Hi everyone! A lot of you have been submitting youtube comments and a lot of
you guys have questions on prostate cancer that you would like us to ask Dr. Scholz
and today we're going to answer those questions.
Alright, Dr. Scholz, well today we're going to be answering some more questions from our
youtube comments section and I believe these are prostate cancer patients and the caregivers
leaving these questions so I'm very excited to be able to answer them with you in person.
So the first one we have is, "I'm a 41 year old with a Gleason score of 3+3 on the right side
and 3+4 on the left side, would radiation be a good treatment? I'm really scared
about doing an operation and what are the chances of the cancer coming back?"
Sounds like a very low-risk situation; we don't really know how many cores are involved
and we don't know what percentage of grade four is present in the
grade seven side of the prostate, but I think the back story here is people are nervous about
giving radiation treatment to younger men because if there are radiation-induced side-effects over
the period of many decades—[e.g.] new cancers, scarring—would a young individual be better off
just doing surgery? And that is sort of the prevailing belief in the medical community that
the younger men need to be operated on and the older men can safely have radiation.
I don't ascribe to that view personally; I think that the modern forms of brachytherapy
(seed implant radiation) which limit the radiation just to the prostate area—they
don't have to beam the radiation through the body to hit the prostate—are quite safe for long-term
exposure considerations and certainly a lot less toxic than doing a radical prostatectomy.
Personally, if I was in that situation with a highly favorable low-grade cancer that
if he was a bit older we might even just put him on active surveillance—we don't know the
details of his pathology—but I would strongly consider doing a radioactive seed implant
at a center of excellence rather than thinking about doing surgery.
Our next question is, "Do you have any suggestions on therapy for ductal carcinoma in the prostate?"
So, ductal carcinoma is a pathologic variant. When we hear about Gleason scores we're looking
at pathologic grading and it's known that ductal variants of prostate cancer are slightly higher
grade than what the Gleason score would indicate. I think a good rule of thumb is that if you're,
you know, if you use the grade grouping system that came from Epstein where you go from one
to five, the ductal carcinoma designation means that you go up about a half a point.
So if you're a two, you go to a two and a half; or if you're a three and a half
you go up to a four, and in the Gleason scoring system it might work like this: if you had a 3+4
you might call it a 4+3. And if you had a 3+3 you might move it up to a 3+4, so it's
a slightly worse indicator. It's not the end of the world; it just suggests that
the cancer is a little bit higher grade than what the Gleason score would suggest.
So our next question is, "Please address which patients should do
a PET scan before TULSA-PRO. Unfortunately, my PET scan was positive for seminal vesicle
invasion and I followed with ViewRay, SBRT, ADT, and Zytiga."
Well, the new PET scans which we've talked about quite a bit—the PSMA PET scans—are going
to change the way that prostate cancer staging is implemented on a routine basis as soon as
they're FDA approved which could be within a year, and who needs a staging scan? I would
say anyone who has intermediate-risk prostate cancer or higher should be
staged. The favorable intermediate-risk patients have such a low risk of metastatic disease it's
probably not necessary to have a staging scan, but if you look at standard intermediate-risk or
unfavorable intermediate-risk—what we call basic or high teal—and then on up through high-risk and
relapse, all those other patients, everyone wants to know if the cancer has metastasized or not and
these new PSMA PET scans are the best way to make that determination. In the meantime, for patients
that don't have access to these PSMA PET scans which are, you know, available at certain academic
centers on an investigational basis, the standard approach is to do a CAT scan of the abdomen and
pelvis or an MRI of the abdomen and pelvis to look for any grossly enlarged lymph nodes,
make sure there's no metastatic disease in that fashion, and then to do a bone scan of some sort.
The old technetium-99 bone scans are covered by medicare but the F-18 pet bone scans are
even more accurate. So a bone scan and a body scan is considered standard for anyone with
at least intermediate-risk prostate cancer to make sure that there's not a surprising
metastatic lesion present somewhere that would totally change the treatment protocol.
So a patient left a question that says, "If prostate cancer is found in 1 core out of 12
and that one core is 5% or less, would this
qualify for as active surveillance—for for the active surveillance protocol?"
Well, it depends on the grade. If it was a Gleason 3+3, absolutely, it's ideal. If it was
a Gleason 3+4 and there's not too much four then it would also be adequate for active surveillance,
and then if it was a higher grade—a very small amount of higher grade—disease in someone that's
over 80 years old, then that also possibly could qualify for active surveillance.
Can you speak on, you know, when we talk to patients a lot in these situations
they've maybe just been diagnosed and they just got their Gleason you know score back,
can you speak to how important it is to get a second opinion on that Gleason score to make
sure if they're going to choose a certain treatment protocol like active surveillance
how important the confirmation of that Gleason is?
Well, reading Gleason scores like many things is an art and the doctors that
have greater experience and exposure to a larger amount of reads that have a
large volume practice are going to be able to grade it more accurately and unfortunately, some
doctors who are reading Gleason scores at small community areas don't do a lot of Gleason grading
and they can make mistakes. As we're talking through these different questions we can see
how critically important the decision-making process is as influenced by the Gleason score. So,
it's very easy to take the biopsy slides—they're safe for 10 years after someone has a biopsy—and
send them off to a place like John Hopkins, get a second opinion as to what the Gleason
score really is, and then you know you're working from the most accurate information.
If you do that are you paying out of pocket and do you know how much that is?
I'm not sure. I think insurance will cover it sometimes and probably on other occasions
it's necessary to pay for it. I don't think it's more than a couple hundred dollars.
Alright, our next question is, "I'm always confused why long-term health is not considered
for men who are in their 70s and 80s like those for when it's in their 40s." And they say that,
"Can you explain this deeper? Because it kind of breaks my heart that doctors
seem not to fight as hard for an elderly patient as they would a young patient."
Well, of course, I don't know what's in the hearts of various doctors but we're,
in the prostate cancer world, we have to be sensitive to the fact that even the worst
prostate cancers take 10 to 15 years to kill someone and also we have to be aware of the
fact that the treatments for prostate cancer can really harm a man's quality of life and make them
impotent, incontinent, and sometimes create GI (gastrointestinal) problems. So,
when the risk of the treatment causing bad quality-of-life issues is greater than the risk of
the cancer causing harm, then people start to slow down on the intensity of the type of treatment
that's being recommended. At least they should. So, it's a difficult balancing act and, of course,
no one wants to be cavalier about the fact that a cancer could, if it behaved particularly badly,
cause problems in less than 10 years. It's fairly rare with prostate cancer but it's not impossible,
but experts can usually identify those bad cancers
early on and take appropriate measures. So, I think in general, I don't think the physicians
are are unconcerned about the longevity of older people although I'm sure that's possible
with some, you know, problems with HMO insurances and whatnot where people are trying to minimize
spending but there's also a logical reason to not be concerned about a low-grade cancer
in a 75-year-old because we can be very confident that cancer will never hurt them.
I think the the other thing about it and talking to a lot of family members
who are having fathers or, you know, caregivers and things like that,
I think it's really important that they realize it's not just a doctor that you
is fighting for that patient. You have to fight for that patient, and the patient has to fight
for themselves, and I know that when I've talked to caregivers they get very frustrated and we've
seen this in a couple of cases where the doctors are kind of like, "well they're older, it's okay."
Well, if you really do your research you know you're either going to find you agree with the
doctor or you're going to find that you need to advocate and so I think that's why the perspective
of PCRI is so important that you are, you know, in charge of your own health in that case.
Yeah, doctors are certainly not infallible and sometimes they're
terribly mistaken about things and it's logical that each patient who only has to concentrate
on their one case should become an expert in the very subset type of prostate cancer that they have
and and speak on a more level plane with their physicians and
their nurses, and busy doctors, busy nurses can overlook things and patients
are the fail-safe. They're the backup plan to make sure that something really foolish isn't done.
Yeah, I really love that perspective because it kind of takes somebody in a
hopeless situation or helpless situation who feels like they can't do anything
and puts them in a more powerful situation where they feel like they could actually make a move and
then have that discussion with the medical team, so it's really cool.
Thank you so much for watching. If you would like Dr. Scholz and I to cover one of your questions,
you can go ahead and leave them in the comments section of this youtube
video or on our other videos and we can go ahead and pick them up from there. Also,
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We come up with new prostate cancer videos every week,
and visit our website pcri.org if you would like more information. We hope you have a great week.