Smilow Shares Greenwich: Promising Progress on Prostate Cancer Detection and Treatment

September 23, 2020

Information

Dr. Michael Leapman

Clinical Program Leader, Prostate & Urologic Cancers Program

Dr. Bruce McGibbon

Medical Director, Greenwich Hospital Radiation Oncology

Dr. Daniel Petrylak

Professor of Medicine (Medical Oncology) and Urology

ID5664

To CiteDCA Citation Guide

00:00You know, welcome to the
00:02folks who have signed in,
00:04and I think we have other individuals
00:06who are still logging on its 703.
00:09So why don't we get started
00:11and let me introduce myself?
00:13I'm doctor Charles Fuchs, Charlie Fuchs.
00:15I'm the Cancer Center director at Yale,
00:18as well as the physician in chief.
00:21At smaller cancer hospital and really
00:23appreciate all of you joining us,
00:25I think actually been in document
00:27given as you may have over heard
00:29our conversation just how much we
00:32appreciate the fact that on a you
00:34know after a long day and evening
00:36people are are willing to do it.
00:38'cause this is our first smile.
00:40Oh shares forum and thank you Renee.
00:42Go dead as well for pulling us
00:44together and I think it's a really
00:47a terrific opportunity for us to
00:49share what we're trying to do.
00:51Particularly in are really aggressive
00:53efforts to combat prostate cancer
00:56and to make it clear what we
00:58want to avail to the community.
00:59And I I just wanted to offer
01:02a few remarks before I turn it
01:05over to my colleagues and let me
01:07if I may share my screen.
01:11Can you guys see it by
01:13Brewster Michael is this?
01:14Is it show up excellent?
01:16Yes oh great.
01:17So you know I think it's a really
01:19exciting time in cancer care and frankly
01:21I think an opportunity that we're
01:24really looking to make big impact in
01:26lower Fairfield County and Westchester.
01:28And in the Greenwich region.
01:30Let me share a few little
01:33background about who we are.
01:35You know at the Yale Cancer Center
01:37has really is a very long and storied
01:40history with the legacy of phenomenal
01:43science and research in cancer.
01:45As part of the war on Cancer
01:48Act in the early 70s,
01:50we were one of the original
01:53national cancerians to designated
01:54comprehensive Cancer Center as a
01:56designation that is only about 40
01:59institutions across the United States.
02:01And we have continued to carry that
02:04important designation and the only one
02:07in Connecticut since the early 70s.
02:09Really,
02:10a transformative event was the
02:12opening of Smilow Cancer Hospital,
02:14New Haven,
02:15a 15 story dedicated hospital to cancer
02:18care and innovation and research,
02:20which is really been a real Center
02:23for what we're doing.
02:25But as well,
02:26I think another important element in terms
02:29of growing our clinical research operation.
02:32Was the opening of a state of
02:34the Art Center for experimental
02:36therapeutics for patients who have,
02:39to some extent,
02:40tried the available therapies?
02:41A center here in New Haven,
02:44where individuals can get access
02:46to exciting new drugs today
02:48are Cancer Center is over 450
02:50physicians and scientists and I'll
02:52talk about this in a moment.
02:54We have 15 care centers as we described
02:57across Connecticut Rhode Island,
02:59who where it's our faculty or staff.
03:02And where we are really committed
03:05to embedding destination expert
03:06state of the art care within,
03:08you know communities across the region.
03:10I should also point out
03:12that we renewed our official
03:14designation with the National
03:15Cancer and student 2018.
03:17And because of the great progress we've
03:20made in clinical care and research,
03:22usually you get a 3% cost of
03:25living increase in our granted
03:26because of the progress we've made,
03:29we got an unprecedented record.
03:3173% increase in funding.
03:33This is our vision,
03:35a world leader in cancer
03:36care research and education,
03:38Yale Cancer Center and Smilow Cancer
03:40Hospital delivers the transformative
03:42scientific discoveries and care
03:43innovations that leverage Yale University,
03:45Yale, New Haven health to bring us
03:48closer to a world free of cancer.
03:51One patient at a time, that is,
03:53we are a diverse community across
03:55the region across disciplines,
03:57and that ultimately we will
03:59leverage all of that talent to
04:02ultimately bring to bear the best.
04:04Compassionate expert care to every patient
04:07residing throughout our catchment area.
04:09Our mission is to provide great
04:12care to conduct the full spectrum
04:15research to promote public health.
04:18To disseminate the innovations that
04:20we have here across the world and to
04:23train the next generation of leaders an
04:26you know one thing that's critically
04:28important is you know patients when
04:30they're diagnosed with cancer.
04:32They want to see the experts and we
04:35have experts in each of these domains.
04:38Tonight we're focused on genito,
04:40urinary cancers, prostate cancer,
04:41but you know across our entire
04:44region and across disciplines,
04:45we bring together physicians,
04:47scientists, nurses, pharmacists,
04:48social workers, everyone.
04:50To actually really create an umbrella
04:52that is focused on innovation in
04:54each of these particular cancers.
04:56The other thing we're committed to
04:59doing is given the extraordinary
05:01talent of Science at Yale.
05:03Is to leverage that,
05:05ultimately,
05:05to novel treatments and really
05:07moving the bar in cancer therapy.
05:10This is actually studies that
05:12came out of our Kansas led by Yale
05:15investigators by our physicians
05:17and faculty just in the past year.
05:20And, you know,
05:21we're talking about practice changing
05:23studies in colon cancer head and neck cancer,
05:26bladder cancer, gastric cancer,
05:28prostate cancer,
05:29lung cancer,
05:30and what's really interesting about
05:32these studies is beyond really informing.
05:34How we practice medicine as you
05:36see in the red,
05:38they have led to food approvals
05:39of new therapies with the Food
05:41and Drug Administration.
05:42Let me just put into context
05:44most cancer centers.
05:45If once every few years you
05:47have one approval with the FDA,
05:49A new drug approval,
05:50that's a big deal to have four in one
05:53year or soon to be 4 ones pending.
05:56That's unprecedented in really reflected
05:58with a great talent we have in our center,
06:01and some of which you'll hear from tonight.
06:04One thing we're committed to,
06:06as I mentioned to you,
06:08is is providing this kind of
06:11expertise care innovation in each
06:13community that we reside in.
06:15We have these 15 centers across Connecticut,
06:18Rhode Island and soon Massachusetts.
06:20And one that's because we are committed
06:22to having a really destination Smilow
06:25Center for every patient within 30
06:28minutes an these are Yale Faculty.
06:30They are the staff nurses.
06:32The pharmacists are employed by us.
06:35We have uniform policies and procedures.
06:37We make sure that the most complex
06:39clinical trials can be enabled in
06:41each of these centers and it's allowed
06:44us to really provide care to a large
06:46proportion of patients across the region.
06:48As I mentioned to you were really
06:51committed to bringing clinical
06:52trials to each of these sites.
06:54In fact, this is the fastest growing part of
06:57our clinical trial portfolio of new drugs,
06:59where you know 25% of the patients
07:02enrolled in clinical trials or
07:04outside of New Haven at places.
07:06Like Greenwich.
07:06An obviously Greenwich is is
07:08something that we're really proud of.
07:10We've really we're now focused
07:12now into really expanding what
07:14we're doing in Greenwich.
07:15We really had our full launch
07:17of Smiley with Greenwich beyond
07:19what we had been doing in July.
07:22Of last year to expand clinical programs.
07:25Clinical trials outreach to
07:26really bring in all disciplines.
07:28We're committed now to building.
07:31In addition to the Bendheim Center,
07:33a new facility neck on the campus.
07:36In addition to the Bendheim Center,
07:39which we're just working on,
07:41the planning which includes an extensive
07:43multidisciplinary practice space,
07:45oppressed center infusion, radiation,
07:46clinical Research Laboratory,
07:48Arelia Boutique Healing Garden
07:50State of the Art Center.
07:52That the communities in Lower Fairfield
07:54County, Westchester can leverage.
07:56Finally, I would be remiss to
07:58say look life is not the same.
08:01We're doing this by zoom and Covid
08:04certainly has been a shock to all of us,
08:07but you know,
08:08we have made throughout this time
08:10since this started in February,
08:12March.
08:12We have remained steadfast an you
08:14know one thing we've done throughout
08:17this is defined new ways to deliver,
08:19care to ensure that we continue to be
08:23steadfast at giving care to every patient.
08:26The expert compassionate care
08:27to ensure their safety,
08:29utmost to protect our staff.
08:30To make sure we have the capacity to
08:33care for covid patients but keep them
08:35separate from all our cancer patients
08:38and to really engage our entire community.
08:41To do that.
08:42And I think we've done it brilliantly.
08:44Care has continued.
08:45The clinical research is continued,
08:47and that's something that
08:49we want people to know.
08:50It's safe to come back.
08:52Don't don't short range yourself
08:54on the opportunities to.
08:56To get expert cancer care and
08:58you know more to follow.
08:59So I apologize for going so long,
09:02but I'm just so proud of the people
09:05that you're going to hear from tonight
09:07and and the what we're doing in the
09:10Kansas Center and appreciate whatever
09:12one is doing to hear this out.
09:14So let me turn it over to our to our
09:17host who will obviously introduce
09:19my other colleagues but were hosted
09:21tonight by doctor Bruce Mcgibbon.
09:24Doctor Mcgibbon is a assistant professor of.
09:26Clinical therapeutic radiology, and.
09:28The medical director of radiation
09:31oncology at Greenwich Hospital.
09:33He received his medical degree
09:35from UCLA School of Medicine.
09:37An document is really been a
09:39leader in innovation in
09:40radiation oncology with expertise and breast,
09:43prostate, lung, rectal, head,
09:45neck and brain tumors and I
09:48think really is interest has been
09:50innovating therapy to look at how
09:53we can modify the course of therapy,
09:55how we can improve quality life
09:58for people on therapy. And.
10:00It really innovate because obviously
10:02radiation is a critical part of
10:04what we do in prostate cancer
10:06as well as other diseases,
10:08and that level of innovation,
10:09I think is moving the field.
10:11So Bruce, thank you for hosting this
10:13for launching this form and really
10:15excited to hear you and perspectives
10:17of Doctor Lehman Doctor Petra
10:19lag. Thank you so much for the
10:21opening remarks introduction.
10:22We definitely very excited to have
10:25this this series and share some
10:27of the exciting things that are
10:29going on in the prostate area.
10:31And as a teacher said,
10:32there will be 3 talks with star Dr Liebman
10:36and myself and then doctor Petra Lack.
10:39We are inviting and encouraging questions,
10:41even put them in through the chat portion.
10:44Were down three talks.
10:45Then I will go through and help moderate
10:48those and see which speaker might
10:50be the best fit to to answer them.
10:53But first and foremost,
10:54it's my pleasure to introduce Doctor Lehman.
10:57He's an assistant professor of urology in
10:59the clinical program leader for prostate,
11:01near logic cancers,
11:02the cancer program at the smile cancer
11:05hospital received his MD from the
11:07University of Maryland and completed his
11:09general surgery and urology training.
11:11At Mount Sinai.
11:12He then went on to a two year.
11:15Your logic Oncology Fellowship at the
11:17University of California, San Francisco.
11:19His clinical interests include treating
11:21patients with prostate, bladder,
11:22testicular and kidney cancers.
11:26OK, thank you so much, Bruce
11:28for the introduction and I'm
11:29thrilled to participate in this
11:31exciting, innovative program.
11:32So let me just try to share my screen
11:35here and we'll get started with our talk.
11:38OK, so I hopefully you can see
11:41everything you can re up here.
11:46Not yet, I don't see it yet.
11:57Bear with me one second, it's giving me a.
12:04OK, perfect great.
12:05Can you see me in full screen there?
12:08OK so so good evening everyone.
12:10I'm Michael Lehmann and I'm an assistant
12:13professor in the Department of Urology.
12:16I'm going to be speaking to you tonight
12:19about prostate cancer and really focusing
12:21on the early spectrum of disease,
12:24early diagnosis,
12:25screening and surgical treatment options.
12:28I have no relevant disclosures and I just
12:31want to tell you a little bit about myself.
12:35I'm a Urologic Oncologist.
12:37I'm a urologist who specializes in the
12:40treatment of urologic cancers, prostate,
12:42bladder, kidney, testicular cancer.
12:44My focus is our inpatient care,
12:46helping patients navigate their
12:48treatment and diagnosis for presumptive,
12:50or, or diagnose, diagnose cancers.
12:53And also more broadly,
12:55understanding and improving how the
12:57early Speck of the early phase of the
12:59disease is managed in terms of diagnosis
13:02and early treatment for prostate cancer.
13:04So what I'm going to be talking
13:07to you tonight about are
13:08really four simple questions.
13:10Number one understanding who is
13:12at risk for prostate cancer.
13:14Understanding how prostate cancer
13:16is diagnosed.
13:17Going over some of the treatment
13:19options for prostate cancer,
13:20if it is detected focusing on the
13:22surgical treatment options which we offer,
13:24and a very brief overview about what
13:26our Department is doing at Yale to
13:29better understand and treat the disease.
13:32So just by way of introduction,
13:34what is the prostate?
13:35And as you can see in this diagram here,
13:38it's really packed in tightly
13:40in valuable real estate.
13:41It sits between the bladder or urine
13:43is stored, and the male urethra.
13:45And so it has clearly close proximity to
13:48other important structures like the rectum,
13:50the nerves and blood vessels
13:52responsible for erectile function.
13:54It's a glance as a reproductive organ,
13:57and its function is to
13:58secrete prostatic fluid,
13:59which is one of the components of semen.
14:04So as the prostate enlarged,
14:06prostate become can become apparent
14:07to men for several reasons.
14:09The most common one is enlargement,
14:11and this happens commonly as
14:13people get older, the Glen simply
14:15enlarges and compresses the urethra.
14:16This is a common complaint
14:19that we hear about.
14:20Symptoms are well known to
14:22many frequent urination.
14:23I need to urinate at night urgency.
14:26A decreased force of stream,
14:28and an inability to hold urine.
14:30These may sound familiar.
14:33Cancer can also arise in the prostate,
14:36which is increasingly common
14:37in all men as they age,
14:39and you know the question often comes up.
14:42What is cancer and what is cancer
14:45and what we're referring to is
14:47uncontrolled cellular growth,
14:48which is capable of spreading
14:50or invading other tissues,
14:52and so that lives on the spectrum of
14:55prostate enlargement and other other
14:57things that can happen in the prostate.
14:59So that distinction between benign
15:01prostate and cancerous prostate.
15:03Is what we're focused on.
15:05Prostate cancer is common.
15:07It's the most commonly diagnosed
15:10non skin cancer in men with
15:13almost 200,000 new cases estimated
15:15to be detected in 2020 alone.
15:17It is also the second leading
15:19cancer killer in men with over
15:2230,000 anticipated deaths from
15:24prostate cancer alone this year.
15:28Survival is highly dependent on stage.
15:31Survival is very high for
15:33patients who are diagnosed with
15:35prostate cancer at an early stage,
15:37but decreases if the cancer has
15:39progressed regionally or distantly.
15:41Where survival is poor.
15:45There are clear risk factors for prostate
15:48cancer and we can think about this
15:50separated as the known fixed risk factors.
15:53Things you really can't help and some
15:55of the things which may be modifiable.
15:58Some of the known fixed risk
16:00factors are age, prostate cancers,
16:01more common as we get older race,
16:04we know that African American ancestry
16:06is associated with a greater risk
16:08for prostate cancer detection and
16:10poor outcome for prostate cancer.
16:12There are also known genetic alterations
16:15associated with the risk of prostate
16:17cancer and family history having a
16:20first degree family relative father,
16:22a brother with prostate cancer
16:25is a risk factor.
16:27There are also commonly spoken
16:29about modifiable risk factors,
16:30including diet, lifestyle, and obesity.
16:32The link there is not as clearly understood,
16:35but our potential modifiable
16:37risk factors for the disease.
16:41How is prostate cancer diognosed
16:43when prostate cancer is localized,
16:45there are seldom symptoms and so having
16:47urinary symptoms are not necessarily a
16:50sign that a man has prostate cancer.
16:52The primary way that it is detected is
16:55through a rectal examination or a blood test,
16:58and the blood test is something
17:01called the prostate specific antigen.
17:03Which is a protein marker that can
17:06be elevated in prostate cancer and
17:08other conditions of the prostate.
17:11When cancer has spread beyond the gland,
17:14there are there can be symptoms that arise
17:18including difficulty urinating blood
17:19in the urine, bone pain, or fatigue.
17:24So as I mentioned,
17:25PSA is a blood test that we commonly
17:28used screen men for prostate cancer.
17:30It's exclusively made by cells
17:32in the prostate.
17:33It does not diagnose prostate cancer,
17:35but it can raise suspicion.
17:37It's not a perfect test because
17:39there can be false positives.
17:41The level can be elevated
17:42because of infection,
17:43inflammation of large prostate.
17:45But of course the reason we do the
17:48test is because if it is elevated does
17:50raise the specter of prostate cancer.
17:55The question often arises
17:56is prostate cancer helpful?
17:57Is screening for prostate cancer
17:59helpful at reducing the risk of death?
18:01And this is some evidence.
18:04That contrast,
18:05the change in metastatic disease
18:08at presentation following the
18:10widespread implementation of
18:11screening for prostate cancer.
18:13So the PSA tests really became
18:16popularized in the early to mid 1990s,
18:19and there has been a precipitous
18:22decline in prostate cancer.
18:24Itassis at presentation and death
18:27that is largely attributed to
18:29the integration of PSA testing.
18:34What do the clinical guidelines
18:36say for prostate cancer detection?
18:38And so we think about these really
18:40in a risk stratified approach,
18:43there is not one one size fits all
18:46approach for screening for prostate cancer,
18:49the national comprehensive cancer network
18:51tends to or advocates a graded approach.
18:54There are clearly patients who are
18:56at high risk patients with African
18:58American ancestry or known rack up one
19:00and two germline mutations and in those
19:03patients who are in a high risk category,
19:06we recommend testing beginning at
19:08an earlier age beginning at the age
19:10of 40 with a baseline PSA level.
19:13For patients at average risk who do
19:15not have a known family history of
19:18baseline PSA test can begin at age 45
19:21and can be repeated every one to two
19:23years based on that baseline value.
19:26And often the question arises when
19:28should screening for prostate cancer and
19:31and there are differences in opinion,
19:33but in general we recommend screening
19:35until patients have a life expectancy
19:38of less than 10 years.
19:40But in some cases it may still be warranted.
19:45So what do you do if your PSA is
19:48abnormal and so he mentioned there's
19:49sort of a normal distribution,
19:51but if the PSA is in the normal range,
19:53continued testing is recommended
19:55for most patients,
19:55and that's often done with
19:57your primary care doctor,
19:58and we can usually be coupled in.
20:00To the.
20:02Into annual lab work.
20:04But what if that PSA level is higher
20:07than expected and there are options for
20:10determining what is the underlying cause?
20:12A simple first step is repeating
20:14the PSA and making making sure
20:17it's not an average value.
20:18There are also biomarkers or tests
20:21that are more specific to detecting
20:23prostate cancer as well as advanced
20:25imaging that can distinguish
20:27between malignant and benign tissue.
20:29But the gold standard to determine
20:32to distinguish between benign
20:33and prostatic cancer,
20:34is a biopsy of the prostate,
20:37and this is a procedure that is performed
20:40generally under local anesthesia
20:41using ultrasound guidance where
20:43samples are taken from the prostate
20:45and examined under a microscope.
20:49One of the innovations at Yale that Yale
20:52has really been in the forefront of is
20:55using prostate MRI to help distinguish
20:57between benign and prostatic disease.
21:00Benign and cancerous disease,
21:01and what we have found an has
21:04been seen in numerous published
21:06studies and clinical trials.
21:07Is that high resolution prostate
21:09MRI significantly improves the
21:11detection of prostate cancer.
21:12If it's present.
21:14In many cases, it can be difficult
21:16to make the diagnosis and more.
21:18I can help distinguish and identify.
21:21Cancerous tumors give present.
21:24We also have the technology to take
21:27this previous MRI image and use a
21:30Fusion based technology where we
21:32actually guide are biopsies two areas
21:35of concern that are identified which
21:37significantly improves the detection
21:39yield for prostate cancer if present.
21:44Like any procedure,
21:45there are risks of prostate
21:47biopsy and those can be thought
21:49of in a few different ways.
21:51One risk is a false positive,
21:53meaning that the PSA is elevated
21:55and there's not cancer there.
21:57So a prostate biopsy may be unnecessary.
22:00Cancer may not be present.
22:01There are procedures,
22:03specific risks, including infection,
22:04seen in about 1 to 4% of patients.
22:07The procedure may be uncomfortable
22:09and also anxiety provoking.
22:11There's also risk of over detecting small,
22:14non aggressive cancers that
22:16may not have become clinically
22:19apparent if we did not detect them.
22:21And treating indolent cancers
22:23that are not dangerous can
22:25lead to lasting consequences
22:27including urinary incontinence,
22:29erectile dysfunction,
22:30and al toxicity.
22:34So what are the options if
22:35prostate cancer is found,
22:37particularly at an early stage,
22:38and I think the kind of the most important
22:41point is that all of these options must
22:43be tailored to the individual needs
22:45and characteristics of each patient.
22:47And I really speak about four
22:49options that are for for cancers
22:51that are found at a localized phase.
22:53The first is called active surveillance,
22:55which is a period of careful
22:57monitoring of prostate cancer.
22:59The second for cancers that are
23:01more aggressive or surgical.
23:02Removal of the prostate.
23:03The third is radiation therapy to the
23:06prostate on the last one is focal therapy,
23:08where we attempt to treat a portion
23:11of the prostate where we believe
23:13that cancer to be localized.
23:15Tonight I'm going to focus
23:17really on these two options.
23:18One careful monitoring of prostate cancer.
23:20The second is surgical removal.
23:22I'll touch briefly on focal therapy
23:24just to give a definition because some
23:26people may be curious about that,
23:28and I'm going to leave you in
23:31doctor McGinnis capable hands to
23:33talked about radiation therapy.
23:35So a question often comes up
23:37about what is active surveillance,
23:39and I've just provided a working
23:40definition for us tonight as the
23:42careful monitoring of prostate cancer
23:44with the intention of preserving
23:46the window for cure.
23:47Should aggressive disease later
23:48be found and what that means is
23:51that we're finding a cancer that
23:53appears to be low grade.
23:54That appears to be not dangerous,
23:56and watching it carefully should
23:58it ever become aggressive?
23:59Or we detect more aggressive features,
24:01we would still have the ability
24:03to offer curate, if local.
24:05Therapy.
24:05We also we of course have to think
24:08about potential benefits and risks.
24:11The benefits involved include
24:12not having treatment,
24:14avoiding potential side effects of treatment,
24:16and the risk include monitoring a cancer,
24:19having awareness of it and a very
24:22low but potential risk of the cancer
24:25progressing while it is being observed.
24:28So who is a candidate for
24:30monitoring prostate cancer?
24:31Who is detected when we think
24:33it's actually about half of the
24:35cancers weed we diagnose are
24:37suitable potentially for active
24:38surveillance and not being treated.
24:40These are private predominantly
24:41men with low risk cancers,
24:43and we make that definition based on having
24:46a low PSA level aloe Gleason Pattern,
24:48which is an estimate of
24:50cancer aggressiveness.
24:51A small amount of prostate cancer,
24:53and no clear evidence of spread
24:55beyond the prostate gland.
24:57Clearly patients who are candidates
25:00for for active surveillance have
25:02to be well informed and able
25:04to attend frequent follow up.
25:06And what do we mean by actress rails?
25:09What does this mean?
25:10It's a protocol where we carefully
25:12monitor we put patients on a plan
25:15that involves PSA testing about every
25:17six months are repeat prostate biopsy
25:19to ensure that we have adequate Lee
25:21staged the cancer imaging of the
25:23prostate using prostate MRI's dimension.
25:25Because it can identify areas
25:27that are concerning.
25:28For high grade disease and regular visits.
25:31And the intention here is to
25:33offer timely curatives treatment
25:34if more aggressive disease is later found.
25:40The second option,
25:41if cancer is more aggressive and
25:43really focusing here on those
25:45cancers that are classified as
25:47intermediate and high risk diseases,
25:48surgical treatment and our objective.
25:50There is to completely remove the
25:52prostate using a robotic assisted approach.
25:55And what is the robotics this
25:57contraption here that we're showing
25:59but essentially involves making
26:00small laparoscopic incisions in the
26:03abdomen and using the surgical robot
26:04to help us more precisely dissect
26:06out the prostate and reconstruct
26:08the urethra and bladder afterwards.
26:11Some of the advantages are less blood loss,
26:13a quicker recovery and a shorter
26:15hospital stay.
26:18And Lastly, focal therapy,
26:20which involves treating a portion of
26:23the prostate gland where we believe
26:25the cancer to be detected and at Yale,
26:27were increasingly relying on MRI
26:29to help make that determination.
26:31Previously we used to decide how much of
26:34the how much of the prostate to treat
26:37based on the distribution of biopsy cores.
26:40But because MRI so reliably identifies
26:42significant prostate cancer we use,
26:44we use that as our road map
26:46for the area to treat.
26:52And Lastly, I'll end with talking
26:54about what we're doing at Yale to
26:57improve the diagnosis and treatment
26:58of early stage prostate cancer.
27:00I think probably the most significant
27:02change has been changed in the
27:04entire paradigm of detection through
27:06the use of image guided diagnosis,
27:08and here is sort of a more
27:10detailed picture describing how
27:12we actually do that diagnosis,
27:13how we how we make that Fusion biopsy occur.
27:17And this is really a two step process,
27:20which I'll highlight briefly where
27:22we obtain an MRI image before,
27:24which is highlighted here and we work
27:26with our radiology colleagues to
27:28identify areas that are suspicious
27:30for prostate cancer.
27:31Then, as the biopsy is occurring,
27:33the urologist creates a 3D
27:35representation of the prostate,
27:36using an ultrasound,
27:37and in the final step we merge those
27:40two imaging modalities together and
27:42help identify the area of concern.
27:44So in this picture,
27:45this Red Square represents the
27:47area we believe to be cancerous.
27:49And the Fusion Biopsy Machine is
27:51going to help us direct our biopsies
27:54with right to this zone to determine
27:56whether or not cancerous present.
28:01And this really does work.
28:03We have found in our data which has been
28:05seen at several other institutions.
28:08This yields to about a.
28:09This results in about a 30% greater yield
28:12of high risk prostate cancer if present,
28:15and also allows us to reduce the number
28:18of low risk cancers that we are detecting.
28:22And the last thing that I'll touch on
28:24briefly is the use of technology and
28:27Genomic classifiers for patients who have
28:29who are found to have prostate cancer.
28:32To help give us more prognostic
28:34information and help us make the
28:36determination of whether cancers
28:37are aggressive or not aggressive.
28:40And here are the results of two Genomic
28:42Classifiers which work by looking at
28:45gene expression levels within a tumor
28:47taken through biopsy to help us make
28:49that determination about whether the
28:51cancer is aggressive or non aggressive.
28:54And this has very practical utility
28:56and helping us decide if a patient is
28:59a candidate for active surveillance
29:00to really be more certain that
29:03their prostate cancer is low risk,
29:05or if it's more aggressive too.
29:08Point them in the direction of more,
29:11more definitive therapy.
29:14So I think I'll end there before I
29:16run over and conclude by saying that
29:18prostate cancer is common in all men.
29:21There are risks and benefits to
29:23screening for prostate cancer that
29:25are that are clear and the decision
29:26to be screen should really occur
29:28within the context of a careful
29:30discussion with the primary care doctor
29:33or physician who knows you well.
29:35There are recent advances in
29:37image guided diagnosis which have
29:39changed the paradigm for the early
29:42detection of prostate cancer.
29:43And the treatment for detecting cancer
29:45should be based on careful consideration
29:47of all the options including monitoring
29:49or active surveillance for candidates
29:50to avoid treatment in situations
29:52where it is unlikely to benefit.
29:55In terms of treatment modalities
29:57surgery radiation therapy and focal
29:59therapy are all effective option.
30:00For men with localized prostate
30:02cancers and are all offered at Yale.
30:05And Lastly,
30:05there are improvements that are constantly
30:07being iterated upon and constantly underway.
30:10In terms of the accuracy of
30:12diagnosis and treatment.
30:13So I will end there.
30:15Thank you for your time and consideration.
30:19Thank you for the invitation Bruce.
30:22Thanks very much. So is with excellent.
30:26China. Share my screen next year.
30:46Let's see, can you see my
30:49screen? There try again.
31:02Can you see the screen now?
31:05OK perfect alright very good.
31:10Start this lunch.
31:17OK. So my talk tonight would be and advances
31:22in radiation therapy, prostate cancer.
31:24Just to reiterate on the medical director for
31:26radiation oncology at Greenwich Hospital.
31:29I came down here about a year ago when
31:32smile came down to enhance services
31:34here in Greenwich and before that I was
31:37up in the Trumbull site for 10 years.
31:39And there's a lot of exciting
31:41stuff that's going on an.
31:43In this space radiation,
31:45so highlight some of those things.
31:48The first thing I want to
31:50show is really just.
31:52A schematic, let me see if I can.
31:55Start the slideshow Gamuda
31:59is having trouble planning to the cartoon,
32:02but that's OK if you look at this.
32:04This picture on the lower right.
32:06This is a picture of the machine that we
32:09have at Greenwich that's made by Co variant,
32:12which is the market leader
32:13and British equipment.
32:14It's called the true beam and this part here.
32:17Hope you can see my cursor is where
32:19the patient lies an this I'll see
32:22shaped object is really the radiation
32:24machine with some of the power of it
32:26coming from behind and the this area.
32:29Here is the treatment head
32:30and their radiation.
32:31Comes down in this direction and we can
32:34spin this machine around the patient
32:36and we can move this this couch that
32:38we can approach the treatment site
32:40from many different angles and with
32:42using a lot of different shapes.
32:47If we look here, actually come back.
32:49If you look at that,
32:50this portion is treatment head.
32:52If we zoom in in your to
32:54look up into that head,
32:56you would see an object looks like this.
32:58It's called an LLC or a multileaf collimator.
33:01And what this is is a
33:02bunch of very thin leaves,
33:04metal leaves and satisfied.
33:06They usually made of tungsten or
33:08tungsten alloy that are very thick
33:10there about 3 inches thick but very
33:12narrow and as you can see this as this
33:14strange Oval oblong shape and we.
33:16Create any shape we want within
33:18that to conform to the target,
33:20and people often ask you
33:22when they come for radiation,
33:23whereas there was there lead blanket
33:25like they get in the dentist office.
33:27We explain that there's no lead
33:29blanket on you because the radiation
33:31that we use is in the Mega Voltage
33:34range of energy and at the dentist
33:36offices kilovoltage SAR radiation
33:37is 1000 times more powerful and
33:39they go through or left blank.
33:41It no problem.
33:42So what we have instead is the
33:44equivalent of a very thick lead blanket.
33:47About 3 inches.
33:48That's up in Heaven machine,
33:49so that's really what's creating
33:51not only the shaping for how we're
33:53trying to get to the target,
33:55but how we're protecting you.
33:57In the Roman this is there have
34:00been advances in the.
34:01In the speed that these leaves
34:03can move and how thin they can
34:05be in how broad the fields are.
34:09If we look at instead of
34:11from the side of machine,
34:12if we look in the lower right corner here.
34:15If you look face on at the machine you
34:17see here again as the treatment head,
34:19but on the sides there are two arms
34:21that can extend and this has what's
34:23called a cone beam CT and it comes out
34:26when you first put the patient on the
34:28table and it spins around and we get
34:30really what looks like a cat scan image.
34:32And so if you look at this image here
34:34with this is what's called an axial
34:37slices a slice through a man's pelvis.
34:39From side to side,
34:40let's say along the Beltline and
34:42when you look at these images
34:43this they seem to be reversed,
34:45in that it's likely looking someone
34:46from their feet towards their heads
34:48so the left side of the screen is
34:50actually the right side of the person
34:51and the left side is the right side.
34:53And this down here is the back
34:55and here's the front.
34:56These objects on the side are the hips.
34:58This is the pubic bone he ran right in
35:00the center with these circles around.
35:02This is the prostate.
35:04In the process,
35:05he has 123 White appearing objects,
35:06which are actually fiducials or markers
35:08are helping us to track the prostate
35:11and behind it is the rectum and if we
35:13scrolled up then on top like Doctor
35:15Lehman was pointing out his picture
35:17is the bladder and So what we can
35:19do is take a planning scan before
35:21someone ever comes to treatment.
35:23We do a planning scan where we create
35:25a certain trem position and we start
35:27to map out how we're going to design
35:30these beams and then when they come
35:32for the daily treatments we can take
35:34this cone between image and fuse it.
35:36With the treatment planning image
35:37and see just how on target we are and
35:40make adjustments and on that day for
35:42example for prostate case we can check
35:44whether the bladder filling is is suitable,
35:46that there's any gas in the rectum
35:48that is too much for that day.
35:50Is there any tip or role of the pelvis
35:53mean to account for and ultimately
35:55we use these gold markers too?
35:57To do some fine fine tuning what
35:59I'm bout millimeter submillimeter
36:01accuracy and so in this view here
36:03the picture which is in the top left
36:05in the lower right is the original
36:07cat scan and the top right and
36:09lower left are the cone beam CT.
36:11So you can see that the image
36:13quality is not exactly the same
36:14but it's very very very very close
36:17and so this is what this is.
36:18One of the key things it's allowed us to be
36:21much more accurate with radiation treatment.
36:24And to really be be confident that
36:26we're on target each day so when we tell
36:29people when you come in get treated,
36:31we will not treat you unless
36:33we're totally satisfied that
36:34we're on target.
36:35We can get you off the table,
36:38reposition, do whatever we need to
36:39do to make sure that we're totally
36:41satisfied before your treatment.
36:43So that's been a very nice advance,
36:45and our ability to to put higher
36:47doses to the targets while maintaining
36:49or improving side effects.
36:51Along with that and going back to that,
36:53Mercier that Multileaf Collimator.
36:55We have been able to advance really
36:57the style of the radiation that spit
36:59out by the machine is ultimately the
37:01radiation is going to positive dose
37:03or an energy and that issue and we
37:05would love to minimize the normal
37:07tissue that's getting that dose.
37:09But X Rays are X Rays,
37:11so they'll enter you and go straight through,
37:13depositing those all the way along.
37:15They lose their powers.
37:17They go through,
37:18but they're still going through and through,
37:20so we have to be creative and work
37:22with our physics crew to figure
37:24out how to make this better.
37:26So on the left side of the screen
37:29you have something which was
37:30in advance in our field,
37:32maybe 2025 years ago is called 3D conformal.
37:35And what you did in this case,
37:37this is someone who is being treated.
37:39For cancer of the esophagus and so this is
37:42the heart and the black areas of the lungs.
37:44And this is the spinal cord here
37:46and in the center of the target.
37:48And the color is called the Copler Wash,
37:51and it's corresponds to certain
37:52amount of dose is being used to
37:54the reddish color is higher dose,
37:56and the teal is medium,
37:57and the blue is lower dose.
37:59And in this case they took one
38:01beam coming in from the front
38:02and one being from the back and
38:04actually two beams from the side
38:06he see his little Speck of blue.
38:08That's all the way over here.
38:11And you can see it's concentrating
38:13those fairly well here,
38:14but you have a lot of dose to the heart,
38:17for example,
38:18and coming back by the spinal cord.
38:20And this fundamentally was limiting.
38:22How much dose that we could really deliver?
38:24Then you come to the right,
38:26which is a much more modern
38:28technique called intensity modulated
38:29radiation therapy for IMRT.
38:30In this is really using the
38:32full power of the machine.
38:34This is is figuring out which well
38:36I should say using multiple angles,
38:38not just one 2, three or four angles.
38:41We can in fact treat people
38:42with a full 360 degree arc,
38:44treating all the way around,
38:45and we can also use that M else
38:47or that multi leave collimator to
38:48change the shape and the intensity
38:50of the beam at each of those angles.
38:52And so we put all that together.
38:54You get a much more refined dose,
38:56distributions you have the same same colors.
38:58Here we can see there's nothing off
38:59on the sides is really very little.
39:01If anything touching that spinal canal there.
39:03There's still a little bit in
39:05the heart because the
39:06heart is right next to
39:07solve this in this case,
39:08but it's much more concentrated,
39:10so again you have a safer treatment.
39:12More accurate and allows us if
39:14needed to to go to higher dose.
39:18Another technique which is become much
39:20more common and popular in the last,
39:23maybe 5 to 8 years is called stereotactic
39:25body radiation therapy or SBRT and
39:28this goes by bunch of different names,
39:30SP, Arty, of course is one of them.
39:33Saber is another or stereotactic
39:35ablative radiation therapy,
39:36an one machine that's become quite famous
39:38that uses definitions called cyber
39:40knife so lot people seen advertisements
39:42for cyber knife on billboards or
39:44on the radio or what have you.
39:47And there are many machines that we
39:49can do SB art, but the core of it.
39:52This is kind of a wordy exclamation here,
39:55but really what it is is you're using hyper
39:58precise treatment over a very limited number.
40:00Treatments instead of I'll talk a
40:02little bit more about this in a minute,
40:04but instead of bringing people
40:05for multiple weeks of treatment,
40:07you bring them for three.
40:09Four or five treatments,
40:10usually 5 treatments.
40:11In the case of prostate and get all
40:13the treatment done and just those
40:15five now to get the power of five
40:17treatments in what would usually
40:18be a multi week treatment.
40:20Those trees have to be much
40:21more powerful per session.
40:22So that means that our burden of
40:24being extra accurate and really
40:26precise goes up even more and see
40:28if you see these pictures down here.
40:30Now we have an IMRT plan of prostate
40:32so to look at the anatomy again
40:34here the hips on the side.
40:36Pubic bone rectum.
40:36Here I'm going to talk a little
40:38later about what this.
40:40Pink object is but here we have the prostate.
40:43And you can see if that same kind
40:45of color wash that there's really no
40:48significant doses off on the side.
40:50It's all concentrated right in here,
40:52and the image on the right is an image,
40:54as if we were looking straight
40:56through from front to back,
40:58and so here in yellow is the bladder
41:00was the rector right behind?
41:02This is the base of penis.
41:04Here we have going here.
41:05And so again,
41:06you can see very little dose going to
41:09the rectum. The bladder is nicely spared.
41:11Lot normal tissues will be spared.
41:13Using IMRT or SBRT.
41:18One thing that gets certainly a
41:20lot of press and a lot of interest
41:22from patients is Cyberknife,
41:24which we talked about there and protons.
41:26I'll skip over to siren,
41:27siren mentioned cyber knife.
41:29If you look at this machine you can
41:31see the shape is totally different
41:33than the one I showed you before,
41:35but with the true beam.
41:37This portion here is actually a
41:38miniaturized version of that machine
41:40and it's attached to a robot arm.
41:42Actually a similar robot to
41:44what's used to help build cars,
41:45and it allows this this race machine to be.
41:48Manipulated in a lot of different
41:50spaces throughout the room,
41:51and ultimately it comes out
41:53as a little pencil beam.
41:54Instead of having that
41:56multileaf collimator idea.
41:57And this machine.
41:58The reason it's become somewhat synonymous
42:00with certain radiation treatments for
42:02prostate is it was the earliest machine
42:05used to treat prostate with Esport.
42:07Now the fields advance so that our machine,
42:09the true beam and many others
42:11can do us party,
42:13but you'll still see some offices
42:15and some some advertisements.
42:16Just calling it cyber knife instead
42:18of the stereotactic treatment.
42:20But it's very nice machine for what it does.
42:23It's not a very flexible machine,
42:25they can't do broader treatments or.
42:27It's not good for longer durations,
42:30but it's it's very good for small treatments.
42:34Protons is Holder.
42:35Exciting thing.
42:36Protons are very,
42:37very expensive machines that are
42:40growing in number in the US were
42:43still fairly limited because of their
42:45cost and to install onto to maintain.
42:48And they have a different physics property
42:51in terms of how they deposit dose.
42:55And before I am RT came along
42:57Protons really had a dose advantage
43:00in treating prostate cancer
43:01compared to the older 3D technique.
43:04But once we got I Marty,
43:06and that's where teen is other things.
43:09Now we're really able with machines like
43:11the true beam to give the same kind
43:14of dose deposit as Proton Machine does.
43:16So we're not right now for
43:19protons versus photons.
43:20We're not really seeing any significant
43:22difference in the outcomes and on
43:24the cure rate on the side effects,
43:26but but it is an area of active research
43:29because there are some exciting physics
43:32properties of machine and and as a.
43:34Radiation feel we're looking to see
43:36which which cancer types might benefit
43:39from that which don't really need it,
43:41and how to harness that power.
43:44But for now, for prostate,
43:46really,
43:46there's no no advantage protons or
43:48photons or photons over Protons.
43:52So diving a little bit more into the you
43:55know how we use radiation, prostate cancer.
43:57There really are three settings I'm going
44:00to touch on two of them. One is intact.
44:02Prostate may have been diognosed.
44:04No surgery is taking place.
44:06You're deciding whether to do surgery that
44:08really options doctor Lehman mentioned.
44:10Is it active surveillance surgery,
44:11radiation or focal therapy? And.
44:15There are within this round
44:17there really two major options.
44:19One is external beam radiation
44:20which is used in conversations.
44:22I've been showing where there's
44:24nothing inserted that's radioactive.
44:25You're just getting X Rays or
44:27protons fired from a distance,
44:29and then you have breaky therapy,
44:31which is usually a radioactive seed implant.
44:33Most of the prostate radiation being done.
44:35the US these days is external beam,
44:38although there are some some
44:39specially sentence that you break
44:41you therapy and within the external
44:43beam world there really are three.
44:45Basic approach is there is that I am RT
44:48have been referring to which for this
44:50settings usually 40 to 45 treatments.
44:52Those are done as 15 minutes per day,
44:54five days a week.
44:55So you're talking about 8 to
44:579 weeks of therapy.
44:58Then you have something which
44:59is a bit of a mouthful,
45:01but it's called moderately
45:02hypofractionated by Marty.
45:03This is using a little bit
45:05higher dose per day,
45:06but shortening the treatment
45:07to 20 to 28 sessions,
45:09and then you have this party that I was
45:11just mentioning with the five treatments.
45:15I won't speak tonight about and
45:17less people have questions.
45:18I'm happy to answer in the Q&A,
45:20but I don't have any slides on how we're
45:23using radiation after prostatectomy,
45:24although that's an exciting area
45:26where if there seems to be prostate
45:28cancer recurrence after surgery,
45:30we can often come in and try to
45:32salvage things with some radiation
45:33dose and the other setting.
45:35I will talk about is all ago meta static.
45:39It really well. This is for news.
45:42Metastatic cancer is where it has
45:44spread beyond the prostate usually.
45:45What type of bones?
45:47In the case of prostate cancer and
45:49all ago means really just a few.
45:52So instead of there being 15 or 20 spots,
45:55maybe there's only one spot
45:56in about one or two.
45:58And is there something we can
46:00do to go after those spots?
46:02Just very limited?
46:03So I speak from about this moderately
46:05hypofractionated radiation.
46:06So this is something that
46:08was used more in the UK,
46:10Canada.
46:10Some other European countries and is
46:12relatively new Comer to the USA Lot
46:14brand new and like I was mentioning,
46:16the whole idea is you know can we
46:19bring men for fewer than 8 to 9 weeks
46:21while still having a great toxicity
46:24profile to integrate cure rate.
46:26And the short answer is yes,
46:27you can do that.
46:29The side effect profile between
46:30that long course and I'll call this
46:32the medium course is very similar.
46:34It might have a slightly worse
46:36set of urinary side effects,
46:37meaning a little more urgency or
46:39frequency of urination or a little
46:41bit more of a burning sensation,
46:43at least temporarily during treatment.
46:44But overall very similar.
46:46And the bowel issues.
46:47Any loose stools or things that nature
46:50that we sometimes get looks to be identical.
46:52So it seems like for most men
46:54that it's a very nice trade off
46:56in terms of more convenient but
46:58not really trading anything in
47:01exchange for being more convenient.
47:03And in fact the NCCN guidelines.
47:05Again,
47:05the Doctor Lehman was referring
47:07to earlier when you look at
47:09this section for radiation,
47:10they now updated that to say
47:12that this this medium version is
47:14moderately hypofractionated is
47:15really the preferred approach.
47:17For external being for treating
47:19intact prostate cancer.
47:20Interesting Lee with kovid you know
47:23we have been looking for ways of
47:25course to make things safer for
47:27patients and one of those things is
47:30keeping you out of medical centers.
47:32So this has been another reason
47:34why there's been a much more rapid
47:36adoption of this technique than
47:38we normally see because patients,
47:40family members and physicians and
47:41medical centers all been really
47:43aligned to your.
47:44How can we make this safer and shorter?
47:47And so this this data that's around,
47:49you know it's really.
47:51Really great tab on hand.
47:52Now we know we have to bring you
47:54free to 9 weeks except in very
47:56selected cases we can get the job
47:58done in more like 4 to 5 weeks
48:00or four to five and a half.
48:04All of the meta static,
48:06so this is a little bit of a busy slide,
48:09but I'll break it down
48:10into the top and bottom.
48:12So like those mentioned,
48:13although metastatic is,
48:14it is spread somewhere else,
48:15but to a very limited degree.
48:17And years ago this is something where we say,
48:20Well, you know it's already escaped,
48:22were really just.
48:23You know, kind of playing defense
48:25here and see what we can do now.
48:27I think here from Doctor Patrylak
48:29about how we're getting more aggressive
48:30with meseck disease in general,
48:32but when we look at all
48:34going to stack would say,
48:35you know what?
48:36What about getting more aggressive
48:37with disease that's around?
48:38And so we have to really good
48:40trials and looked at that one
48:42was called the Stampede trial.
48:43Just came out recently and
48:45it showed that if we go back,
48:47even if you have spots outside the prostate,
48:49their limited if we go back and treat
48:52the prostate for 20 treatments.
48:53We can have an overall survival benefit.
48:57And you know that was something
48:58have been possibly for many years.
49:00But now we have the data says yes,
49:02we absolutely can do that,
49:03and it's actually a little bit lower
49:05dose that then we would use for
49:07an earlier stage prostate cancer.
49:08So we know that men tolerate
49:10it really quite well.
49:11And it has the survival benefit.
49:13So we're starting off with that a lot more.
49:16And the other question is, well,
49:18if you're going to the prostate,
49:19what about those two bone spots?
49:21What should you do?
49:22An are feeling was well,
49:23I think it makes sense to treat those,
49:26but we didn't have the data.
49:27Now we have some data.
49:29It's called the Oriole trial,
49:30and by going after those several spots
49:32with more aggressive treatment like that SPR,
49:34so very focused high dose treatment,
49:36we are able to show a
49:37progression free survival,
49:38meaning that you're not just alive,
49:40but things are being held in check.
49:43So very exciting application of
49:45this fancier version of radiation,
49:47really trying to help out in
49:50the oligo metastatic setting.
49:52Next time we talk about space or gel.
49:55So this was that purple object
49:56was referring to on priceline.
49:58We have been looking into field for years.
50:00Something to help protect the rectum.
50:02Because if you look at this figure here,
50:05which is against some of the
50:06one doctor Lehman,
50:07it showed you have the rectum
50:09in the prostate.
50:10This is looking like slicing from
50:12straight from the front to the back.
50:14They recommend process usually touch each
50:16other and seeing different view here.
50:18So any dose were going to prostate
50:20at least the front bar.
50:21The rectum will get that same dose.
50:23So the higher we went with the
50:25curative dose to the higher the
50:27rectum got its dose and we were
50:29really looking to bring that down.
50:32And finally we have a product
50:34called space or gel.
50:35It's a biodegradable gel.
50:37It's inserted by the urologist between
50:39the prostate in the rectum.
50:40It stays there for three months
50:43and then dissolves back to
50:44water over another three months.
50:46Very well tolerated.
50:47It's done using a little bit of anesthesia
50:51and it has really helped tremendously
50:53to get our dose the rectum down.
50:56And the last time for me is just
50:58just to point out quickly those
51:00gold fiducials I've shown earlier,
51:02again with this cone beam CT look here,
51:04we often use gold,
51:05but other products are there about
51:07the size of a grain of rice,
51:08and so we ask our colleagues at
51:10Doctor Lehman to do is before
51:12coming for radiation planning.
51:13Will have them put in three or
51:15four of these gold markers and
51:17the jail as part of 1 procedure.
51:19And then they come to us for that
51:21radiation planning and we take it from there.
51:24That's all my slides in the app
51:26and he can answer questions later.
51:31I appreciate your attention,
51:34let me. Stop showing slide.
51:42Stop sharing very good.
51:43So let me introduce radio happy induced
51:46doctor Petra Lack is our last speaker.
51:48He's a professor of Medicine
51:50and urology and Co.
51:52Leader of the cancer signaling networks
51:54research program at the Yale Cancer Center.
51:57He received his medical degree from
51:59Case Western Reserve University and
52:01joined the Yale faculty in 2012.
52:03He is a pioneer in the research
52:05and development of new drugs and
52:08treatments for prostate, bladder,
52:09kidney and testicular cancer.
52:12For patients fighting these types of cancers,
52:13he finds recent developments in
52:15the field of immunotherapy it
52:16to be particularly promising.
52:18And he's a national leader in
52:19clinical trials for men with
52:21prostate and bladder cancer,
52:22so I'll turn it over to Doctor Patrylak.
52:27Thanks Bruce. So I guess we have to share
52:30a screen here just while we're doing that.
52:33Was that Carnoustie in your
52:34last slide look like Scotland?
52:37Andrews OK, I was close. I was closed.
52:40I had the good pleasure of playing
52:42on Saturday and Sunday with the
52:44young man who was 63rd in the world
52:46who missed the cut at the US Open.
52:49An man that's on another level so.
52:52But it was a lot of fun.
52:54So how do I just hit the share screen here?
52:56Yes, exactly.
53:01If I can not get too many
53:03things here, let's see.
53:09Ann, you're all set. You
53:11can just OK. I just go ahead terrific.
53:14OK, so it's really great hearing
53:16the two lectures from Doctor
53:17Mcgibbon and Doctor Lehman.
53:19Good friends and colleagues and
53:21what I really would like to focus on
53:24since this is a talk that's for the
53:27community and for patients is how
53:29we think about prostate cancer from
53:31a medical oncology standpoint and.
53:35What I'd like to talk about
53:37first is how we all interact,
53:40and it's important that your
53:41urologist and Oncologist communicate,
53:43and we at Yale like to look at
53:45this in terms that we call the
53:48multidisciplinary approach,
53:49which involves all treating
53:50clinicians for you.
53:51For the patience urologist medical
53:53Oncologist, Radiation Oncologist,
53:54and also your primary care docs as well.
53:57Because some of these treatments that
53:59you're going to receive have implications
54:01in terms of your bone health in
54:03terms of your cardiovascular health.
54:05And it's important that we were able to
54:08focus on that to give you the best care.
54:11And that's actually been proven in
54:13two different institutions where
54:15they have multi display clinics.
54:17Doesn't have to be a physical clinic,
54:20but the conditions should be communicating.
54:23So Jefferson they found that there was
54:25a better survival rate for patients with
54:29advanced prostate cancer compared to
54:31patients who were in the general population.
54:34Jefferson uses a multidisciplinary approach,
54:36same thing with University of Colorado.
54:39Both institutions have demonstrated this.
54:41That's why it's so important for physicians
54:43to work together to communicate.
54:45So we want to optimize
54:47their patients outcomes.
54:48We want to improve access
54:50to specialty therapies.
54:51We want efficacy and patient
54:53and clinician schedules.
54:54We want to coordinate,
54:55care and want to improve provider
54:57communication with the patients through
54:59the entire course of the patient.
55:01Survivorship and that includes the team
55:03of nurses and nurse practitioners that
55:06work with each individual physician.
55:08So what's my role as a medical Oncologist?
55:11The management of your logical cancer.
55:13So what I do is I'll assess the
55:15need for additional therapy in the
55:17treatment of your logical malignancy.
55:20So if Doctor Mcgibbon has a patient
55:22who has localized prostate cancer
55:24as you mentioned before,
55:25whether this is Olga metastatic
55:27disease or localized disease,
55:28and they need hormone therapy or
55:30the treatment in addition to their
55:32hormones to their radiation therapy,
55:34we administer that same thing with
55:36Doctor Lehman. We help decide where.
55:38Whether the patient needs additional
55:40treatment post operatively,
55:41such as a lymph node,
55:43positive patient after they've had
55:45their prostate cancer out and we
55:47want to integrate the specialist
55:49to deliver the best care.
55:50As we're seeing now,
55:52the pathologist is also playing
55:53an extremely important role in the
55:56management of advanced prostate cancer
55:58and will talk about why you should
56:00be asking your doctor about whether
56:02you have molecular marker testing
56:04that for your prostate disease.
56:06Why Glenn at Greenwich Hospital
56:08Yale Cancer Center.
56:09We have access to personalized care.
56:11We interact Urology,
56:12radiation oncology and pathology and
56:13medical oncology all work together.
56:15We have a weekly tumor board and
56:17one of the jokes that we had rather
56:19than having a multi spring clinic,
56:22we have multiple display office
56:23where Doctor Lehman is down the Hall.
56:26From the Doctor Kohlberg,
56:27one of our surgeons, doctor Kenny.
56:29We're all in the same place and we
56:31often can't converse late at night to help.
56:34Best take care of our patients.
56:38What's the problem?
56:38We know that prostate cancer is one of the
56:41most commonly diagnosed a cancers in men,
56:44it's 28% of all cancer diagnosis.
56:45There is a bit of discordance because
56:48it's only about 10% of cancer deaths.
56:50It's the second leading cause
56:52of cancer death in men,
56:53but 30,000 men will die from
56:55metastatic disease every year.
56:57I think it's important to note in
56:59this I don't want to scare anybody,
57:02but it's important to note that this disease
57:05is not curable once it spreads outside,
57:07but it's controllable and we
57:09can have patients live 510 years
57:11with good quality of life.
57:13Good functional activity.
57:14And able to see their grandchildren
57:17graduate from college or to enjoy
57:19their retirement to do other things.
57:21So it's important again to define what
57:25the goals of care are for our patients.
57:29We're moving into a new era
57:31in prostate cancer,
57:32and this is different than the way we've
57:35been thinking about the disease in the past.
57:37Breast cancer and lung cancer.
57:39The tissue biopsies are obtained
57:41are often looked or interrogated for
57:43molecular markers such as her two neu
57:45and a woman with breast cancer and alk.
57:48EGFR in lung cancer.
57:49These are all terms that if if you
57:52have gone through this disease
57:54process you'll you'll know,
57:55but but again, prostate cancer,
57:57we really did not have molecular markers.
58:00Now we do one of the big problems
58:02with this disease is majority of
58:04patients have disease in bone,
58:06so it's difficult to obtain tissue,
58:08sometimes through biopsy,
58:09and we can do that,
58:10but but it may be a little bit more work.
58:13We're developing newer treat
58:15ways of doing this,
58:16and this includes looking at plasma DNA,
58:18circulating tumor cells,
58:19and then novel ways of imaging such
58:21as pet scans or or novel agents that
58:24potentially can detect the disease earlier.
58:28This slide reminds me the fact
58:30that all cancer is genetic,
58:32but not all cancer is hereditary
58:34because they can be mutations
58:36in the germline that are passed
58:38down to patients and Bracha is
58:40one that is really important,
58:42not only for treatment but
58:44is also for prognosis.
58:45An again why we want to think about
58:48the integrative approach because
58:49if you identify Bracha germ lines
58:52in a prostate cancer patient and
58:54that's about 2% of all patients
58:56with localized disease and 10%.
58:58Of patients with disease that spread,
59:00you also want to taking care
59:02of the family as well.
59:03The sister, the daughter of the Suns,
59:06those and the mother, and the father.
59:08All those are involved in germline
59:10mutations and need to be assessed in
59:12terms of their risk for other cancers.
59:14So again, it's it's large.
59:17It's a family that you're taking care of.
59:20Braka is now in the news because
59:22there are two FDA approved drugs.
59:24Elaborate or cap rate for this disease.
59:26This is a gene mutation that's
59:28involved in DNA repair.
59:29Why is the enable reportedly repair
59:31important when you divide yourselves,
59:33you make another copy of the DNA.
59:35If that copy is not the same copy,
59:38or if there are mistakes of that copy,
59:40you can't edit it out.
59:43If you can edit it out,
59:45those mistakes can translate
59:46themselves into mutated proteins,
59:48so prostate cancer tends to be
59:50more aggressive if you have Braca,
59:52and also, as I mentioned before,
59:54you've gotta look for other
59:57cancers and other family members.
59:59This slide looked.
01:00:00Demonstrates the relative risk of
01:00:03different cancers in those patients who
01:00:05have brocker one or Braca two mutations.
01:00:08These include.
01:00:11Breast cancer, Melanoma,
01:00:12pancreatic cancer,
01:00:13no varian cancer.
01:00:15The other marker that we're looking for
01:00:17as well is microsatellite instability,
01:00:20and this is something that's involved in,
01:00:23again, DNA repair.
01:00:24And a way that we correct the DNA,
01:00:28corrects errors and and of course
01:00:31mutated proteins.
01:00:32So if something is unstable or if you
01:00:34have a patient's microsatellite instability,
01:00:37the proteins that come from that particular.
01:00:42Transcription can be mutated
01:00:43and then if there mutated,
01:00:45the body recognizes them as being abnormal,
01:00:48and if they're unstable,
01:00:49you've got a higher rate of having
01:00:51these particular mutated proteins.
01:00:53That makes you likely to respond
01:00:55to immunotherapy,
01:00:56and there's an FDA approved drug
01:00:58pembrolizumab that is that can be
01:01:01administered patients with prostate cancer.
01:01:03Unfortunately,
01:01:03it's only about 3% of all patients.
01:01:06But remember,
01:01:0710% Baraka,
01:01:0810 to 20% DNA repair mutations
01:01:11and in 3% with microsatellite
01:01:13instability you should be asking
01:01:15your doctor these questions.
01:01:16Do I have these particular mutations because
01:01:20the treatments can be life changing.
01:01:23So generally,
01:01:24how do we treat advanced prostate
01:01:26cancer while taking testosterone away?
01:01:28Prostate cancer cells die.
01:01:29This is done by giving a drug that
01:01:32interferes with testosterone production.
01:01:34This can either an antagonist or an agonist.
01:01:37You may have heard of drugs
01:01:40such as Leuprolide dega relics.
01:01:42All of these drugs will lower
01:01:44testosterone levels and this
01:01:45is called Andrew blockade.
01:01:47As I mentioned before,
01:01:48this will control the disease,
01:01:50but it will not cure it.
01:01:54The target is still there.
01:01:56That's the androgen receptor.
01:01:57Imagine if you will a lock and key situation.
01:02:01The Receptor is the is the keyhole.
01:02:03Testosterone is the key and if you turn
01:02:06that key then the cells divide and can grow.
01:02:10Now what we do, of course is with
01:02:13the androgen deprivation therapy.
01:02:15Take the keys away,
01:02:16but prostate cancer can be smart and it
01:02:19can learn to make its own testosterone,
01:02:22or it can change that keyhole such
01:02:24that different ligands are different.
01:02:26Keys can fit in and activate it,
01:02:29so this is one way that
01:02:31patients become resistant.
01:02:33And this slide shows the Natural
01:02:35History of what happens.
01:02:36And we have the initial diagnosis that
01:02:39may be made and treatment by Doctor
01:02:41Leaf and or Doctor Mcgibbon and then
01:02:44patients certainly can progress.
01:02:46We may want to administer hormone
01:02:48therapy and then over a period of time.
01:02:51This will respond.
01:02:52The PS days will drop rapidly.
01:02:55Symptoms will improve,
01:02:56but then you develop something
01:02:58called the castration resistant
01:03:00state where the testosterone is
01:03:02left less than 50 and patients then
01:03:04begin to have progression by bone.
01:03:06Or progression by PSA or in soft tissue.
01:03:11How do we treat that?
01:03:13We have a variety of different
01:03:15agents that we can administer.
01:03:17I mentioned before for MSI
01:03:19high pembrolizumab is something
01:03:20that's administered,
01:03:21but there are proper drugs such as
01:03:24Sipuleucel T which is otherwise
01:03:26known as Provenge.
01:03:27That's an immunotherapeutic agent
01:03:29that we administered to patients
01:03:31that will make patients live longer,
01:03:33but generally does not result in a
01:03:35drop in PSA or a improvement in soft tissue.
01:03:39We think it just simply slows
01:03:41the disease down.
01:03:42There are other hormonal agents.
01:03:44Enzalutamide or Extendi Apalutamide are
01:03:47ludum I'd Abiraterone Uhrzeit Eager.
01:03:49These are all FDA approved their
01:03:52cytotoxic agents such as docetaxel
01:03:54or cabazitaxel than their DNA
01:03:57damaging agents such as radium 223,
01:04:00and then elaborate benro cap rip.
01:04:04The real trick here is how do
01:04:06you sequence these?
01:04:07Because these treatments do
01:04:08wear off after periods of time,
01:04:10and you know the numbers that
01:04:11I have your average numbers,
01:04:13but there's some patients who may get
01:04:15years worth of benefit out of these drugs.
01:04:17And again,
01:04:18how do we select them and understand
01:04:20who is the best patient to
01:04:23receive a particular treatment?
01:04:24What are the things that we're working on?
01:04:26Yale is a new class of drugs
01:04:29called a pro tec.
01:04:30And this is a way of overcoming
01:04:33resistance to hormonal therapy.
01:04:35So we have proteins in our body.
01:04:38We dispose those proteins as they
01:04:42become older as they become.
01:04:45You know not viable an there is a
01:04:47system that basically is a garbage
01:04:49scavenger or protein and that's
01:04:51called the ubiquitin ligase system.
01:04:54And basically what this system does
01:04:55is it recognizes a protein that may be old,
01:04:58it tags it.
01:04:59And then it degrades it.
01:05:01Sort of like a garbage collector.
01:05:04Well, Craig Cruz at Yale has developed
01:05:06a drug that accelerates that process.
01:05:08It's called a pro Tech and a pro
01:05:11tec combined to a disease causing
01:05:13proteins such as the Andrew Receptor
01:05:15and then accelerate that process an
01:05:18degrade that protein more rapidly than
01:05:20it would be in a normal situation.
01:05:23And in fact, one protag molecule can
01:05:25degrade 400 engine receptor proteins.
01:05:27So this is a completely new
01:05:30way of approaching.
01:05:31Prostate cancer and will right now in phase
01:05:34one trials of this particular compound.
01:05:36We presented our preliminary data
01:05:38at Asco this year. And we did it.
01:05:41We were doing a dose finding study.
01:05:44We are looking also at different
01:05:46correlates from that issue.
01:05:47In fact,
01:05:48we've actually demonstrated that the
01:05:50androgen receptor is downregulated in human
01:05:52tissue after we administer the Protag.
01:05:54The first patient was entered
01:05:56at Yale in August of 2019,
01:05:58and we reported at the
01:06:00Asco meeting this year,
01:06:01which is the annual meeting that
01:06:03we had two responding patients in
01:06:05patients who had mutations that were
01:06:08susceptible to that particular pro tech.
01:06:10And the drug is called ARV 110,
01:06:13so we're very excited about these
01:06:15preliminary findings were moving forward
01:06:18with this in a more expanded study.
01:06:20But this is something about
01:06:22the uniqueness of Yale.
01:06:23We're able to go from the laboratory
01:06:25to the patient and take some of
01:06:28these new drugs and move forward.
01:06:30Two of the other things that we're
01:06:32working on right now in collaboration
01:06:34with other institutions are some of
01:06:37these newer molecules called bites.
01:06:39And with a bite is is an antibody.
01:06:43As you know,
01:06:44an antibody recognizes farm proteins,
01:06:46foreign viruses,
01:06:47and there's a specific binding site on
01:06:50that antibody that is used for recognition.
01:06:53Well,
01:06:53there's a bispecific or two part
01:06:56antibody that is designed to Recognise
01:06:58something called prostate specific
01:07:01membrane antigen or prostate stem cell
01:07:03antigen and then bring that closer
01:07:06to the immune cell and then cause a.
01:07:10A reaction and basically healthy
01:07:12immune cell kill cancer cells.
01:07:15These are one of the new generation
01:07:17of therapeutics that we're moving
01:07:20forward with at Yale and then also
01:07:23collaboration with our colleagues in
01:07:25radiation oncology in nuclear medicine.
01:07:27But start looking at drugs that that
01:07:30basically target something called
01:07:32PS may and link antibodies or small
01:07:35molecules to radioactive isotopes that
01:07:37will delight directly deliver isotopes.
01:07:40Two,
01:07:40the cancer cells there are bone
01:07:42targeted isotopes like radium 223,
01:07:44Witch Doctor Mcgibbons collaborates and I
01:07:47collaborate on to administer to patients,
01:07:49but that only targets bone and
01:07:51we're looking to target more
01:07:53extensive areas such as soft tissue,
01:07:55perhaps liver metastases as well,
01:07:57and there are drugs that are
01:07:59about to be approved by the FDA
01:08:02that are targeting and focusing
01:08:04on this particular area.
01:08:06So in conclusion,
01:08:07we're excited about what we're
01:08:09seeing at this Cancer Center on
01:08:11the leadership of doctor folks,
01:08:13and we thank him greatly for these
01:08:16opportunities that we have to treat our
01:08:18patients and bring new drugs forward.
01:08:20But the multidiscipline approach is,
01:08:22I think, the best way to improve
01:08:25prostate cancer survival.
01:08:26All of advanced prostate cancer
01:08:28patients now should be sequenced
01:08:29prior to starting treatment to
01:08:31evaluate these patients for markers
01:08:33to treat their advanced disease.
01:08:35And right now we are looking at.
01:08:38New agents in new targets and
01:08:40finding the optimal sequence of
01:08:42these drugs to move forward.
01:08:44One other study which I didn't mention,
01:08:46which I'm very, very proud of.
01:08:492004, I was behind the approval of docetaxel
01:08:51for castrate resistant prostate cancer,
01:08:54were now combining docetaxel
01:08:55with Pember Lizum app,
01:08:57which is an immunotherapy agent.
01:08:58And that's going in that's going
01:09:01forth in an international randomized
01:09:03trial which were helping to lead.
01:09:05So there are very many opportunities
01:09:07we welcome.
01:09:08Your input and questions and I
01:09:09thank you for your attention.
01:09:14Excellent thank you doctor. Pepper Jack.
01:09:17Now is a great time if anyone has
01:09:20a question they can type it in to
01:09:22the Q&A portion C1. One question.
01:09:24There's so far to get to in a second,
01:09:27but I would just ask question my
01:09:29own for Sanford. For Doctor Lehman,
01:09:31the for image guided biopsy,
01:09:33I'm just curious what.
01:09:35This was a man comes you with
01:09:37an elevated PSA. How?
01:09:38What percentage of the time
01:09:40are you getting an MRI if one
01:09:42hasn't been done and how?
01:09:43From using MRI guided biopsy as the first
01:09:455C as opposed to traditional biopsy?
01:09:47Without that as your first bias?
01:09:50Thank you so much, Bruce.
01:09:52That's an excellent question,
01:09:53so we we're really trying to do an
01:09:55MRI guided biopsy whenever possible.
01:09:57The rationale for that is that number one.
01:09:59It improves the diagnostic.
01:10:01Accuracy of that biopsy.
01:10:02Historically, 40% of men who had an
01:10:04initial negative biopsy biopsy showed
01:10:06no cancer underwent a second biopsy,
01:10:08so the the rationale behind
01:10:10that is by getting an MRI first.
01:10:12If the biopsy shows no cancer,
01:10:15we can be much more confident
01:10:17in telling that individual you
01:10:18do not have prostate cancer,
01:10:20so we are successful.
01:10:21Probably 90% of our biopsies are MRI guided.
01:10:25Excellent and for men who do
01:10:27active surveillance and he
01:10:28said doing a repeat biopsy.
01:10:30How far out do you should do that one year,
01:10:33year and a half two years?
01:10:34When is that? Repeat biopsy.
01:10:36Yeah, so we we tried to do the first
01:10:38biopsy within one year of the of the
01:10:40diagnosis just to be sure that we
01:10:42have not under staged the disease.
01:10:44And based on that biopsy,
01:10:46if it looks if it still looks reassuring,
01:10:48we will do the second biopsy about
01:10:49one to two years later and spaced
01:10:52out subsequently after that.
01:10:53You know, in the early days of active
01:10:56surveillance there was a lot of.
01:10:57Uncertainty about how safe it
01:10:59would be to wait,
01:11:00but the evidence is really emerged
01:11:02to support pulling back on how
01:11:04intensely we're monitoring patients,
01:11:05and so we will frequently go at two
01:11:07or three or even longer your interval
01:11:10if everything else looks good.
01:11:13Excellent thank you. Look at the list here.
01:11:15As someone asked a question me whether the
01:11:18treatments that I have mentioned are also
01:11:20ones used for salvage radiation therapy.
01:11:22So salvage rayshon therapy is the
01:11:24term used if we're at if we're using
01:11:27radiation after prostatectomy.
01:11:28So in that case you've done prostatectomy.
01:11:30PSA should go to an undetectable level.
01:11:33'cause of that point you've
01:11:34removed all sources of PSA.
01:11:36But if we see it creeping back up even at
01:11:39that point to a very low level like .1 or .2.
01:11:43Then we know there's a
01:11:45prostate cancer problem.
01:11:46We see whether some radiation,
01:11:47every pelvis can be of help,
01:11:49and in that thing that's
01:11:51called salvage radiation,
01:11:51and it is very similar to the treatments
01:11:54that I was describing before we
01:11:56treat was called the prostate bed,
01:11:58which is, as you may imagine,
01:11:59where the prostate was an 'cause that's
01:12:02still the highest risk area for to come back.
01:12:04And then,
01:12:05depending on the features,
01:12:06what the Gleason grade was.
01:12:08Again, how aggressive looked under the
01:12:10microscope and whether they are lymph
01:12:12nodes involved or what would the margins.
01:12:14Features like that or how quickly
01:12:15the PSC is coming up after surgery,
01:12:18so there's some other features we use to
01:12:20see if there's something else we should
01:12:22do so sometimes will add some radiation,
01:12:24at least a medium dose of radiation
01:12:26to the pelvic lymph nodes sometimes
01:12:28will get doctor Petra lack involved
01:12:30to see if some of that anti
01:12:32testosterone therapy would be a
01:12:34helper and really just in last year.
01:12:36So I think we're having a appreciation that
01:12:38going a little bigger in that setting,
01:12:41adding some dose to the pelvic
01:12:43nodes and adding some anti.
01:12:44Awesome therapy can really be a big helper,
01:12:47but the fundamentals of using that I
01:12:49am RT and coming for daily treatments.
01:12:52Those are the same as some of that
01:12:55earlier intact prostate an for us.
01:12:57You know those N CCM guidelines
01:12:59typically recommend 37 to 39 daily
01:13:01treatments for that salvage setting.
01:13:03There are some trials that are
01:13:05ongoing looking at a shorter course
01:13:07using that same kind of moderately
01:13:09hypofractionated idea to come
01:13:11for more like 25 or 28 sessions,
01:13:13but I would say that's best done at
01:13:15this point in a clinical trial setting.
01:13:18And we'll see where that where that goes.
01:13:23Looks like I got two questions.
01:13:25Two questions there for doctor Petra.
01:13:27OK so. There's sort of work together.
01:13:30One is. It sounds like you're
01:13:31sequencing advanced cancers does make
01:13:33sense to sequence in earlier stage.
01:13:35That's a great question.
01:13:36The guidelines are now saying
01:13:38that you should be checking
01:13:40pretty much everybody for bracket.
01:13:42It's insidious, it pops up.
01:13:43I've seen it pop up in patients
01:13:46without a family history.
01:13:47And of course you can get
01:13:49spontaneous germline mutations
01:13:50as well that develop in there.
01:13:53Passed on later on.
01:13:54So yes, you need to look for
01:13:56the germline early and then the
01:13:59family should be cancelled so.
01:14:01The question is, when do you test?
01:14:04These markers for a patient with
01:14:07advanced disease and also when does some
01:14:09at it when the simatic mutations develop,
01:14:12that is phenomenally good question,
01:14:14which we don't have an answer too.
01:14:17So the what I tend to do is I will
01:14:21try to do a tissue biopsy first.
01:14:24If it's bone,
01:14:25if it's not available,
01:14:27or if it's if it's archival and very old.
01:14:30I often do a liquid biopsy to assess
01:14:33whether there is semantic mutation or not.
01:14:37I do when I do P testing,
01:14:39it's usually when a patient changes
01:14:41the characteristics of their disease.
01:14:43If they have a rapid acceleration,
01:14:45if they have the development of
01:14:47Patrick Metastic liver metastases,
01:14:48something to suggest that disease
01:14:49is changed in some way.
01:14:51There really are no guidelines for re
01:14:53testing at this point an it's really
01:14:56limited by insurance and what people
01:14:58will pay for at this particular time,
01:15:00but it's a phenomenal question because
01:15:03when we're giving drugs to patients.
01:15:06You're giving these drugs, and it's
01:15:07basically evolution within your body.
01:15:09You kill off the sensitive cells.
01:15:11Then resistant ones are left,
01:15:13and does that change overtime.
01:15:14And do you revert back to a
01:15:17different phenotype again,
01:15:18we really don't know the question.
01:15:20One of the things that we're working
01:15:22on right now, Yale and Joakim,
01:15:24who works with our group is a
01:15:26really dynamic junior attending.
01:15:27He's looking at trying to induce brokenness.
01:15:31And what do I mean by that?
01:15:33Well,
01:15:33as I said before,
01:15:3410 to 20% have brought us some attic
01:15:37or somatic or germline mutations.
01:15:39If you deprive cancer cells of oxygen,
01:15:42they become hypoxic an they
01:15:43can't repair the DNA as well.
01:15:46So if you're effectively introducing brockus,
01:15:48anjo actually did a randomized trial
01:15:50where he showed that the progression
01:15:52was about seven months less if you
01:15:55deplete oxygen or give it what's
01:15:57called an anti angiogenesis agent,
01:15:59and he presented this year at Asco.
01:16:01We're now trying to correlate
01:16:03that with the molecular markers,
01:16:05but it's really an exciting
01:16:07area because now we're going to
01:16:09try to engineer the cells too.
01:16:11Indu sprocket nest.
01:16:16That's great I see a question.
01:16:17Here it says, is this presentation
01:16:19going to be available to watch again?
01:16:21Would answer is yes and.
01:16:23Renee may be able to to speak more
01:16:26about how to how to find that.
01:16:28I know that after this talk,
01:16:30if you have any additional questions,
01:16:32by the way, you can email to cancer
01:16:34answers at Yale.edu's cancer answers.
01:16:37All one word at yale.edu.
01:16:38But yes, this will be
01:16:40available in the figure.
01:16:41How to let you know how that so.
01:16:45It looks like there's another one
01:16:47for doctor Petra Lack here.
01:16:49What time frame you expect the
01:16:51medications currently in trial
01:16:52stages to be released and more
01:16:54broadly used.
01:16:55That's a great question again,
01:16:56so I know that that.
01:17:00This is a really difficult area.
01:17:01I mean, clearly we want to
01:17:03demonstrate that a drug is safe.
01:17:05And also effective and
01:17:06trials take quite some time.
01:17:09So if you go back to tax appear,
01:17:12the first patient was treated in 1996.
01:17:15The phase three trial opened in 1999,
01:17:18closed in 2002 and was mature in 2004.
01:17:21So that's eight years from the time
01:17:24that the drug first one to the
01:17:27patient to the time it move forward.
01:17:31So that that's a long process
01:17:33and patients can't wait.
01:17:35There are now accelerated approvals of drugs
01:17:38based upon what we call phase two data.
01:17:41In other words, if.
01:17:43The drug shows efficacy.
01:17:45Or it looks like it's effective
01:17:47in a small trial that the FDA
01:17:50sense says puts a certain.
01:17:53Response rate, so we just in bladder cancer.
01:17:57We just gotta drug Holden Ford of
01:17:59Doughton approved an accelerated basis in
01:18:01December an so that's December of 2019.
01:18:04The phase two trial opened about
01:18:07two years before that and the phase
01:18:09one trials were open in 2012,
01:18:11so it's still a long process.
01:18:14But it's now available to patients.
01:18:17It's a little bit shorter than we'd
01:18:19have to go through the face through the
01:18:21phase three was confirm atory the phase
01:18:23three data was just announced and press
01:18:25release about three or four days ago,
01:18:27and that was positive.
01:18:28So you know, I encourage everybody
01:18:30to get involved in clinical trials.
01:18:32If available, talk to your doctors about it.
01:18:34We try to make a trial available
01:18:36for every disease state,
01:18:38so if you've come in an you've
01:18:39been on one treatment treatment a,
01:18:41then you go on treatment B and we
01:18:44always try to talk to you about
01:18:46trials at a given point.
01:18:47And again,
01:18:48we appreciate all the patients who
01:18:50have volunteered for this overtime,
01:18:52because you know, it's it's a.
01:18:54It's a hard.
01:18:55It's not easy an you know it's an unknown.
01:18:58These patients are pioneers and
01:19:00they're helping us not only themselves,
01:19:02potentially,
01:19:02but other patients in the future.
01:19:10As she had one more question for
01:19:13Doctor Lehman, actually I know
01:19:14this is mainly a cancer top by you
01:19:17touched on benign prostate enlarge.
01:19:19I know a lot of men that come have a
01:19:21lot of questions about that and drugs
01:19:24like Flomax but also there are lot
01:19:27of things like the loud procedures,
01:19:29green light laser and one using steam
01:19:31energy and in various things what?
01:19:33What do you counsel men who are
01:19:35struggling with their primary
01:19:37care doctor they've been on Flomax
01:19:39some medicines not really.
01:19:40Cutting out what how you talking
01:19:42and having counseling about options
01:19:44include procedures for that?
01:19:46Thanks for
01:19:46his. Yeah it's very much interwoven right?
01:19:49So the so men become very often
01:19:51become aware of their prostate.
01:19:53Having urinary symptoms is almost
01:19:54universal and so that is relevant to
01:19:57the question of prostate cancer because
01:19:59there's awareness of the prostate.
01:20:01That question about could this
01:20:03be cancer always looms large, so.
01:20:06So I think it is important
01:20:08to beginning at beginning,
01:20:09having those conversations
01:20:10clearly make the distinction.
01:20:11But for people who do have
01:20:13benign urinary symptoms,
01:20:14you know the first line treatments
01:20:15are usually medications to help
01:20:17essentially open up the prostate.
01:20:18Let more urine pass out,
01:20:20and that helps you know
01:20:21significant number of men.
01:20:22But there are some who have symptoms
01:20:24that do not respond to medications,
01:20:26and I'm often shocked at how
01:20:28many people don't realize or
01:20:30something else that you can do.
01:20:31We've made great strides here,
01:20:33and we have a few people who
01:20:34specialized really in this field
01:20:36of minimally invasive treatment.
01:20:37Prostate for benign. Prostate cancer.
01:20:39For benign prostate.
01:20:40Simple so not cancerous.
01:20:42Disease of the prostate.
01:20:43One person is named Daniel Kellner,
01:20:46whose outstanding and has really become
01:20:48a leader in a laser approach where
01:20:50they essentially treat very very large
01:20:53prostates which are not cancerous.
01:20:55But removing the center portion of it,
01:20:57which has a very minimal long term side
01:21:00effects and can make really profound
01:21:02differences in the quality of life.
01:21:05For men who are struggling
01:21:06with urinary issues.
01:21:09And tastic, thank you.
01:21:11It looks like there's
01:21:12one more for doctor pet.
01:21:15Relax, this is nothing
01:21:16nice nuanced question.
01:21:18So are there trials for
01:21:20nonmetastatic castrate resistant so
01:21:22castrate yes right now we are sort of
01:21:27in a Limbo period right now because
01:21:29we were working with a vaccine trial.
01:21:33Which was basically PSA vaccine that
01:21:35we're combining with the checkpoint.
01:21:37There are trials I right now I'm sort
01:21:40of in between. Studies the standard.
01:21:43There are three standard FDA
01:21:45approved drugs right now.
01:21:46One is apalutamide, one is enzalutamide
01:21:49and the third is Darrell Odom.
01:21:51I'd so those are drugs you would
01:21:55consider for this situation.
01:21:58At this point,
01:21:59now we don't know if sequential used
01:22:01to these drugs is is going to give
01:22:03you any more benefit if you fail one,
01:22:05then go on to the other but.
01:22:08Stay tuned,
01:22:08hopefully they'll be something
01:22:10opened with the next six months
01:22:12where we're still recovering from
01:22:13Covid in getting our trials going,
01:22:15so it's been a slow process,
01:22:17but it's moving forward.
01:22:24Excellent.
01:22:27See, we're almost finished with our
01:22:29time with or any other questions
01:22:31on his paws from own case.
01:22:33Anyone is gonna be typed in here.
01:22:45Lorraine Renee, are you?
01:22:46Do you have any more specific
01:22:48guidance about how this is going
01:22:49to be available to watch again?
01:22:53You are so the video will be posted
01:22:56to yalecancercenter.org and
01:22:57will also share it
01:22:58out on social media to all
01:23:00smilow cancer hospital pages.
01:23:03One of the things I usually
01:23:05when we open up new trials,
01:23:07I'll put that on Twitter so those
01:23:09of us who would want to follow the
01:23:11Yellow Cancer Center on Twitter
01:23:13as well as my own Twitter account,
01:23:15which is part of the yellow Cancer Center.
01:23:17I also tried to.
01:23:21Let people know that new
01:23:22findings that are coming out.
01:23:26Excellent.