4.0 as the range of normal. It's no longer felt to be a normal versus not normal. It's sort of a convoluted discussion depending on age, depending on how big your prostate is, depending on a number of different features. But in terms of decreasing the PSA, there's nothing that you could do specifically to decrease it. I tell people that PSA is prostate-specific, but it's not necessarily cancer-specific. So I just encourage you, if it is elevated, sometimes I repeat it, but make sure you do get follow-up to follow-through with either urologist or your primary care doctor. Michael, in Baltimore City, Michael, thank you for calling. Go ahead. How are you doing, doc? Thank you for taking my call. Yes, I did the radiation treatment. I did 51 radiation treatments. I was diagnosed with prostate cancer. And I'm experiencing bone pain right now. Is that a normal after effect, after the radiation? Michael, best of luck. Thank you for calling. So bone pain can be for many other things. It certainly could be for metastases from prostate cancer. Hopefully you've been treated well and you have no evidence of disease, and hopefully it's not related to your prostate cancer. But I certainly would recommend, again, you follow up with your physician for further evaluation. Email question. Somebody wants to know, I think the danger of the digital rectal exam, anything can go wrong with that? Not particularly. It's part of the routine physical exam that your physician should be performing. I know it's not the most comfortable, but it is part of our process to evaluate for prostate cancer. It's not very specific, but it is still critical for staging prostate cancer. Who should be doing it from a surveillance standpoint? Is that somebody's, is it the internist, the family doctor, or does it...? Most family physicians or internists do digital rectal exams. A lot of them have moved away from that, but it depends on the individual provider. Certainly if you go to see your urologist, you should expect that you will be having a digital rectal exam. Phone call. Hartford County. This is Charlie. Charlie, thanks for calling. Go ahead. Yes, hi. Thanks for taking my call. I'm at the age where you have to get up and pee about every two hours all night long. And I assume that's from an enlarged prostate. And my question is, does that need to be treated? Is it something that is like an early sign of prostate cancer? Great question. Thank you very much. Those symptoms are not necessarily at all related to prostate cancer. I always tell patients that it depends on how bothered you are by your symptoms. If it's something that bothers you and interrupts your sleep cycle and you're not getting a great night's sleep, then you should consider treatment of that. It's not necessarily related to the prostate. It could be related to the bladder, it could be related to the kidneys. There's lots of different reasons why people can go to the bathroom too many times at night. But again, if it bothers you that much, you should go get treatment. Is it one of those cancers where there's anything people can do to lessen their risk? In general, not really. We recommend a healthy lifestyle to tell people a healthy heart is a healthy prostate. So all the things that you should do in terms of diet, exercise are important for prostate cancer as well. What's the overall outlook for somebody who has this disease? So obviously this can be a deadly disease. However, the vast majority of patients have a very good prognosis, you know, and assuming that they get appropriate treatment. How do patients respond when you list the alternatives? And it depends based on their individual situation. But the idea of the active surveillance, how do patients emotionally respond to that? So obviously there's a range of responses that I'll get to that. In general, there is sort of a movement towards active surveillance, the advantage being that we can avoid some of the side effects of prostate cancer treatment. And this is really appealing for a lot of patients, particularly younger patients. Because the side effects of prostate cancer treatment can affect urinary function, sexual function, and those are really important parts of your life. So for younger men, it is an important thing to talk about all the risks and benefits of each of these treatments in detail. Do some people like the idea that, all right, I can forget about this for a while? But maybe some people, you know, maybe it's just your emotional makeup. You want to respond. You want to take action. Absolutely. There's a significant portion of patients that choose active surveillance initially. But due to the anxiety of worrying about their cancer progressing, decided to actually have it actively treated. A phone call from Washington. This is Kevin. Kevin, thank you for the call. Go ahead. Kevin, are you there? Yes. Your answer. What's the question? Yeah, the question was, you know, the urinating in the middle of the night and all that several times. Could that be associated just to you drinking too much? Absolutely. You're not supposed to drink during the day. Great question. It might be a good way to test that. Absolutely. One of the most important things I ask right off the bat is, you know, when did you last drink? How much did you drink? And what did you drink? I mean, did you drink soda, coffee, tea, alcohol, things that might make you either make more urine or irritate your bladder to make you go more frequently? Think about how much this has changed in the last decade or so. What do you see in the future? So there's a lot of new diagnostic testing that we can do. Aside from just PSA, we have new molecular tests. We have MRIs, which are being utilized in terms of screening and in terms of diagnosing prostate cancer. And certainly one of the biggest movement has been for low-risk disease, meaning patients who are not very likely to die of their prostate cancer to pursue active surveillance as opposed to active treatment. And in a few seconds, if that's possible, give me your screening recommendations again. So again, men between the ages of 55 to 69 recommend an active discussion with their physician about the pros and cons of screening. Very good. Dr. Ryan Dixdine with the University of Maryland School of Medicine, University of Maryland, Baltimore, Washington Medical Center, and Chesapeake Urology. Dr., thank you for the time. Thank you. Your health segments are a co-production of Maryland Public Television and the University of Maryland Medical System.