MedEvidence! Truth Behind the Data

🎙From PSA to Personalized Prostate Care, Part 3 Ep. 294

• Dr. Michael Koren, Dr. Ali Kasraeian • Episode 294

Share episode

Send us a text

Urologist and president of the Duval County Medical Society Dr. Ali Kasraeian joins Dr. Michael Koren to update us on recent advances in Urology. In Part 3 of this series, Dr. Koren and Dr. Kasraeian dive deep into the latest advancements in prostate cancer detection and treatment options. They explore the evolution from basic PSA screening to personalized approaches . Dr. Kasraeian focuses on the modern shift to patient-focused, individualized approaches that meet patients where they are by balancing early detection with quality of life considerations.

Be a part of advancing science by participating in clinical research.

Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com

Listen on Spotify
Listen on Apple Podcasts
Watch on YouTube

Share with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.

Follow us on Social Media:
Facebook
Instagram
X (Formerly Twitter)
LinkedIn

Want to learn more? Checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com

Music: Storyblocks - Corporate Inspired

Thank you for listening!

Announcer:

Welcome to MedEvidence!, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren:

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence!, and I've been having this fabulous conversation with Dr. Ali Kasraeian, a urologist and a media person and somebody that's involved in organized medicine. In our last segment we were just talking about the controversy around PSA and how you have to customize that, the number that you get to the specifics of a person. So, higher risk people you're going to be more aggressive If you had a family history, or African-American, for example and lower risk people maybe you watch it for a longer period of time. But interestingly, even when you get to imaging, there's ways of getting a sense for what the prognosis will be over the next 5, 10, 15, 20 years. So that was a fascinating discussion. So let's jump into that point about what you see as the future for getting better at diagnosing prostate cancer and also identifying the people that truly need to be treated aggressively.

Dr. Ali Kasraeian:

Yeah, you know smarter screening, you know PSA can save your life. Talk to your doctor about PSA screening, know your family history. So if we start with a lab test and it's concerning, then we kind of talk about what to do next. If you show up with a PSA of 10, we recheck it's still elevated, it makes sense to do a biopsy. I think the MRI allows us to do a better biopsy.

Dr. Ali Kasraeian:

If we're on the fence you've had repeat negative biopsies and things of that nature then you know, can we use biomarkers. Biomarkers are lab and urine-based tests that can help guide us to see what is the probability or the possibility that your elevated PSA is due to not just a prostate cancer but a intermediate or higher risk prostate cancer, meaning a prostate cancer that if we found we would treat A lot of times these tests. If the score is in the lower range, that risk is low. If it's in the intermediate to higher range, it's an incremental higher risk. We can take that with an MRI scan, put them together and give a discussion or initiate a discussion of what is the risk, what is your comfort level, what is our next move, and we can personalize it to you, your history and other medical issues that you're going through in your age.

Dr. Michael Koren:

So, starting with the diagnosis, are there specific biomarkers other than PSA that you can mention in this podcast?

Dr. Ali Kasraeian:

Yeah, absolutely so, the three that I use. You know, right now one blood-based test that I use quite a bit is a thing called the 4K score. It looks at PSA with three other cousins intact PSA, total PSA, free PSA, intact PSA and this thing called HK2, a Kallikrein protein 2, which are kind of all in the same family.

Dr. Michael Koren:

So a doctor has to order that specific panel.

Dr. Ali Kasraeian:

It's a lab test, yeah.

Dr. Ali Kasraeian:

And then it comes back with a score and if the score is in the lower risk range, you have a very, very low risk of having an intermediate or higher risk prostate cancer.

Dr. Michael Koren:

Is that something you should do before just getting a standard PSA? Do you think

Dr. Ali Kasraeian:

because, honestly, if you have a low PSA, a stable PSA, why would you leap to another test like that? Because what if it comes back with an in-between result? And now you have a low PSA and it's only valid for PSAs that are a little bit increased anyway. From that standpoint, two urine tests that are wonderful and great science with them. One's an exosome DX test, an exosome DS test.

Dr. Ali Kasraeian:

Beautiful science that they found that exosomes, which we before thought just had mitochondria, actually have messenger RNA in them and so they found it coming off urine. It carries with it messenger RNA and great genetic and DNA information, carbon copies of it coming off urine. That could get prostate information, so that first part of the stream, and they can get predictive information of the risk of prostate cancer off it. Amazing science. So if you're in the low level, the risk of having a prostate cancer that's seven or higher is a little bit higher. If it's in the low range, it's a very low risk of that. So you can do that. And during the COVID pandemic we were very fortunate to be part of the first team using that on an at-home test and it was really really powerful for us to use to be able to guide patients on whether they need to come in and talk about doing a biopsy at a time where people didn't want to leave their house.

Dr. Ali Kasraeian:

So that was really powerful.

Dr. Michael Koren:

Again, that's not for people with a low PSA. Those are people that are identified as having higher PSAs and taking the next step.

Dr. Ali Kasraeian:

Yeah

Dr. Ali Kasraeian:

So is someone with a PSA change that we want to be mindful of. Do we need to do a biopsy next?

Dr. Ali Kasraeian:

from that standpoint,

Dr. Michael Koren:

And would that test, if it was negative, make you feel comfortable that you don't need to do? Imaging of the prostate.

Dr. Ali Kasraeian:

So that's a very controversial discussion and there are a lot of papers looking at that and we as a as urology have not come up with an absolute answer for that. For some people the MRI scan first makes sense. For some people, doing the biomarker first makes sense. Some people are are. You know, the genetics trump the imaging. Some people, imaging trumps that so so for me it's a very personalized approach, you know from that standpoint. So really, for me personally, it's a patient by patient discussion

Dr. Michael Koren:

Got it.

Dr. Ali Kasraeian:

Another test that we use frequently is a My Prostate score. It's a newer of the three. Great test and what I like about this test is a very high negative predictive value. So for someone who's never had a biopsy, they have a 95% negative predictive value.

Dr. Ali Kasraeian:

If your score is in the low range, you have a 95% likelihood of not having prostate cancer. If you've had a previous negative biopsy, you have almost a 99% negative predictive value. So that's very powerful. So I use it often with people who've had negative biopsies and then we want to think about whether or not to do another biopsy, especially if they have had a negative MRI scan.

Dr. Michael Koren:

Yeah. So for listeners out there, tests that have a high negative predictive value usually have a very high sensitivity, so they pick up things. So when they're negative, you feel pretty comfortable that you're not dealing with the problem. The flip side is, when they're positive, it doesn't always mean that you have the problem.

Dr. Ali Kasraeian:

Yeah, it tells you that search further. Right, and that's how I kind of counsel people. You know, if this is a higher, it doesn't mean that we have cancer Absolutely. It just means that we should probably look If it's negative. We feel comfortable that it's negative.

Dr. Michael Koren:

Any other novel biomarkers that you want to?

Dr. Ali Kasraeian:

One thing that's really interesting. That's not quite as novel, but something to keep in the back pocket. There's some tests that we actually use when people have had previous biopsies to decide in the next biopsy if their PSA changes. There's a test called the Confirm MDX where you can actually go back and look at the genetics of a previous negative biopsy and it can tell you at any of those cores that you took could there be genetic changes that could heighten the risk of a positive biopsy at that site. So then when you do the next biopsy it can help guide you to take a few more cores at that site. And that's in the diagnostic phase. And then there are what are called genomic tests that you can do after the biopsy. That can then guide you in terms of the therapeutics and the treatment active surveillance versus treatment so you don't again undertreat a cancer that may be able to be monitored versus overtreating a cancer that can be watched and you know, and an undertreating a cancer that should be treated.

Dr. Michael Koren:

And you mentioning about AI, maybe helping people with decision-making, so I know a big issue of course is, once you're diagnosed with prostate cancer, do you take the prostate out? Do you treat it locally?

Dr. Ali Kasraeian:

Yeah. So the treatment for prostate cancer is always, you know, very controversial and the thing that often drives a lot of people away from actually screening because they think everyone needs a prostatectomy, everyone needs radiation and unfortunately, with both of those technologies, with the advances in robotics, the advances in radiation therapy, especially in high-volume centers, the side effect profiles are getting better, but they're not perfect. So in doing that we want to see can we offer people things like focal therapies now with high intensity focus, ultrasound, cryotherapy, focal laser ablations, a lot of these technologies where if you have a targetable lesion and that's the only area that we have cancer can we just treat that area and leave the unaffected portions of the prostate untreated, and so the more prostate you preserve, the more function you preserve. Is that safe to do? We're working with a company and we're very fortunate to have been early in the adoption of this technology called Unfold AI by a company called Avenda Health really well-validated technology where you take the MRI scan, the biopsy, and then put all of the information together and it tells you how much of the prostate you have to treat, meaning target plus a margin to give you a very high confidence that you treated all the cancer with a high cure rate probability, and so you can talk to the patient about exactly what we need to do and whether they're a wonderful candidate for focal therapy or we should actually pursue a whole gland treatment.

Dr. Ali Kasraeian:

And so that's another way you can personalize the treatment so you don't undertreat a cancer that needs a more robust whole gland treatment and then you can very appropriately offer personal focal therapy. And it's a wonderful technology, very smart. And the way from a data standpoint it was monitored, or whether it was studied, is they took the MRI scan compared to a whole mount prostatectomy, meaning they sliced the pathology specimen like an imaging study, had radiologists look at it by itself, had AI look at it by itself and look at it together, and they found the AI actually did better than the radiologists by themselves, but both together did better than each alone, amazingly well validated.

Dr. Michael Koren:

Are there multiple companies that are pursuing these concepts, or is it

Dr. Ali Kasraeian:

Absolutely? I mean?

Dr. Ali Kasraeian:

there are more companies and there are more to come. The big thing for us to be mindful is how they're validated, how the science goes, and AI, like every AI that we look at, we have to be mindful of. AI is only as smart as a teacher, so what goes in it makes what comes out as smart as it can be. And what I really like about this technology it is really smart. The CEO of the company his PhD was in MRI and MRI sciences for the prostate.

Dr. Ali Kasraeian:

I mean I don't know how much more specific you can get from that in terms of a PhD, but very smart people looked into it and they continue to advance it and put more data into the technology. So it continues to grow, with a very specific focus on having people have better options of treating their prostate cancer and more information to make better choices. Again, it's personalizing it, very similar to breast cancer. So when people get diagnosed with breast cancer, the amount of information they have, a diagnosis to make very wonderful personalized choices for their present and their future and also, you know, for the genetic information for their family's future. And with prostate cancer we're looking to catch up and we're, you know I used to say we're about 20, 20, 30 years behind breast cancer. We're catching up and I think in the next several years we're going to be very, very quick to that, especially in advanced prostate cancer. The amount of medications and the science going into that field is revolutionary and our guidelines keep changing faster than we can keep up, which is a great thing.

Dr. Michael Koren:

Interesting. We're getting to the end of our time together, but any clinical trials that are ongoing that are particularly fascinating to you.

Dr. Ali Kasraeian:

Many. We're always trying to push envelopes in terms of better studies for the focal therapy avenue with diagnostics. There are always things going on in the advanced prostate cancer. There are many things. I mean it's not quite related to this, but you know, when people are diagnosed with prostate cancer advanced prostate cancer, metastatic prostate cancer historically we used to give a hormone blockade medication and there's some studies that came out in the past couple of years where you can give a pill by itself and that's similar outcome for people that have recurrent prostate cancer. We're hoping those studies continue so you can potentially treat those patients better.

Dr. Ali Kasraeian:

We're now, you know, we hope to move and make those kind of diseases, those parts of this disease that used to be uniformly fatal.

Dr. Ali Kasraeian:

We're approaching where we were having 30 to 60 percent radiographic response rate, where things that used to be on imaging are no longer there. Outcomes are better, medicines are better tolerated and so the hope for people with the more advanced prostate cancer is becoming much, much, much, much better. And you know, organ-confined prostate cancer approaches 100% five-year survival, 98% 10-year survival, and so the idea with prostate cancer is don't be afraid of getting screened, because the implication of what the therapy associated with that diagnosis would mean, because we on this side of that diagnosis are very keenly aware of those fears and we're pushing the envelope of trying to do more precise diagnosis. We're trying to do more precise therapies so that we can be impactfully aware of the quality of life impact of this disease and the science is trying to catch up and be aware of that alongside you as your partner, in terms of the right treatment for the gentleman at the right time so that we can achieve both in a personalized way.

Dr. Michael Koren:

So it sounds like there's been tremendous progress across the whole spectrum of diagnosis, particularly early diagnosis, identifying risk, identifying intermediate cases, identifying the people that really need to be treated, and then doing as well as possible, even at advanced stages.

Dr. Michael Koren:

So it's pretty fascinating

Dr. Ali Kasraeian:

yeah amazing study, new England Journal of Medicine.

Dr. Ali Kasraeian:

In Europe they do studies like this randomized trial, active observation, surgery, radiation therapy 10-year, 15-year data 97, 98% of men alive and then 15 years, similar, identical, high, 90, I think it was 97, 98% of 10 years, 96, 97% of 15 years. However, in the observation arm more people needed surgery and radiation somewhere along the line and a slight amount of people needed a hormone blockade because of metastatic disease, but it didn't cause them to pass away. Opens up the discussion of the power of active surveillance appropriately and it opens up the discussion of focal therapy appropriately when you find the right disease in the properly selected patient. So what that tells people is people may not die of prostate cancer if you catch it at the right time and you find the right treatment again for the right gentleman at the right time. That starts with screening at the right time.

Dr. Michael Koren:

Ali, that was an amazing discussion. Thank you for being part of MedEvidence!.

Dr. Ali Kasraeian:

I appreciate it, and anytime we can have better and smarter conversations, you're the best person to have these conversations with.

Announcer:

Thanks for joining the MedEvidence! podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.

People on this episode

Head Shot

Dr. Michael Koren

Host