Smilow Shares Greenwich: Prostate Cancer: Screening,Treatment, and Advances
September 29, 2021Information
Presentations by:
Daniel Petrylak, MD Professor of Medicine (Medical Oncology) and Urology
Gerald Portman, MD Assistant Professor of Clinical Urology
Bruce McGibbon, MD Associate Professor of Clinical Therapeutic Radiology
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- 00:00Alright, good evening everyone.
- 00:02Saw Doctor Mcgibbon here.
- 00:04Welcome you to this smile.
- 00:06Shares addition of advances
- 00:08in prostate cancer.
- 00:09Thank you everyone for joining.
- 00:10We're going to get a start
- 00:13here sharp at 7:00 o'clock.
- 00:15Doctor Petra Lack will be going first.
- 00:18Medical ecology and Dr Portman from
- 00:21urology and then myself for each
- 00:23non college E and the Q&A will be
- 00:25a little bit different tonight.
- 00:27Doctor Patrick will speak first and
- 00:29have his Q&A directly afterwards.
- 00:31And then Doctor Portman,
- 00:33I will have a separate UN A after this.
- 00:36The first I'd like to introduce Dr.
- 00:38Petrick,
- 00:38who was a professor at Yale Medical Ecology,
- 00:42and we talking tonight about
- 00:44some advances there.
- 00:45I'll take it away, Doctor Petrol.
- 00:48OK, thank you very much and
- 00:51sharing my screen here.
- 00:53Think you've got that correct?
- 00:55Yes, can see it nicely.
- 01:00OK, great and we got we have
- 01:01the first slide up correct.
- 01:05Uh, yes. Terrific so as we know
- 01:08I'm a medical oncologist and I
- 01:11take care of those patients who
- 01:13have advanced prostate cancer and.
- 01:15Prostate cancer is is the most common
- 01:19diagnosed cancer in men and the second
- 01:22leading cancer cause of death in men.
- 01:24And we really have two different
- 01:26types of disease.
- 01:26We have the early nonmetastatic
- 01:28localized disease which can be treated
- 01:31with radiation therapy and surgery.
- 01:33We have hormone sensitive disease,
- 01:36which is when a patient relapses
- 01:39either by PSA or relapses by a.
- 01:43Objective measurements,
- 01:43such as a bone scan or a lymph node.
- 01:46And then, of course,
- 01:47hormone therapy is the standard
- 01:48that we use for these patients,
- 01:50as we see from this flow sheet we
- 01:53can flow from localized disease to
- 01:55rising PSA to clinical metastases
- 01:57to eventually metastases that
- 02:00no longer respond to hormones.
- 02:03And we know that the Nobel Prize
- 02:06was awarded in 1966 to a gentleman
- 02:09in Charles Huggins,
- 02:10who described the fact that we could
- 02:13treat patients by depriving testosterone,
- 02:17and this unfortunately can control
- 02:18the disease for long periods of time,
- 02:21but unfortunately can't cure it.
- 02:23So what I focused my research and
- 02:25my career on is the treatment of
- 02:27resistant disease and that's really,
- 02:29really evolved over the last 10 to 15 years.
- 02:34So previously we we really didn't
- 02:36have treatments that were effective.
- 02:38And in in 2004 I was behind the approval
- 02:42of a drug called Docetaxel or taxotere,
- 02:45for the treatment of the most
- 02:47advanced form of prostate cancer,
- 02:49and we've really begun to understand
- 02:51the disease and evolve the disease.
- 02:52Since that period of time.
- 02:54And now we have a variety of different
- 02:56treats for the treatments that are used,
- 02:58and this is sort of a complex map,
- 03:00but it shows us how much we improve survival,
- 03:03and now we're seeing patients
- 03:04who normally only lived a year.
- 03:05We've seen the live so several
- 03:08years with resistant disease.
- 03:10So I like to think of this disease
- 03:12in terms of classes of agents.
- 03:14We have immunotherapeutic agents,
- 03:16hormonal agents as well as cytotoxic
- 03:19agents such as chemotherapy,
- 03:21and now we're looking to agents
- 03:23that can damage DNA isotopes.
- 03:25You'll hear about a drug called F.
- 03:27Types may lutetium 166.
- 03:30Also,
- 03:31pop inhibitors are used for prostate cancer,
- 03:34and it's important that you talk
- 03:36to your oncologist and urologist
- 03:38was radiation oncologist.
- 03:40About the different options that
- 03:42are available to treat patients
- 03:44in this situation.
- 03:45We think about sequencing these drugs in
- 03:47terms of where the patient's disease is,
- 03:49whether they or hormone
- 03:51sensitive or hormone resistant,
- 03:53whether they have had chemotherapy or not,
- 03:55but we've now moved into a different era.
- 03:57For prostate cancer,
- 03:58we moved into the area of biological markers.
- 04:02And this is something you really do
- 04:04need to speak to your doctor about,
- 04:07because now we have biomarkers that
- 04:10can actually predict whether patients
- 04:12respond to different treatments.
- 04:15And prostate cancer presents a unique
- 04:18problem different from other tumors
- 04:20where you have soft tissue lesions
- 04:23like lymph nodes or lung metastases,
- 04:25or spread to the liver that
- 04:27can be biopsied easily.
- 04:28Most prostate cancer patients have
- 04:30disease that's limited to bump.
- 04:32And that leads to a series of different
- 04:35issues in terms of obtaining tissue
- 04:37to look at these advanced markers.
- 04:39So we look at the plasma.
- 04:41We look at some circulating
- 04:43tumor cells in the blood.
- 04:45In those cases where we can
- 04:47actually biopsy a patient,
- 04:48we actually go to the source
- 04:50tissue to biopsy patients,
- 04:52and this is something that you do
- 04:53need to discuss with your doctor,
- 04:54because this can make a big
- 04:56difference in your treatment.
- 04:57These biomarkers can be used to select
- 05:01treatment for different patients.
- 05:03So for example,
- 05:04if we find a mutation in DNA repair
- 05:09such as BRACA one or Brock two,
- 05:11that's about one in 10 patients
- 05:14with advanced prostate cancer.
- 05:15We see that we can actually design
- 05:18drug administered drugs called PARP
- 05:20inhibitors that can actually cause
- 05:22tumor regression and improve survival.
- 05:25We've all seen the advertisements
- 05:27for immune therapy on television
- 05:29for drugs like KEYTRUDA,
- 05:31which I'm often asked whether these
- 05:33drugs have activity in prostate cancer,
- 05:35and the answer is, for the most part, no,
- 05:38but there are a small number of patients,
- 05:40maybe 2 to 3% who have something
- 05:43called microsatellite instability,
- 05:44and that's a marker for.
- 05:46Response to pembrolizumab.
- 05:47In fact, or KEYTRUDA.
- 05:49In fact,
- 05:50this is FDA approved in this
- 05:52group of patients.
- 05:54At Yale,
- 05:55working on new treatments that are
- 05:57are trying to target other parts of
- 05:59the pathway that's involved in the
- 06:01growth of prostate cancer cells,
- 06:03and this is my friend and
- 06:05colleague Doctor Craig Cruz,
- 06:06who is a professor of chemistry at
- 06:09Yale and when I first arrived yield
- 06:112012 cry came up to my office and said,
- 06:13hey,
- 06:14one of my best friends and
- 06:15somebody who I developed a company
- 06:17with a number of years ago died
- 06:19from advanced prostate cancer.
- 06:21What can we do to help this so we?
- 06:24Banter back and forth several
- 06:26different ideas,
- 06:26and Craig was working on a very,
- 06:28very unique drug called a approach.
- 06:32No tech and what this project does is
- 06:36it takes our own system of degrading
- 06:40proteins that may be old and tired,
- 06:43which your body normally turns proteins
- 06:46over and takes these particular proteins
- 06:48and then marks them for degradation.
- 06:51And we've developed a way of
- 06:53accelerating that process and
- 06:55specifically targeting something
- 06:57called the Android receptor,
- 07:00which is expressed in practically
- 07:02all prostate cancer specimens.
- 07:04And we could actually degrade that
- 07:06by having this pro tech bind to it.
- 07:09And actually 400 of those molecules
- 07:11will take out one Pro Tech 11
- 07:13Andrew receptive one.
- 07:14Excuse me the one 400 and receptors
- 07:17can be taken up by can be taken
- 07:19out by one pro tech.
- 07:21And we actually are looking at this.
- 07:23And the molecule actually looks
- 07:24like a dumbbell that way,
- 07:25and that's why that dumbbell fall came from.
- 07:27A tag was seen before
- 07:30we have an area that binds to the protein
- 07:33and that basically brings the enzymes to
- 07:36the protein and then causes the cancer
- 07:39cells to to have this protein degraded.
- 07:44We've actually found that there may
- 07:46be specific mutations in the target,
- 07:48the and receptor that affected
- 07:50or affected by this pro tech,
- 07:52and this is a patient that was actually
- 07:54treated at the Nevada Cancer Center.
- 07:56We've been collaborating with them on this
- 07:58project as well as a company called ARVINAS,
- 07:59which is one of Craig's companies and
- 08:02they make this drug called RV 100.
- 08:05As you can see, where those arrows are,
- 08:08that was a lymph node that track and this
- 08:12patient's PSA went down by 97% and he had
- 08:15had a number of different prior treatments,
- 08:17so we're very excited about these drugs
- 08:19were bringing out a next generation product
- 08:22which will be available for clinical
- 08:24trials both in New Haven and in Greenwich.
- 08:26Another drug which will be available
- 08:28probably next year is something
- 08:30called nutition PSA 116 and this is
- 08:33a way of specifically specifically
- 08:35targeting prostate cancer cells.
- 08:38This molecule, called PSA,
- 08:39is expressed on the surface of
- 08:41cancer cells and this will bind to
- 08:44the cancer cell and then deliver
- 08:47radiation therapy directly to that.
- 08:48And this approach has shown a
- 08:51survival benefit compared to what's
- 08:53called standard of care alone.
- 08:56So conclusion will moved into the area of
- 08:59molecular treatment for prostate cancer.
- 09:01You have to look at all these
- 09:02particular mutations and you need
- 09:04to speak to your doctor about this.
- 09:05The other reason why it's important
- 09:07is some of these genetic mutations
- 09:09are passed down to the family and
- 09:12it's important that you speak to
- 09:13your doctor about when you should
- 09:15see the genetic counselor.
- 09:15Other people we're seeing activity with
- 09:17this RRV woman zero drug and then again
- 09:20you need to talk to your physician
- 09:22about whether drugs like alacran,
- 09:23recap rip are important.
- 09:25Before your care so answer some questions
- 09:27that may be coming from the audience.
- 09:35So for the questions, if you can
- 09:37type them into the Q&A section,
- 09:40then we can read them.
- 09:42Get them answered there.
- 09:43Don't see any popping up yet,
- 09:45but will give it a minute in case
- 09:46we want to type something in.
- 10:06No questions.
- 10:11I can't see my chat here, let's see.
- 10:14Any questions yet? Let's see.
- 10:19Great not thank you so
- 10:21much for your attention.
- 10:27OK, and I don't regret for you go
- 10:29if I if anyone wants to to reach
- 10:31you for consultation. Otherwise,
- 10:33what's a good way to get in touch?
- 10:35Best ways to cut? Contact me through
- 10:36Greenwich Hospital will be happy to see you.
- 10:41See, one question is just
- 10:42popping up here although. His
- 10:45medications like extending ZYTIGA
- 10:47or you be you or you be core.
- 10:50These are all week all next generation
- 10:52into antigens and there are certain
- 10:55points points in the disease process
- 10:57which it may be appropriate for you
- 10:59to have these drugs and you should
- 11:00speak to your physician about them,
- 11:02but they do have significant
- 11:03activity in this disease.
- 11:15Terrific, thank you.
- 11:17Thank you very much all right.
- 11:20Let's move on here to Doctor Portman,
- 11:23who's assistant professor of Urology
- 11:26for Yale, take away Doctor Portman.
- 11:31And see if Doctor Patrick.
- 11:32You could stop sharing your screen and
- 11:34I'm trying to get out of here, let's see.
- 11:51One moment, sorry.
- 11:56The prom got it perfect.
- 12:00Alright doctor Portland
- 12:02OK.
- 12:25OK. So my name is Gerald Portman and
- 12:30I'm a assistant professor of clinical
- 12:32neurology at the at Yale Medicine,
- 12:35and today I'm going to be giving a
- 12:38brief overview over screening and
- 12:40treatment of localized prostate cancer.
- 12:42So prostate cancer, what is what do
- 12:45we need to know about prostate cancer?
- 12:49I have no disclosures.
- 12:52A quick overview about what we're
- 12:54going to go over today is number one.
- 12:57What is the prostate two who should
- 13:00be screened for prostate cancer?
- 13:02Three, what happens if the screening
- 13:05tests come back as abnormal and four?
- 13:08What are some treatment options
- 13:09for localized prostate cancer?
- 13:13So where is the prostate located?
- 13:15As you can see on this diagram,
- 13:17it's located below the bladder and it's
- 13:20between the bladder and the urethra.
- 13:21The urethra actually goes
- 13:23through the prostate.
- 13:25And the prostate is a
- 13:27male reproductive organ.
- 13:28The secrets of fluid.
- 13:30That's one of the components of semen.
- 13:33The ejaculatory duct actually
- 13:35go through the prostate.
- 13:37And that's where semen emission happens.
- 13:41Some problems that can arise
- 13:43from the prostate include
- 13:45enlargement of the prostate.
- 13:47As men get older.
- 13:49Which is called BPH or benign
- 13:51prostatic hyperplasia.
- 13:54And these can lead to symptoms
- 13:57such as frequent urination.
- 13:58The needs of get up at
- 14:01night to urinate urgency.
- 14:02Decreased force of urinary stream.
- 14:04Such weak stream.
- 14:06And the inability to hold urine.
- 14:09None of these symptoms mean
- 14:11that you have prostate cancer.
- 14:13These symptoms are often associated
- 14:15with benign prostatic enlargement.
- 14:19Other problems that can arise in
- 14:21the prostate or prostate cancer.
- 14:24Uhm, which is also more common as men age.
- 14:29And cancer is defined as the
- 14:32uncontrolled growth of cells capable
- 14:34of spreading a tumor cells into other
- 14:37tissues or invading local tissues.
- 14:43So prostate cancer as
- 14:44Doctor Patrick mentioned,
- 14:45is the most commonly diagnosed cancer in men.
- 14:48The median the average age
- 14:51at diagnosis is 66 years old.
- 14:53It's the second leading cause
- 14:55of cancer related death in men.
- 14:57About one in 41 men will die of
- 15:01prostate cancer and today there are
- 15:04about 2.9 million prostate cancer
- 15:06survivors alive in the United States.
- 15:09Most prostate cancers will not
- 15:11spread or cause harm to patients,
- 15:13and that's why it's important for
- 15:15us to understand which treatment
- 15:17options are available and tailor
- 15:18them to the individual patient.
- 15:23So this just shows some background
- 15:25process that we mentioned.
- 15:26Prostate is the number one
- 15:30cause of new cancer diagnosis.
- 15:35And it's the second leading cause of of
- 15:38cancer related death after lung cancer.
- 15:44Localized prostate cancer has a
- 15:46very good five year survival,
- 15:48about more than 99% of patients will
- 15:51be alive within five years after a
- 15:54diagnosis of localized prostate cancer.
- 15:56If there's spreads of the regional
- 15:58lymph nodes, there's also a very
- 16:00good five year for survival.
- 16:02Uh, with distant metastatic disease,
- 16:05a diagnosis. The survival is
- 16:07is much poorer with about 30%,
- 16:11but it this has been getting better
- 16:13as Doctor Petra lack has been
- 16:15discussing with newer treatments.
- 16:19So who? What are some of the
- 16:21risk factors for prostate cancer?
- 16:23So there are known fixed risk factors
- 16:25that patients can change about themselves,
- 16:27such as age. Of prostate cancer is
- 16:30more likely as men get older race.
- 16:33It's a African American men are more likely
- 16:36to have high risk prostate cancer genetics.
- 16:39Certain mutations such as BRCA,
- 16:42which was discussed before,
- 16:44can lead to an increased risk of
- 16:47prostate cancer and family history.
- 16:49Having the first degree relatives such
- 16:51as a brother or father with prostate
- 16:54cancer increases a person's risk.
- 16:56There are newer risk factors
- 16:58that are less understood.
- 17:00Uh, these are modifiable risk factors
- 17:02that are being defined more recently,
- 17:04such as diet,
- 17:06lifestyle and obesity.
- 17:09There is more research going into right now.
- 17:11A plant based diet may have some benefits
- 17:14in reducing certain types of cancers.
- 17:17It's unclear what this does to.
- 17:20Prostate cancer, in the long run.
- 17:23So how is prostate cancer detected?
- 17:26Localized prostate cancer is
- 17:27screened for using a digital rectal
- 17:30examination and a PSA blood test.
- 17:34Localized prostate cancer.
- 17:36Usually during screening
- 17:37does not cause symptoms,
- 17:39however,
- 17:40advanced prostate cancer can be
- 17:41diagnosed due to symptoms such as
- 17:44difficulty urinating blood in the urine,
- 17:46bone pain, and fatigue.
- 17:50So what is PSA?
- 17:51PSA is a protein that's made
- 17:54exclusively by the prostate.
- 17:57And a blood test is used to detect the level.
- 18:00Uh, the level can be high for many
- 18:02reasons other than prostate cancer,
- 18:04such as an enlarged prostate infection,
- 18:06inflammation, and it also
- 18:08does go up with age usually.
- 18:14So some facts about PSA.
- 18:16It's not a perfect test because
- 18:18a lot of men with a high PSA
- 18:21do not have prostate cancer.
- 18:22Some men with normal PSA
- 18:25can have prostate cancer.
- 18:26And PSA screening can lead to detection
- 18:29of some low grade cancers that may
- 18:33not need to be treated because
- 18:35they may not affect the patient.
- 18:37During their lifetime.
- 18:41So who should be screened
- 18:44for prostate cancer?
- 18:45The average person person should
- 18:47undergo screening according to the
- 18:50American Urological Association
- 18:51between the ages of 55 and 70,
- 18:54and this is done by getting an A PSA.
- 18:59And a digital rectal examination
- 19:01every one to two years there are
- 19:04certain high risk patients that can
- 19:07benefit from earlier screening and
- 19:08to get a baseline PSA at age 40,
- 19:11such as African American patients and
- 19:14patients with certain mutations such as BRCA.
- 19:18After age 75 uh.
- 19:20Most urologists recommend the
- 19:22cessation of screening if the
- 19:25PSA has been normal because a.
- 19:28Prostate cancer,
- 19:29for the most part,
- 19:31is very slow growing and some of
- 19:34the treatments can have adverse
- 19:36effects where low grade tumors
- 19:38may not affect the patient.
- 19:40During their lifetime.
- 19:44So since the advent of PSA in the late 80s,
- 19:49early 90s there there has been less
- 19:51metastatic disease at diagnosis
- 19:53and more prostate cancers being
- 19:56diagnosed at an earlier stage.
- 19:58So that's why most urologists do
- 20:00believe that screening is very helpful.
- 20:06And normal PSA is usually defined by
- 20:10level A4 or less by most laboratories.
- 20:15However, there is such a thing
- 20:18called as age adjusted PSA.
- 20:20So patient who's 45 should
- 20:22not be having a PSA for that.
- 20:25That would be considered high
- 20:26for someone of that age.
- 20:28It should be probably less than
- 20:302.5 or even lower than that,
- 20:32and a patient who's in their 70s.
- 20:36With a PSA of 6 does not necessarily
- 20:38need a prostate biopsy right away.
- 20:41Uh, because.
- 20:43A PSA goes up with age and that
- 20:46can be considered normal as long
- 20:48as there's no increase in how
- 20:50fast the PSA has been going on.
- 20:54So what what happens if the PSA is abnormal?
- 20:57The gold standard that has been
- 21:00used since the advent of PSA.
- 21:02When the PSA comes back at abnormal is
- 21:05prostate biopsy and this is done with a
- 21:09transrectal ultrasound and a needle where
- 21:11samples are taken from the prostate.
- 21:14However, in more recent years there's
- 21:17a newer options that are available,
- 21:19such as certain prostate cancer biomarkers
- 21:23such as 4K score or excess MDX,
- 21:26and these can give a percentage
- 21:28chance that a patient has clinically
- 21:30significant prostate cancer.
- 21:32So the patient and the doctor can
- 21:34decide together whether prostate
- 21:36biopsy is warranted and prostate MRI.
- 21:39This has been used over the last
- 21:43eight to nine years.
- 21:44And Yale has been at the forefront
- 21:47of utilizing prostate MRI to help
- 21:49detect any concerning lesions
- 21:51in the prostate on imaging.
- 21:54So this is an example of an MRI of
- 21:56the prostate and the picture on the
- 21:58left shows you a normal prostate and.
- 22:02This white area.
- 22:05Is the peripheral zone of the prostate
- 22:07where 80% of prostate cancer is is found,
- 22:10and this Gray area is the transitional
- 22:13zone where prostatic enlargement occurs.
- 22:15You see on the right here.
- 22:18The white area has this dark lesion that
- 22:20circled with the yellow circle that's
- 22:23obviously different than the other side.
- 22:25And this is an area of concern
- 22:28where a biopsy is warranted.
- 22:33So at Yale, we have the technology
- 22:36to perform MRI fusion biopsy,
- 22:39where we can target these areas
- 22:41that were found on the MRI because
- 22:43the ultrasound machine combines the
- 22:45MRI with the ultrasound to help
- 22:47us target that specific lesion.
- 22:53So there are risks said doing a biopsy.
- 22:56Most men who get a biopsy do not have
- 22:59clinically significant prostate cancer,
- 23:01so, uh, we're subjecting men to
- 23:04unnecessary biopsy in order to find
- 23:07the patients that do have clinically
- 23:10significant prostate cancer.
- 23:12There are risks to biopsies,
- 23:13such as infection, bleeding,
- 23:15and as well as discomfort and anxiety.
- 23:19It can lead to the detection of low grade
- 23:21cancers that may not need to be treated.
- 23:23And it could lead to overtreatment,
- 23:25which could have effects on urination,
- 23:28erections, and the bowel function.
- 23:36So what are some options if the
- 23:38if localized prostate cancer is
- 23:40detected and today we're going to
- 23:42discuss four options which include
- 23:44active surveillance, surgery,
- 23:46radiation? And focal therapy.
- 23:50I will be discussing active surveillance
- 23:52surgery and focal therapy and Doctor
- 23:55Mcgibbon will focus on radiation.
- 23:57And like I said previously,
- 23:58the options must be tailored to the
- 24:00individual needs and characteristics
- 24:02of each patient and the type of
- 24:04prostate cancer that's diagnosed.
- 24:08So first we'll go into active
- 24:09surveillance and the goal of
- 24:11active surveillance is monitored.
- 24:13Monitoring the prostate
- 24:14cancer without treatment.
- 24:16And this is done in order to
- 24:18prevent the adverse effects that
- 24:19come with treatment in terms of
- 24:21urination and sexual function.
- 24:23But these patients still have the
- 24:26ability to obtain cure should more
- 24:28aggressive disease be found in the future?
- 24:32Patients have to be OK with a slight a
- 24:34small risk of progression of prostate
- 24:36cancer while on active surveillance.
- 24:41The ideal candidate for active
- 24:42surveillance has a low PSA level.
- 24:44Usually we consider less than 10 as a
- 24:47good level low Gleason score and biopsy,
- 24:50and these scores are graded from 6 to 10,
- 24:52so usually A6 is a good score
- 24:56for active surveillance.
- 24:57A small amount of cancer, so. Uh.
- 25:02That means that few of the biopsy
- 25:04samples were positive for cancer,
- 25:06and that there's no evidence of
- 25:09disease outside of the prostate
- 25:10in the Seminole vesicles or the
- 25:13lymph nodes and patients have to
- 25:15be willing to have close follow up
- 25:17because the follow for most active
- 25:20surveillance protocols involves
- 25:21monitoring the PSA every six months,
- 25:24getting a repeat biopsy every one to
- 25:27two years and getting an MRI's as well.
- 25:30Everyone to two years.
- 25:32And the goal of actor surveillance is to
- 25:35intervene and treat the prostate cancer.
- 25:37If a more aggressive form is found.
- 25:40Odd repeat biopsy.
- 25:45Next, we'll discuss surgical therapy,
- 25:48so surgery is done to remove the
- 25:51entire prostate and Seminole vesicles,
- 25:54and 95% of this surgery in
- 25:56the United States is done.
- 25:58Laparoscopic Lee,
- 25:58with the assistance of a robot.
- 26:01And on the left this was actually
- 26:03a robot purchased for one of
- 26:06the hospitals in Westerly,
- 26:08RI with and you can see that
- 26:11the four arms of the robot.
- 26:13Are what control the instruments
- 26:16that are used to perform the
- 26:18surgery inside the patient and on
- 26:20the right the surgeon sits at a
- 26:22console to control those instruments
- 26:25and this allows for better.
- 26:26A better view of the pelvis as as well
- 26:30as better precision with the surgery.
- 26:37So what's involved in surgery?
- 26:40So the entire prostate and the
- 26:42Seminole vesicles are removed.
- 26:44As you can see by the dotted line here.
- 26:47And the bladder has to be
- 26:49sutured back to the urethra.
- 26:51It's done with small incisions.
- 26:54And most patients stay in
- 26:56the hospital one night.
- 26:58Most patients will have a Foley
- 26:59catheter for about one week to help
- 27:02with healing where the bladder
- 27:03is sutured back to the urethra.
- 27:05And the robotic laparoscopy helps improve
- 27:09certain characteristics of the surgery,
- 27:11including that there is less blood loss,
- 27:13a faster recovery,
- 27:15and shorter hospital stay than with
- 27:18traditional open prostate surgery.
- 27:23So focal therapy has been a.
- 27:28Investigated for awhile.
- 27:32And Yale is at the forefront of several
- 27:35new technologies and focal therapy.
- 27:37Uh, including cryoablation,
- 27:38which means freezing a specific area of
- 27:41the prostate where the lesion is located.
- 27:44HIFU, which stands for high
- 27:46intensity focused ultrasound where
- 27:48a needle is placed into the lesion
- 27:50and ultrasound is used to heat the
- 27:52area and destroy the cancer cells.
- 27:54Nanoknife Nanoknife is actually used for
- 27:57several solid tumors other than prostate,
- 27:59but it's it's being used in prostate
- 28:02as well where several probes are placed
- 28:05around the lesion and electricity
- 28:07is sent from one probe to another
- 28:10to help kill the cancer cells.
- 28:14And a new technology that was
- 28:18recently developed.
- 28:20Called Tulsa Pro,
- 28:22which stands for transurethral.
- 28:25Ultrasound ablation of the prostate.
- 28:28And this is done under MRI guidance
- 28:32and Yale is one of only 11 centers
- 28:35in the country to have this machine.
- 28:38The caveat with all these treatments
- 28:40is that there is a lot less long
- 28:42term data and a lot of them are not
- 28:44yet FDA approved for the treatment
- 28:45of prostate cancer because it takes
- 28:48years to see how well they work in
- 28:52comparison to surgery or radiation.
- 28:54However,
- 28:54patients with localized lesions
- 28:56and armor I may be good candidates
- 28:59for focal therapy if they want to.
- 29:02If they want to prevent some of
- 29:04the side effects associated with
- 29:06surgery or radiation.
- 29:10So the main advances at
- 29:12Yale have been with MRI.
- 29:14In in terms of helping detect
- 29:16prostate cancer, and as you can
- 29:17see in the picture on the bottom,
- 29:19that's this is an ultrasound of and this
- 29:21is the prostate here and the red area.
- 29:24Is where a lesion was found on the
- 29:28MRI and it's helping us detected on
- 29:31ultrasound and helping us guide the needle.
- 29:33To help biopsy.
- 29:34The area that was identified on MRI.
- 29:37Traditional ultrasound cannot see a
- 29:40prostatic lesions or prostate cancer,
- 29:43so the the the ability to fuse the
- 29:45image with the MRI helps guide
- 29:48biopsy and this improves detection
- 29:50of high risk cancers.
- 29:52And it lowers the detection
- 29:53of lower risk cancers.
- 29:57So in conclusion, as we discussed,
- 29:59prostate cancer is one of the
- 30:01most common cancers in men.
- 30:03A screening of prostate
- 30:04cancer has risks and benefits,
- 30:06so it needs to be tailored to
- 30:09the individual patient as well
- 30:11as the age of the patient.
- 30:12MRI and fusion biopsy or helping
- 30:16guide diagnosis and Yale is
- 30:19helping develop new strategies
- 30:21for diagnosing prostate cancer.
- 30:23And treatment decisions for
- 30:24localized prostate cancer should be
- 30:27tailored to the individual patient,
- 30:28and these treatments include,
- 30:30as we discussed,
- 30:31active surveillance surgery,
- 30:33radiation, and focal therapy.
- 30:39Thank you.
- 30:43Excellent, thank you.
- 30:46Let's see how doctor Apartments
- 30:47finishing sharing screen.
- 30:48I'll share mine moment so feel free to
- 30:51type into the chat with the Q&A section.
- 30:53Any questions productive Portman and
- 30:55feel free to do the same on my talk
- 30:59and then you know I will answer them.
- 31:01At the end, as well as like one or two.
- 31:04Maybe it'll help with that are
- 31:06holdovers from Doctor Petrol.
- 31:10Share my screen.
- 31:20OK, so I'm going to talk through
- 31:22some advances in radiation
- 31:24therapy for prostate cancer.
- 31:28Yeah again, I'm doctor Bruce McGill
- 31:30and I'm the medical director for
- 31:33radiation oncology at Smilow Cancer
- 31:35Hospital Care Center in Greenwich.
- 31:40Screen, yeah. And so one thing that to
- 31:44note is that a lot of what's advance in
- 31:47radiation therapy in the past 10 to 15
- 31:50years is image guidance before we could
- 31:52line people up on the table and have a
- 31:54very good idea where the prostate was,
- 31:56but we couldn't be ultra precise.
- 31:58And and with the advent of imaging on the
- 32:01machines were able to not only create very
- 32:04complex shapes of radiation within the body,
- 32:06but ensure that internally
- 32:08we're really on target.
- 32:10And so if you look at the bottom right here.
- 32:12This is what's called a variant Ruby machine
- 32:14like we have in branch and the treatment
- 32:17head where they actually come out is here.
- 32:19But on the side or these two arms,
- 32:21and those are imaging arms,
- 32:22and so we can spend the machine
- 32:24around the patient while he or she
- 32:26is on the table and take an image
- 32:28that looks very much like a cat scan.
- 32:29So when people come for region planning,
- 32:31we do a special type of
- 32:33cask and that's what we do.
- 32:34Design on.
- 32:35But then we can run a kovid CT and see
- 32:37how things match up on any given day
- 32:39is most people are kind of radiation
- 32:41or not coming just once they're coming.
- 32:43Are often five days a week for
- 32:45for several weeks,
- 32:46and so if you look on the upper left
- 32:49you can see how close the image
- 32:51quality is in that the top right and
- 32:54lower left or the cone beam CT and
- 32:57the lower right and upper left are the
- 33:00regular CT and they look very similar.
- 33:01We can scroll between these two and
- 33:03see how things line up inside and this
- 33:06is how we get that confidence that
- 33:08we're on target for each treatment.
- 33:10Another element is that we've gone
- 33:12from what's called 3D conformal
- 33:14radiation to I MRT or intensity
- 33:16modulated radiation therapy.
- 33:18This picture on the left is what
- 33:19they call a color wash.
- 33:20It's approximating what the dose
- 33:22would look like if you had one beam
- 33:24from the front and one beam from
- 33:25the back and one from each side,
- 33:27and it's quite good,
- 33:28but in this case,
- 33:28this is a picture songs chest,
- 33:30and this is the spinal cord back here,
- 33:32and this is the heart in front and
- 33:34you see with this technique that this
- 33:36dose is splashing through most of the heart,
- 33:38and these black areas on the sides of the.
- 33:40Lungs it's going through that and it's
- 33:42going through the spinal cord quite a bit.
- 33:45But when you use this I MRT technique,
- 33:47you come from many angles,
- 33:49sometimes as few as five or seven.
- 33:51But often it's a 360 degree arc and
- 33:53as the beam is going around it's
- 33:55changing the intensity of the beam
- 33:57and the shape of the beam at each
- 33:59of those points.
- 34:00And so you get a much fancier dose
- 34:02distribution that in this case,
- 34:03for example,
- 34:04is staying better off the hard
- 34:06and better
- 34:06off the spinal cord,
- 34:08and we can employ that technique.
- 34:09Another is the body,
- 34:11such as the prostate.
- 34:13Another thing that's gotten a lot of
- 34:15buzz in the last handful of years.
- 34:17For many treatment areas in the body,
- 34:18but definitely the process is called
- 34:21stereotactic body radiation therapy or SBRT.
- 34:24Some people know it is as Cyberknife,
- 34:27although it's a little bit sweet.
- 34:28Cyber Knife is the name of a machine
- 34:30that's capable of doing this technique,
- 34:32but there are other machines that can do it,
- 34:34but that's why the most common way
- 34:35that people would have heard something
- 34:37like this and start tactic recipe.
- 34:39Aarti is characterized by having special,
- 34:41patient and mobilizations
- 34:42that accept position.
- 34:43Limiting normal tissue exposure to the
- 34:46radiation preventing or accounting for
- 34:48organ motion and it's called stereo taxi,
- 34:51which is in essence a targeting system
- 34:54internally and then sub centimeter accuracy,
- 34:56sometimes down to millimeters of action
- 34:58with the dose instead of bringing people
- 35:00for Monday to Friday for weeks at a time.
- 35:02This is a treatment limited to one to
- 35:06five treatments only and this again
- 35:08we're showing the color wash picture.
- 35:11Where you can see this is targeting
- 35:13the red outline is the process itself.
- 35:16Little purple is is a gold marker,
- 35:18which I'll talk about later and behind here
- 35:20is the ****** and auto size of the hips.
- 35:22You can see we're really keeping the
- 35:24dose very tight to the prostate and
- 35:26not splashing it around other organs.
- 35:30Uhm, there's a quick note about machines
- 35:32so that again this top machine is a.
- 35:34It's a view from the side of the machine.
- 35:36Now it's time earlier that very
- 35:38true being it can do pretty much
- 35:40everything in the radiation.
- 35:42We're almost everything we want to do,
- 35:43including I MRT and SBRT using X rays.
- 35:48Uh, another thing which
- 35:50has come on a baptizing.
- 35:51What interest is showing low left?
- 35:53It's a proton unit.
- 35:55Protons are fundamentally
- 35:56different in terms of power.
- 35:58Kind of what's coming out of machines
- 36:00is a positively charged particle,
- 36:02and that has certain characteristics
- 36:03about how it deposits in the issue,
- 36:05and there may be there.
- 36:07I think there are some occasions
- 36:08where protons are better than X
- 36:10rays and there's some occasions
- 36:11directed better than protons,
- 36:12but really just starting to
- 36:14figure out now you know when is
- 36:16one thing better than the other,
- 36:17and so for prostate cancer.
- 36:19Example,
- 36:19at this point there really no long
- 36:21term data that show an advantage
- 36:23of one machine over the other,
- 36:25certainly not in terms of care or not
- 36:26really even in terms of side effects.
- 36:28More broadly,
- 36:29one of my colleagues at Yale did
- 36:32analysis that showed that X rays
- 36:34were better at certain side effects
- 36:35and protons and certain other ones,
- 36:37but very similar would say,
- 36:40can you see on the lower right?
- 36:41The Cyberlink machine has
- 36:43a totally different shape.
- 36:44It actually has a miniaturized
- 36:46radixin on top of a robotic arm.
- 36:50Arm is the same type this use in
- 36:52high end car assembly but allows the
- 36:55machine to be moved and many many
- 36:57different directions that uses small
- 36:58teams who have to go through a target
- 37:01so it it really is a great machine.
- 37:03One of the great machines are safe for SBRT,
- 37:05but it's not actually capable
- 37:07of treating larger fields.
- 37:09Are bigger targets or treating
- 37:10really practical sense over many
- 37:12weeks like certain other things.
- 37:14So all those machines are
- 37:17applicable for prostate cancer.
- 37:19And some have more flexibility, some summers.
- 37:24Uhm?
- 37:24Kirk out about,
- 37:26you know,
- 37:27prostate cancer radiation when were
- 37:29also when we're being aggressive
- 37:31with the process we were trying
- 37:32to cure or redo something much
- 37:34more than just palliation.
- 37:35So we have three settings we have intact,
- 37:38prostate post prostatectomy,
- 37:40active prospecting,
- 37:41and a new category called Olivo
- 37:44metastatic so for intact prostate.
- 37:45The two major options we can do
- 37:47external being where patients
- 37:48lying on the table machine moved
- 37:50around and took pictures from a
- 37:52distance that can be done in this
- 37:54traditional IM RT which is 40 to 45.
- 37:56Sessions that's gonna nine week
- 37:58course you can have one that's called
- 38:01moderately hypofractionated imarti.
- 38:02It's quite a mouthful,
- 38:03but it's basically a slightly higher
- 38:05dose per day and still done Monday to Friday,
- 38:08but only 20 to 28 sessions.
- 38:10And then SBRT,
- 38:11which in the case of prostate is
- 38:135 sessions and for most or deal
- 38:15with prostate with with low risk
- 38:17or low risk intermediate risk.
- 38:19With things like we have six weeks seven.
- 38:22All these options are great once you
- 38:24move into the higher risk prostate
- 38:27cancer then we really don't have
- 38:29renewed for just five treatments
- 38:30we tend to do either the imarti or
- 38:32the that hypofractionated regimen,
- 38:34or some combination of these things.
- 38:37Try to intensify the dose in the prostate.
- 38:39Will also giving some dose too.
- 38:41Nearby things at risk.
- 38:43Like the public moments.
- 38:45A completely different way to
- 38:46go about his breakey therapy,
- 38:47which is huge amounts of radioactive
- 38:49seed implant on its own.
- 38:51It's also good for early stage,
- 38:54have low risk prostate cancer,
- 38:56and may also be good or it is
- 38:59good as a booster or wave.
- 39:03Increasing the dose of proxy for high
- 39:05risk prostate cancer oftentimes have a
- 39:07little bit of a slightly worse urinary
- 39:10ciphered profile but also good way
- 39:12of going about it after prostatectomy.
- 39:14We have two ways in which
- 39:16we call to offer radiation.
- 39:17One is that.
- 39:20So basically, the surgeon surprised
- 39:21by the results of surgery.
- 39:22There's something much riskier.
- 39:24There was.
- 39:24The lymph nodes are involved
- 39:26or a lot of positive margins.
- 39:27Or you know something that was
- 39:29quite alarming and the persons
- 39:30otherwise in great shape.
- 39:31And then we're calling it radiation
- 39:33about three to six months later
- 39:35that someone unusual that happens.
- 39:37The other case is called
- 39:39salvage radiation therapy,
- 39:40and that's where it looks like
- 39:41the surgery is done quite well.
- 39:43PSA goes to undetectable level,
- 39:45but later starts to rise.
- 39:46We get the feeling that perhaps
- 39:48it's come back in that area with.
- 39:50Plastic was taken 20 plastic better
- 39:52in the pelvic nodes and then we bring
- 39:54them in for 37 to 39 treatments.
- 39:57So it's about an 8 week course
- 39:59to try it again.
- 40:00Cure the problem and and drop pick
- 40:03up with the surgery left off.
- 40:05The third category is all of them into stack,
- 40:06so this is an interesting distinction.
- 40:09So medicine disease is usually
- 40:11defined as the cancer that spread
- 40:13well beyond the area.
- 40:14So in the case of processing,
- 40:16that's usually gone off into the bones,
- 40:18or maybe some distant lymph nodes.
- 40:20And the old feeling was,
- 40:22well, once it's escaped, it's,
- 40:24you know,
- 40:25like we're just gonna play kind of
- 40:27a defensive role here and just slow
- 40:29things down. Or just do palliation.
- 40:30But there's a very narrow category where
- 40:32it seems to only spread to just a few spots,
- 40:35maybe two or three spots.
- 40:37And what we found out is it being aggressive.
- 40:41They are can pay off and we
- 40:42have a survival advantage.
- 40:43Sometimes we're locking in.
- 40:44Those are really the only spots
- 40:45in the body that truly active.
- 40:47It's not hiding elsewhere and other
- 40:48occasions it turns out there's
- 40:50some other spots they're hiding.
- 40:51But by going after the ones that are visible.
- 40:54We can perhaps stimulate the
- 40:55immune system and help to keep the
- 40:58other ones and check for longer.
- 40:59So if we find a gentleman who
- 41:02has prostate cancer
- 41:03as a new diagnosis but has a few,
- 41:05let's say bone spots,
- 41:06we will treat the prostate as the
- 41:08original source for about 20 treatments,
- 41:11but will also treated with SBRT to
- 41:14those metastatic sites and really
- 41:15try to wrestling manage the problem.
- 41:20One thing, nothing that's been
- 41:21great in our world last handful of
- 41:23years is better rectal protection.
- 41:25So if we look at this lower left
- 41:27view we see that dose cloud there.
- 41:29Right behind it in this kind
- 41:31of maroon or burgundy object.
- 41:34That's the ******.
- 41:35So usually directing the
- 41:36prostate are touching.
- 41:37And that means that whatever we
- 41:39give authority should dose to the
- 41:41back edge of the prostate goes
- 41:42exactly the front edge of the
- 41:44****** and that can lead to things
- 41:46like urgency to move bowels or or
- 41:49frequency of Bowser looser stool
- 41:51and well after the treatment.
- 41:52We can sometimes get some bleeding
- 41:55from that and so this project was
- 41:57created called space or Gel which is
- 41:59inserted this diagram like between.
- 42:01Crossing the ****** and uh oh,
- 42:03you can't see it in this cone.
- 42:04Beams on the left.
- 42:05It's actual locations right here?
- 42:07Diagram pink and you're obviously
- 42:09doctor would put the skin for
- 42:12us before the radiation.
- 42:13It stays there for three months.
- 42:15You can see any pictures here.
- 42:17Appears as a white area on MRI
- 42:20and then it dissolves back to
- 42:22water after another three months
- 42:23since his or by the body.
- 42:25Patients generally don't have any
- 42:27symptoms from having in there.
- 42:28Besides maybe just a little sense of
- 42:30formats for a few days and it's a
- 42:33wonderful way to get the radiation.
- 42:35Does the ****** lower in addition to
- 42:38the fancy techniques like I'm RTMS PRT?
- 42:41The other thing is that we ask the
- 42:42girls help for our implanting,
- 42:43sometime fiducials or markers at Greenwich.
- 42:46We typically use gold fiducials.
- 42:49They're about the size of a grain of rice.
- 42:51They have to look carefully the
- 42:53picture they have almost a rough
- 42:55surface so that when they're
- 42:56embedded they don't slide around.
- 42:58Then we stick in after the prostate.
- 43:00And they provide.
- 43:01Really.
- 43:01It's kind of like a GPS system for us.
- 43:03So when we see their relationship to
- 43:06the prostate on our planning scan,
- 43:08then when we line up patient up on the
- 43:10treatment day and do that conga MCT,
- 43:12we can really easily see the markers.
- 43:14Make sure those line and then we
- 43:16know that we're really on target down
- 43:18to the millimeter type accuracy.
- 43:19And the red arrow here is kind of
- 43:21pointing out what these look like.
- 43:23So nice bright light here.
- 43:25You can't mistake them for anything else.
- 43:27Uhm, they look anything else.
- 43:29They look sort of calcifications.
- 43:31The prostate,
- 43:31which are another nice thing for us
- 43:33to line up by so they really stand
- 43:36out and they're fantastic in helping
- 43:37us get that hyper accurate alignment.
- 43:42I.
- 43:42Nothing to touch on is in which I
- 43:45felt were just kind of getting into.
- 43:48Now is better imaging for prostate cancer,
- 43:50so the better we know where cancer
- 43:52is and where it isn't,
- 43:53the more aggressive we can be
- 43:56appropriately or or less aggressive,
- 43:58whatever matches and.
- 44:00When you're flying blind,
- 44:02sometimes you know you're not always.
- 44:04You know,
- 44:04doing you're doing what you think
- 44:06is best
- 44:06at the time, but sometimes you
- 44:08find out there is more there.
- 44:09So conventional imaging now includes
- 44:11things like MRI of the pelvis that Dr.
- 44:14Horton was showing us,
- 44:15see TV ad with pelvis bone scans.
- 44:18These are all very good test still
- 44:20buy insurance, they they were.
- 44:21They are excellent but
- 44:22we have two other tests.
- 44:23I say that come up fairly recently where
- 44:26there were still finding their place.
- 44:28Sometimes when she really needs them,
- 44:30but once called accident.
- 44:31And the other one one the names,
- 44:33the other one is called the clarified.
- 44:35Uhm, axemen it was approved first,
- 44:39so it's a type of these are both
- 44:40types of PET scans and this one is
- 44:43called simplified with Queen F18.
- 44:46So it's really what this is taking
- 44:49advantage of is that there was a
- 44:52thing called amino acid transporter,
- 44:54which is something on the surface of
- 44:56cells help to move things back and
- 44:57forth and they found is that one.
- 44:59This one particular one.
- 45:00Uh is up regulators more of it on
- 45:03prostate cancer cells and so this drug women.
- 45:06It's infused in the body gets
- 45:08preferentially dragged into these
- 45:10prostate cells and the reactive part
- 45:12of it's a little tag then shines out.
- 45:15You can see it on a PET scan.
- 45:17And this is really approved
- 45:18for prostate cancer.
- 45:19Well, to evaluate prostate cancer recurrence.
- 45:22So it's not really approved
- 45:23for a new diagnosis,
- 45:24but it's for men who had
- 45:26surgery had lesion before.
- 45:28PSA is looking really.
- 45:29PSA is coming back and we're looking
- 45:30to find out where the problem is.
- 45:32This can be an excellent test.
- 45:35And according to the
- 45:37company's other research,
- 45:38it may have its size is 68% action
- 45:40rate for current prostate cancer.
- 45:43And you know,
- 45:44I think it's still not a great
- 45:45test of the PSA is very,
- 45:47very low,
- 45:48but once it comes up past about
- 45:50.7 or .8 or so,
- 45:51pretty cool number start to get
- 45:52better and better chances of picking
- 45:54up where the problem might be.
- 45:58The other test, which is a little newer.
- 46:00Other couple versions of it,
- 46:01but it's a it's releasing Dr Patch like
- 46:04let's bring up this PS MA so PSA is
- 46:07prostate specific membrane and Jenn says
- 46:09it's special marker that's unique to
- 46:11prostate cells and pressing cancer cells.
- 46:13It's overexpressed.
- 46:14There's more of it on prostate cancer cells,
- 46:17and in fact, higher expression of it is
- 46:19linked to having hired recent scores,
- 46:21so more aggressive toward type
- 46:23and lower survival.
- 46:24And if you have something which
- 46:26is unique to prostate cell.
- 46:27And you can take advantage of
- 46:28it and try to imagine.
- 46:29So that's what this test is.
- 46:31It takes another type of pet marker,
- 46:34attaches it to something that can go on.
- 46:35Attached to that PS MA and
- 46:38then shines out from there.
- 46:39And this one is a little more flexible.
- 46:41So this is approved both
- 46:43for an initial workout,
- 46:45so new diagnosis or for someone
- 46:47who has a suspected recurrence.
- 46:49So perhaps a little bit more flexible.
- 46:51The company their data shows
- 46:54that specificity, for example,
- 46:55is one of the markets.
- 46:57How to test it?
- 46:58Is air quoting 97.9% versus 65%
- 47:02with conventional imaging.
- 47:05This kind of idealized numbers,
- 47:07but point being that that we may have
- 47:10a role here to bring on these pet scans
- 47:13for better and better evaluation of.
- 47:16Where cancer is here is as a comic
- 47:19classic case from the company where
- 47:21someone this is from one of their
- 47:24studies where gentleman was images
- 47:26with the bone scan yet seen on
- 47:28the left and there's a little bit
- 47:30of Hope's a little bit of uptake.
- 47:32You can see here in this pelvic area.
- 47:34Otherwise look fine.
- 47:35They got the pet image and you see
- 47:38all these all these black dots.
- 47:40I smaller black dots are all cancer sizes.
- 47:42For example,
- 47:43much more cancer than they had
- 47:45thought and that totally changed.
- 47:46The man jumped out, for example.
- 47:51Using the same PS may. Target a doctor.
- 47:55Patrick was touching on that.
- 47:57There's a radiopharmaceutical,
- 47:59so using something called lutetium 177 which
- 48:03is reactive molecule tagged 2P SNAPSMA
- 48:07finding monkey put those in it hunts around.
- 48:10Sounds like a smart bomb idea,
- 48:11finding work crossing cancer
- 48:13is an attacking from there.
- 48:16This so far is really approved
- 48:18and being were not approved yet.
- 48:19We're looking for approval but has shown
- 48:22success in metastatic prostate cancer.
- 48:24No real role so far for earlier stage,
- 48:27although things approved metastatic tend
- 48:30to drift down towards further stage,
- 48:32but so far we're looking and hoping
- 48:35for approval expecting approval for
- 48:36at a static answer.
- 48:38Your system.
- 48:39Prostate cancer.
- 48:40Ah, so that's it for my time there.
- 48:44Stop sharing and let's.
- 48:47Let's jump into the question so.
- 48:52Never question was about PS MA.
- 48:56LU177 being used from your state.
- 48:57So again, currently no,
- 48:59but potentially later or modified version.
- 49:03And perhaps I think so far we're looking for.
- 49:07I guess the disadvantage of that therapy
- 49:09is there's only so much radiation you can
- 49:11get into one area with that technique,
- 49:13so I'm not sure if it ever really
- 49:14replace things like surgery,
- 49:15radiation, and the focal therapy,
- 49:17but certainly it looks to
- 49:19be helpful in metastatic.
- 49:21And other questions of cancers
- 49:23on the pelvic pelvis, wall,
- 49:25lymph nodes or some of US schools?
- 49:27Is it considered local?
- 49:28I would say would be called
- 49:30local slash regional,
- 49:31so that's still if it's really in
- 49:34the powers there and no issues
- 49:36that still curable situation.
- 49:39We tend to go after it with a combination
- 49:42of radiation and anti hormonal therapy,
- 49:44but there's some some options around that.
- 49:48I could see maybe this would
- 49:52be one for Doctor Poormon.
- 49:53What is the role of genomic testing
- 49:55like deciphering treatment choice,
- 49:57any outcomes data?
- 50:00So.
- 50:04Genomic testing is.
- 50:05Uhm, you were testing such
- 50:08as decyfer at Oncotype DX.
- 50:11That gives us a.
- 50:14The percentage chance of
- 50:17metastatic disease developing.
- 50:19Or the chance after prostate biopsy
- 50:23is positive that if we were to
- 50:26remove the prostate that there
- 50:27would be high risk disease present,
- 50:29that the biopsy did not catch?
- 50:31There is no long term outcomes
- 50:34data on this and.
- 50:36We do not have good data on
- 50:40which genomic test is better.
- 50:43In terms of which one to use at Yale,
- 50:48we tend to use decipher because it
- 50:50tests more genes than the other tests.
- 50:53I believe it S 22 genes.
- 50:55And we use it after biopsy in active
- 50:59surveillance to see if someone may
- 51:02have high risk disease and should
- 51:04have treatment earlier rather
- 51:06than having active surveillance.
- 51:11Excellent. Let's see,
- 51:13there's a question for early.
- 51:14I think we stopped for Doctor Patrylak,
- 51:16but came in after left
- 51:18asking for minute hormone.
- 51:19Hormone therapy is working.
- 51:20Are these new drugs can play?
- 51:22I would say the answer to that is yes,
- 51:25potentially to those other ones,
- 51:27but you'd have to ask Medical
- 51:30College for more detailed
- 51:31evaluation of particular case.
- 51:33Once things were starting
- 51:34to show some resistance,
- 51:35a lot of a lot of the drugs are for cash.
- 51:39Three resistant prostate cancer so.
- 51:43If the hormone therapy is working sometimes.
- 51:48A medical oncologist will hold off,
- 51:50but some of them are approved to be
- 51:52used in conjunction with hormone
- 51:55therapy such as abiraterone.
- 51:58Demo a Senior Center department
- 52:02asking for focal treatment is
- 52:04this an Apple samples choice?
- 52:06Is the surgery or is a newer,
- 52:08less invasive procedure?
- 52:09The same rate of success as the knife? So.
- 52:15The focal treatments are not considered
- 52:18Apple saddles. The standard of care
- 52:21is still radiation or surgery.
- 52:24And if we look at our EUA American
- 52:27Urological Association guidelines,
- 52:29which is also the same as the American
- 52:32Society for Radiation Oncology guidelines,
- 52:35they in fact state that specifically
- 52:37focal therapy is not standard of care,
- 52:40and that it's it's only been FDA approved
- 52:45for destruction of prostate tissue.
- 52:47It has not been FDA approved
- 52:50specifically to treat prostate cancer.
- 52:53So. While we can use these treatments.
- 52:59There is, it's with the understanding
- 53:02that it may be less effective.
- 53:06The surgery or radiation,
- 53:07but at the same time with less side effects.
- 53:11So there's a tradeoff,
- 53:12but also because it's not FDA approved
- 53:16for treatment of prostate cancer.
- 53:18A lot of insurances will not
- 53:21cover these treatments.
- 53:26Next question, is it safe to say
- 53:28that machines altogether are more
- 53:30advanced than the old manual method?
- 53:33Certainly in radiation that
- 53:34they know machines are are far
- 53:37better than the prior machines.
- 53:39Old machines could only do
- 53:40technically that 3D technique.
- 53:41I was showing you,
- 53:42and really no modern center has a
- 53:44machine like that around anymore.
- 53:46That's useful prostate treatment,
- 53:47but it's been a world of difference
- 53:50with being able to do things
- 53:52like I am rtin SBRT to be able to
- 53:54escalate the dose to get better PSA
- 53:57control rates while also lowering
- 53:59the dose to knowledge issues.
- 54:01So definitely.
- 54:03Big trade,
- 54:04a positive trade that would you say,
- 54:08I'm sure they're also referring to
- 54:09serve in terms of robot versus non robotic.
- 54:12You have a comment there.
- 54:15In terms of, I'm sorry I
- 54:16didn't outcomes or or toxicity,
- 54:18so the outcomes in terms of cancer control.
- 54:24Uh, erections or a continents have
- 54:27not been proven to be different
- 54:31between open surgery and robotic.
- 54:34The differences are mainly in blood loss,
- 54:37the need for transfusion.
- 54:39It's very rare with the robot length of stay.
- 54:43Patients used to stay three or four
- 54:45days in the hospital with open surgery
- 54:48and now most patients go home the next
- 54:51day after robotic prostatectomy and.
- 54:53A faster recovery at home because
- 54:56the incisions are smaller,
- 54:58but the outcomes have not been
- 55:00proven to be better with the robot.
- 55:02That being said,
- 55:04most prostate surgery in the United States,
- 55:07the vast majority,
- 55:08probably way over 90% is
- 55:10done robotically these days.
- 55:15Uh, let's see next question as John six
- 55:17months ago had 28 days of radiation
- 55:20with three days of higher power,
- 55:22so it's three days of SBRT
- 55:24Boost or Kona Week on,
- 55:26which was nine and 62 years old.
- 55:28Feeling great checkup last week,
- 55:30which I expect in coming years and
- 55:32one of the options that there's
- 55:34progression coming up wrong.
- 55:35So you know, this is a Yale approach
- 55:37and some other signs or kindness really
- 55:39to kind of the best of two worlds.
- 55:41One is to get.
- 55:43The convenience and the lower side
- 55:45effects of the external beam technique,
- 55:47while being able to intensify,
- 55:49escalate that dose in a way that's
- 55:51not identical to breaking therapy,
- 55:53but is getting much closer to the idea
- 55:57because it seems to be a great draft.
- 55:58We've had a lot of success with that in
- 56:00the system and lodged in green from it.
- 56:02You know, if there is a recurrence later,
- 56:05we have to distinguish, and this is working.
- 56:06It comes in is this a recurrent where
- 56:09we've done great in the palace,
- 56:10but something popping up elsewhere?
- 56:12Or is it?
- 56:13Something has to be resisted,
- 56:15and it's it's really needs to
- 56:17be treated in prostate.
- 56:19And if it's elsewhere,
- 56:21that's usually where some like
- 56:23doctor petrol comes into play.
- 56:25Or maybe spot treated with radiation
- 56:27of just a limited number of spots,
- 56:29but it's back on the prostate area that is.
- 56:32That's a bigger challenge.
- 56:34You know,
- 56:35doing salvage prostatectomy
- 56:36is technically can be done is,
- 56:38but it's usually not because
- 56:40the the size of much worse.
- 56:42We do look at some of the.
- 56:44The focal therapies, though,
- 56:45like the doctor appointments,
- 56:46managing probation Tulsa.
- 56:48Things of that nature if I could.
- 56:52Yeah, I was asking.com comma so uh.
- 56:56Like Doctor Mcgibbon said,
- 57:00most urologists hesitate to do a prostate
- 57:05surgery prostate removal after radiation.
- 57:08That being said,
- 57:09there are some specialists who do do it.
- 57:12Our new chairman of Urology at
- 57:16Yale specializes in removal of
- 57:19prostate after radiation. Uhm?
- 57:23However, there are more risks
- 57:24and side effects that can happen
- 57:27after that type of surgery.
- 57:29The other option is cryoablation.
- 57:33Where you freeze the entire prostate,
- 57:35and that's actually in the NCCN guidelines,
- 57:39as an approved secondary treatment,
- 57:42a newer treatment is the Tulsa Pro.
- 57:46It's not FDA approved for prostate cancer,
- 57:48but.
- 57:50Uh, the technology is so impressive and
- 57:54it's so precise that I think eventually.
- 57:58This will be a perfect indication for it,
- 58:01and, uh, there is a machine like this
- 58:04like I mentioned in my presentation.
- 58:06It's in New Haven.
- 58:07It's one of only 11 in the country right now.
- 58:13Great, UM, it looks like a
- 58:15little tight in that they're
- 58:16having a little trouble hearing me.
- 58:18I'll try talk a little.
- 58:19Asher was a connection issue.
- 58:20I'll talk a little louder and
- 58:21closer to the screen here.
- 58:22Hopefully that will help, UM.
- 58:25Let's see, one is a question
- 58:27about when that lutetium
- 58:31177617 will be approved.
- 58:32It's been approved in Israel,
- 58:33Australia, weather in the US.
- 58:35Of course we don't know,
- 58:36but we're hoping within the next
- 58:38year that would be approved.
- 58:40It's somewhat challenging to deliver
- 58:43in terms of radiation safety and and
- 58:46having various resources available,
- 58:47so it'll be hard to really roll
- 58:49out in a massive way in the US,
- 58:51but I think it's definitely
- 58:53exciting treatment.
- 58:54Certainly looks offer in the mail system.
- 58:57Let's see what types of cancer
- 58:59found in the prostate.
- 59:00The foreman handle that one.
- 59:03Yeah,
- 59:03so most prostate cancers
- 59:05called adenocarcinoma or a
- 59:08cancer of the prostate glands.
- 59:12Uh, it's graded from 6 to 10,
- 59:14which is the Gleason score,
- 59:17with six being the lowest,
- 59:19least aggressive and 10 being the highest,
- 59:21most aggressive.
- 59:22Uh, it's very rare to have
- 59:25other types of prostate cancer
- 59:28other than adenocarcinoma.
- 59:31So that's the most common type.
- 59:34Yeah. Uh, let's see?
- 59:37Uh, next time is 76 years old.
- 59:40Had a project in 2015,
- 59:42the rising PSA over five years.
- 59:44What's the trigger for salvage radiation?
- 59:46This is a little tricky.
- 59:48I would say the the
- 59:50classic definition is 0.2.
- 59:51That's our technical definition of peace,
- 59:52of failure with these ultra
- 59:55sensitive PSA's or sometimes seeing
- 59:56you know levels of you know, .03.
- 59:59Going to point 06.12.
- 01:00:01So if we're seeing a distinct rising pattern,
- 01:00:05I think that's.
- 01:00:06That's enough to say, OK,
- 01:00:08there might be a problem here.
- 01:00:09We factor in how fast it's rising and that
- 01:00:13person's overall health and their age.
- 01:00:15Try consider whether this is
- 01:00:16worth going after with radiation,
- 01:00:18so not everybody has a rising PSA
- 01:00:20necessarily need salvage radiation.
- 01:00:21But I'd say 0.2 certainly
- 01:00:24is the classic trigger,
- 01:00:26and in some cases even lower if
- 01:00:29we have several rises in a row.
- 01:00:32Uhm, which scan is better?
- 01:00:34PS MA at the gallium.
- 01:00:37Basically G60 or PS MA with the flooring.
- 01:00:40I don't think there's any data that
- 01:00:41we're up to say that one is really
- 01:00:43bad and the other is just a different
- 01:00:45radioactive tag shining out the F18
- 01:00:47people feel that they are better
- 01:00:49because the half life is longer,
- 01:00:52so we imaging may be easier to pick it up.
- 01:00:54I think these are.
- 01:00:57Subtleties,
- 01:00:57I would say either is is great and
- 01:01:01I'm sure it'll be one winner in the
- 01:01:03US in terms of what's more available,
- 01:01:05but I wouldn't say that one is
- 01:01:07necessarily better than the other.
- 01:01:08Uhm,
- 01:01:09prostate out or stay in with
- 01:01:11metastatic seems different for some,
- 01:01:13although my sex spread hip pain in response.
- 01:01:17Uhm, while becoming about radiation,
- 01:01:19but that part, you have a.
- 01:01:20You have a comment about prostatectomy
- 01:01:23for metastatic prostate cancer.
- 01:01:25Although metastatic prostate
- 01:01:26so this has been a topic that
- 01:01:30we've been debating a lot.
- 01:01:32I know we've discussed it between ourselves.
- 01:01:36Yeah, there's no good data to show that.
- 01:01:41Prostate prostate ectomy improves survival.
- 01:01:43However there is.
- 01:01:45There are some small retrospective
- 01:01:47studies that show it can decrease
- 01:01:50symptoms in the pelvis in the future,
- 01:01:53such as issues with urination,
- 01:01:55or issues with blockages of the ureters.
- 01:02:00But there there's no good data to show
- 01:02:04that it improves survival right now.
- 01:02:07That being said,
- 01:02:08I believe this is something that is being
- 01:02:10investigated right now at MD Anderson.
- 01:02:13I think there's a trial there
- 01:02:16for something like this.
- 01:02:17Yeah,
- 01:02:18we have. There's a little bit more data
- 01:02:20I would say for prostate radiation.
- 01:02:21Although it's it's,
- 01:02:22you know, not huge numbers.
- 01:02:24There's a travel to Stampede trial there.
- 01:02:26She several sections of it,
- 01:02:28but one of them was looking at a local
- 01:02:31therapy like radiation and there did seem
- 01:02:33to be at least a trend towards better
- 01:02:35overall survival wasn't a huge difference,
- 01:02:37but there was some difference.
- 01:02:40And the classic way that we do that is
- 01:02:42with twenty sessions to the process,
- 01:02:44we treat the processing of 20 sections
- 01:02:46and then if there are a few bone spots,
- 01:02:48we go after those aggressively.
- 01:02:50If there.
- 01:02:50I think if I'm reading
- 01:02:52correctly 6 to 7 spots.
- 01:02:53That's Kyle,
- 01:02:54exceeding the number really shown
- 01:02:55in trials to make sense to go
- 01:02:57after all those aggressively.
- 01:02:58So we usually just go after the ones
- 01:03:01that are painful and but still give
- 01:03:04a treatment to to the prostate.
- 01:03:06Uh, let's see next the PSA of 144
- 01:03:10medication tried now in chemotherapy
- 01:03:12should really should be tried first.
- 01:03:14Why was it started suggested?
- 01:03:17You know it's a difficult to you know,
- 01:03:20made up for having more than survive
- 01:03:22difficult to answer on a platform like this.
- 01:03:24Is there a lot of nuances to that?
- 01:03:26There might be a role for radiation
- 01:03:28is surgery,
- 01:03:29but I'd say I have to have a more
- 01:03:31formal consultation to really dig
- 01:03:33into what could be done a lot to pens
- 01:03:36on what's really seen on imaging.
- 01:03:38Not just PSA, but with the imaging is right.
- 01:03:42Yeah, I would agree with that,
- 01:03:44but most patients with a PSA.
- 01:03:46Over 100 will have some metastatic
- 01:03:51disease and the risks of surgery.
- 01:03:56There are there are risks to
- 01:03:59surgery and AY without being a
- 01:04:02clear benefit within patient.
- 01:04:04If they have significant
- 01:04:06metastatic disease so. Uh.
- 01:04:09I think most urologists would agree that.
- 01:04:13Local therapy, unless it's like what you
- 01:04:16just mentioned in the Stampede trial.
- 01:04:19Uhm? Is usually not indicated.
- 01:04:23Yeah, even Stampede.
- 01:04:24It was really what for what
- 01:04:26they call low metastatic burden.
- 01:04:28So men who had a high in this
- 01:04:29area so really a lot of spots
- 01:04:30there was no advantage to treating
- 01:04:32with radiation processing,
- 01:04:33so it's particular they would
- 01:04:36need more information there.
- 01:04:38Uh, is there any efficacy with
- 01:04:40having seeds use a second time using
- 01:04:43extended after metastatic condition?
- 01:04:45We basically never do seed
- 01:04:46implant a second time.
- 01:04:48There is some very early
- 01:04:50data now on radiation,
- 01:04:52so someone had strong being furtively add.
- 01:04:56We've got to seize later,
- 01:04:57or we add stereotactic radiation
- 01:05:01that's that is done in highly
- 01:05:03selected number of cases where
- 01:05:05we feel very confident just in
- 01:05:07the gland and other options.
- 01:05:09But not on the table.
- 01:05:12But you know the details that
- 01:05:14are super important.
- 01:05:15The toxins he does tend to be higher,
- 01:05:17so it's a possibility not to do seeds twice,
- 01:05:20but to do two different kinds
- 01:05:22of radiation twice extended is
- 01:05:24definitely used as one of the
- 01:05:26drugs in the metastatic setting,
- 01:05:29and there are some trials looking
- 01:05:31at using it in high risk.
- 01:05:35Setting up more upfront,
- 01:05:37but those are more in the in
- 01:05:40trials currently.
- 01:05:42Uhm,
- 01:05:42what's the best treatment for
- 01:05:45semi advanced prostate cancer
- 01:05:47bypassing or voiding ADT?
- 01:05:49You know,
- 01:05:49some my view will get Doctor Barnes
- 01:05:51and 2nd is men who have intermediate
- 01:05:53or high risk prostate cancer.
- 01:05:55So high reasons for higher PSA.
- 01:05:57You know,
- 01:05:58although we don't have really great
- 01:06:00data comparing radiation surgery
- 01:06:01for a lot of those things I think
- 01:06:03are best outcomes with radiation.
- 01:06:05For those intermediate,
- 01:06:06higher with anti testosterone
- 01:06:08therapy or ADT and I think if we're
- 01:06:11trying to say if cure is number 1.
- 01:06:14And A and a gentleman does not
- 01:06:15want to do ADT, and I say, well,
- 01:06:18I think we're definitely giving
- 01:06:19something up in terms of pure potential.
- 01:06:20So I think if if radiation and
- 01:06:23antitrust star or equivalent to surgery,
- 01:06:25which I think they often are,
- 01:06:27we can argue that if we're not doing
- 01:06:29the ADT for some advance cases,
- 01:06:31then I'm going to get surgery
- 01:06:32number one and ready shipper 2.
- 01:06:33But for a guy who does not want surgery,
- 01:06:36not want antivir,
- 01:06:37model original install an option.
- 01:06:39It's just not as good as this one.
- 01:06:41We have the drug with.
- 01:06:43What do you think?
- 01:06:44Or
- 01:06:45yeah, I I think it would depend on
- 01:06:48what you're defining as semi advanced.
- 01:06:50If if someone has a Gleason score of
- 01:06:53nine but it on MRI, the lesion is
- 01:06:56clearly completely inside the prostate.
- 01:06:59And you can remove the prostate.
- 01:07:02With and there's no evidence of
- 01:07:04disease in the lymph nodes then
- 01:07:06surgery may be a good option.
- 01:07:08However, if someone has disease in
- 01:07:11the Seminole vesicles it's unlikely,
- 01:07:14or in the lymph nodes that surgery alone.
- 01:07:16Will be currative.
- 01:07:19So the best chance at cure like
- 01:07:21like you said, is.
- 01:07:23Uh, at 18 months of ADT with uh.
- 01:07:29With the radiation therapy.
- 01:07:33Yeah. Let's see, do we have survival
- 01:07:36rates for advanced prostate cancer?
- 01:07:38That or castrate resistant
- 01:07:40and high Gleason values?
- 01:07:43Generally when we talk about Patrick
- 01:07:45resistant, it's not just advanced,
- 01:07:47but it's meta static.
- 01:07:49We don't usually make that distinction
- 01:07:51for localized prostate cancer,
- 01:07:52so that's what we're talking about.
- 01:07:54I it's probably even better.
- 01:07:56Doctor Petrolite question.
- 01:07:57You know how?
- 01:07:59What, what prognosis is more exactly
- 01:08:02definitely things get much trickier when
- 01:08:05castrate resistance come comes around.
- 01:08:08And you know life expectancy
- 01:08:09used to getting shorter.
- 01:08:10It's definitely getting a lot longer there,
- 01:08:12but I don't have a figure out the top of my.
- 01:08:14Yeah,
- 01:08:15each of those medications that
- 01:08:17Doctor Petra lack mentioned usually
- 01:08:19increases survival on average
- 01:08:21somewhere between four to six months.
- 01:08:24And if you combine them all together,
- 01:08:27it's it's being stretched out
- 01:08:29for a number of years now.
- 01:08:31A docetaxel uh up front,
- 01:08:36I believe, had the best survival,
- 01:08:38and I think it was. It.
- 01:08:41Somewhere between 12 and 15 months,
- 01:08:43I don't remember the exact number, uh?
- 01:08:46But if you Add all those
- 01:08:49treatments that he was discussing,
- 01:08:52people can live a number of years even
- 01:08:55with metastatic castrate resistant
- 01:08:56and you have to also remember that.
- 01:08:59They live a number of years before
- 01:09:01it becomes castrate resistant,
- 01:09:03even if it's metastatic with
- 01:09:05the hormone treatments so.
- 01:09:07Uh, I think.
- 01:09:09With the new new advances,
- 01:09:11this is going to continue.
- 01:09:14To grow.
- 01:09:17Uh, I think related to what Doctor was
- 01:09:19saying is this next question Abarat
- 01:09:21Aroun Brock PC down to under 1%.
- 01:09:23How long could this hold an aggressive form?
- 01:09:26I think we did **** saying it is,
- 01:09:27you know, about four to six
- 01:09:29months would be the average is at
- 01:09:31a fair interpretation problem.
- 01:09:33Yeah, I believe that, uh I I think.
- 01:09:39They there were two, uh,
- 01:09:42I believe it's around four to
- 01:09:44six months for abiraterone,
- 01:09:45but that once again I think it's a
- 01:09:47better question for Doctor petrol, yeah?
- 01:09:51Uh, let's see. Do you believe HRD is
- 01:09:53an important biomarker for metastatic
- 01:09:56castrate resistant prostate cancer?
- 01:09:58Just mutation analysis of each RR.
- 01:10:03It's outside my scope,
- 01:10:04I didn't know anything about that.
- 01:10:05Doctor Portland. No, a teacher.
- 01:10:09That we would be a good one to
- 01:10:11follow up with Doctor Doctor Petrol
- 01:10:13and we have more questions there.
- 01:10:15Next session in metastatic setting,
- 01:10:17how high does once?
- 01:10:18Because they have to be in order
- 01:10:20for PET scan to discerning lesion.
- 01:10:22Yeah, I would say really these PET scans,
- 01:10:25the AXEMAN study and and the PSM A.
- 01:10:29You know we're talking even after
- 01:10:32a prostatectomy were picking
- 01:10:34it up at point eight.
- 01:10:361.0 something like that.
- 01:10:37So you know these are tests.
- 01:10:39If someone who's newly diagnosed in the PSA,
- 01:10:41let's say 8:00 or 12:15,
- 01:10:44I think these PET scans haven't
- 01:10:46said chance of showing the lesion.
- 01:10:48Perhaps better than conventional imaging,
- 01:10:50but you know, conventional region
- 01:10:51is still great and still is.
- 01:10:52It's easily approved with insurance.
- 01:10:56They definitely were not seeing routine
- 01:10:58approvals for PS MA at this point.
- 01:11:01With, you know,
- 01:11:03conventional imaging looks clear.
- 01:11:05Uhm,
- 01:11:06how rare is small cell neuron in carcinoma?
- 01:11:08Being founded, project biopsy.
- 01:11:11And so although Adam Carson
- 01:11:12is the most common by far,
- 01:11:14small cell is one of those.
- 01:11:17Uh, you know ones that we see now and then.
- 01:11:19If it absolutely, it's only rare to find it.
- 01:11:21It absolutely impacts the plan.
- 01:11:25I'd say we we rarely see serving being done,
- 01:11:29that that's where
- 01:11:30I think that small.
- 01:11:31So the the mainstay of
- 01:11:33treatment for any small cell
- 01:11:36in any organ is chemotherapy.
- 01:11:38Yeah, so a local treatment is
- 01:11:41unlikely to cure small cell.
- 01:11:45Yeah, I think it's particularly resistant
- 01:11:47basically to the hormone therapy.
- 01:11:48Unless you have a mixture of
- 01:11:50small cell and admin personal,
- 01:11:51but you know it, then yeah, both.
- 01:11:53But yeah, absolutely agreed.
- 01:11:55On 4 minutes a chemo.
- 01:11:58Situation for most part and often like
- 01:12:00we do for small cell cancer lung we
- 01:12:03often add some radiation later for
- 01:12:05getting a good response to the king.
- 01:12:07Uhm, there's some opinions that
- 01:12:09consider at least six nonmalignant, uh.
- 01:12:14Yes, so go ahead. There was a huge
- 01:12:18study done retrospectively and leason
- 01:12:226 almost never metastasizes outside
- 01:12:26of the prostate, so that's why.
- 01:12:31That's the whole rationale
- 01:12:33behind actors surveillance.
- 01:12:35The concern is that. Uh.
- 01:12:40Did the biopsy Miss Gleason seven or
- 01:12:42higher or somewhere else in the prostate?
- 01:12:45And the other concern is, does Gleason
- 01:12:48six turn into a more aggressive cancer?
- 01:12:51And that's a question that's
- 01:12:52very difficult to answer.
- 01:12:54We don't have the answer to that.
- 01:12:55We don't know whether Gleason six turns
- 01:12:58into Gleason Seven or eight or nine,
- 01:13:00or if that just.
- 01:13:02Comes out the novel from benign tissue.
- 01:13:06So uh, while recent sex is normal, ignant.
- 01:13:09Someone who has Gleason six has a
- 01:13:12higher risk of having something else,
- 01:13:14and that's why we recommend
- 01:13:16active surveillance.
- 01:13:18And that didn't comment on side
- 01:13:21effects of hormone therapy,
- 01:13:23so normal therapy lowers the
- 01:13:27testosterone close to 0 initially and
- 01:13:30it causes a lot of the same effects
- 01:13:33that women feel with menopause.
- 01:13:38There's a, there's fatigue
- 01:13:40loss of bone mineral density.
- 01:13:44Hot flashes patients can experience
- 01:13:48occasionally depression A.
- 01:13:50Those are the main effects.
- 01:13:53There is some data now to suggest that.
- 01:13:58Hormone therapy may, uh,
- 01:14:01cause heart disease if.
- 01:14:06If it's given long term.
- 01:14:08Uh, that has not been proven,
- 01:14:10but there's more and more
- 01:14:12data to suggest that.
- 01:14:15Yeah, it's definitely.
- 01:14:16You know, it's a definite plus
- 01:14:18minus with the hormone therapy.
- 01:14:20But we do know that it has such
- 01:14:21a such a powerful role against
- 01:14:23prostate cancer that you know
- 01:14:25something your doctors can help
- 01:14:27way as to whether it's worth it
- 01:14:29with certain other health issues.
- 01:14:31But we know for intermediate risk,
- 01:14:33prostate high risk grants state
- 01:14:35another stack that has really very
- 01:14:38substantial effects or weighing
- 01:14:39the pros and cons there.
- 01:14:42And it looks like last question
- 01:14:44for tonight is a three.
- 01:14:45I think that's what
- 01:14:46multiparametric 3T MRI so
- 01:14:51multiparametric 3T MRI detects
- 01:14:55about 80 to 85% of prostate cancer.
- 01:14:58It's very good in that peripheral zone
- 01:15:01that I showed during my presentation.
- 01:15:03It's not as good at finding cancers
- 01:15:06that originate in in the transitional
- 01:15:09zone where the BPH occurs,
- 01:15:11but it's if it does show a high risk lesion.
- 01:15:16It's it's pretty specific in that most likely
- 01:15:20that that will detect prostate cancer.
- 01:15:25Well, I want to thank everyone for
- 01:15:27joining us tonight as part of a series of
- 01:15:30elections Healthfield TuneIn for the ones,
- 01:15:32but I do appreciate when tuning in and
- 01:15:34thank Doctor Warren for joining us as well.
- 01:15:36And if you well I've asked you first
- 01:15:39born how people want to reach you.
- 01:15:41I went away to get in contact.
- 01:15:45So, uh, you could email me or
- 01:15:48call a Yale office number.
- 01:15:54Oh, I could provide that. OK
- 01:15:57yeah and similar for me.
- 01:16:00Probably the best is you
- 01:16:02can get a Direct Line so.
- 01:16:04You know Google course, but it's
- 01:16:082038633701 that's 8633701 and
- 01:16:11is the Direct Line for our
- 01:16:13department. Easy get in touch
- 01:16:14and mine is 75 two 815.
- 01:16:18Right now you're 3.
- 01:16:20Alright, thanks again.
- 01:16:20Everybody have a good rest
- 01:16:21of the night. Thank you.