Smilow Shares Greenwich: Prostate Cancer: Screening,Treatment, and Advances

September 29, 2021

Information

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

ID6945

To CiteDCA Citation Guide

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.