Episode 11: Prostate Cancer-Making Decisions II...Radiation Therapy and Hormone Deprivation

Part 3 of my 3 Part Interview with Dr. David Ahlborn on Prostate Cancer. In this episode we will address Radiation Treatment and Androgen (Hormone) Deprivation Therapy. We will also talk about some of the myths of prostate cancer.

Transcript

SPEAKER_01 0:00

This podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes only. Always consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health. Thank you.

SPEAKER_02 0:17

When you're in trouble and you need help, go to your inlucknowstreaming.

SPEAKER_01 0:28

Hello there and welcome back to You're in LuckNow Streaming. This is the third and final episode in my three-part series on prostate cancer, an interview with my esteemed colleague, Dr. David Alborn. In the first episode of this series, we discussed breaking the news and we talked about the Gleason score, active surveillance, and all the different treatment options available. In the second episode, we discussed prostate cancer surgery and erectile dysfunction related to prostate cancer. And in this episode, we're going to discuss radiation therapy and androgen deprivation therapy, as well as answering some of the myths of prostate cancer. So without further ado, let's get into the flow. There's different types of radiation out there. There's like an extended radiation where you usually go Monday through Friday for 44 treatments or 30 treatments, depending upon where you're going. And then there's this cyber knife that's out there. That's like one treatment a day for five days. But we would see a lot of patients who had complications such as bleeding. They would have blood in the urine, they would have blood in their stool. And that's because we didn't have more of the technology that we're using today. The kind of stuff that you do. Can you talk about some of that?

SPEAKER_00 2:15

Radiation has come so far in the last few decades. And it's really a good treatment for a lot of people. What you were talking about that extended radiation was the standard of care so that you could try to limit the side effects and spray artifact onto the other organs in the area, the bladder, the colon, yeah, the bones, whatever. And you had to go at a lower lower and slower rate.

SPEAKER_03 2:52

Right.

SPEAKER_00 2:53

And that's why it took so long. Now enter Cyberknife, which it should be noted is a brand name of something called SBRT. So kind of like Band-Aid versus adhesive bandage or Kleenex versus tissue paper. Right. So Cyberknife is just a brand name. But that SBRT, which is that shorter course, that five treatments, is done at a lot at a much higher dosage.

SPEAKER_03 3:23

Right.

SPEAKER_00 3:24

There are things that you do uh prior to the radiation that will help to target the radiation and protect the other organs around it. And that technology has really helped to build up that SBRT program. Those are things like fiducial markers, where we put little gold seeds within the prostate so that while you're getting the treatment, the machine monitors those gold seeds. And if it moves, if you move even a little bit, the machine will recognize that and then relocalize the radiation. So you don't move over half an inch and now your bladder is getting blasted.

SPEAKER_03 4:05

Right.

SPEAKER_00 4:06

The other thing we do is fiducial or um spacer placement. So a spacer is some kind of product, you know, hyaluronic acid or, you know, some kind of gel that you place beneath the prostate and above the rectum because those two organs are very close to each other, millimeters away from each other. And by putting that product there, we separate the rectum from the prostate because when it comes to radiation, small distances will really there's a big drop-off in the intensity of radiation even over small distances. So you increase that few millimeters to a centimeter, and you're really protecting the rectum. And when done correctly, there's we've almost eliminated the risk of radiation proctitis, which is used to be a big issue in radiation, you know, like basically having irritated bowel symptoms going forward, in some cases permanently.

SPEAKER_01 5:09

So this spacer is actually separating, it's increasing the distance. It's not actually a shield from the radiation.

SPEAKER_00 5:20

It's not like a lead-based thing that is blocking the radiation. It is literally increasing the space, the distance between where you want the radiation to go and the thing you're trying to protect.

SPEAKER_01 5:33

Yeah, I think that's a good thing for patients to understand in that term because I think a lot of people think, well, you're putting this gel in, is it going to shield my bladder and my bowel from the radiation? It's not. You're just increasing it because you're trying to prevent the focus of the radiation from getting on those organ organs, and you're trying to keep it directly onto the prostate. Right. Cool. Very cool. Tommy, what do you think the immediate versus long-term effects of radiation are for patients with prostate cancer? Like the cyber knife or the sorry the uh the SBRT versus the XRT.

SPEAKER_00 6:16

Like what is the patient going to experience? Yeah. So radiation is a great option for a lot of people because it's well tolerated in the immediate setting and the long-term setting too. Come to the facility for an hour a day, you go home, you go about your life, and go back to work that day. During your treatments, you can experience fatigue or bladder, like changes in your urination related to kind of swelling and changes in the prostate. The prostate is an important part of your urination. And as that swells and shrinks and changes, you will notice changes in your urination.

SPEAKER_01 7:01

Which is why we give patients, exactly. To help them pee better while they're going through the radiation therapy.

SPEAKER_00 7:08

Right. That, and everyone experiences it differently. Some people coast through it, no issues. Some people, they're really bothered by their symptoms. And whether that's purely related to the prostate or spray artifact on the bladder, it's you know, it's hard to say completely. But the majority of people have a significant recovery and go back to normal three to six months after radiation. The problem long term is there, depending on the degree of spray artifact on the bladder, you can develop things like long-term permanent overactive bladder.

unknown 7:47

Right.

SPEAKER_00 7:48

Because radiation is like a sunburn to the bladder, and now you're just kind of really irritating it. Now we have medications to help with that, but there isn't like a good permanent surgical fix to like correct that. If this is a side effect you develop, it's more about managing the symptom with medication as best we can rather than we're gonna correct it altogether.

SPEAKER_01 8:12

Um I know that I see a lot more patients who have issues if they had had seed placement uh many years ago. And here we are many, many years later. They're the ones who have the overactive bladder symptoms, they're the ones who have the um occasional blood in the urine that has to be worked up.

SPEAKER_00 8:30

Yeah, what you're kind of talking about is you're you're highlighting how far we've come in radiation treatment because these people who had radiation 20 years ago, it was, you know, high doses of radiation that wasn't as well targeted as we are currently doing. Right. So, yes, seeds were a very, you know, brachy therapy was very common. We still do brachytherapy, but it's a little bit less common. Um but I also see people who just had external beam radiation, no seeds decades ago, who are having issues like urinating blood or they have strictures, you know, or something like that. Because radiation changes the the inherent nature of the tissue in the area, and there's not great blood supply after you've done radiation. Blood is what helps tissue stay healthy and repairs any kind of damage. So if you have any kind of damage in a radiated field, it never heals as well.

SPEAKER_03 9:39

Right.

SPEAKER_00 9:40

Now, with the SBRT and the better localization, we're doing a little bit of a better job trying to prevent those things from happening in the long term. But again, we haven't been doing this for as long as you know, we haven't seen those patients who are like 20, 30 years out already from that radiation. So we'll have to see.

SPEAKER_01 10:02

Right. Um, another thing that we do is something called androgen deprivation therapy. Um, this is usually giving a patient an injection of something or um some kind of medication that will prevent their testicles from making testosterone, which I usually explain to patients in layman's terms as um fuel for prostate cancer. I usually say, well, you know, we need to bring your testosterone level down because, you know, it's the testosterone that makes your prostate cancer grow faster or come back. So tell me a little about a little bit about um androgen deprivation therapy and which patients require it and and what is it going to cause? What are they gonna feel?

SPEAKER_00 10:49

Yeah, this is a complicated component of prostate cancer management. Because as you said, prostate cancer is an androgen-sensitive cancer, meaning testosterone is the fuel for cancer. It's important to note that testosterone doesn't cause prostate cancer, but it will keep the cancer going if you have an underlying cancer.

unknown 11:16

Right.

SPEAKER_00 11:18

Because we know that the prostate cancer responds to testosterone, we have incorporated uh hormonal therapy in the treatment of some prostate cancer. And hormonal hormonal therapy is a term thrown out a lot, but it's a little bit of a misnomer because we're not giving you hormones, we're getting rid of the hormone, we're getting rid of the testosterone.

SPEAKER_03 11:43

Right.

SPEAKER_00 11:44

And there's a lot of ways we can do that. I mean, one kind of an old-fashioned way is you could just take the testicles out, right? That's that's number one. Injections with a medication is has been the standard for a long period of time, whether that's an injection once a month, once every three months, every four months, every six months, whatever it is. And we have oral medications that can also have the same effect.

SPEAKER_01 12:12

And that's pretty new. The oral medications.

SPEAKER_00 12:14

That's pretty new. That's pretty new.

SPEAKER_01 12:17

They say that with the oral medications, when you take the oral medications, when you stop them, your testosterone comes back quicker. So you've got a decreased amount of side effects.

SPEAKER_00 12:29

Right. That's something else we can talk about is like the rebound of your testosterone, because you should see a rebound in your testosterone despite having taken these medications. But how long and to what degree you get that recovery depends a little bit on what agent you've used and for how long.

unknown 12:48

Right.

SPEAKER_00 12:49

But back to your question about who needs uh androgen deprivation therapy. There's a couple different populations of people who benefit from it. One is in the metastatic setting. So this is very advanced cancer where it's kind of spread all over the body. Right. Androgen deprivation therapy is the mainstay of treatment there. We do use um different second generations of hormonal therapy, sometimes as an adjunct to the lupron or the you know primary ADT. Um, and we do use chemotherapies. Um, there are also newer, you know, newer agents coming out. There's a there's a lot of exciting research going on in this field, but the hormonal therapy remains kind of like the standard in that setting.

SPEAKER_03 13:38

Right.

SPEAKER_00 13:39

The other population that we use the hormonal therapy on is patients who have slightly more aggressive disease and are getting treated with radiation. So if you're going for surgery, and this would be for like localized prostate cancer. All right, so you can think about it, prostate cancer. It's either localized, meaning contained to the prostate in a manner that we feel that we can cure you with either surgery or radiation. Let's take out partial treatments for a second here. The other population is locally advanced or or you know, node positive, lymph node positive or metastatic. So if you're considered localized prostate cancer, you're going to go for surgery or radiation. If you have an aggressive form of local prostate cancer and you're getting radiation, hormonal therapy is important in that setting.

SPEAKER_01 14:31

How do they know if it is spread? Is there tests that you do to see if it's spread, to know if it's spread through your lymph nodes?

SPEAKER_00 14:41

Yep. So there is PET scan. There are PET scans that we can do. Um the test we use is called PSMA PET, and it's pretty sensitive for metastatic disease. We used to do things like bone scans and CAT scans, uh, but the PSMA PET has is just so much more sensitive now. Right. We do, you know, we the vast majority of patients with prostate cancer will have some kind of prostate MRI, and that looks at the lymph nodes, but you can have enlarged lymph nodes that aren't cancerous, so it's a little bit harder to parse out. But I just wanted to talk for a second about the hormonal therapy as it pertains in the radiation setting. And um, you know, there is the component, oh yes, uh distant cells may respond to um the hormonal therapy, but what's actually important is that testosterone is important in the uh fixing of DNA damage. And when you do radiation, you're damaging the DNA to the point where you cause apoptosis or cell death. That's the the main mechanism of how that works. So blocking the testosterone prevents your body from fixing all those problems.

SPEAKER_03 15:52

Right.

SPEAKER_00 15:54

Um we are using, you know, hormones are one of the worst components of, you know, the hormonal therapy is one of the worst components of prostate cancer treatment because testosterone is what makes us feel like men. Sure. It gives us our strength, our energy, our libido. Our libido. You know, it's it makes us feel like men. And when you get rid of that, you're inducing a male menopause.

SPEAKER_03 16:19

Right.

SPEAKER_00 16:20

So hot flashes, weight gain, muscle mass loss, bone mass loss, erectile dysfunction, depression, depending on how long you're on it for, it can affect other hormones, like diabetes. Like there, there are a lot of issues with it. Um so, in an effort to try to avoid giving patients this treatment, we are looking into more genomic or like risk stratification tests to help say you may or may not benefit from hormones and for how long. Because you could be on hormones for as few as four months or be recommended for as long as three years, depending on how aggressive your cancer is. And that's a that's a big difference.

SPEAKER_01 17:06

And do you do something for a patient who say is on the hormone therapy and they absolutely hate it? But you said, listen, I really recommend that you be on this for at least two years. What can you do for a patient like that?

SPEAKER_00 17:21

Yeah, it depends on it depends on a lot of things. We do have medications to help target various side effects from the hormones, whether it's hot flashes, depression, diabetes, whatever it is, bone fractures, like you know, you can develop osteoporosis from these treatments. So we have, and so that's why patients who are on these medications for long periods of time require close monitoring.

SPEAKER_03 17:53

Right.

SPEAKER_00 17:54

Um but it also is a little bit of conversation about the patient's quality of life and you know, how old are they, like how much do we think this treatment is actually benefiting their life? Because our goal, at least my goal, is to maximize your quality of life years. Right. That's different for everybody. Some people will say, Well, I want to live on a ventilator as long as I can live to 100. Okay. There's some people who say, I, you know, who knowingly have prostate cancer that that they're at an age that I would suspect is going to be an issue in their life. And they say, no, I don't want treatment. Like I don't, this sounds horrible. And not, you know, not having erections, feeling hot all the time, going through radiation. And that's their choice. And it's the physician's job to adequately explain what is going on with the patient, what their options are, what the potential complications are, and what the potential benefits are of any of treatment. But ultimately, it's you know the patient's choice and how they proceed. We've kind of moved on as a society from this patriarchal medical system where the doctor just tells you, you know, you're doing this.

SPEAKER_01 19:09

Right, right. Um, what do you think is the biggest myth about prostate cancer and its treatment?

SPEAKER_00 19:16

Uh I think the biggest myth is people think prostate cancer is a death sentence. And I think it's gotten a little bit better. Uh, you know, as we as a field have done a better job explaining like active surveillance, and we're not doing so much, I don't say unnecessary surgery, but surgery that is maybe a little bit too aggressive. You know, 20, 25 years ago, if you had a diagnosis of prostate cancer, your prostate was coming out. Some of those cancers probably weren't going to kill anybody. You know, that's we've progressed from there. And some of that um mentality that uh cancer is cancer is a death sentence still persists. So I think that's a big myth. Um there's another like very big myth that like size of your prostate is somehow important, um, puts you at risk, or that PSA, I get asked a lot, what can I do to bring my PSA down? It's almost irrelevant, right? The PSA is an important number for me to monitor your prostate cancer and to see what's going on. Driving your PSA down isn't in and of itself gonna change what's going on with your cancer, unless it's like hormonal therapy, unless it's a response to a treatment. But in somebody who's like just active surveillance, we know they have cancer. Giving you a medication to drop your PSA down, which we can do, doesn't change how I think about your cancer at all.

SPEAKER_01 20:42

Right. Like whenever you see a patient who's already on the ADT medications and their PSA is like zero. And you know, patients are so excited, they're like, My PSA is zero, it's zero. I'm like, well, but remember that you're still on this medication. So we don't really know what your true PSA is until we take you off this medication and we wait until everything comes back to baseline.

SPEAKER_00 21:06

Right. Especially if you are doing something like radiation, right? If you do radiation or any of these partial treatments for prostate cancer, you still have a prostate that will make PSA.

SPEAKER_03 21:18

Right.

SPEAKER_00 21:19

You can have an undetectable PSA, but more commonly, if you have any shred of prostate tissue left, you're going to have some kind of PSA. Then it's a matter of monitoring it and making sure it's not rising.

SPEAKER_01 21:33

Right. Um What makes you most optimistic about prostate cancer treatment today and tomorrow?

SPEAKER_00 21:44

We're in a really exciting time of medicine with uh AI and all these genomic tests that are coming out. I think that we are going to do a better job of risk stratifying patients. And picking out those patients who really need treatment and who we can safely watch. We're doing a pretty good job right now, but my suspicion is in the coming years, we're gonna do an even better job. We also, in the very advanced prostate cancer setting, are making, you know, metastatic are making really big strides. Whereas before, just the hormonal therapy that used to be the standard of care, we're coming out with more and more kind of targeted therapies. We're having a better understanding of what mutations are leading to these cancers and how can we target them. So even in the kind of short-term future, I think we're gonna see some significant improvements. Longer term, this is sort of my opinion on all of medicine, is that once AI gets really good at this sort of thing, we should be able to sequence tumors, identify the mutations, and design drugs to target those tumors across the body. Right. It's just gonna take time. Sure. But that's sort of where I see oncology going.

SPEAKER_01 23:02

That's amazing.

SPEAKER_00 23:03

It will be very amazing.

SPEAKER_01 23:04

Um, the one thing I don't think I really touched upon too much, but I was curious. I know that listeners listeners are curious about this. Um if prostate cancer spreads and they are told that it is now metastatic, what kind of treatments can you offer them? And what do you tell these patients about what to expect in the future?

SPEAKER_00 23:28

Yeah, as of today, there's no cure for metastatic prostate cancer, but we have excellent treatments for controlling metastatic prostate cancer and really durable control, like decade, you know. The we we talked a little bit about the hormonal therapy, ADT. The lupron was um has been around for a while, and then we developed these second and third generation anti-androgens, and we use those in combination. We do use chemotherapies, and there's new treatments that are targeting specific receptors, you know, that really have almost like complete responses.

SPEAKER_01 24:12

These are the immunotherapies that they tell you.

SPEAKER_00 24:13

And immunotherapies, yeah.

SPEAKER_01 24:16

That's great.

SPEAKER_00 24:17

So there are there's a lot of exciting work being done in the metastatic setting. And you can have very durable responses. Now, treatments tend to have side effects. Sure. Right? We've talked about the hormonal therapy. Uh, but it is amazing what we're we're doing in that setting.

SPEAKER_01 24:39

But it's important to let patients know just because your prostate cancer is metastasized, it's still not a death sentence.

SPEAKER_00 24:46

It's it's not the end of the road. That's correct.

SPEAKER_01 24:49

Well, that about wraps up my three-part interview series on prostate cancer. I would like to take this opportunity to thank my colleague and friend, Dr. David Alborn, for his generosity with his time and knowledge. As a patient, remember to ask questions and get the answers you need to make the best decision for you. All patients are different, so there's no cookie-cutter answer for your treatment. Be your own advocate. Thanks for listening. I hope this series helps you on your journey, and be sure to subscribe and follow and tell your friends. And remember, if you're in trouble and you need help, go to your unluck.

SPEAKER_02 25:32

When you're in trouble and you need help, go to your unluck. Now stream me.