Disability and Progress-Feburary 6, 2024-Prostate Cancer

[00:00:00] Speaker A: KPI or it's. [00:01:00] Speaker B: This is KFAI 90.3 FM Minneapolis, and kfai.org this is disability and Progress. We bring you insights into ideas about and discussions on disability topics. My name is Sam. I'm the host of this show and I'm also producing in the studio. Charlene Dahl is my PR research person. Hello, Charlene. [00:01:21] Speaker A: Hello everybody. [00:01:23] Speaker B: And Aaron is my podcaster. Aaron, coming back or somewhere in warm places? Want to remind everyone that if you want to be a part of my email list, you can email me at disabilityandprogressamjasmond.com and I'll be happy to put you on. You'll find out what's coming up on the weeks coming up. Today we are speaking with Dr. Christopher Warlick. Dr. Warlick. And he'll be talking about prostate cancer. Hello, Dr. Warlick. [00:01:56] Speaker A: Hello. Thanks for having me. [00:01:58] Speaker B: Dr. Warlick is the head of the Department of Urology at the University of Minnesota Medical School. He's also the urologist who treats adult patients with bladder, genital, urinary, kidney, prostate and testicular cancers. Correct? [00:02:20] Speaker A: Correct. [00:02:21] Speaker B: You have an emphasis on prostate cancer, which is what we're going to be talking about today, by the way. For anybody who doesn't know, today, Tuesday, February 4th, is apparently World Cancer Day. So this is very timely. So Dr. Werlik, could you just start out by giving us a brief history on you? [00:02:45] Speaker A: Yeah, absolutely. So while I was originally born in Buffalo, New York, I have at this point in my life lived in Minnesota longer than any other place. So I definitely consider this, this home. I, like 70% of the physicians in the state, got my medical education at the University of Minnesota. I did my MD and PhD here and then went and did my urologic training at Johns Hopkins and then came back and joined the faculty here a few years ago. Perhaps a few more than perhaps I care to remember, but a few years. [00:03:26] Speaker B: Ago, shall we say, just couldn't stay away, could you? [00:03:30] Speaker A: Couldn't stay away. [00:03:31] Speaker B: Could you start out by telling us about what is the prostate and what role does it play in the body? [00:03:39] Speaker A: Yeah, absolutely. So the prostate gland, we typically describe it as a walnut shaped or sized gland that sits deep in the pelvis between the bladder and the urethra. The prostate, in terms of its normal function, is really a reproductive organ. It makes the lion's share of the seminal fluid and that fluid helps ensure proper sperm activation and function during during fertilization. However, it is perhaps the prostate's more notorious for causing two common problems in men as they age. One is difficulty with urination and the second, prostate cancer. [00:04:31] Speaker B: All right, so talk about what some of the comp. Common symptoms are of prostate cancer. [00:04:40] Speaker A: Yeah, so interestingly, this would come in sort of two. Two different categories, if you will. If people develop advanced prostate cancer before they come to attention and they have metastatic disease, they may present with symptoms such as bone pain, they may have weight loss, they may have difficulty with urination, they may have blood in the urine. But these days, far more commonly, patients are diagnosed through screening, which is detecting the. In this case, potentially detecting the cancer through a blood test. And that occurs at a. Typically, we find cancers through this route roughly six to 10 years earlier than we would find them otherwise. This typically means that people are completely without symptoms this day and age. Actually, the most common symptoms at the time of prostate cancer diagnosis are no symptoms. Actually. While it's true that there is some overlap between people who have prostate cancer or just have enlargement of the prostate that results in urinary symptoms, most of the time, if people have symptoms of difficulty with urination, it's not due to cancer, but due to benign enlargement of the prostate. [00:06:08] Speaker B: All right, so let's take a step back here. So you're talking about how cancer is typically detected or diagnosed. And you're talking about. Now that you start out, I presume you're talking about imaging, like mri, or are you talking about blood tests that you guys do? So would that be included in like a guy getting their just medical, that they're going in for a yearly exam, or would they be going in because they have a family history of prostate cancer? Because generally I think you wouldn't. I mean. Or do you just test everyone yearly if they come in for a medical exam? [00:06:57] Speaker A: Yeah, that's a great question. So in some respects, all of the above could be true. So sometimes people come to attention because they do come into the office, whether it's their primary doctor's office or urologist's office, because they're having some difficulty with urination. And in the course of the workup, again, most likely it may be due to non cancerous enlargement of the prostate, but we always would want to rule out a cancerous cause. So they may end up getting checked out. From that perspective, certainly men who have a strong family history of prostate cancer, typically along the way, if their family members have been treated, they've been alerted to the fact that they should also be checked out starting at a relatively early age. And so that's another way that people come to be tested. And then lastly, as you suggested, just through sort of pure screening, when you come to your doctor after having a discussion about the potential risks and benefits of screening, men may opt to move forward with a blood test called the psa, which stands for prostate specific antigen, which again, is a blood test that helps us determine if there's something going on with the prostate. And one of those things could be prostate cancer. [00:08:24] Speaker B: All right, so I still am a little bit hesitant because, so I think, you know, when boys are growing up, parents try to be pretty good about getting their kids in for their yearly exams and whatnot. But pardon me, all you males out there, guys I, that I know typically don't like to go to the doctor. They just kind of. The yearly exam is something I feel like they think of more as women do. And so a lot of times when I hear about guys going to the doctor, it's not till they're noticing something or there's something wrong or they need something else taken care of. It's not just a yearly, hey, how am I doing? So I'm guessing there are differences. Like there are some men who just do that, go in for a yearly exam, and they're really good about it. And so you must have numbers on how many people come in and are caught at an early stage and how many people get caught at, oh, there's something wrong stage. [00:09:32] Speaker A: Yeah, well, the majority. So you're absolutely right. So men are notorious for, for avoiding the doctor. Sometimes. That is absolutely true. And again, sometimes the way that we end up finding people is because, again, they're having some trouble with urination. And so that sometimes is the way in the door. But again, a large fraction of people that, those that do go to the doctor may have a discussion, and this is often in their primary care doctor's office, about whether they want to be screened for prostate cancer. And the reason why there is sometimes a discussion around this is because the PSA test that we use, while it's a very sensitive marker for, as I like to describe it, for something going on in the prostate, it is not specific for cancer. And so just because the PSA is elevated or considered to be abnormal, does not mean that there's cancer presentation present, but it does mean that perhaps further evaluation may be warranted. And the challenge is that because prostate cancer is extremely variable, there are some prostate cancers that are so slow growing and indolent that they're unlikely to even bother a man during the course of his lifetime, all the way up through life threatening prostate cancer. And the PSA test does not necessarily do a great job of discriminating between those two. So when you get screened for prostate cancer, one of the risks is that you could identify a cancer that you really didn't really need to know about over the course of your lifetime. And then you may end up getting subjected to additional tests and possibly even treatment that could impair quality of life. And it's not clear that that treatment was and will actually extend. Extend your life. [00:11:34] Speaker B: So a downside to doing PSA testing. [00:11:38] Speaker A: Correct. [00:11:39] Speaker B: Can you talk about, for the listeners out there, what PSA stands for and exactly what, what that means when you're getting a PSA test? What are you doing? [00:11:50] Speaker A: So the PSA stands for prostate specific antigen, which means it's a protein that's made only by the prostate gland. And if you have a prostate intact in your body, in other words, if we haven't taken it out of you or radiated it or done something to it, there's always some PSA circulating in your blood. Now, when there is some change in your prostate, shall we say, your PSA may go up. And that change could be something as simple as enlargement of the prostate. So as we get older, our prostates tend to get bigger, and a bigger prostate tends to make more psa. If there's any inflammation in the prostate, like a prostatitis, your PSA may go up. If you have a urinary tract infection, your PSA could go up. If you have urinary retention, your PSA could go up as well as prostate cancer. [00:12:42] Speaker B: Dr. Warlick, I wonder if you could talk a little bit about the different stages and how they might present. [00:12:50] Speaker A: Sure. So the most common way, again, that we identify prostate cancer these days is through PSA screening. And the vast majority of cases that are diagnosed through PSA screening are going to be what we refer to localized prostate cancer, meaning that the cancer is confined to the prostate and, or the immediate surrounding area. And in that situation, then if therapy is warranted, then the therapy is directed essentially to the prostate and the surrounding area, but without necessarily treating the whole body. On the other hand, if prostate cancer at the time it is diagnosed has already spread from the prostate and has taken up residence in some other part of the body, then directing therapy to the prostate alone would be inadequate, and you need something that's going to treat the whole body. The first line therapy for patients with disease that has spread from the prostate to other parts of the body would be what we refer to as hormone therapy, which essentially is a treatment whereby we lower the body's testosterone levels. So you can think about it. That testosterone serves as a fuel for prostate cancer. And if you starve the cells of their fuel, you'll kill many of the cells or halt the growth of others. And that can be a very effective treatment to control, although technically does not cure, but to control prostate cancer that has spread. And typically the control is for years. [00:14:31] Speaker B: So can you talk about some of the primary risk factors for developing prostate cancer? Are there people who could. Who maybe do things in their lives that are more risky, that could make them more prone to developing this cancer? [00:14:51] Speaker A: Yeah. So, interestingly, one of the biggest risk factors for development of prostate cancer is simply age. As we get older, as we get older, our risk of prostate cancer goes up. Now, again, this is an important nuance to understand that because of the wide range of aggressivenesses of prostate cancer, if you will, while the risk of prostate cancer goes up with age, many, many of those cancers are never going to harm a man over the course of his lifetime. And there are some estimates that would suggest that by the time men get into their 80s, well over half of men would have some evidence of prostate cancer in their prostates if you took their prostates out and looked at every last cell. Now, again, the vast majority of those are never going to bother those men over the course of their lifetime. So age is one clear risk factor. We know that diet is a risk factor. And so diets that are rich in things like animal fats, beef, dairy, those sorts of diets are at a higher risk compared to diets that do not contain as much of those components. And so diets that are much higher in fruits, vegetables, and in particular, there are some compounds like lycopene and tomatoes. Other cruciferous vegetables like broccoli and cauliflower with antioxidants can be very helpful. And so, roughly speaking, what we say, is heart healthy, is prostate healthy? So things that you might eat that would help protect your heart will actually, as it turns out, also be protective of for your prostate. Now, it's important to understand that these dietary effects are matter over the course of decades. So very short changes in the course of your diet are unlikely to have a direct effect on your cancer. They're not going to hurt if you make those changes, for sure, and we would never dissuade people from doing that. But really, these effects are over decades, from your sort of early years into midlife. [00:17:09] Speaker B: Gotcha. So is there a genetic component to prostate cancer? And if so, how much does it play into it? [00:17:21] Speaker A: Yeah, it's it's very interesting. The vast majority of patients that get diagnosed with, with prostate cancer, there is not necessarily an obvious family history, necessarily, but there are some instances where there clearly is a very strong family history. And in those families, when we have done analyses to see if there is a specific gene that could be identified, there are a handful of genes that are associated with a significant increased risk of prostate cancer. And probably the most notable of these would be brca. So we typically think about BRCA mutations. [00:18:02] Speaker B: Women. I always think about that in women. [00:18:04] Speaker A: Yeah, absolutely. With breast and ovarian cancer cancer. However, it also is a risk factor for prostate cancer. So in families that have not only high rates of prostate cancer, but if on the in the women in the family also have high rates of breast cancer, then it may be worth screening the men in the family also for BRCA for concern about prostate cancer. [00:18:32] Speaker B: Just an interesting side note, I was told years ago that men can also get breast cancer. It is rare, but they can get that. And you never think of that. [00:18:44] Speaker A: Correct. [00:18:45] Speaker B: So it is amazing what the medical things can happen. So what age should men be getting screened for prostate cancer? And I presume that would also make a difference with if they had a strong genetic component that suggests they are more likely to be to get it. [00:19:10] Speaker A: You are correct. So we generally think about putting people roughly in sort of, in sort of two buckets. Men of average risk and men that are at high risk of developing prostate cancer. And so for men of average risk, this would be typically be men that do not have first degree relatives, that have a history of prostate cancer, and men that are not of African descent. Those would be men that we would generally speaking consider at average risk. And in those men, guidelines would suggest starting screening for prostate cancer at age 50 and certainly by 55 for people who are at higher risk. So again, if you have a first degree relative or multiple first degree relatives with prostate cancer or are of African descent, we would suggest screening five to 10 years earlier. And so for those patients getting a baseline PSA around the age of 40 would be suggested. Now, another really important thing to understand when we're talking about doing PSA testing, particularly in the context of screening, is that we also know it's important that men have to have at least a 10 to 15 year life expectancy to think that they're likely to benefit from detection or finding a screen detected cancer or treatment of a screen detected cancer. In other words, because a lot of prostate cancers are, relatively speaking, slow growing, if men have due to either age and or other health issues. If we think that it's likely that they will succumb to other things within the next 10 years, then one needs to think long and hard and have a very informed discussion about whether it's worth screening for prostate cancer. Because again, in those men, the risk would be that you might discover a cancer that otherwise was never going to bother them. And once you've discovered it, you may be again then subjecting them to testing and, or treatment that may not benefit them in extending their life, but could have detriments to their quality of life. So that's an important thing to remember, that life expectancy is a big determinant about the likelihood of benefit from PSC screening. [00:21:43] Speaker B: So two things I'd like to step back on. So you talked about something that was coming up was race, and you inferred that perhaps if you were of African American descent that you would be at a higher risk of prostate cancer. How much higher does that tend to be? And are there other races that tend to be up high like that? [00:22:11] Speaker A: Yeah, so we tend to see higher rates in African Americans. We also see elevated rates in Native American populations as well, which is relevant for our communities here in Minnesota. And the risk is generally about one and a half times, in the ballpark of one and a half to two times the risk of both in terms of getting prostate cancer and also the risk of dying from prostate cancer is also elevated among those groups. Now, interestingly, as it turns out, that risk of dying from prostate cancer, those that disparity differs based on where you live. And as it turns out, we in Minnesota are actually quite fortunate that we have one of the lowest, if not the lowest disparity at about 1.4 times the risk of death among those of African descent compared to Caucasian populations, compared to, I believe that the latest data that I saw was the worst in the country was actually Washington, D.C. where the risk was about 3.2 times. [00:23:16] Speaker B: And what do you attribute that to? [00:23:18] Speaker A: Well, that's a, that's an even better question, and one that I wish I could give you a very definitive answer. But we certainly know that part of this, of course, has to do with access to care and that if, if underserved populations don't get access, have the same access to care, access to screening and, or, and, or treatment, then we would expect that their risk of death, you know, certainly would be higher. And so, but even in some studies that have looked at the incident and, or risk of death from prostate cancer in situations that would be considered equal access, such as The VA health system, for instance. In some of those studies, we still see differences in the outcomes for men of African descent compared to Caucasians. And interestingly, in other studies, we do not. So it's a very. It turns out that it's a very complex, very complex topic, and one that's still being actively investigated. [00:24:22] Speaker B: It feels like this is the case of many cancers that, you know, some. It's almost. It almost feels to me like when I hear these things that it's, how well does a person's body respond to treatment? Or how well, you know, what does cancer do with that person's individual body? Even though you have statistics, you know. Do you know what I'm saying? [00:24:49] Speaker A: Absolutely. And so to your point, you know, one of the interesting things when you. When you talk about cancer risk in general is that for a given individual, what seemed, you know, one of the how and whether cancer manifests seems to be on some level, an interaction between sort of what your internal makeup is. Okay. And a lot of that governed by what your genetics are. Okay. And that interaction with the environment. And what I mean by that is. So we all know that in general, smoking, for instance, is a big risk factor for things like lung cancer. And yet we probably also know lots. Examples of people who smoked their entire life and never developed lung cancer. And then we also know other people that maybe only were exposed to secondhand smoke and maybe for just a few years during their growing up, and yet they develop lung cancer for other applicable reasons. Right? [00:25:55] Speaker B: Yeah. [00:25:55] Speaker A: So. So sometimes it's our interaction between our genes and the environment that dictates, you know, whether or we are susceptible to given health conditions in general, but certainly cancer. [00:26:11] Speaker B: Now, having said that, before I leave this topic here. Are there races that you see virtually almost no existing prostate cancer in? [00:26:22] Speaker A: I would say there's no populations in which we don't see any prostate cancer. However, there are lower rates in Asian men and in particular, Asian men that live in Asia. And this is presumed. Having supposed. This is presumed to have a lot to do with diet. And there were some studies that have shown that, again, if you take men that live in Asia that have a lower rate, bring them over to a western culture and have them eating western diet for 10 to 20 years, that their risk starts to approximate that of the general population in the western culture that they're living in. So, again, diet probably is an important. Well, definitely is an important component, but again, not in the short term, but kind of over the long haul. [00:27:16] Speaker B: Dr. Warlick, we discussed PSA treatments. I'm not sure if we covered the next treatment, but can you talk about how the different treatments, like, what are the concerns about what the side effects might be? [00:27:38] Speaker A: Sure. So, again, the majority of prostate cancers currently are diagnosed at a relatively early stage of disease, where, again, we believe the cancer is confined to the prostate and. Or the immediate surrounding area. And in that scenario, the two mainstays of. Well, I would say there would be three management strategies. Right. So one would be observation. So for a significant fraction of men, we may choose not to treat them up front at all, but to simply monitor them. And we monitor them through repeating PSAs periodically, roughly every six months. And then we also repeat imaging, such as MRI imaging of the prostate cancer, which is our best way to see prostate cancer. And for some of those men, they also will undergo repeat biopsies, which is where we take small samples of tissue from the prostate to see what we find. That's the gold standard to see what's going on in the prostate is take tissue out of the prostate. And that is, in fact, the only way to technically diagnose prostate cancer. So, again, PSA draws our attention to the prostate. It's a screening tool that says something if it's abnormal, says something may be going on with the prostate. One of those things could be cancer, but then it requires further workup before you're actually diagnosed with cancer. And the way to diagnose cancer is by doing a prostate biopsy, where, again, we take small snippets of. Of tissue out of the prostate and look it under the microscope and the pathologist can tell us if there's cancer there. [00:29:15] Speaker B: I want to stop you just for a minute because, you know, you touched on something that, about surveillance and just kind of watching, and that can create some, in, especially in some people, a high amount of anxiety. And so I'm wondering, are there downsides to just watching? [00:29:35] Speaker A: Yeah. So you're absolutely correct that anytime one uses the word cancer, it definitely increases the anxiety in the person that was given that diagnosis. And so, as it turns out, again, observation certainly, as we suggest, is not for everybody, but for a significant fraction of men, it actually can be quite an effective strategy of balancing the cancer risk with minimizing impacts on quality of life. Generally speaking, the treatments that we have, the definitive treatments for prostate cancer, including surgery and radiation, have some side effects that can impact quality of life in terms of urinary, bowel, and sexual function. Because of that, obviously, if one can avoid those potential side effects or delay them, oftentimes, that's going to be Preferable. And so that's where the concept of active surveillance comes in. And so again, in this process, we monitor men with periodic imaging, PSAs, and again, repeat biopsies. And as long as we don't see evidence of disease progression, we continue to monitor them. Now, there's no question that this is a little bit anxiety provoking in the beginning, but through counseling patients and spending the time to explain what that risk really is and how low that risk is, and so we're talking about, in well selected men, less than 1% of developing disease spread over 10 years, then people start to become a little bit more comfortable with the concept. And as time goes on, after they've been on surveillance for a year, two years, three years, four years, then people become much more comfortable with that concept. So it can be anxiety provoking, no question about it. But that's where hopefully information can help us wage some of that concern. [00:31:34] Speaker B: So presumably when you talk about the radiation therapy and surgery, that that is for people who have either a more aggressive prostate cancer or one that has had prostate cancer proceed beyond the early stage. Can you talk about the outcomes then for patients when they have to do one or the other? Or does radiation always equal having to do surgery as well? Or can you do them separately as far as radiation could take care of everything, or you have to do surgery after? [00:32:17] Speaker A: So generally speaking, when people are being treated for localized prostate cancer, again, when it's confined to the prostate or the immediate surrounding area, the goal is to do one or the other. Ideally you would have surgery or radiation. That being said, if you have surgery, it is possible to do radiation afterwards if we have evidence that the disease has recurred. So that does remain an option. However, it is the intent of that initial curative treatment that hopefully that's all that you would need. [00:32:51] Speaker B: Right. [00:32:52] Speaker A: And so either surgery or radiation, we do consider them to be equivalent in terms of their ability to control and cure cancer. Neither is perfect, but we do consider them equivalent. However, one of the big differences, and this is where the decision making often comes down to, is that there's side effects, profiles are different. And so when patients are deciding which way they want to go, assuming that they're not going to do observation, but they're going to treat their prostate cancer, oftentimes it's a question of which of these side effect profiles sounds the least bad to me. [00:33:30] Speaker B: What's the lesser of two evils? [00:33:33] Speaker A: Exactly. What's the lesser of two evils? And as it turns out, of course, that answer differs by man. Right. And so it depends on what their priorities are, what their lifestyle is like, the things that they think they could live with versus things that they don't think that they could live with. And that often goes into the decision making. That's key in the decision making process. [00:33:55] Speaker B: Can we go through the side effects to which thing? [00:33:58] Speaker A: Absolutely. So with surgery, we typically talk about two big risks, and that would be the risk of leaking urine following the procedure and the loss of erectile function. The reason that urinary control is in this discussion is that essentially in the process of removing the prostate, we get rid of, let's say, two out of the three urinary control mechanisms that men have. And that last urinary control mechanism has to then sort of beef up. It's sort of got to learn to do the work of three. And so over time, and doing some pelvic floor strengthening exercises, the urinary control tends to come back. But it does take several weeks to months for that to happen. Now, fortunately, in this day and age, if you look at a year from surgery, about 90% of guys will get to the point that they are dry socially, meaning that they don't need to wear any pads in their, in their underwear to control the, to control the leakage. So most people get there somewhere in the three month range to six months, but there are some stragglers that take a little longer. But that's why urinary control is in the discussion. And then the other risk of prostate cancer treatment, radiation, and surgery. But certainly surgery is the risk of erectile dysfunction. And this is because the nerves that run to the penis to mediate blood flow for erections are attached to the side of the prostate, kind of where the prostate and the rectum sort of come together. And so in the process of removing the prostate, we inevitably are going to injure those nerves to some extent, because again, they're attached to the prostate. But in, in men in whom it's safe from a cancer control standpoint, we can sort of preserve those nerves, kind of scrape them off of the prostate and leave them largely intact. And those men, the likelihood of being able to have an erection after the procedure is significantly higher. And again, if in an ideal situation with a lot of caveats, up to perhaps 70% of men will still be able to have erection sufficient for intercourse with or without the use of medications like Viagra, again in a year from surgery. [00:36:13] Speaker B: And we talk about like, maybe they have some nerve regrowth. [00:36:18] Speaker A: Well, some nerve recovery, if you will, sort of, you know, there's as I said, there's sort of a little bit of injury to those nerves from the manipulation, but then over time, they heal up. And so the erectile function tends to improve over time for many of those men. And then with radiation, the side effect profile is a little bit different. So there are effects on the urinary system, but in this case, it's really the risk of developing what we would refer to as irritative urinary symptoms, such as urgency of urination or frequency of urination, as opposed to leaking with activity, which is what the risk is after surgery. And then after radiation is also a risk of recurrent blood in the urine from changes, irritation of the bladder from the radiation. And then there also can be irritation of the rectum, because, again, the rectum sits just underneath the prostate gland. And so the rectum can be irritated by radiation as well. That can result in urgency or frequency of stooling, chronically loose stools, or blood in the stool. And now there are some techniques these days, though, that we can. Where we can reduce that risk of rectal toxicity. And so that's been a significant benefit. And then lastly, erectile dysfunction is also a risk of radiation because those same nerves we were talking about can also be damaged by the radiation in addition to surgery. The timing is a little different in terms of the injury. It takes a couple of years before the worsening or new onset of erectile function manifests following radiation therapy. So again, the side effect profile is a little bit different between surgery and radiation. And again, that often goes into the decision making. [00:38:02] Speaker B: And is this because radiation stays in your body so much longer, therefore, you know, you have changing stuff, and then. But if you have surgery, bang, it's done. [00:38:14] Speaker A: To some extent, that is true. So the changes that occur following radiation, they do tend to sort of accumulate over time. And so that while there are some acute effects on the prostate and the surrounding tissues at the time of radiation, some of the effects do tend to manifest down the road that were not present initially. They manifest down the road. And to your point, with surgery, it kind of is a little bit opposite in the fact that you kind of take your hit immediately up front and that things, you know, over the next several months, you know, tend to tend to improve to the degree that they're going to. [00:38:56] Speaker B: Are there new or experimental treatments on the horizon here with this? [00:39:02] Speaker A: Absolutely. So I would say that, you know, one of the most exciting things about. About being in the field of prostate cancer is just the tremendous progress that has been made over, just over even my career. And the biggest area of improvement has been for men with advanced disease. And so, just for just a little bit of perspective, the discovery that lowering the body's testosterone levels could help treat prostate cancer was first identified in 1942 by two guys named Huggins and Hodges. And they ended up getting the Nobel Prize for that. I believe it was 1966. But showing that you could lengthen life for men with metastatic prostate cancer by decreasing their testosterone levels. From that point on until about 2005, there were no new medications or treatments that showed any benefit to lengthening life for men with metastatic prostate cancer. And then in around 2005, became sort of the first new medication, a chemotherapeutic agent that came on board. But since that time, over 2005 till now, so the last 20 years, there's just been an explosion of new treatments that are available, probably on the order of, off the top of my head, about 10 new treatments that have become available, and all of which have shown a survival benefit. And so now where we're at in the. In figuring things out is figuring out, okay, we've got all these tools to work with, what are the best combinations or what are the best sequences to use these medications to get the maximum benefit, when's the best time to introduce them for the first time? And so the field is just a flurry of activity of trying to figure. Figure out with all these new tools, how to best utilize them. And so life expectancy for people with advanced prostate cancer is lengthening sort of almost before our eyes. And so that is a. That's an extremely, extremely positive sort of turn of events, and very exciting. And then the other area that I would suggest is another area of excitement is on the other end of the spectrum. So for men, again, who have localized disease, but for men who have, you know, disease, that. That is a little bit more than we're comfortable watching only, but we're also not convinced that they need to have their entire prostate removed or have their entire prostate radiated. There is the emerging concept of what we refer to as focal therapy, where through a variety of modalities, we try to just treat the part of the prostate where the cancer is and spare the rest of the prostate. And the idea being that we can still gain adequate cancer control, but with a lower risk of side effects. And so that's another very exciting area. [00:42:15] Speaker B: I'm wondering, you touch a bit or quite a bit about radiation. Does chemotherapy or immunotherapy play any part in prostate? And if not, why don't they does it not adequately touch that or. [00:42:35] Speaker A: That's a. That's a great question. And the answer is that, yes, they do play a role. And again, really more recently is where that the data has come from to, to support that. So it's very interesting because the first new agent that I was referring to that came about around 2005 or so was a chemotherapeutic agent by the name of Docetaxel. And the way new drug development typically works is that when you have a new agent, it's often tested in people with the most advanced disease. And if it shows efficacy in patients that have, that have no other, you know, have exhausted all their other choices, that, again, those are the first patients that gets tested in. And if it works there, then oftentimes people start moving it up a little bit earlier in the natural history of the disease and see if it works there. And if it works there, they say, oh, well, maybe there's even more benefit if we introduce this even earlier. And so in the. When docetaxel first came about, it was only introduced in patients who had evidence of metastatic prostate cancer, meaning it already spread to other parts of the body and who no longer. Whose cancer was no longer being controlled by lowering the body's testosterone levels. [00:43:56] Speaker B: Right. [00:43:56] Speaker A: So when you lower the testosterone levels, it controls the disease for a period of time. It does not cure people, but it controls it for a period of time. But then the cells typically figure out how to grow even in that low testosterone environment. And that's where docetaxel first showed a benefit that even in those patients, that at that point, we really didn't have any other options for them. Now we showed benefit, but now it's being introduced earlier and earlier and earlier. So now we are also considering, for many patients, they see docetaxel when they, if they have metastatic prostate cancer, that still would respond to lowering the body's testosterone, and it's used in conjunction with that treatment, and that's been shown to be more beneficial than just doing the lowering of the body's testosterone levels by itself. So, so we do see an evolution in terms of how we're using these, these medications. And so that's where chemotherapy has a role. And again, a growing role compared to what it, what, what the role used to be, you know, 10 years ago. [00:44:57] Speaker B: Right. [00:44:58] Speaker A: And then similarly, immunotherapies are also being looked at, and there's a. It's a smaller fraction of men that benefit from that, but it is also being utilized in some men. [00:45:13] Speaker B: What does recovery time impact look like after treatment? What are we talking? [00:45:22] Speaker A: Yeah, so following following surgery, the recovery time is, is fairly straightforward. So currently, most prostate surgeries are performed robotically. And so this means that we place little keyholes through the abdomen, and then the robotic instruments are inserted through those keyholes. The surgeon, however, is still 100% controlling the robot. So it is not as if you press a button and the robot does the surgery on its own. The surgeon is completely controlling the movements of the robot. But, but this allows us to do it in a, in a, a less invasive way and allows us to do a better operation in a lot of ways than we were able to do when we were doing these with, with traditional open surgery. So the vast majority are, are done robotically, and this allows patients to go home the next day, or there are some places that are even sending patients home the same day following a radical prostatectomy. But, but most patients end up staying overnight, and they, they have a, a catheter, a urinary drainage catheter in their bladders that stays in for seven to, seven to ten days or so. And this is because, as we, when we remove the, we have to separate the prostate from the bladder, separate the prostate from the urethra, and then we bring the bladder down to the urethra and sew them back together. And so it takes about a week or so, a little more than a week for that to become watertight. And so until it does, we have a catheter in the bladder to drain the urine out so it doesn't leak out through that, that area where things were sewn together. And so people have that in for about seven to 10 days, and then that comes out. And then they run a lifting restriction for about six weeks then before they can get back to doing more strenuous activities. And then once that catheter comes out, then they start working on their urinary control as well. And so again, we send patients to physical therapy to do some pelvic floor strengthening exercises to help hasten the return of their urinary control. [00:47:35] Speaker B: So you are talking months. [00:47:38] Speaker A: Yep. [00:47:38] Speaker B: So with anything like this. And I'm wondering If you can, Dr. Warlick, talk a little bit about mental health through all this. How do you think that's appropriately addressed when men are coming in to do all this other stuff? I mean, sometimes I feel like mental health gets neglected. How has that increased the, you know, to be able to do that for men? [00:48:12] Speaker A: Wow, that's a great question. And I would say that you are correct. That Sometimes those issues kind of get pushed back a little bit because to your point, there's so much of the physical that is going on. But it's important to remember for all of us that as we walk with men through this treatment, that there's no question that things such as incontinence that can happen, or even if it's not incontinence, but changes in urinary function, changes in bowel function, changes in erectile function can, in and of themselves, not only are there the physical issues, but cause a lot of anguish and depression in some of these men following their prostate cancer treatments. And so in addition to the fact that they have cancer, the treatments often can result in some sort of decrease in their quality of life. And so there's no question that this can be an issue. One of the things that's important or that seems to be very helpful, of course, for men going through this is a support system. And interestingly, obviously, people have. People have. If they're fortunate enough to have family support and someone that the family that they can share this burden with, that has shown to be extremely helpful. But one of the other things that men find, as it turns out, is sort of the term that we refer to as the reluctant brotherhood. And that is that because. Because prostate cancer is as common as it is, it is often the case that a man will find out that he didn't know it, but several people that he knows or friends of friends have been through have had prostate cancer and maybe managing it in a variety of different ways, but have been diagnosed with the same issue and understand what they're going through. And so oftentimes they find out that people start coming out of the woodwork once they. Once someone finds out that they have prostate cancer, their friends and neighbors, like, oh, I had prostate cancer. Oh, my brother had prostate cancer. Oh. And then that also can provide a community of support that I think people did not necessarily anticipate. We also have things like support groups that people can access that can help provide support. And again, it's important to remember in those situations that everybody's journey is individual and everybody's experiences is unique to them. But there certainly are some commonalities that talking with other people in that same boat, it can be very helpful in supporting their mental health. [00:51:17] Speaker B: Right. And presumably the mental health thing comes with. Sometimes you're dealing with, you know, it can be very taxing on a relationship if you have a partner. And there. And there the. Maybe the side effects of the cancer were a little more than you were expecting, and now you have to make other lifestyle changes. So I hope that medical providers are encouraging, you know, support groups or counseling and things like that. [00:51:52] Speaker A: Yeah, absolutely. And, and again, it's. Especially for men. This is not something that they typically seek out traditionally. And so, you know, we certainly, we certainly encourage that and, and hope that they will take it, take advantage of that, because it can be, it can be very helpful. We do see an evolution over, over time. Whereas, you know, in the beginning, oftentimes men are very focused on, you know, the cancer component, which makes all the sense in the world, and they sometimes in some regards, dismiss a little bit some of the effects of this, of the side effects that, you know, that that may be having on them. But as they get out further and it becomes clear that the cancer seems to be in remission, that we have no evidence of disease, then all of a sudden those other issues start to creep back in importance, and that's a great time to address them again. [00:52:56] Speaker B: I want to quickly open this up to Charlene, my PR person, and make sure she doesn't have any questions in regards to this. [00:53:06] Speaker A: I really don't. Did a good job with the questions and the answers. I have lots of male family members, and we've been fortunate not to have to do with prostate cancer. [00:53:22] Speaker B: You're lucky. [00:53:24] Speaker A: Yeah. [00:53:25] Speaker B: Dr. Warlik, I want to thank you for coming on. I really appreciate your time this morning. So thank you very much. This is very knowledgeable, and I hope that we will have you on again in the future when there's more changes that are coming for treatments. [00:53:41] Speaker A: Absolutely. Thank you so much for having me. It's been a wonderful discussion this morning. Thanks again. [00:53:46] Speaker B: Thank you. You've been listening to Disability and Progress. The views expressed on this show are not necessarily those of KFEI or its board of directors. My name is Sam. I'm the host of this show. Charlene Dahl is my research person. Erin is my podcaster. We are at Disability and [email protected] if you want to chat or bring new topics to the table. Today we were speaking with Dr. Christopher Warlick. Dr. Warlick was talking about prostate cancer. This is KFAI 90.3 FM, Minneapolis and KFAI. Org. Thanks so much for listening.