You know, we need to confirm obviously if somebody's going to choose active surveillance
that it is 3+4, so do you suggest that they get another targeted biopsy and confirm? That they get
a second reading with someone like Dr. Epstein from John Hopkins? What is that process like?
That's right, you have to vet the situation and one popular thing is to order a genetic test in
a situation like this—Oncotype or Prolaris—and that will provide an actual number. Oncotype
will tell you what's the percent likelihood of your particular genre of prostate cancer
spreading within the next 10 years—spreading outside the prostate. That's the defining issue
with all cancers including prostate cancer. The ones that stay home in the prostate are harmless.
If we could be 100% sure that they'll stay home in the prostate then we wouldn't treat anybody
and that's, of course, the policy with a low-risk. We know that 3+3 never spreads and those gentlemen
can safely pursue active surveillance. So, genetic testing would be a start and then making sure that
something is not being missed. The initial biopsy may look very favorable, but if you get a
multiparametric MRI, if you do another biopsy, or if you have the pathology checked by Dr. Epstein,
as you mentioned, sometimes things won't turn out quite as rosy as you initially
thought and you'll have to rethink, is it really safe to do active surveillance?
So, if low Teal is active surveillance, what is basic teal? I know for monotherapy,
but what would monotherapy look like for a patient?
So, we tend to lean towards some form of radiation. There are a
number of things that can be done—surgery, radiation, HI-FU, laser treatments—but
if someone is resigned to the fact that there's going to be a risk of erectile dysfunction
some form of whole prostate treatment is the usual approach with Teal—seed implant radiation,
proton radiation, SBRT, IMRT—are all perfectly fine and depending on an individual's age and
pre-functioning sexual status, you know, there's going to be anywhere from a one out of four to a
one out of two—50% risk—of erectile dysfunction as a result. There is another layer of complexity to
bring in here — some men have unilateral disease after careful vetting and can consider doing
focal therapy—focal radiation, focal laser, focal HI-FU—and that reduces, doesn't eliminate, but it
reduces the risk of getting erectile dysfunction. The disadvantage with focal therapies are finding
someone who's really skilled at doing it, and then since some of the prostate remains untreated,
those men will need active surveillance for the rest of their lives because
they could still catch a new cancer in the untreated portion of their gland.
So for people in the, you know, let's say Basic- to High-Teal categories,
what does the imaging process look like, and, you know, are you automatically going to send
them to an MRI or a PSMA scan in order to confirm this before you decide on a treatment regimen?
Definitely a multiparametric MRI before making any final decisions.
PSMA PET scans have been FDA approved, they're going to be broadly available probably in the next
three to six months. Someone with Basic-Teal, you could, if you're trying to confirm that
the cancer is on one side of the prostate, a PSMA PET scan could be very useful for that.
We don't think that the risk of spread outside the gland is very high, so you don't
need to uniformly or universally do PSMA PET scans in someone with Basic-Teal, but
if you're thinking of focal therapy, maybe yes. Those that have High-Teal, PSMA PET scans
are useful to confirm that there's no early metastatic disease in the pelvic lymph nodes.
Yeah, that's one question I get quite often on helpline is, you know,
they may have gotten that they're a 4+3, and they're figuring out if they're
you know between Basic- and High-Teal, but then they see seminal vesicle invasion,
and they're like, "Okay, does that put me in another category, and what do I do then?"
So seminal vesicle invasion or lymph node
invasion would be an Azure or a high-risk situation. Traditionally,
we've thought of those people needing 18 months of hormone therapy plus radiation to the prostate.
So, what does a conversation look like for somebody in the Basic- to High-Teal range for you?
I mean, is it really just prioritizing quality of life? Because I think a lot of people when they
get diagnosed with prostate cancer and then they realize it's not something that they can monitor,
they get into a kind of a fight or flight mode and they want to make a treatment
decision immediately, and obviously, this sounds like it's quite a process?
Yeah, it's a mistake to go rushing into treatment before you really know what you're doing.
The quality of life still remains an issue. There's a lot of flexibility now
with the advent of these new PSMA PET scans. Historically, we had to take extra precautions
because there could be early spread into the lymph nodes and that necessitated radiation of the
lymph nodes sometimes and six months of hormone therapy. The experts don't really know how much
we can back off of that when people have a PSMA PET scan that shows no spread. There's not a 100%
certainty that there's no spread when you have a clear scan, but it's a much much lower risk,
and taking hormones for six months is not a small undertaking. So, someone may be older or younger,
all these factors are weighed in the process of deciding how aggressive treatment should be.
So, what is the monitoring process for somebody who's going into short-term
hormone therapy? Maybe the PSA is being lowered, what do they need to look for
in order to make sure that they're maintaining that disease control?
Well, almost everybody responds to treatment initially so we're not wondering if treatment
will work. Practically everyone goes into a remission with hormones or radiation or both,
so it's more an issue of what you do afterwards once you stop treatment you want to
check testosterone levels make sure that that's recovering, and of course, watch PSA levels,
and we probably should do another video about what we call the PSA bump or monitoring PSA
after treatment because it can be a little confusing, PSA recovery when testosterone
comes back, the prostate will still make a little bit of PSA and so there are variables, but the
whole idea, of course, if the PSA remains low and stable, you don't have too much to worry about.
Have you had patients where they've gone into permanent remission being a Teal case?
Oh, the cure rates are very high. If you look at it, cure rates for Basic-Teal,
it's over 90%. For High-Teal, probably in the 80%-85% range or perhaps even a little
better than that. But yeah, people are sometimes confused by using the word cure — they always say,
"Well it could always come back." No, that's not really true. You get about five years out—four
or five years out—after radiation, if the PSA is low and stable that person is essentially cured.
Hi everyone it's Alex and Hunter. Hunter is our official PCRI mascot. If you'd like to learn
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