What are the next steps, let's say, for a patient who has 3+4=7. You know, they have
this conversation with their doctor. They do some research, hopefully, on their own.
What's the next steps to deciding treatment?
Well, first I think before you get there, if someone has had a biopsy and an MRI, the
next step is to match up the information. When the doctor does the biopsy, it'll say
it's in this particular region of the prostate and then you can go to the MRI and you can
look at where the lesion is—the spot—and see if those match. Is it on the left side
towards the top of the gland for the biopsy and is it on the left side towards the top
of the gland for the MRI? If a patient has a biopsy that's positive on the left and an
MRI showing a spot on the right, one has to wonder if the spot on the right was missed
in the random biopsy and that patient may need further evaluation to find out if he
has two tumors and if the second tumor might even be a higher grade. So, it's important
to have precision and good clear understanding before you get into that next step which is
to decide what to do, and there's so much variety depending on, you know, is it unilateral,
bilateral, is the tumor larger or small, and all these other factors are going to drive
the decision making process.
So, in that scenario, if there is a tumor that was missed, let's say on the right side
from the random needle biopsy, do you suggest that with the imaging they get a targeted
biopsy in order just to take one or two needles and take the tissue out? Can you explain targeted
biopsy versus random needle biopsy because I don't think a lot of patients realize that
they can have that as a secondary confirmation?
Right, so that... Random biopsies, they do a grid pattern and then they just stick needles—usually
a dozen needles— throughout the gland and the targeted biopsies they use imaging as
a guide, in other words, if there's a spot in the upper right-hand corner, then a needle
is poked in the upper right-hand corner to see what the grade is of that spot. And the
targeted biopsies are picking up in popularity very quickly now. It's been a while; they've
been out for more than 5 years, but the literature and the urologic community is starting to
acknowledge that these are better than random biopsies. You know this is such a sensitive
area of the body and men value their capacity to get erections and perform sexually so so
highly that if people can get precise information about where the tumor is there's always a
possibility that they can just treat a section of the prostate. A lot of people don't realize
that the standard of the industry is to treat the whole gland just to be safe, and that
was necessary when we didn't have imaging to make sure that the cancer was totally eradicated.
But now we have good imaging. We can determine where the tumor is and with skillful doctors,
the possibility of just treating a section of the prostate becomes available and then
that reduces the chance of a man becoming impotent from therapy.
So those are some really good points. I think that one of the things that comes up often
in conversations with patients is the anxiety of having to wait to not jump to treatment
and make sure that everything is done properly. That they've taken look at what type of cancer
they have, the imaging has been done, and if anything else needs to get a targeted biopsy.
Can you speak as to why it's okay to wait? Prostate cancer is slow-growing. I feel like
when patients hear that they're like, "Well how can you say that, it's cancer." and I
know we've talked in the past about the scary "C" word, so can you explain why it's slow-growing
in these cases and why it's okay to take your time and decide on treatment?
It's hard to deal with fear. I mean we're all, you know, nervous about this virus situation
and the rational discussion doesn't always help people get clarity but sometimes it helps
to let people know that the tumor that is being dealt with now, say, you know, this
year, probably started 5-10 years ago and took this long to get big enough to be detected.
And so, since we're playing for such high stakes and precision treatment will lead to
much better outcomes—better cure rates and less side effects—taking a few months, a
few additional months to get it right makes perfect sense. And there have been a number
of studies looking at popular surgeons who have long waiting lists and patients have
had to wait up to six months to get the right doctor to do their radical prostatectomy and
then those doctors have gone back and looked at the cure rates of the patients that waited
six months versus the ones that had immediate treatment. There was no difference in cure
rates.
Then the mindset I would think really needs to change for the patient of quality of life
and what type of side effects they're willing to deal with in the meantime. So, can you
talk about that because I don't think patients realize that the choices that they're making
with prostate cancer lasting, you know, being more of a chronic disease, I don't think patients
realize that the side effects are really what they're going to be living with on a daily
basis? You know, the fear may dissipate, they may feel comfortable, but that's a huge factor.
Yeah, this is something that's actually true with all types of prostate cancer because
the prostate is located in such a sensitive area of the body which can affect, you know,
people are going to the bathroom all day long and they're going to be reminded every day
for the rest of their life if that doesn't work properly. Sexual activity can be irreversibly
changed. So that, and people live for a long time with prostate cancer regardless of how
serious the cancer is. So, all of this needs a sort of a repositioning of the way people
think about prostate cancer. This attitude would be irresponsible if we were talking
about lung cancer or colon cancer where if you don't win the battle on the first go-round
and cure it, those people will go on and die of the disease. Prostate cancer you get a
second chance, a third chance to cure it, and then even if you don't cure it on the
third try, you can control it for 10-20 years with hormone treatment. So, it's a totally
different type of situation compared to most cancers.
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