Ask Us Anything About… Prostate Cancer

Screen opens inside a private clinic room where two male individuals are standing next to each other in front of medical equipment attached to the wall. Standing on the left is Dr. Jay Raman and on the right is Scott Gilbert.

Scott Gilbert – Welcome to another installment of Ask us Anything About here from the Milton S. Hershey Medical Center. Today it’s Ask us Anything about Prostate Cancer. It was in a media interview earlier today that actor Ben Stiller revealed that he was diagnosed with prostate cancer two years ago. And he underwent laparoscopic surgery to cure it. His diagnosis came after a prostate specific antigen or PSA test that he underwent at age 46. It flagged the issue. A couple of years later he had an MRI that confirmed the diagnosis along with a biopsy as well. Now Stiller does not have a family history of prostate cancer nor any specific risk factors yet his doctor decided to include that PSA test in a routine physical at age 46 for him. Now that probably has some men wondering exactly when they should start getting a PSA test because the kind common guidance we often hear is around age 50. So here to help answer some of those questions for us is Doctor Jay Raman. He’s head of the division of urology here at the Milton S. Hershey Medical Center. Doctor Raman thanks for making the time today.

Doctor Jay Raman – Yeah. Thanks very much, Scott. Appreciate it

Scott Gilbert – Yeah absolutely. Let’s start by talking about the PSA test for people who may not know what it is. What exactly is it? What does it tell you as a physician?

Doctor Jay Raman – So the PSA test is a blood test. PSA is prostate specific antigen. It’s a protein. And any man with a prostate will have some PSA circulating in the blood. What we know is that higher PSA levels can be a clue that there is some problem within the prostate: maybe an enlarged prostate, maybe inflammation, maybe infection. But what we really worry about the most is could a high PSA be a sign of prostate cancer?

Scott Gilbert – So it doesn’t indicate a definite diagnosis of cancer? It’s takes things — well, I guess in Ben Stiller’s case it was an MRI and then a biopsy. Is that a typical course that these things follow in diagnosing?

Doctor Jay Raman – Yes, I think you’re absolutely right. So a PSA being elevated simply is a clue that there may be some problems, some pathology in the prostate. But it certainly is not diagnostic of cancer. In fact, the only way that we can truly diagnose cancer is through a prostate biopsy where we take small specimens — small snippets from the prostate, and then pathologists look at this under a microscope and determine; okay, does this snippet look like cancer or not? MRI is a really interesting tool that’s been used increasingly to help us really determine is a biopsy warranted? And what portions of the prostate are suspicious areas that may require greater detail in biopsy or greater attention at the time of biopsy? I would tell you that the standard of care some centers tend to use biopsy as well as MRI. Others simply take an elevated PSA. And if the PSA is high enough, progress directly to biopsy without using MRIs and adjunct.

Scott Gilbert – Now is PSA the main early diagnostic tool for something like prostate cancer? Or are there other things you use at that early stage?

Doctor Jay Raman – Yeah, so I think when you look at diagnostic tools for prostate cancer, PSA was developed back in 1995. So it’s sort of has the street credibility. It’s been there for 20 years. It is probably our most well used and most often used test. But I think owing to some of the limitations — owing to the fact that not all men with an elevated PSA will necessarily have cancer. There are some newer tests that have come out: prostate health index or PHI, the PCA3 test which is prostate cancer antigen test, Pro-PSA. So these are all different versions that can be used in a diagnostic screening setting. But many of them have been more in an exploratory phase and not any of them have really supplanted PSA in 2016.

Scott Gilbert – You’re watching Ask Us Anything about Prostate Cancer from the Milton S. Hershey Medical Center here on Facebook live. Feel free to add your questions to the comment field below and we’ll pitch them over here to Doctor Raman and ask him those questions. And I guess then the next question I have is about the issue that’s raised by Ben Stiller with his type diagnosis. He and his doctor were on a satellite radio interview this morning saying, “Listen, Ben here was diagnosed because of a PSA test he had at age 46, 40 years before the kind of standard guidelines recommend having it at age 50. So he’s encouraging every man 40 and older to have a conversation with their Doctor.” What’s your take on that?

Doctor Jay Raman – So I think Ben Stiller’s case is an unusual one. And I think if you look at national statistics on the diagnosis of prostate cancer and rates of prostate cancer when you have men under 50 years of age, you’re looking at about five percent of men having cancer. And so one of the challenges is, appropriately screening patients. So you don’t want to necessarily screen everyone to identify a very few number that may benefit from diagnosis and therapy. I seem to subscribe very much to the idea of our national guidelines which are the American Neurologic Association which is really screening patients between ages 50 and 65 who have an average life expectancy anticipated at 10 years or greater. The idea is at that timeframe, you will likely pick up a high enough percentage of men with cancers and cancer that may require therapy. And so although his case is a unique one and clearly he has benefited from early diagnosis, I would still subscribe to 50 years of age unless there are highly suspicious features in the family would be when I would start screening for [inaudible].

Scott Gilbert – I guess it all comes down to trying to strike a balance, right , between making sure you catch it early and not over testing?

Doctor Jay Raman – I think that’s absolutely right. So I think when you look at some of the controversies associated with PSA, the issue is largely overuse of PSA in patients perhaps who are too young or even those who are too old — those who are maybe 75, 80, 85 who may die of other causes within 3 to 5 years. And one could argue very much what’s the utility of sending a PSA test at that point diagnosing that person with prostate cancer if they’re likely to die of some other cause. So I really think that appropriate use and counseling for when we use the PSA, how do we react to a PSA being high, do we need to repeat these values, do we need to progress to a biopsy? Sort of a judicious use of the test, I think is what’s critical for the whole screening process.

Scott Gilbert – The numbers I’ve heard: is it about one in seven men in their lifetime will face a diagnosis of prostate cancer? Is that the latest?

Doctor Jay Raman – That’s right. So in 2016, one in seven men — and really to put it into context, about 30,000 men a year will die of prostate cancer. So when we talk about the fact that men are diagnosed — many are diagnosed at a very favorable stage; similar to Ben Stiller. But we have to remember at the end of the day, that there are prostate cancers that are aggressive and about 30,000 men a year do die of this disease.

Scott Gilbert – Every person’s cancer is different. Some will have a slow-growing tumor; right? And some, well, some can be rather aggressive. His, he said, had a Gleason score of seven which he said made it a midrange aggressive tumor. Could you talk about what that means? What the Gleason score is and that sort of deal?

Doctor Jay Raman – Sure. So, I think you’re absolutely correct. When you look at prostate cancer, this is certainly not one homogeneous entity. So you can have low-risk prostate cancers, intermediate risk, and high-risk. And the way that we assign a lot of these low, intermediate, high risk, is based a little bit on your PSA at the time you’re diagnosed but also your Gleason score. And a Gleason score was really what the pathologist looking under a microscope when they look at the cells, how aggressive are these cells? A sixth is the least aggressive, a seven is midrange, and when you get up to eight, nine, and ten; those are the highest scores, that’s what we call aggressive prostate cancer.

Scott Gilbert – So, we do have a question from online here. I’d like to share it. It’s from a gentleman named Randy who asks, “The PSA of plus five at age 60. What is your personal recommendation? Next step was slightly enlarged prostate. Normal otherwise.” So, when we talk about a plus five, that’s rather low on the scale; right?

Doctor Jay Raman – Well, I mean what we use is we use age-appropriate PSA values. So what that means is a 50-year-old is allowed to have or should have a lower PSA than a 75-year-old. So for someone that’s 60 years of age, a PSA that would be normal would be a PSA under 3.5. And in this case — in this patient’s case that was — or the gentleman’s case that sent the message in, we’re looking at a PSA that’s elevated for their age. So I usually do two things when we see situations like this. The first thing is: I usually will repeat it. We want to make sure that we don’t overreact to a single value that may be high. Similar to how nobody is diagnosed with diabetes because of one sugar that’s high. Nobody is diagnosed with high blood pressure because one blood pressure reading is high. Same thing with PSA. We don’t want to over react to a single value. There are also other adjunctive tests. You can look at PSA by itself, three in total fraction. So there’s different ways of looking at PSA values in fractionated combinations that can really give you a clue. Does this PSA value alerts us enough that we may need to go down the road of MRI and biopsy?

Scott Gilbert – Good to know. You’re watching Ask Us Anything about Prostate Cancer from the Milton S. Hershey Medical Center. I’m Scott Gilbert joined by Doctor Jay Raman the Head of our Division of Urology here at the medical center. And we welcome your questions. You can add them to the comment field either now, if you’re watching live, or you can even add them to the video if you’re watching this maybe after-the-fact. You’re watching a playback version. We will pass those questions along to Doctor Raman for an answer as well. One question for you about the course of treatment. It looks like Ben Stiller, he had surgery. Laparoscopic prostatectomy it was called. And that was all he needed. He didn’t need radiation or chemotherapy. How common is that? Or is it — I guess this is another thing that’s very individualized?

Doctor Jay Raman – Yeah. So I think when you have a patient who’s been diagnosed with prostate cancer, the first thing we want to know is: is this localized to their prostate or is this spread elsewhere? Is it in lymph nodes? Is it in bone? Is it in liver? And I think prognosis and treatment very much depends on: is this confined to the prostate or has it gone elsewhere? Now in his case, he had a diagnosis; he had an MRI showing that it had not spread elsewhere. And so in those situations, we have several options: surveillance, if it’s a very low-grade cancer perhaps in an older patient; surgery, as he had which is really perhaps the standard of care in patients who have a long life expectancy. Such as he was diagnosed at age 48, life expectancy 20 or 30 years, one would argue that surgery gives the best potential long-term outcomes as well as radiation to treat the prostate. But those are all for clinically localized decease. And if you have disease that spread elsewhere, prognosis goes down but also the need for systemic treatment such as hormones and chemotherapy increase.

Scott Gilbert – Let’s go back to that issue of screening because that’s really what it seems like Ben Stiller and his physician are talking about in media today. They’re saying every man over age 40 should have a discussion with their doctor. What is your guidance today? And what will it continue to be, you know, for men coming into your office; your clinic?

Doctor Jay Raman – Sure. Well I think for me coming into the office, I think if they’re under 50 years of age, I tend to recommend not treating unless they have significant symptomatology attributable to their prostate, significant urinary tract symptoms, inability to urinate, blood in the urine, or if they have a notable family history of prostate cancer — father, brother, grandfather, multiple first-degree male relatives. Beyond that select group, I really look at men — starting at age 50 — I recommend that they have a discussion with either the urologist or the family doctor or their internal medicine doctor about the merits of prostate cancer screening. And that entails a little bit life expectancy, how they would deal with a diagnosis if a PSA was elevated that resulted in a biopsy, whether they would desire treatment or no treatment. And I think it’s important to have these discussions upfront because there are some patients who really would not want to know and would not want to pursue treatments. And I think that’s very important to have that conversation before lab tests are sent off. Beyond that, I really recommend checking PSA’s with rectal examinations every one to two years for men in their fifties and sixties. And I think the importance of that is really in identifying PSA trends and rectal examination trends so you can highlight and find cancers at an early stage before they’re locally advanced or metastatic.

Scott Gilbert – We do have one other question. This is from Randy. He asks us to explain again the specific MRI used. He’s asking for some details around that. Can you shed some light on that?

Doctor Jay Raman – Yes. So many centers use — we use for example here at Penn State it’s called a pelvic MRI. The pelvic MRI is with and without contrast. And what it really does is it gives us a zoomed-in view of the pelvic lymph nodes, the prostate, and the surrounding structures: the rectum, the bladder, the lymph nodes, the nerves that control sexual function. And so we call it here a Prostate Protocol MRI which has different sequences: T1, T-2, axial, diffusion weighed, fat saturation — all of which are sort of a word salad, but ultimately what it does is it gives us multiple different pictures to get a very crisp, clear view of the prostate to determine the capsule and whether there’s any penetration outside the capsule.

Scott Gilbert – And again, that’s the test that’s done after an elevated PSA is detected. But bottom line an elevated PSA is not necessary a reason to panic; correct?

Doctor Jay Raman – Correct. I mean I think in most cases if you look at men who have an elevated PSA — and even those that have an elevated PSA between 4 and 10 who go on to have a biopsy, only about 35 percent of those men at the time of biopsy will have prostate cancer. So realize that only about a third who have concerning enough features with a biopsy of cancer, two thirds don’t. And so some of the uses of the MRI are to help refine those predictions of who may benefit most from the biopsy perhaps to increase the diagnostic yield. Meaning, you would love to have a biopsy — a procedure where more of the biopsy has a yield thereby avoiding biopsying those who may not need it. And that’s the role of the MRI.

Scott Gilbert – You’re watching Ask Us Anything about Prostate Cancer from the Milton S. Hershey Medical Center. I’m Scott Gilbert alongside Doctor Jay Raman and we thank you for the questions online. And like we said, we encourage you to continue asking those questions online even if you’re not watching this live. You’re watching a playback version. We’ll make sure we get those questions to Doctor Raman and ask him to provide a written response that we’ll add to the comment field under this episode here. In closing, Doctor Raman, any last words of advice here for people watching about prostate cancer? The real takeaway, what you want them to know.

Doctor Jay Raman – Yeah. I think that the screening is key. And I think that knowledge about having yourself checked, having a rectal examination done, having the blood work done appropriately. I think one of the challenges is if you look at statistics, men sort of have a macho attitude. They don’t like to see doctors. They certainly don’t love to have blood drawn. And most would prefer never having a rectal examination. And I think the reality is, is that unfortunately prostate cancer is not symptomatic until it has spread to distant organs. And at that point, it’s not curable. So the challenge there is similar to breast self-examinations where you can feel a lump that can help you diagnose breast cancer. The only way in some situations to know that there’s a problem in the prostate before it’s gone elsewhere, is rectal examination and PSA. And, you know, I just finished my office hours today. And I think about several patients that I’ve seen who are younger guys who have PSAs in the several hundreds who have evidence of metastatic disease. And I think to myself a little bit: these are patients who if we had improved screening, we could perhaps identify them and capture them before we’re at a phase where we cannot cure them but we can simply treat them and try to control their disease.

Scott Gilbert – And as you mentioned, there are a lot of screening methods kind of being tested, being hashed out in addition to the PSA being —

Doctor Jay Raman – Yeah. So, I mean 10 years ago we only had PSA. Now we have PSA, we have PHI, we have PCA3, we have a number of different modalities not only at diagnoses; but if you have a biopsy and you have cancer, about perhaps predicting which ones of those cancers are going to progress. We have improved imaging, we have MRI, we have PET scans. So the technology that’s available to improve our ability to diagnose but also predict who has bad cancer or not, has dramatically improved over the past 10 years.

Scott Gilbert – Doctor Jay Raman, thank you for your time today.

Doctor Jay Raman – I appreciate it. Thank you very much.

Scott Gilbert – Doctor Raman is Director of the Division of Urology here at the Milton S. Hershey Medical Center. He joined us today for Ask us Anything about Prostate Cancer. And we thank you for joining us as well. We encourage you to follow him and Milton S. Hershey Medical Center on Facebook so you can get a heads up about future editions of Ask us Anything About. As I mentioned before, you’re watching a playback of this interview. Don’t hesitate to add your comments, your questions into the comment field. And we’ll make sure that we get an answer for you and post that online. Thank you again for watching Ask us Anything about Prostate Cancer today. Have a great evening.