Alicia Morgans: Hi. My name is Alicia Morgans. I am a GU Medical Oncologist at Northwestern University. I'm joined today by Doctor David Penson, the Chair of Urology at Vanderbilt University Medical Center. Thanks so much for coming to talk with me today, Dave.

David Penson: Thanks, Alicia. It's great to be here.

Alicia Morgans: I know this means a lot to both of us as we think about the patients that we treat and about this disease. What is the significance of Prostate Cancer Awareness Month, and what does it mean to you and your patients, Dave?

David Penson: Well, you know, Alicia, and you have more experience with this than I do, given your medical oncology training. People will often compare prostate cancer to breast cancer. Women are so much more proactive about taking care of their health, if I can generalize a bit. I think that's a fair stereotype. Prostate Cancer Awareness Month is a real opportunity to make people who don't really think about their health very much and think about issues that may affect them more aware of a very common cancer. I think a lot of men, and I can speak for myself, so I'm not going off the reservation here, don't really think about their own health. They walk around thinking they're invincible. They're tougher than nails, et cetera so forth.

The reality is that most men, if you look at cancers, prostate cancer is the most common solid tumor among American men. Most men don't even think about it, and they need to a little bit. So I think Prostate Cancer Awareness Month gives us a chance to talk about prostate cancer and perhaps some other men's health issues in a very safe space where men can reflect on it and hopefully take advantage of the increased awareness to talk to their family members, spouses, their friends, and hopefully their doctor, if need be, and get checked for prostate cancer if they want to, because this is still the most common cancer, like I said. Importantly, it's the second most common cause of cancer death in the US.

Alicia Morgans: Absolutely agree with you. What you're saying is absolutely true. One of the things that I think I just want to reiterate that you mentioned is that a lot of men are really stoic and really turn a blind eye to their health because of who they are in their family and the position that they hold, often being the bread winner, the bedrock of the family. That can be to their detriment.

One of the things that's so important to me about Prostate Cancer Awareness Month is that it gives the opportunity for them or for their family members, actually, to talk to them about this disease. For kids to talk to their parents about it. For friends to talk to their friends or their loved ones about it. So it really kind of, like you said, makes this safe space.

One of the challenges with prostate cancer has been the changes that have come about in the last few years with recommendations for screening. The USPSTF, which is an organization that helps internists and all of us, really, understand and interpret the data regarding screening recommendations has had some changes in the last few years regarding ... Or the last year mostly, most importantly, I guess ... regarding the recommendations for screening for prostate cancer.

I am really curious to hear your thoughts on the recent updates to the USPSTF screening recommendations, as it applies to Prostate Cancer Awareness Month and what you think these changes may do for us in terms of the disease.

David Penson: Yeah. We're covering a lot of ground there, Alicia. It's ground that you and I are really familiar with. It's been a long and winding road around prostate cancer screening and what the right and wrong thing is to do. I think it's worth just thinking for a minute about what prostate cancer screening is and why there's any controversy in the first place, because it seems like a slam dunk. Oh, if you find cancer earlier and we treat it earlier, everyone is going to do great. It's not quite a slam dunk.

Prostate cancer screening, as you know, is two things. A blood test ... Most men don't mind getting their blood drawn ... and a rectal exam. I know a lot of guys really despise the idea of going to the doctor and having a rectal exam, but it's literally 10 seconds of your life, and it could save your life. Not just in terms of prostate cancer, but potentially even in terms of anorectal cancers as well. In that regard, I think that the screening piece, men are put off by it. They need to take a big, deep breath and tough it out for what's a real quick and relatively painless experience.

The problem with the test, and it's really about the PSA test, the blood test, is that it's a very sensitive test. There are other things than prostate cancer that can bump it up. Sometimes it finds prostate cancers that are so slow growing and so indolent that they don't need to be treated. That combination means that we're going to find a lot. A lot of men are going to undergo a work up for prostate cancer, which often includes a biopsy, which is not a pleasant experience. It's manageable, but you don't want to have it unless you really need it. Some men will actually have treatment, and maybe they don't even need treatment, because that cancer will never grow and never cause them problems in lifetime.

There's been a lot of back and forth. This organization you mentioned, the USPSTF, about now six years ago in 2012 made a recommendation against screening for prostate cancer of any sort, because they basically said, "Look. We're finding a lot of cancers that don't need to be treated. There's a lot of over treatment. Overall, we're maybe not doing as much good as we should." I have to say, and you know this and you can comment on your clinical experience, I think that was a mistake. It was very draconian, very black and white on a topic that's very gray. What we've seen is a reduction in prostate cancer diagnosis since that recommendation six years ago. That's actually not a good thing. The reason it's not a good thing is because we are certainly avoiding some cancers that don't need to be treated, but we're probably missing some cancers which do need to be treated and we could have cured.

Over the last six years, a lot of things have changed, but more data came out. Frankly, the way we treat prostate cancer has changed as well with regard to active surveillance, which we should probably talk about a little bit in a minute or two. That really changed the math, both the fact that there are new studies that show the screening probably had a bigger benefit than we thought and not everyone was getting treated. Then earlier this tier, this USPSTF, which as you said, is the organization which makes recommendations, primarily to primary care docs, but most docs and many other people will listen to it. They said, "Listen. Prostate cancer screening, it's not black and white. It's gray." They changed their letter recommendation, which used to be a D, which stands basically for don't do it, to a C, which you can think of as see about the risk and the benefits and make your own choice.

They aren't saying everyone should get screened without thinking about it. What they're saying is that you need to have a discussion with your doc about the pros and cons of the blood test and what happens when you get screened and make your own personal decision. That plays really well into Prostate Cancer Awareness Month, because really what it's about is it's about knowing what could happen. Knowing about the risks and benefits and each guy making his own decision. That's where we are now. I think we're in the right place now, because the evidence for prostate cancer screening, it's okay, but it's not the same as some other tests we do, say colonoscopy is an example. I think most people agree that colonoscopy is something that really has tremendous benefits. Prostate cancer screening has benefits, but it's not this slam dunk, everyone gets benefit from it.

Every man has to make up his own mind. That's kind of where USPSTF came down. I think I know that's where AUA is, and I think that's where ASCO is, too, isn't it?

Alicia Morgans: It is where ASCO is. I guess this all in my mind still ties back to prostate cancer awareness, but really, in addition to just being aware of being screened and potentially diagnosed, it's about being aware of what's going on in prostate cancer more generally, because it is so nuanced, as you were talking about. Ultimately what we as medical oncologists and urologists want is to take care of patients who need to be taken care of with more intensive treatments and to not intensively treat or over treat people who do have those indolent cancers that you mentioned that may be diagnosed, particularly if we're screening more patients after these shared decision sorts of conversations.

Active surveillance I know has been an interest of many of the urologists at Vanderbilt, certainly of yours and mine. When we practiced together, we would often think about and tumor boards and things and certainly patients who have very low risk disease or even low risk disease who are appropriate candidates getting them on active surveillance protocols, because we certainly don't want to over treat patients. I think that's one of the reasons that the USPSTF really did change their guidelines over the last few years.

David Penson: Yeah. Active surveillance was really a paradigm shift for urologists and radiation oncologists, for that matter, in that once it is almost a knee jerk reaction. Someone would come into our office who had prostate cancer, and we would say, "Okay. We've got to treat you. You've got cancer." I don't think that there's anything nefarious about that. Some people look and say it's all about making business. I strongly disagree with that. I think it is doctors for the most part, they want to do the right thing. There's this sort of we hear the word cancer, and we immediately figure why take any chances at all? If there's a tiny chance that it could be a dangerous cancer, better safe than sorry. Then patients want that, too.

What's happened in the last really decade is that people have realized that the low grade cancers, and frankly that constitutes a significant number of the cancers detected, probably about 30, 40%. The low grade cancers are very indolent. They're almost like age spots. So for most men ... Not for all. Some men, they're going to worry about it and it becomes a quality of life issue. Some men, it's not as clear. But for most men with low grade disease, it's very safe to watch the cancer and do active surveillance.

What active surveillance is is two things. It's repeat PSAs serially over time, so every six months, every year, depending on how far out you are from your diagnosis, and repeat biopsies. Now, I said before that biopsies are unpleasant for patients, and I believe that, but I think things are changing with biopsies. There are a couple of things happening which I think you know about and we've talked about before. One is prostate MR imaging, which allows us to get a better view of the prostate. Also, if there's no lesion there, it really helps with screening and may help with active surveillance. Also, using the MR to guide biopsies so we get a more accurate biopsy using MR fusion. It's better than our old ultrasound biopsy, which the prostate looks like an old static on an old black and white TV, a lot of the time, whereas the MR, you really start to see things.

The other thing I think is coming down the pike ... We're just getting started with it at Vanderbilt. I know in Michigan, they're doing it a lot and out in Baltimore ... is going from transrectal biopsies to transperineal biopsies. A biopsy, the way we do it now with the transrectal is we put a probe into a gentleman's rectum, which frankly is not comfortable, and we pass the needle through the rectum into the prostate. That creates some problems with infection, because the rectum is a dirty space. You don't want to ... There's about one in 50 men gets an infection after a biopsy. This new transperineal approach, they still put an ultrasound into the rectum to see where you're going, but they numb up the skin just below the scrotum, that perineum area, and then after they numb that up, they do the biopsy through the perineum, which is much cleaner. It drastically reduces the risk of infection.

So when you put that together, you're looking and say, okay, active surveillance. If you're the sort of person who is not going to worry, and I think with the proper counseling, that's where a good doc comes in and is able to explain this to the patient. It goes back to being aware of prostate cancer. Active surveillance is a great option in that we're able to avoid treatment in cancers that don't need to be treated because we're following patients closely. If they do need treatment, we're catching them early and still getting them treated. It really is beneficial to a man's quality of life. It's an exciting time in that regard.

Alicia Morgans: I completely agree, as usual. We always agree.

David Penson:

Alicia Morgans: We do. I appreciate that discussion on these nuances. I think one of the other things that I wanted to touch on with you, because you have so many areas of interest and expertise that I think our listeners would find valuable. One of the other areas that you're really interested in I'm actually really, really interested in as well, which is making sure that we understand the patient's perspective on quality of life and what they deal with as a man living with prostate cancer, as a man cured of prostate cancer living after his treatment or as a man living as a survivor with prostate cancer. Listening to the patient's voice I think is really, really important. I know you've done some work in that area, and it's an important piece of your practice, as well.

David Penson: Yeah. You're being too modest, as usual. You've done a lot of this work, and we've done it together. I think it's important. I think the patient's perspective is really paramount in this disease, more so than any other disease that I treat and probably maybe for you, too. I don't know, but I suspect so. It's very interesting, because every step in this process, whether it's screening, whether it's getting diagnosed, whether it's treatment, every step in the process has an effect on a man's quality of life. It can be a profound effect that lasts a long time. So when we look at say, surgery, the risk of surgery, it is not good for your sex life. It causes erectile dysfunction, and it can cause urinary problems. When we look at radiation, it can cause urinary problems. It can cause some sexual problems, but usually less, and it can cause some bowel problems. Each one has a different effect on survival. Maybe surgery is better than radiation. Maybe it's not. Maybe they're exactly the same.

Then you're looking at active surveillance, and you say, okay, active surveillance is not going to affect any of those things that I mentioned. Sexual function, urinary function, bowel function, but maybe some men are going to worry. So you could take 10 guys with the exact same tumor characteristics, and you've done this in your practice, Alicia. You'll see 10 guys going four different ways. Each guy is right for his own personal situation. Certainly when you talk to men, you realize that you have to have a patient-centered approach to diagnosing and treating prostate cancer. The research backs that up.

I think the future is ... Not the future, but we're doing this now, but more and more it's really about shared decision making, because as a physician, you or I can't really figure out ... We can't put ourselves in the patient's place, because everyone is different. I have my personal preferences. You have your preferences. The patient has his preferences. Patient also has got to think about what his spouse is thinking, maybe what his kids are thinking, et cetera so forth. This really becomes a very personal decision.

The work that you've done and I've done looking at quality of life, in your case cognition, this is really important, because it really should be driving how patients make choices in treatment, because there's no slam dunk. This isn't like other cancers where you say okay, we have to do X. If we don't, you're going to die in six months. Prostate cancer doesn't work that way, as you know. There's X, Y, and Z, and no matter what you choose, you're probably going to be alive for five years, 10 years even in the worst case. So we really have to be taking this patient-centered approach to our clinical decision making. As providers and researchers, we want to get more information to help patients make those decisions.

Alicia Morgans: I think that, like you're saying, this patient-centered approach is really where we need to go, where we need to be with prostate cancer. That really all circles back to this Prostate Cancer Awareness Month, because as we as physicians think about this, as men and their families think about this, as listeners think about this, prostate cancer awareness really spans the gamut from screening, being aware of the disease, while being aware of how common it is, being aware of guidelines and recommendations for screening and taking those steps for appropriate men to screen for this disease. Then also, to be aware of the choices that men have when they are diagnosed with prostate cancer and for men especially to really take ownership and to engage with their physicians, with their family members.

Think about what's important to them. Make these decisions and move forward and certainly to be aware of the prostate cancer survivors among us and to think about their day-to-day. As physicians really trying to maximize their quality of life in every visit that we have with them and to stay focused on what's most important, which is the patient and his preferences and beliefs and just make sure that we do our best for them. 

I have truly enjoyed having this conversation with you, Dave. I appreciate your thoughts on all of these aspects of prostate cancer care, and so just thank you for your time.

David Penson: Thank you, Alicia. I always enjoy speaking to you.