So, the first question we have is can a DRE performed before a PSA test
in any way affect the results of the PSA test?
It certainly can, anything that has impacted the prostate gland can raise PSA levels. DREs right
before drawing the blood. Sometimes people for reasons unknown to me will check their PSA after
they've had a biopsy. Biopsies, where people get their prostates poked with needles, can keep PSA
levels high for as long as two months afterward. Recent sexual activity within a day or two can
cause the PSA to be high. We do ultrasounds in the office — pushing on the prostate
and then drawing a PSA right after that can cause the PSA to go up. So, accurate PSA testing
requires that people withhold these activities for a day or two before they they test for PSA.
So if a person goes in, and the doctor wants to do a PSA test that like that day right after they've
had a DRE, you would suggest that they come back and do the PSA test a couple days later?
That's reasonable. You can test because the PSA won't always be high, but it can be high.
So if the PSA comes back normal, it's fine, but if it's elevated you're going to wonder
is it because something's going on or is it because of the recent digital rectal exam.
Our next question is regarding hormone therapy, so it's a hormone therapy called Erleada,
and first of all, can you explain what Erleada is, and then also does it help suppress a growing PSA?
Hormone therapies, of which Erleada is one, definitely will suppress PSA in most cases.
There are some exceptions. Erleada is a second-generation hormone medicine
that works inside the cancer cell. It was realized 10, 15 years ago that hormone-resistant prostate
cancer, that means people who have cancers that aren't responding to lupron, come about because
certain cancer cells learn how to make their own testosterone, and Erleada works inside the cancer
cell to block the testosterone's activity there and brings the cancer back under control again.
So, for a man who maybe is now failing Lupron,
would you say Erleada is the first line for him to take out of the
second-generation [agents] or does it matter really just on how the doctor is prescribing?
Well, it's an excellent choice. There are other agents such as Provenge which will often
administer Provenge first and then start Erleada or one of the other second-generation hormone
medicines like Xtandi or Nubeqa or Zytiga, but yeah, they're all very effective in that role.
So Provenge is interesting because it's not a hormone therapy it's an immune therapy,
so how does that work to fight cancer?
People describe it sort of like a cancer vaccine which
that's something that lay people understand — vaccinations where the immune system is awakened
to a new target, and Provenge takes immune cells out of out of a patient's bloodstream,
the memory cells, and awakens them to a an antigen on the surface of the cancer cells called PAP,
and then once those memory cells have been awakened to the
presence of this antigen which is on the surface of cancer cells,
these cells are reinfused and then they awaken the patient's immune system to attack the cancer.
So just to summarize, when a patient is now failing lupron or finasteride,
and we see this a lot in different cases, they need to talk to the doctor about Provenge
and then if they're going to choose hormone therapy they need to kind of go through
those options of whether it's Erleada, Xtandi, or Nubeqa or anything like that?
Yeah, our usual sequence is if people develop a rising PSA on Lupron, get a PSMA PET scan—many
of the insurance companies require to demonstrate some metastasis somewhere most of these patients
will have a lymph node or something like that—if a single metastasis is found we'll probably radiate
the lymph nodes, start some Provenge right after that, and the Provenge is done in six weeks,
and then we'll start the Erleada or the second generation hormone therapy subsequent to that.
I appreciate that you mentioned the lymph node because I think a lot of people when
they think about metastasis, and they go get a scan, they don't think about lymph nodes being
a metastasis versus maybe just bone metastasis, and so a lot of these people are qualifying but
they don't know that it's available to them, so I appreciate that definition.
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