Online Health Chat with Jayram Krishnan, DO

June 24, 2016


Prostate cancer is the most common cancer in men, and the second leading cause of cancer death among men in the United States. Every year, about 185,000 new cases of prostate cancer are diagnosed nationally. There are many treatment options available including active surveillance, radiation therapy, brachytherapy and surgical procedures such as open prostatectomy and robot assisted surgery.

Active surveillance requires no treatment for a discovered prostate cancer until your doctor detects signs that the cancer is growing more aggressively. Radiation therapy is the use of high-energy x-rays, electron beams or radioactive isotopes to kill cancer cells and shrink tumors. Brachytherapy is a form of radiation therapy during which radioactive pellets, each about 1/4-inch long and 1/32-inch thick, are implanted in the prostate.

Complete removal of the prostate, called a radical prostatectomy, is one of the most common treatments for prostate cancer. During an open radical prostatectomy, the entire prostate is removed through an incision in the lower abdomen. During a robot-assisted surgery, a type of minimally invasive surgery (MIS), robotic equipment is used to imitate surgical movements. MIS procedures allow surgeons to operate through small ports rather than large incisions. Surgical robotics combines minimally invasive techniques with highly advanced clinical technology. The results of robotic and open surgery are equal, with similar lengths of stay and recovery times. The most important factor in getting a good result is choosing a surgeon experienced in the technique.

Today’s chat will discuss prostate cancer and various treatment options. We are excited to have Cleveland Clinic urologist, Jayram Krishnan, DO, here to answer your questions.  Dr. Krishnan is a board-certified urologist at Cleveland Clinic Urology, Las Vegas.

About the Speakers

Jayram Krishnan, DO, earned his medical degree from New York College of Osteopathic Medicine in 2004; he had previously completed his undergraduate studies at Villanova University in 2000. He completed his urological surgery residency at Kennedy Memorial Hospitals University Medical Center in Stratford, NJ and his advanced urological robotic and laparoscopic fellowship at Cleveland Clinic in Cleveland, OH.

Dr. Krishnan’s specialty interests include minimally invasive and robotic surgery for kidney, bladder and prostate cancers, general urology, kidney stones, reconstructive urology, female urology, men’s health, benign prostate disease and adrenal disorders

Let’s Chat About Prostate Cancer and Treatment Options

Perspectives on Prostate Cancer

mcneuman: What causes prostate cancer and is there any way to prevent it?

Jayram_Krishnan,_DO: We believe that there is a genetic link to prostate cancer, and we have mapped the genes related to prostate cancer. We still do not have clear details on the causes of prostate cancer, and we do not know how to prevent it.

vegan: Are there symptoms for prostate cancer?

Jayram_Krishnan,_DO: Prostate cancer, by nature, is “silent” in its early stages. Its symptoms don't appear until later when patients may notice a need to urinate frequently, particularly at night. Prostate cancer may also cause other problems with urination including: having trouble urinating, a flow of urine that is weak or stops and starts, or painful and burning urination. Other symptoms may include: painful ejaculation, blood in urine or semen, and frequent pain or stiffness in the lower back, hips or legs.

demitri: Will frequent sex protect against prostate cancer?

Jayram_Krishnan,_DO: Our studies have shown no difference between frequent/infrequent sex (ejaculation) and prostate cancer.

LuLu: Is there anything similar to recurrent prostate cancer? I am just drawing a correlation between recurrent metastasized breast cancer, which I have lost three friends to in the past year (all diagnosed young and had double mastectomies 15 years prior). Does treatment for prostate cancer cure it?

Jayram_Krishnan,_DO: Eighty-nine percent of men diagnosed with prostate cancer will live at least five years, while 63 percent will live 10 years or longer. Because prostate cancer is a slow-growing disease, many affected men will die from other causes. Many patients who have a prostate screening every year detect their prostate cancer while it can be cured.

Eman: Are there truly benefits to consuming pomegranate juice to prevent prostate cancer?

Jayram_Krishnan,_DO: Studies are preliminary now regarding prostate cancer and pomegranate juice. There needs to be further studies before making direct correlations.
There are more ongoing clinical trials. Talk to your doctor first before making any diet changes.

Diagnostic Details

jjsjjs: I am 79 years old and in reasonably good health. Since June 2014, my PSA has hovered in the low to mid fives. In May 2016 it was 5.5. I was examined by a urologist who suggested I have a biopsy, but I am concerned about the accuracy of the test and the side effects. Blindly running needles through the dirtiest part of my body into my prostate seems like a potential for trouble and inconclusive results. My internist has suggested watchful waiting until my PSA reaches eight and then have the biopsy. According to the University of Texas questionnaire, I have a 15 percent chance of having a serious prostate cancer. What is your recommendation for me? Is a PSA of eight a safe number?

Jayram_Krishnan,_DO: We have two additional tests that we use to risk stratify for prostate cancer. They are the PCA-3 test and the 4K score test. These tests are more specific for finding prostate cancer in men with high PSA levels. The PCA-3 test is a urine test done after a rectal examination. The 4K score is a relatively new test that is done with a blood sample. These tests can help us decide if you have prostate cancer. Also, if your insurance will allow it, a high-quality MRI of the prostate can be performed, and this will show us if you have suspicious areas that could indicate cancer. Then a biopsy can be performed “targeting” these areas specifically so that it is not done blindly. The only challenge is getting insurance to approve a costly MRI of the prostate.

Sy210: What diagnostic tests are used to determine prostate cancer?

Jayram_Krishnan,_DO: We use the PSA, Free PSA, PSA Density and the PCA-3 as well as the 4K Score blood test. These all help us find out if you are at risk of having prostate cancer. These will be followed by a prostate biopsy.

Screening Sense

NTN8908: My fiancé’s side of the family is prone to prostate cancer. What would be a good age for him to start getting checked?

Jayram_Krishnan,_DO: If he has a family history, then he may need screening earlier than the general population. Check with his family doctor or urologist about when is the best time to start screening in light of his family history.

GED: Is there an increased risk of prostate cancer if you have had a vasectomy? What about combining a family history of a father who had prostate cancer and the fact that I had a vasectomy at age 50?

Jayram_Krishnan,_DO: The American Urology Association guidelines panel could not find an association between vasectomy and an increased risk of developing prostate cancer. You will require screening since your father had prostate cancer.

Jack_in_Florida: The American Medical Association recommends against PSA tests for prostate screening. What is your feeling regarding this?

Jayram_Krishnan,_DO: The PSA is still the best test we have for the detection of prostate cancer. We use the PSA in conjunction with many other tests, including a digital rectal examination, the PCA-3 test and the 4K score, to assess your risk of having prostate cancer.

farmerdan: Is genetic testing recommended in general or is it primarily in the research phase for targeting specific types of treatments or medications. I was reading something about this regarding the MSK-IMPACT test.

Jayram_Krishnan,_DO: There are a number of new prostate genetic tests on the market now. Many of them are in their preliminary stages and require more studies to prove that they actually mean something for the patient. This is a very exciting area for us involved with prostate cancer treatment.

Jack_in_Florida: Does BPH require more aggressive cancer screening for a 73-year-old? Does BPH in itself lead to prostate removal due to its symptoms (frequent urination, urgency, etc.)?

Jayram_Krishnan,_DO: BPH is a benign condition (not cancer) of the prostate that causes symptoms urinating. The diagnosis of BPH alone does not require more aggressive prostate cancer screening.

Treatment Tactics

Bird: What is watchful waiting? What determines when prostate cancer treatment is started?

Jayram_Krishnan,_DO: Watchful waiting is now known as active surveillance. This is when we watch different characteristics of your prostate cancer and make sure that you are within a low risk or very low risk category. If anything changes and your risk goes up, then we can start talking about prostate cancer treatment.

Bird: What are the different types of treatment options?

Jayram_Krishnan,_DO: There are many treatment options for prostate cancer including active surveillance, when we watch the cancer closely but do not use surgery. Other treatments include radiation, surgery, cryotherapy and more. For more details, check out our comprehensive link on the Cleveland Clinic website:

Wm.: I am not sure if my friend had radioactive seed implants or brachytherapy, but a complication has been diarrhea for several months. Is this common?

Jayram_Krishnan,_DO: Brachytherapy is when radioactive seeds are implanted into the prostate for cancer treatment. It can cause problems with the urethra afterward requiring a catheter. Your friend needs to see his urologist and radiation oncologist for more information about his diarrhea.

DanH: What are the precautions for having brachytherapy? Can radiation be passed on to others?

Jayram_Krishnan,_DO: Even though radiation does not travel far from the prostate with this form of therapy, there are some risks. Because the prostate is close to the urethra, brachytherapy may cause more severe urinary problems than external beam therapy. Some patients need a catheter (a thin, hollow tube) to help them urinate while the radiation remains most active, usually about six months, although it may take up to a year for the radiation to completely leave the body. Also, because exposure to radiation can be dangerous for pregnant women and small children, patients who have brachytherapy should stay at least six feet away from these individuals for the first few months of therapy.

Bruce: Does the initial choice of treatment for prostate cancer affect what other treatments you can have later?

Jayram_Krishnan,_DO: Yes, the initial choice of treatment does matter, especially if your prostate cancer comes back. It will dictate further treatments if needed if your cancer comes back.

dmack1106: Can you give me your opinion of GreenLight laser therapy for BPH?

Jayram_Krishnan,_DO: Although this is not a treatment for prostate cancer, it is a common treatment for benign enlargement of the prostate. Please check with your urologist for more information about this treatment.

DanH: What is biological therapy?

Jayram_Krishnan,_DO: Biological therapy involves the use of living organisms, substances derived from living organisms or laboratory-produced versions of such substances to treat disease. Some biological therapies for cancer use vaccines or bacteria to stimulate the body’s immune system to act against cancer cells. This is being looked at for all cancers now.

Medication Messages

jracq: What is the best test procedure for those with stage 1 prostate cancer? Also, are medicines safe to take at the same time when diagnosed with a liver problem and kidney cysts?

Jayram_Krishnan,_DO: I would need more information about your stage 1 prostate cancer, because it is treated in many different ways. Many times, we simply watch stage 1 prostate cancers closely without instituting any treatment. Taking different medications may be best answered by your primary care doctor, who can help coordinate side effects and dosages tailored to your body. Thank you.

dmack1106: Do you know if there is a generic for Levitra? Can I use two 20mg Levitra instead of regular one 20MG Levitra?

Jayram_Krishnan,_DO: I am not aware of a generic Levitra. Please check with your urologist about doubling Levitra, as this is not the recommended dosage for this medication.


That is all the time we have for questions today. Thank you, Dr. Krishnan, for taking time to educate us about prostate cancer and its treatments.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

For Appointments

To make an appointment with Jayram Krishnan, DO, or any of the other urology specialists at Cleveland Clinic Urology, Las Vegas, please call 702.796.8669, or visit us at for more information.

For More Information

Cleveland Clinic Department of Urology
The Department of Urology within the Glickman Urological & Kidney Institute is ranked No. 2 in the nation by U. S. News & World Report. Urologists in this institute are also recognized worldwide for excellence in patient care, teaching and research in all aspects of urology.

Cleveland Clinic Health Information
Learn more about symptoms, causes, diagnostic tests and treatments options for prostate cancer:

Prostate Cancer Care at Cleveland Clinic

Elevated PSA (Prostate-Specific Antigen) Level

Prostate Ultrasound and Biopsy

Prostate Cancer - Treatment

Erectile Dysfunction Treatments for Patients with Prostate Cancer

For additional health information, visit

Cleveland Clinic Prostate Cancer Online Learning Center

Cleveland Clinic Treatment Guide

Please use this guide as a resource to learn about the causes of prostate cancer and your treatment options. As a patient, you have the right to ask questions and seek a second opinion.

Clinical Trials
For additional information about clinical trials, visit:

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