Smilow Shares with Primary Care: Prostate Cancer

Transcript

• 00:00Oh, it's really exciting.
• 00:05Super, super exciting.
• 00:07Thank you guys for being the kickoff.
• 00:12Yeah, and who knew
• 00:13that September 6th was the
• 00:15day after Labor Day? OK.
• 00:21Karen, I didn't tell you yet.
• 00:23I got covered over the weekend,
• 00:24so I'm COVID recovering now. You
• 00:30are in the ranks of the proud
• 00:33who who held out for that full 2
• 00:361/2 years before going down now.
• 00:40With a really, really long Oh my goodness,
• 00:43OK, we are live actually. OK.
• 00:49Well, welcome everybody tonight to
• 00:51to Smilo shares with primary care.
• 00:54It's our kickoff. Wait just a few
• 00:58minutes so that people can join.
• 01:51Before we get started,
• 01:52I see we have about 14 people did did.
• 01:55Maybe you can answer the
• 01:57question and the answer.
• 01:59Did anybody have a difficult
• 02:01have difficulty logging on?
• 02:03Through the zoom link.
• 02:06If anybody did, please please just give
• 02:08us this the the feedback in the Q&A.
• 02:18And then if you might be asking the
• 02:20wrong people, I know. They got on.
• 02:27Is 16126 and
• 02:30Dan, can you go on mute please?
• 02:33Thanks. OK. All right, well,
• 02:35let's get started because we
• 02:38have a lot going on tonight.
• 02:41My name is Anne Chang.
• 02:42I'm a medical oncologist
• 02:44and deputy CMO for Smilo,
• 02:47and I've been working very closely
• 02:49with Karen Brown and Ryan O'Connell.
• 02:52I'll let you guys introduce yourselves.
• 02:55Good. So I'm Karen brown.
• 02:56I'm the medical director of primary
• 02:59care for Northeast Medical Group and
• 03:01thrilled to see this series get Off.
• 03:04Ryan O'Connell, General Internist
• 03:06at NE Medical
• 03:07Group know I think most everyone,
• 03:10but for those I haven't met, thank you.
• 03:13And really a special shout out to Ann
• 03:15Karen and to all the panelists who have
• 03:18really worked hard to make this really
• 03:22meaningful and highly educational.
• 03:23I'm really excited.
• 03:25Great. And Kevin Billinsley,
• 03:27who's also our course director
• 03:29but is unable to attend today.
• 03:31So first just to opening slide,
• 03:36if you can pull that up, please?
• 03:39Telling you what this series is,
• 03:41it's a monthly series.
• 03:43It's called smilo shares.
• 03:45Actually. It's called with
• 03:47primary care for primary care.
• 03:48I think we ultimately decided with with
• 03:51primary care and this month is focused
• 03:53on prostate cancer and each month
• 03:56it's going to be a different topic.
• 03:58These are topics that both Karen
• 04:00and Ryan chose for primary care,
• 04:03not only for themselves,
• 04:04but thinking about and talking
• 04:06to other people.
• 04:07The designated audience is.
• 04:10Primary care clinicians.
• 04:12And our faculty,
• 04:13we tried to choose people from
• 04:15a specific geographic region.
• 04:18So today, we're in Greenwich really,
• 04:19and focusing on prostate cancer.
• 04:22And the idea is really to link
• 04:24up and build relationships
• 04:25between primary care and smilo
• 04:28physicians and EMG physicians.
• 04:30And and this is going to be a
• 04:32monthly series just like that.
• 04:33Trust your gut so you can get used
• 04:34to it and put it on your calendar.
• 04:36It's going to be the first Tuesday
• 04:39of the month from 5 to 6 virtually.
• 04:41And hopefully maybe this year we can
• 04:43do a few of these in person as well.
• 04:46And the the Big Y is really as
• 04:48we were talking about this that
• 04:51there there's just there's an
• 04:53explosion of information around
• 04:55cancer even for oncologists and
• 04:57I think for primary clinicians.
• 05:00This is an area where,
• 05:01you know,
• 05:02understanding the updated recommendations
• 05:04and some of the new approaches are
• 05:06really important to hear about and
• 05:08while there are lots of different,
• 05:10you know.
• 05:11Lectures around cancer,
• 05:13specifically this this format is
• 05:16really focused on primary care.
• 05:19And those questions that are most
• 05:21most important to you and it'll be
• 05:23case based tonight we have three
• 05:25cases that are really going to
• 05:27highlight those what we thought would
• 05:30be very topical or very important
• 05:33questions that you run that you come
• 05:35across in clinic and to highlight
• 05:38the clinical pearls from our our faculty.
• 05:41So let's go to the next slide.
• 05:43Ohh,
• 05:44this is the agenda.
• 05:46So we're going to do the the
• 05:47three case presentations.
• 05:48We will have some time for
• 05:50for a question to answer.
• 05:52Each one will take about 15 minutes.
• 05:55So we'll encourage you guys to
• 05:57put your questions in the chat.
• 06:00Some of those may be answered as we go along.
• 06:02Some of those if if you want
• 06:04to hold them to the end,
• 06:05we will hope to have hope to have
• 06:08a little bit of time at the end.
• 06:10And then our our terrific faculty is here.
• 06:16Or you wanna introduce Aaron?
• 06:21Or we have Aaron Culbert, who is an
• 06:25internist in the Greenwich region,
• 06:28well respected by her colleagues and
• 06:31her patients, and turns out to be quite
• 06:35knowledgeable about prostate cancer.
• 06:39How she's a mother
• 06:41as well as a physician and has all sorts
• 06:44of athletic activities as well as well.
• 06:49And and next is Bruce Mcgibbon.
• 06:51He's already he's been a radiation
• 06:53oncologist at Yale for 13 years,
• 06:55and he is the medical director of Rad
• 06:57ONC at Greenwich for the past three.
• 07:00And he's particularly
• 07:01interested in prostate cancer,
• 07:03also very active and and an owner of
• 07:06a new kitten he informed us last week.
• 07:10And then my colleague Dan Petrovac,
• 07:12who's a medical oncologist,
• 07:14he's a professor of medicine and leads
• 07:17the Gu cancers for Yale and Smilo.
• 07:20Uh, in New Haven.
• 07:21He's been in Greenwich for for
• 07:24practicing for 10 years as well he is.
• 07:27Do you expert these develop new drugs
• 07:31he's brought them to FDA approval
• 07:34really just known internationally
• 07:37and and an amazing clinician and
• 07:41and a clinical researcher and also
• 07:43very active in tennis and golf.
• 07:45And then finally Jerry Portman who
• 07:48has been a urologist at Yale for 10
• 07:51years in Greenwich for a year and he
• 07:53is you know he does generally urology
• 07:55but really focuses on urologic.
• 07:57Ecology and he loves to travel.
• 07:59In fact,
• 08:00he was participating on his vacation
• 08:02last week in planning of this event.
• 08:04So we're going to get going and
• 08:07turn it right over to Aaron to
• 08:10start us off on the first case.
• 08:12Thanks,
• 08:12Karen.
• 08:13All
• 08:13right. Thank you so much and
• 08:14thank you so much, Karen,
• 08:16for that kind introduction.
• 08:17We're going to start with our first case,
• 08:21pretty typical primary care,
• 08:23bread and butter.
• 08:24We have our 47 year old white male.
• 08:28Nonsmoker patient who presents
• 08:30today for a routine physical exam.
• 08:34When asked, he notes no urinary symptoms,
• 08:37unless of course he has coffee
• 08:39at night right before bedtime,
• 08:41which results in one to
• 08:43two episodes of nocturia.
• 08:44When we questioned him about family history,
• 08:47he relates his father was diagnosed with
• 08:49prostate cancer at the age of 61 and
• 08:52notes that his paternal grandfather was
• 08:54also diagnosed with prostate cancer.
• 08:56Not sure of the age for that.
• 08:59Uh, so he uhm,
• 09:01unless we count that coffee is
• 09:05asymptomatic for urinary symptoms.
• 09:08He expresses concern to us about
• 09:11his family history of prostate
• 09:15cancer and says DOC,
• 09:17can I get screened for prostate cancer?
• 09:20So we are going to talk uh to him.
• 09:24I think it's easier to go through
• 09:29some of the screening recommendations
• 09:31utilizing our care signature pathway
• 09:34for prostate cancer screening.
• 09:36This was a collaboration between
• 09:40our clinicians also involved
• 09:42review of a lot of the evidence
• 09:45that's available as well.
• 09:49Consideration of the
• 09:51national recommendations,
• 09:52I think Mike Lehman was involved as
• 09:55well as our other affiliated urologists
• 09:57were involved in developing this pathway
• 10:00and keeping it as up to date as we
• 10:02can with the change in recommendations.
• 10:04Certainly since 2018 there's
• 10:06been a lot of changes,
• 10:09especially with the Class C recommendation
• 10:13for prostate cancer screening for
• 10:15patients 55 to 69 and a lot of debate.
• 10:19Revolve revolving around the
• 10:20prostate specific antigen as
• 10:21well as digital rectal exams.
• 10:23So we'll go through that as if you were
• 10:26in the room talking to your patient,
• 10:29going through the pathway to
• 10:31evaluate his prostate cancer risk
• 10:34and go through the screening.
• 10:39So we have our test patient here.
• 10:42Karen's kind enough to drive for me,
• 10:43so she's going to open up that pathway.
• 10:46So this is how it would look
• 10:47if you were in doing your note.
• 10:51If you type in prostate,
• 10:53not prostate, uh, it will come up
• 10:56with the prostate cancer screening.
• 10:59Pathway or you wanna click on
• 11:01that initial screening pathway?
• 11:05And it will open up.
• 11:08Obviously the entire pathway,
• 11:10she's gonna fit it to our screen here.
• 11:13So we're gonna go through uh and see our,
• 11:16our our case,
• 11:18uh for today was 47 years old.
• 11:21Karen, if you want to open up the authors,
• 11:23I think you want to give full credit to
• 11:26the contributors for the pathway content,
• 11:28because I know this took a lot of work.
• 11:30Uh, so there's our list.
• 11:32Mike Leitman up at the top,
• 11:33an extra bacus who's from
• 11:35the Greenwich region as well,
• 11:37Jerry Portman, who's with us today,
• 11:39Karen Brown who's with us today,
• 11:42as well as a host of others.
• 11:44So thank you very much for making this
• 11:46easy to use on the primary care side.
• 11:50Alright. So we're going to
• 11:52go through the pathway.
• 11:54We're going to spend a little
• 11:56bit of time here because it
• 11:57does open up into some detail.
• 11:59We're going to talk about some risk factors.
• 12:01We're going to go through as well,
• 12:04OK, if we check the PSA and it
• 12:06comes back at a certain level.
• 12:08So we'll give you a whole
• 12:11pathway overview here.
• 12:12So our patient is 47,
• 12:14he meets the criteria being above 40.
• 12:18So we'll consider prostate
• 12:20cancer screening for him.
• 12:21It's important to note this does not
• 12:24apply to patients who have a prior
• 12:27prostate biopsy with a high grade
• 12:29neoplasia or atypical cell proliferation.
• 12:32We also want to double check that our patient
• 12:34has a greater than 10 year life expectancy.
• 12:38Our patient is healthy,
• 12:39has no other medical comorbidities
• 12:41that we know of.
• 12:42Uh, and he is younger than 75 years old.
• 12:45So we're gonna proceed down that pathway
• 12:47and then we go to risk factors which
• 12:50I want to spend a little bit of time
• 12:54about certainly African American descent,
• 12:56we need to note.
• 12:58So on our initial case presentation slide,
• 13:00you know if he were African American
• 13:02that would be an additional risk factor
• 13:05on top of his family history and it
• 13:07gives you the incidence rates as as well,
• 13:10but it it's quite elevated.
• 13:11So they.
• 13:12That population should definitely be
• 13:14screened at an earlier age greater
• 13:17than one or one or greater first
• 13:19degree relative within the history of
• 13:22prostate cancer on either side actually.
• 13:25So maternal and paternal
• 13:27diagnosed that less than 65.
• 13:30Family history of other cancers is important.
• 13:34You want to consider not
• 13:36only prostate cancer,
• 13:37but you do want to consider breast
• 13:40cancer either male or female colorectal.
• 13:43I think Melanoma is on that
• 13:45list or it was ovarian,
• 13:48pancreatic,
• 13:49uterine and then it expands down
• 13:52at the bottom if you have two
• 13:54or more first or second degree
• 13:57relatives with cancer at any age,
• 13:58so if you have multiple relatives.
• 14:02They will also count for you.
• 14:04So he does have a family history
• 14:07of prostate cancer and his father.
• 14:09So we're going to say, yes,
• 14:11he's a high risk patient and then we'll
• 14:15initiate shared decision making for him.
• 14:18I'm going to come back to that.
• 14:20Thank you.
• 14:21There's a bunch of resources there.
• 14:23I did want to touch on the germline mutations
• 14:26and the genetic testing that's available,
• 14:29so not.
• 14:32Not very common to talk about.
• 14:34It's something that Yale offers
• 14:36for our patients, which is great.
• 14:38If you click that hyperlink that
• 14:40says referral to cancer genetics,
• 14:42it'll automatically bring up to sign
• 14:45off on that ambulatory referral to genetics,
• 14:48type in the referral reason,
• 14:49send it off.
• 14:51There's also a Yale Generations project
• 14:53which you can offer to your patients,
• 14:56which is a DNA sequencing project
• 14:59that's free to participate in,
• 15:01provides a lot of genetic screening.
• 15:03Uh, opportunities?
• 15:06And Karen just pull and pull
• 15:08up our our flyer for that.
• 15:10So that is definitely available to our
• 15:14patients either blood or saliva testing.
• 15:16And then patients will get that
• 15:19results and have a nice QR code they
• 15:21can scan to get involved with that.
• 15:24So we can print that and give that to our
• 15:26patients or just click on that link and scan
• 15:28the QR code in the visit, which is nice.
• 15:32In terms of genetic testing,
• 15:34BRCA gene testing is important.
• 15:37And then there's additional.
• 15:41Remind mutations that if you
• 15:42Scroll down and click on,
• 15:44that germline mutations line
• 15:46up right above Karen.
• 15:50There's also additional testing
• 15:52related to Lynch syndrome.
• 15:55I think the ATM gene,
• 15:56there's a few genes that we know are
• 15:59linked to higher risk of prostate cancer.
• 16:02So when it comes to shared decision making,
• 16:06while I'm in the room with my patients,
• 16:09you can open this up.
• 16:11I know everybody has a different
• 16:13report with their patients,
• 16:14but basically the important thing
• 16:16is to let the patients know.
• 16:19What the recommendations are,
• 16:21uh, what the testing is,
• 16:25as well as the risks of the testing.
• 16:29So there's a lot of great handouts
• 16:31from the American Cancer Society
• 16:33resources from up to date that provide
• 16:36a great informational overview,
• 16:38especially with patients 47.
• 16:40He's probably never had prostate
• 16:42cancer screening before.
• 16:43Would give them a great overview to
• 16:45know exactly what we're getting into
• 16:47because once you start screening.
• 16:49It's going to be continued most
• 16:52likely until they're 75 based
• 16:54on the current guidelines.
• 16:56So I would take this patient through, OK.
• 16:58Yes, we should talk about
• 17:00prostate cancer screening.
• 17:01Your dad had a history of prostate cancer.
• 17:05These are the ways that we would screen.
• 17:08PSA is is the most commonly used.
• 17:11We'll come back to other methods.
• 17:14There are risks of false positive.
• 17:16Uh, if you Scroll down,
• 17:17there is a list of the acute factors.
• 17:19Yep, you got it.
• 17:21That may alter PSA results.
• 17:24So we'll get into that.
• 17:25But there is a nice smart phrase
• 17:27you can put in your note.
• 17:28It's dot prostate cancer screening,
• 17:31SDM's shared decision making.
• 17:32So you can put that into your note.
• 17:34Get full credit for having that
• 17:37lengthy shared decision making
• 17:39conversation with your patient.
• 17:40So you want to let the patient know,
• 17:44you know, hey.
• 17:45PSA is not a perfect test.
• 17:47If you have some urinary
• 17:49retention instrumentation,
• 17:50vigorous physical activity or perineal
• 17:54trauma can sometimes raise the PSA.
• 18:00So if they say, OK,
• 18:01I understand they're the
• 18:02risks involved with PSA,
• 18:04I want to proceed.
• 18:05You would then click on the screening
• 18:07PSA order either through Yale or
• 18:09LabCorp or through Quest and it's
• 18:11going to look exactly like that if
• 18:13you see on the upper right hand side.
• 18:16So you can just hit accept and it will
• 18:18sign off on that screening PSA order.
• 18:21Yeah, there you go.
• 18:23Perfect.
• 18:26Alright. So say we sign off that our 47
• 18:31year old male is otherwise pretty healthy.
• 18:33It's a week or two later, depending on
• 18:36whether he went to Quest or LabCorp,
• 18:38he should have gone to Yale. And then, uh,
• 18:42as you go through the pathway, there's Umm,
• 18:45if you go down to that 3rd result,
• 18:47that PSA interpretation?
• 18:51Normal result discussion.
• 18:52You can then go through that pathway and it
• 18:55literally takes you through step by step.
• 18:57So Umm, we're going to go through,
• 19:02we're going to come back to
• 19:03the digital rectal exam.
• 19:04I have a couple slides on that.
• 19:05Umm, we'll talk about that in a minute.
• 19:10If the PSA is greater than 10.
• 19:13It should be repeated in
• 19:15about four to six weeks.
• 19:17Uh, you want to make sure we
• 19:19weren't missing part of our history,
• 19:21some unknown instrumentation or unknown
• 19:24symptoms that they didn't realize they had?
• 19:27Uh, we also, uh,
• 19:29wanna review what that repeat lab is.
• 19:33If it's still elevated,
• 19:35then that generates a reflex.
• 19:37You can hit that refer to urology
• 19:40hyperlink up there on the right.
• 19:42Yeah.
• 19:43And at that point,
• 19:45we need to get your urology involved
• 19:48because that indicates more of a
• 19:50high risk probability if our young
• 19:5247 year old has a PSA less than 10,
• 19:55which thankfully most of them do.
• 19:58We need to consider.
• 20:01Other factors so say he was 47 and on
• 20:05finasteride to help prevent hair loss.
• 20:07Umm, that's your 5A reductase inhibitor.
• 20:11So there actually is a correction
• 20:13factor for that,
• 20:14something which I had to brush
• 20:16up on for this.
• 20:18So not that I have a lot of patients on it,
• 20:20but if you do have a patient
• 20:22that's already on it,
• 20:23you really should double your PSA value.
• 20:28If the PSA increases while they're
• 20:30already on a 504 reductase inhibitor,
• 20:33that also should be evaluated by urology.
• 20:36The reason for that is because higher
• 20:39grade lesions are more common when
• 20:41you're on a 5A reductase inhibitor.
• 20:43So assuming he's not on finasteride,
• 20:46which our patient was not,
• 20:48you can go by age category,
• 20:51even though the lab cut off will
• 20:53be 4.0 nanograms per milliliter.
• 20:55It really does go by age so
• 20:58that first decade.
• 20:5940 to 49,
• 21:01if it's greater than two
• 21:03is considered abnormal,
• 21:05then 50 to 59 greater than
• 21:07three also considered abnormal,
• 21:09and then 60 and above.
• 21:10You can use that upper limit
• 21:13normal of the lab cut off at 4.
• 21:16So you can go through based on all of that.
• 21:22If his PSA was less than 2.0
• 21:25nanograms per milliliter,
• 21:27then you would go to the right
• 21:29and he would have a normal PSA,
• 21:31and actually it'll break it down
• 21:33even further into when you should
• 21:35be repeating the PSA numbers,
• 21:37and you can actually go into
• 21:39your health maintenance screen.
• 21:42And you can update the modifier and
• 21:45select the frequency that you want to.
• 21:48I think you might have to hit edit modifier.
• 21:51Yep.
• 21:54Yeah, there it is.
• 21:59Wonderful. And it should pop up.
• 22:02Although. For us, it's not.
• 22:07So you should be able to edit that
• 22:09modifier to be specific for the time
• 22:12interval that you want to repeat.
• 22:14You do not have to do it every year,
• 22:17uh, but for higher risk patients,
• 22:19uh, like our patient you should.
• 22:21And then for lower risk patients
• 22:23you can do every two to four years
• 22:26depending on how low their PSA is.
• 22:29And I think that about covers the
• 22:31more important points of the pathway.
• 22:35Just Scroll down, make sure
• 22:36I didn't miss anything.
• 22:41Yeah. And then it's all the same.
• 22:44If PSA is abnormal again, then you
• 22:46would refer to urology at that point.
• 22:50Thank you, Karen.
• 22:53All right. Hopefully that the
• 22:56health maintenance didn't
• 22:57work because of the age.
• 22:59So we just looking at that we just
• 23:01problem solved and that will get fixed.
• 23:06Yeah, we picked an older patient for testing.
• 23:09All right. So I just want to draw
• 23:11some attention to the smart phrases.
• 23:13There's that shared decision
• 23:15making smart phrase.
• 23:16And then if you want to,
• 23:17rather than clicking on the
• 23:19hyperlinks in the pathway,
• 23:20if you felt like you wanted
• 23:21to do the prostate resources
• 23:23in your after visit summary,
• 23:25there is a smart phrase for that as well.
• 23:26At the bottom, another key update,
• 23:30we need to circle back to
• 23:33the digital rectal exam.
• 23:34It is no longer recommended
• 23:36for screening purposes,
• 23:38but it absolutely should be done.
• 23:39For diagnostic purposes,
• 23:40if our patient maybe didn't drink the
• 23:43two cups of coffee before bedtime and
• 23:46still had those episodes of nocturia,
• 23:48you know,
• 23:49we may want to consider
• 23:51evaluating what's going on.
• 23:53But for average screening purposes
• 23:56is not recommended in terms of
• 23:59when to start PSA screening
• 24:01for prostate cancer screening,
• 24:03if it is elevated risk,
• 24:04you need to tell the patient
• 24:06that there are higher risk engage
• 24:07in that shared decision making.
• 24:09I know it takes a little bit of time,
• 24:10but it's worth it.
• 24:11Because then they understand what
• 24:13they're getting into and have
• 24:15better follow-up going forward.
• 24:16If there's really no increased
• 24:18and that'll start at 40 to 45,
• 24:21if they really don't have
• 24:22any increased risk factors,
• 24:24you can start at 50.
• 24:26If we go to the next slide,
• 24:28I wanted to spend a little bit of time
• 24:31talking about that digital rectal exam,
• 24:33everybody's favorite test.
• 24:36So I, I, you know,
• 24:38kind of had some trouble adjusting
• 24:40to this and and probably still do
• 24:43because I was kind of trained in medicine.
• 24:45If if you could see it and touch it
• 24:46and it was right in front of you,
• 24:48you should check it.
• 24:50But with the digital rectal exam
• 24:52that's not necessarily the case.
• 24:55As I mentioned,
• 24:56definitely for symptoms,
• 24:57not so much for screening.
• 24:59It does have a low sensitivity
• 25:01and low specificity.
• 25:03The most generous estimate that
• 25:04I could find was that it had a
• 25:0641% positive predictive value.
• 25:08But that was out of a meta analysis
• 25:10where when you broke it down into
• 25:13the individual studies did not have
• 25:15such great evidence backing it up.
• 25:17So that was probably overgenerous.
• 25:20They think the OR have shown that
• 25:23the digital rectal exam will
• 25:25increase the PSA a bit, you know,
• 25:27up to .4 nanograms per milliliter.
• 25:29And of course,
• 25:30just because of anatomy and physics.
• 25:33You can only detect that that
• 25:35back surface of the prostate,
• 25:37making the earlier stages of
• 25:39prostate cancer undetectable
• 25:40based on just the Dre alone.
• 25:43So for that reason.
• 25:45You know,
• 25:46up to 1/3 of cancer is detected
• 25:48by a digital rectal exam alone or
• 25:51advanced versus less than 10% or
• 25:53advanced stages when you use the PSA.
• 25:57So there is an advantage there.
• 25:59There have been additional comparisons,
• 26:02you know,
• 26:03looking at positive predictive
• 26:04value using abnormal digital
• 26:06rectal exam with a normal PSA,
• 26:09that's about a 10% positive predictive value.
• 26:12And then there were additional
• 26:13studies looking at OK,
• 26:14well, if you.
• 26:15Have a normal digital rectal exam
• 26:17but then you have an abnormal PSA.
• 26:20Positive predictive value goes up
• 26:21to you know 25% a little bit more.
• 26:25So there was you know,
• 26:27an advantage to using the PSA over
• 26:30just the digital rectal exam.
• 26:32Certainly if you're using the
• 26:35Dre for evaluating symptoms
• 26:37or if the patient says Doc,
• 26:39I can't sleep tonight unless you
• 26:41check my prostate and you find
• 26:44something nodule and duration.
• 26:46It's asymmetric.
• 26:47Regardless of what the PSA level is,
• 26:50you're going to refer that patient
• 26:52to urology to have that evaluated.
• 26:54Alright, I think that's all of my slides.
• 26:58All right, Jerry, onto you.
• 27:01All right.
• 27:02Good evening, everyone.
• 27:04So my patient is more your
• 27:08average patient that usually gets
• 27:11diagnosed with prostate cancer.
• 27:12So it's a 57 year old
• 27:15asymptomatic man with PSA of 5.6.
• 27:18We always try to get a repeat PSA to
• 27:20make sure that it wasn't an aberration.
• 27:23Re PSA's basically the same.
• 27:26And for almost all our patients at Yale,
• 27:30we try to get an MRI.
• 27:33Before any biopsy because it
• 27:35increases and improves detection
• 27:37and if we're we have technology that
• 27:41helps target the specific areas on
• 27:43the MRI to make it a better biopsy.
• 27:45So target biopsy was performed and
• 27:48it shows Gleason 3 + 4 prostate
• 27:50cancer and five out of 17 cores.
• 27:53And these biopsies can be performed
• 27:55in the office under local,
• 27:56which most of us do,
• 27:58but also a lot of patients
• 28:00have anxiety about this.
• 28:02So we do offer to do it in
• 28:04the OR under sedation as well.
• 28:06I would say 80% of my patients
• 28:09tolerated very well in the office
• 28:12because we could do a good prosthetic
• 28:15nerve block and about 20% have it
• 28:18done in the OR in terms of so the
• 28:21Gleason 3 + 4 prostate cancer and.
• 28:24Go into the risk groups in a second,
• 28:25but it's considered intermediate
• 28:27risk favorable.
• 28:28The two main treatment options that we offer.
• 28:32Active surveillance is usually for
• 28:33low risk and we offer radiation
• 28:35and robotic surgery,
• 28:36which are standard of care treatments.
• 28:39There are also focal therapies that
• 28:42are considered newer treatments and
• 28:44don't have as much data behind them.
• 28:46Prostate cancer is a very
• 28:48slow growing disease,
• 28:49so a therapy has to be
• 28:52around for 1510 to 15 years.
• 28:54Before we know how well it works
• 28:55in terms of recurrence risk and
• 28:58then this question always comes
• 29:00up in terms of staging.
• 29:02For patients with prostate cancer,
• 29:04CAT scan and bone scan is recommended
• 29:06for grade Group 3 or higher,
• 29:08meaning Gleason 4 + 3 or higher.
• 29:11And there are instances where we
• 29:13use a newer PET scan called PSA PET,
• 29:16which Bruce Mcgibbon will go
• 29:17into a little bit in his slides.
• 29:22If we could go to next slide,
• 29:25so I just wanted to go over the
• 29:27risk stratification because we
• 29:28throw around these terms, low risk,
• 29:30intermediate risk, high risk.
• 29:31What do they mean?
• 29:32So very low risk is a small amount of
• 29:35leasing 6 basically with a low PSA.
• 29:38Gleason, Six is considered a very.
• 29:43Unaggressive and the chance of
• 29:45it spreading outside of the
• 29:47prostate is extremely low.
• 29:50In most studies,
• 29:51it's actually believed to be 0.
• 29:54So both very low risk and low risk
• 29:57patients we usually recommend
• 29:58for active surveillance.
• 30:01Intermediate risk patients are split
• 30:03up into favorable and unfavorable
• 30:06and that's basically how much of the
• 30:09Gleason 4 component that they have.
• 30:11Also, it can be based on PSA.
• 30:13PSA is above 10.
• 30:14It's also falls into intermediate risk.
• 30:17High risk is usually Gleason 4 + 4 or higher.
• 30:20So great Group 4-5 and very high
• 30:24risk if there's evidence on MRI,
• 30:26if someone vascular invasion,
• 30:27noble disease, metastatic disease,
• 30:29or if the the top.
• 30:31Component of the Gleason score
• 30:32is the Gleason 5.
• 30:35So in terms of treatment
• 30:38for intermediate risk,
• 30:40robotic surgery and radiation
• 30:42are considered equally effective
• 30:44in prostate cancer treatment.
• 30:46We haven't been able to prove that
• 30:48one is better than the other,
• 30:49so we usually go over the side
• 30:51effect profiles of each one and the
• 30:54benefits and risks of each each
• 30:56one and let the patient decide.
• 30:58Robotic surgery,
• 30:59usually it involves A1 day stay in the
• 31:01hospital and a catheter for one week.
• 31:03You it's we we do a robotically,
• 31:06but it's still a three to four week
• 31:08recovery radiation treatments,
• 31:10usually 5 or 28 treatments
• 31:14depending on the patient and
• 31:15cancer characteristics or let Bruce
• 31:17go over that a little bit more.
• 31:19The main effects of both radiation and
• 31:22surgery are on urinary and erectile function.
• 31:26Newer less proven therapies are the
• 31:29focal therapies and there are four
• 31:32or five of these that depending
• 31:34on the institution.
• 31:35And I'll go over one of the newer
• 31:38ones that we have here at Yale.
• 31:40Prior to radiation,
• 31:42patients usually undergo a procedure
• 31:44which is similar to a biopsy
• 31:46where we place gold markers into
• 31:48the prostate to help target the
• 31:50radiation and we place a space or
• 31:52gel and Bruce will have some slides
• 31:54on that and then the important thing.
• 31:56To know is patients who are getting
• 31:59radiation treatment even for localized
• 32:02cancer, if it's grade Group 3,
• 32:04the NCCN guidelines recommend four
• 32:06to six months of androgen deprivation
• 32:09therapy and for great Group 4 to 5,
• 32:12the NCCN guidelines recommend
• 32:13at least 18 months for androgen
• 32:15deprivation therapy.
• 32:16This used to be two to three years.
• 32:18They've decreased it in the last two,
• 32:21two years.
• 32:23To make it a little bit more tolerable,
• 32:26next slide,
• 32:27so to just go over some newer technologies,
• 32:30we have a. Yo.
• 32:35We,
• 32:35we have been using for the last
• 32:3710 years the Artemis system to
• 32:39help target MRI lesions.
• 32:41We've just upgraded to the exact view,
• 32:43which is a very powerful ultrasound.
• 32:48It's 300 three,
• 32:49100% more powerful than standard ultrasound,
• 32:51which is 7 megahertz.
• 32:53And on this ultrasound we could
• 32:56actually see prostate cancer
• 32:59lesions and that's what the bottom
• 33:01right hand corner is showing.
• 33:03It's the ultrasound is so powerful
• 33:06that the the slide on the left
• 33:09is actually showing that you can
• 33:11actually see the previous needle
• 33:12tract through the prostate.
• 33:16You can still do MRI fusion on these
• 33:19machines, which is very important
• 33:21because most of our patients
• 33:23get the MRI before the biopsy.
• 33:25OK. Next slide.
• 33:28And then one of these newer
• 33:31technologies that's also available
• 33:33at Yale is the Tulsa Pro.
• 33:34And what this is is transurethral
• 33:37ultrasound ablation of the prostate.
• 33:38So the top device of the patient is
• 33:41asleep under anesthesia and it gets
• 33:44inserted into the urethra like a catheter.
• 33:47And the bottom device gets inserted into
• 33:50the ****** uh for cooling the rectal area
• 33:53and if you could go to the next slide.
• 33:56And basically what this device does,
• 33:58it rotates and under MRI guidance it ablates
• 34:01the prostate in a circumferential fashion.
• 34:04Within 1 millimeter of the capsule,
• 34:06it's very precise.
• 34:10You can do focal therapy as shown on
• 34:12the slide on the left where you could
• 34:14just do 1/4 of the plot prostate,
• 34:17you could do 1/2 of the
• 34:19prostate or the entire thing.
• 34:20So there are two clinical trials
• 34:22right now at Yale investigating this.
• 34:25One is comparing it to surgery
• 34:27and one is just comparing.
• 34:30Is just the observational
• 34:32study to see the the.
• 34:34It's believed to be that the side
• 34:36effects with this are significantly
• 34:38lower than with surgery or radiation.
• 34:41Another area of interest for this
• 34:43treatment is in salvage treatment for
• 34:45patients who have undergone radiation
• 34:48and now have recurrence.
• 34:51And now I'll turn it over to
• 34:53Bruce to discuss radiation
• 34:54treatment. Thanks, Jerry. So
• 34:59just want to break down some of
• 35:01the different scenarios where we
• 35:02do radiation and and give some.
• 35:04Some of the core details I think would
• 35:06be most interesting to you guys.
• 35:08So for intact prostate
• 35:10basically the two options,
• 35:11one is external beam radiation where
• 35:13patients lying on a table machine
• 35:15moves around at the distance and
• 35:18shoots X-rays and the others breakey
• 35:20therapy usually with with seed implant.
• 35:22The vast majority of the of the
• 35:25gentleman these days in the US and
• 35:27really I think internationally get
• 35:29external beam breaking therapy
• 35:30still quite effective but in a much
• 35:32smaller percentage of the cases.
• 35:34Uh, and it's less commonly available.
• 35:37So within external beam you have what's
• 35:40really considered traditional IRT,
• 35:42which is intensity modulated
• 35:43radiation therapy that I think
• 35:44most people are familiar with.
• 35:45That's the nine week course,
• 35:47which is 40 to 45 treatments.
• 35:49We kind of rarely use that anymore.
• 35:52That's really for guys who have
• 35:54very large process or have a lot
• 35:56of urinary issues where we're
• 35:57trying to be very gentle per day.
• 35:59So most guys don't need that.
• 36:01We're mainly doing like Jerry referring
• 36:02to either the 28 treatments or the five.
• 36:04Treatments 20 actually can be 20 or
• 36:0628 in the Yale system we we followed
• 36:09the data most closely from the
• 36:1128 fraction or treatment regimen.
• 36:13So that's what we'll see.
• 36:14It's official title is moderately
• 36:16hypofractionated IRT,
• 36:17but for us it's 28 treatments.
• 36:21The other is the five treatment option.
• 36:22This one has a lot of nicknames.
• 36:24There's a lot of advertising around it.
• 36:26So I think it's important to know
• 36:28that the core technique is SBRT or
• 36:31stereotactic body radiation therapy.
• 36:33This is the technique that the cyber knife.
• 36:35Sheen does, but other machines do as well.
• 36:37So our machine here at Greenwich
• 36:39is the true beam, for example,
• 36:41and a lot of machines like that,
• 36:43they're high end machines that
• 36:44are capable of this,
• 36:45but Cyber net does it also sometimes called
• 36:48Saber in the Sloan Kettering system,
• 36:51excuse me,
• 36:51it's referred to as precision RT.
• 36:53But anyway,
• 36:54important to know that a lot of
• 36:56machines do this technique.
• 36:58It is very focused.
• 36:59The cure rates are the same between
• 37:01these options.
• 37:02The bowel issues and urine issues are very,
• 37:05very similar.
• 37:06There is some thought or or hints
• 37:08that the five treatment option
• 37:09because it's more intense per day
• 37:11might have a little more of an
• 37:13acute urinary side effect profile
• 37:15in the data that's out there that
• 37:17actually looks very, very similar.
• 37:18But anecdotally I think some
• 37:20physicians especially urologist who
• 37:22who follow the complications the most.
• 37:24Mostly feel like maybe there are
• 37:26sometimes some extra issues with that.
• 37:28For us,
• 37:29I think the big distinguisher is
• 37:32prostate size and baseline urinary
• 37:34issues if you have a prostate size
• 37:37under 60CC's and really fairly
• 37:39low urinary issues.
• 37:40And I think these guys tend to
• 37:41be a good candy for either one.
• 37:43But if you're anything beyond that,
• 37:45I really strongly caution guys that
• 37:47they kind of asking for trouble with
• 37:49five and we should really do the 28,
• 37:51which is a very solid track
• 37:53record in terms of.
• 37:54Pure and and toxicity breakey therapy
• 37:57briefly mentioned that's the seed
• 37:59implant or sometimes temporary
• 38:00catheters that are put in and then a
• 38:02radioactive source is placed in and out.
• 38:03I think this technique again very
• 38:05good especially for the low risk
• 38:07and favorable intermediate the
• 38:09jury was mentioning probably is
• 38:11the worst of the urinary staff
• 38:12profiles and can also be combined
• 38:15with external beam for high risk guys.
• 38:17But that's a bit of a of a nuance
• 38:20that it's probably not not so
• 38:22important for this this chat.
• 38:25For post prostatectomy.
• 38:27You're sometimes asked to give
• 38:28radiation within about 6 to 12
• 38:30months as adjuvant treatment.
• 38:31There's some very risky looking
• 38:33features that surgery pelvic nodes or
• 38:35the PSA does not go to undetectable.
• 38:37But most of what we're doing these
• 38:39days is called salvage radiation
• 38:41therapy and that's where the PC's
• 38:43gone undetectable and subsequently
• 38:45risen typically to something like
• 38:47.2 is our our most common cut
• 38:50off and we see the guys there.
• 38:53It's about a 37 to 39 treatment course,
• 38:55it's about 8 weeks and.
• 38:58There's some developing data about,
• 38:59including four to six months,
• 39:01usually six months of engine
• 39:02deprivation for these guys as well,
• 39:04especially if they're coming to
• 39:06us with a little bit higher PSA
• 39:08or some other feature that's
• 39:09a little riskier for Gleason.
• 39:11And the third category which is I
• 39:13think definitely the new kid on the
• 39:14block and you know is really not as
• 39:16well known but it's becoming really
• 39:17important is oligo metastatic.
• 39:19So these are the guys who have,
• 39:21they do have metastatic disease
• 39:23based on whichever imaging we'll
• 39:24talk in a later slide about that.
• 39:26But let's say they have in the
• 39:28prostate and they have two bone sites.
• 39:30Should we treat this guy the same as
• 39:32a guy who has 17 bone sites and some
• 39:35nodes in his in his chest and you
• 39:37know the the most recent data says
• 39:39that really we should treat these
• 39:41guys differently if they have all of them.
• 39:43That disease we should treat the
• 39:45prostate as part of the case is not
• 39:48replace hormone therapy and other
• 39:49things that that Dan will talk about.
• 39:51But in addition to that,
• 39:52treating the prostate has a survival benefit.
• 39:55And if we have again a limited
• 39:57number of bone sites,
• 39:58actually going after those bone
• 40:00sites can help to prevent additional
• 40:02bone sites from coming up and
• 40:05create a longer PSA control.
• 40:07Next slide please.
• 40:09Just give a little more detail,
• 40:11Jerry's mentioning.
• 40:11We put in the the gold markers and
• 40:13the gel refer to the gel first.
• 40:14So this is called the main product that's
• 40:17available these days is called space or gel,
• 40:19and this is a biodegradable gel.
• 40:21So it goes in,
• 40:22it lasts for three months and
• 40:23then dissolves back to water
• 40:25over another three months and
• 40:26just absorbed by the body.
• 40:28And as you can appreciate in the
• 40:29upper left in the cartoon and then
• 40:32the real MRI pictures on the right,
• 40:34it's really trying to create this pad of
• 40:36gel between the prostate and the ******.
• 40:38And as I tell patients, it's not.
• 40:40It's not a shield, it's not absorbing
• 40:42radiation in some magical way,
• 40:44but it's creating with that gap that's
• 40:46allowing us to drop the dose very quickly
• 40:48between the process and the ****** and
• 40:50it helps to reduce rectal side effects.
• 40:52So not every guy is a
• 40:54good candidate for this,
• 40:56but most guys are.
• 40:57And if there's a a nuance to it,
• 40:59then we work with the urologist about,
• 41:00you know, who's a good candidate versus not.
• 41:02So some guy who has posterior extension of
• 41:05of cancer on MRI that's pretty pronounced,
• 41:07may not be a good candidate for example,
• 41:09but most guys are.
• 41:12And so I think you'll be hearing more
• 41:14and more about guys who got gel on with
• 41:17their markers with definitely a big helper.
• 41:19Next slide, please.
• 41:22There are different
• 41:23fiducials that are possible.
• 41:24I say the most common ones
• 41:25and that we use are gold and
• 41:27you can see a zoomed in view.
• 41:28They they have a little bit of a
• 41:30texture or rifling to them to help
• 41:33stick in the prostate not migrate.
• 41:35But there there are ceramic
• 41:36versions of these.
• 41:37There are long coiled versions.
• 41:39There's another one that has a a called
• 41:43Calypso that has an electromagnetic.
• 41:46Frequency is like an RF powered device that
• 41:48can be checked multiple times a second.
• 41:50So there are multiple types,
• 41:52but I think you know the goal ones are
• 41:54the most standard work really well.
• 41:56The imaging on on the lower right is
• 41:59what's called a cone beam CT you know
• 42:01when when patients are asking us,
• 42:02you know, how do you know that,
• 42:04that the treatment is accurate?
• 42:05You can't see my prostate,
• 42:06but the treatment say,
• 42:07well every day before we treat you,
• 42:08we spin the machine around and we
• 42:10take an image that's a cone beam CT
• 42:12that looks very much like a CAT scan.
• 42:13We overlay it with the real CAT
• 42:15scan that we get for planning.
• 42:16Services.
• 42:17So in this view here with this
• 42:19kind of quartered view,
• 42:21the upper left and the lower right is
• 42:23from the real CAT scan and the cone
• 42:25beam is the upper right and the lower left.
• 42:28You can see that there's some slight
• 42:29differences in how the tissues appear,
• 42:31but they're really,
• 42:32it's really very robust and you
• 42:34can see with the this red arrow
• 42:36what the gold markets like.
• 42:37So the gold markers are are very
• 42:40easily distinguished and this is
• 42:41what helps us to have a high degree
• 42:44of confidence that we're on target.
• 42:46Now some guys are not a candidate for this.
• 42:47They, you know,
• 42:48they're on blood thinners and they.
• 42:49If we feel from primary care that
• 42:51you're for their cardiologist that
• 42:52that's just not going to be safe
• 42:54to go off blood thinners again
• 42:55or they simply don't want another
• 42:56procedure or whatever it is.
• 42:57So we do have an option to not
• 43:00do gel and not do markers.
• 43:02If we're going without markers,
• 43:03then the margins that we use around
• 43:05the prostate are a little bit larger
• 43:07because we don't have quite the same
• 43:09degree of confidence about the alignment.
• 43:11We can still take this comb beam
• 43:13image and see the soft tissues.
• 43:15So we we can get very, very close,
• 43:16but the markers even even nicer.
• 43:19Next slide please.
• 43:21Uh,
• 43:22just a quick word about better
• 43:23imaging for prostate.
• 43:24So if we're moving into that intermediate
• 43:26or high risk prostate cancer and
• 43:28above where we're trying to staging,
• 43:30you know, convention,
• 43:31we're getting an MMR and usually
• 43:33getting a CAT scan, abdomen,
• 43:34pelvis and bone scan.
• 43:36These are still good,
• 43:38still highly supported.
• 43:39Some insurance companies will still insist
• 43:41on getting those instead of a pet scan,
• 43:43but I think that the that
• 43:45the trend is definitely
• 43:47to allow PET scans.
• 43:48The first PET scan that we had access
• 43:50to around here was called Axemen.
• 43:52The newer one, I think we have
• 43:54a little more confidence in.
• 43:55It has some trade names like Polara 5,
• 43:57but it's really a PSM, a pet CT,
• 44:01another slide about this in a moment,
• 44:03but currently for the PSA pet,
• 44:07we're having a gentleman go up to New Haven,
• 44:09but later this month it will be
• 44:11available at Greenwich as well.
• 44:12We'll see this popping up I
• 44:14think in other places over time.
• 44:16Next slide please.
• 44:18Just a little little bird
• 44:20I'm going to focus on,
• 44:21on the mid and bottom part of the slide.
• 44:22So this this PSM, a pet can be
• 44:24used for gentleman with an initial
• 44:27diagnosis prostate cancer or if
• 44:29they're post treatment either post
• 44:31prostatectomy or post radiation.
• 44:33We're seeing a PSA rise and we want to
• 44:35hunt down where the spot is or spots are.
• 44:37This is a a great study for that.
• 44:40PSA is prostate specific membrane antigen.
• 44:43So this is a little more specific
• 44:45to prostate cells is overexpressed
• 44:46and over 90% of prostate cancer
• 44:48cells and that's really the magic
• 44:49of how we can make this work.
• 44:51So this is not a regular
• 44:53pet scan with glucose.
• 44:54This is really targeted to to PSA and
• 44:57interestingly and hopefully it is has
• 44:59a high degree of expression with those
• 45:02higher leasing score, nastier tumors.
• 45:04Next slide please.
• 45:07Are you OK?
• 45:13Turn this over to Dan.
• 45:23Hi, Dan, I think you're on mute still.
• 45:29I think it's important to note that
• 45:31we've made a tremendous amount of
• 45:33progress in metastatic disease,
• 45:35not only in the earlier treatment
• 45:37of prostate cancer when we call
• 45:39the hormone sensitive state,
• 45:40which is what this patient is,
• 45:42but in the hormone resistant
• 45:44or castration resistant state.
• 45:46In fact, in 1991, my esteemed Lake colleague,
• 45:51Alan, you go to my published paper
• 45:53saying that patients only lived
• 45:54about a year with chemotherapy.
• 45:55Well, we've extended that out with
• 45:57all of our other treatments to
• 45:59about three years at this point
• 46:00and with good quality of life
• 46:02and for metastatic patients such
• 46:03as this five year survival to 7
• 46:06year survival is not unexpected.
• 46:08So this 82 year old male,
• 46:11very active develops lower back
• 46:13pain while playing tennis.
• 46:14He goes to see his internist,
• 46:16who does a series of L spine films,
• 46:18which demonstrate sclerotic bone metastases.
• 46:22He has a PSA of 1200.
• 46:23He's referred for a biopsy of his prostate,
• 46:26which demonstrates at least
• 46:28nine adenocarcinoma.
• 46:29Imaging detects multiple bone
• 46:31metastases in the ribs and thoracic
• 46:33as well as lumbar sacral spine.
• 46:35So this is not the patient that
• 46:37Doctor Mcgibbon spoke about before.
• 46:39This patient would not benefit from
• 46:41receiving radiation therapy to his
• 46:43prostate or to the metastases but.
• 46:45Would really require systemic therapy.
• 46:48So this patient goes on androgen
• 46:51deprivation therapy with a drug
• 46:53called degarelix which rapidly
• 46:55reduces the testosterone levels
• 46:57within 24 to 48 hours to less than
• 47:0050 nanograms per deciliter which is
• 47:02considered to be castrate and also he
• 47:05starts a drug called enzalutamide.
• 47:07Which is in next generation and antigen,
• 47:09which is originally,
• 47:11which was originally approved for
• 47:12patients with resistant disease,
• 47:14but now is being moved up front
• 47:16to these patients.
• 47:17So all these patients really deserve
• 47:20the chance of having what we call
• 47:23the best next generation agent.
• 47:25And drugs such as enzalutamide,
• 47:27apalutamide,
• 47:28abiraterone are all given to these
• 47:32patients in the early stages of
• 47:33metastases rather than the late
• 47:35stages where they originally approved.
• 47:37And we see that there's more of a survival.
• 47:38Benefit in these patients with
• 47:40this treatment,
• 47:41chemotherapy is also administered
• 47:42in this area as well,
• 47:44so common complications that an internist
• 47:47may see in this disease include hot flushes,
• 47:51osteoporosis, anemia.
• 47:53Impotence, fatigue,
• 47:55and weakness, muscle wasting.
• 47:58That's something we can do something about.
• 48:00All of my patients with prostate cancer,
• 48:03I recommend that they maintain
• 48:05an active exercise program,
• 48:07including lifting weights.
• 48:08They have to maintain the muscle mass
• 48:11because of course without testosterone
• 48:13we can have issues cardiovascular side
• 48:15effects of being newly identified.
• 48:17And these include a higher risk
• 48:19of a second myocardial infarction
• 48:21within six in a patient who's had
• 48:23a myocardial infarction within
• 48:25six months of starting an engine
• 48:28deprivation therapy.
• 48:28And the guidelines for managing
• 48:30cardiovascular patients are really
• 48:32not as clear as we would like them
• 48:34to be at this particular point.
• 48:37Next slide. Hot flushes occur
• 48:39at about half to 80% of men.
• 48:42It's usually a sudden perceived
• 48:44increase in temperature,
• 48:46accompanied by reading of the
• 48:47skin and profuse sweating.
• 48:48Next slide, please.
• 48:51And this is usually spontaneous,
• 48:54changes in body position or
• 48:55ingestion of hot liquids can also
• 48:58cause this particular problem,
• 48:59environmental changes as well.
• 49:01So what do we do about hot flashes?
• 49:03We generally will ask the patient
• 49:05try to try soy products because
• 49:07they do have phytoestrogens and
• 49:09that tends to counteract that.
• 49:11Additionally, drugs such as effects Effexor,
• 49:14Clonidine are also effective
• 49:15in these patients.
• 49:17We generally will reserve
• 49:18that for severe hot flushes.
• 49:21Osteoporosis is really a more recognized
• 49:24problem in men over the last several years,
• 49:27and about 25 to 30% of all osteoporotic
• 49:30hip fractures do occur in men.
• 49:33By 2025 we expect about 1.1 million cases,
• 49:36and as one would expect with a patient
• 49:38zoning going ancient deprivation therapy,
• 49:40the major causes hypogonadism.
• 49:43Women can also experience this who are
• 49:46on LHRH agonists for endometriosis,
• 49:49and that's why.
• 49:50The use is usually limited
• 49:52to about six months.
• 49:53Next slide please.
• 49:56So generally a man will lose,
• 49:59after age 35, zero .5 to 1% of their
• 50:03bone mineral density per year.
• 50:05That's accelerated in the patient
• 50:07on androgen deprivation therapy
• 50:09to 1.4% to 2.6% per year and
• 50:12compared to age matched controls.
• 50:16Men on energy deprivation therapy
• 50:17have a 6.5% to 7070.3% risk of
• 50:21higher bone loss and the rates
• 50:23of fractures are higher.
• 50:25So in the hormone sensitive state
• 50:28the patient we would consider
• 50:30giving calcium and vitamin D2.
• 50:35And we see this is in a patient who's
• 50:37head does not have bone metastases,
• 50:40who's treated for more than six months.
• 50:43This is 218 patients.
• 50:45A 6% fracture rate is seen and the median
• 50:48time to fracture is 28 months. Next slide.
• 50:52So we we generally as I said
• 50:54before in a metastatic patient,
• 50:55I generally don't do dexa scans.
• 50:57But in a patient that we're treating
• 51:00with the urologist as well as
• 51:01radiation oncologist who may be
• 51:03on Angie and deprivation therapy
• 51:04who don't have metastatic disease,
• 51:06we we do do dexa scans and then
• 51:08treat the patient accordingly
• 51:09depending upon the level of bone
• 51:11metal density loss at baseline.
• 51:19Great. That was terrific.
• 51:21Dan, really, can we stop sharing?
• 51:27This means we actually have a a decent
• 51:30amount of time for for questions and
• 51:32the Q&A which which is wonderful.
• 51:35So folks who are listening,
• 51:37please type in your questions in the Q&A.
• 51:41And as we were discussing this initially,
• 51:45I know that there are a number of people
• 51:47who had questions already for each other.
• 51:49So I'm going to allow Aaron to start off.
• 51:54Alright. I guess dance,
• 51:55since you finished most recently,
• 51:57uh, I wanted to ask if there a
• 51:59recommendation for how often to check,
• 52:01uh, bone density testing on
• 52:04those patients who receive
• 52:06androgen deprivation therapy?
• 52:10I think you're on mute, Dan. Sorry.
• 52:14It's usually every two
• 52:15years we we check it, OK?
• 52:17OK, I figured that with the, uh,
• 52:19I guess the 28 month marker there
• 52:21that you gave the average bone loss.
• 52:23OK, and have you had any experience
• 52:27with gabapentin helping with hot
• 52:28flashes for your patients with?
• 52:32But I've not really tried it.
• 52:33I've used predominantly Effexor.
• 52:35But anyway some literature
• 52:37that that does use it.
• 52:38You know, The funny thing is that that
• 52:41the soil products do actually work.
• 52:43Not. Soy milk, which has very
• 52:45little soy but tofu soy cheese.
• 52:47It will least reduce the the
• 52:50frequency or actually the intensity
• 52:52of the hot flashes may make not
• 52:54make them go away completely,
• 52:55but makes it a little more tolerable.
• 52:59Do you have any soy products you recommend?
• 53:00I have a lot of patients who
• 53:02like supplements, tofu, tofu.
• 53:06Sounds tasty to me.
• 53:08Here's a question from Beth Allard.
• 53:10Can you address PSA testing and
• 53:13patient on on testosterone replacement,
• 53:16the frequency and cut offs for referral?
• 53:21Yeah, that's a great question.
• 53:23UM, to my knowledge,
• 53:24when I looked at the most recent guidelines,
• 53:28there was not a strong relationship
• 53:32between testosterone and worsening
• 53:35of prostate cancer outcomes.
• 53:38So I think the guidelines
• 53:39are still the same for.
• 53:41Those patients.
• 53:42But Dan, correct me
• 53:43if I'm wrong.
• 53:45Uh, it. At Harvard, they've actually
• 53:48been looking into that question.
• 53:50They do have a number grammar 7 adjustment.
• 53:54And I'm blanking on the author's name.
• 53:57I can. If if I think of it,
• 54:00I'll put it in the chat but
• 54:01but they but they have it.
• 54:02Looking at this particular issue
• 54:04interestingly I thought the other
• 54:06question would be should a man with
• 54:08prostate cancer go on androgen,
• 54:09androgen supplementation.
• 54:10That's one of the more
• 54:12controversial areas right now.
• 54:14And in fact we're actually using
• 54:16high dose testosterone in some
• 54:18patients for right with resistant
• 54:19disease and about a third of those
• 54:21patients will respond to that.
• 54:23So that testosterone is a very.
• 54:26Poorly understood hormone.
• 54:29And you know, again,
• 54:31I think you really should consult with
• 54:33your physician before embarking on
• 54:34any of those particular supplements.
• 54:38Ryan, were you going to add to that?
• 54:42No, sorry, I was just
• 54:44responding. I was since the best
• 54:46question was answered, I just
• 54:48took it out of the queue. I'm sorry.
• 54:53Let's see another question from the chat.
• 54:54If a Dre is abnormal and the
• 54:57PSA within normal, what is the
• 55:00next step maybe going to Jerry?
• 55:03Yeah, so I would have probably recommend.
• 55:06Referring to the urologist at that point.
• 55:10Because I think we, you know.
• 55:18It's rare for me to call a Dre
• 55:22abnormal unless I, you know,
• 55:24truly, truly feel something.
• 55:27Because of the the sensitivity and
• 55:30specificity that Aaron quoted,
• 55:32so you know if if there is
• 55:35something real on the Dre,
• 55:37usually the PSA is 15 to 20
• 55:40and those patients as well.
• 55:43There are rare instances
• 55:45when that's not the case.
• 55:47And there are some instances
• 55:49where the patient is older
• 55:50and doesn't have a PSA level.
• 55:52So if the Dre is abnormal
• 55:54and we were very concerned,
• 55:56I would get a PSA on that patient and.
• 56:01There have been patients that have
• 56:02been diagnosed that way who have
• 56:04stopped PSA screening because of their
• 56:07age and the Dre was very concerning.
• 56:11Yeah, but I think it's important.
• 56:12If the DVR is abnormal it
• 56:14it needs a second opinion.
• 56:19I agree.
• 56:24Nope, and I think you're on
• 56:25mute. Having an epidemic of mute.
• 56:29Any data on acupuncture for
• 56:31hot flashes and flashes?
• 56:32Keep these questions coming in.
• 56:34They're fantastic.
• 56:38No, not that I found. Dan anything?
• 56:41I've not found that either. I found
• 56:44mixed mixed mixed experiences with it.
• 56:51And then why stop PSA at 75 years old?
• 56:59How proud here this
• 57:01is actually. Pretty controversial, uh?
• 57:07The AUA guidelines actually
• 57:09recommend 55 to 70.
• 57:11I I did have a discussion
• 57:14with my patients at age 75.
• 57:16And we discussed the harms
• 57:18of continuing to test.
• 57:21The problem is when you can.
• 57:23When you tell a patient to
• 57:25consider life expectancy,
• 57:26that's not something that
• 57:27they want to consider.
• 57:29So it's it's it's it is difficult to stop
• 57:32testing at 75 because most patients will.
• 57:36I I've had, I've had a lot of patients
• 57:38who've come to see me who were
• 57:41told by their previous urologist.
• 57:43You're you're going to die anyway.
• 57:45Why? Why test your PSA?
• 57:46And they don't like hearing that, so, uh, it.
• 57:49I usually look at their
• 57:52medications and comorbidities.
• 57:55If the patient is on Plavix and
• 57:57aspirin and has had three stents,
• 58:00you know,
• 58:01the chance that you're gonna
• 58:03increase their lifespan with
• 58:04PSA testing is pretty low.
• 58:06Most prostate cancer that's intermediate
• 58:09risk probably takes anywhere from 7
• 58:12to 10 years to actually metastasize.
• 58:15So.
• 58:15That's why the 10 year life
• 58:17expectancy is a good rule as well.
• 58:24Got it. We were talking about Dre
• 58:26also earlier in in the planning and
• 58:29it is something that many of us are
• 58:32have grown up in a certain way and
• 58:35it it marks their dates us I guess.
• 58:38Karen Ryan, any thoughts on on on
• 58:41the Dre and and how things have
• 58:44changed recommendations over time?
• 58:48So
• 58:48I was going to ask a different
• 58:50question, but a quick story.
• 58:52Remember, I once told the patient,
• 58:53this is 20 years ago, back when it was,
• 58:55I think, still a standard of care about
• 58:58to do a digital rectal exam. And he said,
• 59:00oh, they're digital now.
• 59:03True story, true story.
• 59:05No, I think you know what. What we
• 59:07find, and I'll be really interested
• 59:08in Karen's perspective as well, is
• 59:10that, you know, old habits
• 59:11die hard and,
• 59:12you know, it's hard to convince
• 59:15people that the evidence is evolved. And,
• 59:19you know, we
• 59:19find that, you
• 59:20know. Conversations like this
• 59:22or presentations like this are
• 59:25ways in which we can share best
• 59:28evidence and evolve practice.
• 59:31But you know for the record when I
• 59:33trained it was the standard of care
• 59:35and I'm wrapping my head around it.
• 59:37So Karen, I don't know
• 59:38more thoughtful answer than mine.
• 59:42I mean the answer that
• 59:45I mean Aaron presented some of the
• 59:48statistics we we do get a lot of false
• 59:52positives and urology consultation I
• 59:53still consider a precious resource
• 59:55and so you know I want to make sure
• 59:58that most of the people who most need
• 01:00:01to get there do and and the reality
• 01:00:03is and and it's kind of funny because
• 01:00:05ten years ago we weren't saying this,
• 01:00:07but the blood test does work remarkably well.
• 01:00:11It's not perfect,
• 01:00:13but I think most of us have really.
• 01:00:16At the same time,
• 01:00:17we decreased our our rectal exams,
• 01:00:19we increased our PSA and and
• 01:00:21so on a kind of summary level,
• 01:00:24you know, my,
• 01:00:25my guess is that we're finding more
• 01:00:28prostate cancer and being more sensitive.
• 01:00:30I mean I, I,
• 01:00:31I offered every man, I said,
• 01:00:33you know, I don't, I'm not required to
• 01:00:36do a rectal exam anymore, but I'm happy
• 01:00:38to do one if you would like.
• 01:00:39And I find that actually most patients
• 01:00:41are far more happy to give it up than
• 01:00:44if I phrased it any other way. Uh, but
• 01:00:48you know. I mean, everything we do,
• 01:00:51there's always a risk of missing something
• 01:00:53and and so everything we do just has to
• 01:00:56be with the greatest good in mind and and
• 01:00:59what we can do routinely for everybody.
• 01:01:03Just want to make one point.
• 01:01:05I think it's great that you
• 01:01:07having that discussion.
• 01:01:08Going back to the preventative task force,
• 01:01:10there was a study that was done at
• 01:01:12ASCO presented at Asco Gu this year
• 01:01:15where they look state by state at the
• 01:01:19incidence of prostate cancer and the.
• 01:01:22The development of metastatic disease
• 01:01:24and there's been a 28% increase in
• 01:01:27metastatic disease since that task
• 01:01:29force made that recommendation.
• 01:01:31So I'm glad that we're getting back
• 01:01:33to having shared discussions because
• 01:01:35clearly we want to move to a curable
• 01:01:37situation rather than incurable situation.
• 01:01:41And that's go ahead, Chris.
• 01:01:44I was just going to add to that that
• 01:01:46you know Jerry and Dan and I are.
• 01:01:48Are managing these days really a really
• 01:01:50high number of gentlemen in their late,
• 01:01:53mid to late 70s to early 80s who have
• 01:01:55great longevity in their family,
• 01:01:58relatively few comorbidities and they
• 01:02:00have Gleason 8-9 disease and no Mets
• 01:02:02on on advanced imaging and I think
• 01:02:04these guys are are gentlemen where they
• 01:02:07don't all need treatment but I think
• 01:02:09quite a few of them really do benefit
• 01:02:11from treatment you know they and and I
• 01:02:13what the this part of the discussion
• 01:02:14I have with guys is that you know
• 01:02:16long before prostate cancer kills you.
• 01:02:18If it spreads it creates a considerable
• 01:02:20reduction in your quality of life
• 01:02:23and so you know the the offer
• 01:02:25treatment is trying to help survival.
• 01:02:27But as maybe even before that with
• 01:02:28that older gentleman it's hey can
• 01:02:30I can I keep you from being on long
• 01:02:32term manager deprivation having
• 01:02:33bone Mets with pain a fracture.
• 01:02:35And I think these are all really important
• 01:02:38discussions to to have so I think.
• 01:02:40You know being more flexible and you
• 01:02:42know individualized with PSA screening
• 01:02:44these things and maybe going a
• 01:02:46little longer I think is paying off.
• 01:02:48We're just seeing a lot of these
• 01:02:50guys these days who fit that that
• 01:02:51description and and if we pick some
• 01:02:53up and it's released in six or seven
• 01:02:55and like Jerry's referring to they
• 01:02:56don't all need treatment.
• 01:02:57But again there are a lot of these guys,
• 01:02:59the higher grade disease that I
• 01:03:01think need need attention.
• 01:03:02I think that actually
• 01:03:04that attitude that's allowed us
• 01:03:06to feel more comfortable with more
• 01:03:08PSA screening, I mean it there.
• 01:03:10There was a point where it felt a little bit
• 01:03:13like if you had an elevated PSA, you know,
• 01:03:15the people may be getting unnecessary care,
• 01:03:17some component of the care was under.
• 01:03:19And with the better risk stratification
• 01:03:22and attention to the kind of geriatric
• 01:03:25and comorbid medical concerns that,
• 01:03:28you know, I feel like even if there
• 01:03:30is a PSA that's mildly elevated.
• 01:03:33People get the right care, you know,
• 01:03:35on both ends of the urology
• 01:03:37primary care spectrum.
• 01:03:38And have you had that same
• 01:03:40kind of ability to let go and
• 01:03:41feel more comfortable doing it?
• 01:03:44No, it's it's definitely added to,
• 01:03:46I think my comfort as well as my
• 01:03:49patients knowing that there's you know,
• 01:03:51a procedure, there's great
• 01:03:53specialists who are highly involved.
• 01:03:55There's so much to offer these patients
• 01:03:58now versus you know 20 years ago we we
• 01:04:02just haven't had this explosion in.
• 01:04:05And tech and and options.
• 01:04:08I think it's a great development.
• 01:04:10And I think that shared decision making is
• 01:04:13employed is it's what we're doing today too.
• 01:04:16So in the Smiler shares with primary care.
• 01:04:18So we have run out of time unfortunately.
• 01:04:21It's been fantastic discussion,
• 01:04:23a few more questions that maybe
• 01:04:25we can answer after the fact,
• 01:04:27but really appreciate all of the panelists.
• 01:04:31Karen Ryan are really pleased
• 01:04:33with the attendance and tell your
• 01:04:35friends we'll be back next month.
• 01:04:37Thanks so much. OK.
• 01:04:39Thanks, everybody. Thank you.