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

September 29, 2021

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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ID: 6945
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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.