Prostate Cancer Awareness: Screening & Treatment

Men are more likely than women to delay or avoid seeking medical care. That's a big problem when it comes to catching and treating serious medical conditions including prostate cancer. 

One in 9 men in the U.S. will be diagnosed with prostate cancer in his lifetime, and most will not have any symptoms. Regular medical check-ups and the appropriate screenings are crucial in diagnosing the disease at an early stage, when it is easiest to treat successfully.

To mark Prostate Cancer Awareness Month, host, Dr. Jonathan Fialkow welcomes Marcio Fagundes, M.D., medical director of radiation oncology at Miami Cancer Institute, to the podcast to talk about the importance of screenings and the latest advances in radiation treatment for prostate cancer.

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Announcer:

At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk Podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.

Dr. Jonathan Fialkow:

Welcome back Baptist HealthTalk Podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventative cardiologist and lipidologist at the Miami Cardiac and Vascular Institute at Baptist Health South Florida, as well as Chief Population Health Officer at Baptist Health.

Dr. Jonathan Fialkow:

Many studies over the years have revealed that men are more likely than women to delay or avoid seeking medical care. And some of the most common excuses we hear are I don't have time, or I'm not really sick enough and even believe it or not, I just don't want to know. As a doctor who's been practicing for almost 30 years, I can assure you what you don't know can hurt you. That's true, whether we're talking about heart disease, diabetes, or the subject we're covering today, prostate cancer.

Dr. Jonathan Fialkow:

The latest statistics show that one in nine men will be diagnosed with prostate cancer during his lifetime, about 191,000 new cases will be diagnosed in the US this year alone. With September being prostate cancer awareness month, I've invited Dr. Marcio Fagundes to the podcast. Dr. Fagundes is medical director of radiation oncology at Miami Cancer Institute and a renowned expert in the treatment of prostate cancer. Welcome to the podcast, Marcio.

Dr. Marcio Fagundes:

Thank you for having me.

Dr. Jonathan Fialkow:

So a lot to unpack there, and I do want to get into the innovative treatments for prostate cancer, especially those that are being performed at Miami Cancer Institute, but let's level set a little bit for the listeners. First, I'm going to ask you a kind of silly question it may seem, but more so what is the prostate, what's it for? What does it do?

Dr. Marcio Fagundes:

So the prostate, we call it a gland. It serves several purposes. One of the main ones is used for sphincter control to help control your urine voluntarily when you want to urinate, you do. So the prostate has this sphincter component that holds the urine along with the bladder. It also has a function of reproductive purposes where some of those seminal vesicle and secretions that make the ejaculation come from the prostate. So actually to conceive and sperm and secretions all have a contribution from the prostate gland itself.

Dr. Jonathan Fialkow:

So there are many things that our body does that we don't consciously think about or appreciate, but arguably the prostate is something that men should certainly appreciate and pay attention to.

Dr. Marcio Fagundes:

Right.

Dr. Jonathan Fialkow:

Now having said that, and again, we're going to get the prostate cancer. There's lots of other things that can go wrong on the prostate. If a man has prostate cancer, are they more likely to present with symptoms of something and found to have cancer, or is it more likely that cancer would be picked up via other mechanisms, including screening?

Dr. Marcio Fagundes:

So that's a great question because men will frequently think that prostate cancer should cause pain or problems that they would notice. And that's not usually the case. So prostate cancers can be detected very early in patients where when they are in their 50s and 60s, by tracking a subtle rise in the PSA, PSA is a blood test that men should start doing as part of their routine screening. And a PSA goes up above what is anticipated that would indicate that there's a risk, that there could be a prostate cancer. Along with that, patients should have a digital rectal exam of the prostate also, along with the PSA check to make sure that there aren't any palpable nodules in the prostate.

Dr. Jonathan Fialkow:

So those screening tests, the digital rectal exam, where a physician can feel something that may be cancer or the blood test be part of our screening procedures. Is there an age when a man should start getting those tests done? And if so, how frequently?

Dr. Marcio Fagundes:

Yeah. So that is determined by risk, mainly a risk in the family, meaning that if you don't have any relatives with prostate cancer, you can start later, like in your 50s doing annual checks. If you have one or two relatives, close relatives that have prostate cancer in the family, you should really start earlier like 40, 45. And it's most important to mention this, one in 10 or one in 20 patients that have prostate cancer, the PSA will not elevate. And the tumors frequently are only identified, the cancer is only identified via a digital exam, palpation of the rectum, or even sometimes on an MRI scan, which is becoming a more and more used imaging study to detect early prostate cancer that can be identified.

Dr. Jonathan Fialkow:

So two questions to that statement, which I appreciate. The first is, is the MRI for everyone, or should it just be for the patients who have that high risk from a family history where I know you said it's evolving a little bit where we using the MRI selectively?

Dr. Marcio Fagundes:

So the MRI is evolving in the following sense. It's being used before a biopsy, increasingly more often before the biopsy is done to identify any suspicious lesions that could be missed on a random biopsy. So a random biopsy is taking 12 samples from the prostate, from the top, the middle and the bottom, and an MRI-guided biopsy is doing an MRI before the biopsy, seeing if there's any suspicious change that would indicate a more aggressive pattern cancer and making sure that one spot is sampled. And that spot could be less than a centimeter in size no less than a half an inch. So it could be quite small.

Dr. Jonathan Fialkow:

So we'll start with the MRI. That would be in someone who either has a digital exam that's abnormal or an elevated PSA, then you say-

Dr. Marcio Fagundes:

Yeah.

Dr. Jonathan Fialkow:

... Okay. Good.

Dr. Marcio Fagundes:

Yeah. I just mentioned that because nowadays when we do a PSA, we do a digital we say, we should do a biopsy. It's increasingly more common that we do an MRI before the biopsy.

Dr. Jonathan Fialkow:

Fair enough. Going back to the digital exam and the PSA, I'm a cardiologist come person comes in, we're going to do a whole workup on lipids and sugar. And they say, okay, throw a PSA in there. You did say annually, the PSA should be done as a screening in that high-risk population or a man of a certain age. No reason to do it if it's okay, less than annually. Is that correct? If it is normal.

Dr. Marcio Fagundes:

Yeah. I mean, if it's low risk and if you've done baseline, you can start doing it biannually. But frankly, in the high-risk patient population that has relatives, you would want to do it annually. And there's something called a PSA velocity. If the PSA is rising more than a certain amount per year, then that would trigger the suspicion to do a biopsy. There's also the free PSA versus total PSA. So these are all things that are looked into by the specialist that is doing the triage and screening.

Dr. Jonathan Fialkow:

So arguably a PSA can be done as a routine annual physical exam with primary care, digital exam. If there's an abnormality, then the person may be referred to a specialist for further assessments, which is again, great information.

Dr. Marcio Fagundes:

Exactly.

Dr. Jonathan Fialkow:

Appreciate that. So again, we're going to get to specifically prostate cancer in a second. So that's the screening, which is the digital rectal exam and the blood test. Are there any symptoms that would make a man more likely to be showing signs of prostate cancer or anything they should get checked out because it may be cancer?

Dr. Marcio Fagundes:

You know, prostate enlargement, benign enlargement called BPH benign prostatic hypertrophy, which is benign growth happens with age very slowly. That is what men tend to feel. It's not the cancer. It's very rare that a man, any men would feel the cancer. So aging, it goes along with benign growth and with aging comes increased risk of cancer. So they all they happen together, but there isn't a symptom that is a trigger or this is prostate cancer. No. Typically, no.

Dr. Jonathan Fialkow:

So going back to that point, the screening is how we pick it up. And the way men get screened is to actually get screened, which then speaks towards the importance of, especially in this COVID environment, getting your regular checkups, not avoiding seeing the doctor. Feeling well with no symptoms does not mean nothing's going on. So it does speak towards regular exams and regular checkups for-

Dr. Marcio Fagundes:

Right. And then just to emphasize, why would you want to do the screening, right? Because if you identify cancers in a stage where the only thing you have is an elevating, early elevating PSA and not non-palpable tumor, we can't feel anything. We call that stage T1c. We can't feel it, but the PSA is slightly elevated and a biopsy showed a cancer. That stage is usually the earliest stage you can have. And it is highly curable. We're talking about more than nine out of 10 patients will be cured. Whether you do radiation or surgery, you'll be cured. As opposed to waiting until the cancer grows and grows outside of the prostate. Now the cure rates go down, can go down significantly. So you want to do a screening early detection, identify cancers when they're most curable.

Dr. Jonathan Fialkow:

So that's a great segue to talking out something about the cancer and the assessments and the treatment. So a man gets screened appropriately over a few years. Now you're finding the PSA is starting to elevate or the digital exam's abnormal. Follow up, MRI maybe, biopsy shows there's cancer. Now what would be the options that individual, what goes into the assessments, arguably including the patient decision as to what do I do? I have prostate cancer.

Dr. Marcio Fagundes:

Yeah. So there is something called the National Comprehensive Cancer Network, NCCN. This is a national guideline for recommendation of proven therapies. I just mentioned this because it is in these kinds of multidisciplinary well-vetted study, tested environments that we can come up with suggestions and conclusions that this treatment works. And this is based on data. So it's not like we're coming out with a recommendation that is without evidence-based substantiated.

Dr. Marcio Fagundes:

So the treatments for prostate cancer range from radiation alone, or surgery alone for early stage, where you don't need to do anything else, just do all radiation or surgery. In more advanced tumors, like with very high, higher PSA, higher Gleason score, more aggressive cancers. Radiation usually goes along with hormone blocking up testosterone, or you could have the option to do surgery, but the treatment will change depending on the aggressiveness. I just want to make that point.

Dr. Jonathan Fialkow:

Right. To some degree and I can tell you as a non-oncologist, it does seem like the Wild West out there with these different claims of different treatments for prostate surgeries. But you're certainly speaking to evidence-based guideline-driven treatment options. And arguably that's the way we approach the patient at the Miami Cancer Institute. Can you speak a little bit about now if a person's referred to you or other doctors in the Miami Cancer Institute, how that treatment plan goes into effect? What are the conversations that one would have? Is it a solicitation of side effects of the treatments or what are the components that come into place when someone's referred to the Miami Cancer Institute?

Dr. Marcio Fagundes:

So we always help the patient understand where he falls in the risk group. Is it low risk, low aggressiveness, more curable? Okay. If that's the case, the first question we ask is-

Dr. Jonathan Fialkow:

If I can interrupt for a second, If I can interrupt, you're talking about risk of death from prostate cancer?

Dr. Marcio Fagundes:

... Yes. Yes.

Dr. Jonathan Fialkow:

Okay, okay. Right. That's all. Go ahead.

Dr. Marcio Fagundes:

So the first question we ask is, is the tumor aggressive enough that it needs to be treated? So there is something called active surveillance where we actively monitor patients by repeating a biopsy once a year. And if the cancer becomes a more aggressive, the PSA goes up, then we decide to treat. So first question is to ask, does the patient need treatment? Let's say that the tumor is aggressive enough that it needs to be treated. Then we would say, well, there are two options that are well proven long-term followup, which is radiation and surgery. And these two options are then presented to the patient.

Dr. Marcio Fagundes:

We usually go over the pros and cons, side effects, benefits, logistical aspects of the treatment, and try to help the patient understand what would be the reasoning for him choosing one or another, but they need to be educated to help them make the decision themselves with our help. We're not there to make the decision for the patient. We're there to help them make the decision for themselves.

Dr. Jonathan Fialkow:

So it's a very individualized assessment, a very individualized discussion. Ultimately, the patient makes the decision. And as you said, there are circumstances where the decision may be let's not do anything right now. It's not that aggressive. Your risk is not that high. Let's let's monitor it. Correct?

Dr. Marcio Fagundes:

Right, right.

Dr. Jonathan Fialkow:

Yeah. That's good. Yeah.

Dr. Marcio Fagundes:

Yeah, exactly. I mean, one of the things that happens a lot is we have a patient that should be treated. Okay. And then the discussion is, well, what are the probabilities of cure with one treatment being radiation? We present data. Obviously they've usually have seen the surgeon, they've gone over some of the surgical aspects or prostatectomy. And then we discuss, well, what are the benefits of radiotherapy? For example, radiotherapy does involve nowadays several visits, which could be a four-week regimen Monday through Friday. So it's a commitment of four weeks coming in, laying down for 20 minutes, getting a treatment, which you don't feel, but it is a commitment that takes several weeks, but there is no recovery. The risk of incontinence, losing urine is much lower than surgery. It's virtually no risk of incontinence of urine. So some of these things will make patients decide that that's what they want to do because they don't want to run those risks. So we have to weigh the pros and cons of each modality with the patient.

Dr. Jonathan Fialkow:

Very well said, very helpful. What kind of new or exciting advances are we seeing in prostate cancer therapies and specifically that you were leading and what we're doing at Miami Cancer Institute?

Dr. Marcio Fagundes:

So that's a great question because it's becoming more and advanced, effective, and practical. So for earlier stage cancers, which is really the majority, patients can be treated in many cases in just five sessions, which is very practical. It's every other day, it takes two weeks. We called this stereotactic body radiotherapy, and it's a very advanced form of therapy. We have all the tools, all of the equipment available in radiotherapy we have at Miami Cancer Institute to do this. So there's a five session treatment called SBRT.

Dr. Marcio Fagundes:

Now we have proton therapy, which is probably the most advanced form of radiotherapy there is. It uses particles that go into the body and stop. They don't keep going through and through the body like x-rays. So they radiate less normal tissues like bladder rectum. And proton therapy is frequently used in either more advanced or even early stage. We use it frequently to do treatments over like four weeks. Again, it's 20 sessions, very convenient treating the prostate seminal vesicles. In many cases, we treat lymph nodes as well.

Dr. Marcio Fagundes:

So we have to say something about protons. It's evolved significantly over the years, it's been around for decades. We have the most advanced proton technology there is currently. And patients that have higher risk disease, where we have to treat lymph nodes. These are the patients that probably benefit the most from protons because we eliminate unnecessary radiation to the intestines and patients go through radiation treatment with protons, without any diarrhea, for example. So side effects from treatment are minimized with that.

Dr. Jonathan Fialkow:

Well, I think those points are well taken as well because there's some myths regarding getting prostate cancer. I don't want to get treated because of the side effects, which can be real in certain populations, but certainly this day and age, less likely than maybe in the past. So to reiterate, it speaks to get your screening done, digital rectal exams, PSA, get that early detection, less involved treatment, better outcomes if you're detected early and treated early. And again, the individualized treatment at Miami Cancer Institute is what differentiates the way we are handling prostate cancer in our community compared to others. Great information-

Dr. Marcio Fagundes:

And also-

Dr. Jonathan Fialkow:

... Go ahead, please.

Dr. Marcio Fagundes:

... And also since 2015, there is something called rectal spacer. And you may have heard about this. Several patients may have heard about it. This is a liquid that is injected between the prostate and the rectum, and it pushes the rectum away from the prostate. It's a one-time injection, a very thin needle. I do it myself and I was actually the first one to apply this product once the FDA cleared it in April, 2015 in patients treated with proton therapy in prostate cancer. And have been doing this for hundreds, almost thousands of patients now, a thousand patients now.

Dr. Marcio Fagundes:

And what happens is that patients have this concept that radiation can harm the rectum. But if you do the treatment with rectal spacer, you just don't have any inflammation of the rectum. And that was proven in a study before the FDA cleared this product. And that has been my experience, over the years in using it. So we were pioneer in introducing this in South Florida, back when we opened, and I had been doing this product application with protons and other modalities of radiation from when I was up in Tennessee prior to relocating to Florida. So it's a great advancement in radiotherapy and proton therapy that makes radiation safer on the rectum.

Dr. Jonathan Fialkow:

So again, an advancement that may not affect the outcome in terms of surviving the cancer, but looking at the quality of life and the consequences of the procedure and something that we're pioneering.

Dr. Marcio Fagundes:

Right.

Dr. Jonathan Fialkow:

So that's great. Last, question. What's going on... Let me phrase that, is there any research that's being done at Miami Cancer Institute? Are we involved in any kind of state-of-the-art clinical trials regarding prostate cancer?

Dr. Marcio Fagundes:

Yes. There are several studies that are ongoing. And one that we in particular we support has to do with proton therapy. Some of the insurances have asked the centers that practice proton therapy to provide a level-one evidence, which is a randomized trial comparing protons to non-protons. And so this trial is ongoing. It is quite flexible in the sense that patients can come to us and be treated with protons and they can still participate in the trial. All it is is that their information, how well they did after treatment is used anonymously. Obviously, it's anonymous participation trial, and it's voluntary by the way, patients only participate if they want to. But the information is used to prove that protons is as good as we know it is.

Dr. Marcio Fagundes:

And this will be used down the road to help maintain coverage for proton. So that insurance is like Blue Cross Blue Shield will continue to cover it. So this is important. We always explain to patients by just doing your treatment as part of this route, it's the same as we would do after study, but you're just sharing your information when you enroll in the study anonymously, you will be helping other patients down the road to get covered without us.

Dr. Jonathan Fialkow:

Thank you, Marcio, for this wonderful information. Hopefully it'll engage our listeners to, for the men to get checked, for women to have their male friends and partners get checked. We cannot enforce enough, or at least encourage enough, the screening as the real bulwark against prostate cancer deaths. But for those that do have prostate cancer, many innovative approaches are available through Miami Cancer Institute and through Baptist Health South Florida. Any final comments or any thoughts that you want to add before we wrap up the podcast?

Dr. Marcio Fagundes:

Yeah. I mean, we have so many patients, even physicians that come to be treated and continue working during their treatment. Patients have the impression that going through treatment for prostate cancer can be debilitating. No. With radiation proton therapy, you continue working, exercising, carry normal life. You just come in to get treatment early in the day, late in the day and continue normal activities. It's quite convenient and not disrupting to your life.

Dr. Jonathan Fialkow:

Thank you very much for those final points. To our listeners as usual, if you have any thoughts or ideas or topics that you'd like us to deal with in future podcasts, please email us at baptisthealthtalk@baptisthealth.net, that's baptisthealthtalk@baptisthealth.net. Thank you for listening to this podcast. Stay safe and mask up.

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