From WXXI news.

This is connections.

I'm Evan Dawson.

Our connection this hour was made with the announcement that President Joe Biden has cancer.

Prostate cancer, which has spread to his bones.

He will begin treatment.

And he says he's hopeful for a good outcome.

But in the world of metastasized cancer, it's hard to say exactly what a good outcome would be.

That is changing, certainly with better treatment options.

And we're going to talk about that.

This news has prompted many people to ask questions about prostate cancer.

What exactly are PSA levels?

How and when should I get checked?

How aggressive can it be?

Typically, what can we learn from the president's story?

This hour we welcome the experts to answer your questions.

I already have some emails, and you can communicate with the program in various ways this hour.

If you want to email us if some of you are already doing it's connections at Easy Dawg connections at six nine talk.

If you are watching on the sky news YouTube channel, you can join the YouTube chat there.

You can call the program toll free at 844295 talk (844) 295-8255.

Let me welcome our guest, two guests in studio with us.

Doctor Tommaso Shinseki is a urologist, an assistant professor in the Department of neurology at the University of Rochester Medical Center.

Doctor Kosinski, welcome.

Thank you for being with us.

Thank you for having me.

Doctor Matthew Truong is with us, a urologist who practices general urology and urologic oncology at the center for urology, which is associated with Rochester Regional Health.

Doctor Trang, welcome.

Thank you for being with us.

Thanks for having me.

And on the line with us is doctor Supremo Healey, who is a geriatric oncologist and professor in the Department of Medicine, hematology, oncology, surgery, cancer Control and the Cancer Center, and Vice chair for Academic Affairs in the department, Department of medicine at the University of Rochester Medical Center.

Doctor Healey, welcome.

Thank you for being with us.

Thank you.

I've listened to your show for so long, and it's an honor to be here today.

Oh, well, that's very kind of you.

And listeners, I want to stress, three outstanding experts who are going to try to answer your general questions.

they are not here to sort of wade through the morass of possible political allegations, but they will talk in general about not only prostate cancer, but maybe what we can learn just medically from the last several days.

And, let me just start in studio.

I'll start with you, Doctor Truong.

You know, that news certainly last Friday hit like a shockwave.

And it whenever there's a president diagnosed in this way.

Now, this is a president at his age, who is, you know, maybe the age makes it a little bit less of a shock, but I'm wondering how the news hit you.

My first response was, a bit of a shock.

you know, just because he is the president, the president of the United States, former president of United States, and being diagnosed with such an advanced stage, sort of, puts a little bit of a wonder in terms of what type of screening paradigm was used for a president.

you know, there's there's certain guidelines that would suggest that perhaps PSA screening, may not be warranted in individuals over the age of 70 or who may have a limited life expectancy.

but I would say my initial reaction was that if it were the president of the United States, I would expect perhaps a little bit more, of an aggressive screening paradigm.

But that's just my own personal opinion about that subject.

Yeah.

And, I wonder if not just a prostate cancer announcement, but metastasis to the bones.

Does that change the way that news hits you?

It does.

And you know, you know, prostate cancer is diagnosed in a number of different ways.

The most common way it's diagnosed is really based on an initial screening PSA.

And we have specific guidelines for that.

and so it's it's very common for men to start their PSA screening at the age of 50.

And this is, written in a variety of different guidelines.

And, some guidelines may differ slightly, but typically around the age of 50 is when most men start their PSA screening.

Now, there are patients who are at higher risk inherently of having prostate cancer.

These include, patients of African descent, patients who have an extensive family history of prostate cancer may choose to get their screening, and earlier.

And in fact, our updated guidelines recommend screening starting the age of 40 in some of those individuals.

Now, when I when we hear about this diagnosis of metastatic prostate cancer at the initial presentation, it's fairly uncommon to see because we usually detect cancer in the localized stage where the cancer is still contained within the prostate.

it's only about 5% of the time when patients come to my office and already have advanced prostate cancer that has already metastasized to the bone.

And, you know, oftentimes when we see those types of patients, the first thing I look at is what was their PSA screening history?

you know, what sort of led to this, state where perhaps, you know, the patient didn't, follow up regularly, with a physician or perhaps the primary care physician?

may have checked the PSA a little bit too late in life.

That could sometimes, sort of delay the diagnosis.

so these are questions that, crossed my mind whenever I see a patient with, what we call the Novo metastatic prostate cancer, a prostate cancer that's diagnosed metastatic at presentation.

Doctor Oshinsky, how did the news that you.

You know, it's always devastating to hear these types of, diagnoses and, you know, just thoughts and prayers of the Biden family.

I guess I wasn't too surprised by a prostate cancer diagnosis, because I think about a month ago, they released a news story saying there was a nodule found on exam, and then, I was surprised that it had metastasized to the bones, like Doctor Truong was saying, you know, about 5% of cases end up that way.

in terms of the screening, it's difficult because if you follow what the Uspstf has put out there, they would recommend against screening for people that are 70 years and older.

And it sounds like that is what he did.

And, you know, screening is often meant to detect cancer when it's asymptomatic.

Before you have any symptoms.

And what it sounds like is he was having increasing urinary symptoms.

And this is what led to the exam and the workup at this time.

So, while I it seemed like with the news a month ago, I wasn't too surprised that the prostate cancer diagnosis, a little bit surprised that it was that advanced when it was actually discovered.

Yeah.

As you both mentioned, it's prostate cancer.

We'll talk about how common I don't know if the word is common, but I mean, certainly you see plenty of patients with it, but it the numbers you're giving us 19 out of 20 times, you see it, it has not metastasized.

That's right.

Correct.

Yeah.

Yeah.

I mean, so that's it's so finding that one out of 20.

Yeah.

Go ahead, Doctor Healey.

Yeah.

So so I met, medical oncologist and a geriatrician.

So my expertise is in taking care of patients aged 65 and over with cancer.

And I think on the medical oncology side, we may see patients who present with advanced disease more commonly, there are times when patients present with advanced prostate cancer that we don't even get a biopsy, because we have we can make a diagnosis by an elevated PSA.

And for some older adults who may be more frail, it doesn't make sense for them to even go through a biopsy.

and because we can treat with medical treatment.

So I, I think the prevalence is a little bit higher, maybe 10 or 15%, rather than five, because I think it's just the way people get into the system.

Yeah.

And so, maybe I'll start with you on this next one.

Doctor McNealy.

And I want all of you to weigh in on this.

And again, this is to help listeners understand how this news can maybe be a guideline for us to think more seriously.

I'm not great at it.

As a 46 year old male, I'm embarrassed to say with three doctors on the panel that I have not had a colonoscopy yet, I'm about to get a lecture.

I know, I know, I know, it's got to get scheduled.

Men aren't great at this.

So that's in general.

Now this was a president.

And so then here's what The New York Times reports.

the New York Times reports about the president's testing regime and says the following Biden aides told The New York Times that physicians stopped testing President Biden's PSA.

His prostate specific antigen was surges with cancer after 2014.

And so the president's doctors perhaps did not know there was a problem.

Now, our guest, Doctor Mo Healy in studio, have said, you know, PSA screening start at 50.

I've read different guidelines, 50, maybe 55, whatever the number is, it's not 78, which is what President Biden entered office as.

And so, does it strike you as unusual?

If that is true, no one is asking any of the doctors here to sort through medical records that they don't have.

That's not fair to the doctors here.

We're talking in general.

Would it be unusual for someone of that age to have had PSA testing done, but stopping that 11 years ago?

Doctor yeah, yeah.

Go ahead doctor.

Yeah, it's absolutely not unusual.

as was discussed, the guidelines say, use a chronological age, as is, the time to consider stopping screening.

And the guidelines do, say, 50 to 69.

And when somebody is 70, because there's there's a sense of limited life expectancy, that screening, should be stopped.

as a geriatrician, and I think a lot of my colleagues who are geriatrician may not agree with using chronological age as a decision maker.

fitness, overall fitness is quite a, significant predictor of outcomes.

And people are living longer and living healthier lives like President Biden that we should be thinking about, using objective, life expectancy assessments or other kinds of assessments like geriatric assessment to think about fitness, and use that as a guideline of who should get screening.

that's a new area of research.

We need lots of research in this area, especially with the aging of the population and how prevalent prostate cancer is.

And older adults, I think we need a lot more information.

So it's not surprising, but I think there's a big gap here.

and I'm not sure that the guidelines are appropriate for many of our many individuals.

And, the community.

Yeah.

Doctor Sinicki, I think that's part of what, the former president's office is saying is that, look, he was tested yearly up to the age of 69.

That was the guideline.

And there's nothing sort of unusual about that.

What do you think?

Yeah, it's always a shared decision making.

And, not knowing what those conversations look like.

I mean, he had cancer in his family.

it's difficult.

And one of the reasons why they do even have a cutoff for these ages is that there is an indolent nature of prostate cancer.

So every year in the US, there's over 300,000 diagnoses each year.

And despite there being so many diagnoses, around 35,000 men each year die from their prostate cancer.

So many, many, many fewer men die each year from prostate cancer than we're diagnosing.

And any treatment that we give, even if we're treating it in the localized state, the side effects of that.

And that's where if you start testing for it and you find it, you have to follow it through.

And that's where the shared decision making comes in of knowing not just, you know, is there cancer is or not cancer, but what the future looks like as you move forward.

If you do have a diagnosis and there's some prostate cancer we know is indolent, you know, like Gleason six, prostate cancer, that's the lowest on the scale.

We watch it even though we find it.

But most people wouldn't ignore Gleason nine, prostate cancer.

But they found it.

But he wasn't.

He didn't have that.

Probably in 2014, either.

Right.

And so I let me try to make sure I understand it, as best I can here and tell me if I'm wrong about this.

So I think about my stepfather, who passed away at the age of 90 last year, but at 85 had, a pretty significant, cancer.

He had merkel cell carcinoma, pretty aggressive form of skin cancer.

And, he had a number of cancers in his 80s.

And he always said, I don't want any chemo at my age.

I don't want it.

I don't want what it would do to me.

He had radiation after the merkel cell, tumor was removed, but stopped halfway through because of what it was doing to his skin and the pain and everything.

And he said, look, I I've done half the treatment I'm stopping.

And part of what I'm hearing you say is like, when you get to a certain ages, if you discover it, then you may end up down a course treatment that could have its own side effects that someone like my stepfather never wanted.

Is that correct?

Yeah.

And you have to understand that, Joe Biden had just, in 2014.

I'm not sure if his son was diagnosed with a brain tumor at that point.

He died in 2015.

I don't know when the diagnosis was yet, but he probably saw him going through those treatments as well.

And I can't put myself into that situation.

I don't know what those conversations look like, but I can only imagine, knowing my experience with patients, that that probably weighed into his decision making.

So, Doctor Trung, for for listeners, there's a 70 year old listener who's been tested every year for the last 15 years listening right now going, does this mean I'm not tested every year in my 70s?

What's the conversation like?

Yeah.

So the conversation that I have is that if this is going to be an individual decision, we have guidelines specifically about with age cutoffs.

And you know I agree with doctors in ski.

There is there's certainly a conversation that has had with the patient and their physician in terms of the value, the benefit of continued screening, because there's sort of a trade off as men get older.

There's competing causes of death.

You know, men can die from heart attacks, strokes, car accidents, any number of things.

And we have to weigh in the risk of those events versus prostate cancer.

And generally over the age of 70 and the average life expectancy, men are very unlikely to die from prostate cancer.

If you if you continue screening beyond that age.

Now we have seen some very healthy individuals in the age of 70 or very active and who clearly have a greater than ten year life expectancy, and I will continue to do PSA screening in those individuals, because I know there's going to be potentially a benefit, for those individuals.

Now, you know, I don't know the types of conversations that were had between, President Biden and his physician as far as his anticipated life expectancy.

Yet, you know, in his 70 or 71, whenever he stopped the screening.

but certainly there may have been a, you know, a genuine conversation in that time about the risks and benefits of screening.

And they may have made a judgment call about that.

All right.

So here's what we're going to do.

I'm going to start reading your emails and feedback in just a moment.

I see the phone ring.

And we're going to get a lot of feedback here from people.

On questions about prostate cancer.

I do want all three of our guests to just weigh in.

And one other important point here with the Biden story, which is, had this been a generation ago, a metastasis to the bone diagnosis would be very different.

It doesn't mean that there is a I'm going to use the word cure, probably very clumsily, but, I want our guests.

I'll start with Doctor Trung to just kind of describe how treatment has improved a little bit here and why this, this could still be a 5 to 10 year lifetime horizon for the president.

Yeah, absolutely.

I mean, there's so many options available today, and this has evolved.

not just, within the last 20 years, but just within the last few years, the treatments have, evolved tremendously.

So the, the most common treatment, for men who are diagnosed with metastatic prostate cancer is some, some form of hormone therapy.

So these are typically injections, or potentially even pills that suppress the testosterone levels and slow, slow down the growth of the prostate cancer.

currently, it's not just the hormone therapy that has been shown to be effective, but we we're starting to see that there are combination drug therapies, that can be given, in combination with hormone therapies.

And these are called second generation anti androgens.

And there's a number of, approved drugs that can be combined with hormone therapy to, to effectively improve survival.

and then in the last few years, there has been, further developments in the use of chemotherapy.

there is a chemotherapy drug called docetaxel that can be combined, with not only the hormone therapy, but some of these second generation anti androgens to really maximize survival in, patients with metastatic prostate cancer.

Okay.

Doctor Pinsky, you want to add to that.

Yeah.

Thank you.

And I I'd like to add that a lot of these studies have been funded by NIH over the even the past decade or 15 years, and a lot of research has poured into this.

Doctor Huggins was one of the only urologist to win a Nobel Prize.

He made the discovery that, prostate cancer cells were responsive to androgens like testosterone back in the 70s.

And then over the past several years, we've developed these newer second generation anti androgen.

So really lower those testosterone levels even further.

And even within the past five years, there's a medication, that can also see where the prostate cancer cells are.

It's called Plavix.

So it actually tries to attack and kill those prostate cancer cells in just those prostate, prostate cancer cells by delivering chemotherapy directly to them.

So, you know, over the past decade, we've really seen drastic improvements and better overall survival for people that are even diagnosed with metastatic prostate cancer, which I think might answer Byron's email, who just sent in saying even though Biden's cancer is hormone sensitive, wouldn't play victory or Zo figure would be potentially curative and better than Lupron.

So I will leave that to doctor McCullough a little bit because she, would be better able to.

But usually insurance restricts, first and second line therapies a little bit.

so, so that's where the decision making goes into this a little bit as well.

Okay.

Doctor Healy.

Yeah, I'll, I'll go back to what you said about shared decision making.

It's really important, just like in PSA screening, to go over the risks and benefits of each of the therapeutic options with patients.

For older adults, patient preference and values and goals are very important to address upfront.

Just like you said about your father in law, I believe, it's really important to understand what's important to them.

I'll echo the importance of clinical trials.

All of the treatments we have thus far are derived from clinical trials.

It's absolutely important to continue to invest, and for patients to know that your participation in clinical trials helps not just you as an individual, but all patients that come after you.

because that's how we develop the guidelines and the decisions.

in clinical trials, survival is usually the first and primary outcome because that's so important.

And knowing if those treatments work and know and that's important to patients too.

But we need other outcomes like function and quality of life.

in those trials to understand what the impact is of those treatments for older adults, they may tell me in my clinic, I have a geriatric oncology clinic at, well, my cancer institute, which is one of the few in the country, we do, geriatric evaluations plus, evaluate kols and think about the best course of treatment for that individual patient.

It's a very personalized.

And they a lots of patients tell me, you know, we want to live long, but we also want our function to be as best as it can be.

I want to be independent.

I want to be cognitive li functionally good physically could be able to do things with my grandkids.

And that really plays into what we do for treatments.

Hormonal treatment is the best first option and then whether or not we do combination combination treatments will depend on patient preference because all treatments have toxicities and the more we do, the more it will affect function and quality of life.

And so you know, how to make those individual decisions with patients really is, the art of communication.

And we have to use the patient's information for perfecto that that treatment is not approved for first line treatment.

it, it is used later in the course.

And most patients have to be on some form of hormonal treatment to receive that drug.

that treatment, information.

Well, let's get to some of your feedback here with, three medical experts talking about prostate cancer, answering your questions.

And we're going to start on the phone in San Diego.

Here's Greg.

Hey, Greg.

Go ahead.

Hello?

Hello.

I am, concerned with the, matter of prevention, so I'd like to know if I am taking this correctly.

That, PSA test is a simple blood test, like a test for a Navy, for, an infection.

And as a person who turns as a man turned 17, forget about getting that PSA blood test, then, because ignorance is bliss.

And, you know, I, you know, that is an indicator that something is on this.

And, you know, so far I've heard a lot about treating it after the symptoms become evident.

But I really, disappointed to hear that the importance of, prevention of getting just a simple blood test which might indicate, you know, if everything is clean, if your PSA is for then, you know, you definitely don't have anything to worry about, that somehow the age of 70 is a magic number.

one that simple blood tests should be style.

being performed saying thank you.

That's my first.

Yeah.

So, Greg, so first of all, I'm going to do it again, my best as the lay person to kind of translate some of what I'm hearing.

And then the doctors will correct everything I get wrong here.

But I will say, you sound like the kind of person that you want.

That information doesn't matter your age.

If you want, you want the info, get it?

I mean, I think what I'm hearing from the doctors is the the 55 to 69 or 50 to 69 is generalized.

That is not looking at every individual who may have very different preferences, like yourself, may have different health profiles, may have different family histories.

And so certainly if that is something that's going to be a big priority for you, I don't I have not heard anything from the doctors that would say otherwise.

I don't think they're saying ignorance is bliss.

I think they're saying typically when we're not talking about metastasized prostate cancer, if it is not a fast moving cancer, that would still maybe lead to radiation or other treatments.

that that could affect quality of life for a person in their 70s, 80s, 90s, vis-a-vis someone in their 50s, 40s, 30s, we see breast cancer diagnosis in the 20s and 30s now in ways that I was not aware of when I was younger.

So I that's what I'm hearing from the doctors.

This individualized decision making, general guidelines.

And for for Greg, it sounds Doctor Truong like he wants to test you.

You understand that.

Absolutely.

You know, this is a this is a great question because it highlights the importance of shared decision making.

And that patient's values may differ.

So, you know, the 70 is a guideline number as far as when to stop PSA screening.

But you know that can differ from one individual to the next.

Now there are we see exceptions to the rule all the time.

In fact there's patients that fall out of the standard guidelines.

Let's go ahead.

Just to give you a couple examples.

You know, recently I diagnosed a young man, 48 years old with a Gleason nine prostate cancer.

fortunately for him, it was localized, and he falls completely out of the standard guidelines.

He's a Caucasian male, doesn't have any family history of risk factors in Gleason nine, the highest is ten.

It is the.

Yes.

So Gleason nine is in ten or are pretty much the highest you can get as far as aggressiveness.

Okay.

so he was found the most found to have the most aggressive prostate cancer below when the the guidelines would suggest that he start screening.

And that's just an example.

And you know, just just a couple weeks ago, I, I saw a gentleman who is African American who is 55 years old, diagnosed with metastatic, also Gleason nine, prostate cancer, but also has metastasized to the bones.

And so he was only in his 50s.

His lower 50s.

And so it's you know, this is one of those situations that, you know, some patients don't fall within, you know, what the guidelines would say.

And so these are this is part of the art of medicine is being able to to catch those, you know, so not let those types of patients fall through the cracks.

And it's always a victory when you when you deviate from the guidelines and find a cancer that could potentially be life saving.

Doctor.

Since key part of what Greg is saying is, isn't it just a simple blood test.

Painless.

Shouldn't we just do that?

Yeah.

It's a so is that correct for a PSA test?

A PSA is a blood test.

and he said it's prevention and I just need to make one small correct.

It doesn't it won't prevent you from getting prostate cancer, but it will help lead to an earlier diagnosis that we think.

And it's not perfect.

There's a range.

So some people, you can have prostate cancer below the normal level and you can have really elevated levels of PSA.

And and you might not have prostate cancer.

And at a certain age when we know that people are less likely to die from their prostate cancer, even if they did have it, an elevated level will lead to biopsies which have complications, anxiety imaging, every one of those steps along the way have their own sorts of risk and complications and anxiety and everything else that goes along with it.

So while it's just a simple blood test, it's everything after it as well.

Okay.

And Doctor Healy, yeah, I agree with what has been said.

it, blood tests will lead to other interventions, either active surveillance where you're doing, ongoing blood tests.

And there is a real entity called PSA anxiety.

There's research on this where getting multiple PSA can make people anxious.

And we heard already that people can live a long time without even knowing they have prostate cancer.

And the prostate cancer may not ever affect their survival.

I think President Biden actually falls outside the guidelines to for an older man to be diagnosed with advanced prostate cancer, that's Gleason nine is very unusual.

and it's it's not typical of who we see, as was discussed before.

Okay.

Greg, good luck to you.

And again, you sound like the kind of person who wants a ton of information.

I'm sure you will communicate that to your doctors.

And and that's good.

I mean, that's kind of conversation that people should be having.

The one thing we shouldn't be doing is just not going to the doctor.

Men.

Okay, okay.

Let me at the top of the list.

Oh, boy.

Rick in Greece, next on the phone.

Hey, Rick, go ahead.

Hi.

I, I have a similar comment from the, previous caller.

I'm 70, one, and I just had, was notified by my doctor that my PSA level through a blood test was higher once for for an MRI and a biopsy.

And thank goodness everything, has been benign.

But I am going to be going for treatment every three months.

and, although the tests were a bit uncomfortable, they, they certainly weren't painful.

And, I'm just glad that this level can be monitored and so I don't that develop, prostate cancer whether I'm 70 or 80, I will continue to, to request, that test.

which have, advanced, greatly since my poor father went through biopsies, very painful biopsy years ago.

And a friend of mine also survived prostate cancer.

So thank you for this, important information being shared with all of us.

Yeah.

Rick.

Yeah.

Good luck to you, Rick, I continued, good fortune and good health to you.

And, you know, I, I'm very sorry to hear about your father.

but again, this is somebody who, at Rick's age, given family history, given everything he's experiencing, he wants to kind of keep the light on and keep, keep, keep looking and keep testing.

And that's exactly what the doctors are saying is have those conversations and be aware of the different options.

So, I, I hope that you continue to get good results there, Rick, and I'm really grateful for that.

Let me read some emails, that have come in two emails from two different Gary's.

The first, Gary says having personal experience.

I do think my prostate cancer could have been detected earlier if attention had been paid to the steady increase in PSA numbers over a few years, as much as the number threshold where it becomes a concern.

I always tell people that if they see a steady increase toward that threshold number, and with the PSA into cancer detectable numbers, it's worth going, asking to go ahead and take the next steps toward detection, especially, as with me, it's in the family I do.

Worrisome physicians may pay heed largely just to the threshold number, and not so much to the trend of the PSA overall.

That's from Gary.

Doctor Trung, I'll start with you.

I'll go around the panel here.

What do you make of Gary's point there?

Yeah, that Gary's made a really good point about PSA.

And that's in the threshold that, people frequently used to determine whether PSA is abnormal or not.

And that's usually a threshold of for now, what we're learning is that the threshold itself is less important.

Sort of incorporating the age is far more important.

So if you see a young man with a very slow, steady rise in his PSA, that may prompt further workup even before the PSA reaches the threshold of four.

So that's really important.

Incorporating other risk factors such as family history, are also important.

Now, there there are, a lot of adjunctive tests that people are not, potentially aware of other than the PSA.

No PSA is, the most commonly used test.

But we have to remember that PSA is a very inaccurate test in general.

So it's estimated to be about 55% accurate, which is actually not a very accurate test for making a cancer diagnosis.

And we often use, adjunctive tests now to further supplement this.

And one of the things that we can do that's very simple is a digital rectal exam.

And this can be, you know, just a finger in a man's rectum, which is a 15 to 20 second procedure, that can really provide additional information.

So if there's a nodule that's felt or any kind of firmness, you know, that would suggest that, there may be cancer there, even in the absence of a PSA elevation.

In addition, you know, we're we're using adjunctive tests now, such as imaging.

MRI, for instance, is a very popular test to supplement the PSA and determine if there's any abnormalities within the prostate that can be targeted on a biopsy.

you know, there's also urinary tests that are now noninvasive and can be used to determine whether or not a man might need a biopsy.

So we have a lot of tools now then, rather than just the initial PSA that we had, you know, just a couple decades ago.

Okay, doctor, since you want to add to that.

yeah.

So it's actually against our guidelines to just work up a man for prostate cancer.

If the PSA level is going up, it's called a PSA velocity.

But but even with that said, you know, you don't just take the one piece of information, by itself.

You know, you go into family history, and you look at a lot of other factors.

And I'd like to add on to the MRI being a really important tool that's really come out for prostate cancer in the past 5 to 10 years, which is really mainstream for us working up these PSA is when you do a digital rectal exam, the prostate is situated between the bladder and the urethra and it surrounds it.

And when you do when you do the exam, you know, you're maybe only feeling 5 or 10% of the entire prostate.

so, you know, where prostate cancers most commonly come from, that's where you're feeling usually.

But that's not the only area.

And what the MRI does is it gives us an ability to look at that entire organ, and does a better job of risk stratifying, what's going on as opposed to just the PSA along?

Okay.

Doctor Healy, anything to add?

Yeah.

As a geriatrician, I just want to, really think about overall health as also, something to assess when thinking about, moving forward with PSA screening and the subsequent interventions.

As people get older, they develop other comorbidities, heart disease, maybe lung disease.

And if those medical problems are so severe that it would limit someone's life expectancy going through the diagnostic procedures and interventions and even treatments for prostate cancer may not be, may not help that that individual.

And so that is part of the shared decision making discussion.

Also, I'll also say that online there are some really great shared decision making tools for prostate cancer screening.

you can go on the internet and find them.

They're really developed nicely and can help individual cells think about how they want to communicate their goals and preferences with their doctors.

Well, related to some of what you just heard in response to Gary's email.

And Gary, thank you for that.

Related to a question of the different kinds of tests.

So PSA test, the digital rectal exam, Frederick is asking, what are the false negative and positive rates of the PSA test and of the digital rectal exam?

You heard Doctor Truong say PSA is about 55% accurate.

What about a digital rectal exam?

Digital rectal exam should never be used as a standalone test.

It's more as an adjunct to the PSA.

We don't have, good information as far as its accuracy.

In fact, our, guidelines state that it's actually an optional test.

I personally do this because once a year I'll diagnose a very advanced prostate cancer by digital rectal exam only.

So I, you know, there's there's clearly individuals that have, that benefit from this.

But in general, for most men, a digital rectal exam, itself is not going to be a great standalone test.

All right.

I've got a bunch of great questions.

We're so late for a break here.

So we're just going to come take that very short break, come right back with the doctor's talking about prostate cancer and your questions answered next.

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This is connections.

I'm Evan Dawson, doctor Supriya mohini, Tommaso Minsky, Matthew Truong all with us talking about prostate cancer and you and answering your questions.

And on and on we go.

There are a lot of great questions here.

there was a question about insurance, about if insurance basically cuts off and when a person turns 70 for testing.

And is that why the system is saying, maybe we stopped testing at 70?

The doctors are telling me off air, there's no indication that that is not what is driving the guidelines on testing.

And you haven't seen insurance all of a sudden is not covered in this.

So it's never, never an issue.

Okay.

So that should be at least comforting there.

Keith in Rochester called in to ask if there is a relationship between sexual activity and prostate cancer.

if men ejaculate more, does that lower or increase the risk?

Any data on that?

Doctor Truong no, but I would like to see a study.

So you think this does bear more research?

Well, you know, it's it's one of those things that are hard to study.

You know, there's there's, you know, there's theoretically an inflammatory inflammation, component to this.

We just don't know, if there's any impact, the only thing that people are really looking into now, is the impact on, in terms of red meats and whether this has a potential impact in prostate cancer prevention.

There there have been some studies in the past looking at, vitamin E and and various other, compounds to try to prevent prostate cancer is never been really a positive study in terms of something, that, that, could potentially prevent prostate cancer.

So related to that, Doctor Ski and Doctor Healy Allen wrote in to say great info this hour.

But what about actual prevention?

What can a person do health wise, diet, lifestyle, etc.

to support and boost our immune system to prevent prostate cancer?

So what I would say is vitamin E has actually been linked to more aggressive and increased risk of prostate cancer.

So that's where we really need these studies to understand what prevention looks like.

There is a medication people use for hair loss, as well as in large prostate called finasteride.

There's some people that have advocated for that.

There's also some evidence to suggest that it leads to more aggressive prostate cancers.

In terms of prevention.

That is one thing that's been discussed about.

And at least there's some data with that.

you know, those are my thoughts, okay.

And but there's not a silver bullet that.

Well, if you stop eating this or, and, healthy diet less meat, you know, normal calorie diet, less obesity, all those things.

And that's just not prostate cancer.

That's overall health.

That's cardiovascular health.

That's all cancers.

And doctor McKinley, every article I read, there's speculation on whether sex is something that has a contributing factor here.

Anything you want to add on that point?

Oh, yeah.

No, I don't know of any data that links that to and I agree.

I think what we're hearing is there's really a need for more research.

we don't have great.

as you say, silver bullets for prevention because we don't have enough research and cancer prevention.

Cancer prevention research is so important to identify.

you know, areas of, of need and, interventions that could help prevent prostate cancer.

I agree with heart healthy, good exercise, good nutrition, to prevent cancer in general.

And then if someone unfortunately would to develop cancer, the fitter someone is, the more apt they're going to be able to tolerate and have tolerate therapy and have, good successful outcome.

Well, related to the question on sexual activity, perhaps, Michael says, as a 63 year old male and a lymphoma survivor, I get six month PSA.

I asked why I never had the digital, the digital exam and was told it is no longer standard practice.

First of all, is that correct?

Not correct.

I know that that's that's an area of controversy.

The the American Urological Association has a guideline statement that says that a digital rectally exam is optional.

There's no statement that says it's discouraged and there's no statement saying that it's absolutely necessary.

Okay.

And then he concludes with this.

He says, then one day my PSA went from 1 to 5 and I did get the exam.

It is quick, easy and painless.

It turns out being sexually active before your PSA can lead to higher readings.

My last test went back to one.

That's Mike who's watching on YouTube.

so being sexually active right before you have a PSA test can lead to higher readings is there data on that?

Yes.

That's correct.

So I usually try to tell people to wait about three days to a week, after their last sexual activity to get a PSA, especially if it's elevated some.

For some people it doesn't matter.

And then other people it does seem to shoot up.

Okay.

Good information Mike.

Thank you.

Good luck to you.

Good luck.

Good health to you.

Dallas wrote in to reference got Adams who the creative a comic he created Dilbert.

In recent years, you've become, a political commentator and a podcast host.

And so after the Biden news came out, Scott Adams, revealed that he has essentially the same diagnosis, but his is further along.

And I want to listen to some of what he said because his listeners kind of deluged him with, hey, you should be using ivermectin.

And there's there's these miracle cures and you're not doing it.

I want to listen to what Scott Adams said about that.

I have the same cancer that Joe Biden has.

so I also have prostate cancer that has also spread to my bones, but I've had it longer than he is at it.

Well, longer than he's admitted having it.

So my life expectancy is maybe the summer.

I expect, I expect to be checked out from this, domain sometime in the summer.

You might ask yourself, is it possible that he was not showing signs in August of 2024, but that between then and now, the, you know, we showed signs but that it had spread to his bones.

And the answer is, yeah, that's possible.

I was making a big deal online about the claims that ivermectin and and Amazon are a cure for this exact condition.

Well, in case you're wondering, I did try that, and I did try it with the assistance of the doctor.

Obviously, the famous doctor.

Doctor Marcus.

And it wasn't that I believed it would work, it was just there wasn't much downside risk.

So with my doctors, you know, blessing, he didn't think it would work, of course.

And it didn't work at all.

So I did it for a few months.

My PSA probably went up.

That's got Adam saying that those treatments that a lot of people are telling him are going to be this miracle cure just didn't work.

And Doctor Healey, I think we would have heard from all three of you by now if there was a miracle cure out there.

Is that fair?

Yes, I think that's true.

And I, I just want to, let your audience know and that science is really important.

this is how we really learn about what works and what doesn't work.

It's done in a very thoughtful way with people who are experts, who are designing the trials.

We have a lot of oversight of those trials, institutionally, through our regulatory bodies, through the NIH, through industry partners and people on those trials are closed, tightly monitored.

They get actually extra care.

and, good, good care delivery because they're getting all of these this extra attention on the trial for those treatments that have not been studied for specific cancers on clinical trials, we just don't know if they work or don't work.

And I will say they can cause harm if especially if they're given with more standard treatments, because there are drug interactions that we may not be aware of, and also symptoms that patients may develop where they don't feel well and we just won't know why.

And so I will just echo that clinical trials are really important.

That's how we learn about how to treat cancer.

All right.

Well, let me continue here with the feedback.

We'll get as much in as we can for the rest of the.

Our second Gary email said that he had an aggressive form of prostate cancer about seven years ago.

He says his oncologist told him that if a man lives long enough, he will get prostate cancer.

And Gary says, my understanding is that this is more common than thought.

he also was asking about he says he had no symptoms.

He felt perfectly healthy.

It was discovered during an annual physical.

The previous exam showed no signs of cancer.

He says he wasn't hiding anything.

And, you know, he was wondering if the guest could weigh in on, you know, if it makes sense that President Biden's prostate cancer could have been covered up, or could it be discovered like this late?

And again, I want to say again, the doctors are here not to address possible political cover ups or cover ups for political reasons.

There's a lot of information that people don't have.

It is plausible, as we've heard, even if it's not the most common way for it to go, for it to go this way.

If you're not getting annual PSA screenings, which apparently President Biden wasn't for the last 11 years.

And so, I don't think there's an easy answer on that part, Gary.

But, you know, it's interesting, Gary saying his oncologist said, if a man lives long enough, he will get prostate cancer.

Doctor, since.

Is that a fair statement?

That's a common saying.

I don't know that everyone will get prostate cancer, but, you know, somewhere around 30 to 40% of men would probably develop prostate cancer if they lived long enough.

And, you know, that's just reflective in those numbers that 300,000 men in the US every year are diagnosed with prostate cancer, with 35,000 men each year dying from prostate cancer.

And, I mean it, the it would be pretty cynical to think that someone would hide this until a point where, you know, then they would release a story a month ago to put out that there was a nodule found, and then, there was a really advanced case of prostate cancer.

I mean, there would be a lot of corroboration.

I think that would have to happen for that to occur.

you know, with that said, it's not completely unexpected for a man to have Gleason nine prostate cancer a year ago, not have any symptoms, and all of a sudden have this discovered.

We you know, we've heard about some of those patient stories today from Doctor Truong, Dallas, followed up by saying, does anyone survive, bone cancer?

He says, I don't think so.

My understanding is a metastasized form of cancer from prostate to bone is not something that you can cure, that if you live long enough.

This president is either going to die of this cancer or he will pass from something else.

But if they contain it successfully and he gets more years, which is certainly plausible given what we've been hearing from our guest today, it may be something else that kills him.

Is that a short, fair way of describing Doctor Trunk?

Yeah.

So just to clarify the the fact that you can't you you can't.

So with metastatic prostate cancers, there's sort of two states.

There's there's what's called a micro metastatic state.

And then there's sort of the widely metastatic state.

And we don't know which which applies to President Biden.

And we're starting to learn from our radiation colleagues that patients with limited metastases to the bone could still be cured of their prostate cancer with what's called metastasis directed therapy.

So what that means is that if a patient has limited sites of metastasis, typically they use the cutoff of three or fewer.

You could be a candidate for a combination of hormone therapy to the prostate and radiation to those sites, and potentially be curative.

We just don't know which state President Biden falls under.

now, as far as his age of life expectancy, expectancy, it's very possible that had this never been diagnosed, he may have died from other causes.

It's a very plausible thing for his age.

It it's not surprising that he has this diagnosis given his age.

All right, doctor, since can you get the next one?

We got to go fast here.

Ken says many men have an enlarged prostate.

Does that relate to PSA into cancer?

Larger prostate usually make more PSA.

All it is is a protein that's secreted by the prostate.

Prostate cancer cells tend to release more of it also enlarged prostate do so often as a cause of negative workups, meaning no prostate cancer discovered during the time of that workup.

Okay, so it's not definitive, but in a large prostate can have that meaning.

Okay.

I make a comment about that.

So, what we've actually found is that larger prostates are actually less correlated with aggressive prostate cancers.

And I could have, you know, whole our conversation about why this might be.

But but you would you know, what?

You know, just just from you know, you would think that a larger prostate might have a greater risk, but it's actually the opposite.

And one of the reasons potentially behind this is that men who have in large practice may present with symptoms a lot earlier, and so they may see a urologist sooner and get screened and treated for prosecutor, prostate cancer in an earlier age.

The other potential explanation is that they may have present with higher PSA.

It's like doctor Rosenstiel was saying and that they may, this may alert their physicians a lot sooner, and so they may have a better outcome in general.

As we wrap here, Tim emailed to say his grandfather had prostate cancer and died of heart disease years later, and his family came to think of prostate cancer as something you just die with, not from.

And you kind of shrug it off.

I think we've learned this our you don't ever shrug off cancer in any form, and that prostate cancer can present in a lot of different ways.

And the best thing we can do is be very well educated about it, about ourselves, and have good relationships with those who treat us, which means going to see them with some regularity.

That's talking to myself, everybody.

Doctor Trong, Doctor Sinicki in studio.

Thank you for sharing your expertise with us.

Thanks so much for having him and Doctor Supremo Healy on the line with us.

Thank you for being generous with your time as well.

We look forward to the next conversation.

Doctor.

Thank you.

More connections coming up in just a moment.

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