So, Dr. Scholz, you know, we have hundreds and at this point thousands of patients who
are watching our channel now, and we have many people who are in this concept of high-risk
disease and it can be a very confusing field, as with any category of prostate cancer, but
this one because of the name high-risk brings a lot of emotion to it. So,
can you define what high-risk is and talk about cure rates?
Yeah, I think you're right. I think it is a misnomer because the
high-risk other cancers usually mean that you know you're nigh on to early mortality and that's
certainly not representative of the status for a high-risk prostate cancer patient. We define
high-risk technically as a Gleason score over 7, a PSA over 20,
or if you have someone that's had a scan that shows some activity in their lymph nodes around
the prostate or in their seminal vesicles, but what does that really mean? The whole issue
with any cancer, including prostate cancer, is whether or not it's spreading outside the
prostate, or is it likely to spread. Most of the high-risk patients don't,
historically, have any confirmed or documented proof of spread and so they're called high-risk
rather than D1 which is if they have lymph node disease or D2 if they have bone met disease,
and so it's an incredibly important question. Everyone who has been given a diagnosis of
prostate cancer immediately has to ask themselves the question, has this spread? Or, is it likely
to spread? Because that's really what defines the danger of the disease. If it never spreads,
if it stays inside the prostate, it's a really a harmless entity. It's only the potential for
spread that makes it dangerous and this is why the usual policy for so long now has been
when prostate cancer is discovered, treat it immediately with the hope that you're eradicating
it before it spreads, and that was what was so revolutionary about low-risk disease where people
were being told to watch their prostate cancer because they have a genre that never spreads
and as long as it stays in the prostate, no problem. It's not going to create urinary problems
or any other sexual difficulties. The prostate is very forgiving of small
tumors growing inside of it it's not going to have any real consequence. With all that is a
giant preamble. Now, we have a the advent of these new PSMA PET scans that can actually tell
you whether spread has occurred or not. In the historical sense, with cat scans and bone scans,
they were such crude forms of technology that they could never promise you that if they were clear,
oh so you're safe. Everyone knew you weren't and that's why we created this
high-risk category. It was a very sensible thing, then, to treat high-risk men with
preventative things like radiating the lymph nodes just in case there was some small cancer
in them or giving men hormone therapy just in case there's cancer outside the gland that maybe we can
eradicate it in its baby stages. So this is the milieu of high-risk, and it is now, in my opinion,
changing rapidly because PSMA PET scans are so much more accurate at detecting early spread.
When someone has a PSMA PET scan that conveys the message that there's nothing outside the prostate,
you have a lot more confidence now that there really is nothing outside the prostate, whereas,
in the past we had no confidence at all if it was a higher Gleason score or if it was a higher PSA.
The assumption is, well there's probably some microscopic disease out there,
but now we know with the PSMA PET scans that the chances of something being outside in a high-risk
patient is probably around one in five, so we have a better handle on how risky high-risk is
now. When we can do a PSMA PET scan, people can take precautions against the possibility of there
being a one in five chance of microscopic disease in the lymph nodes, they can have hormone therapy,
they can have radiation, or perhaps as they start to get older, they'll say I don't want to
take those precautions, I would just want to keep getting a PSMA PET scan every year and then I'll
address something in the lymph nodes if I'm in the unfortunate 20%,
the one out of five that has something, I'll catch it at an early stage and treat it with all those
very aggressive measures at that juncture. What we've worked out over the last 20 years
for treating men with high-risk disease—which means eradicate the tumor in the prostate (we
prefer radiation, some doctors use surgery) take precautions against lymph node disease,
take hormone therapy for 18 months, and radiate the lymph nodes as a preventative measure—I think,
now, it has to be called into question with the advent of these new PSMA PET scans.
So, in regards to radiation, I know in your book, "The Keys to Prostate Cancer," you mentioned
that previously there was some concern about expanding the radiation field to
the lymph nodes, so that's now safe and considered safe across the board?
So, the technology to radiate lymph nodes has evolved very rapidly and is far less dangerous
in 2022 than it used to be say 5-10 years ago. The risk of radiating lymph
nodes at state-of-the-art center, now, is far less than radiating the prostate
because when the prostate is undergoing radiation, we still face the risk of long-term irreversible
erectile dysfunction, and that's not a risk with radiating lymph nodes. In the past,
because of imprecision, there was risk of radiating the intestines and causing a
burn to the intestines that would never heal and causing long-term diarrhea and GI problems
which could be miserable and that, in theory, is still a risk if someone doesn't manage or
administer the radiation skillfully, but in my experience now—and many men
that have had radiation therapy to the lymph nodes—that the side effects are are minimal.
So, how does age factor into the decision-making when it comes to
treatment and high-risk disease? If you have an older patient who has a high-risk cancer,
would you still treat it the same as somebody who's maybe sixty years old versus 80 years old?
Not at all. Of course, we know that with high-risk patients that only a relatively
small percentage of them let's say historically 10% of them
would go on and succumb to prostate cancer in the next 10 to 20 years, almost zero within five
years, very few within 10 years, and then after 10 to 15 and sometimes 20 years the disease would
catch up with these unfortunate high-risk patients and then they would succumb to the disease. So, if
it's going to take 10 to 15 to 20 years to die of the disease with in the worst-case scenario with
optimal treatment, you can imagine if someone's 80 years old that they might prefer to risk
undergoing less aggressive therapy because their own risk from dying of other causes becomes so
large after a certain point that the risk of dying of prostate cancer is even further diminished. So,
it makes a lot of sense to adjust the intensity of treatment depending on the patient's age.
So, there's been a lot of research in early use of Taxotere-like chemotherapies and high-risk
disease. How do you see that playing out and do you do that in your patients?
If people have for example a PSMA PET scan that shows that there is lymph node disease. So,
this patient has a documented genetic variant of prostate cancer with proven capacity to get
outside the gland and grow somewhere, those are the people that define the serious forms
of prostate cancer, and studies clearly show that if you treat them earlier with
aggressive effective treatment—Lupron, Zytiga, and Taxotere, that they have better survival rates.
So, Dr. Scholz, you mentioned hormone therapy as a possible treatment along with radiation.
For patients who are concerned about the side effects of hormone therapy, is there a way that
they don't have to take it? Is there a certain circumstance in which that would be valid?
Well, now, I think men who have high-risk disease and their PSMA PET scans show no spread
can have a conversation about skipping all these preventative measures that have been considered
routine in the past. Of course, there's a big difference between 18 months of low testosterone
versus say four months of low testosterone which is the amount of hormone blockade that's used for
men with intermediate-risk. So, we've tended to manage our high-risk patients—high Gleason scores,
high PSAs who have PSMA pet scans showing nothing outside the prostate more like an
intermediate-risk prostate cancer patient because they certainly have far less danger than a patient
who has either high-risk disease that hasn't been scanned because you just don't know,
or someone that has intermediate-risk disease. I think that the
discussions that are necessary now have become very interesting because it is a daunting prospect
to have someone block your testosterone. There is the whole issue too of will the testosterone
recover normally? So, if you take a 65 year old man and give him 18 months of hormone blockade,
it'll probably take 30 months or more for his testosterone to recover, and will that
individual ever be the same? Two and a half three year holiday from having any sexual libido
is a long time and especially when you're older, people don't bounce back like they do when they're
younger. So, yeah, I think that the concerns about the side effect of hormone therapy are
very justified and everyone has to kind of look individually at their own risks and then decide
what kind of chances they want to take. This is prostate cancer there's never going to be a
risk-free option whether it's how you treat it or the treat the treatment side effects
or the disease. So, this is becoming a sophisticated equation where people have to kind
of look at the odds of what will their cure rate be and then how serious will the side effects be.
It is possible to embark down a treatment path with hormone therapy and try it for a while see
how people tolerate it. They can always jump ship; that's not like you're irreversibly committed to
the treatment. There's a lot of complexity to it and it's, and different patients are
going to come to different conclusions depending on what their priorities are.
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