So, Dr. Scholz, we have a couple questions from our YouTube channel regarding pre-treatment
and the first question is, "When should a man start to get DREs,
and is it annual, is it every two years? What does that look like?"
This is the unpleasant finger in the behind test that some people debate whether it needs
to be done at all given that we have PSA testing. PSA testing is certainly much more
sensitive, meaning detects more cancer than digital rectal exams do,
and some have been concerned that by advocating digital rectal exams that men are put off and
don't even come in for their PSA tests, but there are types of prostate cancer that can be detected
by digital rectal exam when the PSA is still in the normal range,
and it turns out that those types of prostate cancers are the type you want to diagnose; they're
the more dangerous types, the ones that don't make as much PSA. They're not very common, but
it's a simple test, and it takes a very brief time, and it should be performed in people that
want to be thorough, and make sure that they don't end up dying of a preventable illness.
So, the age that is advocated varies from different groups. Probably the most aggressive
stance is to start around age 40. The thinking is that maybe in African-Americans or people with a
family history to start around age 40. Other more conservative organizations think around age 50.
Why hesitate? Why not check it in 30-year-olds? It's a cheap test, but there's always a trade-off;
the industry, the surgical industry, is very aggressive in treating people with prostate
cancer, and no one disputes that many men are over-treated, so there's always this kind of
love-hate relationship with PSA because it can lead to people getting unnecessary
surgery which can ruin your quality of life, sexual life, urinary function,
etc, so that's why there's always a balance, and there have been organizations in the past
that said don't even do PSA testing, but we will go into that now. Whenever PSA testing starts,
that's when digital rectal exams should start, and if there's an age which you stop PSA testing—and
that's another debate—then maybe that's when the digital rectal exam should end. So, annual
PSA testing with digital rectal exams, I think, would be reasonable to start around age 40-45.
So, we get a lot of questions regarding people getting secondary biopsy
reviews. What is that process like? Do they have to get another biopsy?
Yeah, so that is a misconception. When people undergo a biopsy, the little
cores that are removed from the prostate are transferred—they're sliced very thinly—and then
they're transferred onto glass slides, and the people that process this—the pathologist—look
at those slides under the microscope and assign a Gleason score. The good news is those glass
slides are almost immortal. They— and I believe that most of the centers that process these
slides are required by law to keep the slides in an archive for at least five to ten years,
so they will always be there for evaluation if they need to be evaluated again in the future.
So it's not at all difficult, then, to have those glass slides put in the mail and sent
off to an expert somewhere. We've used Johns Hopkins a lot for this purpose, and for a small
fee have a world-class prostate pathologist review the images—or through the microscope—and
render their own opinion as to what the grade is. And assigning a Gleason score is a bit subjective,
and we rely so heavily on this information, and so the difference between a 3+4
and a 4+3, or a 3+3 and a 3+4 is huge. People routinely advocate that 3+3 should simply be
watched and many doctors say that 3+4s should be treated, so it's a fulcrum point that can
be incredibly important, and I certainly do see changes in Gleason score all the time in people
that initially were evaluated in some community center, and then when a reference center—an
academic center of excellence—re-reviews the slides and the Gleason score changes. So,
it's a good starting place to make sure that you can trust the Gleason score by having a,
you know, center of excellence review the pathology slides. It's not difficult to do.
Speaking of Gleason score— we have a person who's kind of wondering
what is the intensity of cancer considering they have Gleason 7, but they have perineural invasion?
So, perineural invasion comes up a lot because you see it in the pathology reports,
and I believe that Dr. Epstein did a nice video on Gleason scoring force at the PCRI one time,
so people can access that information, but it turns out that although the pathologists
talk about perineurial invasion—which merely means that the cancer cells can be seen in the
biopsy specimen to be growing along the edge of a nerve. The original concern is is that the nerves
lead outside the prostate and therefore the cells can track along the surface of
the nerve and get outside the prostate, and if a person is going to have a radical prostatectomy,
and their nerve is outside the prostate, then that doctor's going to leave some cancer behind and it
won't all be removed at the time of surgery—very relevant. It has been shown that if you look
at other important factors like the Gleason score, the number of core biopsies positive,
how high the PSA is— whether or not someone has perineurial invasion doesn't really have
any impact on the long-term outcome. So, you just go back to the what what is the Gleason score and
pretty much jettison the whole question of whether or not there's perineurial invasion. Does it
impact surgery to some degree? I suppose there is a scenario we could cook up an idea where it might
make a difference. I'm—as most people know—not an advocate of surgery for prostate cancer
given the options, the alternatives, are so much better than surgery, but maybe it would
be a question that would arise in someone that just insists on having a radical prostatectomy,
and has appropriate care been exercised to make sure that there's no extra capsular extension?
Have you found that lesions that are missed on an MRI can be seen on color doppler imaging?
Occasionally. The the good news is that relatively little is missed on multiparametric MRI
and that technology is rendered even more powerful when doctors are looking at sequential images from
year to year. So, they can take last year's images put them up right next to this year's images,
and see if there are any slight differences. Color doppler is an independent imaging method.
It looks at sound waves bounced off of the image rather than, you know, electromagnetic
radio waves emitted in a high-intensity magnetic field, and so yes, sometimes we will see things
on color doppler that are not seen on MRI. Some of the things that we would see in color doppler
will be low-grade lesions. MRI is semi-famous for missing Gleason 6, which is a good thing.
We don't really want to know about Gleason 6, but color doppler probably picks up Gleason 6
a little bit better than MRI does, and so you have to be restrained in getting over-excited
about little spots because sometimes they're just low-grade lesions that can be watched.
Thanks for watching. If you would like more information
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